Asthma symptoms in women employed in domestic cleaning: a community based study

The application of the mobile application for the assessment of cleaning workers' exposure to cleaning products: a pilot study

BACKGROUND

Cleaning product use has been associated with adverse respiratory health effects such as asthma in cleaning staff and healthcare workers. Research in health effects from cleaning products has largely depended upon collecting exposure information by questionnaires which has limitations such as recall bias and underestimation of exposure. The aim of this study was to develop a Cleaning and Hazardous Products Exposure Logging (CHaPEL) app with a barcode scanner and to test the feasibility of this app with university cleaners.

METHODS

The CHaPEL app was developed to collect information on demographics, individual product information, and exposure information. It also included an ease-of-use survey. A pilot study with university cleaning workers was undertaken in which cleaning workers scanned each product after use and answered the survey. Respiratory hazards of cleaning substances in the scanned cleaning products were screened by safety data sheets, a Quantitative Structure-Activity Relationship model and an asthmagen list established by an expert group in the US.

RESULTS

Eighteen university cleaners participated in this study over a period of 5 weeks. In total, 77 survey responses and 6 cleaning products were collected and all reported that using the app was easy. The most frequently used product was a multi-surface cleaner followed by a disinfectant. Out of 14 substances in cleaning products, ethanolamine and Alkyl (C12-16) dimethyl benzyl ammonium chloride were found as respiratory hazardous substances.

CONCLUSION

The CHaPEL app is a user-friendly immediate way to successfully collect exposure information using the barcodes of cleaning products. This tool could be useful for future epidemiological studies focused on exposure assessment with less interruption to the workers.

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.

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.

Effects of cleaning spray use on eyes, airways, and ergonomic load

BACKGROUND

Cleaning workers are exposed to chemicals and high physical workload, commonly resulting in airway problems and pain. In this study the response in the upper airways and the physical workload following airborne and ergonomic exposure of cleaning spray was investigated.

METHODS

A survey was answered by professional cleaning workers to investigate their use of cleaning sprays and the perceived effects on eyes, airways and musculoskeletal pain. A human chamber exposure study was then conducted with 11 professional cleaning workers and 8 non-professional cleaning workers to investigate the airborne exposure, acute effects on eyes and airways, and physical load during cleaning with sprays, foam application and microfiber cloths premoistened with water. All cleaning products used were bleach, chlorine, and ammonia free. The medical assessment included eye and airway parameters, inflammatory markers in blood and nasal lavage, as well as technical recordings of the physical workload.

RESULTS

A high frequency of spray use (77%) was found among the 225 professional cleaning workers that answered the survey. Based on the survey, there was an eight times higher risk (p < 0.001) of self-experienced symptoms (including symptoms in the nose, eyes and throat, coughing or difficulty breathing) when they used sprays compared to when they cleaned with other methods. During the chamber study, when switching from spray to foam, the airborne particle and volatile organic compound (VOC) concentrations showed a decrease by 7 and 2.5 times, respectively. For the whole group, the peak nasal inspiratory flow decreased (-10.9 L/min, p = 0.01) during spray use compared to using only water-premoistened microfiber cloths. These effects were lower during foam use (-4.7 L/min, p = 0.19). The technical recordings showed a high physical workload regardless of cleaning with spray or with water.

CONCLUSION

Switching from a spraying to a foaming nozzle decreases the exposure of both airborne particles and VOCs, and thereby reduces eye and airway effects, and does not increase the ergonomic load. If the use of cleaning products tested in this study, i.e. bleach, chlorine, and ammonia free, cannot be avoided, foam application is preferable to spray application to improve the occupational environment.

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.

Impact of socioeconomic factors and house cleaning on asthma control in women

Background: It is known that socioeconomic factors affect various chronic diseases and also might affect asthma control. Exposure to house-cleaning products has been shown to impact both the onset and control of asthma. Objective: This study aimed to determine the effect of socioeconomic factors and house cleaning on asthma control of women with asthma. Methods: Adult women with asthma (N = 204) with informed consent were included in this single-center, cross-sectional observational study. A questionnaire, including items related to demographic, clinical, and socioeconomic features of the patients, was administered with a face-to-face interview by an investigator. A test to assess the level of asthma control was used to classify the patients as uncontrolled, partially controlled, and fully controlled. Wealth perception was measured with a visual analog scale. Investigated socioeconomic features were household size, monthly household income, education status, working status, occupation, and education status of the mothers of the patients. Results: Of the 204 adult female patients, 68.6% had uncontrolled, 14.7% had partially controlled, and 16.7% had fully controlled asthma. Partially or fully controlled asthma was higher (odds ratio [OR] 2.6 [95% confidence interval [CI], 1.09-6.22]) in the highest income quantile compared with the lowest income quantile. Asthma was better controlled in women with a visual analog scale score of wealth perception ≥ 7 (OR 1.93 [95% CI, 1.04-3.59]) and, in those who cleaned their houses, one to two times per week compared with zero times per week (OR 2.94 [95% CI, 1.19-7.26]). Conclusion: Having a higher household income was the only socioeconomic factor associated with better asthma control. After adjusting for age, duration of asthma, and comorbidities, better asthma control was significantly associated with cleaning the house one to two times a week.

A pilot study of total personal exposure to volatile organic compounds among Hispanic female domestic cleaners

Cleaners have an elevated risk for the development or exacerbation of asthma and other respiratory conditions, possibly due to exposure to cleaning products containing volatile organic compounds (VOCs) leading to inflammation and oxidative stress. This pilot study aimed to quantify total personal exposure to VOCs and to assess biomarkers of inflammation and pulmonary oxidative stress in 15 predominantly Hispanic women working as domestic cleaners in San Antonio, Texas, between November 2019 and July 2020. In partnership with a community organization, Domésticas Unidas, recruited women were invited to attend a training session where they were provided 3M 3500 passive organic vapor monitors (badges) and began a 72-hr sampling period during which they were instructed to wear one badge during the entire period ("AT," for All the Time), a second badge only while they were inside their home ("INS," for INSide), and a third badge only when they were outside their home ("OUT," for OUTside). At the end of the sampling period, women returned the badges and provided blood and exhaled breath condensate (EBC) samples. From the badges, 30 individual VOCs were measured and summed to inform total VOC (TVOC) concentrations, as well as concentrations of the following VOC groups: aromatic hydrocarbons, alkanes, halogenated hydrocarbons, and terpenes. From the blood and EBC samples, concentrations of serum C-reactive protein (CRP) and EBC 8-isoprostane (8-ISP) and pH were quantified. Data analyses included descriptive statistics. The 72-hr average of personal exposure to TVOC was 34.4 ppb and ranged from 9.2 to 219.5 ppb. The most prevalent class of VOC exposures for most women (66.7%) was terpenes, specifically d-limonene. Overall, most women also experienced higher TVOC concentrations while outside their home (86.7%) as compared to inside their home. Serum CRP concentrations ranged from 0.3 to 20.3 mg/dL; 8-ISP concentrations ranged from 9.5 to 44.1 pg/mL; and EBC pH ranged from 7.1 to 8.6. Overall, this pilot study demonstrated personal VOC exposure among Hispanic domestic cleaners, particularly to d-limonene, which may result from the use of scented cleaning products.

