Health Effects of Cleaning Products

1. Health Effects of Cleaning Products Dr. Susan Duty Asst Professor Simmons College, Nursing Department

2. Objectives • Identify occupational groups at risk from exposure to cleaning products • Identify 2 of the most frequent health effects associated with cleaning products • Discuss strategies to reduce exposure and minimize ill effects.

3. What is the problem? • Many workers have job duties that include the use of chemical cleaning materials • Even more workers may be exposed as by-standers • Exposure may occur during prescribed use or during a spill or other accident • Illness can occur through the combination of the Product selected and the Processes used to apply the chemical

4. Carpet Cleaner Floor wax Stripper Disinfectant Toilet Cleaner Glass Cleaner Janitor, Teacher, Office Worker, Health Care Worker, Maid Nurse, Health Care Workers and Restaurant Workers Housekeeper, Hotel Maintenance, Janitor Type of Worker Cleaning Product

5. What Cleaners Have the Most Risk?

6. Job Processes Associated with Cleaning Chemicals • Inadequate ventilation • Reducing frequency and volume of air exchanges or climate controls designed to save energy can increase concentration of chemicals in the indoor air • Ventilation is often reduced at night to save energy but night shift if often when major cleaning processes take place to minimize exposure to others • With ‘tight’ building designs, windows and doors don’t often open to allow fresh air intake

7. Job Processes: Mixing Chemicals • Mixing Chemicals • Many come in concentrated form and have to be diluted • Often times ill health is associated with use of too concentrated product • Incompatible chemicals combined together can create a toxic gas (ie bleach and quarternary ammonium can create chloramine gas)

8. Job Processes: Application • Use of spray bottles, aerosol cans, and machines that may create a fine mist (carpet washers, buffers etc) can increase the amount of chemical suspended in the air and cause breathing trouble • Switch from aerosols and pumps to pour and wipe applications • Use enclosed systems to capture vapors and dusts when using strippers, polishers etc

9. Health Effects Associated with Cleaning Products • Work-Related Asthma [WRA]) • Contact Dermatitis • Burns • Skin • Eyes • Chemical pneumonitis • Pulmonary edema

10. Work Related Asthma New Onset Work-Related Asthma (NOA) Work-Aggravated Asthma (WAA) Without Latency (Irritant) With Latency (Sensitizer) Reactive Airways Dysfunction Syndrome (RADS) Occupational Asthma Workplace exposure to known asthma inducer? Objective evidence of asthma present?

11. Asthma • Chronic inflammatory disorder of the airways that results in • Wheezing • Coughing • Chest tightness • Dyspnea (trouble breathing) • Inflammation makes the airways sensitive to allergens, chemical irritants, tobacco smoke, cold air and exercise Am J Respir Crit Care Med vol 167 pp 787-797, 2003

12. Sensitizer-induced OA / WRA (immunologically mediated) • High molecular weight agents: • Animal material: dander, excreta etc • Plant material: flour, grain, wood dust etc • Low molecular weight agents: • Spray paints (toluene diisocyanate) • Western red cedar wood dust • Biocides:glutaraldehyde, chloramine T • Irritants: • chlorine, isocyanates, acetic acid

13. Sensitizer induced OA / WRA • Prevalence: • 2% among latex-exposed workers • 50% among detergent enzyme workers • Higher among people with atopy (history of multiple allergies and eczema) • Higher with interaction between smoking and atopy

14. Sensitizer Induced AsthmaClinical presentation • One or more symptoms of episodic cough, wheeze, retrosternal chest tightness and dyspnea • Which began during work life • Increased suspicion if symptoms are worse at work and improve on weekends or holidays • Allergic rhinitis (runny nose) often predate OA • Need to address this early in disease because once sensitized, the asthmatic now reacts to all kinds of irritants and other stimuli which can cloud the diagnosis

15. Case study: NOA with Sensitization • A 55 year old female worked as a housekeep in a hospital for eight years. She had a 2 year history of wheezing, cough, shortness of breath and chest tightness that were worse at work. She particularly noted symptoms when she used a floor cleaner that contained quaternary ammonium salts, ethyl alcohol, and sodium hydroxide. • She had no history of asthma, bronchitis or allergic rhinitis prior to the onset of symptoms at work and had never smoked cigarettes. She quit her job because of her illness. After six weeks away from work her symptoms had markedly decreased.

16. Irritant-induced OA (RADS)(without sensitization) • Onset usually within 24 hours following exposure to high level respiratory irritant (often go to ER) • Symptoms persist more than 12 weeks • Objective evidence of asthma • No previously documented history of asthma or other chronic lung disease • Findings suggest RADS accounts for a minority of OA cases (~10%) • But of the RADS cases, cleaning products (23%) and unspecified chemicals (16%) were most frequently reported

17. Case Study Example: RADS • 41 year old plumber who worked for 6 years installing HVAC equipment. He frequently worked with insulation in dusty areas. One day, while spraying conductor coils with sodium hydroxide, the wind shifted and he inhaled a large, concentrated amount of the sodium hydroxide. Within 24 hours he experienced wheezing, coughing, chest tightness and shortness of breath. He was treated in the ER and required inhalers and steroids. He had no previous history of asthma and had quit smoking 7 years before this accident. One year later he still had symptoms which were worsened by dust and other household chemicals. He has been unable to return to work. SENSOR Occupational Lung Disease Bulletin; November 2000

