Health Hazard Evaluation Report 2015-0053-3269 (Revised Page 1

09/2018)

Evaluation of exposure to a new cleaning 

and disinfection product and symptoms in 

hospital employees 

Report No. 2015-0053-3269

September 2018

 (This report replaces the online report dated January 2017)

Brie Hawley, MS, PhD

Megan Casey, RN, BSN, MPH

Kristin Cummings, MD, MPH

Nicole Edwards, MS

Alyson Johnson, MPH

Jean Cox-Ganser, PhD

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

After initial release of this report, the authors were notified by their contract laboratory 

of a reporting error in acetic acid values originally reported to the authors in 2015, and 

which were used for analyses presented this report. In 2018, the contract laboratory 

informed authors that the values originally reported were biased high by a factor of 1.66, 

and the authors were provided with updated values. In addition, the authors noted that 

the concentrations of some air samples were below their respective limits of detection 

(LODs). Nine hydrogen peroxide, 11 peracetic acid, and five acetic acid samples were 

below their respective LODs. The method described by Ganser and Hewett was used 

to impute values for samples below their associated LODs [Ganser and Hewett 2010]. 

Although several results were modified, the associations and overall conclusions of 

the report remain unaffected. The online version of the report has been corrected.
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

Contents

Highlights...............................................i

Abbreviations ..................................... vi

Summary.............................................. 1

Introduction......................................... 4

Process Description............................. 5

Methods ............................................... 5

Results .................................................. 9

Discussion .......................................... 25 

Conclusions........................................ 26

Recommendations............................. 26

References.......................................... 31

Appendix A ........................................ 33 

Acknowledgements........................... 44

The employer is required to post a copy of this report for 30 days at or near the 

workplace(s) of affected employees. The employer must take steps to ensure 

that the posted report is not altered, defaced, or covered by other material.

The cover photo is a close-up image of sorbent tubes, which are used by the HHE

Program to measure airborne exposures. This photo is an artistic representation that may

not be related to this Health Hazard Evaluation.
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page i

We evaluated employee health concerns 

and exposures to the three main chemicals, 

hydrogen peroxide, peracetic acid, and 

acetic acid, found a sporicidal product 

used by hospital cleaning staff. Hydrogen 

peroxide, peracetic acid, and acetic acid 

were detected in all full-shift air samples. 

We observed upper airway, eye, and 

lower airway symptoms in staff exposed 

to vapors from the sporicidal product. 

We recommend that management 

tailor the use of sporicidal disinfectants 

containing hydrogen peroxide, peracetic 

acid, and acetic acid to areas of high 

risk for healthcare-acquired infections 

and minimize the use of sporicidal 

products on noncritical surfaces and in 

non-patient areas. We also recommend 

that management provide workplace 

accommodations for employees who 

develop symptoms related to the use of 

products containing hydrogen peroxide, 

peracetic acid, and acetic acid. Additionally, 

we provide several means to reduce 

employee exposure to o the hydrogen 

peroxide, peracetic acid, and acetic 

acid vapors, mists, and liquids from the 

sporicidal product. 

Highlights of this Evaluation

The Health Hazard Evaluation Program received a confidential employee request for the 

National Institute for Occupational Safety and Health to conduct a health hazard evaluation 

at a hospital. The request cited concerns about exposure of hospital employees to a sporicidal 

product that contains hydrogen peroxide, peracetic acid, and acetic acid, and described 

symptoms experienced by employees. Employee symptoms noted in the health hazard 

evaluation request included burning eyes, nose, and throat; runny nose; cough; headache; 

dizziness; nausea; nose bleeds; asthma exacerbation; skin burns; and rashes. 

What We Did

● We visited the hospital in April 2015 to observe cleaning staff while they performed 

their regular cleaning duties and 

to talk with them about cleaning 

product use and any related health 

concerns.

● We collected 11 bulk samples of the 

diluted sporicidal product in April 

2015.

● We discussed the process for 

recording work-related injuries and 

illnesses with representatives from 

occupational health in April 2015.

● We returned in July 2015 to perform 

air sampling on a small number of 

environmental services employees. 

We collected full-shift and cleaning 

task-based personal time-weighted 

average air samples on 5 employees 

and analyzed the samples for 

hydrogen peroxide, peracetic acid, 

and acetic acid content. 

● We also administered a post-shift 

survey of acute symptoms to the five 

environmental services staff who 

wore full-shift samplers in July 2015.

● We returned in August and 

September 2015 to administer a 

health and work history questionnaire 

to a total of 163 hospital employees, 79 

of whom were environmental services staff.
Page ii Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

● In September 2015, we collected an additional 45 full-shift personal air samples on 

environmental services staff and observed staff while they performed their regular 

cleaning duties. We also administered a post-shift survey of acute symptoms to the 45 

environmental services employees who participated in air sampling. We combined 

results from the September 2015 post-shift surveys of acute symptoms with the five 

post-shift surveys collected in July 2015 for a total of 50 post-shift surveys.

● We performed an assessment of the heating, ventilation and air-conditioning systems in 

place in September 2015. 

● In April 2016, we provided a report with our interim findings and recommendations.

What NIOSH Found

● We found that the sporicidal product containing hydrogen peroxide, peracetic acid, 

and acetic acid is used predominantly by environmental services staff and that nursing 

and ancillary staff predominantly use PDI® or bleach wipes for routine point-of-care 

cleaning activities.

● We observed environmental services employees using the sporicidal product containing 

hydrogen peroxide, peracetic acid, and acetic acid on surfaces throughout the hospital, 

including patient rooms, patient bathrooms, operating rooms, and public bathrooms.

● We observed pH measurements of the diluted poricidal product that ranged from 2.85-

4.86. The product’s safety data sheet indicates that the product should be diluted to a 

pH of 3.

● We noted that some environmental services staff reported that there was no ventilation 

in some of the bathrooms that they cleaned. Several environmental services staff 

mentioned that their symptoms were worse when performing cleaning duties in the 

bathrooms, especially in the shower stalls. 

● We observed that the environmental services staff cleaning closets in the 3100 and 

5300 units had no supply or return airflow.

● Several employees reported previous splashes and spills of the sporicidal product that 

resulted in skin or eye irritation.

● We observed that the log of work-related injuries and illnesses (Occupational Safety 

and Health Administration’s Form 300) is maintained and generated by a third-party 

claims administrator that handles workers’ compensation claims for the hospital, which 

could lead to underestimation of work-related injuries and illnesses. 

● We did not observe a comprehensive system for reporting and tracking workplace 

injuries and illnesses that includes reports of near-misses, minor injuries and illnesses, 

and employee safety concerns.

● We found that employees using the sporicidal product containing hydrogen peroxide, 

peracetic acid, and acetic acid reported respiratory symptoms that came on during their 

shift.
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page iii

● We detected hydrogen peroxide, peracetic acid, and acetic acid in all full-shift air 

samples. 

● We found that increased exposure to hydrogen peroxide, peracetic acid, and acetic acid 

vapors was associated with increases in acute work-related nasal and eye symptoms 

and with increased shortness of breath on level ground reported by cleaning staff. 

What the Employer Can Do

● Minimize the use of sporicidal products in non-patient care areas. 

● Ensure that the sporicidal product dispensers are calibrated to effectively dilute the 

product to a pH of 3. If the sporicidal product is not effectively diluted, a pH of less 

than 3 may increase skin, eye, and respiratory symptoms in exposed employees.

● Require lids for all of the sporicidal product buckets to minimize generation of 

hydrogen peroxide, peracetic acid, and acetic acid vapors that can be inhaled.

● Ensure that employees use only rags and wipes to apply the sporicidal product to 

surfaces and that the sporicidal product is not used as a spray.

● Require employees to wear extended cuff nitrile gloves or rubber gloves when using 

the sporicidal product and goggles or a face shield while dispensing and pouring the 

sporicidal product into or out of the bucket on their cleaning cart.

● Ensure that all heating, ventilation, and air-conditioning systems meet all ASHRAE 

standards. Specifically, ensure that additional airflow is provided to EVS closets in the 

3100 and 5300 units to meet the ASHRAE requirement of a minimum of 10 air changes 

per hour. 

● Ensure that all patient bathrooms meet minimum total air changes per hour as specified 

by ASHRAE. ASHRAE standard 2013-170 requires inpatient bathrooms to have at 

least 10 air changes per hour.

● Review the process for Occupational Safety and Health Administration Form 300 

reporting and maintenance to assure that all reportable injuries are recorded, regardless 

of whether a workers’ compensation claim is filed. 

● Consider implementing a comprehensive system for reporting and tracking workplace 

injuries and illnesses that includes reports of near-misses, minor injuries and illnesses, 

and employee safety concerns. This information should be reviewed by the Safety 

Officer on a regular basis to identify hazards, implement risk-reduction strategies, and 

prevent significant injuries and illnesses. 

● Provide workplace accommodations to employees who develop work-related symptoms 

after exposure to sporicidal products containing hydrogen peroxide, peracetic acid, and 

acetic acid. Consider relocating employees who develop work-related symptoms to 

areas of the hospital where sporicidal products containing hydrogen peroxide, peracetic 

acid, and acetic acid are used less frequently.
Page iv Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

What Employees Can Do

● Report patient rooms or bathrooms with no ventilation or airflow to your manager.

● Wear extended cuff nitrile gloves or rubber gloves when using the sporicidal product 

containing hydrogen peroxide, peracetic acid, and acetic acid. Wear goggles or a face 

shield when dispensing and pouring the sporicidal product into or out of the bucket on 

your cleaning cart.

● Do not use a spray bottle to apply the sporicidal product containing hydrogen peroxide, 

peracetic acid, and acetic acid to surfaces. Spraying the product can generate mists that 

can be hazardous for you to breathe.

● Keep a lid on the sporicidal product bucket whenever possible to minimize the 

generation of hydrogen peroxide, peracetic acid, and acetic acid vapors that can be 

inhaled.

● Report new, persistent, or worsening symptoms to your personal healthcare provider 

and, as instructed by your employer, to a designated individual at your workplace. 
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page v

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Page vi Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

Abbreviations

AA Acetic acid

ACGIH® American Conference of Governmental Industrial Hygienists

AHU Air-handling unit

cc Cubic centimeters

CFR Code of Federal Regulations

CI Confidence interval

EPA U. S. Environmental Protection Agency

EVS Environmental Services

°F Degrees Fahrenheit

HICPAC Healthcare Infection Control Practices Advisory Committee

HP Hydrogen peroxide

HVAC Heating, ventilation, and air-conditioning

ICU Intensive care unit

mL/min Milliliters per minute

NIOSH National Institute for Occupational Safety and Health

NHANES National Health and Nutrition Examination Survey

NICU Neonatal intensive care unit

OM Oxidant exposure mixture

OR Odds Ratio

OSHA Occupational Safety and Health Administration

PAA Peracetic acid

PEL Permissible exposure limit

PPE Personal protective equipment

ppm Parts per million

ppb Parts per billion

PR Prevalence ratio

REL Recommended exposure limit

SMR Standardized morbidity ratio

STEL Short-term exposure limit

TCU Transitional care unit

TM Total mixture

TWA Time-weighted average

TLV® Threshold limit value

WCBC Womancare birth center
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 1

Summary

The National Institute for Occupational Safety and Health (NIOSH) received a confidential 

employee request to conduct a health hazard evaluation at a hospital. The request cited 

concerns about exposure of hospital employees to a sporicidal product containing hydrogen 

peroxide, peracetic acid, and acetic acid and described symptoms experienced by employees. 