Indoor exposure levels of ammonia in residences, schools, and offices in China from 1980 to 2019: A systematic review

Indoor ammonia (NH₃ ) pollution has been paid more and more attention in view of its health risk. However, few studies have investigated the exposure level in the non-occupational environment in China. This study systematically reviewed the indoor ammonia exposure level in different regions, the equivalent exposure concentration of different populations, and the factors that influence indoor air ammonia in residences, offices, and schools in China. The literature published in 1980-2019 from main databases was searched and detailed screened, and finally, 56 related studies were selected. The results illustrated that the median concentration of indoor air ammonia in residences, offices, and school buildings was 0.21 mg/m³ , 0.26 mg/m³ , and 0.15 mg/m³ . There were 46.4%, 71.4%, and 40% of these samples exceeding the NH₃  standard, respectively. The national concentrations and the equivalent exposure levels of adults and children were calculated and found to be higher than 0.20 mg/m³ . The concentration of ammonia varied greatly in different climate zones and economic development regions. Higher concentrations were found in the severe cold zone and the regions with higher economic level. This review reveals a high exposure risk of indoor air ammonia and the crucial impact of human emission, indoor air temperature, new concrete, and economic level, suggesting further investigation on indoor air ammonia evaluation and health effects.

Associations of residential and occupational history with the distribution of persistent pollutant mixtures in adipose tissue samples

This research aims to explore clusters of a mixture of 15 Persistent Toxic Substances (PTSs) in the adipose tissue of 227 individuals of an adult cohort from Granada Province (Southern Spain). Information about residence and occupation during participants lifetime was gathered by means of validated questionnaires. Clusters of pollutants in the study population were identified by Principal Component Analyses (PCA). PCA analyses revealed three major clusters of pollutants: PC1, representing predominantly an assortment of metal(loid)s, namely aluminium, arsenic, chromium, nickel and lead; PC2, including mostly Organochlorine Pesticides (OCPs), such as HCB, β-HCH and p,p'-DDE; and PC3, gathering mainly a mixture of Polychlorinated Biphenyls (PCB-138, PCB-153 and PCB-180) and metals (cadmium, cobalt and chromium). The patterns of distribution of individual pollutants and their mixtures were explored through Geographic Information Systems and multivariable linear regression models. Living in rural areas was associated with decreased levels of the mixture of PCBs and metals. Residents of industrial and heavy traffic areas showed increased levels of the mixture of metal(loid)s. Those living in rural and semi-rural areas at recruitment had decreased levels of the OCP mixture. Occupational history related to agriculture and food industry was associated with increased levels of the mixture of metal(loid)s, whereas those who had been involved in motor and industrial activities showed increased levels of the OCP mixture. Participants who had worked in cleaning and housekeeping activities for long periods showed decreased levels of the mixture of PCBs and metals. Our research revealed suggestive clusters of exposure, that emphasized the need for further epidemiological studies to address the effect of environmental pollutants from a mixture perspective. Results also highlight the potential of adipose tissue as a matrix for exposure assessment to combinations of different families of contaminants.

Cleaning products and respiratory health outcomes in occupational cleaners: a systematic review and meta-analysis

There is consistent evidence of increased respiratory symptoms in occupational cleaners; however, uncertainty remains on type of respiratory health effects, underlying causal agents, mechanisms and respiratory phenotypes. We aimed to conduct a systematic review and if possible, a meta-analysis of the available literature to characterise and quantify the cleaning-related respiratory health effects. We searched MEDLINE and EMBASE databases and included studies that evaluated the association of any respiratory health outcome with exposure to cleaning occupation or products in occupational cleaners. A modified GRADE was used to appraise the quality of included studies. We retrieved 1124 articles, and after applying our inclusion criteria, 39 were selected for the systematic review. We performed a meta-analysis of the 21 studies evaluating asthma which showed a 50% increased pooled relative risk in cleaners (meta-relative risk (RR)=1.50; 95% CI 1.44 to 1.56). Population-based cross-sectional studies showed more stable associations with asthma risk. No evidence of atopic asthma as dominant phenotype emerged. Also, we estimated a 43% increased risk (meta-RR=1.43; 95% CI 1.31 to 1.56) of chronic obstructive pulmonary disease. Evidence for associations with bronchial-hyper-responsiveness, lung function decline, rhinitis, upper and lower respiratory tract symptoms was weaker. In our systematic review and meta-analysis, we found that working as a cleaner is associated with an increased risk of reversible and even irreversible obstructive airway diseases. All studies lacked quantitative exposure assessment to cleaning products; this would help elucidate underlying causal agents and mechanisms. Exposure control and respiratory surveillance among cleaners is warranted to prevent the associated respiratory health burden. Trial registration number: CRD4201705915.

