2013 FOM ASM Presentation

Dr Syed Nasir

The Respiratory Health of Cleaners in NHS Highland

Background

Previous studies found increased risk of lower respiratory symptoms in cleaners compared to administrative staff.

Previous Research

Largest data set on cleaners from ECRHS (European Community Respiratory Health Survey) study – 26 centres in 12 countries.

Spanish EPIASLI, Canadian cross-sectional surveys.

Swedish, Singapore, New Zealand surveys.

National surveillance schemes across 4 continents. Accessed from: http://www.ecrhs.org/ECRHS%20I.htm

NHS Highland Cleaners

6% of NHS Highland employees. Vital in protecting health of patients and staff.

Exposure to occupational respiratory hazards such as cleaning agents and dust.

In NHS Highland cleaners had higher sickness absence and staff turnover rates than administrative staff.

NHS Highland features

Single Health Board with discrete, standardised working conditions.

Covers 40% of Scottish mainland area in Northwest.

Objectives

To estimate the prevalence of respiratory symptoms among cleaners compared with administrative workers.

To identify any associations between specific occupational exposures and respiratory symptoms among cleaners.

Method Cross-sectional postal

questionnaire survey of: - All NHS Highland cleaners. - Comparison group of all

NHS Highland administrative staff. 2nd mailing to non-

responders.

Questionnaire

Respiratory symptoms

questions from the validated European Community Respiratory Health Survey (ECRHS) questionnaire.

Exposure

asked about history of cleaning work; cleaning agents; cleaning tasks; duration of work as a cleaner; cleaning locations and training on the use of cleaning agents.

Results : Response Rate

The overall response rate was 56%:

-645/1270 administrative staff (62%).

-216/545 cleaners (40%).

Demographic profiles

No significant difference between the groups in terms of the age distribution (p=0.075) or gender distribution (p=0.19).

A significantly greater proportion of administrative staff were educated beyond secondary school level (p<0.001).

Smoking profiles

Greater proportion of cleaners had ever smoked (52% vs 34%).

Comparing the pack-years of smoking in the two groups, cleaners smoked statistically significantly more than the administrative staff [p=0.003]

Power of study

80% power at a 0.05 significance level, to detect a 9% difference in the prevalence of asthma or chronic bronchitis symptoms.

Greater than the pre-study projection.

Key findings

After adjusting for age and smoking, no significant differences were found in the occurrence of asthma and chronic bronchitis in cleaners compared to administrative staff.

Cleaners had significantly less upper respiratory tract symptoms (allergic rhinitis).

Risk of respiratory symptoms : adjusted odds

ratio Cleaners

[OR (95%CI)]

Administrative

staff (never

cleaners)

Wheezing with

breathlessness

0.81 (0.44-1.44) 1.0

Ever asthma 0.65 (0.39-1.04) 1.0

Current asthma 1.25 (0.80-1.92) 1.0

Chronic bronchitis 1.26 (0.79-1.97) 1.0

Ever rhinitis 0.59 (0.41-0.86) 1.0

Exposures : Cleaning agents

No significantly increased risk of asthma or chronic bronchitis symptoms with any of the chlorine-containing cleaning agents.

Cleaning substance Current asthma

[OR (95%CI])

Actichlor™ 1.56 (0.73-3.45)

Cleenol bleach™ 1.11 (0.39-2.81)

Precept™ 2.13 (0.44-8.13)

Exposures : Chlorine – based agents

Exposures : Cleaning tasks

No significantly increased risk with dusting/polishing furniture or cleaning up chemical spills of current asthma or chronic bronchitis.

Dusting/polishing furniture -current asthma OR 2.76, 95% CI 0.63 – 12.23 -chronic bronchitis OR 1.07, 95% CI 0.38 – 3.01.

Cleaning up chemical spills -current asthma OR 1.37, 95% CI 0.59 – 3.19 -chronic bronchitis OR 1.88, 95% CI 0.86 – 4.10.

Exposures : Cleaning Areas

No significantly increased risk in operating theatres, hospital wards, kitchens and corridors:

– Asthma [OR 1.11, 95%CI 0.45–3.18]

– Chronic bronchitis [OR 0.95, 95%CI 0.40 – 2.54]

Risk by Geographical Area

No significantly increased risk of current asthma or chronic bronchitis symptoms by area

(4 CHPs).

Discussion

First epidemiological study of respiratory symptoms in cleaners working with standardised working conditions, substances and training in a large healthcare organisation.

Possible explanations

The preventive measures put in place by NHS Highland addressed many risk factors highlighted by previous studies.

Hierarchy of Control

ELIMINATION Sprays, Enzymatic/Biological agents, Sanitiser powder,

Fume-emitting Destainer, Bactericidal gel.

Introduction of Steam cleaner using hot water-avoids use

of chemicals.

SUBSTITUTION Lower chlorine concentrations in cleaning agents

ENGINEERING Use of enclosed bucket to dissolve chlorine-based tablet in

tepid water

ADMINISTRATIVE Colour coding of cleaning equipment/areas (NPSA)

Standard Procurement Process

HAI/HEI audits

INFORMATION,

INSTRUCTION,

TRAINING

NHS Highland-wide trainers

Standard training programme for cleaners

Framework of NHS Scotland Policies (Cleaning Services ,

Agenda for Change, Cleaner Education and Training),

Cleanliness Champions

PPE Risk-assessed: Masks, Gloves, Uniform

Other factors

Median length of service of cleaners (6 years).

Mean age of cleaners (47.3 years) less than the peak age for diagnosis of COPD (>55 years).

Study strengths

Discrete, well-defined occupational groups with homogenous working conditions.

Groups well-matched by age, gender.

Unexposed group never employed as cleaners.

Validated ECRHS questionnaire.

Evaluation of exposures (tasks, substances, locations).

Study weaknesses

Low response rate in cleaners (40%)

Responder bias

Healthy Worker Effect

Conclusion

No significant increase in the prevalence of lower respiratory symptoms in NHS cleaners.

No significantly increased risks of respiratory symptoms among cleaners:

– in the highest risk areas

– using chlorine-based cleaning agents

– by cleaning tasks

– by geographical division

Possible explanations: Risk assessment and controls; Cleaners’ age and length of service.

Any questions?