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Are Hospital Cleaning Staff at Risk When Using a One-step Cleaner?

Posted on by Brie M. Hawley, PhD

 

Workers’ health and safety is an important consideration when choosing cleaning and disinfectant products. In health care settings, disinfection products help minimize healthcare-acquired infections.  In January 2015, the National Institute for Occupational Health (NIOSH), received a request to conduct a health hazard evaluation at a Pennsylvania hospital using a new surface cleaning product consisting of hydrogen peroxide (HP), peroxyacetic acid (PAA), and acetic acid (AA).  The request cited concerns about exposure of hospital environmental services staff to the cleaning product and reported symptoms including burning eyes, nose, and throat; cough; headache; asthma exacerbations; and skin burns.  A summary of the NIOSH evaluation was recently published in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

The cleaning product is an EPA-registered non-bleach sporicide (kills spores) advertised as a one-step disinfectant cleaner, virucide (destroys viruses), and deodorizer. According to the manufacturer’s safety data sheet, the product requires no personal protective equipment when it is diluted with water by an automated dispenser before use.

As part of the NIOSH response, researchers interviewed 79 (78%) of 101 current environmental services staff about their health. Full-shift, time-weighted average personal air samples were also collected from a convenience sample of 50 workers for measurement of HP, AA, and PAA. Of the 79 interviewees, 68 (86%) reported using the cleaning product.  Among the 68 employees who worked with the product, the most commonly reported health outcomes were watery eyes (46%), nasal problems (41%), asthma-like symptoms (28%), use of allergy medicine (16%), and shortness of breath (16%). A total of 30 (44%) reported at least one work-related health outcome. Most commonly reported work-related symptoms were watery eyes (29%) and nasal problems (22%). Among 10 respondents with self-reported physician-diagnosed asthma, six reported that something at work brought on or worsened their asthma, and three mentioned the cleaning product specifically by name. All air sampling measurements for HP (ranging from 6 parts per billion (ppb) to 511 ppb) and AA (7 ppb–530 ppb) were below their respective occupational exposure limits of 1,000 ppb and 10,000 ppb (2). PAA measurements ranged from 1 ppb to 48 ppb.  No full-shift exposure limit is established for PAA.

To date, few cross-sectional assessments of worker exposure to HP, AA, and PAA in healthcare settings have been performed, despite the use of this product in more than 500 hospitals nationwide. This evaluation found that hospital cleaning staff using a product containing HP, AA, and PAA frequently reported work-related symptoms despite measured exposures that were below established limits for two of the three chemicals for which full-shift exposure limits are established. However, because both HP and PAA are strong oxidants, it is plausible that the mixture of HP and PAA contributed to the symptoms reported by workers, despite low documented levels of exposure. Furthermore, existing exposure limits might not be protective against asthma-like symptoms. The Association of Occupational and Environmental Clinics recently listed this product as an asthmagen in its Exposure Database (4).

 

How do we protect workers?

Hospitals should be alert for respiratory, skin, and eye symptoms in environmental services staff. Hospital management can implement a reporting system that would permit employees to report work-related symptoms, with the option for employees who do not wish to be identified to remain anonymous. If environmental services staff do report respiratory, skin, and/or eye symptoms, a combination of engineering and administrative controls might be needed to reduce employee exposures. Additionally, although a one-step disinfectant, virucide, and deodorizer might be considered for widespread use in a hospital, the decision to use disinfectants in specific areas of a health care facility should reflect the level of risk of a health care acquired infection. Finally, physicians should be aware of the potential adverse health effects of occupational exposure to cleaning products and disinfectants when evaluating patients with respiratory and skin complaints.

Have you experienced health effects related to the cleaning products you use at work? Tell us how your workplace addressed the situation in the comment section below.

If you or others in your workplace have experienced symptoms related to use of cleaning products or disinfectants and are interested in a NIOSH evaluation you can request information at the HHE website. A health hazard evaluation can help workers and employers learn whether health hazards are present at their workplace.

 

Brie M. Hawley, PhD

Dr. Hawley is an industrial hygienist in the NIOSH Respiratory Health Division. 

 

 

Posted on by Brie M. Hawley, PhD

22 comments on “Are Hospital Cleaning Staff at Risk When Using a One-step Cleaner?”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».

    Thanks for posting this. I’ve been receiving many complaints about products with these ingredients from our union members in healthcare across the nation, primarily EVS workers. The switch to these products appears to be driven by hospital infection prevention managers. Manufacturer’s representatives claim the products are green and safe. Unfortunately, occupational health staff are not generally consulted to review worker protections.

    My place of employment uses oxycide and I have experienced the burning eyes, chemical burns in mucous membranes with ulcerations in nose with loss of smell and nose bleeds and asthma like symptoms. I was issued the wrong ppe’s and told to avoid the product, work the night shift( because they do not have to use it on nights) or seek employment elsewhere’s. Every exposure seems to get worse which the hospital dr said could/would happen. Currently seeking employment elsewhere and possible legal advice.

