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Preventing Workplace Preventing Workplace Asthma: Consider the Asthma: Consider the
Cleaning ProductsCleaning Products
June 7, 2007June 7, 2007
Elise Pechter MPH, CIHElise Pechter MPH, CIH
Massachusetts Depart Public HealthMassachusetts Depart Public Health
Anila Bello MS Doctoral CandidateAnila Bello MS Doctoral Candidate
University of Massachusetts LowellUniversity of Massachusetts Lowell
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OutlineOutline
Case studiesCase studies
AsthmaAsthma– Work-related asthmaWork-related asthma– Focus on health care workersFocus on health care workers
Exposure to cleaning agentsExposure to cleaning agents– InhalationInhalation– DermalDermal
Disinfectants marketedDisinfectants marketed
RecommendationsRecommendations
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Incident—Small community Incident—Small community hospitalhospital
Cluster of respiratory problems among Cluster of respiratory problems among operating room staff 9/2005operating room staff 9/200518 employees to Employee Health18 employees to Employee Health2 employees persistent WAA, reported 2 employees persistent WAA, reported to OHSP as WRA (October 2005). to OHSP as WRA (October 2005). Unable to return to work in ORUnable to return to work in OR
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Incident and causesIncident and causes
Persistent leaks into ORPersistent leaks into OR
Planned repair on HVACPlanned repair on HVAC
Moved equipment in Moved equipment in preparation for relocationpreparation for relocation
Planned repair of air-Planned repair of air-handling unithandling unit
Extra OR cleaningExtra OR cleaning
Prompt action by hospitalPrompt action by hospital
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Four Possible ExposuresFour Possible Exposures
Silicone sealant used in repairing AHUSilicone sealant used in repairing AHU
Fungi, mold, bacteria from previous leaksFungi, mold, bacteria from previous leaks
Dust from moving OR equipmentDust from moving OR equipment
HB Quat and other disinfectants and HB Quat and other disinfectants and cleaners used in ORcleaners used in OR
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Quaternary ammonium compound Quaternary ammonium compound (“quats”) most likely agent(“quats”) most likely agent
AOEC list has two “quats” as AOEC list has two “quats” as recognized asthmagensrecognized asthmagens
Hospital kept two workers out of the Hospital kept two workers out of the OR for 6-7 monthsOR for 6-7 months
Changed cleaning chemical from HB Changed cleaning chemical from HB Quat to PCMX, workers returned—Quat to PCMX, workers returned—only temporary solutiononly temporary solution
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Quaternary ammonium compound Quaternary ammonium compound (“quats”) most likely agent(“quats”) most likely agent
Two “quats” Two “quats” recognized recognized asthmagensasthmagensTwo workers out of Two workers out of the OR for 6-7 the OR for 6-7 monthsmonthsChanged cleaning Changed cleaning chemical from HB chemical from HB Quat to PCMX, Quat to PCMX, workers returned—workers returned—only temporary only temporary solutionsolution
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59 y/o Haitian woman had 59 y/o Haitian woman had episodic shortness of breath episodic shortness of breath while walking, climbing, while walking, climbing, carrying. Recalled symptoms carrying. Recalled symptoms for previous 5 years. Worked for previous 5 years. Worked with cleaning agents as with cleaning agents as housekeeper for 26 years in housekeeper for 26 years in same urban hospital. same urban hospital. Cleaning products contained Cleaning products contained quaternary ammonium quaternary ammonium compounds (quats), phenols.compounds (quats), phenols.
