Update on asthma and cleaners

Quantifying fomite hotspots and targeted hygiene impacts in a hotel lobby

Environmental surfaces in public settings serve as reservoirs for microbial pathogens, including norovirus, rhinovirus, and adenovirus, which can persist and spread through hand-to-fomite contact. Despite limited evidence of SARS-CoV-2 fomite transmission, hygiene protocols were widely intensified during the pandemic. This study evaluates viral spread and infection risks in a hotel lobby and assesses the efficacy of a Targeted Hygiene intervention designed to reduce contamination while minimizing excessive chemical use. A viral tracer study, using bacteriophage Phi X174, and human behavior observations were utilized to monitor surface contamination patterns, followed by Quantitative Microbial Risk Assessment (QMRA) to estimate infection probabilities. Tracer organisms seeded on high-touch surfaces spread to 50 % of sampled fomites within 4 h. A subsequent Targeted Hygiene intervention, using disinfecting wipes, sprays, or aerosols tailored to surface types, resulted in a statistically significant 97.36 % reduction in viral concentrations (1.57 log10 reduction, p < 0.0001). The proportion of cross-contaminated surfaces (i.e., non-seeded sites testing positive) decreased from 13 % to 2 %, and the overall percentage of positive surfaces dropped from 50 % to 42 %. QMRA modeling demonstrated that infection risks from a single fomite-hand-face contact were highest for rhinovirus, rotavirus, and adenovirus. Following intervention, infection risk was reduced by over 97 % for all modeled pathogens. Risk levels for all viruses and bacteria met the U.S. EPA and WHO benchmark of less than 1 infection per 10,000 exposures used in drinking water guidelines. Notably, bacterial infection risks, already low pre-intervention, were further reduced to meet the more stringent 1 infection per 1,000,000 risk threshold. This is the first study to integrate real-world human behavior, viral tracer data, and QMRA modeling to assess Targeted Hygiene in a hospitality setting. Findings support the implementation of evidence-based hygiene protocols that prioritize high-risk surfaces and timing, offering a sustainable approach to reducing infection risks in public environments.

Household cleaning agents impact on pediatric asthma: a systematic review and meta-analysis

BACKGROUND

Household cleaning agents promote hygiene along with causing respiratory effects, especially pediatric asthma. This systematic review quantified the association between exposure to household cleaning agents and pediatric asthma.

METHOD

Five databases were searched. Data were analyzed qualitatively and quantitatively. RevMan 5.4 calculated odds ratios (OR) with 95% confidence intervals (CI), and a funnel plot assessed publication bias. The Mixed Methods Appraisal Tool (MMAT) and GRADE framework assessed methodological quality and certainty respectively.

RESULTS

Sixteen studies met the eligibility criteria. Meta-analysis showed a significant association between the use of household cleaning agents and pediatric asthma (OR 2.90 (95% CI: 2.13-3.95; p < 0.01, I2 = 98%). Exposure stages also showed significant (p < 0.01) association with household cleaning agents (OR 2.92 (95% CI: 2.12-4.03, I2 = 98%). No publication bias or high risk of bias was found.

CONCLUSION

A strong association between exposure to household cleaning agents and an increased risk of pediatric asthma was found. .

Inhalation exposure to nanosized aerosols of disinfectants for the application of continuous releasing sprayers and fogger

This study aimed to investigate the airborne exposure to aerosols according to the particle size distribution of three different spray types (nano-nozzled spray gun, low-temperature steam spray, and fogger) and compare the concentrations of inhaled aerosols between children and adults. Airborne aerosols released from three products were observed using size-segregated particle measurements, and particle concentrations deposited in the respiratory tracts of adults and children were estimated using multi-path particle dosimetry lung deposition models. All types of sprayers generated the most nanoparticles (~100 nm). Due to their higher respiratory rate than adults, a larger number of particles <1.0 μm deposited in the children's respiratory tracts was higher. The sequences of the total number of particles in the respiratory regions after spraying nano-nozzled spray gun and fogger were alveolar (AL)>tracheobronchial (TB)>head airway (HA) in adults and AL>HA>TB in children. Meanwhile, the trend of low-temperature steam spray was AL>TB>HA in adults and AL>TB>HA in children.

Factors Affecting Chlorinated Product Formation from Sodium Hypochlorite Bleach and Limonene Reactions in the Gas Phase

During use of sodium hypochlorite bleach, gas-phase hypochlorous acid (HOCl) and chlorine (Cl2) are released, which can react with organic compounds present in indoor air. Reactivity between HOCl/Cl2 and limonene, a common constituent of indoor air, has been observed. The purpose of this study was to characterize the chemical species generated from gas-phase reactions between HOCl/Cl2 and limonene. Gas-phase reactions were prepared in Teflon chambers housing HOCl, Cl2, and limonene. The resulting chemical products were analyzed using gas-phase preconcentration, followed by gas chromatography and high-resolution mass spectrometry. Several chlorinated products were detected, including limonene species containing one, two, and three chlorines and limonene chlorohydrin. Product concentrations and yields were estimated for the most abundant products, and greater than 80% of transformed limonene was represented in the detected products. Temporal sampling of the reactions allowed time courses to be plotted for limonene decay and chlorinated limonene product generation under different conditions, including the treatments of HOCl/Cl2, Cl2 only, high vs low relative humidity, and ± ozone. These experiments add product speciation, yield estimates, and an understanding of environmental factors affecting product formation to previous studies, further highlighting the chemical transformations initiated by sodium hypochlorite bleach in indoor air.

Airway Diseases Related to the Use of Cleaning Agents in Occupational Settings

Exposure to disinfectants and cleaning products (DCPs) is now a well-established risk factor for work-related asthma (WRA). However, questions remain on the specific causal agents and pathophysiological mechanisms. Few studies have also reported an association between DCPs and rhinitis or chronic obstructive pulmonary disease. This review discusses the recent evidence pertaining to airway diseases attributable to occupational exposure to DCPs. In contrast to other agents, the incidence of WRA due to DCPs has increased over time. The use of DCPs in spray form has clearly been identified as an added risk factor. The mechanisms for WRA associated with DCPs remain poorly studied; however, both allergic and nonallergic responses have been described, with irritant mechanisms thought to play a major role. An early diagnostic workup based on clinical assessment accompanied by evaluation of lung function and immunological and airway inflammatory markers is important to guide optimal care and exposure avoidance to the implicated agent. Future research should focus on the effects of "green" products, pathophysiological mechanisms, and quantitative exposure assessment including the use of barcode-based methods to identify specific agents. There is an urgent need to strengthen preventive measures and interventions to reduce the burden of airway diseases associated with DCPs.

Lifestyle Changes and Industrialization in the Development of Allergic Diseases

PURPOSE OF REVIEW

Modernization and Westernization in industrialized and developing nations is associated with a substantial increase in chronic noncommunicable diseases. This transformation has far-reaching effects on lifestyles, impacting areas such as economics, politics, social life, and culture, all of which, in turn, have diverse influences on public health. Loss of contact with nature, alternations in the microbiota, processed food consumption, exposure to environmental pollutants including chemicals, increased stress and decreased physical activity jointly result in increases in the frequency of inflammatory disorders including allergies and many autoimmune and neuropsychiatric diseases. This review aims to investigate the relationship between Western lifestyle and inflammatory disorders.