    In February of 2014, the ACGIH Board of Directors approved a Short Term Exposure Limit for peroxyacetic acid (PAA) of 0.4 ppm as a 15-minute time-weighted average, although no Permissible Exposure Limit has been set by OSHA. I believe that PAA is the proximate asthmagen. Thanks, LWR

    Your statement: “No exposure limit is established for PAA.” There is a ACGIH 2013 TLV STEL for PAA (peracetic acid-[79-21-0]) at 0.4 ppm inhalation fraction and vapor (IFV).

    Great point. Because we collected full shift, time-weighted average personal exposures, we could not compare these samples to the ACGIH STEL. This sentence has been modified to include the detail that there currently is no full-shift exposure limit established for PAA. We also added the full-shift PAA measurement results which ranged from 1 ppb to 48 ppb.

    Thanks for the feedback!

    During my time as an industrial hygienist for major University based Hospital there was a switch-over from glutaraldehyde high-level disinfectant to PAA/HP/AA product used for endoscope reprocessing. With this switchover we began receiving complaints from employees in multiple re-processing (automated) areas of nasal burning, eye irritation, respiratory irritation, and exacerbation of asthma symptoms in persons with reported history of asthma. We conducted multiple investigation in several of these locations including air monitoring for PAA, HP, and AA. The air monitoring for HP/PAA was performed using filter and sorbent method developed by a French research group. This method is under review by OSHA SLC lab. All our samples results were below occupational exposure limits, including the ACGIH TLV-STEL (0.4ppm) for PAA. During our literature review we noted that PAA is a very potent irritant at considerable lower concentration than HP and AA. From our work it appears that either the sampling/analytical methodology may not adequately quantifying the PAA levels or the recommended OEL is not protective enough. During this time I received report from our industrial hygienist at other healthcare site of similar complaints.

    Nowdays this kind of acid and chemical products must be baned inhospital and goverment and hospital authority must be take some strong action , so that no one have to bother this all. Few months I have visited (name removed) and its really a very nice hospital and the things that made me wonder that in (name removed) for clearing they using some natural herbal cleaner.

    Glad that workers’ experiences have finally been validated. You and others might be interested in the unique toolkit designed to help employers, procurement staff, health and safety committees, and health and safety activists and specialists choose less toxic cleaning products. (I think that microfibre cloths usually can do the job now done by chemicals.)

    “Tools for informed substitution: How do you find safer chemicals for the workplace?” was prepared for a project in British Columbia. With a little local content (e.g., requirements to substitute carcinogens), it’s useful far beyond BC’s borders.

    ChemDAQ Inc. has developed a portable PAA monitoring system called SafeCide that incorporates a small sensor that can be held, worn or placed to detect PAA vapor levels below the ACGIH TLV-STEL (0.4ppm). The sensor connects to a tablet via BlueTooth and collects accurate, real-time PAA exposure data. See details at [www.chemdaq.com].

    This chemical is use at my job as well at hospital in Silver spring , Maryland and as employee that’s a housekeeper inside the operation rooms it’s harsh ! I have fallen on floor while working with this chemical to burning eyes. I don’t understand how a hospital has no care for the employees for using this on daily basics. I understand that it works for all diseases especially C. Diff but there need to be another way keep not only the patients safe but the housekeepers that have to use this product as well.

    Thanks for sharing good information. Your all blogs are very nice and fantastic. I really like your blog about hospital cleaning staff . Thanks for writing this awesome article. I’m a long time reader but I’ve never been compelled to leave a comment. Brilliant job Thank you.

    Cleaning is very important and when you are working in hospital, it becomes more necessary as the health of patients and other workers around depends very much on that. It is very helpful post you are sharing here with us. The hospital cleaning staff should be more concerned about that.

    I am currently going through the process at my hospital due to respiratory issues with [product names of the specific sporicidal disinfectant cleaners removed] that we have started using. I work in Pharmacy and it is used to clean there. I hope they figure out a solution soon! What about patients who have respiratory issues, how is this affecting them?

    I agree! I work with this product at my job and I was not informed of how harsh this chemical would be on me. I have Asthma and since I’ve been exposed to the horrible chemical, my nose run uncontrollably, my face has broken out in rash, my eyes are irritated, some of the patients ask us not to use it because it make them nauseous. Especially the ones with respiratory issues. Even some of the nurses hate it. I’ve been doing my own research and it is very hazardous to health. I hate using it

    I work as an EVS employee and I have recently been doing some research on this product due to several other employees as well as myself complaining of nose bleeds,headaches,eyes burning,runny nose as well as eyes watering and stomach aches. I truly agree that the hospitals need to be cleaned but not at the expense of causing health issues for its workers. Im currently getting statements from my co workers to send to OSHA as well.

