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Health Effects of Peracetic Acid-Based Disinfectant
in Operating Room Workers
Kathryn Buikema DO, MPH
Sentinel Health Event
• Initial patients: 57 year-old female operating room
(OR) nurse and 30 year-old female OR surgical tech
• Presented to the Occupational Medicine clinic with
multiple complaints that were worse at work and
improved away from work.• Nasal congestion and irritation
• Sore throat
• Itchy, irritated eyes
• Pruritis
• Cough, Shortness of breath, Chest tightness
• Lightheadedness, Headaches
History
Symptoms started after use of new disinfectant
OR team duty change: New cleaning process in ORs to
decrease Hospital Acquired Infections
Terminal cleaning: ceiling, walls, all surfaces
Cleaning in one OR triggered the most symptoms
Some workers continued to use old wipes while others
used new disinfectant
Physical Exam and Assessment/Plan
PPE: nitrile gloves and N95 mask
PE:
• posterior oropharynx erythematous
• edematous nasal mucosa bilaterally
• cervical lymphadenopathy bilaterally
• otherwise unremarkable
Assessment: Irritation likely due to new disinfectant
Plan: Modified duty to include no use of disinfectant for
one week
Initial steps
• Safety officer informed
• Safety goggles and proper gloves (neoprene
or rubber) ordered
• Education by company on dilution and use
Two weeks later
34 year old female OR nurse with six weeks of • Persistent sore throat
• Daily worsening headaches
• Decreased endurance
• Inability to catch her breath
• Improvement of signs and symptoms away from work
Symptoms started with use of new disinfectant to
clean the operating room
PPE: N95 and neoprene gloves
Exam
PE: hyperemic nasal turbinates,
otherwise unremarkable
Spirometry: Normal Forced Expiratory
Volume in one second / Forced Vital
Capacity (FEV1/FVC)
• Tracing shows pattern of plateau
near the beginning of exhalation
o Consistent with vocal cord
dysfunction
Assessment and Plan
A: Vocal Cord Dysfunction and new daily
persistent headache due to use of Perisept
P: Only participate in two cleanings per shift and
only use Perisept with proper PPE
Independent Medical Exam
Conclusion: Her Vocal Cord Dysfunction was
due to use of Perisept
Recommendations at the worksite:N99 mask
Neoprene or rubber gloves
Proper splash goggles
IH Investigation Results
One personal sample collected in OR during terminal cleaning
was half the ACGIH 15 minute STEL (0.2 parts per million).
Ventilation issue, resolved
Follow-up personal sample 0.09 ppm
During terminal cleaning, potential for exposure of at least half of
the ACGIH STEL for Peracetic acid (0.4 ppm)
Amending cleaning procedure by not cleaning the floors with
Perisept resulted in less exposure to Peracetic acid
Clean floors with an alternative cleaning product when a patient
does not have confirmed C. difficile
Perisept
Peracetic acid: Highly reactive, unstable, corrosive
oxidizer
Perisept:
• Diluted combination of peracetic acid, hydrogen
peroxide, and acetic acid
• Industrial uses: • Healthcare, meat-packing, daycares, and the food
& beverage industry
Other disinfectants commonly used in health care settings
• Alcohol
• Chlorine and Chlorine Compounds
• Formaldehyde
• Glutaraldehyde
• Hydrogen Peroxide
• Iodophors
• Ortho-phthaladehyde (OPA)
• Phenolics
• Quaternary Ammonium Compounds
Why Peracetic Acid is favored
• Lacks harmful decomposition products
• Enhances removal of organic material
• Leaves no residue
• Non-allergenic
• Sporicidal disinfectant
• Kills Clostridium difficile
Perisept
Difficult to measure
No standardized method for peracetic acid
• REL: none
• PEL: none
• ACGIH TLV-STEL: 0.4 ppm
• Draft IDLH: 0.64 ppm
Safety Data Sheet
PPE
Eye/face protection: Safety glasses with side shields (or goggles)
and a face shield.
Hand protection: Appropriate chemical resistant gloves, as
recommended by the glove supplier.
Other: Appropriate chemical resistant clothing. Use of an impervious
apron is recommended.
Respiratory protection: If engineering controls do not maintain
airborne concentrations below recommended exposure limits (where
applicable) or to an acceptable level (in countries where exposure
limits have not been established), an approved respirator must be
worn--chemical respirator with organic vapor cartridge.
http://steinsinc.com/MSDS/SSS/Perisept_62_Sporicidal_Disinfectant_Cleaner.pdf
Studies of Perisept
Few studies have evaluated cleaning workers’ full-shift
exposures to cleaning fluids and disinfectants
corresponding to reported respiratory symptoms
Few studies of hospital workers exposed to disinfectants
composed of hydrogen peroxide, peracetic acid and
acetic acid
French study
Case study by Emmanuelle Cristofari-Marquand et al,
2007: Asthma caused by peracetic acid-hydrogen
peroxide mixture• 48 year old male & 47 year old female nurses who sterilized
endoscopic equipment with a combination of peracetic acid &
hydrogen peroxide
• Developed cough, wheezing and shortness of breath after being
exposed to disinfectant’s vapors
• Serial peak expiratory flows of subject 1 and an inhalation
challenge test of subject 2 suggested that peracetic acid-
hydrogen peroxide mixture can induce occupational asthma
HHE
2018 NIOSH health hazard evaluation examined
symptoms and exposures associated with use of a
sporicidal agent containing hydrogen peroxide, peracetic
acid, and acetic acid in a hospital
Despite measured levels that were below limits of
detection, workers had symptoms of sneezing; itchy,
burning, runny nose; eye irritation; burning, dry or sore
throat; chest tightness; shortness of breath; and difficulty
breathing
Limitations of study
• Small sample size
• Exposures likely higher than recorded
• No objective datao Absence of physiological confirmation of symptoms
• Pilot study
• Meant to serve as building block for
subsequent studies
Conclusions
• Lack of exposure limits for these chemicals which
need to be developed
• Perisept likely triggers symptoms and potential health
issues at levels lower than previously thought
• The health of workers is being jeopardized
• More specific PPE information needed in Safety Data
Sheets
Final Question
How do you balance protecting patients from
Hospital Acquired Infections while protecting the
workers who protect the patients?
References
• CDC. Chemical Disinfectants Webpage. Guideline for Disinfection and
Sterilization in Healthcare Facilities (2008.
https://www.cdc.gov/infectioncontrol/guidelines/disinfection/disinfection-
methods/chemical.html.
• Cristofari-Marquand, E., Kacel, M. et al. Asthma caused by peracetic
acid-hydrogen peroxide mixture. J Occup Health. 2007 Mar;49(2):155-8.
• Hawley, B., Casey M. et al. Respiratory Symptoms in Hospital Cleaning
Staff Exposed to a Product Containing Hydrogen Peroxide, Peracetic
Acid, and Acetic Acid. Annals of Work Exposures and Health, 2018, Vol.
62, No. 1, 28-40. doi: 10.1093/annweh/wxx087.
• Steins, Inc. Safety Data Sheet: SSS Navigator #62 Perisept Sporicidal
Disinfectant Cleaner. Date Prepared: 06/04/2015. Revision Date:
08/23/2016. Version No.: 1.
http://steinsinc.com/MSDS/SSS/Perisept_62_Sporicidal_Disinfectant_Cle
aner.pdf
chwe.ucdenver.edu @CHWENews@CHWENews
Stay Connected
kathryn.buikema@ucanchutz.ed
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