Peracetic Acid Disinfectant CleanersPatient & Employee Safety Considerations

By: Daniel C. Maser, MS, CIH, CSP, ROH, FAIHA

Enviroair Consultants, Inc.

April 2019

Background Information

Telephone Call in 2017:

Concern about this new disinfectant called PAA.

Suppose to be nonhazardous – Mfg. almost implies one can drink it.

Receiving comments and concerns from cleaning staff – respiratory irritation!

Desire to do air testing to see what concentrations employees are being exposed.

Learning About PAA Peracetic acid (CH3C(O)OOH) is a mixture of acetic acid

(CH3COOH) and hydrogen peroxide (H2O2) in a watery solution.

PAA has a strong vinegar-like smell around 0.1 ppm (white vinegar is acetic acid) but becomes significantly irritating above about 1 ppm.

Peracetic acid is a very effective antimicrobial compound against bacteria, mold and viruses, even more effective than hydrogen peroxide.

Extensively used for treatment of fruits, vegetables, tree nuts, cereal grains, herbs, spices, beer bottles, used as a sterilant during the cleaning of endoscopes and other medical devices, and in meat production industry since it leaves no residue and decomposes rapidly to acetic acid, oxygen and water.

PAA Disinfectants in Healthcare- “The New Clean”

4

• Face of the “New Clean” [Tradenames: Oxycide, Peridox, Steriplex SD+: also contains ethanol-30%]

• All of these products have two active ingredients:

PERACETIC ACID (PAA) breaks down outer membrane of the spore, bacteria or virus

HYDROGEN PEROXIDE destroys the inner component (DNA, proteins)

Note: They also contain acetic acid to help stabilize the product.

• Chemical Properties: Strong oxidizer and corrosive.

• Benefits- good disinfectant and sanitizer; sporicidal, no-rinsing required and environmentally friendly.

Slide contents provided by Terry Fisk, Non-Clinical Loss Control Director, Trinity Health

Learning More About PAA

• As discussed, the two key strengths of peracetic acid are its effectiveness as a biocide and its high reactivity which causes it to quickly degrade to harmless byproducts.

• This high reactivity though presents a risk to workers using PAA for food processing environment, and anecdotal reports indicate that some workers have been adversely affected by exposure to PAA and similar chemicals.

• In the March, 2017 Federal Register, NIOSH states that acute exposure to PAA is irritating to the eyes, respiratory tract, and skin. PAA is a strong sensory irritant considered to be more potent than acetic acid or hydrogen peroxide, and indicated that healthcare workers may have experienced asthma associated with workplace exposures to PAA.

What Are The Exposure Limits For PAA

• OSHA (MIOSHA) has not yet promulgated permissible exposure limits for PAA.

• In 2014 American Conference of Government Industrial Hygienists (ACGIH) issued a threshold limit value short-term exposure limit (STEL) for PAA, calculated as a TWA over 15 minutes of 0.4 ppm.

• In August 2016 NIOSH proposed an IDLH of 0.64 ppm for PAA, but in March 2017 published in the Federal Register that they are now proposing a new IDLH of 0.55 ppm. (See Federal Register Vol. 82, No.43 Tuesday, March 7, 2017)

(The term immediately dangerous to life or health (IDLH) is defined by NIOSH as exposure to airborne contaminants that is "likely to cause death or immediate or delayed permanent adverse health effects or prevent escape from such an environment.“)

EPA Suggested Exposure Limits for Public• The EPA has issued Acute Exposure Guideline Levels (AEGLs) for

peracetic acid. There are three levels of AEGL corresponding to the severity of symptoms of exposure. These levels can be loosely translated as:• irritation (AEGL -1), • disabling irritation or permanent injury (AEGL-2), • and serious injury or death (AEGL-3).

10 minute 30 minute 60 minute 4 hour 8 hour

AEGL–1 0.17 ppm 0.17 ppm 0.17 ppm 0.17 ppm 0.17 ppm

AEGL–2 0.5 ppm 0.5 ppm 0.5 ppm 0.5 ppm 0.5 ppm

AEGL–3 19 ppm 9.6 ppm 4.8 ppm 2 ppm 1.3 ppm

Acetic Acid & Hydrogen Peroxide Exposures

• NIOSH states that Exposure to the vapors of acetic acid causes eye, skin, mucous membrane, and upper respiratory tract irritation.

