Occupational Respiratory Allergic Diseases in Healthcare Workers

Respiratory Flora Intervention: A New Strategy for the Prevention and Treatment of Occupationally Related Respiratory Allergy in Healthcare Workers

Occupational allergic respiratory disease in healthcare workers due to occupational exposure has received widespread attention. At the same time, evidence of altered respiratory flora associated with the development of allergy has been found in relevant epidemiologic studies. It is of concern that the composition of nasopharyngeal flora in healthcare workers differs significantly from that of non-healthcare workers due to occupational factors, with a particularly high prevalence of carriage of pathogenic and drug-resistant bacteria. Recent studies have found that interventions with upper respiratory tract probiotics can significantly reduce the incidence of respiratory allergies and infections. We searched PubMed and other databases to describe the burden of allergic respiratory disease and altered respiratory flora in healthcare workers in this narrative review, and we summarize the mechanisms and current state of clinical research on the use of flora interventions to ameliorate respiratory allergy, with the aim of providing a new direction for protecting the respiratory health of healthcare workers.

Inconsistent health hazard information across safety data sheets for substances in cleaning products used in healthcare centres

Safety Data Sheets (SDSs) are used to inform downstream users of any hazardous substances in chemical products and advise on how to manage the risks from using these products. It is therefore important that information on the SDS is accurate and consistent. This study investigates the accuracy and consistency of hazard information included in the SDSs of cleaning products used in the healthcare sector in England and Wales. Data on cleaning products used in the National Health Service (NHS) in England and Wales and their chemical composition and any hazard information (as H-statements) were collected from the products' SDSs obtained from the NHS supply online catalogue. By each hazard, mainly respiratory hazards, the number of hazardous substances specified as hazardous in all SDSs was identified. Moreover, we investigated hazard characteristics of substances identified by only SDS (at least one SDS) or only through Harmonised Classifications and Labeling (CLH) or by SDS and through CLH simultaneously. In total, 229 unique chemical substances were found in 473 cleaning products' SDSs. All 4 respiratory sensitisiers were identified in all SDSs and through CLH. However, only 14 of the 25 respiratory irritants (56.0 %) were consistently labelled across all SDSs. Although respiratory irritation characteristics of 3 substances were classified through CLH, it was not identified by any of the relevant SDSs. Substantially incorrect and inconsistent health hazard information for the same substances was identified across SDSs. Therefore, healthcare workers and their managers may not receive accurate information on the presence of and potential for exposure to hazardous substances in the cleaning products they are using.

Occupational inhalation exposure during surface disinfection-exposure assessment based on exposure models compared with measurement data

BACKGROUND

For healthcare workers, surface disinfections are daily routine tasks. An assessment of the inhalation exposure to hazardous substances, in this case the disinfectant´s active ingredients, is necessary to ensure workers safety. However, deciding which exposure model is best for exposure assessment remains difficult.

OBJECTIVE

The aim of the study was to evaluate the applicability of different exposure models for disinfection of small surfaces in healthcare settings.

METHODS

Measurements of the air concentration of active ingredients in disinfectants (ethanol, formaldehyde, glutaraldehyde, hydrogen peroxide, peroxyacetic acid) together with other exposure parameters were recorded in a test chamber. The measurements were performed using personal and stationary air sampling. In addition, exposure modelling was performed using three deterministic models (unsteady 1-zone, ConsExpo and 2-component) and one modifying-factor model (Stoffenmanager®). Their estimates were compared with the measured values using various methods to assess model quality (like accuracy and level of conservatism).

RESULTS

The deterministic models showed overestimation predominantly in the range of two- to fivefold relative to the measured data and high conservatism for all active ingredients of disinfectants with the exception of ethanol. With Stoffenmanager® an exposure distribution was estimated for ethanol, which was in good accordance with the measured data.

IMPACT STATEMENT

To date, workplace exposure assessments often involve expensive and time consuming air measurements. Reliable exposure models can be used to assess occupational inhalation exposure to hazardous substances, in this case surface disinfectants. This study describes the applicability of three deterministic and one modifying-factor model for disinfection of small surfaces in healthcare settings, in direct comparison to measurements performed and will facilitate future exposure assessments at these workplaces.

