By Paul K. Henneberger, MPH, ScD, and Margaret M. Quinn, ScD, CIH
Cleaning and disinfecting are important parts of a comprehensive infection prevention strategy. While the need for cleaning and disinfecting is increasing, there is also growing evidence that these activities can result in serious health problems, particularly respiratory illness. Occupational health programs in state health departments are receiving reports from the healthcare sector like the following case from the Commonwealth of Massachusetts.
Eighteen employees in a hospital operating room developed respiratory symptoms, two of whom experienced onset of work-related asthma. After a detailed investigation, the hospital determined that cleaning and disinfecting with quaternary ammonium compounds was the likely cause. The hospital switched to a product with parachlorometaxylenol that did not cause employees to have symptoms. However, testing of the parachlorometaxylenol product by the hospital indicated it was not effective at killing Staphylococcus aureus.
The hospital decided the new product put patients at an unacceptable infection risk and returned to using the original product with quaternary ammonium compounds. The two asthmatic employees had to stop working in the operating room. The hospital was able to provide an alternate work assignment for one employee, but had to lay off the other (Quinn 2015).
This and similar cases reported in state-based disease surveillance programs across the country (Pechter 2005; MA DPH 2015) illustrate the complexity of infection prevention and occupational health issues related to cleaning and disinfecting in healthcare.
Findings from epidemiologic studies confirm the association of the onset and exacerbation of asthma and other respiratory symptoms with the use of various cleaning and disinfecting products and activities in healthcare settings (Delclos 2007). There is a need for an integrated approach to cleaning and disinfecting in healthcare that maximizes both effectiveness and safety.
NIOSH Assembles a Working Group
This body of evidence came to the attention of the National Institute for Occupational Safety and Health (NIOSH), which is the component of the Centers for Disease Control and Prevention (CDC) responsible for conducting research and developing recommendations to prevent worker injury and illness. NIOSH directs the National Occupational Research Agenda (NORA) program that enlists members of various constituent communities to meet and develop goals that will stimulate innovative research on occupational health and improve workplace practices. The NORA program maintains 10 industry Sector Councils comprising different groups of stakeholders from industry, labor, government, academia, disease-support groups, and professional organizations. These Sector Councils set goals, develop strategies, encourage partnerships, and promote im-proved practices that contribute to worker health and safety. In 2012, the NORA Sector Council for Healthcare and Social Assistance (HCSA) became concerned by the association of respiratory problems with cleaning and disinfecting in healthcare settings. HCSA Sector Council members were aware that collaboration between the infection prevention and occupational health communities was necessary to achieve effective prevention activities for healthcare-associated infections (HAIs) that would also protect the respiratory health of workers and others in healthcare institutions.
In this context, the HCSA Sector Council initiated the Cleaning and Disinfecting in Health Care (CDHC) Working Group, with the charge to conduct a multidisciplinary review of the issues and to identify research and practice needs. The CDHC Working Group had two co-chairs, one from a U.S. university (MMQ) and the other from NIOSH (PKH), who enlisted more than 40 individuals into the Working Group. Participants were from both the infection prevention and occupational health communities and represented various organizations including state and federal govern-ment offices, healthcare products companies, healthcare centers, labor unions, academic institutions, and professional organizations. The Working Group members were mostly from the U.S., with representatives from France, The Netherlands, and Switzerland, including the World Health Organization. The chairs conducted regular conference calls with the entire group from October 2012 through March 2014, and also initiated numerous calls with subsets of the entire group to address specific topics in greater detail.
Goals and Objectives of the Working Group
The Working Group had the practical goal of developing a document that would fulfill the following specific objectives: 1) To provide a multi-disciplinary summary of the benefits and hazards related to cleaning and disinfection of noncritical environmental surfaces and patient-care items in healthcare. 2) To identify key scientific literature. 3) To identify major gaps in knowledge, policies, or practice. 4) To identify needs for research, practice guidance, and preventive actions (Quinn 2015).