• NIOSH states that Exposure to vapor from hydrogen peroxide may cause extreme irritation of the eyes, nose, and throat.

• Exposure Limits:

* ACGIH provides directions in Appendix E of the TLV book for calculating short term Excursion exposure limit for chemicals without a STEL or Ceiling value.

Chemical MI-OSHA ACGIH NIOSH

Acetic Acid 10 ppm PEL (8-hr. TWA) 10 ppm TLV (8-hr. TWA)15 ppm STEL (15 Min)

10 ppm REL (8-hr. TWA) 15 ppm STEL (15 Min)

Hydrogen Peroxide 1 ppm PEL (8-hr. TWA) 1 ppm TLV (8-hr. TWA)5 ppm 15 Min Excursion*

1 ppm REL (8-hr. TWA)

Estimations of Airborne Exposure Issues

Dispensing OxyCide™ From EcoLab Dispenser. (27.5% Hydrogen peroxide, 5.8% PAA, 8% Acetic acid).

8% Acetic Acid has pH value of Less Than 2.4

27.5% Hydrogen peroxide has pH value of ~ 10.5

5.8% Peracetic Acid mix has pH value of ~ 3.06

~pH 7.5

~pH 5 ~pH 5.5

Lungs ~pH 6.69

Learning More About PAA

• Published in Oxford Occupational Medicine March 27, 2019 - A 48-year-old man employed as a mycologist and environmental microbiologist at a Birmingham city hospital, UK, exhibited following an acute exposure to PAA-HP mixture causing lacrimation, burning optic pain and headache. He had also experienced symptoms suggestive of OA for the preceding 10 months, and the diagnosis was confirmed through OASYS analysis of serial peak expiratory flow measurements. He had been exposed to PAA-HP mixture whilst working in the endoscopy department for 12 months prior to the acute episode, and a subsequent specific inhalation challenge test was positive with a late asthmatic response to PAA-HP mixture.

• Conclusion – “This case provides evidence for a sensitization mechanism in OA caused by PAA-HP mixture.” (https://doi.org/10.1093/occmed/kqz032)

Oxford Academic

Investigate Recommended Sampling Methods

• For PAA use two coated filters preloaded in a 25 mm filter cassette (SKC-225-9030) and one 800 mg Silica sorbent tube (SKC-226-193-UC) at 1 Liter per min (L/min) for 15 minutes.

• For Hydrogen Peroxide use two coated filters preloaded in a 25 mm filter cassette (SKC-225-9030) at 2 Liter L/min for 30 minutes.

• Acetic Acid use a 150 mg charcoal tube at 1 to 0.5 l/min for 20 to 45 minutes respectively.

**(Discuss Sample Media Methods & NIOSH Comments about PAA – See NIOSH HHE Report No. 2015-0130-3290 Sept. 2017)

Investigate Direct Read Sampling Methods

• Most of the real time sampling methods identified for PAA is either portable GC, electrochemical sensor, Far Ultraviolet Spectrophotometry, or Infrared Spectrophotometry. Only the electrochemical sensor approach seamed plausible and portable enough, but could only sample PAA or hydrogen peroxide or acetic acid; not PAA, hydrogen peroxide and acetic acid at the same time.

• As we pointed out sampling the three chemicals at the same time is important?

Direct Read Sampling Selected• The Gasmet DX4040 Fourier Transform Infrared

Spectroscopy (FTIR) analyzer is designed for on-site measurements of various organic and inorganic compounds at low concentrations in ambient air. Analysis results of up to 25 pre-calibrated compounds are displayed on screen of an industrial-grade PDA with validated results in 25 seconds.

• Gasmet Extended Reference Library including over 5000 gases

• Identification of gas components using library search routine

• Possibility to use NIST library of over 10,000 chemicals

Thus we could sample all three chemicals concentrations real-time at the same time!

