Acute Antimicrobial Pesticide-Related Illnesses Among Workers in Health-Care Facilities --- California, Louisiana, Michigan, and Texas, 2002--2007

Acute Antimicrobial Pesticide-Related Illnesses Among Workers in Health-Care Facilities --- California, Louisiana, Michigan, and Texas, 2002--2007
Weekly
May 14, 2010 / 59(18);551-556


Antimicrobial pesticides (e.g., sterilizers, disinfectants, and sanitizers) are chemicals used to destroy or suppress the growth of harmful microorganisms on inanimate objects and surfaces (1). Health-care facilities use antimicrobial pesticides to prevent pathogen transmission from contaminated environmental surfaces (2). Occupational exposures to antimicrobial pesticides are known to cause adverse health effects. To assess the nature and frequency of such exposures in health-care settings, CDC analyzed data from pesticide poisoning surveillance programs in California, Louisiana, Michigan, and Texas (the only four states that regularly collect data on antimicrobial pesticide-related illness) for the period 2002--2007. This report summarizes the results of that analysis, which identified 401 cases of work-related illness associated with antimicrobial pesticide exposures in health-care facilities. Most cases were identified through workers compensation systems (61%) and occurred among females (82%) and persons aged 25--54 years (73%). The most frequent occupations reported were janitors/housekeepers (24%) and nursing/medical assistants (16%). The reported mechanism of injury usually was splashes/spills (51%). The eyes were the most common organ/system affected (55%); only 15% of the 265 persons who had exposures while handling antimicrobial pesticides reported using eye protection. Reported symptoms were mostly mild and temporary. One fatality due to acute asthma and subsequent cardiopulmonary collapse was identified. Health-care facilities should educate workers about antimicrobial pesticide hazards, promote the use of personal protective equipment (PPE) as appropriate, and implement effective risk communication strategies for antimicrobial pesticide use to prevent bystander exposure. Improved design of handling equipment might prevent handler and bystander exposure.

Approximately 5,000 antimicrobial pesticide products are registered with the U.S. Environmental Protection Agency, and approximately 60% of these are targeted to control infectious microorganisms in health-care settings (1). Antimicrobial pesticide products are formulated into sprays, liquids, concentrated powders, and gases (1). Occupational exposure to disinfectants (e.g., glutaraldehyde), cleaning products (e.g., bleach), or sanitizers (e.g., quarternary ammonium compounds [QACs]) can cause acute irritant symptoms, respiratory and skin sensitization, and asthma (3--5). Although information on the risks for occupational exposure to antimicrobial pesticides is available, little is known about the magnitude and characteristics of acute antimicrobial pesticide illnesses among workers in health-care facilities.

The four states require health-care providers to report pesticide-related illness to designated state agencies. State surveillance programs collect data on acute pesticide illness cases from various sources (e.g., physicians, poison control centers, workers compensation systems, and state and local government agencies) and classify cases based on the strength of evidence for pesticide exposure, health effects, and their causal relationship (6) (Table 1). CDC obtained data for the California cases from the California Department of Pesticide Regulation (CDPR), and data for the other three states from the Sentinel Event Notification System for Occupational Risks (SENSOR)-Pesticides program.* Case categories of definite, probable, possible, and suspicious from SENSOR-Pesticides and definite, probable, and possible from CDPR were included in the data analysis. An antimicrobial pesticide-related illness was defined as any acute adverse health effect resulting from exposure to an antimicrobial pesticide product. Health-care facilities were defined as hospitals, nursing and personal-care facilities, medical clinics, and other health service settings involving patient care.† Home health-care services were excluded. Data were analyzed for demographics, occupation, health effects, severity,§ outcomes (e.g., hospitalization and lost work time), pesticide toxicity, active ingredients, and nature of exposure (e.g., type of activity, type of exposure, and PPE use).

During 2002--2007, a total of 401 acute illnesses associated with work-related antimicrobial pesticide exposures in health-care facilities were reported: 287 cases (72%) in California, 56 (14%) in Texas, 43 (11%) in Michigan, and 15 (4%) in Louisiana (Table 2). These antimicrobial pesticide exposure cases accounted for 87% of all work-related pesticide illnesses reported in health-care facilities. The annual number of cases increased from 51 in 2002 to 77 in 2007. The majority of cases were among females (82%) and persons aged 25--54 years (73%). Occupations with the most cases were janitors/housekeepers (24%), followed by nursing/medical assistants (16%) and technicians (15%).

Most cases (85%) had low-severity illness. Fifty-six cases (14%) had moderate-severity illness, two cases had high-severity illness, and one death occurred. Eight cases (2%) were hospitalized, and 68 persons (17%) experienced ≥1 day of lost time from work. Ocular symptoms/signs (e.g., eye irritation/pain and conjunctivitis) were the most commonly experienced health effects (55%), followed by neurologic (e.g., headache and dizziness) (32%), respiratory (e.g., throat irritation/pain, cough, and dyspnea) (30%), and dermal (e.g., irritation and rash) (24%) symptoms/signs. Among the 121 cases with respiratory symptoms/signs, 11 (9%) were in persons with asthma who had acute asthma, and six (5%) were in persons without asthma who experienced wheezing; all 17 were classified with moderate or higher severity illness.

The fatal case occurred in a woman aged 52 years employed as a laundry worker at a Michigan nursing home who had a 2-year history of non--steroid-dependent asthma and chronic bronchitis. She smoked two packs of cigarettes and some marijuana daily. In February 2007, she was exposed to nondiluted bleach fumes from an open pail near a running clothes dryer for 10--15 minutes. She complained of shortness of breath, used her albuterol inhaler, but collapsed. 9-1-1 was called, and cardiopulmonary resuscitation and intubation were performed at the scene. She never regained consciousness and died 5 days later in the hospital.

The most common active ingredients responsible for illnesses were QACs (38%), glutaraldehyde (25%), and sodium hypochlorite (18%). Sixty-six percent of cases were in persons exposed while they handled antimicrobial pesticides and 18% were in bystanders (16% had unknown activity at time of exposure). Inadvertent exposure by splashes/spills/leaks accounted for 51% of cases. Among 265 persons who handled antimicrobial pesticides, 74% were wearing some type of PPE, including primarily work clothes or gowns (60%) and gloves (55%). Only 15% wore eye protection, including safety glasses, goggles, or face shield, and 5% wore surgical masks or respirators.

Reported by
L Mehler, MD, California Dept of Pesticide Regulation. A Schwartz, MPH, Michigan Dept of Community Health. B Diebolt-Brown, MA, Texas Dept of State Health Svcs. R Badakhsh, MPH, Louisiana Dept of Health and Hospitals. GM Calvert, MD, Div of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health; SJ Lee, PhD, EIS Officer, CDC.

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Acute Antimicrobial Pesticide-Related Illnesses Among Workers in Health-Care Facilities --- California, Louisiana, Michigan, and Texas, 2002--2007