Antiviral Natural Products, Their Mechanisms of Action and Potential Applications as Sanitizers and Disinfectants

Plant extracts, natural products and plant oils contain natural virucidal actives that can be used to replace active ingredients in commercial sanitizers and disinfectants. This review focuses on the virucidal mechanisms of natural substances that may exhibit potential for indoor air and fomite disinfection. Review of scientific studies indicates: (1) most natural product studies use crude extracts and do not isolate or identify exact active antiviral substances; (2) many natural product studies contain unclear explanations of virucidal mechanisms of action; (3) natural product evaluations of virucidal activity should include methods that validate efficacy under standardized disinfectant testing procedures (e.g., carrier tests on applicable surfaces or activity against aerosolized viruses, etc.). The development of natural product disinfectants requires a better understanding of the mechanisms of action (MOA), chemical profiles, compound specificities, activity spectra, and the chemical formulations required for maximum activity. Combinations of natural antiviral substances and possibly the addition of synthetic compounds might be needed to increase inactivation of a broader spectrum of viruses, thereby providing the required efficacy for surface and air disinfection.

Work-related allergy and asthma associated with cleaning agents in health workers in Southern African tertiary hospitals

BACKGROUND

Health workers (HWs) are exposed to diverse cleaning agents in large hospitals. This study determined the prevalence of work-related symptoms, allergic sensitization, and lung function abnormalities in HWs of two tertiary hospitals in Southern Africa.

METHODS

A cross-sectional study of 699 HWs (South Africa: SAH, n = 346; Tanzania: TAH, n = 353) was conducted. Health outcomes were assessed using a standardized ECRHS questionnaire, immunological tests (specific IgE antibody to common aero-allergens and to occupational allergens: natural rubber latex [NRL]  Hev b5 and Hev b6.02, chlorhexidine, and ortho-phthalaldehyde [OPA]), spirometry [pre-and post- bronchodilator], methacholine challenge, and fractional exhaled nitric oxide (FeNO).

RESULTS

A large proportion of participants (78%) were women. Median age was 42 years, with 76% nurses, 12% cleaners, and 5% administrative workers. Current smoking was more common in SAHWs (12%) than TAHWs (1%). The overall prevalence of doctor-diagnosed asthma was 7%. Atopy was present in 43% of HWs, while 4% were sensitized to OPA, 2% to NRL, and 1% to chlorhexidine. Prevalence of work-related ocular-nasal symptoms (16%) was higher than skin (12%) and chest (7%) symptoms. TAHWs had significantly lower mean lung volumes, higher degrees of significant airflow obstruction and impaired lung function. The prevalence of bronchial hyperresponsiveness in SAHWs (14%) was high. Overall, 23% of HWs had abnormal FeNO; 6% having high (>50 ppb) levels. FeNO was positively associated with sensitization to occupational allergens, primarily OPA and NRL.

CONCLUSIONS

HWs from both hospitals had similar prevalence of work-related respiratory symptoms. Sensitization to OPA and NRL appears to be contributing to allergic airway inflammation in these HWs.

Sleep, Fatigue, and Depressive Symptoms among Female Nurses with Allergic Rhinitis

Allergic rhinitis (AR) is a common chronic disease that negatively affects physical and mental health. The purpose of this study was to determine the effects of allergic rhinitis on sleep, fatigue, and depressive symptoms among Korean female nurses. This was a cross-sectional study conducted using data from the Korea Nurses' Health Study (KNHS), and a total of 8645 female nurses was selected for the final analysis. The demographic characteristics, Body Mass Index, alcohol consumption, shift work, comorbidities (atopic dermatitis and asthma), self-rated health, sleep disturbance (Jenkins Sleep Questionnaire), fatigue (Chalder Fatigue Scale), and depressive symptoms (Perceived Health Questionnaire-9) were collected. The data were analyzed using chi-square tests, t-tests, and hierarchical multiple regression analyses. Participants with allergic rhinitis had significantly greater sleep disturbance, fatigue, and depressive symptoms than those without allergic rhinitis, and allergic rhinitis was a significant factor influencing sleep disturbance and fatigue among the participants after controlling for confounding variables. Therefore, it is imperative to develop effective interventions to manage allergic rhinitis symptoms and improve sleep and fatigue in affected nurses.

Cleaners and airway diseases

PURPOSE OF REVIEW

Evidence for adverse respiratory effects of occupational exposure to disinfectants and cleaning products (DCPs) has grown in the last two decades. The relationship between DCPs and asthma is well documented but questions remain regarding specific causal agents. Beyond asthma, associations between DCPs and COPD or chronic rhinitis are plausible and have been examined recently. The purpose of this review is to summarize recent advances on the effect of occupational exposure to DCP and chronic airway diseases.

RECENT FINDINGS

Recent epidemiological studies have often focused on healthcare workers and are characterized by efforts to improve assessment of exposure to specific DCPs. Despite increasing knowledge on the effect of DCPs on asthma, the burden of work-related asthma caused by DCPs has not decreased in the past decade, emphasizing the need to strengthen prevention efforts. Novel data suggest an association between occupational exposure to DCPs and other chronic airway diseases, such as rhinitis, COPD, and poor lung function.