Consumer exposure and risk assessment to selected chemicals of mold stain remover use in Korea

Mold stain remover (MSR) is used to clean mold and mildew spots from surfaces and contains a variety of chemical substances. In this study, we estimated the inhalation and dermal exposures associated with the use of trigger spray MSRs, and performed screening-level risk assessments for the use of this type of product in Korea. Inhalation and dermal exposures were estimated using exposure algorithms based on exposure factors obtained from a nationwide survey of 10,000 participants and chemical analyses of the four most popular trigger spray MSRs. The hazard quotients (HQs) for noncancer risk and excess cancer risk (ECR) were calculated for each chemical. The mean inhalation exposure estimates for formaldehyde, benzene, chloroform, and carbon tetrachloride were 6.9 × 10^-7, 1.7 × 10^-7, 5.4 × 10^-6, and 2.7 × 10^-5 mg/kg/day, respectively. Dermal exposures of the chemicals were 5.7-6.5 times higher than inhalation exposures. The HQs for total exposure were all below 1, which indicated little noncancer risk from the use of MSRs. The safe ECR value of 1 × 10^-6, was exceed in one subject for inhalation exposure of benzene and four subjects for dermal exposure of formaldehyde, while 19.8% for dermal exposure of benzene were above this value. Therefore, use of trigger spray MSRs in Korea should require more detailed exposure and risk assessment, especially for benzene.

Working Conditions and Work-Related Health Issues of Female Domestic Workers in Four Districts of Karachi

OBJECTIVES

To determine the working conditions and work-related health issues of female domestic workers (FDWs) in four districts of Karachi.

METHODS

Population-based cross-sectional study was conducted in four squatter settlements of Karachi with sample size of 406 FDWs in 2018. Pretested questionnaire was administered to collect data through snowball technique. Multivariate logistic regression examined the association between different factors and experiencing violence, work-related injuries, and chemical exposures.

RESULTS

Only (14.5%) of domestic workers earned Rs 15 000 (75 GBP month-1) and above. >1% had financial support for the health or education of children. Verbal violence included shouting (40.9%), constant critique of work (17.2%), and job threats (13.5%). Common workplace injuries were cuts (30.8%), burns (27.6%), and bruises (23.6%). Doing laundry showed significant positive association with experiencing cuts [odds ratio (OR) = 2.09; 1.15-3.71], looking after children to bruises (OR = 2.29; 1.07-4.88), and cooking to burns (OR = 4.66; 2.68-8.08).

CONCLUSIONS

Creating economic environment which is equal for all low wage workers, setting up domestic labor standards and holding employers accountable to them is essential.

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.

Characterization of airborne particles from cleaning sprays and their corresponding respiratory deposition fractions

Cleaning workers are exposed to many risk factors, including handling of cleaning products. Epidemiological studies show that they have a high incidence of asthma and other respiratory symptoms. Some studies have indicated an even higher incidence of asthma in individuals using cleaning sprays regularly. It is known that sprays produce an aerosol that can expose the respiratory system to chemicals. Knowledge of the physical characteristics of the airborne particles, as well as the characteristics of the gas phase, is needed to determine how they affect the respiratory tract and why they cause airway symptoms. The aim of this study was to characterize the aerosols from seven different ready-to-use trigger cleaning sprays in terms of total airborne mass fraction, particle size distribution, and new particle formation from ozone reactions. An additional aim was to calculate the respiratory deposition fraction of the measured particles. The total airborne mass fraction was determined by comparing the mass deposited on the chamber wall with the mass emitted from the bottle during spraying. Particle number concentration and size distribution of the airborne particles were measured using an aerodynamic particle sizer and a fast aerosol mobility size spectrometer. The total airborne mass fraction was between 2.7% and 32.2% of the mass emitted from the bottle, depending on the product. Between 0.0001% and 0.01% of the total airborne mass fraction consisted of residual particles. However, these particles had a mass median aerodynamic diameter between 1.9 µm and 3.7 µm, constituting a total respiratory deposition of up to 77%. New particle formation in the presence of ozone was also shown to vary between 5,000 cm^-3 and 35,000 cm^-3 depending on the product, in the studied settings. These findings confirm that a substantial part (up to 1/3) of the mass sprayed from the bottle does not reach the intended surface. Thus, the use of cleaning sprays can result in chemical airway exposure, with particles in the relevant size range for both nasal and alveolar deposition.

Work-Related Symptoms of Patients with Asthma: A Multicenter Study

OBJECTIVES

It is considered that occupational exposure accounts for up to 25% of all cases of adult asthma. We need detailed individual-level data regarding the relationship between asthma, occupation, and work-related symptoms in Turkey to inform policies on workplace safety. This study aimed to investigate the association between asthma symptoms, occupation type, and workplace exposure in patients with asthma.

MATERIALS AND METHODS

In this cross-sectional multicenter study, adult patients with asthma were investigated by a questionnaire in terms of relationship between asthma symptoms and workplace exposure. The study population was adult patients who had been diagnosed with asthma for at least six months prior to study and who were under follow-up in Ankara, İstanbul, Erzurum, Düzce, Trabzon, Denizli, and Diyarbakır.

RESULTS

The mean age of the 345 cases (188 females) was 41±13 years. The majority of the patients (36.8%) were "housewives"; other common occupations were office workers (6.7%), textile workers (4%), students (3.8%), hospital staff (3.5%), and cleaners (2.9%). Thirty-five percent of patients described worsening of asthma during working periods. Among patients with a history of increased symptoms in workplace, 100 (83%) developed asthma after starting work, while 20 patients (17%) had pre-existing asthma. Half of the patients described workplace exposure to dust, fume, and gases. Exposure to cleaning supplies at home was present in 43% of the subjects. Of all housewives, 12% (n=15) described an increase in their asthma symptoms during housework. The frequency of bleach or hydrochloric acid use alone among housewives was 60% and 34%, which was significantly higher than other occupations. The FEV₁/FVC ratio of housewives who frequently used hydrochloric acid (FEV₁/FVC=71.5) was lower than that of non-users (FEV₁/FVC=74.9) (p=0.024).

CONCLUSION

Patients with asthma experience significant workplace exposures that exacerbate their symptoms. Housewives experience significant exposure that triggers allergic and asthma symptoms. It is important to raise awareness about the prevalence and risks of occupational (including in-home) exposures in asthmatics patients and physicians to minimize asthma triggers and exacerbations.

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.

Work experiences of Latino building cleaners: An exploratory study

BACKGROUND

There are roughly 3.8 million cleaning workers in the United States. The cleaning workforce is largely composed of women, immigrants, and ethnic minorities who receive low wages and have low education levels. They are exposed to physical, chemical, biological, and psychosocial hazards.

METHODS

Qualitative methodology was used to investigate how Latino immigrants experience work as building cleaners. A grounded theory coding approach was used to analyze focus group data from 77 participants.