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Public Health Impact of AsthmaPublic Health Impact of Asthma**
20.7 million adults reported asthma (8.9 20.7 million adults reported asthma (8.9 million children)million children)
Adult asthmaAdult asthma– 12.9 million office visits for asthma 12.9 million office visits for asthma – 1.7 million ED visits for asthma1.7 million ED visits for asthma
Children have higher rates than adults, but Children have higher rates than adults, but asthma is an adult diseaseasthma is an adult disease
http://www.cdc.gov/nchs/fastats/asthma.htmhttp://www.cdc.gov/nchs/fastats/asthma.htm
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SSentinel entinel EEvent vent NNotification otification SSystem ystem for for OOccupational ccupational RRisks isks
(SENSOR)(SENSOR)
Active state-based surveillance for ‘sentinel’ Active state-based surveillance for ‘sentinel’
work-related conditionswork-related conditions
Focus on prevention-oriented workplace Focus on prevention-oriented workplace
interventionintervention
Funded by National Institute for Occupational Funded by National Institute for Occupational
Safety and Health (NIOSH)Safety and Health (NIOSH)
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Surveillance case definitionSurveillance case definitionWork-related asthmaWork-related asthma
Health care professional diagnosis Health care professional diagnosis consistent with asthma consistent with asthma
ANDAND
An association between symptoms of An association between symptoms of asthma and workasthma and work
Includes both new onset asthma (OA, Includes both new onset asthma (OA, RADS) and work-aggravated asthmaRADS) and work-aggravated asthma
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Surveillance of Work-Related Surveillance of Work-Related Asthma (WRA)Asthma (WRA)
Mandatory reporting of WRA (confirmed Mandatory reporting of WRA (confirmed and suspected)and suspected)
1993 to present, >1100 cases reported, of 1993 to present, >1100 cases reported, of whom about 600 have been interviewedwhom about 600 have been interviewed
Track industries, occupations and agents Track industries, occupations and agents that cause or exacerbate WRAthat cause or exacerbate WRA
Design interventions to reduce WRADesign interventions to reduce WRA
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Massachusetts Surveillance System for Work-Related Asthma
Hospital Discharges
Heath Care
Provider reportsEmergency Dept
Visits (65 per year)
OHSP
Worker interviewMedical records
Worker follow-up•Educational materials•Resources in state
Employer follow-up
•Worksite investigations
Summary data analysis
Industry-wide interventions
Workers’ comp
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Work-related asthma,1995—2005, Work-related asthma,1995—2005, Massachusetts n=550Massachusetts n=550Health Care WorkersHealth Care Workers
162 cases, 30% of all confirmed cases162 cases, 30% of all confirmed cases
85% of HCW are female85% of HCW are female
88% white88% white
94% work in health care industry94% work in health care industry
Most likely health care worker with WRA is Most likely health care worker with WRA is a nurse, non-smoker, with allergiesa nurse, non-smoker, with allergies
PROVISIONAL DATAPROVISIONAL DATA
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Occupations of health care workers Occupations of health care workers with work-related asthma, n=162with work-related asthma, n=162
NursesNurses 103103Aides/therapistsAides/therapists 17 17 Office workersOffice workers 14 14TechniciansTechnicians 13 13Dental healthDental health 7 7Janitor/FoodJanitor/Food 5 5OtherOther 3 3
PROVISIONAL DATAPROVISIONAL DATA
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HCW v non-HCW, Work-related HCW v non-HCW, Work-related asthma,1995-2005, MA n=550asthma,1995-2005, MA n=550
Health care workersHealth care workersN=162N=162
85% female85% female
88% white88% white
38% ever smoke38% ever smoke
3% currently smoke3% currently smoke
58% allergies58% allergies
57% ER visit57% ER visit
PROVISIONAL DATAPROVISIONAL DATA
Non-health care workerNon-health care workerN=388N=388
46% female46% female
82% white82% white
52% ever smoke52% ever smoke
17% currently smoke17% currently smoke
47% allergies47% allergies
55% ER visit55% ER visit
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Health Care Workers—4 states, Health Care Workers—4 states, 1993-19971993-1997
• 305 of 1,879 cases = 16%305 of 1,879 cases = 16%• Leading exposuresLeading exposures
• Cleaning products 24%Cleaning products 24%• Latex 20%Latex 20%• Glutaraldehyde 9%Glutaraldehyde 9%• Chemicals, NOS 9%Chemicals, NOS 9%• Paints, solvents 7%Paints, solvents 7%
American Journal of Industrial Medicine 47:265-275 (2005) Pechter et al.