    I work in a hospital pharmacy that has gone to using [name removed], a one-step cleaner composed of HP, PAA, and AA. There has been many complaints of burning eyes, runny noses, skin irritation from accidental contact, and respiratory issues (it even leaves a taste in the back of your throat that is hard to get rid of). My first direct exposure to this product was doing a terminal clean, which took 71/2 hours to complete. We wore gown, gloves, and booties, with either N95 masks or standard hospital issue masks, but no respiratory protection. I suffered all of these symptoms.

    A few months ago, I was cleaning with this product and became dizzy, lightheaded, and weak. I left the area, but progressed to headache and nausea. Long story short, I was sent to a workman’s comp provider, who gave me the choice of either calling someone to take me to the emergency room or going by ambulance, as my pulmonary function was low. I was diagnosed with an unspecified respiratory condition due to chemicals, gases, fumes, and vapors by the workman’s comp provider, and Toxic effect of other specified substances, accidental (unintentional) by the emergency room physician.

    I have since recovered, but it took weeks before the effects of that exposure abated fully. One exposure. This is not a safe product in any way, shape, or form. I agree that cleaning is important for the health of the patients, but not at the expense of the employees health. This product is too dangerous to be used in this manner.

    Addendum : OSHA will not help you, as they claim there is nothing they can do due to the products MSDS claiming it is safe when used as directed (MSDS’s are created by the products manufacturer, who want to sell their product – could there possibly be a conflict of interest there?). Perhaps we should take note of products such as [name removed], an NSAID said to be safe until it was removed from the market due to increased risk of heart attack and death; or [name removed] and [name removed], recalled for cancer risk, or the antidepressants that require a black box warning for increasing suicidal risk. Clearly manufacturers do not know (or reveal, in some cases) all the risks involved with their products, yet they claim they are safe anyway. I can find no long-term studies on the effects of these products (HP, PAA, and AA formulations), which leaves the general public (or at least the ones being forced to use these products) to be guinea pigs. If enough people have serious consequences as a result of this product, then maybe it will be withdrawn from the market, leaving the people complaining about it to deal with their suffering (or worse). At that point, all they will have left is “I told you so” as they contend with the unnecessarily inflicted health consequences of exposure; including potentially having their lives cut tragically short.

    Oxicyde oxidize oxicide!!! Had no training on proper ppe. Our nose burns ,sore throat ,dizziness, skin itching,and yes , now waiting on results of a skin growth !!! finally read the label on bottle,because nobody addressed the warnings on the label. This stuff is toxic,! Now i realize this could be coincidence ,but a coworker recently died of throat cancer and used it daily

    I am getting nausea, bloating, and stomach pain every time I’m at work. I began to notice it would get worse when I sat at my computer to chart. That area is constantly wiped with (name removed). I began to place a towel down at my computer before the beginning of my shift. It made the symptoms 90% better. I did notify my manager after several months of dealing with the discomfort at work. She alerted upper management, and they did NOTHING about it. My manager told upper management my complaints maybe exaggerated. However, others had complained as well about the wipes.

    I have never heard of Oxycide until tonight when I went into the employee bathroom at the hospital I work at and came out having the most intensive asthma attack, throat burning that I have ever had. I asked the EV supervisor what he used to clean the bathroom and he said Oxycide. I felt nauseous and now my chest hurts. Are there also carcinogens in this product?

    The Safety Data Sheet (SDS) for OxyCide (https://cdndadepaper.blob.core.windows.net/paper-images/937f71b2-2e8b-40fa-a2c0-1de9aa5133b2.pdf) reports that it is a mixture of hydrogen peroxide, acetic acid, and peroxyacetic acid. NIOSH does not list hydrogen peroxide as an occupational carcinogen (https://www.cdc.gov/niosh/npg/npgd0335.html). Likewise, acetic acid is not listed by NIOSH as an occupational carcinogen (https://www.cdc.gov/niosh/npg/npgd0002.html). NIOSH is presently evaluating the risks from exposure to peroxyacetic acid, also known as peracetic acid, with respect to its properties as a strong sensory irritant (https://www.cdc.gov/niosh/docket/archive/docket295.html). NIOSH has conducted health hazard evaluations (HHEs) in hospital settings such as the one you describe. We recommend that management tailor the use of sporicidal disinfectants containing hydrogen peroxide, peracetic acid, and acetic acid to areas of high risk for healthcare-acquired infections and minimize the use of sporicidal products on noncritical surfaces and in non-patient areas.; i.e., not for use in cleaning employee rest rooms (https://www.cdc.gov/niosh/hhe/reports/pdfs/2015-0053-3269revised092018.pdf).

    My mom is a resident at a nursing home that used Oxycide for a while and intends to bring it back. She says that simply wiping her bed table with the product takes her breath away and makes her eyes water. The staff is very concerned about I’ll effects and does not want to use the product again.

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