RESULTS

Three major themes were identified: economic vulnerability, psychosocial stressors, and health and safety effects. Although workers are aware of the safety hazards associated with their jobs, they believe their immigration status limits employment opportunities leading them to accept poor working conditions. They work through injuries and cope psychologically through minimizing negative health impacts and normalizing work-related injuries and illnesses.

CONCLUSIONS

The findings suggest that interventions for these workers should recognize the hostile organizational and psychosocial contexts within which immigrants often work.

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.

Fragrance inhalation and adverse health effects: The question of causation

The toxicology of fragrance materials is largely well understood. Although most are benign, a minority have the potential to cause adverse health effects, notably allergic contact dermatitis resulting from skin sensitization. As a consequence, industry guidelines have banned certain materials and strictly limited the use of others. Recently, data have been published that have been interpreted to suggest that inhalation of fragrances is associated with the occurrence of a variety of health effects, ranging from headaches to asthma attacks. In this review, the evidence basis for these assertions is examined critically and the biological basis and mechanistic plausibility for causation by fragranced products of these health effects is explored. This review concludes that respiratory effects, including irritation and allergy appear highly unlikely to occur by this route. While some sensory/psychosomatic effects are possible, this does not explain the very high rates of adverse effects reported in the recently published questionnaire studies, which this review concludes are more likely to be attributed to methodological weaknesses. Ultimately, it is concluded that adverse health effects arising from fragrance inhalation are uncommon and remain to be identified and confirmed by methodologically rigorous epidemiological investigations supported by a convincing biological and mechanistic basis.

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.

Cleaning and disinfecting environmental surfaces in health care: Toward an integrated framework for infection and occupational illness prevention

BACKGROUND

The Cleaning and Disinfecting in Healthcare Working Group of the National Institute for Occupational Safety and Health, National Occupational Research Agenda, is a collaboration of infection prevention and occupational health researchers and practitioners with the objective of providing a more integrated approach to effective environmental surface cleaning and disinfection (C&D) while protecting the respiratory health of health care personnel.

METHODS

The Working Group, comprised of >40 members from 4 countries, reviewed current knowledge and identified knowledge gaps and future needs for research and practice.

RESULTS

An integrated framework was developed to guide more comprehensive efforts to minimize harmful C&D exposures without reducing the effectiveness of infection prevention. Gaps in basic knowledge and practice that are barriers to an integrated approach were grouped in 2 broad areas related to the need for improved understanding of the (1) effectiveness of environmental surface C&D to reduce the incidence of infectious diseases and colonization in health care workers and patients and (2) adverse health impacts of C&D on health care workers and patients. Specific needs identified within each area relate to basic knowledge, improved selection and use of products and practices, effective hazard communication and training, and safer alternatives.

CONCLUSION

A more integrated approach can support multidisciplinary teams with the capacity to maximize effective and safe C&D in health care.

Domestic exposure to volatile organic compounds in relation to asthma and allergy in children and adults

Over the past decades, the prevalence of asthma, allergic disease and atopy has increased significantly and in parallel with the increased use of products and materials emitting volatile organic compounds (VOCs) in the indoor environment. The purpose of this review is to examine the evidence of the relationship between quantitatively measured domestic exposure to VOCs and allergic diseases and allergy in children and adults. Sources, potential immune-inflammatory mechanisms and risks for development and severity of asthma and allergy have been addressed. Available evidence is based on studies that have mainly used observational designs of variable quality. Total, aromatic, aliphatic, microbial VOCs and aldehydes have been the most widely investigated VOC classes, with formaldehyde being the most commonly examined single compound. Overall, the evidence is inadequate to draw any firm conclusions. However, given indicative evidence from a few high-quality studies and significant potential for improvements in asthma outcomes in those with established disease, there is a need to consider undertaking further investigation of the relationship between domestic VOC exposure and asthma/allergy outcomes that should encompass both high-quality, robust observational studies and ultimately clinical trials assessing the impact of interventions that aim to reduce VOC exposure in children and adults with asthma.

Airborne exposures to monoethanolamine, glycol ethers, and benzyl alcohol during professional cleaning: a pilot study

A growing body of epidemiologic evidence suggests an association between exposure to cleaning products and respiratory dysfunction. Due to the lack of quantitative assessments of respiratory exposures to airborne irritants and sensitizers among professional cleaners, the culpable substances have yet to be identified.

PURPOSE

Focusing on previously identified irritants, our aims were to determine (i) airborne concentrations of monoethanolamine (MEA), glycol ethers, and benzyl alcohol (BA) during different cleaning tasks performed by professional cleaning workers and assess their determinants; and (ii) air concentrations of formaldehyde, a known indoor air contaminant.

METHODS

Personal air samples were collected in 12 cleaning companies, and analyzed by conventional methods.

RESULTS

Nearly all air concentrations [MEA (n = 68), glycol ethers (n = 79), BA (n = 15), and formaldehyde (n = 45)] were far below (<1/10) of the corresponding Swiss occupational exposure limits (OEL), except for ethylene glycol mono-n-butyl ether (EGBE). For butoxypropanol and BA, no OELs exist. Although only detected once, EGBE air concentrations (n = 4) were high (49.48-58.72mg m(-3)), and close to the Swiss OEL (49mg m(-3)). When substances were not noted as present in safety data sheets of cleaning products used but were measured, air concentrations showed no presence of MEA, while the glycol ethers were often present, and formaldehyde was universally detected. Exposure to MEA was affected by its amount used (P = 0.036), and spraying (P = 0.000) and exposure to butoxypropanol was affected by spraying (P = 0.007) and cross-ventilation (P = 0.000).

CONCLUSIONS

Professional cleaners were found to be exposed to multiple airborne irritants at low concentrations, thus these substances should be considered in investigations of respiratory dysfunctions in the cleaning industry; especially in specialized cleaning tasks such as intensive floor cleaning.