SUMMARY

Epidemiological and experimental data showed that many chemicals contained in DCPs are likely to cause airway damage, indicating that prevention strategies should target multiple products. Further research is needed to evaluate the impact of DCP exposure on occupational airway diseases beyond asthma.

Occupational Exposure to Metals and Solvents: Allergy and Airway Diseases

PURPOSE OF REVIEW

Occupational allergic diseases (OAD) such as occupational contact dermatitis (OCD), occupational asthma (OA), and occupational rhinitis (OR) are the most prevalent occupational diseases in industrialized countries. The purpose of this review is to provide an update about the main occupational metal and solvent exposures related to allergy and airway diseases and to discuss newly defined causative agents and industries in this field.

RECENT FINDINGS

Currently for over 400 causative agents for OA and OCD, several hundreds of agents for OR have been identified. Although many studies have reported an overall decline in OAD related to known agents after implementation of efficient and effective workplace preventive measures, the constant development of new products continuously introduces to the market potential unknown respiratory hazards. Workplace allergens are often high molecular weight (HMW) agents that are > 10 kDa molecular weight and capable of eliciting IgE sensitization. Sensitizing low molecular weight (LMW) agents are often reactive chemicals. Metals and solvents are two large causative agent groups related to OADs that mainly behave as LMW (< 10 kDa) sensitizers and/or irritants. Avoidance of causative exposures through control strategies is the primary prevention approach for OADs. These strategies must be applied and covered for all known and newly defined causative agents. This review aims to summarize current status of known occupational metal and solvent exposures related to allergy and airway diseases and to discuss newly defined causative agents and industries in this field.

Exposures to Volatile Organic Compounds among Healthcare Workers: Modeling the Effects of Cleaning Tasks and Product Use

Objectives

Use of cleaning and disinfecting products is associated with work-related asthma among healthcare workers, but the specific levels and factors that affect exposures remain unclear. The objective of this study was to evaluate the determinants of selected volatile organic compound (VOC) exposures in healthcare settings.

Methods

Personal and mobile-area air measurements (n = 143) from 100 healthcare workers at four hospitals were used to model the determinants of ethanol, acetone, 2-propanol, d-limonene, α-pinene, and chloroform exposures. Hierarchical cluster analysis was conducted to partition workers into groups with similar cleaning task/product-use profiles. Linear mixed-effect regression models using log-transformed VOC measurements were applied to evaluate the association of individual VOCs with clusters of task/product use, industrial hygienists' grouping (IH) of tasks, grouping of product application, chemical ingredients of the cleaning products used, amount of product use, and ventilation.

Results

Cluster analysis identified eight task/product-use clusters that were distributed across multiple occupations and hospital units, with the exception of clusters consisting of housekeepers and floor strippers/waxers. Results of the mixed-effect models showed significant associations between selected VOC exposures and several clusters, combinations of IH-generated task groups and chemical ingredients, and product application groups. The patient/personal cleaning task using products containing chlorine was associated with elevated levels of personal chloroform and α-pinene exposures. Tasks associated with instrument sterilizing and disinfecting were significantly associated with personal d-limonene and 2-propanol exposures. Surface and floor cleaning and stripping tasks were predominated by housekeepers and floor strippers/waxers, and use of chlorine-, alcohol-, ethanolamine-, and quaternary ammonium compounds-based products was associated with exposures to chloroform, α-pinene, acetone, 2-propanol, or d-limonene.

Conclusions

Healthcare workers are exposed to a variety of chemicals that vary with tasks and ingredients of products used during cleaning and disinfecting. The combination of product ingredients with cleaning and disinfecting tasks were associated with specific VOCs. Exposure modules for questionnaires used in epidemiologic studies might benefit from seeking information on products used within a task context.

