Association Between Occupational Exposure to Disinfectants and Asthma in Young Adults Working in Cleaning or Health Services: Results From a Cross-Sectional Analysis in Germany

Exposure Profiles for the Long-Term Use of Disinfectants and Cleaning Products and Asthma

BACKGROUND

Using disinfectants and cleaning products (DCPs) at home and work is known to influence both the onset and course of asthma, but most epidemiological studies did not consider the multiplicity and correlations of exposures to DCPs. We aimed to identify exposure profiles for the long-term weekly use of DCPs by latent class analysis (LCA) and assess their associations with asthma.

METHODS

LCA was conducted on data from 1143 young adults initially recruited in the German centers of Phase II of the International Study of Asthma and Allergies in Childhood (ISAAC) and followed up three times. In our LCA model, we included the use of cleaning sprays, disinfectant sprays, and nonspray disinfection methods, measured at ages 19-24 (first assessment) and 29-34 years (second assessment). Associations between identified exposure profiles and current as well as incident asthma/wheeze were evaluated by logistic regression.

RESULTS

We identified five long-term exposure profiles to DCPs (latent classes): no weekly use of DCPs (55% of participants), use in first assessment (7%), use in second assessment (18%), persistent use (8%), and persistent cleaning sprays use (12%). Compared to "no weekly use," being in the "persistent use" profile was associated with both current asthma (OR = 1.68, 95% CI = [0.48-5.88]) and current wheeze (OR = 1.71, 95% CI = [0.75-3.90]). For incident asthma/wheeze, interval estimates were very wide.

CONCLUSIONS

Our study identified five distinct long-term exposure profiles to DCPs. Among those, only a persistent weekly use of multiple DCPs over time seemed to have an adverse effect on asthma. However, large confidence intervals indicate considerable uncertainty.

Respiratory quaternary ammonium and volatile organic compound exposures experienced by home care aides during residential bathroom cleaning using conventional and green products

INTRODUCTION

US home care (HC) aide visits to clients' homes typically involve cleaning and disinfecting (C&D) environmental surfaces, particularly in bathrooms. Some ingredients in C&D products are associated with respiratory illness: sodium hypochlorite (bleach), quaternary ammonium compounds (QACs), and volatile organic compounds (VOCs). This study assessed and compared aides' respiratory exposures to specific VOCs and QACs while using 2 conventional and 1 "green" household C&D spray products during bathroom cleaning. Measured exposures were compared to ingredients listed on publicly available sources.

METHODS

Three C&D products were selected with principal active disinfecting ingredients: 1% to 5% sodium hypochlorite by weight ("bleach-based"); 0.1% to 1% QACs ("QACs-based"); and 0.05% thymol ("green"). Twenty-two aides were recruited to perform C&D tasks in a simulated residential bathroom constructed in an environmental monitoring laboratory. A balanced experimental study design involved each aide visiting the lab 4 times to perform typical cleaning tasks with the 3 products and distilled water (as a control), randomly assigned across the 4 visits. Aides wore air sampling equipment for breathing zone samples: canisters to collect whole air for VOC analyses and filter cassettes for QACs analyses.

RESULTS

Aides performed 84 cleaning visits contributing approximately 20 air samples each for VOCs and QACs, for each of the 3 products and distilled water. In total, 38 unique VOCs were identified in the canister whole air samples: 20 in the QACs-based product samples, 15 in the bleach-based, and 10 in the green. Most VOCs were not listed in publicly available sources of cleaning product ingredients. Toxicity information was limited. Few VOCs had occupational exposure limits. The QACs-based product generated QACs aerosol: benzalkonium chloride (BAC)12 (geometric mean (GM) = 6.98 µg/m3), BAC14 (GM=2.97 µg/m3), BAC16 (GM=0.78 µg/m3); and the 3 QACs summed (GM=10.86 µg/m3).

DISCUSSION

The use of C&D spray products for residential cleaning can generate respiratory exposures to complex mixtures of volatile and nonvolatile compounds. Notably, we measured aerosols containing QACs during the use of the QACs-based product. Dermal is usually considered the main route of exposure because QACs are nonvolatile salts. This study provides evidence that QACs inhalation exposure should be recognized and minimized in addition to the well-accepted dermal exposure routes. The green product generated the fewest VOCs. However, more toxicity information is needed on the health impacts of green C&D products. Spraying of C&D products, conventional and green, should be avoided.

CONCLUSIONS

Aides' respiratory health should be protected from chemical exposures while performing C&D in home care.

