EH sleuth: The case of the coughing HCWs

Search for indoor air culprit is complex

It took eight months for the supervisor in the hospital’s pharmacy to realize that she and most of her co-workers had a persistent cough. That revelation began an employee health investigation, with employee health nurse Janet Abernathy, RN, COHN-S, on the trail of an indoor air culprit.

Indoor air quality concerns are among the most challenging that an employee health professional may face, says Abernathy, who is now at Queen of the Valley Hospital in Napa, CA. "It is difficult, and it isn’t always straightforward."

Abernathy will be presenting her "lessons learned" from an extensive indoor air quality investigation at the upcoming annual conference of the Association of Occupational Health Professionals in Healthcare.

Abernathy began probing for a cause when she learned that five of seven full-time employees of the hospital’s outpatient pharmacy suffered from similar symptoms, including persistent cough, asthma, headache, and burning and itching eyes. One employee suffered from recurrent fainting. Even a housekeeper who worked in the area for two hours a day was symptomatic. (Abernathy declined to name the hospital, a former employer.)

She began by taking medical histories of the employees. What she found was startling. All had sought medical treatment for their symptoms; none of them improved. All of them had preexisting medical conditions, including two employees with asthma and one with a workers’ compensation claim of multiple chemical sensitivities.

"When I started to get their detailed past histories, they had so much underlying history and disease process going on, I knew I was over my head and needed additional assistance," notes Abernathy. "By the time we got notification [of the problem], most of the employees had been treated multiple times with their own private doctors with a variety of diagnoses. Nothing seemed to help them."

She was able to contract with an occupational health physician, who also was a pulmonologist, who worked at the hospital. He turned out to be a valuable resource as the investigation became more complex.

The occupational health physician conducted physical exams, which included TB skin tests (all negative) and IgE allergy blood tests (all but one elevated, indicating some allergic response). The employees had pulmonary function tests and chest X-rays. (One employee with a previous history of breast cancer had a shadow on her X-ray; further evaluation showed no sign of cancer. Another employee was taken from radiology immediately to the hospital’s emergency department; he had congestive heart failure, a severe diagphragmatic hernia, and an enlarged heart. He later died of that condition.)

To monitor changes in their lung capacity, the employees used peak flow meters and kept a record of the rates both at the beginning and end of the day. They also filled out symptom questionnaires, indicating when the symptoms seemed to be worse, and kept a symptom log. (See sample form.)

None had Legionnaires’ disease, but one employee had pneumonia. The occupational health physician contended those with asthma were not being treated adequately. More aggressive treatment brought the asthma under control.

Despite all these personal health problems, Abernathy continued to pursue the indoor air concerns in the pharmacy. "We knew there was an allergic component going on because all of them but one had elevated IgE levels," she says.

The hospital’s industrial hygiene department suggested hiring an outside contractor to conduct an environmental evaluation of the work site. After all, research by the National Institute for Occupational Safety and Health shows that 52% of indoor air problems are caused by inadequate ventilation, Abernathy notes. Another 16% of the incidents are caused by indoor contamination, such as fumes from copier chemicals or pesticides.

"If you’ve checked out your ventilation system and everything is good, you move on to the next most likely culprit," she says.

Meanwhile, Abernathy spent hours observing work practices in the pharmacy. She noticed that the automatic drug dispenser created drug dust that settled on a platform. It would collect there, then fall onto the carpeted floor. When the housekeeper vacuumed, the drug dust would circulate in the air.

"We started to suspect that, perhaps, they were allergic to some of the drug dust, which was present in the room," she says. "The people who were symptomatic were spending most of their day near these cells that were constantly in action, creating more and more dust."

The hospital removed the carpet, replaced the vacuum cleaner with one that uses a HEPA filter, and brought in a self-contained drug-dispensing machine. They repaired the ventilation system in another part of the pharmacy.

With those changes, the symptoms resolved. "The fix was relatively easy," Abernathy explains. "But how would we have known to even do that? Getting to that [fix] was the hard part."

Good communication with employees is essential so that they trust the process, she says. The log was an important tool as Abernathy monitored symptoms. "It really facilitated the communication because it required us to be in constant contact with the employees," she says.

Abernathy also learned that "personal, non-occupational health factors are critically important. You’re not starting with the ideal physical specimen. It’s also important to look at the people who are not symptomatic in the same area and figure out the differences," she says.

(Editor’s note: More information on indoor air quality investigation is available from the National Institute for Occupational Safety and Health at www.cdc.gov/niosh/topics/indoorenv/.)