1. OCCUPATIONAL ASTHMA IN HEALTHCARE Thomas P. Fuller ScD, CIH, MSPH, MBA Tech Environmental, Waltham, MA

2. Asthma SymptomsCauses Routes of Exposure (inhalation, skin, GI) Exposure Pathways TreatmentPrognosis Relationship to respiratory sensitization

3. Asthma Definition: Inflamation, restricted airways, increased IgE antibodies, immunologic sensitization Bronchial challenge, restricted air flow, asthma medicine, airway hyperresponsiveness, subepitheleal fibrosis Wheezing, whistling, reduced FEV 1, SOB, chest tightness, chronic inflammation, death Variable airway narrowing (McCunney)

4. ASTHMA Work Related Asthma (WRA) Occupational Asthma (OA)(10-23% new cases) (HCWH) 1.7 to over 33 % of adult populations in industrialized countries (A. Johnson,T. Ng, M. Kogevinas, Brooks, Friedman-Jimenez) Pharmacologic, immunologic, inflammatory

5. Prognosis Patients who remain in the same job and continue to be exposed to the same causal agent after diagnosis generally worsen with time. (Venables) Avoidance is the best management technique. Functional improvement is associated with exposure duration, concentration, and time away from exposure. Effects can last for years.

6. Materials that cause Asthma ChemicalsCleanersMolds/Fungi Animals (dander, droppings, feathers, hair) Pollen/GrassesGlutaraldehydeFormaldehydePerfumes Grain, flour Metals Molecular Weight (hi,lo) Tobacco smoke Hydroquinone Acrylic compounds (methacrylate) LatexEtO Alcohol, Phenol, Hydrogen Peroxide, Hydrogen Chloride VOCsXyleneEnzymesGlue Quatenary ammonia

7. Departments in Healthcare RadiologyEndoscopyLaboratories Animal Care Centers Nursing Central Sterile MortuaryHousekeepingFacilitiesDietary

8. Jobs in Healthcare X-ray Tech., Darkroom Tech. Nurses and support staff Lab workers Animal Handlers Painters Maintenance staff BakersGroundskeepers

9. Exposure Matrix Helps identify workers and departments with exposures to Asthma causing agents.

10. Exposure Reduction Alternatives SubstitutionEliminationControl Administrative Measures –Transfers –Training –Job Rotation –Medication

11. Cases - Problems Review Materials used Observe Activities Assess Exposures – –Routes (skin, ingestion, inhalation) –Levels (concentration, quantity, existing controls) –Measures (monitoring –air, surface, biological) Controls – Engineering, Administrative, PPE Alternatives

15. Alternative Pilot Review alternative products and processes Determine selection acceptance criteria Select an alternative Implement alternative and observe changes Grade the new process/product Develop procedures and institute changes Train workers on new materials and tasks.

16. Floor Care Pilot Worker history – asthmatic response to floor wax stripping (numerous other complaints), Product and practices (monoethanolamine, sodium hydroxide, NFPA Health = 3), Every six months, general exhaust in area, OSHA exposure limits.

17. Floor Care Alternatives Replaced with cationic surfactant lactate mixture (NFPA Health rating of 1), Less volatile, No worker complaints, no general ventilation requirements, Gets floors just as clean, Slightly more expensive, No air monitoring required (per se), No OSHA limits to meet.

18. Gluteraldehyde Project 29 hospital sites with Glutaraldehyde, Worker exposures and symptoms, Lost worktime and compensation, OSHA limits and monitoring requirements, Often misused or uncontrolled.

19. Glutaraldehyde Alternatives Replaced with Ortho-opthamaldehydes, Somewhat safer, no OSHA limits or monitoring requirements, No health related symptoms reported (9 mos. after), FDA approved high level disinfectant, Slightly more expensive per bottle, Process took over 9 months, No more calls or complaints, Only two sites still use Glut.

20. Operating Room Nurses Nurses with OA from using disinfectants with Phenols, Changed to Quaternary Ammonium disinfectants which led to other nurses with OA, Now observing workplace practices and reviewing alternative products (ongoing).

21. Unfortunate Lessons Tricky people will switch back and revert to old products and practices when no one is looking (workers, supervisors, and managers), Despite the months and sometimes years it takes to prove that a new product works and to get it approved people and departments can get new “bad” products in without going through the review process,

22. Unfortunate Lessons People may also misuse the new “safer” product in such a manner that causes “symptoms” and then people relate those to the new product (nothing is perfect), Once a new “worse” product or method is used the first indicator to the Safety Office is often a report of symptoms !

23. Final Word! Keep fighting – it is worth fighting for.

24. Thank You.