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

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

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

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

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

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

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

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.

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

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)

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

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

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

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

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

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

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.

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

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

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

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

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

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

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

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

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”

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

Skin exposures Skin exposures floor cleaning: new mopping techniquefloor cleaning: new mopping technique

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

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

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

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?

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