RECENT FINDINGS

Several hypotheses have been put forth trying to explain the observed increases in these diseases, such as 'Hygiene Hypothesis', 'Old Friends', and 'Biodiversity and Dysbiosis'. The recently introduced 'Epithelial Barrier Theory' incorporates these former hypotheses and suggests that toxic substances in cleaning agents, laundry and dishwasher detergents, shampoos, toothpastes, as well as microplastic, packaged food and air pollution damage the epithelium of our skin, lungs and gastrointestinal system. Epithelial barrier disruption leads to decreased biodiversity of the microbiome and the development of opportunistic pathogen colonization, which upon interaction with the immune system, initiates local and systemic inflammation. Gaining a deeper comprehension of the interplay between the environment, microbiome and the immune system provides the data to assist with legally regulating the usage of toxic substances, to enable nontoxic alternatives and to mitigate these environmental challenges essential for fostering a harmonious and healthy global environment.

Recruitment strategies in marginalized industries for occupational health research: an example in a pilot study of cleaning staff during COVID-19

This commentary describes challenges in recruiting workers from marginalized industries with examples from a pilot study of janitors, custodians, and maids and their experiences of cleaning and disinfection protocols during COVID-19 and potentially associated respiratory symptoms. Recruitment strategies included contacting a local hospital, national workers' unions, and a large Arizona employer; using online Facebook groups; and contacting Arizona maid service companies and a school district. English and Spanish online and hard copy surveys about cleaning protocols and respiratory symptoms were used. Participants could also participate in online/phone interviews. Worker's compensation, liability, and confidentiality were concerns across organizations. Online surveys yielded unreliable data. Hard copy surveys were used due to workers' limited technology access. We reflect upon these challenges and discuss other strategies for recruiting from marginalized populations for occupational health research. Building trust with organizations and workers and considering technology access may ultimately increase recruitment feasibility.

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.

Cleaning Tasks and Products and Asthma Among Health Care Professionals

OBJECTIVE

Health care workers are at risk for work-related asthma, which may be affected by changes in cleaning practices. We examined associations of cleaning tasks and products with work-related asthma in health care workers in 2016, comparing them with prior results from 2003.

METHODS

We estimated asthma prevalence by professional group and explored associations of self-reported asthma with job-exposure matrix-based cleaning tasks/products in a representative Texas sample of 9914 physicians, nurses, respiratory/occupational therapists, and nurse aides.

RESULTS

Response rate was 34.8% (n = 2421). The weighted prevalence rates of physician-diagnosed (15.3%), work-exacerbated (4.1%), and new-onset asthma (6.7%) and bronchial hyperresponsiveness symptoms (31.1%) were similar to 2003. New-onset asthma was associated with building surface cleaning (odds ratio [OR], 1.91; 95% confidence interval [CI], 1.10-3.33), use of ortho-phthalaldehyde (OR, 1.77; 95% CI, 1.15-2.72), bleach/quaternary compounds (OR, 1.91; 95% CI, 1.10-3.33), and sprays (OR, 1.97; 95% CI, 1.12-3.47).

CONCLUSION

Prevalence of asthma/bronchial hyperresponsiveness seems unchanged, whereas associations of new-onset asthma with exposures to surface cleaning remained, and decreased for instrument cleaning.

The epithelial barrier: The gateway to allergic, autoimmune, and metabolic diseases and chronic neuropsychiatric conditions

Since the 1960 s, our health has been compromised by exposure to over 350,000 newly introduced toxic substances, contributing to the current pandemic in allergic, autoimmune and metabolic diseases. The "Epithelial Barrier Theory" postulates that these diseases are exacerbated by persistent periepithelial inflammation (epithelitis) triggered by exposure to a wide range of epithelial barrier-damaging substances as well as genetic susceptibility. The epithelial barrier serves as the body's primary physical, chemical, and immunological barrier against external stimuli. A leaky epithelial barrier facilitates the translocation of the microbiome from the surface of the afflicted tissues to interepithelial and even deeper subepithelial locations. In turn, opportunistic bacterial colonization, microbiota dysbiosis, local inflammation and impaired tissue regeneration and remodelling follow. Migration of inflammatory cells to susceptible tissues contributes to damage and inflammation, initiating and aggravating many chronic inflammatory diseases. The objective of this review is to highlight and evaluate recent studies on epithelial physiology and its role in the pathogenesis of chronic diseases in light of the epithelial barrier theory.

COVID-19 cleaning protocol changes, experiences, and respiratory symptom prevalence among cleaning services personnel

Introduction

Cleaning protocols were changed in response to the COVID-19 pandemic with unknown occupational health impacts. There is evidence that COVID-19 transmission risks from contaminated surfaces are low and that exposure to cleaning products can increase risks of work-related asthma. The study objective was to investigate relationships between reported COVID-19-related changes in cleaning protocols and prevalence of asthma-related respiratory symptoms for asthmatic and non-asthmatic janitors and maids. A secondary objective was to characterize experiences of respiratory symptoms associated with cleaning and barriers to personal protective equipment (PPE) use.

Methods

Employees from two Tucson-based maid service companies (approximately 30 personnel in total) and one Phoenix-based school district (>300 janitors/custodians) were invited to participate in a written survey and/or a one-on-one interview in Spanish or English. Fisher's exact tests (α = 0.05) were used to test for statistically significant associations between reported respiratory symptoms by self-reported physician-diagnosed asthma status and changes in cleaning protocols. Interviews were transcribed and then analyzed by at least two researchers in English or Spanish.

Results

Eighty-three percent reported that cleaning protocols had changed during COVID-19, with the two most reported changes including increased cleaning frequency (92%) and change of application type (e.g., fog, spray, wipe) (53%). There was a statistically significant association between multiple respiratory symptoms and self-reported physician diagnosed asthma. Reporting a type of application change (e.g., fog, spray, wipe) and being awakened during the night by attack/episode of cough were statistically significantly associated (p = 0.04). Interviews elucidated respiratory issues related to fogging devices.

Discussion

This study provides preliminary evidence that changes in cleaning and disinfection protocols during COVID-19 (namely, the use of fogging/mechanical spraying devices) may have had negative impacts on the health of workers in the cleaning industry with little benefit to reducing COVID-19 risks. Further research is needed to evaluate the generalizability of our findings across larger geographical areas and to develop guidance for employers and employees on how to protect and promote respiratory health.

Characterization of the aerosol release from spray cleaning and disinfection products - Spray scenarios in a climate chamber

Cleaning work using spray products has been associated with adverse respiratory effects but little is known of the exposure concentrations. The purpose of this study was to characterize aerosol generation at spray scenarios in a controlled climate chamber. Spraying on vertically and horizontally oriented surfaces, as well as spraying on a cloth, was investigated. Furthermore, the effect of nozzle geometry was tested. The average mass generation rates of six pressurized spray cans and 13 trigger sprays were about 1.7 g/s and did not differ significantly, but the average values of the individual sprays had large variations (0.5-3.1 g/s). The time required to halve the air concentration of aerosol particles, the half-life time, was determined for all spray products. The average half-life time of the total particle mass concentration (TPMC) of the pressurized spray cans was 0.5 h versus 0.25 h for trigger sprays. Gravimetrically determined airborne fractions of pressurized spray cans tended to be higher than those of trigger sprays. However, airborne fractions based on the measured peak TPMC were up to three orders of magnitude smaller. A comparison of different trigger spray nozzles when spraying the same product showed that the TPMC can be up to 18 times higher for the largest emitting nozzle. The distance of the nozzle to a cloth should be 1 cm to significantly reduce the concentration of the generated aerosols. ConsExpo modeling predicted the measured peak TPMC well but less well the decay.

