Biocidals and Respiratory Effects- Adverse respiratory effects

related to occupational exposure to chlorine-based cleaning products

Institute for Occupational Health of R. Macedonia, SkopjeWHO Collaborative Center

GA2LEN Collaborative Center

Prof. Jordan Minov, MD PhD

3rd International Biocidal Congress Antalya, Turkey, November 22-25, 2016

Biocides

Biocides are defined in the European legislation as chemical substances or microorganisms

intended to destroy, deter, render harmless, or exert a controlling effect on any harmful organisms by chemical or biological means

Biocides

Biocidal products (BP)

The products containing one or more biocidal active substances (mostly chemical products)

and other non-active co-formulants that ensure the effectiveness as well as desired characteristics

(pH, viscosity, color, odor, etc.) of the final product

BP classification

According to the Biocidal Product Regulation (BPR) EU 528/2012,BP are classified into 22 product types (application categories),

grouped in four main groups:

- Disinfectants and general biocidal products (five product types)- Preservatives (eight product types)- Pest control (seven product types)

- Other biocidal types (two product types)

BP Main Group 1 – Disinfectants and general biocidal products Chemical substances used to destroy

vegetative microbes (bacteria and fungi) and viruses on surfaces, materials, medical equipment and other man-made objects

SanitizersChemicals able to kill 99+ % of microorganisms in applicable situations

Antiseptics Chemicals able to prevent growth and reproduction of various microbes, but do not destroy them,

used to disinfect skin

The ideal disinfectant should offer complete sterilization without harming other forms of life, be inexpensive, and non-corrosive.

An ideal disinfectant does not exist.

All disinfectants are, by their very nature, potentially harmful for humans and animalsand should be used with appropriate care

Disinfectants

Common disinfectants:

- Chlorine and its compounds(hypochlorites, chlorine dioxide, chloramine, sodium chlorite/chlorate, etc.)

- Iodine - Alcohol

- Hydrogen peroxide- Phenol and other phenolics

- Ozone- Potassium permanganate

- Quaternary ammonium salts- Toluene

Disinfectants

Disinfectants

The choice of disinfectant to be used depends on the particular situation.Some disinfectants have a wide spectrum (kill nearly all microrganisms),

other kill a smaller range of disease-causing microorganisms, but are preferred for other properties

(may not be corrosive and relatively not toxic to humans)

There is a recommendation not to mix disinfectants(especially those used in people’s homes)

with other cleaning products as chemical reactions can occur

www.globalsafe.com.au

Chlorine

symbol Cl, atomic number 17, relative atomic mass 35.5

halogen groupyellow-green diatomic gas

highly reactivethe highest electron affinity

and the third highest electronegativity of all reactive elements

strong oxidizing agent

free chlorine is rare on Earth

chlorine compounds:chlorides, chlorine oxides, chlorates, perchlorates, chlorites, hypochlorites,

chloramine, organic chlorine compounds

Chlorine

Chlorine is the most widely used industrial biocide today

(a broad-spectrum germicide)- disinfection of drinking water

and swimming pool water- insecticides, disinfectants and

cleaning products

Chlorine is used in the production of a wide range of

industrial and consumer products and materials from paper to plastics, from paints to dyes,

and from textiles to agrochemicals

Chlorine

Concentration(ppm in air)

Acute Health Effects

1-3 ppm Mild mucous membrane irritation

5-15 ppm Upper airways inflammation

30 ppm Lower airways inflammation

40-60 ppm Toxic pneumonitis / toxic lung edema

450 ppm Death within 30 minutes

1,000 ppm Death within a few minutes

Listed as a hazardous air pollutant in 1990 Clean Air ActRegulated workplace exposureOSHA – PEL 1 ppm (3 mg/m3)

NIOSH – 0.5 ppm/15 minutes

Hypochlorites

Salts from hypochlorous acid (HOCl)formulated in several different forms.

As biocides are usually applied sodium hypochlorite (NaOCl) and calcium hypochlorite (Ca(OCl)2)

Hypochlorites function the same way as chlorine, although they are a bit less effective

Neutrophils of the human immune system produce small amounts of hypochlorite inside phagosomes,

which digest bacterias and viruses

Sodium hypochlorite

An effective sanitizer as low as 2%As a household bleach available as 5-6%As a disinfectant available as 8-12-15%

Effective on a wide variety of bacteriaInhibits algae growth (cooling towers)

Not affected by hard water saltsGenerally inexpensive

CorrosiveIrritating to the skin and airways

Decreased effectiveness in the presence of organic matter

Decreased effectiveness with increasing pHDeteriorates when exposed to light

Sodium hypochlorite

Sodium hypochlorite

Production of hypochlorites in R. Macedonain 2011 – 115 t (Cl)

State Statistical Officewww.stat.gov.mk

Sodium hypochlorite

Health effects and hazards of exposure to hypochlorites are similar to those of chlorine

Exposure to sodium hypochlorite is associated with: - short-term respiratory effects

(upper airways syndrome, transient obstructive syndrome, etc.)- long-term respiratory effects

(reduced lung function, bronchial hyperresponsiveness, exercise-induced bronchoconstriction, occupational asthma, etc.)