Employee symptoms noted in the health hazard evaluation request included burning eyes, 

nose, and throat; runny nose; cough; headache; dizziness; nausea; nose bleeds; asthma 

exacerbation; skin burns; and rashes. 

We performed a walk-through assessment of cleaning product use at the hospital on April 9, 

2015, and informally interviewed employees about their cleaning product use and any related 

health concerns that they may have had. We learned that a sporicidal product containing 

hydrogen peroxide, peracetic acid, and acetic acid was used predominantly by environmental 

services staff and that nursing and ancillary staff predominantly used PDI® or bleach 

wipes for routine point of care cleaning activities. We observed that the sporicidal product 

containing hydrogen peroxide, peracetic acid, and acetic acid was the main cleaning product 

used by environmental services staff for all surface cleaning duties. Environmental services 

staff were observed occasionally using other asthmagen-containing products including 

products containing ethanolamines, bleach, or quaternary ammonium compounds when 

cleaning glass, general surfaces, or bathroom surfaces. Asthmagens are substances capable of 

causing asthma.

On July 29, 2015, we performed a small-scale air sampling and a post-shift survey of 

environmental services staff. We collected ten samples, including full-shift, task-based, and 

15-minute exposure samples, from employees’ breathing zones while they performed regular 

cleaning tasks. All samples were analyzed for the three chemicals found in the sporicidal 

product: hydrogen peroxide, peracetic acid, and acetic acid. All 15-minute air samples for 

acetic acid were below the NIOSH recommended short-term exposure limit of 15 parts per 

million (ppm). All 15-minute and task-based exposure air samples for hydrogen peroxide and 

peracetic acid were below the limit of detection for the instrument used to detect the analyte. 

The limit of detection 4 μg of hydrogen peroxide per sample and 2 μg of peracetic acid per 

sample. We combined all full-shift time-weighted average samples and post-shift survey 

results from the small-scale survey on July 29 with the results from our full environmental 

survey from September 8-11, 2015.

We returned in August 2015 and administered a voluntary health and work history 

questionnaire to 79 environmental services staff and 84 non-environmental services staff for 

a total of 163 hospital employees. Non-environmental services staff were recruited from the 

same areas and departments of the hospital where environmental services staff were located. 

Questions addressed respiratory and dermatological symptoms, asthma and other diagnoses, 

smoking history, work history and practices, and demographic information. 

On September 8-11, 2015, we returned to perform full-shift air sampling on environmental 

services staff performing cleaning activities. We collected 45 full-shift air samples for 
Page 2 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

hydrogen peroxide, peracetic acid, and acetic acid from the daylight, evening, and night shift 

environmental services staff. We also administered a voluntary post-shift survey identical 

to the post-shift survey used in July 2015 to all staff who participated in the air sampling 

survey. We observed environmental services staff while they performed their regular cleaning 

duties and noted task duration, cleaning product use and duration, and use of any personal 

protective equipment. We also assessed the ventilation systems in areas of the hospital where 

frequent cleaning was observed. 

The highest full-shift time-weighted average exposures to hydrogen peroxide, peracetic acid, 

and acetic acid were observed in the Womancare Birth Center, Birth Center Triage, Birth 

Center Operating Rooms, and the Medical-Surgical areas. Full-shift time-weighted average 

exposure levels for hydrogen peroxide, peracetic acid, and acetic acid ranged from <11 parts 

per billion (ppb) – 511.4 ppb for hydrogen peroxide, < 2.2 ppb – 48.0 ppb for peracetic acid, 

and < 8.8 ppb – 319.4 ppb for acetic acid. Nine HP, 11 PAA and five AA samples were below 

their respective LODs and were spread out across different locations. All full-shift timeweighted average air samples for hydrogen peroxide and acetic acid were below established 

U.S. occupational exposure limits. The OSHA permissible exposure limit and NIOSH 

recommended exposure limit is 1 ppm for hydrogen peroxide and 10 ppm for acetic acid. To 

date, no full-shift time-weighted average occupational exposure limit for peracetic acid has 

been established in the United States. 

The most commonly reported symptoms in the health and work history questionnaire were 

nasal problems and watery eyes. Forty-two percent of health and work history questionnaire 

participants reported nasal problems and 40% of all questionnaire participants reported 

watery eyes. Other commonly reported health outcomes included, asthma-like symptoms 

(28%), skin problems (19%), and wheeze (16%). Among reported symptoms, some 

were described to be work-related, as they improved away from the facility. Users of the 

sporicidal product containing hydrogen peroxide, peracetic acid, and acetic acid reported 

higher prevalence of work-related health outcomes including cough, shortness of breath, 

asthma-like symptoms, asthma attack, use of asthma medicine, asthma symptoms, use of 

allergy medicine, nasal problems, and skin problems, with wheeze and watery eyes being 

significantly higher in the sporicidal product users than non-users. 

Nasal and eye irritation were also the most frequently reported symptoms in the post-shift 

survey of acute symptoms. We observed increases in work-related acute upper and lower 

airway symptoms in employees exposed to hydrogen peroxide, peracetic acid, and acetic 

acid vapors. Increased exposure to hydrogen peroxide, peracetic acid, and acetic acid was 

significantly associated with increases in acute nasal and eye irritation. For employees who 

participated in our air sampling survey as well as the health and work history questionnaire, 

shortness of breath on level ground was also significantly associated with increased exposure 

to hydrogen peroxide, peracetic acid, and acetic acid.

We provide several means to reduce employee exposure to the sporicidal product containing 

hydrogen peroxide, peracetic acid, and acetic acid. We recommend that management 

customize the use of sporicidal products containing hydrogen peroxide, peracetic acid, and 
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 3

acetic acid to areas of high risk for healthcare-acquired infections and minimize the use of 

sporicidal disinfectants on non-critical surfaces and in non-patient areas. We also recommend 

that management provide workplace accommodations for employees who develop symptoms 

related to the use of sporicidal and high-level disinfectants. Management should also ensure 

that all heating, ventilation, and air-conditioning systems are functioning well and meet all 

applicable ASHRAE standards. Additional details and recommendations to reduce employee 

exposure to liquids, vapors, and mists from the sporicidal product are provided in this report.
Page 4 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

Introduction

The National Institute for Occupational Safety and Health (NIOSH) received a confidential 

employee request to conduct a health hazard evaluation at a hospital. The request cited 

concerns about exposure of hospital employees to a disinfectant cleaner1 that is one of a 

group of sporicidal products marketed under various trade names that contain hydrogen 

peroxide (HP), peracetic acid (PAA), and acetic acid (AA). In their health hazard evaluation 

request they described symptoms experienced by employees including: burning eyes, 

nose, and throat; runny nose; cough; headache; dizziness; nausea; nose bleeds; asthma 

exacerbation; skin burns; and rashes. 

In response to the health hazard evaluation request, we performed a walk-through assessment 

of cleaning product use at the hospital in April 2015, and informally interviewed employees 

about their cleaning product use and any related health concerns that they may have had. 

We learned that the sporicidal product is a one-step sporicidal disinfectant that consists of 

hydrogen peroxide (HP), peracetic acid (PAA), and acetic acid (AA). The product is diluted 

with water prior to use to a pH of 3. We observed that the sporicidal product containing HP, 

PAA, and AA was the main cleaning product used for all surface cleaning duties and was 

used predominantly by Environmental Services (EVS) staff. We also noted that EVS staff 

occasionally used other asthmagen-containing products, to include products containing 

ethanolamines, bleach, or quaternary ammonium compounds when cleaning glass, general 

surfaces, or bathroom surfaces. Asthmagens are substances capable of causing asthma.

In July 2015, we performed a small-scale air sampling and post-shift survey of EVS staff. 

In August 2015, we administered a voluntary health and work history questionnaire to 

hospital employees. In September 2015, we returned to the hospital to perform a full-shift air 

sampling survey and collect air samples from employees performing cleaning activities.

We also administered a voluntary post-shift survey identical to the post-shift survey used in 

July 2015, to all staff who participated in the September air sampling survey. We observed 

EVS staff during both the July and September air sampling surveys, while they performed 

their regular cleaning duties and noted task duration, cleaning product use and duration, and 

use of any personal protective equipment. Additionally in September 2015, we performed an 

assessment of the heating, ventilation and air-conditioning (HVAC) systems in place during 

the September 2015 survey. 

In this report, we summarize the results from our environmental survey and HVAC 

assessment. We also summarize results from the health and work history questionnaire 

and post-shift survey of acute symptoms. Additionally, we provide recommendations to 

help protect the health of employees. We previously mailed letters with interim results and 

recommendations in May and October of 2015, and April of 2016.

1 OxyCide® is a sporicidal product with the EPA Registration number 1677-237
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 5

Process Description 

The hospital that is the subject of this health hazard evaluation is primarily a women’s 

hospital, and specializes in obstetrics and gynecology services for women. The hospital 

also offers medical and surgical services for both women and men. Beginning in March 

and April of 2015, the sporicidal product containing HP, PAA and AA was used by EVS 

staff as the primary sporicidal disinfectant for all surface cleaning duties throughout the 

hospital. Environmental services staff were the primary housekeeping staff and performed 

cleaning duties and tasks in areas throughout the hospital. Other healthcare personnel, 

such as nursing and ancillary staff, performed occasional surface cleaning tasks, such as 

wiping down medical equipment in occupied patient rooms, as part of routine point-of-care 

cleaning activities. The product containing HP, PAA, and AA was used predominantly by 

environmental services staff and nursing and ancillary staff predominantly used PDI® or 

bleach wipes for routine cleaning activities. 

Methods

Measurement of pH of diluted product samples in April 2015

During the walkthrough assessment in April 2015, we collected bulk samples of the diluted 

sporicidal product containing HP, PAA, and AA from multiple hospital units. Bulk samples 

of the diluted sporicidal product were collected to assess the sporicidal product dispenser 

calibration. Dispenser calibration was assessed by measuring diluted product pH at a time 

point less than 12 hours after collection. Samples were kept capped and stored at room 

temperature (21°C−23°C). Measurements of sample pH were taken using a pH meter (Fisher 

Scientific International Inc., Hampton, NH).

Air Sampling Survey and HVAC Assessment in July and September 2015 

We performed a pilot air sampling survey of EVS staff performing cleaning tasks on July 29, 

2015. We collected five full-shift, one task-based, and four 15-minute exposure samples from 

daylight shift employees’ breathing zones while they performed regular cleaning tasks. On 

September 8-11, 2015, we performed a larger air sampling survey and collected 45 additional 

full-shift samples on daylight, evening, and night shift employees. Thirty-six of the full-shift 

samples were collected from employees’ breathing zones while they performed their regular 

cleaning duties. Nine of the samples collected in September were moving area samples. For 

the moving area samples, we followed employees while they performed their cleaning duties 

and placed the samplers near EVS staff while they were cleaning. We also performed an 

assessment of HVAC systems in place as of September 2015. Additionally, we observed staff 

while they performed their regular cleaning duties and noted task duration, cleaning product 

use and duration, and use of any personal protective equipment.

