1. Preventing Workplace Asthma: Consider the Cleaning Products June 7, 2007 Elise Pechter MPH, CIH Massachusetts Depart Public Health Anila Bello MS Doctoral Candidate University of Massachusetts Lowell

2. Outline Case studies Asthma –Work-related asthma –Focus on health care workers Exposure to cleaning agents –Inhalation –Dermal Disinfectants marketed Recommendations

3. Incident — Small community hospital Cluster of respiratory problems among operating room staff 9/2005 18 employees to Employee Health 2 employees persistent WAA, reported to OHSP as WRA (October 2005). Unable to return to work in OR

4. Incident and causes Persistent leaks into OR Planned repair on HVAC Moved equipment in preparation for relocation Planned repair of air- handling unit Extra OR cleaning Prompt action by hospital

5. Four Possible Exposures Silicone sealant used in repairing AHU Fungi, mold, bacteria from previous leaks Dust from moving OR equipment HB Quat and other disinfectants and cleaners used in OR

6. Quaternary ammonium compound ( “ quats ” ) most likely agent AOEC list has two “quats” as recognized asthmagens Hospital kept two workers out of the OR for 6-7 months Changed cleaning chemical from HB Quat to PCMX, workers returned— only temporary solution

7. Quaternary ammonium compound ( “ quats ” ) most likely agent Two “quats” recognized asthmagens Two workers out of the OR for 6-7 months Changed cleaning chemical from HB Quat to PCMX, workers returned— only temporary solution

8. 59 y/o Haitian woman had episodic shortness of breath while walking, climbing, carrying. Recalled symptoms for previous 5 years. Worked with cleaning agents as housekeeper for 26 years in same urban hospital. Cleaning products contained quaternary ammonium compounds (quats), phenols.

9. Public Health Impact of Asthma * 20.7 million adults reported asthma (8.9 million children) Adult asthma –12.9 million office visits for asthma –1.7 million ED visits for asthma Children have higher rates than adults, but asthma is an adult disease http://www.cdc.gov/nchs/fastats/asthma.htm

10. Sentinel Event Notification System for Occupational Risks (SENSOR) Active state-based surveillance for ‘sentinel’ work-related conditions Focus on prevention-oriented workplace intervention Funded by National Institute for Occupational Safety and Health (NIOSH)

11. Surveillance case definition Work-related asthma Health care professional diagnosis consistent with asthma AND AND An association between symptoms of asthma and work Includes both new onset asthma (OA, RADS) and work-aggravated asthma

13. Surveillance of Work-Related Asthma (WRA) Mandatory reporting of WRA (confirmed and suspected) 1993 to present, >1100 cases reported, of whom about 600 have been interviewed Track industries, occupations and agents that cause or exacerbate WRA Design interventions to reduce WRA

14. Massachusetts Surveillance System for Work-Related Asthma Hospital Discharges Heath Care Provider reports Emergency Dept Visits (65 per year) OHSP Worker interview Medical records Worker follow-up Educational materials Resources in state Employer follow-up Worksite investigations Summary data analysis Industry-wide interventions Workers’ comp

15. Work-related asthma,1995—2005, Massachusetts n=550 Health Care Workers 162 cases, 30% of all confirmed cases 85% of HCW are female 88% white 94% work in health care industry Most likely health care worker with WRA is a nurse, non-smoker, with allergies PROVISIONAL DATA

16. Occupations of health care workers with work-related asthma, n=162 Nurses103 Aides/therapists 17 Office workers 14 Technicians 13 Dental health 7 Janitor/Food 5 Other 3 PROVISIONAL DATA

17. HCW v non-HCW, Work-related asthma,1995-2005, MA n=550 Health care workers N=162 85% female 88% white 38% ever smoke 3% currently smoke 58% allergies 57% ER visit PROVISIONAL DATA Non-health care worker N=388 46% female 82% white 52% ever smoke 17% currently smoke 47% allergies 55% ER visit

18. Health Care Workers—4 states, 1993-1997 305 of 1,879 cases = 16% 305 of 1,879 cases = 16% Leading exposures Leading 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.