Association between maternal occupational exposure to cleaning chemicals during pregnancy and childhood wheeze and asthma

Background

Asthma is a leading cause of childhood morbidity in the U.S. and a significant public health concern. The prenatal period is a critical window during which environmental influences, including maternal occupational exposures, can shape child respiratory health. Cleaning chemicals are commonly encountered in occupational settings, yet few studies have examined the potential link between prenatal occupational exposures to cleaning chemicals and risk of childhood wheeze and asthma.

Methods

We evaluated the potential influence of maternal occupational exposure to cleaning chemicals during pregnancy on pediatric asthma and wheeze at child age 4-6 years in 453 mother-child pairs from two longitudinal pregnancy cohorts, TIDES and GAPPS, part of the ECHO prenatal and early childhood pathways to health (ECHO-PATHWAYS) consortium. Maternal occupational exposure to cleaning chemicals was defined based on reported occupation and frequency of occupational use of chemicals during pregnancy. Child current wheeze and asthma outcomes were defined by parental responses to a widely-used, standardized respiratory outcomes questionnaire administered at child age 4-6 years. Multivariable Poisson regression with robust standard errors was used to estimate relative risk (RR) of asthma in models adjusted for confounding. Effect modification by child sex was assessed using product interaction terms.

Results

Overall, 116 mothers (25.6%) reported occupational exposure to cleaning chemicals during pregnancy, 11.7% of children had current wheeze, and 10.2% had current asthma. We did not identify associations between prenatal exposure to cleaning chemicals and current wheeze [RRadjusted 1.03, 95% confidence interval (CI): 0.56, 1.90] or current asthma (RRadjusted 0.89, CI: 0.46, 1.74) in the overall sample. Analyses of effect modification suggested an adverse association among females for current wheeze (RR 1.82, CI: 0.76, 4.37), compared to males (RR 0.68, CI: 0.29, 1.58), though the interaction p-value was >0.05.

Conclusion

We did not observe evidence of associations between maternal prenatal occupational exposure to cleaning chemicals and childhood wheeze or asthma in the multi-site ECHO-PATHWAYS consortium. We leveraged longitudinal U.S. pregnancy cohorts with rich data characterization to expand on limited and mixed literature. Ongoing research is needed to more precisely characterize maternal occupational chemical exposures and impacts on child health in larger studies.

The Relationship Between Potential Occupational Sensitizing Exposures and Asthma: An Overview of Systematic Reviews

OBJECTIVES

The aim was to identify, appraise, and synthesize the scientific evidence of the relationship between potential occupational sensitizing exposures and the development of asthma based on systematic reviews.

METHODS

The study was conducted as an overview of systematic reviews. A systematic literature search was conducted for systematic reviews published up to 9 February 2020. Eligibility study criteria included persons in or above the working age, potential occupational sensitizing exposures, and outcomes defined as asthma. Potential occupational sensitizing exposures were divided into 23 main groups comprising both subgroups and specific exposures. Two reviewers independently selected studies, extracted study data, assessed study quality, and evaluated confidence in study results and level of evidence of the relationship between potential occupational sensitizing exposures and asthma.

RESULTS

Twenty-seven systematic reviews were included covering 1242 studies and 486 potential occupational sensitizing exposures. Overall confidence in study results was rated high in three systematic reviews, moderate in seven reviews, and low in 17 reviews. Strong evidence for the main group of wood dusts and moderate evidence for main groups of mites and fish was found. For subgroups/specific exposures, strong evidence was found for toluene diisocyanates, Aspergillus, Cladosporium, Penicillium, and work tasks involving exposure to laboratory animals, whereas moderate evidence was found for 52 subgroups/specific exposures.

CONCLUSIONS

This overview identified hundreds of potential occupational sensitizing exposures suspected to cause asthma and evaluated the level of evidence for each exposure. Strong evidence was found for wood dust in general and for toluene diisocyanates, Aspergillus, Cladosporium, Penicillium, and work tasks involving exposure to laboratory animals.

Airway inflammatory profile among cleaning workers from different workplaces

Background

Cleaning workers represent a significant proportion of the active population worldwide, with poor remuneration, particularly in developing countries. Despite this, they remain a relatively poorly studied occupational group. They are constantly exposed to agents that can cause symptoms and respiratory problems. This study aimed to evaluate upper airway inflammation in professional cleaning workers in three different occupational settings by comparing nasal cytology inflammation and clinical profiles.

Methods

We performed a cross-sectional study on the prevalence of upper airway inflammation and symptoms of asthma/rhinitis related to cleaning work, according to workplace. A total of 167 participants were divided into four groups: hospital, university, housekeeper and control. A nasal swab was collected for upper airway inflammation evaluation. Clinical profiles and respiratory symptom employee evaluations were performed using specific questionnaires (European Community Respiratory Health Survey—ECRS and the International Study of Asthma and Allergies in Childhood—ISAAC).

Results

Cleaning workers showed increased neutrophils and lymphocytes; the hospital and university groups showed increased macrophages compared to the housekeeper and control groups. The hospital and housekeeper groups showed increased eosinophils when they performed cleaning services for up to one year and reported having more asthma symptoms than the control group. Cleaning workers showed increased rhinitis symptoms. The university group showed increased rhinitis symptoms aggravated by the workplace compared with the hospital and housekeeper groups. Cleaning workers showed an increased affirmative response when directly asked about rhinitis symptoms compared to the control group.

Conclusions

Cleaning workers showed airway inflammation, asthma symptoms and rhinitis, regardless of the occupational environment to which they were exposed, as well as showed increased rhinitis and asthma symptoms. Hospital cleaning workers showed increased macrophages, lymphocytes and eosinophils compared to the others. The length of time spent performing cleaning work was not related to nasal inflammation or respiratory symptoms in this population. However, there were differences in workplaces. Registered on ClinicalTrials.gov. Trial registration number: NCT03311048. Registration date: 10.16.2017. Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01949-5.

Antiviral activity of galvanic microcells of zinc and copper contained within painted surfaces

This study presents research related to the antiviral activity of painted surfaces containing galvanic microcells of zinc and copper. The aim of this study was to investigate the virucidal activity of galvanic microcells of zinc and copper grains fixed with adequate homogeneity and degree of aggregation in water-based acrylic paint layers in reference to a non-treated reference control. This paper provides evidence that a paint coating with a total copper surface area of 4.4% displays antiviral activity against human coronavirus NL63 according to ISO 21702 and inactivates > 99% of virus after 4 h of contact relative to a non-treated reference control.