All air samples were analyzed for the three chemicals found in the sporicidal product: HP, 

PAA, and AA. HP and PAA were collected and analyzed according to the methods specified 

by Hecht et al. [2004]. AA was collected and analyzed according to the Occupational Safety 

and Health Administration (OSHA) Method PV2119 [OSHA 2003]. Results from the July 
Page 6 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

and September 2015 air sampling surveys were combined and are summarized in the Results 

section. 

Post-Shift Survey of Acute Symptoms in July and September 2015 

We administered a voluntary post-shift survey in July and September 2015 that asked if 

employees had experienced acute symptoms during their shift as follows: (1) burning, itchy, 

runny nose; (2) sneeze; (3) burning, itchy, watery eyes; (4) burning, dry, sore throat; (5) 

cough; (6) wheeze; (7) chest tightness; (8) shortness of breath; (9) difficulty breathing; and 

(10) dizziness. When employees reported symptoms that occurred during their work shift, 

we asked (1) if their symptom had worsened during their shift; (2) what they were doing 

when the symptom first began; and (3) if they had that symptom upon arrival at work that 

day. Work-related symptoms were defined as symptoms that occurred during the participants’ 

shift that were not present upon arrival at work that day. Results from the July and September 

2015 post-shift surveys were combined and are summarized in the Results section. 

Health and Work History Questionnaire

We administered a voluntary health and work history questionnaire to hospital employees in 

August and September 2015. We aimed to offer the health and work history questionnaire 

to all EVS staff working the week of our visit, and an equal number of non-EVS staff in 

the same departments. Non-EVS staff were recruited from the same areas and departments 

of the hospital where EVS staff were located. Questions addressed eye, respiratory, and 

dermatological symptoms; asthma and other diagnoses; smoking history; work history 

and practices; and demographic information. Questions regarding respiratory symptoms 

and asthma were taken from the Third National Health and Nutrition Examination Survey 

(NHANES III) [CDC 1996] and the European Community Respiratory Health Survey 

[Burney et al. 1994; ECRHS 2014]. 

We defined asthma-like symptoms as a response of “yes” to any of the following questions 

[Grassi et al. 2003]: 

1. Are you currently taking any medicine (including inhalers, aerosols or tablets) for 

asthma? 

2. Have you had wheezing or whistling in your chest at any time in the last 12 months?

3. Have you woken up with a feeling of tightness in your chest at any time in the last 12 

months?

4. Have you been woken by an attack of asthma at any time in the last 12 months?

Symptoms that improved when the employees were away from work, either on their days off 

or when they were on vacation, were considered work-related.

Statistical Analyses

Comparison of Pre-hire and Post-hire Onset Asthma

The incidence densities of self-reported adult-onset asthma diagnosed by a physician 

before and after hire were estimated using birth date, hire date, and diagnosis date. Asthma 
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 7

incidence density before hire was calculated by adding the number of adult-onset asthma 

diagnoses that occurred before hire and dividing by the total number of participants’ adult 

years at risk before hire. Asthma incidence density after hire was calculated by adding the 

number of adult-onset asthma diagnoses that occurred after hire and dividing by the total 

number of participants’ years at risk after hire. An incidence ratio was calculated using 

Poisson regression.

Comparison to U.S. Population

We compared the observed prevalence of symptoms and diagnoses among participants to 

expected values for the U.S. adult population obtained from NHANES III. To compare 

the survey participants to the U.S. adult population, we calculated Standardized Morbidity 

Ratios (SMRs) using indirect standardization for race (White, Black, or Mexican-American), 

sex, age (range: 17 to 39 years or ≥ 40 years), and cigarette smoking status (ever vs. never 

smoker) [CDC 1996]. 

Health Outcomes and Exposure Metrics Associations: EVS vs. Non-EVS and Product Use 

vs. Non-Product Use 

Statistical significance was assessed using t-test for continuous variables and chi-square 

test for categorical variables. We used Fisher’s exact test when cell sizes were less than 5. 

We considered two-sided p ≤ 0.05 to be statistically significant. Prevalence ratios were 

calculated for symptoms and diagnoses using Poisson regression. 

Associations Between Acute and Chronic Health Outcomes and Exposure Metrics: Individual 

Level Exposure 

We explored associations between employee’s personal exposure to HP, PAA, and AA 

and work-related acute symptoms and symptoms occurring in the last 12 months using 

log-binomial regression. We used the American Conference of Governmental Industrial 

Hygienists’ (ACGIH) Additive Mixture Formula to create mixture exposure groups for the 

total mixture (TM) of HP, PAA, and AA as well as the oxidant exposure mixture (OM) of 

HP and PAA [ACGIH 2016]. Measurements below the LODs were replaced by imputations, 

which were randomly simulated from 0 to the corresponding LODs [Ganser and Hewett 

2010]. Measured ppm concentrations of HP and AA were divided by their established OSHA 

Permissible Exposure Limit (PEL) and NIOSH Recommended Exposure Limit (REL) of 1 

ppm for HP and 10 ppm for AA (Equations 1 and 2). Measured ppm concentrations of PAA 

were divided by 0.2 ppm, the occupational exposure limit proposed by multiple researchers 

[Gagnaire et al. 2002; Pechacek et al. 2015; Pacenti et al. 2010]. TM and OM exposure was 

determined using Eq. (1) and (2),

 (1)

 (2)
Page 8 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

where [HP], [PAA], and [AA] represent the measured full-shift TWA concentrations for HP, 

PAA, and AA. The summed values from the additive formula were divided into tertiles to 

create TM and OM exposure variables with low, medium, and high exposure categories. TM 

and OM exposure variables were used for exposure and health outcome analyses. 

SAS PROC GENMOD’s log-binomial regression was used to calculate prevalence ratios and 

95% confidence intervals for acute and chronic symptoms associated with individual level 

exposure. TM exposure was analyzed as continuous or categorical, with categories defined 

as (1) low = less than 0.088, (2) medium = 0.088 to 0.228, or (3) high = greater than 0.228. 

OM exposure was analyzed as continuous or categorical with categories defined as (1) low = 

less than 0.08, (2) medium = 0.080 to 0.218, and (3) greater than 0.218. When the GENMOD 

models did not converge, Fischer’s exact test was used to compare symptom prevalence 

among the exposure categories. Age, gender, and smoking status were initially included in 

the GENMOD log-binomial regression models; however, the models did not converge. The 

LOGISTIC procedure in SAS was used to examine associations of age, gender, or smoking 

status with eye, upper and lower airway symptoms. 

We also explored associations between work-related acute symptoms and age, gender, tenure, 

smoking status, and use of cleaning products containing known asthmagens using logistic 

regression. Asthmagen-containing cleaning products were defined as products containing 

quaternary ammonium compounds, bleach, or ethanolamines. Use of quaternary ammonium 

compounds, bleach, or ethanolamines was recorded from our direct observations of EVS staff

while they performed their regular cleaning duties. We explored associations between workrelated symptoms and use of products containing (1) quaternary ammonium compounds; (2) 

bleach; or (3) ethanolamines. We also assessed associations between work-related symptoms 

and use of a combination of these products throughout the work day by using an asthmagen 

index value. The asthmagen index value (0-3) was determined by adding the number of 

asthmagen products that an employee was observed using on the day of air sampling. 

Associations Between Acute and Chronic Health Outcomes and Exposure Metrics: 

Departmental Level Exposure

We also calculated the average TM exposure for each of the nine hospital departments where 

air sampling was performed. Eighty-five survey participants worked on a department where 

air sampling was performed. We assessed associations between average departmental TM 

exposure and symptoms reported by staff. SAS PROC GENMOD’s Poisson regression was 

used to calculate unadjusted prevalence ratios and 95% confidence intervals for symptoms 

associated with department level exposure. TM exposure was analyzed as a categorical 

variable by dividing each of the nine departments into three categories: high, medium 

and low TM exposure, with three departments in each category. SMRs for symptoms were 

calculated among individuals who worked on the department with the highest TM exposure.

Comparison of Post-shift Survey and Health and Work History Questionnaire

We summarized the prevalence of symptoms reported by EVS staff in both the post-shift 

acute symptom survey and health and work history questionnaire. Symptoms that were asked 

about in both the post-shift acute symptom survey and work history questionnaire included: 
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 9

nasal irritation, eye irritation, cough, wheeze, shortness of breath, and chest tightness.

Results

Major findings in relation to EVS staff, use of a sporicidal product containing HP, PAA, 

and AA, and related exposure measurements are presented below. Supplemental analyses 

and findings from the site visits are presented in Appendix A. In general, we observed that 

the sporicidal product containing HP, PAA, and AA was the main cleaning product used for 

all surface cleaning duties. We noted that some hospital employees had the impression that 

because the chemicals contained in this product are similar to common household products, 

there is little health risk from exposure to this product. We also noted that the sporicidal 

product containing HP, PAA, and AA was formerly used as a spray cleaner by some staff 

in some units. Several employees reported previous splashes and spills of this product that 

resulted in skin or eye irritation. Some environmental services staff reported that there was 

no ventilation in some of the bathrooms that they cleaned. Several staff mentioned that their 

symptoms were worse when performing cleaning duties in the bathrooms, especially in the 

shower stalls. 

During our visits, we observed that EVS staff used automated dispensers designed to dilute 

the concentrated product to its at-use pH of 3. We made pH measurements of the diluted 

product that ranged from 2.85-4.86. The product’s safety data sheet indicates that should be 

diluted to a pH of 3. We observed staff using the automated dispensers to pour directly into 

plastic bottles. The plastic bottles were then used to pour into open faced buckets that housed 

a roll of disposable cloth wipes. We observed that nitrile gloves were used routinely when 

working with cleaning products. Staff occasionally chose to also wear goggles or a surgical 

mask when dispensing or working with cleaning products. 