Synergistic interaction of co-exposure to humidifier disinfectant chemicals CMIT/MIT and PHMG in lung injury

A number of biocidal disinfectant chemicals are used as household products to prevent spread of pathogens. People are commonly exposed to multiple chemicals through those disinfectants. However, effects of interactions (e.g., synergism) between disinfectants on human health outcomes have been rarely studied. In this study, we aimed to investigate associations of a mixture of chloromethylisothiazolinone/methylisothiazolinone (CMIT/MIT) and polyhexamethylene guanidine (PHMG), which had been used as humidifier disinfectants (HDs) in South Korea, with HD-associated lung injury (HDLI) in a Korean population (n = 4058) with HD exposure through use of HD products. Exposure to HD was retrospectively assessed by an interview-based standardized survey, and HDLI was determined by clinical assessment. After adjusting for covariates, PHMG-specific exposure indices (e.g., amount of use, indoor air concentration, and weekly exposure level) were dose-dependently associated with HDLI (their odds ratios for the comparison of third tertile versus first tertile were 1.95, 1.77, and 2.16, respectively). CMIT/MIT exposure was not observed to have a significant association with HDLI in a single chemical exposure model; however, associations between PHMG exposure and HDLI were strengthened by co-exposure to CMIT/MIT in combined chemical exposure models, where synergistic interactions between CMIT/MIT use and PHMG indices (amount of use and weekly exposure level) were observed (p-interaction in additive scale: 0.02 and 0.03, respectively). Our findings imply that adverse effects of PHMG exposure on lung injury among HD users might be worsened by co-exposure to CMIT/MIT. Given that plenty of household products contain disinfectants on global markets, epidemiological and toxicological investigations are warranted on interaction effects of co-exposure to disinfectants.

Avoidance of Inhaled Pollutants and Irritants in Asthma from a Salutogenic Perspective

Much is known about the role of aeroallergens in asthma, but little is described about the damage caused by inhaled pollutants and irritants to the respiratory epithelium. In this context, the most frequent pollutants and irritants inhaled in the home environment were identified, describing the possible repercussions that may occur in the respiratory tract of the pediatric population with asthma and highlighting the role of the caregiver in environmental control through a salutogenic perspective. Searches were carried out in the MEDLINE/PubMed, Web of Science, Lilacs and Scopus databases for articles considered relevant for the theoretical foundation of this integrative review, in which interactions between exposure to pollutants and inhaled irritants and lung involvement. Articles published in the last 10 years that used the following descriptors were considered: air pollution; tobacco; particulate matter; disinfectants; hydrocarbons, fluorinated; odorants; chloramines; pesticide; asthma; and beyond Antonovsky's sense of coherence. Exposure to smoke and some substances found in cleaning products, such as benzalkonium chloride, ethylenediaminetetraacetic acid and monoethanolamine, offer potential risks for sensitization and exacerbation of asthma. The vast majority of the seven main inhaled products investigated provoke irritative inflammatory reactions and oxidative imbalance in the respiratory epithelium. In turn, the caregiver's role is essential in health promotion and the clinical control of paediatric asthma. From a salutogenic point of view, pollutants and irritants inhaled at home should be carefully investigated in the clinical history so that strategies to remove or reduce exposures can be used by caregivers of children and adolescents with asthma.

Development and Cognitive Testing of Occupational Safety and Health Questions for a Youth Survey: Addressing the Research Needs for a Vulnerable Working Population

BACKGROUND

While more than 2.5 million U.S. high students worked in 2020, data to assess how work affects this group are sparse. To facilitate such research, a set of occupational safety and health questions for inclusion on the Youth Risk Behavior Surveillance System (YRBSS) and other youth-focused surveys was developed.

METHODS

Survey questions about occupational experiences of young workers were adapted from other surveys or created de novo. Key audiences were engaged to define priority topic areas and develop draft questions, which were further refined through cognitive interviews with working youth.

RESULTS

Twenty-one resulting questions spanned multiple work-related topics: employment status; health outcomes; psychosocial exposures; and safety climate. Cognitive testing revealed that youth (aged 14-19) had difficulty with temporal concepts. Some difficulties reflected the propensity of youth to engage in multiple, online, and informal jobs. During 3 rounds of interviews, questions were adjusted to better reflect youth employment circumstances and language. Four states added at least 1 work-related question to their 2023 Youth Risk Behavior Survey questionnaire, and the full set of questions has been disseminated to federal agencies and partners.