Asthma and exposure to cleaning products - a European Academy of Allergy and Clinical Immunology task force consensus statement

Professional and domestic cleaning is associated with work-related asthma (WRA). This position paper reviews the literature linking exposure to cleaning products and the risk of asthma and focuses on prevention. Increased risk of asthma has been shown in many epidemiological and surveillance studies, and several case reports describe the relationship between exposure to one or more cleaning agents and WRA. Cleaning sprays, bleach, ammonia, disinfectants, mixing products, and specific job tasks have been identified as specific causes and/or triggers of asthma. Because research conclusions and policy suggestions have remained unheeded by manufactures, vendors, and commercial cleaning companies, it is time for a multifaceted intervention. Possible preventive measures encompass the following: substitution of cleaning sprays, bleach, and ammonia; minimizing the use of disinfectants; avoidance of mixing products; use of respiratory protective devices; and worker education. Moreover, we suggest the education of unions, consumer, and public interest groups to encourage safer products. In addition, information activities for the general population with the purpose of improving the knowledge of professional and domestic cleaners regarding risks and available preventive measures and to promote strict collaboration between scientific communities and safety and health agencies are urgently needed.

Asthma related to cleaning agents: a clinical insight

OBJECTIVE

To determine the agents causing asthmatic reactions during specific inhalation challenges (SICs) in workers with cleaning-related asthma symptoms and to assess the pattern of bronchial responses in order to identify the mechanisms involved in cleaning-related asthma.

DESIGN

A retrospective case series analysis.

SETTING

The study included all participants who completed an SIC procedure with the cleaning/disinfection products suspected of causing work-related asthma over the period 1992-2011 in a tertiary centre, which is the single specialised centre of the French-speaking part of Belgium where all participants with work-related asthma are referred to for SIC.

RESULTS

The review identified 44 participants who completed an SIC with cleaning/disinfection agents. Challenge exposure to the suspected cleaning agents elicited a ≥20% fall in forced expiratory volume in 1 s (FEV1) in 17 (39%) participants. The cleaning products that induced a positive SIC contained quaternary ammonium compounds (n=10), glutaraldehyde (n=3), both of these agents (n=1) and ethanolamines (n=2). Positive SICs were associated with a significant decrease in the median (IQR) value of the provocative concentration of histamine causing a 20% fall in FEV1 (PC20) from 1.4 (0.2-4.2) mg/mL at baseline to 0.5 (0.4-3.0) mg/mL after the challenge and a significant increase in sputum eosinophils from 1.8 (0.8-7.2)% at baseline to 10.0 (4.1-15.9)% 7 h after the challenge exposure while these parameters did not significantly change in participants with a negative SIC. Overall, 11 of 17 participants with positive SICs showed greater than threefold decrease in postchallenge histamine PC20 value, a >2% increase in sputum eosinophils, or both of these outcomes.

CONCLUSIONS

These data indicate that a substantial proportion of workers who experience asthma symptoms related to cleaning materials show a pattern of bronchial reaction consistent with sensitiser-induced occupational asthma. The results also suggest that quaternary ammonium compounds are the principal cause of sensitiser-induced occupational asthma among cleaners.

Asthma and rhinitis in cleaning workers: a systematic review of epidemiological studies

OBJECTIVE

This article presents a systematic review of epidemiological studies linking cleaning work and risk of asthma and rhinitis.

METHODS

Published reports were identified from PubMed covering the years from 1976 through June 30, 2012. In total, we identified 24 papers for inclusion in the review. The quality of studies was evaluated using the Strengthening of the Reporting of Observational Studies in Epidemiology (STROBE) statement checklist of 22 items for cross-sectional, cohort and case-control studies.

RESULTS

Increased risk of asthma or rhinitis has been shown in 79% of included epidemiological studies. In four studies the increased risk of asthma in cleaning workers was confirmed by objective tests, such as bronchial hyper-reactivity or airflow obstruction. Level of exposure to cleaning products, cleaning sprays, bleach, ammonia, mixing products and specific job tasks has been identified as specific causes of asthma and rhinitis.

CONCLUSIONS

Possible preventive measures encompass the substitution of cleaning sprays, bleach and ammonia, avoidance of mixing products, the use of respiratory protective devices, worker education and medical surveillance.

Environment and asthma in adults

The present review addresses recent advances and especially challenging aspects regarding the role of environmental risk factors in adult-onset asthma, for which the causes are poorly established. In the first part of the review, we discuss aspects regarding some environmental risk factors for adult-onset asthma: air pollution, occupational exposures with a focus on an emerging risk represented by exposure to cleaning agents (both at home and in the workplace), and lifestyle and nutrition. The second part is focused on perspectives and challenges, regarding relevant topics on which research is needed to improve the understanding of the role of environmental factors in asthma. Aspects of exposure assessment, the complexity of multiple exposures, the interrelationships of the environment with behavioral characteristics and the importance of studying biological markers and gene-environment interactions to identify the role of the environment in asthma are discussed. We conclude that environmental and lifestyle exposures play an important role in asthma or related phenotypes. The changes in lifestyle and the environment in recent decades have modified the specific risk factors in asthma even for well-recognized risks such as occupational exposures. To better understand the role of the environment in asthma, the use of objective (quantitative measurement of exposures) or modern tools (bar code, GPS) and the development of multidisciplinary collaboration would be very promising. A better understanding of the complex interrelationships between socio-economic, nutritional, lifestyle and environmental conditions might help to study their joint and independent roles in asthma.

Functional and biological characteristics of asthma in cleaning workers

OBJECTIVES

Cleaning workers have an increased risk of asthma but the underlying mechanisms are largely unknown. We studied functional and biological characteristics in asthmatic cleaners and compared these to healthy cleaners.

METHODS

Forty-two cleaners with a history of asthma and/or recent respiratory symptoms and 53 symptom-free controls were identified. Fractional exhaled nitric oxide (FeNO) was measured and forced spirometry with reversibility testing was performed. Total IgE, pulmonary surfactant protein D and the 16 kDa Clara Cell secretory protein were measured in blood serum. Interleukins and other cytokines, growth factors, cys-leukotrienes and 8-isoprostane were measured in exhaled breath condensate. Information on occupational and domestic use of cleaning products was obtained in an interview. Associations between asthma status, specific characteristics and the use of cleaning products were evaluated using multivariable linear and logistic regression analyses.

RESULTS

Asthma was associated with an 8% (95% confidence interval (CI) 1-15%) lower postbronchodilator FEV1, a higher prevalence of atopy (42% vs. 10%) and a 2.9 (CI 1.5-5.6) times higher level of total IgE. Asthma status was not associated with the other respiratory biomarkers. Most irritant products and sprays were more often used by asthmatic cleaners. The use of multiuse products, glass cleaners and polishes at work was associated with higher FeNO, particularly in controls.