Indoor PM2.5, VOCs and asthma outcomes: A systematic review in adults and their home environments

INTRODUCTION

As the amount of time people spend indoors increases globally, exposure to indoor air pollutants has become an important public health concern. Asthma is a complex disease caused and/or exacerbated by increased exposure to diverse chemical, physical and biological exposures from multiple indoor and outdoor sources. This review aims to investigate the relationship between increased indoor PM and VOC concentrations (i.e. objectively measured) and the risk of adult asthma in higher-income countries.

METHODS

Eleven databases were systematically searched on the February 1, 2019 and again on the February 2, 2020. Articles were limited to those published since 1990. Reference lists were independently screened by three reviewers and authors were contacted to identify relevant articles. Backwards and forward citation chasing was used to identify further studies. Data were extracted from included studies meeting our eligibility criteria by three reviewers and assessed for quality using the Newcastle-Ottawa scale designed for case-control and cohort studies.

RESULTS

Twelve studies were included in a narrative synthesis. We found insufficient evidence to determine the effect of PM2.5 on asthma in the indoor home environment. However, there was strong evidence to suggest that VOCs, especially aromatic compounds, and aliphatic compounds, were associated with increased asthma symptoms.

DISCUSSION & CONCLUSION

Although no single exposure appears to be responsible for the development of asthma or its associated symptoms, the use of everyday products may be associated with increased asthma symptoms. To prevent poor health outcomes among the general population, health professionals and industry must make a concerted effort to better inform the general population of the importance of appropriate use of and storage of chemicals within the home as well as better health messaging on product labelling.

Ultrafine particle emission from floor cleaning products

The new particle formation due to the use of cleaning products containing volatile organic compounds (VOCs) in indoor environments is well documented in the scientific literature. Indeed, the physical-chemical process occurring in particle nucleation due to VOC-ozone reactions was deepened as well as the effect of the main influencing parameters (ie, temperature, ozone). Nonetheless, proper quantification of the emission under actual meteo-climatic conditions and ozone concentrations is not available. To this end, in the present paper the emission factors of newly generated ultrafine particles due to the use of different floor cleaning products under actual temperature and relative humidity conditions and ozone concentrations typical of the summer periods were evaluated. Tests in a chamber and in an actual indoor environment were performed measuring continuously particle number concentrations and size distributions during cleaning activities. The tests revealed that a significant particle emission in the nucleation mode was present for half of the products under investigation with emission factors up to 1.1 × 10¹¹ part./m² (8.8 × 10¹⁰ part./mL_product ), then leading to an overall particle emission comparable to other well-known indoor sources when cleaning wide surfaces.

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.

Chemicals inhaled from spray cleaning and disinfection products and their respiratory effects. A comprehensive review

Spray cleaning and disinfection products have been associated with adverse respiratory effects in professional cleaners and among residents doing domestic cleaning. This review combines information about use of spray products from epidemiological and clinical studies, in vivo and in vitro toxicological studies of cleaning chemicals, as well as human and field exposure studies. The most frequent chemicals in spray cleaning and disinfection products were compiled, based on registrations in the Danish Product Registry. The chemicals were divided into acids, bases, disinfectants, fragrances, organic solvents, propellants, and tensides. In addition, an assessment of selected cleaning and disinfectant chemicals in spray products was carried out. Chemicals of concern regarding respiratory effects (e.g. asthma) are corrosive chemicals such as strong acids and bases (including ammonia and hypochlorite) and quaternary ammonium compounds (QACs). However, the evidence for respiratory effects after inhalation of QACs is ambiguous. Common fragrances are generally not considered to be of concern following inhalation. Solvents including glycols and glycol ethers as well as propellants are generally weak airway irritants and not expected to induce sensitization in the airways. Mixing of certain cleaning products can produce corrosive airborne chemicals. We discuss different hypotheses for the mechanisms behind the development of respiratory effects of inhalation of chemicals in cleaning agents. An integrative assessment is needed to understand how these chemicals can cause the various respiratory effects.

Peaks, Means, and Determinants of Real-Time TVOC Exposures Associated with Cleaning and Disinfecting Tasks in Healthcare Settings

Cleaning and disinfecting tasks and product use are associated with elevated prevalence of asthma and respiratory symptoms among healthcare workers; however, the levels of exposure that pose a health risk remain unclear. The objective of this study was to estimate the peak, average, and determinants of real-time total volatile organic compound (TVOC) exposure associated with cleaning tasks and product-use. TVOC exposures were measured using monitors equipped with a photoionization detector (PID). A simple correction factor was applied to the real-time measurements, calculated as a ratio of the full-shift average TVOC concentrations from a time-integrated canister and the PID sample, for each sample pair. During sampling, auxiliary information, e.g. tasks, products used, engineering controls, was recorded on standardized data collection forms at 5-min intervals. Five-minute averaged air measurements (n = 10 276) from 129 time-series comprising 92 workers and four hospitals were used to model the determinants of exposures. The statistical model simultaneously accounted for censored data and non-stationary autocorrelation and was fit using Markov-Chain Monte Carlo within a Bayesian context. Log-transformed corrected concentrations (cTVOC) were modeled, with the fixed-effects of tasks and covariates, that were systematically gathered during sampling, and random effect of person-day. The model-predicted geometric mean (GM) cTVOC concentrations ranged from 387 parts per billion (ppb) for the task of using a product containing formaldehyde in laboratories to 2091 ppb for the task of using skin wipes containing quaternary ammonium compounds, with a GM of 925 ppb when no products were used. Peak exposures quantified as the 95th percentile of 15-min averages for these tasks ranged from 3172 to 17 360 ppb. Peak and GM task exposures varied by occupation and hospital unit. In the multiple regression model, use of sprays was associated with increasing exposures, while presence of local exhaust ventilation, large room volume, and automatic sterilizer use were associated with decreasing exposures. A detailed understanding of factors affecting TVOC exposure can inform targeted interventions to reduce exposures and can be used in epidemiologic studies as metrics of short-duration peak exposures.

Respiratory health in professional cleaners: Symptoms, lung function, and risk factors

BACKGROUND

Cleaning is associated with an increased risk of asthma symptoms, but few studies have measured functional characteristics of airway disease in cleaners.

AIMS

To assess and characterize respiratory symptoms and lung function in professional cleaners, and determine potential risk factors for adverse respiratory outcomes.

METHODS

Symptoms, pre-/post-bronchodilator lung function, atopy, and cleaning exposures were assessed in 425 cleaners and 281 reference workers in Wellington, New Zealand between 2008 and 2010.

RESULTS

Cleaners had an increased risk of current asthma (past 12 months), defined as: woken by shortness of breath, asthma attack, or asthma medication (OR = 1.83, 95% CI = 1.18-2.85). Despite this, they had similar rates of current wheezing (OR = 0.93, 95% CI = 0.65-1.32) and were less likely to have a doctor diagnosis of asthma ever (OR = 0.62, 95% CI = 0.42-0.92). Cleaners overall had lower lung function (FEV₁ , FVC; P < .05). Asthma in cleaners was associated with less atopy (OR = 0.35, 95% CI = 0.13-0.90), fewer wheezing attacks (OR = 0.40, 95% CI = 0.17-0.97; >3 vs ≤3 times/year), and reduced bronchodilator response (6% vs 9% mean FEV₁ -%-predicted change, P < .05) compared to asthma in reference workers. Cleaning of cafes/restaurants/kitchens and using upholstery sprays or liquid multi-use cleaner was associated with symptoms, whilst several exposures were also associated with lung function deficits (P < .05).