Summary of July 2015 and September 2015 Air Sampling Results and Post-Shift Survey of 

Acute Symptoms

Full shift air sample results ranged from <11 parts per billion (ppb) to 511 ppb for HP, < 8.8 

ppb to 319.4 ppb for AA, and < 2.2 ppb to 48 ppb for PAA (Figure 1). Nine HP, 11 PAA, 

and five AA samples were below their respective LODs and were spread out across different 

locations. For AA, 15-minute air samples ranged from 442 ppb to 456 ppb. All 15-minute and 

task-based exposure air samples for HP and PAA were below the limit of detection for the 

instrument used to detect the analyte. The limit of detection was 4 μg of hydrogen peroxide 

per sample and 2 μg of PAA per sample. The Womencare Birth Center (WCBC ) had the 

highest average measurements of hydrogen peroxide (165.63 ppb) and peracetic acid (25.13 

ppb) and the second highest average of acetic acid (142.85 ppb). 
Page 10 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

Figure 1. Box-plots of full-shift time-weighted average (TWA) exposure levels of hydrogen peroxide, peracetic acid, 

and acetic acid, NIOSH survey, July and September 2015. Note: ppb=parts per billion. The boxplots illustrate each 

quartile with the lowest quartile shown as the line and hatch mark below the box, the second and third quartiles 

indicated by the shaded box, and the highest quartile indicated by the line and hatch mark above the boxes. The line 

within each box indicates the median air sample concentration. Outlier air samples are denoted by dots. The OSHA 

PEL and NIOSH REL is 1000 ppb (1 ppm) for hydrogen peroxide and 10,000 ppb (10 ppm) for acetic acid. 
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 11

Table 1. Arithmetic mean, geometric mean, and 95th percentile concentrations (in parts per billion) of hydrogen peroxide, peracetic acid, and 

acetic acid, by hospital area, July and September 2015

95%ile

AAHP+P

GM Mean (± SD) 95%ile

AA+AA

GM

HP+P

Mean

(± SD) 95%ile

AcidAcetic 

GM Mean (± SD) 95%ile

Acid Peracetic 

GM Mean (± SD) 95%ile

oxide ogen Per

GM

Hydr

Mean

(± SD)

Area Hospital 

Main OR

(n=3)

13

(± 11) 10 26 3 (± 4) 2 7 26 (± 35) 13 67 42 (± 51) 26 101 16 (± 15) 12 33

WCBC

(n=10)

186

(± 132) 144 511 23 (± 12) 20 46 159 (± 75) 145 307 368 (± 183) 327 701 208 (± 132) 173 522

WCBC, Triage

(n=3)

90

(± 42) 85 138 32 (± 14) 30 48 81 (± 41) 75 129 203 (± 56) 197 248 122 (± 42) 117 166

WCBC OR 

(n=3)

175

(± 59) 167 222 26 (± 20) 21 48 150 (± 49) 143 185 350 (± 119) 335 455 200 (± 72) 191 270

Ante- and Postpartum (n=6) 64 (± 30) 55 94 18 (± 12) 15 41 122 (± 36) 117 167 204 (± 65) 193 270 82 (± 36) 73 117

Medical-Surgical

(n=2)

113

(± 52) 106 149 21 (± 8) 21 27 158 (± 104) 140 231 292 (± 148) 272 396 134 (± 44) 130 165

Surgery, Orthopedics

(n=3)

32

(± 36) 19 72 5 (± 7) 2 13 47 (± 63) 22 119 84 (± 105) 48 204 37 (± 42) 22 85

ICU

(n=2)

62

(± 15) 61 73 15 (± 1) 15 15 84 (± 3) 84 86 161 (± 12) 161 170 77 (± 15) 76 88

Oncology

(n=3)

97

(± 107) 45 215 9 (± 10) 5 21 40 (± 20) 37 64 147 (± 110) 110 253 106 (± 108) 52 222

NICU

(n=5)

133

(± 168) 60 423 11 (± 9) 5 22 32 (± 27) 24 73 175 (± 197) 100 510 143 (± 172) 67 437

Outpatient Clinic

(n=3)

14

(± 7) 12 19 7 (± 6) 5 12 30 (± 13) 27 39 51 (± 26) 45 70 21 (± 13) 18 31

Public BR

(n=1) 25

̶

̶ 5 ̶

̶ 122

̶

̶ 151

̶

̶ 29

̶

̶

Float

(n=4)

69

 (± 92) 26 202

12

(± 16) 5 34 128 (± 135) 63 319 210 (± 238) 107 555 81 (± 108) 31 236

Floors

(n=1) 6 ̶

̶ 1 ̶

̶ 6 ̶

̶ 13

̶

̶ 7 ̶

̶

Note: SD=one standard deviation, ± one standard deviation shown in parentheses; GM=geometric mean; 95%= 95th percentile; HP=hydrogen peroxide; PAA=peracetic acid; AA=acetic acid; OR = operating room; WCBC = Womancare Birth Center; NICU = neonatal intensive care unit; BR = bathroom. The symbol , - , indicates too few samples from location to calculate GM or %ile. 
Page 12 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

Currently, there is no OSHA PEL or NIOSH REL for exposure to the mixture of HP, PAA, 

and AA. Most exposure limit values are created for exposure to a single chemical substance 

[ACGIH 2016]. There are occupational exposure limits for exposure to HP or AA. The 

OSHA PEL and NIOSH REL is one ppm (1000 ppb) for exposure to HP and 10 ppm (10,000 

ppb) for exposure to AA. All measurements for HP and AA were below their respective 

OSHA PELs and NIOSH RELs [NIOSH 2010] for exposure to HP or AA alone. There is 

currently no OSHA PEL or NIOSH REL for occupational exposure to PAA, however, several 

research groups have suggested 0.2 ppm as an exposure limit [Gagnaire et al. 2002; Pechacek 

et al. 2015; Pacenti et al. 2010]. ACGIH developed a mixture formula that can be used 

when multiple chemical exposures occur simultaneously and have similar biological effects 

[ACGIH 2016]. The ACGIH mixture formula was used to create the TM and OM used for 

the results presented below. HP and PAA are strong oxidants, and their mixture is listed as an 

asthmagen and respiratory sensitizer by the Association of Occupational and Environmental 

Clinics [AOEC 2015]. Asthmagens are substances that can cause asthma. Respiratory 

sensitizers are materials that can cause an immune response and adverse respiratory effects, 

even at low levels of exposure.

Mucous membrane irritation (burning eyes and/or burning nose) was reported by 64% (n = 

32/50) of post-shift survey participants, and 84% (n = 27/32) of these participants reported 

symptom onset while cleaning. Lower airway symptoms such as cough, wheeze, chest 

tightness, shortness of breath or difficulty breathing were reported in 34% (n = 17/50) of 

post-shift survey participants; of whom 88% (n = 15/17) reported symptom onset during 

cleaning activities. Symptom prevalence in low, medium, and high TM and OM exposure 

groups can be seen in Table 2. Prevalence of work-related acute eye and upper airway 

symptoms were similar in the TM and OM exposure groups (Table 2). 

In the highest TM exposure group, 1.4–4.6-fold more participants reported work-related 

nasal irritation, eye irritation, sneeze, and burning, dry or sore throat compared to the lowest 

exposure group. In the highest TM exposure group, 87.5% of participants reported workrelated nasal irritation; 81.3%, reported eye irritation; 37.5%, reported sneeze, and 25.0% of 

participants reported burning dry or sore throat. 

Age, smoking status, gender, and use of products containing other asthmagens were not 

significantly associated with acute eye, upper airway, or lower airway symptoms reported 

in the post-shift survey and were not included in our models. Nasal and eye irritation were 

significantly associated with increased TM and OM exposure. The highest TM and OM 

exposure groups had 3 fold and 3.5 fold higher prevalence of nasal irritation symptoms when 

compared to the lowest TM and OM exposure groups (Figure 2). Eye irritation prevalence 

was similar for both the highest TM and OM exposure groups as well, with 4.6–6.4 fold 

higher prevalence, when compared to the lowest TM and OM exposure groups (Figure 2). 

An exposure-response relationship was observed for sneeze and throat symptoms as well, 

although the increases were not statistically significant. Employees in the highest TM mixture 

exposure group had 3.2 (p = 0.12) and 1.4 (p = 0.38) fold higher prevalence of sneeze 

and burning throat, respectively, when compared to the lowest exposure group (Figure 2). 

Employees in the highest OM exposure group had 5.3 (p=0.11) and 1.4 (p=0.6) fold higher 
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 13

prevalence of sneeze and burning throat, respectively, when compared to the lowest exposure 

group. 

The number of employees that reported lower airway symptoms during their shift was too 

small to calculate prevalence ratios using the GENMOD log-binomial procedure in SAS. 

No employees in the lowest TM or OM exposure groups reported acute work-related (1) 

wheeze; (2) chest tightness; (3) shortness of breath; or (4) difficulty breathing. In comparison, 

employees exposed to mixture levels in the medium and highest TM and OM exposure 

groups (n = 33) reported (1) wheeze (n = 3, 9%); (2) chest tightness (n = 2, 6%); (3) 

shortness of breath (n = 3, 9%); and difficulty breathing (n = 2, 6%) (Table 2). Despite these 

trends, Fisher’s Exact Test did not indicate any significant associations.

We also explored associations between exposure to HP, PAA, or AA and acute symptoms 

occurring during the work shift using logistic regression (Appendix A, Table A4). Mucous 

membrane irritation symptoms, specifically burning itchy, runny nose, sneeze, and burning, 

itchy, watery eyes, were statistically significantly positively associated with HP, AA, and 

PAA exposure, indicating an increase in symptoms with increasing exposure. We also 

explored associations between age, gender, tenure, smoking status, and use of cleaning 

products containing known asthmagens and work-related acute symptoms using logistic 

regression. No associations were found.

Summary of Chronic Upper and Lower Airway Symptoms in Participants in the Air 

Sampling, Post-shift Survey, and Health and Work History Questionnaire

Thirty-five employees participated in all three components of our employee evaluation: the 

personal air sampling, the post-shift survey of acute symptoms, and the health and work 

history questionnaire. 

On the health and work history questionnaire, 57.1% of these 35 participants reported chronic 

nasal problems and 51.4% reported watery eyes in the last 12 months (Table 2). Regarding 

chronic lower respiratory symptoms, 5.7% of these participants reported cough; 22.9% 

reported usual shortness of breath on level ground; 14.3% reported wheeze in the previous 12 

months; and 17.1% reported awaken from chest tightness in the previous 12 months. 

The highest TM and OM exposure group for these 35 participants had 3.1 and 3.7 fold higher 

prevalence of shortness of breath on level ground when compared to the lowest TM and OM 

exposure groups (Table 3). Shortness of breath on level ground was significantly associated 

with increased TM exposure (p = 0.022) and OM exposure (p = 0.017). Prevalence of wheeze 

in the last 12 months was 2.5-2.8 fold higher in the highest TM and OM exposure groups, 

when compared to the lowest exposure group (Table 3). Age, smoking status, gender, and 

use of products containing other asthmagens were not significantly associated with chronic 

eye, upper airway or lower airway symptoms reported in the health and work history 

questionnaire and were not included in the analyses presented here. 
Page 14 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

Table 2. Acute and chronic symptom prevalence, by total mixture and oxidant mixture exposure group, 

July-September 2015 

Overall 

Prevalence TM Prevalence (%) OM Prevalence (%)

(%)

Work-Related 

Acute Symptom

(post-shift survey)

(n=50) Low Medium High Low Medium High

Nasal irritation*† 52.0 29.4 43.8 87.5 25.0 50.0 86.7

Eye irritation*† 44.0 17.7 37.5 81.3 12.5 44.4 80.0

Sneeze 22.0 11.8 18.8 37.5 6.3 27.8 33.3

Burning, dry, sore throat 18.0 17.7 12.5 25.0 18.8 11.1 26.7

Cough 20.0 23.5 18.8 18.8 18.8 22.2 20.0

Wheeze 6.0 0 12.5 6.3 0 11.1 6.7

Chest tightness 4.0 0 6.3 6.3 0 5.6 6.7

Shortness of breath 6.0 0 6.3 12.5 0 5.6 13.3

Difficulty breathing 4.0 0 12.5 0 0 11.1 0

Dizziness 6.0 5.9 6.3 6.3 6.3 5.6 6.7

Chronic Symptom 

(health and work 

history questionnaire)