CONCLUSIONS

Asthma in cleaning workers is characterised by non-reversible lung function decrement and increased total IgE. Oxidative stress, altered lung permeability and eosinophilic inflammation are unlikely to play an important underlying role, although the latter may be affected by certain irritant cleaning exposures.

Passive smoking, pulmonary function and bronchial hyper-responsiveness among indoor sanitary workers

Pulmonary function parameters of 21 cleaning/sanitary women workers who have never smoked, exposed to environmental tobacco smoke (ETS) at work were compared with 34 non-exposed women workers of comparable age and other work characteristics. The studied subjects were subjected to an interview questionnaire, pulmonary function measurements, bronchial responsiveness assessment and clinical chest examination. A higher prevalence of dyspnea was found (42.9%) among exposed compared to (14.7%) among the non-exposed workers (p=0.019), also wheezing (52.4% vs. 11.8%; p=0.001). Pulmonary measurements showed a lower FVC, FEV(1)/FVC and FEF(75) values among exposed compared to non-exposed (p<0.05), and a higher prevalence of borderline bronchial hyper-responsiveness (38.1% vs. 11.8%; p=0.021) in the exposed workers. This study provides evidence of adverse respiratory effects in sanitary/cleaning women workers associated with passive smoking in the workplace. The findings support a stricter implementation measures to protect respiratory health of all workers.

Bronchial asthma and COPD due to irritants in the workplace - an evidence-based approach

BACKGROUND

Respiratory irritants represent a major cause of occupational obstructive airway diseases. We provide an overview of the evidence related to irritative agents causing occupational asthma or occupational COPD.

METHODS

We searched MEDLINE via PubMed. Reference lists of relevant reviews were also screened. The SIGN grading system was used to rate the quality of each study. The modified RCGP three-star system was used to grade the body of evidence for each irritant agent regarding its causative role in either occupational asthma or occupational COPD.

RESULTS

A total of 474 relevant papers were identified, covering 188 individual agents, professions or work-sites. The focus of most of the studies and the predominant diagnosis was occupational asthma, whereas occupational COPD arose only incidentally.The highest level assigned using the SIGN grading was 2+ (well-conducted systematic review, cohort or case-control study with a low risk of confounding or bias). According to the modified RCGP three-star grading, the strongest evidence of association with an individual agent, profession or work-site ("**") was found for 17 agents or work-sites, including benzene-1,2,4-tricarboxylicacid-1,2-anhydride, chlorine, platinum salt, isocyanates, cement dust, grain dust, animal farming, environmental tobacco smoke, welding fumes or construction work. Phthalic anhydride, glutaraldehyde, sulphur dioxide, cotton dust, cleaning agents, potrooms, farming (various), foundries were found to be moderately associated with occupational asthma or occupational COPD ("*[+]").

CONCLUSION

This study let us assume that irritant-induced occupational asthma and especially occupational COPD are considerably underreported. Defining the evidence of the many additional occupational irritants for causing airway disorders will be the subject of continued studies with implications for diagnostics and preventive measures.

Household chemicals, immune function, and allergy: a commentary

In recent decades, in the US and in Western and Northern Europe, there has been a significant increase in the prevalence of atopic allergic disease. Although that increase may now be slowing, or have already reached a plateau, there remains considerable interest in the factor or factors that may have caused this increased susceptibility to allergy and asthma. Certainly, the changes recorded have been too rapid to implicate a change in the gene pool, and for that reason attention has focused on the possible impact of environmental, dietary, and lifestyle factors. Although the hygiene hypothesis proposes that increased susceptibility to allergic sensitization is associated with changes in childhood exposure pathogenic microorganisms, other factors have been considered also. Among these is exposure to chemicals and atmospheric pollutants. There is some evidence that exposure to certain chemicals may elicit or exacerbate respiratory reactions in those who are already sensitized, or who already have existing airway disease. However, a recent article has proposed that exposure to specific household cleaning products may be one factor that is able to affect susceptibility to allergic sensitization. In the light of that article it is timely now to consider again the ability of chemical exposure to influence sensitization to common antigens.

Occupation and the prevalence of respiratory health symptoms and conditions: the Atherosclerosis Risk in Communities Study

OBJECTIVES

To examine associations between occupation and respiratory health in a large, population-based cohort of adults in the United States.

METHODS

Data from 15,273 participants, aged 45 to 64 years, in the Atherosclerosis Risk in Communities study were used to examine associations of current or most recent job held with the prevalence of self-reported chronic cough, chronic bronchitis, wheezing, asthma, and measures of lung function collected by spirometry.

RESULTS

Eleven percent of participants reported wheezing and 9% were classified as having airway obstruction. Compared with individuals in managerial and administrative jobs, increased prevalences of respiratory outcomes were observed among participants in selected occupations, including construction and extractive trades (wheezing, prevalence ratio = 1.92, 95% confidence interval = 1.35, 2.73; airway obstruction, prevalence ratio = 1.31, 95% confidence interval = 1.05, 1.65).

CONCLUSIONS

Specific occupations are associated with adverse respiratory health.

Transient receptor potential genes, smoking, occupational exposures and cough in adults

Background

Transient receptor potential (TRP) vanilloid and ankyrin cation channels are activated by various noxious chemicals and may play an important role in the pathogenesis of cough. The aim was to study the influence of single nucleotide polymorphisms (SNPs) in TRP genes and irritant exposures on cough.

Methods

Nocturnal, usual, and chronic cough, smoking, and job history were obtained by questionnaire in 844 asthmatic and 2046 non-asthmatic adults from the Epidemiological study on the Genetics and Environment of Asthma (EGEA) and the European Community Respiratory Health Survey (ECRHS). Occupational exposures to vapors, gases, dusts, and/or fumes were assessed by a job-exposure matrix. Fifty-eight tagging SNPs in TRPV1, TRPV4, and TRPA1 were tested under an additive model.