Early group discussions quickly highlighted differences in background knowledge and assumptions between members of the infection prevention and occupational health communities. These differences compelled members to educate each other so that they had enough of a common understanding to make progress. The information shared included the definitions of different levels of disinfection, who in healthcare performs cleaning or is exposed to cleaning products, evidence for the transmission of infectious agents from environmental surfaces and how transmission can be prevented, the potentially hazardous chemicals used in cleaning and disinfecting, the adverse respiratory effects associated with cleaning and disinfecting, and the search for less toxic approaches to cleaning and disinfecting. While the compilation of this background information was not one of the stated objectives, key literature findings were summarized and included in the final document to provide read-ers with the same expansion of understanding that was realized in the Working Group, and to encourage appreciation of the challenges con-fronted by different disciplines.
An Integrated Framework to Improve Infection and Occupational Illness Prevention
The CDHC Working Group deliberations were summarized in an article titled, “Cleaning and disinfecting environmental surfaces in healthcare: Toward an integrated framework for infection and occupational illness prevention,” published in early 2015 in the American Journal of Infection Prevention (Volume 43, pp 424-434), and available online (open access) at http://www.ajicjournal.org/article/S0196-6553(15)00075-9/fulltext.
The Results section of the paper begins with gaps in knowledge that are encompassed by two broad statements of need that express the collaboration between the two different areas of study: 1) There is a need to better understand the effectiveness of cleaning and disinfecting products and procedures to reduce the incidence of infectious diseases and colonization in healthcare workers and patients; and 2) There is a need to better understand the adverse impact of cleaning and disinfecting products and procedures on the health of healthcare workers and patients, especially the impact on respiratory health (Quinn 2015). The paper then identifies a series of more specific gaps and needs related to future research directions to inform basic knowledge about the causal chain between environmental surface contamination and the incidence of infections, improved selection and use of cleaning and disinfecting products and procedures, effective hazard communications, and options for safer alternatives.
The authors believe the CDHC Working Group demonstrated the advantage of working across disciplines to yield a stronger product. The paper is the result of collaboration and can be used by professionals from different disciplines as they develop new research projects and practice guidelines to improve both infection and occupational illness prevention in healthcare settings.
Paul K. Henneberger, MPH, ScD is a senior epidemiologist with the Division of Respiratory Disease Studies, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, in Morgantown, W. Va. He has published extensively on the topic of work-related asthma, and is currently involved in several studies of asthma and related symptoms among healthcare workers.
Margaret M. Quinn, ScD, CIH is a professor in the Department of Work Environment at the University of Massachusetts Lowell. Her research focuses on occupational and environmental exposure assessment for studies of human health risks and on methods to promote healthy environments in healthcare.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the National Institute for Occupational Safety and Health (NIOSH).
Delclos GL, Gimeno D, Arif AA, et al. Occupational risk factors and asthma among health care professionals. Am J Respir Crit Care Med 2007; 175:667-675.
Massachusetts Department of Public Health, Occupational Health Surveillance Program, Sentinel Event Notification System for Occupational Risk, Occupational Lung Disease Bulletin, Spring 2015, accessed May 12, 2015 at www.mass.gov/dph/ohsp
Pechter E, Davis LK, Tumpowsky C, et al. Work-related asthma among health care workers: surveillance data from California, Massachusetts, Michigan, and New Jersey, 1993-1997. Am J Ind Med 2005; 47:265-275.
Quinn MM, Henneberger PK, National Occupational Research Agenda (NORA) Working Group on Cleaning and Disinfection in Healthcare. Cleaning and Disinfecting Environmental Surfaces in Healthcare: towards an integrated framework for infection and occupational illness prevention. Am J Infect Control 2014;43:424-434. http://dx.doi.org/10.1016/j.ajic.2015.01.029 Open Access: http://www.ajicjournal.org/article/S0196-6553(15)00075-9/fulltext