CONCLUSION

Including tailored questions about employment in surveys of youth will facilitate occupational health surveillance for this group. Analysis of resulting data can help to close knowledge gaps, provide current prevalence data, inform policy, and allow development of focused prevention and intervention strategies to reduce adverse outcomes among young workers.

Comprehensive analysis of disinfectants on the horizontal transfer of antibiotic resistance genes

The propagation of antimicrobial resistance (AMR) is constantly paralyzing our healthcare systems. In addition to the pressure of antibiotic selection, the roles of non-antibiotic compounds in disseminating antibiotic resistance genes (ARGs) are a matter of great concerns. This study aimed to explore the impact of different disinfectants on the horizontal transfer of ARGs and their underlying mechanisms. First, the effects of different kinds of disinfectants on the conjugative transfer of RP4-7 plasmid were evaluated. Results showed that quaternary ammonium salt, organic halogen, alcohol and guanidine disinfectants significantly facilitated the conjugative transfer. Conversely, heavy-metals, peroxides and phenols otherwise displayed an inhibitory effect. Furthermore, we deciphered the mechanism by which guanidine disinfectants promoted conjugation, which includes increased cell membrane permeability, over-production of ROS, enhanced SOS response, and altered expression of conjugative transfer-related genes. More critically, we also revealed that guanidine disinfectants promoted bacterial energy metabolism by enhancing the activity of electron transport chain (ETC) and proton force motive (PMF), thus promoting ATP synthesis and flagellum motility. Overall, our findings reveal the promotive effects of disinfectants on the transmission of ARGs and highlight the potential risks caused by the massive use of guanidine disinfectants, especially during the COVID-19 pandemic.

Demonstrating the In Vitro and In Situ Antimicrobial Activity of Oxide Mineral Microspheres: An Innovative Technology to Be Incorporated into Porous and Nonporous Materials

The antimicrobial activity of surfaces treated with zinc and/or magnesium mineral oxide microspheres is a patented technology that has been demonstrated in vitro against bacteria and viruses. This study aims to evaluate the efficiency and sustainability of the technology in vitro, under simulation-of-use conditions, and in situ. The tests were undertaken in vitro according to the ISO 22196:2011, ISO 20473:2013, and NF S90-700:2019 standards with adapted parameters. Simulation-of-use tests evaluated the robustness of the activity under worst-case scenarios. The in situ tests were conducted on high-touch surfaces. The in vitro results show efficient antimicrobial activity against referenced strains with a log reduction of >2. The sustainability of this effect was time-dependent and detected at lower temperatures (20 ± 2.5 °C) and humidity (46%) conditions for variable inoculum concentrations and contact times. The simulation of use proved the microsphere's efficiency under harsh mechanical and chemical tests. The in situ studies showed a higher than 90% reduction in CFU/25 cm² per treated surface versus the untreated surfaces, reaching a targeted value of <50 CFU/cm². Mineral oxide microspheres can be incorporated into unlimited surface types, including medical devices, to efficiently and sustainably prevent microbial contamination.

Environmental and health impacts of spraying COVID-19 disinfectants with associated challenges

Coronavirus refers to a group of widespread viruses. The name refers to the specific morphology of these viruses because their spikes look like a crown under an electron microscope. The outbreak of coronavirus disease 2019 (COVID-19) that has been reported in Wuhan, China, in December 2019, was proclaimed an international public health emergency (PHEIC) on 30 January 2020, and on 11 March 2020, it was declared as a pandemic (World Health Organization 2020). The official name of the virus was declared by the WHO as "COVID-19 virus", formerly known as "2019-nCoV", or "Wuhan Coronavirus". The International Committee on Virus Taxonomy's Coronavirus Research Group has identified that this virus is a form of coronavirus that caused a severe outbreak of acute respiratory syndrome in 2002-2003 (SARS). As a result, the latest severe acute respiratory syndrome has been classified as a corona virus 2 (SARS-CoV-2) pathogen by this committee. This disease spread quickly across the country and the world within the first 3 months of the outbreak and became a global pandemic. To stop COVID-19 from spreading, the governing agencies used various chemicals to disinfect different commercial spaces, streets and highways. However, people used it aggressively because of panic conditions, anxiety and unconsciousness, which can have a detrimental impact on human health and the environment. Our water bodies, soil and air have been polluted by disinfectants, forming secondary products that can be poisonous and mutagenic. In the prevention and spread of COVID-19, disinfection is crucial, but disinfection should be carried out with sufficient precautions to minimize exposure to harmful by-products. In addition, to prevent inhalation, adequate personal protective equipment should be worn and chemical usage, concentrations, ventilation in the room and application techniques should be carefully considered. In the USA, 60% of respondents said they cleaned or disinfected their homes more often than they had in the previous months. In addition to the robust use of disinfection approaches to combat COVID-19, we will explore safe preventative solutions here.