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Focus on cleaning productsFocus on cleaning productsRosenman et al 2003 JOEM 45(5):556-63Rosenman et al 2003 JOEM 45(5):556-63
Cleaning Cleaning productproduct
# cases# cases
UnspecifiedUnspecified 104104
BleachBleach 4343
Acids, bases, Acids, bases, oxidizersoxidizers
2323
DisinfectantsDisinfectants 2020
Carpet cleanerCarpet cleaner 1717
Floor stripper/ Floor stripper/ waxwax
1616
AmmoniaAmmonia 1414
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Exposures to cleaning agentsExposures to cleaning agents
Anila BelloAnila BelloSustainable Hospitals Project Sustainable Hospitals Project
Department of Work Department of Work EnvironmentEnvironment
University of Massachusetts University of Massachusetts LowellLowell
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ScopeScope
Cleaning agents serve different Cleaning agents serve different purposespurposes
– Cleaners : remove surface contaminants Cleaners : remove surface contaminants – Disinfectants: destroy microorganisms Disinfectants: destroy microorganisms
– cleaner/disinfectant combination very common cleaner/disinfectant combination very common
Our focus:Our focus:– Cleaning products used for common cleaning Cleaning products used for common cleaning
activities such as : window; counter; washroom; activities such as : window; counter; washroom; and floor cleaningand floor cleaning
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MethodsMethods
Investigated products used in five workplaces Investigated products used in five workplaces Four hospitals Four hospitals One university One university Interviewed environmental health and safety representatives Interviewed environmental health and safety representatives
Collected MSDSs and identified ingredients Collected MSDSs and identified ingredients
Reviewed literatureReviewed literature – Chemical and physical properties Chemical and physical properties – Health effects : respiratory & skin irritation and sensitizationHealth effects : respiratory & skin irritation and sensitization
Prioritized ingredients Prioritized ingredients Toxicity ; Concentration ; Frequency of useToxicity ; Concentration ; Frequency of use
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MethodsMethods
Observed cleaning tasks in the workplaces Observed cleaning tasks in the workplaces
Simulated cleaning tasksSimulated cleaning tasksIn two bathrooms at UML (small and large)In two bathrooms at UML (small and large)Measured temperature and humidityMeasured temperature and humidity mirror cleaning, toilet bowl cleaning and sink cleaning mirror cleaning, toilet bowl cleaning and sink cleaning
Measured airborne exposures Measured airborne exposures Measured with a Direct Reading Instrument Measured with a Direct Reading Instrument Measured with integrated methods: EPA-TO-17Measured with integrated methods: EPA-TO-17
Assessed potential for the dermal exposuresAssessed potential for the dermal exposures DREAM methodDREAM method
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Results: what do they contain?Results: what do they contain? Mixtures of ingredients Mixtures of ingredients
Surfactants, solvents, disinfectants, fragrances etc.Surfactants, solvents, disinfectants, fragrances etc. 50+ ingredients in 18 products50+ ingredients in 18 productsMany irritants and several sensitizers Many irritants and several sensitizers
The most hazardous ingredientsThe most hazardous ingredients Quaternary ammonium compoundsQuaternary ammonium compounds2-buthoxyethanol 2-buthoxyethanol Phenols Phenols AmmoniaAmmoniaEthanolamineEthanolamine
Exposure routes: airborne and dermal exposure Exposure routes: airborne and dermal exposure
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Measurements of air exposures Measurements of air exposures
Cleaning products contain Cleaning products contain volatile volatile semi-volatile semi-volatile and non-volatile compounds and non-volatile compounds
Complex mixtures ; very difficult to measure Complex mixtures ; very difficult to measure
What to measure for ?What to measure for ?TVOCsTVOCsHazardous ingredients such as 2-BE and “quats”Hazardous ingredients such as 2-BE and “quats”Several methods are needed –very expensiveSeveral methods are needed –very expensive
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Measurements techniquesMeasurements techniques
DRI instrumentDRI instrument Integrated sampling Integrated sampling methodmethod
– Sorbent tubes Sorbent tubes – Sampling pumps at Sampling pumps at
60-75 ml/min60-75 ml/min– Analysis GS/MSAnalysis GS/MS
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Results from other studiesResults from other studies(experimental studies) (experimental studies)
It takes long time for the air concentrations to go down to It takes long time for the air concentrations to go down to the background levelthe background level– At least 24 hours for some compounds At least 24 hours for some compounds Reference : Peder Wolkoff et al, Sc.Tot. Env 1998 215:135-156Reference : Peder Wolkoff et al, Sc.Tot. Env 1998 215:135-156