Clustering asthma symptoms and cleaning and disinfecting activities and evaluating their associations among healthcare workers

Asthma is a heterogeneous disease with varying severity and subtypes. Recent reviews of epidemiologic studies have identified cleaning and disinfecting activities (CDAs) as important risk factors for asthma-related outcomes among healthcare workers. However, the complexity of CDAs in healthcare settings has rarely been examined. This study utilized a complex survey dataset and data reduction approaches to identify and group healthcare workers with similar patterns of asthma symptoms, and then explored their associations with groups of participants with similar patterns of CDAs. Self-reported information on asthma symptoms/care, CDAs, demographics, smoking status, allergic status, and other characteristics were collected from 2030 healthcare workers within nine selected occupations in New York City. Hierarchical clustering was conducted to systematically group participants based on similarity of patterns of the 27 asthma symptom/care variables, and 14 product applications during CDAs, separately. Word clouds were used to visualize the complex information on the resulting clusters. The associations of asthma health clusters (HCs) with exposure clusters (ECs) were evaluated using multinomial logistic regression. Five HCs were identified (HC-1 to HC-5), labelled based on predominant features as: "no symptoms", "winter cough/phlegm", "mild asthma symptoms", "undiagnosed/untreated asthma", and "asthma attacks/exacerbations". For CDAs, five ECs were identified (EC-1 to EC-5), labelled as: "no products", "housekeeping/chlorine", "patient care", "general cleaning/laboratory", and "disinfection products". Using HC-1 and EC-1 as the reference groups, EC-2 was associated with HC-4 (odds ratio (OR) = 3.11, 95% confidence interval (95% CI) = 1.46-6.63) and HC-5 (OR = 2.71, 95% CI = 1.25-5.86). EC-3 was associated with HC-5 (OR = 2.34, 95% CI = 1.16-4.72). EC-4 was associated with HC-5 (OR = 2.35, 95% CI = 1.07-5.13). EC-5 was associated with HC-3 (OR = 1.81, 95% CI = 1.09-2.99) and HC-4 (OR = 3.42, 95% CI = 1.24-9.39). Various combinations of product applications like using alcohols, bleach, high-level disinfectants, and enzymes to disinfect instruments and clean surfaces captured by the ECs were identified as risk factors for the different asthma symptoms clusters, indicating that prevention efforts may require targeting multiple products. The associations of HCs with EC can be used to better inform prevention strategies and treatment options to avoid disease progression. This study demonstrated hierarchical clustering and word clouds were useful techniques for analyzing and visualizing a complex dataset with a large number of potentially correlated variables to generate practical information that can inform prevention activities.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Update on asthma and cleaning agents

PURPOSE OF REVIEW

Asthma due to cleaning products has been known for 20 years, and the interest in this topic is still large because of the number of cleaning workers with respiratory problems. In this review, we sought to highlight the most recent findings on the relationship between exposure to cleaning products and asthma and to summarize the specific literature published between 2013 and 2016.

RECENT FINDINGS

Women are confirmed as most of workers exposed to cleaning products and have a higher frequency than men of work-related respiratory symptoms and diseases. Many cases of asthma due to cleaning products occur in healthcare occupations. The increased risk of asthma has been shown to be related to the number of years in the job and to early life disadvantage. Recent evidence suggests that predisposition to adult-onset asthma may be related to interaction between genes and occupational exposure to low-molecular weight agents/irritants. There is some evidence that an irritant mechanism is more common, although several case reports showed animmunologic mechanism (e.g. disinfectants, amine compounds, aldehydes and fragrances).

SUMMARY

The review updated recent findings on epidemiology, cleaning agents and their mechanism, and prevention of asthma due to cleaning agents. This article provides new information on the level of exposure, which is still high in professional cleaners and even more in domestic cleaners, and on the frequency of asthma in professional and domestic cleaners. An irritant mechanism is more common, although an immunological mechanism is possible, especially in healthcare workers exposed to disinfectants.

Current asthma and asthma-like symptoms among workers at a Veterans Administration Medical Center

INTRODUCTION

Healthcare workers are at increased risk for respiratory disorders. The purpose of our respiratory health survey was to estimate the prevalence of current asthma and asthma-like symptoms and their association with workplace exposures and tasks among healthcare workers at a Veterans Administration (VA) Medical Center.

MATERIAL AND METHODS

Information on respiratory health and work characteristics, including tasks performed, products used, and exposures, were collected by questionnaire from a convenience sample of workers employed at the VA Medical Center during 2012-2014. Associations of asthma and asthma-like symptoms with cleaning and disinfecting tasks and products as well as exposure to dampness and molds, and construction dust were evaluated using log-binomial regression.

RESULTS

The prevalence of current asthma was 17.6% and almost half of all workers reported asthma-like symptoms. We observed elevated prevalence of current asthma among the VA healthcare workers compared to the U.S. general and working adult populations. Asthma and asthma-like symptoms were significantly associated with mold, dampness, and construction material exposures; cleaning and disinfecting products; and cleaning or disinfecting tasks.

CONCLUSIONS

Workplace exposures and tasks associated with current asthma and asthma-like symptoms were identified but further research is needed to investigate the temporal association between workplace exposures and current asthma and asthma-like symptoms.