Occupational and work-related respiratory disease attributed to cleaning products

Our plain-English summary of Occupational and work-related respiratory disease attributed to cleaning products, by M. Carder, M.J. Seed, A. Money, et al (Occupational and Environmental Medicine, 2019).

The study

• Authors: M. Carder, M.J. Seed, A. Money, R.M. Agius, M. van Tongeren
• Journal: Occupational and Environmental Medicine
• Published: 2019;76(8):530-536
• Cited by: 40 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objectives: Exposure to cleaning products has been associated with adverse respiratory outcomes. This study aimed to investigate the medically reported incidence, trends in incidence and occupational determinants of work-related respiratory disorders attributed to cleaning agents and to explore the role of 'Quantitative Structure Activity Relationships' (QSAR) in corroborating the identification of chemical respiratory sensitisers.

Methods: Respiratory diagnoses attributed to cleaning agents were extracted from The Health and Occupation Research (THOR) surveillance network, 1989-2017. Incidence, trends in incidence and incidence rate ratios by occupation were investigated. Agents were classified by chemical type and QSAR hazard indices were determined for specific organic chemicals.

Results: Approximately 6% (779 cases) of the (non-asbestos) THOR respiratory cases were attributed to cleaning agents. Diagnoses were predominantly asthma (58%) and inhalation accidents (27%) with frequently reported chemical categories being aldehydes (30%) and chlorine/its releasers (26%). No significant trend in asthma incidence (1999-2017) was observed (annual average change of -1.1% (95% CI -4.4 to 2.4)). This contrasted with a statistically significant annual decline in asthma incidence (-6.8% (95% CI -8.0 to -5.6)) for non-cleaning agents. There was a large variation in risk between occupations. 7 of the 15 organic chemicals specifically identified had a QSAR generated hazard index consistent with being a respiratory sensitiser.

Conclusion: Specific occupations appear to be at increased risk of adverse respiratory outcomes attributed to cleaning agents. While exposure to agents such as glutaraldehyde have been addressed, other exposures, such as to chlorine, remain important. Chemical features of the cleaning agents helped distinguish between sensitising and irritant agents.

© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.