Results

Statistically significant associations of 6 TRPV1 SNPs with cough symptoms were found in non-asthmatics after correction for multiple comparisons. Results were consistent across the eight countries examined. Haplotype-based association analysis confirmed the single SNP analyses for nocturnal cough (7-SNP haplotype: p-global = 4.8 × 10^-6) and usual cough (9-SNP haplotype: p-global = 4.5 × 10^-6). Cough symptoms were associated with exposure to irritants such as cigarette smoke and occupational exposures (p < 0.05). Four polymorphisms in TRPV1 further increased the risk of cough symptoms from irritant exposures in asthmatics and non-asthmatics (interaction p < 0.05).

Conclusions

TRPV1 SNPs were associated with cough among subjects without asthma from two independent studies in eight European countries. TRPV1 SNPs may enhance susceptibility to cough in current smokers and in subjects with a history of workplace exposures.

Irritant-induced airway disorders

Thousands of persons experience accidental high-level irritant exposures each year but most recover and few die. Irritants function differently than allergens because their actions proceed nonspecifically and by nonimmunologic mechanisms. For some individuals, the consequence of a single massive exposure to an irritant, gas, vapor or fume is persistent airway hyperresponsiveness and the clinical picture of asthma, referred to as reactive airways dysfunction syndrome (RADS). Repeated irritant exposures may lead to chronic cough and continual airway hyperresponsiveness. Cases of asthma attributed to repeated irritant-exposures may be the result of genetic and/or host factors.

The epidemiology of work-related asthma

Much has been learned from epidemiologic studies conducted in the past 4 decades that can be directly applied to the management of workers affected with occupational asthma. Studies have provided information about host factors, environmental exposure, and occupational agents posing the highest risks for development of severe irreversible airway obstruction and asthma disability. Investigators have developed methods for screening workers at risk and novel interventions that may prevent new cases among exposed worker populations. Less is known about the natural history and chronic morbidity associated with work-aggravated asthma and irritant-induced asthma syndromes; more studies are needed in at-risk worker populations.

Effect of exposure to detergents and other chemicals on biomarkers of pulmonary response in exhaled breath from hospital cleaners: a pilot study

PURPOSE

The main aim of the study was to provide evidence whether professional cleaning was associated with biomarkers of lung damage in non-invasively collected biological fluids (exhaled air and exhaled breath condensate--EBC).

MATERIALS AND METHODS

This cross-sectional study involved 40 cleaners regularly exposed to cleaning detergents and 40 controls. The subjects completed a standard questionnaire from European Community Respiratory Health Survey (ECRHS II) and underwent a spirometry. Fractional exhaled nitric oxide (F(E)NO) was measured online, and pH, ammonium (NH(4) (+)), H(2)O(2) and 4-hydroxynonenal (4-HNE) were assayed in EBC.

RESULTS

Among the cleaners, the frequency of asthma and rhinitis was, respectively, 2.5 and 20%. The most frequently reported symptoms were sneezing (27.5%), nasal and/or pharyngeal pruritus (25%), ocular pruritus (22.5%) and cough (22.5%). There were no significant differences in comparison with the control group. Median F(E)NO levels were higher in African than in Caucasian cleaners (21.5 [16.5-30.0] ppb and 18.0 [13.5-20.5] ppb; p < 0.05). H(2)O(2)-EBC (0.26 [0.09-0.53] μM vs. 0.07 [0.04-0.15] μM; p < 0.01), NH(4) (+)-EBC (857 [493-1,305] μM vs. 541 [306-907] μM; p < 0.01) and pH-EBC (8.17 [8.09-8.24] vs. 8.06 [7.81-8.10]; p < 0.01) were higher in the cleaners than in the controls. Finally, the cleaners showed significant correlations between pH-EBC and NH(4) (+)-EBC (r = 0.33, p < 0.05) and a weak correlation between 4-HNE-EBC and H(2)O(2)-EBC (r = 0.37, p < 0.05).

CONCLUSION

The promising role of EBC analysis in biomonitoring of exposed workers was confirmed. It was also possible to identify the potential biomarkers of exposure to alkaline products (increased ammonium-EBC and pH-EBC levels) and potential biomarkers of oxidative stress (increased H(2)O(2)-EBC levels correlated with 4-HNE-EBC levels) in workers with no signs of airway diseases.

Occupational asthma in professional cleaning work: a clinical study

BACKGROUND

Several epidemiological studies have reported an increased risk of asthma among professional cleaners. To date, however, no analysis of large patient series from clinic of occupational medicine has been published.

AIMS

To describe the cases of occupational asthma (OA) diagnosed at the Finnish Institute of Occupational Health (FIOH) during the period 1994-2004 in workers employed in professional cleaning work.

METHODS

OA was diagnosed according to patient history, lung function examinations and specific challenge tests with measurements of the forced expiratory volume in 1 second and peak expiratory flow values.

RESULTS

Our series comprised 20 patients, all female, with a mean age of 48.8 years (range 27-60 years). The mean duration of cleaning work before the onset of the respiratory symptoms was 14.3 years (range 1-36 years), and the mean duration of cleaning work before the FIOH examinations was 18.6 years (range 3-38 years). OA was triggered by chemicals in 9 cases (45%) and by moulds in 11 cases (55%). The chemicals were cleaning chemicals (wax-removing substances containing ethanolamines in five cases and a cleaning agent containing chloramine-T in one case) and chemicals used in the industrial processes at workplaces (three cases). Of the moulds, the most frequently associated with OA was Aspergillus fumigatus (nine cases).

CONCLUSIONS

OA was attributed not only to cleaning chemicals but also to other chemicals used in work environments. Moulds are presented as a new cause of OA in cleaners.

Quantitative assessment of airborne exposures generated during common cleaning tasks: a pilot study

BACKGROUND

A growing body of epidemiologic evidence suggests an association between exposure to cleaning products with asthma and other respiratory disorders. Thus far, these studies have conducted only limited quantitative exposure assessments. Exposures from cleaning products are difficult to measure because they are complex mixtures of chemicals with a range of physicochemical properties, thus requiring multiple measurement techniques. We conducted a pilot exposure assessment study to identify methods for assessing short term, task-based airborne exposures and to quantitatively evaluate airborne exposures associated with cleaning tasks simulated under controlled work environment conditions.