Disinfection in the time of COVID: Safe solutions are critical for schools

Surface disinfection is part of school protocols designed to decrease the risk of students and staff contracting COVID-19. However, exposure to disinfectants can have short- and long-term health consequences. Given that the risks are well-described and safer products are readily available, it is critical that schools consciously employ safer disinfection strategies.

Sanitizer-associated systemic side effects in the era of COVID-19: a pharmacovigilance study

Background

The practice of proper hand sanitization became of utmost importance and one of the best protective measures during the pandemic outbreak of COVID-19. However, misuse of disinfectants can be an overwhelming issue because of increasing demands, public panic, and unawareness, which can negatively affect human health and the environment. Therefore, we aimed to determine whether the outbreak was associated with increased reports of adverse events related to hand sanitizers through the data of adverse events reported to the pharmacovigilance database of the Food and Drug Administration Adverse Event Reporting System (FAERS). FAERS database was analyzed for hand sanitizer reports including alcohol-based and alcohol-free formulations.

Results

Adverse events reports associated with hand sanitizers increased significantly by 2020 with variable severity degrees, noting that most serious cases were reported with alcohol-based sanitizers.

Conclusion

Based on data mining of the FAERS database, we claim that the increased reports associated with alcohol hand sanitizer use deserve attention. However, FAER's database has some limitations, such as case duplication and lack of a control group. Hence, further monitoring with more robust sources of data sources is critically needed.

Identifying cleaning products associated with short-term work-related respiratory symptoms: A workforce-based study in domestic cleaners

Domestic cleaners have an increased risk of asthma-like and other respiratory symptoms and conditions. Uncertainty exists about which products are most hazardous. We aimed to investigate, among professional domestic cleaners, the associations of ocular/respiratory outcomes with using specific types of products at work and with the ability to choose their own products. Among domestic cleaners employed by "service vouchers" companies in Belgium, we administered an online questionnaire on ocular/respiratory symptoms (frequency and time relation to workdays), frequency of use of 40 types of products, and ability to choose one's own products. Work-relatedness was defined as symptoms improving/disappearing on days off-work. We studied associations between frequency of product-use with work-related outcomes (eye irritation, rhinitis symptoms, sore throat, laryngeal symptoms, asthma symptoms, cough) and with chronic bronchitis, using multivariable logistic and elastic net regression. Adjusted odds ratios (OR) with 95%-confidence intervals were obtained per time a product was used per week. Among 1,586 domestic cleaners (99% women), the number of times sprays were used (median 13/week) was significantly associated with all outcomes (ORs between 1.012 and 1.024 per time sprays were used per week). Bleach/disinfectant-containing liquid products were associated with all outcomes, except for laryngeal symptoms (ORs 1.086 to 1.150); ammonia with work-related upper airway symptoms and chronic bronchitis. Cleaners able to choose their own products had fewer work-related eye symptoms (OR 0.728;0.556-0.954), rhinitis (OR 0.735;0.571-0.946) and cough (OR 0.671;0.520-0.865). Using elastic net regression, work-related rhinitis was most strongly associated with mould removal spray (OR 1.108;1.006-1.248), carpet/seat/curtain spray (OR 1.099;1.001-1.304) and ammonia (OR 1.081;1.002-1.372); work-related asthma with carpet/seat/curtain spray (OR 1.103;1.017-1.322), mould removal spray (OR 1.029;0.995-1.199) and drain cleaner (OR 1.023;0.979-1.302). In a large group of domestic cleaners, we documented that cleaning products have a range of adverse respiratory effects. Empowering cleaners to choose their products may reduce the burden of symptoms.

Dynamic and quantitative characterization of antagonism within disinfectant mixtures by a modified area-concentration ratio method