(n=35) Low Medium High Low Medium High

Nasal problems, 

previous 12 months 57.1 45.5 45.5 76.9 45.5 50.0 75.0

Watery eyes, previous 

12 months 51.4 45.5 36.4 69.2 45.5 41.7 66.7

Usual cough 5.7 9.1 0 7.7 9.1 0 8.3

Shortness of Breath on 

level ground† 22.9 9.1 27.3 30.8 9.1 25.0 33.3

Wheeze, previous 12 

months 14.3 9.1 9.1 23.1 9.1 8.3 25.0

Awaken from chest 

tightness, previous 12 

months

17.1 27.3 0 23.1 27.3 8.3 16.7

Asthma medication use 8.6 9.1 0 15.4 9.1 0 16.7

Asthma-like symptoms 28.6 36.4 9.1 38.5 36.4 16.7 33.3

Note: TM=total mixture (hydrogen peroxide, peracetic acid, and acetic acid); OM=oxidant mixture (hydrogen 

peroxide and peracetic acid). *Indicates symptoms significantly positively associated with increased exposure to 

the total mixture (p ≤ 0.05). †Indicates symptoms significantly positively associated with increased exposure to the 

oxidant mixture (p ≤ 0.05).
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 15

Table 3. Acute and chronic symptom prevalence ratios relative to the low exposure group, by total 

mixture and oxidant mixture exposure group, July-September 2015 

TM Prevalence Ratio (95% CI) OM Prevalence Ratio (95% CI)

Acute Symptom Medium High Medium High (post-shift survey)

Nasal irritation*† 1.49 (0.59-3.74) 2.98 (1.39-6.36) 2.00 (0.76-5.26) 3.47 (1.45-8.29)

Eye irritation*† 2.13 (0.64-7.10) 4.60 (1.61-13.20) 3.56 (0.88-14.35) 6.40 (1.71-23.98)

Sneeze 1.59 (0.30-8.33) 3.19 (0.75-13.55) 4.44 (0.58-34.14) 5.33 (0.70-40.54)

Burning, dry, sore throat 0.71 (0.14-3.70) 1.42 (0.37-5.37) 0.59 (0.11-3.11) 1.42 (0.38-5.33)

Chronic Symptom 

(health and work history 

questionnaire)

Medium High Medium High

Nasal problems, previous 

12 months 1.0 (0.4-2.5) 1.69 (0.83-3.45) 1.10 (0.47-2.60) 1.65 (0.80-3.41)

Watery eyes, previous 12 

months 0.8 (0.29-2.21) 1.52 (0.73-3.2) 0.92 (0.36-2.33) 1.47 (0.69-3.14)

Usual cough ̶ 0.84 (0.06-12.01) ̶ 0.92 (0.06-12.95)

Shortness of Breath on 

level ground† 3.0 (0.36-24.6) 3.38 (0.44-26.0) 2.75 (0.33-22.69) 3.67 (0.48-28.00)

Wheeze, previous 12 

months 1.0 (0.07-14.05) 2.54 (0.31-21.06) 0.92 (0.06-12.95) 2.75 (0.33-22.69)

Awaken from chest 

tightness, previous 12 

months ̶ 0.85 (0.21-3.38) 0.31 (0.04-2.52) 0.61 (0.12-3.00)

Asthma medication use ̶ 1.69 (0.18-16.3) ̶ 1.83 (0.19-17.51)

Asthma-like symptoms 0.25 (0.03-1.90) 1.06 (0.37-3.0) 0.46 (0.10-2.03) 0.92 (0.30-2.81)

Note: TM=total mixture (hydrogen peroxide, peracetic acid, and acetic acid); OM=oxidant mixture (hydrogen 

peroxide, and peracetic acid). Prevalence ratios were calculated for the medium and high exposure groups, compared 

to the low exposure group. Cough, wheeze, chest tightness, shortness of breath, difficulty breathing, and dizziness 

reported in the post-shift survey were too few to calculate prevalence ratios using PROC-GENMOD in SAS and are 

not included in this table. 

*Indicates symptoms significantly positively associated with increased exposure to the total mixture (p ≤ 0.05). 

†

Indicates symptoms significantly positively associated with increased exposure to the oxidant mixture (p ≤ 0.05). 

Number of employees that reported symptoms was too small to calculate prevalence ratios using the GENMOD logbinomial procedure in SAS.
Page 16 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

Figure 2. Prevalence ratios and 95% confidence intervals for eye and upper airway symptoms reported 

during as occurring during employees’ shift in the medium and high compared to low total mixture 

(hydrogen peroxide, peracetic acid, and acetic acid) and oxidant mixture (hydrogen peroxide and 

peracetic acid) exposure groups, July and September 2015. *signifies symptoms significantly positively 

associated with the highest exposure group (p-value ≤ 0.05). 

Heating, Ventilation, and Air-conditioning System Evaluation 

All of the air-handling units and associated ductwork appeared to be in good working order 

and well maintained. We assessed the ventilation systems present in 29 areas in the hospital, 

including rooms in the following units: 2700, 2800, 3100, 3200, 3700, 3800, 4100, 4800, 

5300, 5800, Neonatal Intensive Care Unit, and Womancare Birth Center. We observed that 

the EVS cleaning closets in the 3100 and 5300 units had no supply air and no return flow. 

Participant Demographics and Responses to Health and Work History Questionnaire 

A total of 163 current employees, including 79 EVS staff and 84 non-EVS staff, completed 

the health and work history questionnaire. The participation rate among EVS staff who were 

working on the days of the health and work history questionnaire administration was 77%. 

Table 4 describes the job groups of non-EVS participants.
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 17

The median age of EVS participants was 45 years (range: 20 years to 67 years) compared 

to 40 years among non-EVS participants (range: 19 years to 67 years) (Table 5). A higher 

proportion of EVS participants (49%) than non-EVS participants (13%) were male. The 

majority of non-EVS staff were white (85%); whereas, the majority of EVS participants were 

black (59%). Tenure and smoking history was similar between the two groups.

Although most EVS staff were sers of the product containing HP, PAA, and AA, and most 

non-EVS staff did not use the sporicidal product, 11 (14%) EVS staff indicated that they did 

not use the product containing HP, PAA, and AA, while 10 (12%) non-EVS staff members 

indicated that they used the product. 

Table 4. Job groups of 84 non-EVS questionnaire participants, August – September 2015

Job Group N (% of total non-EVS)

Nursing staff* 27 (32%)

Other patient care staff† 25 (30%)

Administrative staff‡ 13 (15%)

Other hospital staff§ 19 (23%)

Note: EVS=environmental services staff

* Nursing Staff includes Staff Nurses, Registered Nurses, Nurse Coordinators, 

Professional Staff Nurses, Resource Nurses, and Collaborative Practice Nurses. 

 † Other Patient Care Staff includes Patient Care Technicians, Certified Nursing Assistants, Clinicians, 

Respiratory Therapists, Medical Assistants, Nurse Practitioners, Surgical Technicians, Surgical 

Technologists and Ultrasound Technicians. 

‡ Administrative Staff includes Patient Access Staff, Business Managers, Health Unit Coordinators, 

Administrative Assistants, Unit Directors, and Unit Secretaries.

§ Other Hospital Staff includes Pharmacists, Cooks, Pharmacy Technicians, Laboratory staff, Registered 

Dieticians, Room Service Attendants, Patient Transporters, Sanitation Aides, and Valet Parking 

Attendants.
Page 18 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Table 5. Demographic characteristics of survey participants, NIOSH survey, August-September 2015 p* oduct Non- Pr UsersUse (n= 85 ) Prudct Users (n= 78 ) p* Non-EVS (n= 84) EVS (n= 79) All Participants (N=163) Characteristic Age, years, median (range) 43 (19-67) 45 (20-67) 40 (19-67) 0.40 43 (20-67) 43 (19-67) 0.43 Tenure, years, median (range) 5 (0.13- 43) 5 (0.21-36) 5 (0.13-43) 0.83 5 (0.21-36) 5 (0.13-43) 0.57 Male, n (%) 50 (31%) 39 (49%) 11 (13%) <0.05 33 (42%) 17 (20%) <0.05 Race, n (%) White 92 (56%) 21 (27%) 71 (85%) <0.05 26 (33%) 66 (78%) <0.05 Black 57 (35%) 47 (59%) 10 (12%) 41 (53%) 16 (19%) Asian 4 (2%) 4 (5%) 0 (0%) 4 (5%) 0 (0%) Other† 7 (4%) 5 (6%) 2 (2%) 5 (6%) 2 (2%) Unknown‡ 3 (2%) 2 (3%) 1 (1%) 2 (3%) 1 (1%) Smoking status, n (%) Current 27 (17%) 16 (20%) 11 (13%) 0.36 16 (21%) 11 (13%) 0.42 Former 32 (20%) 13 (16%) 19 (23%) 14 (18%) 18 (21%) Never 104 (64%) 50 (63%) 54 (64%) 48 (62%) 56 (66%) Notes: EVS=environmental services staff * P values calculated using Chi-Square Test for categorical variables or T-test for continuous variables † Includes participants who indicated more than one race ‡ Participants who refused to indicate a race
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 19

All participants’ responses to questions about symptoms and self-reported diagnoses can be 

seen in Table 6. The most commonly reported symptoms were nasal problems and watery 

eyes. Nasal problems were reported by 42%, and watery eyes were reported by 40% of all 

participants. Other commonly reported health outcomes included asthma-like symptoms 

(28%), skin problems (19%) and wheeze (16%). Among reported symptoms, some were 

described to be work-related, as they improved away from the facility. The prevalence of 

work-related symptoms ranged from 2% to 18%.

Table 6. Symptoms and self-reported diagnoses of all questionnaire participants (N=163), 

August-September 2015

Health Outcome All Participants, n (%) Work Related*, n (%)

Cough 9 (6%) 4 (2%)

Shortness of breath 21 (13%) 7 (4%)

Wheeze† 26 (16%) 6 (4%)

Chest tightness† 18 (11%) 4 (2%)

Asthma attack† 8 (5%) 4 (2%)

Asthma medicine 18 (11%) 6 (4%)

Allergy medicine 48 (29%) 9 (6%)

Asthma-like symptoms§ 46 (28%) 16 (10%)

Nasal problems† 68 (42%) 29 (18%)

Watery eyes† 65 (40%) 31 (18%)

Skin problems† 31 (19%) 19 (11%)

Asthma

 Ever 32 (20%)

 Current 23 (14%)

Nasal allergies 37 (23%)

*Work-related symptoms were defined as symptoms that improved away from the facility, either on days 

off or on vacation.

† In the past 12 months 

‡ Asthma-like symptoms were defined as current use of asthma medicine and/or one or more of the 

following symptoms in the last 12 months: wheezing or whistling in the chest, awakening with a feeling of 

chest tightness, or attack of asthma.

Comparison of EVS and Non-EVS Staff

Physician Diagnosed Asthma Reported by EVS and Non-EVS Staff

There was no significant difference between EVS and non-EVS staff with regard to ever 

having a physician’s diagnosis of asthma or current asthma (Appendix A, Table A1). The 

prevalence of ever having a physician diagnosis of asthma among EVS staff participants was 

2.1 times (95% CI = 1.2, 3.7) that of the expected prevalence for the U.S. adult population, 

while the prevalence of current asthma among EVS staff was 2.3 times (95% CI = 1.2, 4.3) 

the expected prevalence for the U.S. adult population. Similarly, among non-EVS staff, these 

prevalences were higher than the expected values for the U.S. adult population; 2.6 times 

(95% CI = 1.6, 4.1) higher for ever-asthma, and 2.4 times (95% CI = 1.3, 4.2) higher for 

current asthma.

