Occupational asthma: Health crisis in health care workers
Occupational asthma: Health crisis in health care workers
Common triggers: Cleaning agents, latex, and disinfectants
While national data don't give us the overall picture, cases of work-related asthma logged in four states that track the disease indicate it is a major health issue among health care workers. Massachusetts, New Jersey, Michigan, and California conduct surveillance of work-related asthma as part of the federal Sentinel Event Notification System for Occupational Risk (SENSOR) program. Data from 1993 through 1997 showed that 16% of all confirmed occupational asthma cases in those states were in health care workers.
Most (67%) developed new-onset asthma, according to Elise Pechter, MPH, CIH, industrial hygienist with the Massachusetts Department of Health Occupational Health Surveillance Program. Those cases were nurses or other health care workers who had never had asthma in their lives or who had been symptom-free for two or more years. "No doubt about it, it's a serious problem," she says. "In Massachusetts and two other states, there were more cases from health care than from any other industry."
Work-related asthma is asthma that is caused or made worse by environmental exposures in the workplace. The diagnosis is made first by confirming asthma and then by establishing a relationship between asthma and work. According to industrial medicine literature, occupational asthma should be considered in any case of adult-onset asthma or in an adult whose asthma is growing worse.
Several studies on occupational asthma show workplace exposures are responsible for up to 29% of all asthma cases among adults, according to the American Thoracic Society (ATS), which estimates that more than one out of seven adult asthma sufferers in the United States has occupational asthma. "What you have to remember is that this is a preventable disease, if we do a good job preventing it," explains Pechter.
Cleaning products often to blame
Work-related asthma falls into three categories: immunologically mediated disease caused by exposure to sensitizers in the workplace, asthma resulting from acute exposure to irritants in the workplace, and pre-existing asthma made worse by workplace exposures.
"Health care workers with work-related asthma were exposed to latex and disinfectants that cause asthma and to numerous other chemicals that can exacerbate asthma, including cleaning products, renovation materials, mold, and poor indoor air quality," Pechter says. In fact, there are more than 400 recognized asthma triggers found in workplaces, including manufacturing chemicals, cleaning products, animals, insects, latex gloves, and preservatives, according to Jennifer Flattery, MPH, an epidemiologist with the California Department of Health Services' Occupational Health Branch.
Flattery and Robert Harrison, MD, MPH, chief of occupational health surveillance for the California Department of Health, wrote in a report for the ATS that while removing the worker from the source of exposure is the primary treatment for work-related asthma, the outlook for recovery is affected by the length of the exposure. "The majority of people who develop occupational asthma fail to fully recover, even after several years without exposure," Flattery and Harrison report in "Work-Related Asthma," a report available at the ATS web site. (See resource, at end of article, for information on how to access full report.) Several studies have shown that 50% to 60% of workers remain symptomatic three to four years after exposure has ended.
Compared to cases employed in other industries, health care workers with work-related asthma were more likely to be female (93% vs. 50%) and white (79% vs. 72%).
Pechter says that while latex gloves are anecdotally linked to occupational asthma (and historically have been triggers for asthma), she has not seen any sentinel reports involving latex in the past couple of years. "So maybe that means fewer people are using latex gloves and using nitril instead, or maybe the latex gloves have improved," she theorizes.
Cleaning products have been and continue to be the leading irritants in work-related asthma cases reported to the SENSOR program. "In the [1993-1997] study, the people interviewed were asked what their exposures were; it was cleaning products," Pechter explains. "[Just as] replacing powdered latex gloves with non-latex or low-allergen, powder-free gloves is one example of eliminating a sensitizing agent from the health care environment, reducing use of disinfectants, by cleaning more and using disinfectants selectively, is another method."
Another frequent offender is glutaraldehyde, a broad-spectrum antimicrobial used as a cold sterilization agent for medical instruments. It is also an ingredient in X-ray developer and pathology tissue fixative. (See box below for a list of common occupational asthma triggers.) There are alternatives to using glutaraldehyde as a disinfectant, including peracetic acid, hydrogen peroxide, and orthophthalaldehyde, the SENSOR study suggests. "Work-related asthma among health care workers is a preventable disease," Pechter insists. "Health care workers should be protected from respiratory diseases that result from their work."
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Occ health nurses help reduce exposure
Efforts such as the Sustainable Hospitals Program provide occupational health providers in the health care setting resources for elimination of some hazardous workplace exposures. (For more information on the program, see resource information at end of article.)
"Occupational health nurses can play a really important role by making sure cleaning products and processes selected and used are not triggers, or if they are, [by determining] what their effects will be on employees and patients," Pechter says. "If you are disinfecting floors, for example, are you putting more [cleaning agent] into the air than is needed?" The first question to ask is whether the product can be eliminated, and if it can be replaced with a product that is safer. "Where you can't replace the product, and you have to use a disinfectant, ask, use it wisely, and, wherever possible, clean instead of disinfecting when the goal is cleaning rather than disinfecting," says Pechter.
When investigating a substitute for a product that is triggering or exacerbating asthma, the nurse should be cautious of new products and make sure the substitute accomplishes what is needed and is safe in the process. "Always ask the question about the products you are using and about the safer alternatives," Pechter says. "Ask if the alternative is safer." In the SENSOR reporting states, as well as other states, work-related asthma must be reported to the state by health care providers.
Sources/Resource
For more information on work-related asthma, contact:
- Elise Pechter, MPH, CIH, Industrial Hygienist, Massachusetts Department of Public Health, Occupational Health Surveillance Program, Boston, MA. Phone: (617) 624-5681.
- Jennifer Flattery, MPH, Epidemiologist, and Robert Harrison, MD, MPH, Chief of Occupational Health Surveillance, California Department of Health Services, Oakland, CA. Phone: (510) 620-5757.
Flattery J, Harrison R. Work-related asthma. Available at www.thoracic.org/sections/chapters/ca/current-news/resources/WorkRelatedAsthma113004.pdf.
For information on the Sustainable Hospitals Program, a resource for products and processes that reduce occupational asthma exposures, go to www.sustainablehospitals.org.
While national data don't give us the overall picture, cases of work-related asthma logged in four states that track the disease indicate it is a major health issue among health care workers.Subscribe Now for Access
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