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By Mark Hodgson and Nicole KennyDisinfection of surfaces is a vital component of any healthcare organization’s infection control program to prevent transmission of infectious agents to patients.1 To minimize the risk of transmission, hospitals use a wide range of chemicals on a daily basis to help clean and disinfect surfaces and materials. However, many of the disinfectants used today present inherent health and safety risks. It is not uncommon to see the use of disinfectant products that present a risk of permanent eye, skin and mucus membrane damage and even the use of potentially carcinogenic products. From a risk assessment perspective, the pathogens left behind on surfaces are worse than the chemicals in the disinfectants.
Protecting Staff but Not Patients?
The Occupational Safety and Health Administration (OSHA) regulates the use of hazardous chemicals in work environments under the Occupational Safety and Health Act of 1970. The act requires employers to protect employees from exposure to hazardous chemicals. Significantly, there are no similar regulations to protect patients who may be in a room where personnel are using the disinfectants. In most instances, hospitals require personnel who use disinfectants to use personal protective equipment (PPE) when working with hazardous products. Typically this includes use of impervious gloves and some form of eye protection such as goggles.
Studies Cite Health Effects of Widely Used Hospital Disinfectants
Both chronic and acute health effects are associated with the use of disinfectants in hospitals. In 2010, the Centers for Disease Control and Prevention (CDC) published a study of occupational illness from four states in the U.S., identifying 401 acute cases in a six-year period, of which 151 were caused by surface disinfectants that used quaternary ammonium compounds (quats),2 a chemical found in many of today’s commonly used disinfectants. The majority of the injuries identified in the CDC study were eye (222), followed by neurologic (130) and respiratory (121). The CDC study did not look at any patient injuries. In a 2008 study, Arif et al. showed a significant increase in the rate of occupational asthma for nursing staff associated with the use of disinfectants.3 The Arif study notes that the majority of the products used were bleach or quat-based.
Protecting Staff: Personal Protective Equipment is Not the First Choice
Presently, healthcare facilities commonly rely on PPE to protect staff from hazardous chemicals in disinfectants. According to OSHA however, PPE use should not be the first option. OSHA’s hierarchy of recommended controls includes:
Healthcare facilities often adopt option four on the assumption that engineering controls are not feasible. This assumption may no longer be correct, due to the introduction of new disinfectant technologies to the healthcare market.
Choosing a Safer Disinfectant: Understanding HMIS Ratings
The Hazardous Materials Identification System (HMIS) is a measure of the health and safety hazard presented by a product, which is represented by a numerical rating from 0 to 4 for health risk, flammability and physical hazard. The numbers are normally presented in the format of X/X/X, with the health and safety hazard as the first number, or in blue when presented in table format as shown above. If a product has an HMIS rating of 0, PPE is typically not required from a chemical hazard perspective. If the health and safety hazard is 1 or higher, then increasing levels of PPE are required. For disinfectant products regulated by the Environmental Protection Agency (EPA), the product master label will show the health hazard associated with the product and the required PPE. The product material safety data sheet (MSDS) should clearly state the PPE requirements and match the master label. Note that in many instances, the MSDS is treated as a marketing document and does not accurately reflect the information on the master label. Users are cautioned to always refer to the source document rather than secondary materials. Having said that, responsible companies will publish an accurate HMIS statement on their MSDS. If you find one that is not accurate, reporting this to the EPA Pesticides Control Division is always an option.
In the latest version of HMIS, the health bar has two spaces, one for an asterisk and one for a numeric hazard rating. If present, the asterisk signifies a chronic health hazard, meaning that long-term exposure to the material could cause a health problem such as emphysema or kidney damage. To help better understand the HMIS numerical measurement system for health, flammability and physical hazards, the definitions can be found below.
The Next Generation of Disinfectants: Lowest Possible HMIS Rating
Today’s commonly used disinfectant technologies rely on relatively high and hence hazardous concentrations of sodium hypochlorite (bleach), quats and alcohols, which present known health hazards and often don’t kill pathogens effectively. Next-generation technologies such as accelerated hydrogen peroxide, which is based on low levels of hydrogen peroxide, are effective against pathogens yet gentle for hospital staff and patients. These EPA-registered hospital-grade disinfectants have an HMIS rating of 0, presenting far less of a hazard to both workers and patients compared with commonly used disinfectant technologies with HMIS ratings of 2 or 3.
Selecting the right disinfectant for your infection control program requires consideration of many factors, including not only the product’s effectiveness against pathogens but also its potential health impact on patients and staff. Ideally, you should consider a product that provides the optimal balance of carrying the lowest possible HMIS rating of 0/0/0 while providing the broadest range of efficacy as a disinfectant, including effectiveness against increasingly challenging pathogens such as norovirus. As you review the product label or MSDS for your present disinfectant products, know that better options are available. Adopting the newer technology would allow your hospital to engineer out a significant health risk.
About the Authors
Mark Hodgson is vice president of Virox Healthcare, and Nicole Kenny is director, professional and technical services, for Virox Technologies Inc.
1 Centers for Disease Control and Prevention. Guidelines for disinfection and sterilization in health-care facilities, 2008. Available at http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/disinfection_nov_2008.pdf.
2 Centers for Disease Control and Prevention. Acute antimicrobial pesticide-related illnesses among workers in healthcare facilities — California, Louisiana, Michigan, and Texas, 2002–2007. MMWR. 2010 May 14;59(18):551-556. http://www.ncbi.nlm.nih.gov/pubmed/20467413
3Arif AA, et al. Occupational exposures and asthma among nursing professionals. Occup Environ Med. doi:10.1136/oem.2008.042382.