In the fierce battle against healthcare-associated infections, healthcare workers have unwittingly become collateral damage, developing skin irritation, headaches, and even asthma from cleaners and disinfectants. To address those health hazards, infection preventionists and occupational health professionals have come together in an unprecedented collaboration.

The National Institute for Occupational Safety and Health (NIOSH) gathered more than 40 experts from various fields to review what is known about cleaning and disinfection of hospital surfaces and to identify knowledge gaps and research needs. Their conclusion: Hospitals should engage interdisciplinary teams to evaluate the hazards of their cleaning and disinfecting products.1

“The [multidisciplinary] model we used in our working group can also be used in healthcare settings,” says Paul Henneberger, MPH, ScD, NIOSH research health scientist in Morgantown, WV, and co-chair of the Cleaning and Disinfecting in Healthcare Working Group.

“The difference would be that the professions involved would go beyond infection prevention and occupational health,” he says. “It should also include the people who are actually doing the work — the environmental services workers, nurses, and technicians who would be impacted by any policies and practices.”

By their nature, cleaning and disinfecting products must be toxic enough to kill a wide range of microbes, including Clostridium difficile spores. Almost a half-million people develop C. difficile infection annually, and about two-thirds of the cases are associated with an inpatient stay, according to the Centers for Disease Control and Prevention. Hospitals are under intense pressure to reduce those and other infections.

But studies show that hospital workers exposed to cleaning and disinfecting products have an increased risk of asthma and other respiratory problems.2 And anecdotally, the use of new products has led to complaints of skin and throat irritation, respiratory problems and headaches. When the Occupational Safety and Health Administration announced a wider focus in hospital inspections, the agency included hazardous chemical use, such as disinfectants, in the scope of review by inspectors. (See HEH, August 2015)

“Cleaning and disinfecting agents, especially disinfecting products, are designed to kill organisms. While that’s an essential function in some areas of healthcare, we have to treat them as chemicals that can have human health impacts, as well,” says Margaret Quinn, ScD, CIH, professor in the Department of Work Environment at the University of Massachusetts Lowell.

Choosing a product certified as “green” isn’t necessarily the answer. There is no standard definition of a “green” product, and the criteria do not necessarily include human health effects, said the working group, which was convened through NIOSH’s National Occupational Research Agenda.

New product triggered symptoms

When a new cleaning product was introduced into a large health system as part of an effort to combat C. difficile, environmental services workers began complaining of symptoms: burning eyes, inflamed throat, headaches, difficulty breathing.

Some unit managers switched to a different product while others insisted that the product was necessary, says Mark Catlin, health and safety director of the Service Employees International Union (SEIU).

What the workers really needed was a methodical evaluation by infection control and employee health, he says. Was there an effective product with fewer health hazards? Was there a safer way to use the product? What protective measures, such as better ventilation or respirators, could reduce the risks?

“You would want the manager of environmental services, occupational health and safety, and frontline workers to work together to figure out how to introduce a new product so it prevents infections and workers don’t get sick,” he says. “What I hear from the workers is that the issue of controlling hospital-acquired infections is a big push that overrides everything else.”

Healthcare has a higher rate of work-related asthma than other industries. In New Jersey, one of a handful of states that conducts surveillance, almost 18% of cases of work-related asthma identified from 1993 to 2011 were in healthcare — more than in any other industry. Cleaning products, particularly bleach and ammonia, have been linked to work-related asthma.

In one case cited by the working group, 18 operating room employees developed respiratory symptoms, including two cases of work-related asthma, when a new disinfecting product containing quaternary ammonium compounds was introduced. The hospital switched to a product that didn’t cause symptoms but then switched back when tests showed that the alternative wasn’t effective against Staphylococcus aureus. The two employees with asthma had to leave the OR. One was reassigned and the other lost the job.1

“Because of the need to balance risks — chemical exposures versus infectious disease — finding safer alternatives is not simple or straightforward in a hospital setting,” says Justine Weinberg, MSEHS, CIH, industrial hygiene research scientist in the Occupational Health Branch of the California Department of Public Health. “But the decision to keep using a product that is causing the employees’ asthma symptoms had serious career and livelihood consequences for those employees.”

Reducing the hazard doesn’t just mean seeking an alternative product, notes Weinberg. New disinfection methods, such as UV light, may replace some chemical use. Hospitals also should consider whether they are overusing disinfectants, such as disinfecting floors in areas where that isn’t necessary.

“There should be a systematic assessment to determine what areas and surfaces can be cleaned only and which should be disinfected,” Weinberg says. (For key steps to reducing chemical hazards, see related story in this issue.)

Environmental services workers aren’t the only ones at risk from cleaning and disinfecting agents. Henneberger and colleagues tracked workers in 14 occupations at five hospitals for 216 shifts. They found that nurses perform cleaning activities on about one-fourth of their workdays, and some technicians are involved in frequent equipment cleaning.3

A 2003 survey found that nurses were more likely to have asthma than physicians, respiratory therapists or occupational therapists, and exposure to cleaning or disinfecting products doubled the risk of asthma.4 George Delclos, MD, MPH, PhD, professor in the Division of Epidemiology, Human Genetics, and Environmental Sciences at the University of Texas School of Public Health in Houston, is now repeating that survey.

To prepare for the survey, Delclos and his colleagues are conducting focus groups and walk-throughs to learn more about how cleaning products are used. Employee health professionals should also take the time to “walk the beat” and learn about the work practices of environmental services, says Delclos, who was a member of the working group and lead author of the original study of asthma among nurses and other clinicians.

Employee health professionals also should be alert for health effects, he says. “Be on the lookout for employees with asthma symptoms, especially if they cluster or if [employees] describe an incident that immediately preceded the onset of certain symptoms,” he says. “Use them as sentinel events to take a closer look.”

Problems may stem from work practices — how the product is diluted, or whether it is sprayed or wiped. “Sometimes a product that has been used for a long time goes from not having a health effect to having a health effect because of the way it’s applied,” he says.

But whatever a hospital does to resolve health effects, it must continue to use products that kill dangerous microbes, says Quinn.

“The infection preventionists on our working group reminded us that infection is also an employee hazard,” she says. “We’re not trying to stop the cleaning and disinfecting processes. We want to reduce the infection risks both for patients and employees. We need to think about ways to do that while reducing the risk of the chemicals.”


  1. Quinn MM, Henneberger PK, and members of the National Institute for Occupational Safety and Health National Occupational Research Agenda Cleaning and Disinfecting in Healthcare Working Group. Cleaning and disinfecting environmental surfaces in healthcare: Toward an integrated framework for infection and occupational illness prevention. Am J Infect Control 2015;43:424-434.
  2. Folletti I, Zock JP, Moscato G, et al. Asthma and rhinitis in cleaning workers: a systematic review of epidemiological studies. J Asthma 2014 51:18-28.
  3. Saito R, Virji MA, Henneberger PK, et al. Characterization of cleaning and disinfecting tasks and product use among hospital occupations. Am J Ind Med 2015;58:101-111.
  4. 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.