CONCLUSIONS AND CLINICAL RELEVANCE

Cleaners are at risk of some asthma-associated symptoms and reduced lung function. However, as it was not strongly associated with wheeze and atopy, and airway obstruction was less reversible, asthma in some cleaners may represent a distinct phenotype.

Estimating the time-varying generation rate of acetic acid from an all-purpose floor cleaner

Understanding the relationship between consumer product use and risk of adverse health outcomes facilitates appropriate risk management and product stewardship. A preferred method for estimating the systemic and respiratory tract exposure and dose tailored to cleaning products use has been proposed, refining previously issued exposure guidance. Consistent with other exposure and risk-assessment frameworks, it is dependent upon high-quality exposure determinant data that also serve as model inputs. However, as publicly available exposure determinant data are scarce, the risk assessor is left with the option of estimating determinants such as the generation rate or employing empirical methods to estimate them. When the exposure scenario involves a chemical mixture, estimating the generation rate may not be feasible. We present an approach for estimating the time-varying generation rate of an aqueous acetic acid mixture representative of the base formulation for many consumer and DIY cleaning products that was previously assessed in a screening-level assessment. The approach involved measuring the evaporation rate for a reasonable worst-case scenario under controlled conditions. Knowing the mass applied, a time-varying generation rate was estimated. To evaluate its portability, a field study was conducted in a home where measurements were collected in an all-purpose room with the exterior door open (Room 1) and closed (Room 2), and a bathroom (Room 3) using a portable Fourier Transform Infrared (FTIR) spectrophotometer. Acetic acid concentrations were modeled using two common indoor air models, the Well Mixed Room model. Measured and modeled acetic acid concentrations were compared, with the WMR 95% confidence intervals encompassing measured concentrations for all three rooms, supporting the utility of the approach used and portability of the generation rate derived from it.

Biocidal spray product exposure: Measured gas, particle, and surface concentrations compared with spray model simulations

The purpose of the study was to compare measured air and surface concentrations after application of biocidal spray products with concentrations simulated with the ConsExpo Web spray simulation tool. Three different biocidal spray products were applied in a 20 m³ climate test chamber with well-controlled environmental conditions (22 ± 1 °C, 50 ± 2% relative humidity, and air exchange rate of 0.5 h^-1). The products included an insect spray in a pressurized spray can, another insect spray product, and a disinfectant, the latter two applied separately with the same pumped spray device. The measurements included released particles, airborne organic compounds in both gas and particle phase, and surface concentrations of organic compounds on the wall and floor in front of the spraying position and on the most remote wall. Spraying time was a few seconds and the air concentrations were measured by sampling on adsorbent tubes at 9-13 times points during 4 hr after spraying. The full chamber experiment was repeated 2-3 times for each product. Due to sedimentation the concentrations of the particles in air decayed faster than explained by the air exchange rate. In spite of that, the non-volatile benzalkonium chlorides in the disinfectant could be measured in the air more than 30 min after spraying. ConsExpo Web simulated concentrations that were about half of the measured concentrations of the active substances when as many as possible of the default simulation parameters were replaced by the experimental values. ConsExpo Web was unable to simulate the observed faster decay of the airborne concentrations of the active substances, which might be due to underestimation of the gravitational particle deposition rates. There was a relatively good agreement between measured surface concentrations on the floor and calculated values based on the dislodgeable amount given in the selected ConsExpo Web scenarios. It is suggested to always supplement simulation tool results with practical measurements when assessing the exposure to a spray product.

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.

Prenatal use of cleaning and scented products and its association with childhood asthma, asthma symptoms, and mental health and developmental comorbidities

INTRODUCTION

Occupational use of cleaning chemicals has been related to asthma in adults. However, little information is available on the effect of non-occupational use of cleaning products during pregnancy on childhood asthma. This study examines the association between prenatal exposure to cleaning and scented products with childhood asthma, asthma symptoms, and mental and developmental comorbidities among low-income families in Karachi, Pakistan.

METHODS

Four hundred children from the Koohi Goth Women's Hospital were included in the study. Parents' or guardians reported current asthma, asthma-related symptoms, mental health problems, and behavioral problems among the children. Multivariable logistic regression analysis was used to examine the association between the use of cleaning and scented products during pregnancy and seven different outcome variables.

RESULTS

The odds of nocturnal cough were significantly elevated among children whose mothers reported the use of cleaning products (OR: 2.23, 95% CI: 1.15-4.31) or scented products (OR: 2.15, 95% CI: 1.22-3.77) during pregnancy. Mental health comorbidities were threefold elevated (OR: 3.05, 95% CI: 1.74-5.35) among children whose mothers reported using scented products during pregnancy. There was no statistically significant association of the prenatal use of cleaning or scented products with current asthma status or nocturnal symptoms of wheezing, shortness of breath, and chest tightness among children.

CONCLUSIONS

The study results indicate prenatal exposure to cleaning and scented products is associated with nocturnal cough among children. The study also suggests an association between prenatal use of scented products and mental health comorbidities among children.

Cleaning at Home and at Work in Relation to Lung Function Decline and Airway Obstruction

RATIONALE

Cleaning tasks may imply exposure to chemical agents with potential harmful effects to the respiratory system, and increased risk of asthma and respiratory symptoms among professional cleaners and in persons cleaning at home has been reported. Long-term consequences of cleaning agents on respiratory health are, however, not well described.

OBJECTIVES

This study aimed to investigate long-term effects of occupational cleaning and cleaning at home on lung function decline and airway obstruction.

METHODS

The European Community Respiratory Health Survey (ECRHS) investigated a multicenter population-based cohort at three time points over 20 years. A total of 6,235 participants with at least one lung function measurement from 22 study centers, who in ECRHS II responded to questionnaire modules concerning cleaning activities between ECRHS I and ECRHS II, were included. The data were analyzed with mixed linear models adjusting for potential confounders.

MEASUREMENTS AND MAIN RESULTS

As compared with women not engaged in cleaning (ΔFEV₁ = -18.5 ml/yr), FEV₁ declined more rapidly in women responsible for cleaning at home (-22.1; P = 0.01) and occupational cleaners (-22.4; P = 0.03). The same was found for decline in FVC (ΔFVC = -8.8 ml/yr; -13.1, P = 0.02; and -15.9, P = 0.002; respectively). Both cleaning sprays and other cleaning agents were associated with accelerated FEV₁ decline (-22.0, P = 0.04; and -22.9, P = 0.004; respectively). Cleaning was not significantly associated with lung function decline in men or with FEV₁/FVC decline or airway obstruction.

CONCLUSIONS

Women cleaning at home or working as occupational cleaners had accelerated decline in lung function, suggesting that exposures related to cleaning activities may constitute a risk to long-term respiratory health.