18. Work-aggravated Asthma • Must have a history of asthma which worsens at work AND improves when away from work AND is exposed to potential respiratory irritants at work • Even low levels of respiratory irritants can aggravate pre-existing asthma • ETS, cleaning agents, paints, fumes, dust • Baseline control of asthma influences susceptibility to WRA • Relevant allergen exposure can increase airway responsiveness for weeks so a non-work-related cat exposure can leave the asthmatic more susceptible to work-related irritants for several weeks

19. Case Study:Work Aggravated Asthma • A 38 year old woman who worked as a lab technician in a hospital developed wheezing, cough, chest tightness and shortness of breath within 10 minutes of exposure to a floor cleaner which was applied to an adjacent work area. She was seen in the emergency room and admitted to the ICU after this incident. • The woman had a history of asthma and allergies but reports that her symptoms have become more severe since this incident despite the fact that she is no longer exposed to the floor cleaner

20. Surveillance of OA / WRA • 4 states conduct surveillance • California • New Jersey • Michigan • Massachusetts • From 1993-1997 • 1915 WRA cases were reported • 22% of new onset WRA were RADS • 235 (12%) were associated with cleaning products • Most frequent occupations were janitors/cleaners and nurses/nurses aids

21. Massachusetts SENSOR Data • From 1993-2002, 873 cases were reported • 55% (481) completed interviews • 451 met OA criteria • Most female (63%) and white (86%) • 90% were new onset asthma (405) • 10% of these (43) were RADS • 10% (46) were work aggravated asthma • 2.3% (10) were cleaning occupations while 39% where teaches, nurses and office workers • Specific agents identified as inducing asthma included indoor air pollutants (21%), cleaning products (17%), mold (12%) and dust (10%)

22. Public Health Consequences • If someone is diagnosed with sensitizer induced asthma, HCP should treat this as a ‘sentinel event’ and initiate investigation for others in the workplace similarly affected • In MA report to ‘SENSOR’ • http://www.mass.gov/dph/bhsre/ohsp/sensor/astbull_jan05.pdf • 617-624-5632 • Most sensitizer-induced asthmatics fail to recover even after removal from exposure • Most often a result of delayed diagnosis with longer duration of exposure

23. Advice to Prevent Breathing Problems • Read the MSDS (material safety data sheet) for all the chemicals you work with • Read warning labels and follow instructions • Leave windows and doors open or use fans to increase air exchange rate • Keep cleaners in the original containers • Take special precautions if working in small rooms or confined spaces

24. Prevention of OA • Primary • Control exposure • Substitution • Ventilation • Change process • Education regarding hazards • Use according to directions (ie don’t use full strength if directions tell you to dilute first) • Do not mix different products together (especially bleach and ammonia or bleach and acids because the combination can create poisonous fumes)

25. Recognize Warning Signs ! • Wheezing • Chest tightness • Cough • Shortness of Breath

26. Other Health Effects of Exposure to Cleaning Chemicals

27. Eye and Skin Burns • Disinfectants: • Quaternary ammonium chlorides • Alcohols • Hydrogen peroxide • Phenols • Bleach (sodium hypochlorite) • Iodine • Metal and Glass Cleaners • 2-Butoxyethanol • Dry Cleaning Fluid • Tetrachloroethlene; Perchloroethylene; "Perc"; • Floor cleaners strippers and Degreasers • Ethanolamine

28. Contact Dermatitis • Soaps/detergents, cleaning agents, and solvents, are among the most frequent causes of irritant contact • Most detergents are alkaline, but even at neutral pH (7); they de-fat the skin and interfere with hydration causing cracks, fissures open lesions • Many can cause sensitization (allergic contact dermatitis) • Primary Irritants • Absolute Irritants • Marginal Irritants

29. Detergent Dermatitis

30. Alkali Exposure (Sodium or Potassium Hydroxide)

31. Advice to Prevent Skin Problems • Wear gloves and make sure they are the appropriate glove for that chemical • Check the MSDS for recommended gloves • If chemical gets on your skin rinse thoroughly under running water for 15 minutes to minimize burn • Seek medical attention

32. Eye Injuries: Alkali Burns • Alkalis are chemicals that have a high pH. • Alkali burns are the most dangerous type of chemical burn. Alkalis penetrate the surface of the eye and can cause severe injury. • Common alkali substances contain the hydroxides of ammonia, potassium, sodium, calcium, and magnesium. • Substances that contain alkali substances include lye, drain cleaner, metal polishes, oven cleaners, cement, lime, and ammonia.

33. Eye Injuries: Acid Burn • Acid burns are caused by chemicals with a low pH • Acid burns tend to be less severe than alkali burns. • Acids usually damage the very front of the eye. • Common acids causing eye burns include sulfuric acid, sulfurous acid, hydrochloric acid, nitric acid, acetic acid, chromic acid, muriatic acid, and hydrofluoric acid.

34. Symptoms of Eye Burns • Eye pain • Burning • Tearing www.eyecasualty.co.uk/ maincontent1/burn.htm

35. Advice to Prevent Permanent Eye Injury • Wear Goggles • Adhere to safe working guidelines • Flush IMMEDIATELY with full-flow eye wash station for 15 minutes