Among the 32 participants who reported ever having a physician diagnosis of asthma, 

approximately double the percentage of EVS staff (62%) compared to non-EVS staff (32%) 
Page 20 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

indicated that something at work brings on or worsens their asthma; the prevalence of asthma 

brought on or made worse by work for EVS and non-EVS staff is shown in Figure 4. Among 

the 14 employees that said something at work brings on or worsens their asthma, 36% 

indicated that the sporicidal product containing HP, PAA, and AA brought on or made their 

asthma worse.

 

Symptoms and Medication Use Reported by EVS Staff

EVS staff reported higher prevalences of work-related health outcomes including shortness 

of breath, asthma-like symptoms, use of asthma medicine, use of allergy medicine, nasal 

problems, and skin problems, with statistically significant higher reports of wheeze and 

watery eyes (Figure 3; Appendix A, Table A1). In addition, EVS staff had significantly higher 

prevalence of nasal problems and watery eyes brought on or made worse by something at 

work (Figure 4). Among the 32 employees who said that something at work brought on or 

made their nasal problems worse, 56% specified the product by name. Seventy-one percent 

of those who reported that something at work brought on or made their watery eye symptoms 

worse at work, also specified the sporicidal product containing HP, PAA, and AA by name. 

Among EVS staff reporting skin problems, 75% reported that something at work brought on 

or made this symptom worse, compared to 42% of non-EVS staff. Fifty-three percent of staff 

who reported that something at work brought on or made their skin problems worse specified 

that the product containing HP, PAA, and AA brought on or made their skin problems worse.
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 21 Figure 3. Prevalence of health outcomes brought on or made worse by something at work by EVS vs. non-EVS staff, August-September 2015. Percentages reflect the number of participants who reported a health outcome and indicated if it was brought on or made worse by something at work. Note: EVS=environmental services staff * Statistically significant differences (p ≤ 0.05) are indicated by an asterisk next to the name of the symptom. † Indicates all symptoms specific to the last 12 months 
Page 22 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Figure 4. Prevalence of work-related health outcomes by environmental services staff (EVS) vs. non-EVS staff, August-September 2015. Work-related symptoms were defined as symptoms that improved away from the facility, either on days off, or on vacation. Work-related medicine use was defined as increased use of medicine on work-days. *Statistically significant differences (p ≤ 0.05) are indicated by an asterisk next to the name of the symptom. † Indicates all symptoms specific to the last 12 months ‡ Asthma-like symptoms were defined as current use of asthma medicine and/or one or more of the following symptoms in the last 12 months: wheezing or whistling in the chest, awakening with a feeling of chest tightness, or attack of asthma.
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 23

Comparison of Product Users and Non-users

In general, the comparisons between users of the sporicidal product containing HP, PAA, and 

AA and non-users showed similar patterns to those described above for EVS staff and nonEVS staff.

Physician Diagnosed Asthma Reported by Product Users and Non-Users

There was no significant difference between users of the sporicidal product containing HP, 

PAA, and AA and non-users with regard to ever having a physician’s diagnosis of asthma or 

current asthma. Both groups had higher than expected asthma prevalence when compared to 

the U.S. population (Appendix A, Table A2). 

Other Health Outcomes Reported by Product Users and Non-Users

Users of the sporicidal product containing HP, PAA, and AA reported higher prevalence of 

work-related health outcomes including cough, shortness of breath, asthma-like symptoms, 

asthma attack, use of asthma medicine, asthma symptoms, use of allergy medicine, nasal 

problems, and skin problems, with wheeze and watery eyes being significantly higher 

(Appendix A, Figure A1).

Associations with department-level exposures

WCBC had the highest average measurements of hydrogen peroxide (165.63 ppb) and 

peracetic acid (25.13 ppb) and the second highest average of acetic acid (142.85 ppb). 

Prevalence ratios comparing the WCBC to the 3 departments with the lowest average TMs 

(2700/2800, Outpatient Clinic, and 4100) were calculated for wheeze, chest tightness, 

nasal problems, watery eyes and asthma-like symptoms and can be seen in Figure 5. 

Statistically significant results were found for watery eyes in the WCBC (PR= 2.88, 95% 

CI=1.18-7.05) and for the three highest units (WCBC, 5300, and NICU) with high ACGIH 

mixture concentrations (PR= 2.58, 95% CI=1.07-6.26) when compared to departments with 

low concentrations. When compared to all other departments, there were no significant 

differences among the survey participants in the WCBC with regard to sex, race, smoking 

status or those working in EVS. However, participants on the WCBC unit were significantly 

younger, with an average age of 37 and workers on all other units with an average age of 44 

(t-test, p=0.0169).

We compared the prevalence of shortness of breath, cough, wheeze, watery eyes and asthma 

diagnosis among workers in the WCBC compared to the U.S. population. The prevalence 

of watery eyes (SMR= 1.70, 95% CI= 1.06-2.72), lifetime asthma diagnosis (SMR=2.50, 

95% CI=1.07-5.85), and current asthma (SMR= 3.47, 95% CI= 1.48-8.13) was significantly 

higher than expected when compared to the U.S. population. Watery eyes and current 

asthma among workers in all other departments was not significantly higher than expected. 

However, lifetime asthma diagnosis was significantly higher than expected (SMR=2.52, 95% 

CI=1.41-4.51) in these other departments.
Page 24 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

Figure 5. Prevalence ratios for symptoms in the Labor and Delivery Department (WCBC), 3 departments 

with the highest average TM (WCBC, 5300, NICU) and 3 departments with medium TMs (5800, 

3700/3800, 4800) compared to the 3 departments with the lowest average TMs (4100, Outpatient Clinic, 

2700/2800). Statistically significant results are noted with an (*). All symptoms specific to the last 12 

months are noted with an (†). Asthma-like symptoms (§) were defined as current use of asthma medicine 

and/or one or more of the following symptoms in the last 12 months: wheezing or whistling in the chest, 

awakening with a feeling of chest tightness, or attack of asthma.

We compared the prevalence of shortness of breath, cough, wheeze, watery eyes and asthma 

diagnosis among employees in the WCBC to the U.S. population. The prevalence of watery 

eyes (SMR= 1.70, CI= 1.06-2.72), lifetime asthma diagnosis (SMR=2.50, CI=1.07-5.85), and 

current asthma (SMR= 3.47, CI= 1.48-8.13) were significantly higher than expected when 

compared to the U.S. population. Watery eyes and current asthma among employees in all 

other departments were not significantly higher than expected. However, lifetime asthma 

diagnosis was significantly higher than expected (SMR=2.52, CI=1.41-4.51) in these other 

departments.
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 25

Discussion 

Overall, we observed a higher prevalence of work-related health outcomes in EVS staff, 

when compared to non-EVS staff. EVS staff reported a higher prevalence of work-related 

shortness of breath, asthma-like symptoms, use of asthma medication, use of allergy 

medicine, nasal problems, and skin problems. In addition, EVS staff had significantly 

higher prevalence of work-related nasal problems and watery eyes (Figure 4). Among 

employees who said that something at work brought on or made their nasal problems worse, 

approximately half (56%) specified the sporicidal product containing HP, PAA, and AA. 

Almost three-quarters (71%) of staff who reported that something at work brought on or 

made their watery eye symptoms worse at work also specified this product. When compared 

to non-EVS staff, EVS staff had almost twice the prevalence (75% EVS staff, 42% non-EVS 

staff) of skin problems that were brought on or made worse at work. Of staff who reported 

that something at work brought on or made their skin problems worse, 53% specified the 

sporicidal product containing HP, PAA, and AA. Work-related watery eyes and wheeze were 

significantly more common among EVS staff when compared to non-EVS staff.

EVS staff using the product containing HP, PAA, and AA, reported acute and chronic 

symptoms. Symptoms were associated with exposure to the mixture of vapors from the 

product. The highest HP, PAA, and AA vapor exposure group (TM) had 3.5 and 6.5 fold 

increases in acute nasal and eye irritation, respectively (Figure 2). Increases in exposure to 

the HP, PAA, and AA vapors vapors were also significantly associated with chronic shortness 

of breath on level ground. The highest TM exposure group had 3.4 fold higher prevalence 

of shortness of breath. The highest TM exposure group also had 2.5 fold higher prevalence 

of wheeze in the last 12 months, when compared to the lowest exposure group, albeit this 

difference was not significant (Table 3). 

Our results suggest that exposure to vapors from the sporicidal product containing HP, 

PAA, and AA contributed to acute eye and upper airway symptoms, as well as shortness 

of breath, in hospital cleaning employees using the sporicidal product. The results of our 

evaluation are consistent with previous studies that have reported an increased risk for 

dermatitis, chronic bronchitis and work-related rhinitis and asthma in workers exposed to 

cleaning and disinfectant chemicals [Maçãira et al. 2007; Rosenman et al. 2003; Vizcaya et 

al. 2011; Charles, Loomis, and Demissie 2009]. We observed health effects in cleaning staff 

at exposure levels below established occupational exposure limits. Because both HP and 

PAA are strong oxidants, the mixture of HP and PAA potentially contributed to the airway 

symptoms reported by cleaning staff, at the relatively low levels of measured exposures. 

We observed that some hospital employees were informed and had the impression that 

because the chemicals contained in the sporicidal product are similar to common household 

products, there is little health risk from exposure. The 2008 HICPAC Guideline recommends 

that each worker be informed of the possible health effect(s) of his or her exposure to 

chemicals. Specifically, employees should be educated on the documented health risks from 

exposure to HP, AA and PAA, as well as chemicals found in other cleaners at the hospital. 

This information should be consistent with Safety Data Sheets, Environmental Protection 
Page 26 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

Agency regulations, and OSHA requirements and identify areas and tasks where there is 

the potential for exposure. In 2015, this sporicidal product specifically, was listed as an 

asthmagen, or a substance that causes asthma, by the Association of Occupational and 

Environmental Clinics (AOEC) [AOEC 2015].

We recommend that company management pursue the actions listed below to reduce 

employee exposure to the sporicidal products containing HP, PAA, and AA. Because 

employees are most familiar with the areas and tasks involved, we recommend that 

management involve employees that perform the work duties in each respective area when 

enacting any actions described below. Labor-management health and safety meetings 

are an opportune environment to discuss department specific recommendations and 

develop an action plan. Many of our recommendations come from the CDC’s Healthcare 

Infection Control Practices Advisory Committee (HICPAC), which developed a Guideline 

for Disinfection and Sterilization in Healthcare Facilities in 2008 [CDC 2008]. This 

Guideline acknowledges that occupational diseases among cleaning personnel have 

been associated with disinfectant use at levels below OSHA or NIOSH exposure limits. 

HICPAC recommends that controls be used to minimize exposure to disinfectants, including 

elimination or substitution of the chemical, engineering or administrative controls, or 

the use of personal protective equipment. Additional information is provided in the 

Recommendations section, below.