19. Focus on cleaning products Rosenman et al 2003 JOEM 45(5):556-63 Cleaning product # cases Unspecified104 Bleach43 Acids, bases, oxidizers 23 Disinfectants20 Carpet cleaner 17 Floor stripper/ wax 16 Ammonia14

20. Exposures to cleaning agents Anila Bello Sustainable Hospitals Project Department of Work Environment University of Massachusetts Lowell

21. Scope Cleaning agents serve different purposes –Cleaners : remove surface contaminants –Disinfectants: destroy microorganisms –cleaner/disinfectant combination very common Our focus: Our focus: –Cleaning products used for common cleaning activities such as : window; counter; washroom; and floor cleaning

22. Methods Investigated products used in five workplaces Four hospitals One university Interviewed environmental health and safety representatives Collected MSDSs and identified ingredients Reviewed literature –Chemical and physical properties –Health effects : respiratory & skin irritation and sensitization Prioritized ingredients Toxicity ; Concentration ; Frequency of use

23. Methods Observed cleaning tasks in the workplaces Simulated cleaning tasks In two bathrooms at UML (small and large) Measured temperature and humidity mirror cleaning, toilet bowl cleaning and sink cleaning mirror cleaning, toilet bowl cleaning and sink cleaning Measured airborne exposures Measured with a Direct Reading Instrument Measured with integrated methods: EPA-TO-17 Assessed potential for the dermal exposures DREAM method

24. Results: what do they contain? Mixtures of ingredients Surfactants, solvents, disinfectants, fragrances etc. 50+ ingredients in 18 products 50+ ingredients in 18 products Many irritants and several sensitizers The most hazardous ingredients Quaternary ammonium compounds 2-buthoxyethanolPhenolsAmmoniaEthanolamine Exposure routes: airborne and dermal exposure

25. Measurements of air exposures Cleaning products contain volatilesemi-volatile and non-volatile compounds Complex mixtures ; very difficult to measure What to measure for ? TVOCs Hazardous ingredients such as 2-BE and “quats” Several methods are needed –very expensive

26. Measurements techniques DRI instrument Integrated sampling method –Sorbent tubes –Sampling pumps at 60-75 ml/min –Analysis GS/MS

27. Results from other studies (experimental studies) It takes long time for the air concentrations to go down to the background level –At least 24 hours for some compounds Reference : Peder Wolkoff et al, Sc.Tot. Env 1998 215:135-156 Reference : Peder Wolkoff et al, Sc.Tot. Env 1998 215:135-156 “Risk in cleaning : chemical and physical exposure” “Risk in cleaning : chemical and physical exposure” Some compounds such as glycol ethers are released from the surface after one hour of the application Reference : Singer et al, Indoor Air 2006 16:179-191 Reference : Singer et al, Indoor Air 2006 16:179-191 “ Cleaning products and air fresheners :emissions and resulting concentrations of glycol ethers and terpenoids” “ Cleaning products and air fresheners :emissions and resulting concentrations of glycol ethers and terpenoids” Repeated application of the product on the surface causes background concentration to build up with time Reference : Nazaroff et al, Atm. Env. 2004 38:2841-2865 Reference : Nazaroff et al, Atm. Env. 2004 38:2841-2865 “Cleaning products and air fresheners :exposure to primary and secondary air pollutants” “Cleaning products and air fresheners :exposure to primary and secondary air pollutants”

28. Dermal exposure assessment DREAM categories

29. Skin exposures floor cleaning: new mopping technique

30. Exposures to “quats” Case reports : association of asthma with quats exposure How are nurses getting exposed ? Quats are not volatile compounds !!! –Very low concentrations in the air (Vincent et al, 2006) Possible exposure routes: important for controlling exposures important for controlling exposures 1.Dermal exposure 2.Re-suspended in the air : through dust 3.Aerosolization

31. Conclusions Cleaning agents contain irritants and sensitizers Inhalation and dermal exposures should both be considered for controlling workplace exposures Air concentrations higher than expected Dermal exposure could be primary exposure route for important hazardous ingredients At risk : not only cleaning workers –nurses, doctors and patients entering the room after the tasks are performed

32. Promotion of Disinfection Promotion of Disinfection Cleaning products have added chemicals –Hospitals vs schools and homes –“Remind moms & dads to donate Clorox® Disinfecting Wipes to the classroom, but make sure parents bring it themselves! Kids should not be carrying them.” “Fear” messages When/where

34. What do we recommend! Use disinfectants only when needed Promote cleaning When and where is disinfection needed (hallway floors?) Is disinfection achieved with common practices? 10 minute requirements? the more - the better? Are current disinfectants effective?

35. What do we recommend! Purchase green cleaning products available for common cleaning activities Green seal certified Purchase safer disinfectants Use effective PPE ( example gloves ) Be aware of health effects