Type and severity of respiratory impairment vary according to amount and duration of exposure,

as well as to endogenous characteristics of the exposed individual

Indoor cleaners

Indoor cleaning work is carried out in homes, offices, public and commercial objects, as well as in industrial objects

Indoor cleaners

Indoor cleaning-related exposure includes a number of irritants and sensitizers

which may cause adverse respiratory effects or contribute to their occurrence

Common compounds of indoor cleaning-related exposure include:

- active substance (e.g. chlorine and its compounds, ammonia, caustic soda,

quaternary ammonium compounds, etc.), - perfumes and scents (e.g. lemon or pine scent),

- preservatives (e.g. isothiozolinones), - corrosion inhibitors (e.g. ethanolamines)

Use of natural rubber latex gloves may involve the risk of sensitization to latex allergens

A higher risk of mite sensitization, especially in household cleaning

Short-term effectsAcute irritative respiratory sy

Acute irritative respiratory sy related to workplace exposuresIOH – WHO CC

84 patients in the period 2011-2015

22 indoor cleaners (26.2%) - upper airways sy in all of them

- transient obstructive sy in five of them

Symptoms occurred 15-30 minutes after work with sodium hypochlorite-based cleaning product/disinfectant (5.25-8%)

Short-term effectsAcute irritative respiratory sy

Positive bronchodilator test in office cleaner with transient obstructive sy

Negative metacholine challenge in the same patient six months after resolution of the symptoms

Long-term effectsReduced lung function

84 female office cleaners 27 exposed and 57 unexposed to environmental tobacco smoke (ETS) at the workplace

54 female office workers

matched to office cleaners by age and smoking status

Long-term effectsReduced lung function

Spirometric parameter

Exposed to ETSin the workplace

(n = 27)

Unexposed to ETSin the workplace

(n = 57)

P-value

FVC (% pred) 90.8 ± 10.6 91.6 ± 9.1 P > 0.05

FEV1 (% pred)FEV1/FVC%

82.8 ± 10.974.1 ± 5.4

85.1 ± 8.775.2 ± 4.5

P > 0.05P > 0.05

MEF50 (% pred)MEF25 (% pred)

62.3 ± 7.853.6 ± 6.0

65.9 ± 9.963.7 ± 9.4

P > 0.05P < 0.05

MEF25-75 (%pred) 69.1 ± 12.7 71.8 ± 13.2 P > 0.05

Mean values of spirometric parameters in office cleaners in regard to their exposure to environmental tobacco smoke (ETS) at the workplace

Mean values of spirometric parameters in office cleaners and matched controls

Spirometric parameter

Office cleaners(n = 84)

Office workers(n = 54)

P-value

FVC (% pred) 91.3 ± 11.9 95.7 ± 13.2 P < 0.05

FEV1 (% pred)FEV1/FVC%

84.1 ± 12.774.9 ± 5.2

88.6 ± 10.878.1 ± 4.8

P < 0.05P < 0.05

MEF50 (% pred)MEF25 (% pred)

64.7 ± 8.955.4 ± 7.8

72.5 ± 11.267.3 ± 7.2

P < 0.05P < 0.05

MEF25-75

(%pred)70.3 ± 11.9 78.7 ± 13.4 P < 0.05

Long-term effectsBHR

38 female domestic cleaners

38 female office cleaners

38 female office workers

complementary by age and smoking status

Long-term effectsBHR

21.1%

18.4%

13.2%

0

5

10

15

20

25

Domestic cleaners Office cleaners Office workers

7.8%

10.5%

2.6%

0

2

4

6

8

10

12

Domestic cleaners Office cleaners Office workers

Prevalence of BHR in examined subjects

Prevalence of borderline BHR in examined subjects

Mild BHR in domestic cleaner (PC20 = 2.3 mg/mL)

Borderline BHR in domestic cleaner (PC20 = 5.1 mg/mL)

Long-term effectsEIB

43 female office cleaners

45 female office workers

matched to office cleaners by age and smoking status

Long-term effectsEIB

Spirometric parameter Office cleaners(n = 43)

Office workers(n = 45)

P - value

FVC (%pred)FEV1 (%pred)FEV1/FVC%MEF50 (%pred)MEF25 (%pred)MEF25-75 (%pred)

87.2 14.482.3 9.472.6 4.163.4 10.951.6 12.270.2 11.7

104.8 10.196.1 6.779.6 3.882.6 12.774.8 10.991.7 13.4

P < 0.05P < 0.05P < 0.05P < 0.05P < 0.05P < 0.05

Mean values of spirometric parameters in office cleaners and matched controls

Variable Office cleaners(n = 43)

Office workers

(n = 45)

P- value

EIB prevalence (%)

Mean exercise load (Watt)

Mean fall index FEV1 in the subjects with positive exercise challenge (%)

Mean time of EIB occurrence (minutes after exercise)

9.3

96.7 15.4

23.7 4.8

6.4 2.3

6.7

98.8 17.6

16.1 5.3

6.9 3.1

P > 0.05

P > 0.05

P < 0.05

P > 0.05

EIB characteristics in office cleaners and matched controls

Long-term effectsOA

The products used to clean and disinfect can cause sensitizer- or irritant-induced OA or to aggravate pre-existing asthma

Chlorine compounds may cause sensitizer-induced OA (chloramine-T, chlorhexidine, hexachlorophene, etc.)

Chlorine compounds, including sodium hypochlorite, may cause irritant-induced OA

- Reactive airway dysfunction syndrome (RADS)single exposure to very high level of chlorine compounds

- Non-RADS-irritant-induced OArepeated exposure to moderate-to-high level of chlorine compounds

Chlorine compounds may aggravate pre-existing asthmawork-aggravated asthma (WAA) or work-exacerbated asthma (WEA)

Differentiation of the certain OA types is a matter of growing interest, and not with a little controversy

Long-term effectsOA

Long-term effectsOA

0

50

100

150

200

250

300

350

400

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30

Days

mL

min max mean

Serial PEFR measurements at and away from work in female cleaner with OA

Prevention

Adverse respiratory effects related to workplace exposure

to chlorine-based cleaning products/disinfectants are potentially preventable

Primary preventionControl of exposure:Engineering control

respiratory protective devices

Secondary preventionEarly detection and intervention:

Regular periodical check-ups

Tertiary preventionManagement of advanced disease

Thank You!