Use of cleaning agents at home and respiratory and allergic symptoms in adolescents: The PIAMA birth cohort study

BACKGROUND

It has been suggested that adults who use cleaning agents in their homes have a higher risk of asthma and allergic symptoms. The associations of asthma and allergic symptoms with household use of cleaning agents in adolescents have not been investigated yet.

OBJECTIVES

To examine the associations of household cleaning agents use with the prevalence of asthma, rhinitis and eczema in adolescents.

METHODS

In this cross-sectional analysis, we included participants of the PIAMA birth cohort study with data on household use of 10 types of cleaning agents and information on asthma, rhinitis and/or eczema from parent-completed questionnaires at age 14 (N = 2333). For the cleaning agents, we developed a composite score ranging from 0 (no exposure) to 30 points (household use on 4-7 days per week for all 10 types of cleaning agents). Logistic regression was used to analyse associations between household cleaning agents use (composite score and specific cleaning agents) and outcomes, adjusting for potential confounders.

RESULTS

Seven, 13 and 11% of the participants had asthma, rhinitis and eczema, respectively, at age 14. The composite score for household use of cleaning agents was not associated with asthma, rhinitis and eczema. For instance, adjusted odds ratios (95% confidence interval) for the prevalence of asthma, rhinitis and eczema comparing those with the highest use of cleaning agents (≥10 points) to those with never/seldom use (0-4 points) were 0.95 (0.56, 1.63), 1.23 (0.82, 1.82) and 0.95 (0.56, 1.63), respectively. For individual cleaning agents, we only found the use of ammonia to be significantly associated with a lower risk of rhinitis [0.60, (0.44, 0.82)].

CONCLUSIONS

There was no indication of an increased prevalence of asthma, rhinitis or eczema among adolescents living in households within the highest category of cleaning agents use.

Job hazards and respiratory symptoms in Hispanic female domestic cleaners

The occupational hazards and respiratory symptoms of domestic cleaners in USA are largely unknown. We conducted a cross-sectional study among 56 Hispanic female domestic cleaner on their health status and frequency of cleaning products used and tasks performed. While women used multi-use products (60.0%) and toilet bowl cleaners (51.8%) most days of the week, many (39.3%) reported not using personal protective equipment while cleaning. Itchy/watery eyes (61.8%) and itchy nose (56.4%) were the most frequently reported symptoms. A history of physician-diagnosed asthma was reported by 14.3% while 33.9% had symptoms of bronchial hyperresponsiveness (BHR). In conclusion, this vulnerable population has high prevalence of physician-diagnosis asthma and BHR symptoms and is potentially exposed to myriad occupational hazards. Further research exploring associations between products use, cleaning tasks and respiratory symptoms is warranted.

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.

Is residential ambient air limonene associated with asthma? Findings from the Canadian Health Measures Survey

Asthma is a common chronic disease. Exposure to limonene is commonplace because it may be used in the manufacture of personal care products and household cleaners. We investigated the influence of limonene on asthma in a population-based sample of approximately 3000 Canadians. During the Canada Health Measures Survey, carried out between 2012 and 2013, participants were asked if they wheezed or had a diagnosis of asthma, and underwent spirometry and measurement of the fraction of exhaled nitric oxide (FeNO). These variables were tested for an association with limonene concentrations measured in their household air samples, using linear regression analysis A 100% increase in air limonene concentration was associated with an approximate 17% adjusted relative increase wheezing with an odds ratio of 1.17 (95%CI 1.16, 1.18). The percent change in FeNO for a 100% increase in limonene was twice as large for children, 2.89% (95% CI 1.88, 4.43) compared to adults, 1.44% (95%CI 1.16, 1.79). Among boys, the odds ratio was 1.50 (95%CI 1.48, 1.52) between a 100% increase in limonene and a diagnosis of asthma. This study provides evidence that household exposure to limonene may increase the prevalence of asthma in the general population.

Cleaning and disinfection in home care: A comparison of 2 commercial products with potentially different consequences for respiratory health

BACKGROUND

Home care aides perform personal care and homemaking services in client homes, including cleaning and disinfection (C&D). Although C&D are performed to remove soil and dust, they are increasingly performed for infection prevention. Many C&D products contain respiratory irritants. The objective of this study was to evaluate 2 commercial products for C&D effectiveness on common household surfaces in seniors' homes.

METHODS

Two C&D visits were conducted in 46 seniors' homes. One visit applied a bleach-containing cleaning product and the other applied an environmentally preferable product. Before and after C&D, the study team performed organic soil bioluminometer measurements on surfaces and collected cotton swab and wipe samples for total bacteria count, Staphylococcus aureus, and Clostridium difficile identification.

RESULTS

Both products removed microorganisms from tested surfaces. S aureus was found in 7 households, 1 strain of which was methicillin-resistant. Both products removed S aureus from all surfaces. Bleach-containing products removed somewhat more soil than environmentally preferable products, although results were statistically significant for only 1 surface.

CONCLUSIONS

The study showed similar, not identical, C&D performance for 2 cleaning products with potentially different consequences for respiratory health. Additional research is needed to develop robust recommendations for safe, effective C&D in home care.

Control of Antimicrobial Resistance Requires an Ethical Approach

Ethical behavior encompasses actions that benefit both self and society. This means that tackling antimicrobial resistance (AMR) becomes an ethical obligation, because the prospect of declining anti-infectives affects everyone. Without preventive action, loss of drugs that have saved lives over the past century, will condemn ourselves, people we know, and people we don't know, to unacceptable risk of untreatable infection. Policies aimed at extending antimicrobial life should be considered within an ethical framework, in order to balance the choice, range, and quality of drugs against stewardship activities. Conserving availability and effectiveness for future use should not compromise today's patients. Practices such as antimicrobial prophylaxis for healthy people 'at risk' should receive full debate. There are additional ethical considerations for AMR involving veterinary care, agriculture, and relevant bio-industries. Restrictions for farmers potentially threaten the quality and quantity of food production with economic consequences. Antibiotics for companion animals do not necessarily spare those used for humans. While low-income countries cannot afford much-needed drugs, pharmaceutical companies are reluctant to develop novel agents for short-term return only. Public demand encourages over-the-counter, internet, black market, and counterfeit drugs, all of which compromise international control. Prescribers themselves require educational support to balance therapeutic choice against collateral damage to both body and environment. Predicted mortality due to AMR provides justification for international co-operation, commitment and investment to support surveillance and stewardship along with development of novel antimicrobial drugs. Ethical arguments for, and against, control of antimicrobial resistance strategies are presented and discussed in this review.

Significant OH production under surface cleaning and air cleaning conditions: Impact on indoor air quality

We report measurements of hydroxyl (OH) and hydroperoxy (HO₂ ) radicals made by laser-induced fluorescence spectroscopy in a computer classroom (i) in the absence of indoor activities (ii) during desk cleaning with a limonene-containing cleaner (iii) during operation of a commercially available "air cleaning" device. In the unmanipulated environment, the one-minute averaged OH concentration remained close to or below the limit of detection (6.5×10⁵  molecule cm^-3 ), whilst that of HO₂ was 1.3×10⁷  molecule cm^-3 . These concentrations increased to ~4×10⁶ and 4×10⁸  molecule cm^-3 , respectively during desk cleaning. During operation of the air cleaning device, OH and HO₂ concentrations reached ~2×10⁷ and ~6×10⁸  molecule cm^-3 respectively. The potential of these OH concentrations to initiate chemical processing is explored using a detailed chemical model for indoor air (the INDCM). The model can reproduce the measured OH and HO₂ concentrations to within 50% and often within a few % and demonstrates that the resulting secondary chemistry varies with the cleaning activity. Whilst terpene reaction products dominate the product composition following surface cleaning, those from aromatics and other VOCs are much more important during the use of the air cleaning device.