In plain English

This study analysed work-related respiratory disease reported to the UK THOR surveillance network by chest physicians (1989–2017), occupational physicians (1999–2017) and general practitioners (2006–2017). It concerns cleaning products; asbestos cases were excluded. About 6% (779) of non-asbestos cases were attributed to cleaning agents, mostly asthma or inhalation accidents. Aldehydes (30%) and chlorine or its releasers (26%) were most reported. In chest physician reports for 1999 to 2017, launderers, dry cleaners and pressers had about 40 times the rate of all other occupations (incidence rate ratio 39.7, 95% CI 19.3 to 81.4), based on few cases. The ratio was 20.5 (95% CI 15.4 to 27.3) for cleaners and 6.8 (95% CI 5.2 to 8.9) for nurses, nursing auxiliaries and assistants. Reported asthma attributed to cleaning agents showed no statistically significant trend; for other agents it fell by an average of 6.8% a year (95% CI 5.6% to 8.0%). Seven of 15 specific chemicals scored above a threshold suggesting respiratory sensitisation. The authors concluded that specific occupations appear to be at increased risk. They noted that cases may have been wrongly included, misattributed or under-reported.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: analysis of case reports from a UK physician-based surveillance network for work-related disease, with a computer model (QSAR) estimating whether specific chemicals are likely respiratory sensitisers
• Who was studied: 779 cases of work-related respiratory disease attributed to cleaning agents in the UK: 690 reported by chest physicians (SWORD, 1989–2017), 73 by occupational physicians (OPRA, 1999–2017) and 16 by general practitioners (THOR-GP, 2006–2017); asbestos cases were excluded
• Exposure: cleaning agents (any material used for cleaning or disinfecting), grouped into 12 chemical categories such as chlorine/releasers, aldehydes (e.g. glutaraldehyde), acids, caustics, chloramines, solvents and quaternary ammonium compounds
• Main results:
  • Approximately 6% (779 cases) of the non-asbestos THOR respiratory cases were attributed to cleaning agents
  • Of 702 diagnoses among the 690 chest physician (SWORD) cases, 418 (60%) were asthma and 195 (28%) inhalation accidents
  • Across all schemes, the most frequently reported chemical categories were aldehydes (30%) and chlorine/its releasers (26%)
  • In SWORD reports for 1999–2017, launderers, dry cleaners and pressers had an incidence approximately 40 times the average of all other occupations (incidence rate ratio 39.7, 95% CI 19.3 to 81.4, based on 4 actual cases)
  • Cleaners (SWORD, 1999–2017): 56 actual (177 estimated) cases; incidence rate ratio 20.5 (95% CI 15.4 to 27.3) for all respiratory diagnoses compared with all remaining occupations combined
  • Nurses, nursing auxiliaries and assistants (SWORD, 1999–2017): 67 actual (89 estimated) cases; incidence rate ratio 6.8 (95% CI 5.2 to 8.9) for all respiratory diagnoses
  • Care assistants and home carers had a lower rate than other occupations: incidence rate ratio 0.3 (95% CI 0.2 to 0.6) for all respiratory diagnoses
  • Respiratory disease attributed to cleaning agents (SWORD, 1999–2017) changed by an average of −1.8% per year (95% CI −4.8 to 1.3), which the authors describe as not statistically significant
  • For asthma attributed to cleaning agents (SWORD reports), the average annual change was −1.1% (95% CI −4.4 to 2.4)
  • For reports attributed to non-cleaning agents there was a statistically significant average annual decline: −5.0% (95% CI −5.9 to −4.0) for total respiratory disease excluding asbestos and −6.8% (95% CI −8.0 to −5.6) for asthma
  • Excluding aldehydes, cleaning-agent cases showed an average annual increase of 2.7% (95% CI −0.8 to 6.4) for total respiratory disease and 3.6% (95% CI −0.3 to 7.7) for asthma. Both trends were significantly different from the declining trends for non-cleaning agents (p less than 0.001)
  • Of 15 specific low molecular weight chemicals blamed for at least one case of occupational asthma, 7 had a QSAR hazard index above the 0.39 cut-point suggesting respiratory sensitiser potential; glutaraldehyde (index 0.6) accounted for 172 reported cases
• The authors' conclusion: The authors concluded that specific occupations appear to be at increased risk of adverse respiratory outcomes attributed to cleaning agents, that exposures such as chlorine remain important, and that chemical features helped distinguish sensitising from irritant agents
• Limitations the authors state:
  • Cases may have been wrongly included or excluded, particularly for chemicals with uses other than cleaning
  • The same case may have been reported to more than one THOR scheme
  • Reporting physicians may have misattributed the cause or the job
  • Relevant cases are likely under-reported to THOR
  • The highest-risk estimate (launderers, dry cleaners and pressers) was based on a relatively small number of cases

Topics

Medical terms in this study, explained in our Lexicon: Incidence.

Related studies

• SWORD '93. Surveillance of work-related and occupational respiratory disease in the UK — B.A. Sallie, D.J. Ross, et al. (1994)
• SWORD '97: surveillance of work-related and occupational respiratory disease in the UK — D.J. Ross, H.L. Keynes, et al. (1998)
• Work-related respiratory disease in the United Kingdom, 1989-1992: report on the SWORD project — S.K. Meredith, J.C. McDonald (1994)
• SWORD '94: surveillance of work-related and occupational respiratory disease in the UK — D.J. Ross, B.A. Sallie, et al. (1995)
• Occupational respiratory diseases in the Czech Republic — P. Brhel (2003)
• Chest physician-reported, work-related, long-latency respiratory disease in Great Britain — M. Carder, A. Darnton, et al. (2017)

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