““Risk in cleaning : chemical and physical exposureRisk in cleaning : chemical and physical exposure””
Some compounds such as glycol ethers are released from Some compounds such as glycol ethers are released from the surface after one hour of the applicationthe surface after one hour of the application Reference : Singer et al , Indoor Air 2006 Reference : Singer et al , Indoor Air 2006 16:179-19116:179-191 “ “ Cleaning products and air fresheners :emissions and resulting Cleaning products and air fresheners :emissions and resulting
concentrations of glycol ethers and terpenoids”concentrations of glycol ethers and terpenoids”
Repeated application of the product on the surface causes Repeated application of the product on the surface causes background concentration to build up with timebackground concentration to build up with time Reference : Nazaroff et al, Atm. Env. 2004 38:2841-2865Reference : Nazaroff et al, Atm. Env. 2004 38:2841-2865 “ “Cleaning products and air fresheners :exposure to primary and Cleaning products and air fresheners :exposure to primary and
secondary air pollutants”secondary air pollutants”
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Dermal exposure assessment Dermal exposure assessment
DREAM categoriesDREAM categories
0
20
40
60
80
100
120
140
sink cleaning toilet bowlcleaning
mirrorrcleaning
floor cleaning1
floor cleaning2
Potentail exposure
Emission
Deposition
Transfer
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Skin exposures Skin exposures floor cleaning: new mopping techniquefloor cleaning: new mopping technique
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Exposures to “quats”Exposures to “quats”
Case reports : association of asthma with quats Case reports : association of asthma with quats exposureexposure
How are nurses getting exposed ?How are nurses getting exposed ?
Quats are not volatile compounds !!!Quats are not volatile compounds !!!– Very low concentrations in the air (Vincent et al, 2006)Very low concentrations in the air (Vincent et al, 2006)
Possible exposure routes:Possible exposure routes: important for controlling exposures important for controlling exposures
1.1. Dermal exposureDermal exposure2.2. Re-suspended in the air : through dustRe-suspended in the air : through dust3.3. Aerosolization Aerosolization
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ConclusionsConclusions
Cleaning agents contain irritants and Cleaning agents contain irritants and sensitizerssensitizers
Inhalation and dermal exposures should both be Inhalation and dermal exposures should both be considered for controlling workplace exposuresconsidered for controlling workplace exposures
Air concentrations higher than expected Air concentrations higher than expected Dermal exposure could be primary exposure route for Dermal exposure could be primary exposure route for important hazardous ingredientsimportant hazardous ingredients
At risk : not only cleaning workersAt risk : not only cleaning workers– nurses , doctors and patients nurses , doctors and patients
entering the room after the tasks are performedentering the room after the tasks are performed
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Promotion of DisinfectionPromotion of Disinfection
Cleaning products have added chemicalsCleaning products have added chemicals– Hospitals vs schools and homesHospitals vs schools and homes– ““Remind moms & dads to donate Clorox® Remind moms & dads to donate Clorox®
Disinfecting Wipes to the classroom, but make Disinfecting Wipes to the classroom, but make sure parents bring it themselves! Kids should sure parents bring it themselves! Kids should not be carrying them.” not be carrying them.”
““Fear” messagesFear” messages
When/whereWhen/where
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What do we recommend!What do we recommend!
Use disinfectants only when needed Use disinfectants only when needed Promote cleaning Promote cleaning
When and where is disinfection needed When and where is disinfection needed (hallway floors?)(hallway floors?)
Is disinfection achieved with common Is disinfection achieved with common practices?practices?
10 minute requirements?10 minute requirements?
the more - the better?the more - the better?
Are current disinfectants effective?Are current disinfectants effective?
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What do we recommend!What do we recommend!
Purchase green cleaning products Purchase green cleaning products available for common cleaning activitiesavailable for common cleaning activities
Green seal certified Green seal certified
Purchase safer disinfectants Purchase safer disinfectants
Use effective PPE (Use effective PPE (example glovesexample gloves))
Be aware of health effectsBe aware of health effects