Evaluation of exposure to a new cleaning and disinfection product and symptoms in hospital employees
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Evaluation of exposure to a new cleaning and disinfection product and symptoms in hospital employees

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      The National Institute for Occupational Safety and Health (NIOSH) received a confidential employee request to conduct a health hazard evaluation at a hospital. The request cited concerns about exposure of hospital employees to the sporicidal disinfectant, OxyCide, and described symptoms experienced by employees. Employee symptoms noted in the health hazard evaluation request included burning eyes, nose, and throat; runny nose; cough; headache; dizziness; nausea; nose bleeds; asthma exacerbation; skin burns; and rashes. We performed a walk-through assessment of cleaning product use at the hospital on April 9, 2015, and informally interviewed employees about their cleaning product use and any related health concerns that they may have had. We learned that OxyCide was used predominantly by environmental services staff and that nursing and ancillary staff predominantly used PDI or bleach wipes for routine point of care cleaning activities. We observed that OxyCide was the main cleaning product used by environmental services staff for all surface cleaning duties. Environmental services staff were observed occasionally using other asthmagen-containing products including products containing ethanolamines, bleach, or quaternary ammonium compounds when cleaning glass, general surfaces, or bathroom surfaces. Asthmagens are substances capable of causing asthma. On July 29, 2015, we performed a small-scale air sampling and a post-shift survey of environmental services staff. We collected ten samples, including full-shift, task-based, and 15-minute exposure samples, from employees' breathing zones while they performed regular cleaning tasks. All samples were analyzed for the three chemicals found in OxyCide: hydrogen peroxide, peracetic acid, and acetic acid. All 15-minute air samples for acetic acid were below the NIOSH recommended short-term exposure limit of 15 parts per million (ppm). All 15-minute and task-based exposure air samples for hydrogen peroxide and peracetic acid were below the limit of detection for the instrument used to detect the analyte. The limit of detection 4 ug of hydrogen peroxide per sample and 2 ug of peracetic acid per sample. We combined all full-shift time-weighted average samples and post-shift survey results from the small-scale survey on July 29 with the results from our full environmental survey from September 8-11, 2015. We returned in August 2015 and administered a voluntary health and work history questionnaire to 79 environmental services staff and 84 non-environmental services staff for a total of 163 hospital employees. Non-environmental services staff were recruited from the same areas and departments of the hospital where environmental services staff were located. Questions addressed respiratory and dermatological symptoms, asthma and other diagnoses, smoking history, work history and practices, and demographic information. On September 8-11, 2015, we returned to perform full-shift air sampling on environmental services staff performing cleaning activities. We collected 45 full-shift air samples for hydrogen peroxide, peracetic acid, and acetic acid from the daylight, evening, and night shift environmental services staff. We also administered a voluntary post-shift survey identical to the post-shift survey used in July 2015 to all staff who participated in the air sampling survey. We observed environmental services staff while they performed their regular cleaning duties and noted task duration, cleaning product use and duration, and use of any personal protective equipment. We also assessed the ventilation systems in areas of the hospital where frequent cleaning was observed. The highest full-shift time-weighted average exposures to hydrogen peroxide, peracetic acid, and acetic acid were observed in the Womancare Birth Center, Birth Center Triage, Birth Center Operating Rooms, and the Medical-Surgical areas. Full-shift time-weighted average exposure levels for hydrogen peroxide, peracetic acid, and acetic acid ranged from 5.5 parts per billion (ppb) -- 511.4 ppb for hydrogen peroxide, 1.1 ppb -- 48.0 ppb for peracetic acid, and 6.7 ppb -- 530.3 ppb for acetic acid. No full-shift samples were below the limit of detection. All full-shift time-weighted average air samples for hydrogen peroxide and acetic acid were below established U.S. occupational exposure limits. The OSHA permissible exposure limit and NIOSH recommended exposure limit is 1 ppm for hydrogen peroxide and 10 ppm for acetic acid. To date, no full-shift time-weighted average occupational exposure limit for peracetic acid has been established in the United States. The most commonly reported symptoms in the health and work history questionnaire were nasal problems and watery eyes. Forty-two percent of health and work history questionnaire participants reported nasal problems and 40% of all questionnaire participants reported watery eyes. Other commonly reported health outcomes included, asthma-like symptoms (28%), skin problems (19%), and wheeze (16%). Among reported symptoms, some were described to be work-related, as they improved away from the facility. OxyCide users reported higher prevalence of work-related health outcomes including cough, shortness of breath, asthma-like symptoms, asthma attack, use of asthma medicine, asthma symptoms, use of allergy medicine, nasal problems, and skin problems, with wheeze and watery eyes being significantly higher in OxyCide users than non-users. Nasal and eye irritation were also the most frequently reported symptoms in the post-shift survey of acute symptoms. We observed increases in work-related acute upper and lower airway symptoms in employees exposed to hydrogen peroxide, peracetic acid, and acetic acid vapors. Increased exposure to hydrogen peroxide, peracetic acid, and acetic acid was significantly associated with increases in acute nasal and eye irritation. For employees who participated in our air sampling survey as well as the health and work history questionnaire, shortness of breath on level ground was also significantly associated with increased exposure to hydrogen peroxide, peracetic acid, and acetic acid. We provide several means to reduce employee exposure to OxyCide. We recommend that management customize the use of sporicidal disinfectants like OxyCide to areas of high risk for healthcare-acquired infections and minimize the use of sporicidal disinfectants on non-critical surfaces and in non-patient areas. We also recommend that management provide workplace accommodations for employees who develop symptoms related to the use of sporicidal and high-level disinfectants. Management should also ensure that all heating, ventilation, and air-conditioning systems are functioning well and meet all applicable ASHRAE standards. Additional details and recommendations to reduce employee exposure to OxyCide liquids, vapors, and mists are provided in this report.

      Recommended citation for this report: NIOSH [2017]. Evaluation of exposure to a new cleaning and disinfection product and symptoms in hospital employees. By Hawley B, Casey M, Cummings K, Edwards N, Johnson A, Cox-Ganser J. Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, NIOSH HHE Report No. 2015-0053-3269.

      NIOSHTIC No 20049145

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