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.

Cleaning and asthma: A systematic review and approach for effective safety assessment

Research indicates a correlative relationship between asthma and use of consumer cleaning products. We conduct a systematic review of epidemiological literature on persons who use or are exposed to cleaning products, both in occupational and domestic settings, and risk of asthma or asthma-like symptoms to improve understanding of the causal relationship between exposure and asthma. A scoring method for assessing study reliability is presented. Although research indicates an association between asthma and the use of cleaning products, no study robustly investigates exposure to cleaning products or ingredients along with asthma risk. This limits determination of causal relationships between asthma and specific products or ingredients in chemical safety assessment. These limitations, and a lack of robust animal models for toxicological assessment of asthma, create the need for a weight-of-evidence (WoE) approach to examine an ingredient or product's asthmatic potential. This proposed WoE method organizes diverse lines of data (i.e., asthma, sensitization, and irritation information) through a systematic, hierarchical framework that provides qualitatively categorized conclusions using hazard bands to predict a specific product or ingredient's potential for asthma induction. This work provides a method for prioritizing chemicals as a first step for quantitative and scenario-specific safety assessments based on their potential for inducing asthmatic effects. Acetic acid is used as a case study to test this framework.

Chemical-induced asthma and the role of clinical, toxicological, exposure and epidemiological research in regulatory and hazard characterization approaches

Uncertainties in understanding all potential modes-of-action for asthma induction and elicitation hinders design of hazard characterization and risk assessment methods that adequately screen and protect against hazardous chemical exposures. To address this challenge and identify current research needs, the University of Cincinnati and the American Cleaning Institute hosted a webinar series to discuss the current state-of-science regarding chemical-induced asthma. The general consensus is that the available database, comprised of data collected from routine clinical and validated toxicological tests, is inadequate for predicting or determining causal relationships between exposures and asthma induction for most allergens. More research is needed to understand the mechanism of asthma induction and elicitation in the context of specific chemical exposures and exposure patterns, and the impact of population variability and patient phenotypes. Validated tools to predict respiratory sensitization and to translate irritancy assays to asthma potency are needed, in addition to diagnostic biomarkers that assess and differentiate allergy versus irritant-based asthmatic responses. Diagnostic methods that encompass the diverse etiologies of asthmatic responses and incorporate robust exposure measurements capable of capturing different temporal patterns of complex chemical mixtures are needed. In the absence of ideal tools, risk assessors apply hazard-based safety assessment methods, in conjunction with active risk management, to limit potential asthma concerns, proactively identify new concerns, and ensure deployment of approaches to mitigate asthma-related risks.

Association of household cleaning agents and disinfectants with asthma in young German adults

OBJECTIVES

We scrutinised the association of private use of household sprays and disinfectants with asthma incidence in young adults in the transition from school to working life.

METHODS

Between 2007 and 2009,2051 young adults aged 19-24 years living in two major German cities took part in the Study on Occupational Allergy Risks II. Self-reported exposure to household sprays and disinfectants was characterised according to a composite score for frequency of use as no use (score=0), low use (score between 1 and the median), medium use (score between the median and the 90th percentile) and high use (score above the 90th percentile). Two outcome variables (current asthma and current wheezing) with four mutually exclusive categories (never, incident, persistent and remittent) were used for the risk analyses. Multinomial logistic regression models examined the association between the frequency of using household sprays and disinfectants with asthma and wheezing adjusting for potential confounders.

RESULTS

Compared with no use, high use of disinfectants was associated with a more than twofold increased odds of incident asthma (OR 2.79, 95% CI 1.14 to 6.83). In addition, low/medium use of disinfectants was associated with remittent asthma (OR 2.39, 95% CI 1.29 to 4.47). The evidence for an association between high usage of household sprays and asthma incidence was weak (OR 2.79, 95% CI 0.84 to 9.20).

CONCLUSION

Our results support the hypothesis of an association between the use of cleaning products and elevated risks for asthma and wheezing in young adults at the start of working life.

Effects by inhalation of abundant fragrances in indoor air - An overview

Odorous compounds (odors) like fragrances may cause adverse health effects. To assess their importance by inhalation, we have reviewed how the four major abundant and common airborne fragrances (α-pinene (APN), limonene (LIM), linalool (LIL), and eugenol (EUG)) impact the perceived indoor air quality as odor annoyance, sensory irritation and sensitization in the airways. Breathing and cardiovascular effects, and work performance, and the impact in the airways of ozone-initiated gas- and particle phase reactions products have also been assessed. Measured maximum indoor concentrations for APN, LIM and LIL are close to or above their odor thresholds, but far below their thresholds for sensory irritation in the eyes and upper airways; no information could be traced for EUG. Likewise, reported risk values for long-term effects are far above reported indoor concentrations. Human exposure studies with mixtures of APN and LIM and supported by animal inhalation models do not support sensitization of the airways at indoor levels by inhalation that include other selected fragrances. Human exposure studies, in general, indicate that reported lung function effects are likely due to the perception rather than toxic effects of the fragrances. In general, effects on the breathing rate and mood by exposure to the fragrances are inconclusive. The fragrances may increase the high-frequency heart rate variability, but aerosol exposure during cleaning activities may result in a reduction. Distractive effects influencing the work performance by fragrance/odor exposure are consistently reported, but their persistence over time is unknown. Mice inhalation studies indicate that LIM or its reaction mixture may possess anti-inflammatory properties. There is insufficient information that ozone-initiated reactions with APN or LIM at typical indoor levels cause airway effects in humans. Limited experimental information is available on long-term effects of ozone-initiated reaction products of APN and LIM at typical indoor levels.

Supporting hospital renewal through strategic environmental sustainability programs

Although the impact the environment can have on human health is well understood, the healthcare system's impact on the environment is a topic that's only been explored since the mid-1990s. More recent has been a realization of the risks that climate change poses to health and healthcare. Although there are numerous direct benefits for hospitals adapting environmental sustainability programs, this article examines how the systemic approach taken by the University Health Network's (UHN) Energy & Environment program not only improves the hospital's environmental performance and provides significant cost savings but also supports several areas of focus that are part of UHN's current journey of renewal.

Work-related asthma among professional cleaning women

The job of cleaning has developed dynamically as a working service, and women constitute the majority of all professional cleaning workers. Cleaners are at an increased risk of work-related asthma (WRA). This study characterizes work-related respiratory symptoms reported by female cleaners, evaluates any associated factors of WRA, and shows diagnostic management of medical certification. The study group comprised 50 professional cleaning women referred to our Occupational Diseases Department due to suspicion of occupational asthma (OA). A questionnaire, skin prick tests, serum specific IgE antibodies, and specific inhalant challenge were performed in all of the participants. Work-related asthma was recognized in 46% of symptomatic cleaners, of whom 15 were considered as having work-exacerbated asthma (WEA) and 8 as having OA. Sensitization to latex and disinfectants played an important role as a causative agent in OA of cleaners.