The coexistence of various typical disinfectant pollutants has the potential to produce toxicity interaction towards organisms in the environment. A suitable model is necessary to evaluate the interaction quantitatively. Hence, the area-concentration ratio (ACR) method was modified (MACR) by combing confidence intervals to dynamically and quantitatively evaluate the toxicity interactions within disinfectant mixture pollutants. Disinfectant mixtures were designed by the direct equipartition design ray method using three guanidine disinfectants, chlorhexidine diacetate (CD), chlorhexidine (CHL), and polyhexamethylene biguanidine (POL) and one chlorine-containing disinfectant calcium hypochlorite (CAL). The toxicities of the four disinfectants and their mixtures towards Vibrio qinghaiensis sp.-Q67 (Q67) were determined by the time-dependent toxicity microplate analysis method. And the toxicity mechanism was analyzed by determining the effects of four disinfectants and their binary mixtures on the structure of cell, DNA and proteins (Pro) for Q67. The results show that the toxicities of CD and CHL to Q67vary little with time, but POL and CAL show the obvious time-dependent toxicity. The toxicities of CD, CHL and POL to Q67 are significantly stronger than that of CAL at the same exposure time. The toxicities of three binary mixture systems don't have significant difference in different exposure time. MACR can dynamically, quantitatively and accurately characterize toxicity interactions compared with ACR. According to MACR, the antagonism intensity dynamically changes with the prolongation of exposure time for binary mixture rays of three guanidine disinfectants and CAL, and linearly correlates with the components' concentration ratios. Four disinfectants all can destroy cell membrane and cause desaturation DNA of test organism, and CAL even can destroy the structure of DNA and protein. The probably reason for the antagonism within binary mixtures is the reaction between guanidine group and ClO^-, which is called chemical antaogism.

Assessment of home care aides' respiratory exposure to total volatile organic compounds and chlorine during simulated bathroom cleaning: An experimental design with conventional and "green" products

Home care (HC) aide visits to clients' homes often involve cleaning and disinfecting (C&D) bathrooms. Some ingredients in C&D household products are associated with respiratory illness, including sodium hypochlorite (bleach) and quaternary ammonium compounds (quats). "Green" products may be safer for the environment, however there are limited quantitative evaluations of their respiratory risks. This study assessed airborne concentrations and time profiles of total volatile organic compounds (TVOC) and chlorine generated during typical bathroom cleaning performed by aides using conventional and green products. Aides performed cleaning tasks in a simulated residential bathroom constructed in an environmental air sampling laboratory. A balanced experimental design involved each aide coming to the lab for four visits during which she performed two 20-min cleaning sessions using one of three C&D products (bleach-based, 1-5% sodium hypochlorite by weight; quats-based, 0.1-1% by weight quaternary ammonium compounds; and "green," 0.05% by weight thymol, a component of botanical thyme oil) or distilled water as a control. TVOC and chlorine direct reading instruments were attached to aides with sample inlets located in the breathing zone. Ten-second averages of TVOC and chlorine gas concentrations and instantaneous peak concentrations were recorded for the sessions' duration. TVOC concentrations by methods of C&D application (spraying, streaming, wiping) also were evaluated. The study completed 169 air sampling sessions with 22 aides. The quats-based product generated more than twice the average TVOC concentrations (mean = 1,210 ppb) than the bleach-based (mean = 593 ppb) or green (mean = 498 ppb) products. Each product generated TVOC concentrations that rose rapidly within the first few minutes of application. Spraying produced the highest TVOC exposures, wiping the lowest. Thirteen aides (65%) experienced peak chlorine exposures above the OSHA PEL ceiling limit (1 ppm) when using the bleach-based product. HC aides may experience respiratory hazards from use of conventional or green C&D products formulated with bleach or other respiratory irritants and sprayed in small, poorly ventilated spaces typical of bathrooms. Spraying should be avoided.

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.

Consequences of chemical impact of disinfectants: safe preventive measures against COVID-19

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has created a significant threat to global health. It originated in Wuhan, China and caused a total of 83,483 confirmed cases and 4634 deaths until June 2020. This novel virus spread primarily through respiratory droplets and close contact. The person-to-person transmission by direct transmittance through cough, sneeze, droplet inhalation, and contact spreading from dry surfaces contaminated with secretions of nose, mouth, and eyes of an infected person has been proven about SARS-CoV-2 transmission. As disease progressed, a series of complications tends to develop, especially in critically ill and immunocompromised patients. Pathological studies showed representative features of acute respiratory distress syndrome (ARDS) and implications on multiple organs as well. However, no specific antiviral drugs or vaccines are immediately available for the treatment of this lethal disease. The efficacy of some promising antivirals needs to be investigated by ongoing clinical trials. In current circumstances, supportive care, precautions, and social distancing are the only preventive options to ameliorate COVID-19. To disinfect the environment, mainly chemical disinfectants are being used robustly. However, due to panic state, fright, and unawareness, people are using it violently, which can have an adverse effect on human health and environment. This review discusses about the potential harmful effect of disinfectants, if used inappropriately. Here, we will also discuss safe preventive options as an alternative to robust use of disinfection methods to fight against COVID-19.