Sampling and Results During Dispensing

• Concentrate has pH of 1.0, but diluted mix (3 oz. per gallon of water) used by cleaning staff has an approximate pH of 3.06. SDS does not recommend any PPE for diluted mix.

• Staff required to wear chemical goggles and gloves when handling concentrate.

• Dispensing process took ~ 5 minutes

Results: PAA=0.09 ppm, HP=0.0 ppm, AA=0.11 ppm

Patient Room PAA Cleaning

• Environmental Service Employee cleans 16 Patient Rooms per shift, of which 4 are Discharge Patient Rooms (DPR).

• Take 30 to 45 minutes to clean DPR.

• For DPR all horizontal surfaces cleaned except floor.

• A C-Diff DPR takes longer since all surfaces are cleaned.

• Only PPE = gloves

Patient Discharge Room Sampling Results• We collected samples from 3 different personnel

cleaning PDRs, one of the three was cleaned as if it were a C-Diff Room.

• Results consistently suggested 2 sample locations caused elevated breathing zone readings: Cleaning around toilet and cleaning seat in window Bay.

• Results:

And You feel you had a bad day!

CleanType

Window Bay Result Bath Toilet Result ACGIH NIOSH

PAA HP AA PAA HP AA PAA HP AA PAA HP AA

PDR 0.5 0.21 0.29 0.49 1.42 0.740.4 5 15 0.55 - 15

C-Diff 0.41 0.35 0.39 0.78 2.01 0.86

Exposures Based on Additive EffectsAppendix E of the ACGIH TLV Book explains about assessing employee exposures for mixtures where the chemicals have similar toxicological effects. For this one, it is irritation to the respiratory tract.

𝑪𝟏

𝑻𝑳𝑽𝟏+

𝑪𝟐

𝑻𝑳𝑽𝟐+

𝑪𝟑

𝑻𝑳𝑽𝟑…+

𝑪𝒏

𝑻𝑳𝑽𝒏=

If the sum of the mixture exceeds unity (i.e., 1.0); the exposure limit for the mixture is considered to be exceeded.

Discharge Patient Rooms (DPR) Result: 0.78 (below Unity)*

C-Diff DPR Result: 1.18 (above Unity)

*Using the Action Level concept, if results are greater the 0.5 the limit, it is not possible to be 95% confident that an overexposure will not occur.

Cleaning with Paridox RTU™

Paridox RTU™ was ~ 4.8% Hydrogen Peroxide, ~10% Acetic acid and ~0.29% PAA. Has a pH of ~1.9. Is used without dilution!

Used for Inpatient Pharmacy Clean Room and Ante Room Cleaning.

SDS suggests it will cause severe irritation to skin and eyes. With this information in mind the mucus membranes and respiratory tract will also be severely irritated from the vapors.

• PPE used by Cleaning Personnel was 3M R95 Model 8246 single use respirator. This respirator is designed for protection from particulate and nuisance levels of acid gases. Employee also donned chemical gloves and chemical goggles once in the Ante Room.

• Areas where highest airborne levels found: In Clean Room – while cleaning walls behind hoods –

PAA = 0.59 ppm, HP = 1.40 ppm, AA = 6.38 ppm Unity Result: 1.31

In Ante Room – wall cubbies for paperwork -PAA = 0.91 ppm, HP = 2.57 ppm, AA = 7.38 ppmACGIH PAA 15 min. STEL also exceeded – Result: 0.477 ppm Unity Result: 1.48

Cleaning with Paridox RTU™ - Cont.

Summary NIOSH suggests PAA may be associated with chemical asthma

There is no fully validated sampling methods for PAA.

PAA has proven to be an important cleaner for controlling Hospital Microorganisms

Health issues associated with airborne exposures of PAA during hospital cleaning is poorly understood.

Hospital staff cleaning with PAA need to use better PPE to help prevent possible job related injury or illness.

Oxford Medical suggest Hospital Cleaning Staff are at risk of overexposure & OA

More IH exposure studies are needed to gain a better understanding of risk to hospital staff and patients.

Thank You!

Questions