METHODS

Sink, mirror, and toilet bowl cleaning tasks were simulated in a large ventilated bathroom and a small unventilated bathroom using a general purpose, a glass, and a bathroom cleaner. All tasks were performed for 10 minutes. Airborne total volatile organic compounds (TVOC) generated during the tasks were measured using a direct reading instrument (DRI) with a photo ionization detector. Volatile organic ingredients of the cleaning mixtures were assessed utilizing an integrated sampling and analytic method, EPA TO-17. Ammonia air concentrations were also measured with an electrochemical sensor embedded in the DRI.

RESULTS

Average TVOC concentrations calculated for 10 minute tasks ranged 0.02 - 6.49 ppm and the highest peak concentrations observed ranged 0.14-11 ppm. TVOC time concentration profiles indicated that exposures above background level remained present for about 20 minutes after cessation of the tasks. Among several targeted VOC compounds from cleaning mixtures, only 2-BE was detectable with the EPA method. The ten minute average 2- BE concentrations ranged 0.30 -21 ppm between tasks. The DRI underestimated 2-BE exposures compared to the results from the integrated method. The highest concentration of ammonia of 2.8 ppm occurred during mirror cleaning.

CONCLUSIONS

Our results indicate that airborne exposures from short-term cleaning tasks can remain in the air even after tasks' cessation, suggesting potential exposures to anyone entering the room shortly after cleaning. Additionally, 2-BE concentrations from cleaning could approach occupational exposure limits and warrant further investigation. Measurement methods applied in this study can be useful for workplace assessment of airborne exposures during cleaning, if the limitations identified here are addressed.

Prevention of occupational asthma

Prevention of occupational asthma related to a work-sensitizing agent ideally would be achieved by avoidance of exposures that cause immunologic sensitization and subsequent asthma. There are a few examples in which a sensitizing agent has been removed from a work process and others in which exposure has been significantly changed or reduced with associated reduced rates of sensitization and disease. Additional measures include containment, use of robots, ventilation measures, exposure monitoring, and use of respiratory protective devices. Secondary prevention includes medical surveillance, which may involve periodic respiratory questionnaires, spirometry, and immunologic tests aiming to detect sensitization or disease early to allow intervention and improve outcomes. Education measures for workers to understand the meaning of work-related respiratory symptoms and appropriate workplace safety measures have not been formally evaluated but may also be expected to enhance protective measures and lead to earlier diagnosis. Tertiary prevention includes medical management and workers' compensation.

Reported occupational respiratory diseases in three Spanish regions

BACKGROUND

In 2002, a voluntary registry of occupational respiratory diseases was initiated in the test phase in Asturias, Catalonia, and Navarre (Spain). Based on data from the fully implemented voluntary registry, we assessed the differences in the incidence and characteristics of the diseases reported in the three regions studied and compared them with those notified to the compulsory official system.

METHODS

Physicians whose daily practice includes patients with occupational respiratory diseases were invited to participate. Newly diagnosed cases occurring during 2003 in the work force of the three regions studied were reported on a notification form every 2 months. Data from the compulsory official notification system were obtained from statistics on work-related diseases for possible disability benefits.

RESULTS

Five hundred thirty-three new cases, representing a cumulative incidence of 183.52 (168.27-199.78) per million workers per year, were reported. The number of cases and the incidence, overall and for each disease, causes of the diseases, and the occupations varied considerably between regions. The number of cases reported to the voluntary system was more than threefold greater than the number reported to the compulsory official system.

CONCLUSIONS

The compulsory scheme for reporting occupational respiratory diseases is seriously under-reporting in the three Spanish regions studied. Our voluntary surveillance program, which showed considerable differences in the characteristics and incidence of these diseases among the regions, appears to be more effective.

An assessment of the ability of phthalates to influence immune and allergic responses

It has been suggested that one possible contributor to the increasing prevalence of atopic (IgE-mediated) allergic diseases and asthma in Europe and the US is exposure to chemicals that may act as adjuvants. Certain commonly used phthalate plasticisers, such as di-(2-ethylhexyl) phthalate, have been implicated in this regard. The evidence for the ability of phthalates to impact on immune and allergic responses has been examined, encompassing epidemiological investigations and results deriving from studies using experimental animals and from analyses in vitro. The epidemiological data provide some evidence that exposure to phthalates may be associated with increased risk of development of allergies and asthma, however, the lack of objective exposure information limits the interpretation. A variety of studies have been performed in mice to examine the influence of phthalate (delivered via various routes of exposure) to impact on immune responses. Measurement of antibody responses is the commonest read out, although other parameters of inflammation such as eosinophil infiltration and cytokine production have been used also. Although certain phthalates, when delivered at appropriate doses, and via an appropriate route, have been reported to impact on immune and inflammatory function in rodents, as yet no consistent pattern has emerged. Results ranged from potentiation of immune or inflammatory responses, to the absence of any effect, to inhibitory or immunosuppressive activity. In addition, comparatively low doses of phthalates have been associated with immune effects only when routes of administration (subcutaneous or intraperitoneal) are used that do not reflect, and are much less relevant for, opportunities for human contact with phthalates. There is clearly a case to be made for the design of more definitive animal studies that will allow development of a more detailed understanding of whether and to what extent, and under what conditions, phthalates are able to effect meaningful changes in immune function that may in turn impact on human health.

Invisible work, unseen hazards: The health of women immigrant household service workers in Spain

BACKGROUND

Household service work has been largely absent from occupational health studies. We examine the occupational hazards and health effects identified by immigrant women household service workers.

METHODS

Exploratory, descriptive study of 46 documented and undocumented immigrant women in household services in Spain, using a phenomenological approach. Data were collected between September 2006 and May 2007 through focus groups and semi-structured individual interviews. Data were separated for analysis by documentation status and sorted using a mixed-generation process. In a second phase of analysis, data on psychosocial hazards were organized using the Copenhagen Psychosocial Questionnaire as a guide.

RESULTS

Informants reported a number of environmental, ergonomic and psychosocial hazards and corresponding health effects. Psychosocial hazards were especially strongly present in data. Data on reported hazards were similar by documentation status and varied by several emerging categories: whether participants were primarily cleaners or carers and whether they lived in or outside of the homes of their employers. Documentation status was relevant in terms of empowerment and bargaining, but did not appear to influence work tasks or exposure to hazards directly.

CONCLUSIONS

Female immigrant household service workers are exposed to a variety of health hazards that could be acted upon by improved legislation, enforcement, and preventive workplace measures, which are discussed.