Conclusions 

In summary, acute eye symptoms and upper and lower respiratory symptoms were common 

in EVS staff during their shifts. EVS staff using a disinfectant cleaner that is one of a group 

of sporicidal products marketed under various trade names that contain HP, PAA, and 

AA, reported acute eye and airway symptoms, as well as chronic airway symptoms at low 

levels of measured exposures. Increased exposure to HP, PAA, and AA was significantly 

associated with increases in work-shift acute nasal and eye irritation and shortness of breath 

on level ground. All full-shift TWA air samples for HP and AA were below established 

occupational exposure limits. Whether analyzed by EVS staff versus non-EVS staff or by 

sporicidal product containing HP, PAA, and AA use versus non-product use, we found 

higher prevalences of work-related symptoms in the potentially exposed group versus the 

comparison group. We also found positive associations between exposure measurements 

related to this product’s use and some health effects. Our results indicate a need to (1) 

monitor respiratory and eye symptoms in hospital cleaning staff using cleaning products 

containing HP, PAA, and AA, and (2) use a combination of engineering and administrative 

controls to reduce employee exposures.

Recommendations 

Our recommendations are based on an approach known as the hierarchy of controls. This 

approach groups actions by how effective they are at removing or reducing hazards. In most 

cases, the primary approach is to eliminate hazardous materials or processes, and to install 
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 27

engineering controls to reduce exposure or shield employees. Administrative measures and 

personal protective equipment may be needed until such engineering controls are in place, or 

if engineering controls are not effective or feasible. Hospital management has already taken 

some steps to minimize employee exposure to the sporicidal product containing HP, PAA, 

and AA, and address employee concerns. Below, we provide additional recommendations in 

the continued effort to improve employee health and safety. 

Elimination or Substitution

A primary approach to minimizing exposure risk is to eliminate hazardous materials or 

processes. Sporicidal disinfectants are an important part of reducing healthcare-acquired 

infections. However, the choice to use sporicidal disinfectants in specific areas of the 

hospital should be prudent and reflect the level of risk of a healthcare-acquired infection. We 

observed the sporicidal product containing HP, PAA, and AA being used by cleaning staff on 

surfaces throughout the hospital, including surfaces in non-patient areas. HICPAC provides 

recommendations for when and where sterilization with sporicides, versus disinfection 

with high-and low-level disinfectants, should occur in healthcare facilities [CDC 2008]. 

HICPAC states that HP and PAA can be used as high-level disinfectants for semicritical items 

that come into contact with mucus membranes or non-intact skin like respiratory therapy 

and anesthesia equipment, and some endoscopes [CDC 2008]. Surfaces that may come 

into contact with non-intact skin for short periods of time, like bed side rails, are typically 

considered noncritical surfaces and may be disinfected with phenolic, iodophors, alcohols, 

or chlorine compounds [CDC 2008]. Exposure to vapors containing HP, PAA, and AA could 

be reduced by substituting intermediate or low-level disinfectants for sporicidal products 

containing HP, PAA, and AA, when cleaning and disinfecting noncritical surfaces like bed 

rails, patient furniture, and bedside tables, and when cleaning surfaces in non-patient areas. 

HICPAC states that detergent and water are adequate for cleaning surfaces in non-patient care 

areas. We recommend that poricidal products containing HP, PAA, and AA, not be used in 

non-patient care areas such as public bathrooms or administrative offices. 

Engineering Controls

Engineering controls can reduce employees’ exposures by lowering air concentrations 

with increased ventilation or by placing a barrier between the hazard and the employee. 

Engineering controls protect employees effectively without placing primary responsibility of 

implementation on the employee.

1. We recommend that additional return airflow be provided in the janitorial closets 

in 3100 and 5300 to ensure that the ASHRAE requirement of a minimum of 10 air 

changes per hour is met [ASHRAE 2013].

2. Ensure that all patient bathrooms meet minimum total air changes per hour as specified 

by ASHRAE. ASHRAE standard 2013-170 requires inpatient bathrooms to have at 

least 10 air changes per hour.

3. Ensure that the dispensers for the sporicidal product containing HP, PAA, and AA are 

calibrated to effectively dilute the product to a pH of 3. If the sporicidal product is 

not effectively diluted, a pH of less than 3 may increase skin, eye, and respiratory 
Page 28 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

symptoms in exposed employees.

4. We recommend that management replace the current open-face buckets used to hold 

the wipes and sporicidal liquid product with bucket wipe dispensers. Exposure to 

vapors from HP, PAA, and AA vapors from the sporicidal product may be minimized 

by requiring lids for the containers that EVS staff use to hold the sporicidal liquid 

product and wipes. Several companies make bucket wipe dispensers that could be used 

to allow wipes to be pulled from the sporicidal product containers while minimizing 

vapor exposure. 

Administrative Controls

Administrative controls refer to employer-dictated work practices and policies to reduce or 

prevent hazardous exposures. Their effectiveness depends on employer commitment and 

employee acceptance. Regular monitoring and reinforcement are necessary to ensure that 

policies and procedures are followed consistently.

1. Minimize the use of sporicidal products containing HP, PAA, and AA, in non-patient 

care areas.

2. Review the process for Occupational Safety and Health Administration Form 

300 reporting and maintenance to assure that all reportable injuries are recorded, 

regardless of whether a workers’ compensation claim is filed. Consider implementing 

a comprehensive system for reporting and tracking workplace injuries and illnesses 

that includes reports of near-misses, minor injuries and illnesses, and employee safety 

concerns. This information should be reviewed by the Safety Officer on a regular 

basis to identify hazards, implement risk-reduction strategies, and prevent significant 

injuries and illnesses. 

3. We recommend that management implement a reporting system that would allow 

employees to report work-related symptoms, with the option to remain anonymous 

for employees who do not wish to be identified. As a performance indicator for 

disinfection and sterilization, HICPAC recommends that healthcare facilities develop 

a mechanism for the reporting of all adverse health events potentially resulting from 

exposure to sporicidal disinfectants and sterilants. These reports should be reviewed 

regularly, and the facility should implement controls to prevent future exposures. 

4. Health and safety concerns related to cleaning and disinfecting products should be 

regularly evaluated. An annual post-shift survey of acute symptoms may be a useful 

tool for (1) alerting management to symptoms experienced by cleaning staff and (2) 

identifying areas of the hospital where symptoms may be more commonly reported 

and exposures may be higher. Such a system may allow employees with symptoms 

related to cleaning or disinfecting products to be offered relocation to an area or unit 

of the hospital with lower risk of exposure to sporicidal disinfectants. This type of 

evaluation may also help the facility identify additional controls to reduce employee 

exposure.

5. Employees should report new, persistent, or worsening symptoms to their personal 
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 29

healthcare provider and, as instructed by their employer, to a designated individual at 

their workplace. An individualized management plan (such as assigning an affected 

employee to a different work location) is sometimes required, as indicated by medical 

findings and recommendations of the physician. Employees with symptoms should 

provide their personal physicians or other healthcare providers with a copy of this 

report.

6. A team approach should be used when introducing a new cleaning product or system. 

A committee of EVS staff, infection preventionists, and occupational health and safety 

representatives should be convened when new cleaners and sporicidal disinfectants 

are chosen for the facility. Acquiring buy-in from these different groups prior to 

investment is key to implementing a new cleaning product or system. A trial period 

with a new cleaning system or product, with selected trial units or areas of the hospital, 

could be used to acquire feedback from stakeholders, including EVS staff, to evaluate 

new cleaning systems or products. Evaluation of a new cleaning system or product 

should consider effectiveness, cost, and employee health and safety concerns.

7. Ensure employees understand the potential hazards from exposure to cleaning 

products and how to protect themselves. OSHA’s Hazard Communication Standard, 

also known as the “Right to Know Law” [29 CFR 1910.1200] requires that employees 

are informed of potential work hazards and trained on associated safe practices, 

procedures, and protective measures. Ensure employees have access and are informed 

of potential hazards and trained on the associated safe practices per the information 

found in the cleaning products’ Safety Data Sheets. We found that some hospital 

employees have the impression that because the chemicals contained in the sporicidal 

product are similar to common household products, there is little health risk from 

exposure. The 2008 HICPAC Guideline recommends that each worker be informed 

of the possible health effect(s) of his or her exposure to chemicals. Specifically, 

employees should be educated on the documented health risks from exposure to 

HP, AA and PAA, as well as chemicals found in other cleaners at the hospital. This 

information should be consistent with Safety Data Sheets, Environmental Protection 

Agency regulations, and OSHA requirements and identify areas and tasks where there 

is the potential for exposure. 

8. In an interim letter dated October 19, 2015, we observed that the sporicidal product 

containing HP, PAA, and AA was formerly used as a spray cleaner by some staff in 

some units. Because spraying the sporicidal product may increase an employee’s 

risk of inhalational exposure to HP, PAA, and AA, we recommend that employees 

discontinue the practice of using the sporicidal product as a spray cleaner. Instead, 

employees should continue using rags or wipes to apply the product to surfaces.

Personal Protective Equipment

Personal protective equipment is the least effective means for controlling hazardous 

exposures. Proper use of personal protective equipment requires a comprehensive program 

and a high level of employee involvement and commitment. The right personal protective 

equipment must be chosen for each hazard. Supporting programs such as training, change-out 
Page 30 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

schedules, and medical assessment might be needed. Personal protective equipment should 

not be the sole method for controlling hazardous exposures. Rather, personal protective 

equipment should be used until effective engineering and administrative controls are in place.

1. Require employees to wear extended cuff nitrile gloves or rubber gloves when using 

the sporicidal product containing HP, PAA, and AA, and goggles or a face shield while 

dispensing and pouring the product into or out of the bucket on their cleaning cart.
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 31

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Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 33

Appendix A : Supplemental Analyses

All participants - Asthma

Twenty percent (n=32) of participants reported ever being diagnosed with asthma, which 

was 2.4 times higher (95% confidence interval (CI) = 1.6-3.4) than expected, compared to 

the U.S. adult population. Current asthma was reported by 14% (n=23) of participants and 

was 2.3 times higher (95% CI= 1.5-3.6) than expected. A total of 15 (9%) participants had 

adult-onset asthma, which was 2.8 times higher (95% CI=1.7-4.7) than expected. The prehire adult-onset asthma incidence density was 4.8 cases per 1000 person-years. The post-hire 

adult-onset asthma incidence density was 5.5 cases per 1000 person-years. This produced an 

incidence density ratio of 1.15, which shows no difference in adult-onset asthma between the 

pre-hire and post-hire group. 

Health outcomes by EVS and non-EVS staff

Among EVS participants, the most commonly reported health outcomes were watery 

eyes (42%), nasal problems (41%), asthma-like symptoms (28%), and shortness of breath 

(16%). The most commonly reported health outcomes for non-EVS staff were use of allergy 

medicine (43%), nasal problems (43%), watery eyes (38%), and asthma-like symptoms 

(29%) (Table A2). Only the use of allergy medication and nasal allergies diagnosis (p≤0.05) 

were significant between EVS and non-EVS participants (Table A1). When compared to 

expected values for the U.S. adult population, EVS staff were not significantly different for 

the prevalence of shortness of breath, cough, wheeze, and watery eyes. Non-EVS staff were 

not significantly different when compared to the U.S. adult population for the prevalence of 

cough, wheeze and watery eyes. However, they were 57% less likely to report shortness of 

breath than the U.S. adult population and this difference was significant (SMR= 0.43, CI= 

0.21-0.89).
Page 34 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

Table A1. Health outcomes of EVS and non-EVS Staff, NIOSH survey August-September 

2015

Health Outcome EVS (n= 79) Non-EVS (n= 84) p*

Cough 3 (4%) 6 (7%) 0.50

Shortness of Breath 13 (16%) 8 (10%) 0.24

Wheeze† 11 (14%) 15 (18%) 0.53

Chest Tightness† 11 (14%) 7 (8%) 0.32

Asthma Attack† 2 (3%) 6 (7%) 0.28

Asthma Medicine 8 (10%) 10 (12%) 0.81

Allergy Medicine 12 (15%) 36 (43%) ≤0.05

Asthma-Like Symptoms§ 22 (28%) 24 (29%) 1.00

Nasal Problems† 32 (41%) 36 (43%) 0.87

Watery Eyes† 33 (42%) 32 (38%) 0.75

Skin Problems† 12 (15%) 19 (23%) 0.24

Asthma

Ever 13 (16%) 19 (23%) 0.33

Current 10 (13%) 13 (15%) 0.66

Nasal Allergies 10 (13%) 27 (32%) ≤0.05

Note: EVS=environmental services staff

* P-values calculated using Chi-Square or Fisher’s Exact Test; p ≤ 0.05 considered significant

† In the past 12 months.