Do chronic workplace irritant exposures cause asthma?

PURPOSE OF REVIEW

The present review summarizes the recent literature on the relation between chronic workplace irritant exposures and asthma, focusing on exposures of low to moderate levels. We discuss results from epidemiological surveys, potential biological mechanisms, and needs for further research. These aspects are largely illustrated by studies on exposure to cleaning products.

RECENT FINDINGS

Recent results from nine population-based and workplace-based epidemiological studies, mostly cross-sectional, found an increased risk of both new-onset and work-exacerbated asthma among participants exposed to moderate level of irritants and/or cleaning products.

SUMMARY

Evidence of a causal effect of chronic workplace irritant exposure in new-onset asthma remains limited, mainly because of a lack of longitudinal studies and the difficulty to evaluate irritant exposures. However, recent epidemiological studies strengthen the evidence of an effect of chronic exposure to irritants in work-related asthma. The underlying mechanism remains unknown but may be related to oxidative stress, neurogenic inflammation and dual irritant and adjuvant effects. However, disentangling chronic irritant effects from either acute irritant-induced asthma or immunological low molecular weight agent-induced asthma is difficult for some agents. Further research is needed to improve assessment of irritant exposures and identify biomarkers.

Cleaning practices and cleaning products in nurseries and schools: to what extent can they impact indoor air quality?

In the framework of a nationwide survey on indoor air quality conducted from September 2009 to June 2011 in 310 nurseries, kindergartens, and elementary schools in all regions of France, cleaning practices and products were described through an extensive questionnaire completed on-site by expert building inspectors. The questionnaire included the cleaning frequencies and periods, cleaning techniques, whether windows were open during cleaning, and the commercial names of the products used. Analysis of the questionnaire responses showed that cleaning was generally performed daily for furniture and floors. It was performed mostly in the evening with wet mopping and with one or more windows open. Five hundred eighty-four different cleaning products were listed, among which 218 safety data sheets (SDSs) were available and analyzed. One hundred fifty-two chemical substances were identified in the SDSs. The typical substances in cleaning products included alcohols, chlorides, terpenes, aldehydes, and ethers; more than half of them are irritants. Two endocrine disruptors, 2-phenylphenol and Galaxolide, were identified in two cleaning products used every day to clean the floors, in seven kindergartens and in a nursery respectively. Eleven reactive substances containing C=C double bonds, mostly terpenes, were identified in a wide variety of cleaning products.

Job strain, bullying and violence at work and asthma in Peruvian cleaners-a cross-sectional analysis

OBJECTIVES

An increased asthma prevalence was found in cleaners. Many of them work in precarious employment conditions, potentially leading to stress, a known risk factor for asthma. We aimed to analyze whether asthma in cleaners might partly be explained by psychosocial working conditions.

METHODS

The study population of this cross-sectional study included 199 cleaners employed at regional public health services in Puno Province (Peru). They were compared to 79 unexposed workers from Lima, Peru (response 83%). Both groups answered the short version of the European Working Condition Survey and a modified version of the European Community Respiratory Health screening questionnaire. After multiple imputation, the association between psychosocial working conditions and asthma (wheeze without cold or use of asthma medication) was assessed.

RESULTS

The 12-months prevalence of asthma was 22% among cleaners versus 5% among unexposed workers (pChi(2) = .001). Cleaners were more likely than unexposed workers to work with temporary or sub-contracts, have a high employment insecurity, high strain working conditions and low social support (all pChi(2) < .05). Twenty-six percent vs. 10% reported a high bullying score; 39% vs. 8% had experienced violence at work (both pChi(2) < .001). High bullying score (adjusted Odds Ratio 5.6; 95% Confidence Interval 1.5-21.4) and violence (2.4; 1.1-5.4) were the main predictors of asthma. Taking these factors into account, being a cleaner was not statistically significantly associated with the outcome (3.5; 0.9-13.8).

CONCLUSIONS

Poor psychosocial working conditions of cleaners may partly explain the high prevalence of asthma. The underlying mechanism might be a stress-induced inflammatory immune response.

Occupational health risks associated with the use of germicides in health care

Environmental surfaces have been clearly linked to transmission of key pathogens in health care facilities, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, Clostridium difficile, norovirus, and multidrug-resistant gram-negative bacilli. For this reason, routine disinfection of environmental surfaces in patient rooms is recommended. In addition, decontamination of shared medical devices between use by different patients is also recommended. Environmental surfaces and noncritical shared medical devices are decontaminated by low-level disinfectants, most commonly phenolics, quaternary ammonium compounds, improved hydrogen peroxides, and hypochlorites. Concern has been raised that the use of germicides by health care personnel may increase the risk of these persons for developing respiratory illnesses (principally asthma) and contact dermatitis. Our data demonstrate that dermatitis and respiratory symptoms (eg, asthma) as a result of chemical exposures, including low-level disinfectants, are exceedingly rare. Unprotected exposures to high-level disinfectants may cause dermatitis and respiratory symptoms. Engineering controls (eg, closed containers, adequate ventilation) and the use of personal protective equipment (eg, gloves) should be used to minimize exposure to high-level disinfectants. The scientific evidence does not support that the use of low-level disinfectants by health care personnel is an important risk for the development of asthma or contact dermatitis.

EPHECT III: Health risk assessment of exposure to household consumer products

In the framework of the EU EPHECT project (Emissions, Exposure Patterns and Health Effects of Consumer Products in the EU), irritative and respiratory effects were assessed in relation to acute (30-min) and long-term (24-h) inhalation exposure to key and emerging indoor air pollutants emitted during household use of selected consumer products. A detailed Health Risk Assessment (HRA) was performed for five selected pollutants of respiratory health relevance, namely acrolein, formaldehyde, naphthalene, d-limonene and α-pinene. For each pollutant, the Critical Exposure Limit (CEL) was compared to indoor air concentrations and exposure estimates for the use of 15 selected consumer products by two population groups (housekeepers and retired people) in the four geographical regions of Europe (North, West, South, East), which were derived previously based on microenvironmental modelling. For the present HRA, health-based CELs were derived for certain compounds in case indoor air quality guidelines were not available by the World Health Organization for end-points relevant to the current study. For each pollutant, the highest indoor air concentrations in each microenvironment and exposure estimates across home microenvironments during the day were lower than the corresponding acute and long-term CELs. However, considerable contributions, especially to acute exposures, were obtained in some cases, such as formaldehyde emissions resulting from single product use of a floor cleaning agent (82% CEL), a candle (10% CEL) and an electric air freshener (17% CEL). Regarding multiple product use, the case of 30-min formaldehyde exposure reaching 34% CEL when eight product classes were used across home microenvironments, i.e. all-purpose/kitchen/floor cleaning agents, furniture/floor polish, combustible/electric air fresheners, and perfume, needs to be highlighted. Such estimated values should be evaluated with caution, as these may be attributed to the exposure scenarios specifically constructed for the present study, following a 'most-representative worst-case scenario' approach for exposure and health risk assessment.