§ Asthma-like symptoms were defined as current use of asthma medicine and/or one or more of the 

following symptoms in the last 12 months: wheezing or whistling in the chest, awakening with a feeling of 

chest tightness, or attack of asthma.

Health outcomes by product use

A comparison of health outcomes between sers of the sporicidal product containing HP, PAA, 

and AA and non-users are shown in Table A2. The most commonly reported symptom among 

product users were watery eyes (45%), nasal problems (40%), and asthma-like symptoms 

(31%). Commonly reported symptoms among product non-users were nasal problems (44%), 

use of allergy medicine (38%), and watery eyes (35%). Only nasal allergy diagnosis and the 

use of allergy medication was significantly different between users and non-users (p≤0.05). 

Both product users and non-users were also not significantly different from the U.S. adult 

population for upper and lower respiratory symptoms. 

The prevalence of ever having a physician diagnosis of asthma among product users was 2.1 

times (95% CI = 1.2-3.7) that of the expected U.S. adult population. Similarly, the prevalence 

of current asthma among product users was 2.5 times (95% CI = 1.4-4.6) the expected 

prevalence for the U.S. adult population. Among product non-users, the prevalence of ever 

having a physician diagnosis of asthma or current asthma was also higher than the expected 

values for the U.S. adult population. Among product non-users, the prevalence of ever 

having physician diagnosed asthma was 2.6 times (95% CI = 1.6-4.2) and current asthma 

was 2.2 times (95% CI = 1.2-4.0), the expected prevalence for the U.S. adult population. 
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 35

The prevalence of work-related symptoms was generally higher in in users of the sporicidal 

product containing HP, PAA, and AA (Figure A1). 

Table A2. Symptoms and self-reported diagnoses of the survey participants (N=163), 

by Product Use, NIOSH survey, August-September 2015

Prodcut Use Non-Product Use Symptom p* (n= 78 ) (n= 85 )

Nasal Problems† 31 (40%) 37 (44%) 0.64

Watery Eyes† 35 (45%) 30 (35%) 0.26

Asthma-Like 

Symptoms§ 24 (31%) 22 (26%) 0.60

Skin Problems† 12 (15%) 19 (22%) 0.32

Wheeze† 12 (15%) 14 (16%) 1.00

Shortness of Breath 11 (14%) 10 (12%) 0.82

Chest Tightness† 10 (13%) 8 (9%) 0.62

Cough 5 (6%) 4 (5%) 0.74

Asthma Attack† 3 (4%) 5 (6%) 0.72

Medication Use

Allergy Medicine 16 (21%) 32 (38%) <0.05

Asthma Medicine 10 (13%) 8 (9%) 0.62

Diagnosis

Asthma

Ever 14 (18%) 18 (21%) 0.69

Current 12 (15%) 11 (13%) 0.66

Nasal Allergies 11 (14%) 26 (31%) <0.05

Notes:

*P values calculated using Chi-square or Fisher’s Exact Test

†In the past 12 months.

§Asthma-like symptoms were defined as current use of asthma medicine and/or one or more of the 

following symptoms in the last 12 months: wheezing or whistling in the chest, awakening with a feeling of 

chest tightness, or attack of asthma.
Page 36 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Figure A1. Prevalence of work-related health outcomes by product use, August-September 2015. Work-related symptoms were defined as symptoms that improved away from the facility, either on days off or on vacation. * Statistically significant differences (p≤0.05) are indicated by an asterisk next to the name of the symptom. † Indicates symptoms reported in the last 12 months.
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 37

Results for the 68 EVS participants who reported product use are shown in Table A3.

Table A3. Health outcomes of EVS staff who reported product use (N=68), NIOSH survey, 

August-September 2015

Work Related Symptom Prevalence, Symptom Symptom* Prevalence, n (%) n (%)

Cough 3 (4%) 1 (1%)

Shortness of Breath 11 (16%) 5 (7%)

Wheeze† 10 (15%) 5 (7%)

Chest Tightness† 9 (13%) 2 (3%)

Asthma Attack† 2 (3%) 1 (1%)

Asthma-Like Symptoms§ 19 (28%) 10 (15%)

Nasal Problems† 28 (41%) 15 (22%)

Watery Eyes† 31 (46%) 20 (29%)

Skin Problems† 10 (15%) 7 (10%)

*Work-related symptoms were defined as symptoms that improved away from the facility, either on days 

off or on vacation.

† In the past 12 months.

§ Asthma-like symptoms were defined as current use of asthma medicine and/or one or more of the 

following symptoms in the last 12 months: wheezing or whistling in the chest, awakening with a feeling of 

chest tightness, or attack of asthma.

Acute symptoms in EVS staff during a work shift

Table A4 shows the results of logistic regression of acute symptoms during a work-shift in 

EVS staff in relation to exposure to acetic acid, hydrogen peroxide, and peracetic acid. 
Page 38 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Table A4. Odds ratios** for acute symptoms and exposure to hydrogen peroxide, peracetic acid and acetic acid in EVS staff, July and September 2015 Acid (95% CI) Acetic Acid (95% CI) Peracetic oxide (95% CI) ogen Per Hydr Symptom Burning, itchy, runny nose* 1.01 (1.00-1.02) 1.08 (1.02-1.15) 1.01 (1.00-1.02) Sneeze 1.01 (1.00-1.01) 1.02 (0.97-1.07) 1.00 (1.00-1.01) Burning, itchy, watery eyes* 1.01 (1.00-1.02) 1.10 (1.04-1.18) 1.02 (1.01-1.03) Burning, dry, sore throat 1.00 (1.00-1.01) 1.02 (0.97-1.08) 1.00 (1.00-1.01) Cough 1.00 (0.99-1.00) 1.03 (0.98-1.09) 1.00 (1.00-1.01) Wheeze 1.01 (1.00-1.02) 1.00 (0.89-1.08) 1.00 (0.99-1.01) Chest Tightness 1.00 (0.98-1.01) 1.05 (0.94-1.16) 1.00 (0.98-1.01) Shortness of Breath 1.00 (0.99-1.01) 1.05 (0.97-1.15) 1.00 (0.98-1.01) Difficulty Breathing 1.00 (0.97-1.01) 1.04 (0.94-1.15) 1.00 (0.98-1.01) Dizziness 1.00 (0.98-1.01) 1.03 (0.95-1.12) 1.00 (0.98-1.01) * 95% confidence intervals are displayed in parentheses. ** The odds ratios represent the change for every parts per billion change in exposure measurements. An odds ratio greater than one indicates an increase in symptoms for an increase in exposure. 

Exposures that were significantly associated with work-related acute symptoms at p 

< 0.05 are noted in bold.
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 39

Demographics of Air Sampling, Acute Symptom Survey, and Health and Work History 

Questionnaire Participants

Demographic information for cleaning staff who participated in the air sampling, post-shift 

survey, and health and work history questionnaire can be seen in Table A5. The median age 

of participants was 40 years and ranged from 20 to 67 years. Forty-three percent were male. 

Median tenure was 3.5 years and ranged from 0.21 to 26.2 years. Current, former, and never 

smokers accounted for 23%, 6%, and 71% of participants, respectively.

Table A5. Demographic characteristics of air sampling, acute symptom survey and health and 

work history questionnaire participants, August-September 2015

Hospital Cleaning Staff Characteristic (N=35)

Age, years, median (range) 40 (20-67)

Tenure, years, median (range) 3.5 (0.21- 26.2)

Male, n (%) 15 (43%)

Race, n (%)

 White 11 (31%)

 Black 17 (49%)

 Asian 2 (6%)

 Other† 4 (11%)

 Unknown‡ 1 (3%)

Smoking status, n (%)

 Current 8 (23%)

 Former 2 (6%)

 Never 25 (71%)

† Includes participants who indicated more than one race.

‡ Participants who refused to indicate a race.

Comparison between Responses Observed in the Post-Shift Acute Symptom Survey and in the 

Health and Work History Questionnaire

Thirty-five EVS employees participated in the health and work history questionnaire, 

post-shift survey, and personal air sampling. In Figure A2, we show the prevalence of 

symptoms reported by 35 employees in both the post-shift survey and health and work 

history questionnaire. Nasal and eye irritation were the most commonly reported symptoms 

in both surveys. Cough, nasal, and eye symptoms were more often reported in the post-shift 

survey as acute symptoms that were experienced during their work shift. Overall, employees 

reported similarly for acute symptoms that began during their work shift and symptoms 

reported as usually occurring or as having occurred in the last year.

We also explored associations between exposure to hydrogen peroxide, acetic acid, and 

peracetic acid and symptoms reported as occurring in the previous 12 months using logistic 

regression (Table A6). Asthma-like symptoms, nasal irritation, eye irritation, wheeze, and 
Page 40 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

shortness of breath were associated with exposure to acetic acid, hydrogen peroxide, and 

peracetic acid. Shortness of breath was significantly associated with hydrogen peroxide 

exposure. Additionally, exposure to hydrogen peroxide was associated with cough, chest 

tightness, and allergy medication use. We also explored associations between the use 

of cleaning products containing known asthmagens and work-related acute symptoms 

using logistic regression. The use of any single cleaning product containing quaternary 

ammonium compounds, bleach, ethanolamines or any combination of these products was 

not significantly associated with work-related acute symptoms. Overall, we observed similar 

reporting of work-related symptoms in the post-shift acute symptom survey and symptoms 

that employees had experienced in the last year. We observed associations between exposure 

to hydrogen peroxide, acetic acid, and peracetic acid and work-related symptoms in EVS 

employees who participated in both the post-shift acute symptom survey and health and work 

history questionnaire.

Figure A2. Prevalence of work-related symptoms reported by employees in the post-shift acute symptom 

survey and health and work history questionnaire (n=35), NIOSH survey, July-September 2015. Work Related Symptoms Prevalence
Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 41 Table A6. Odds ratios** for symptoms reported as usually occurring or in the last 12 months with exposure to hydrogen peroxide, peracetic acid, and acetic acid, NIOSH survey, July-September 2015 AcidAcetic (95% CI) Acid Peracetic (95% CI) oxide ogen Per (95% CI*) Hydr Condition Nasal Problems, previous 12 months 1.01 (1.00-1.02) 1.07 (1.00-1.16) 1.00 (1.00-1.007) Watery Eyes, previous 12 months 1.01 (1.00-1.02) 1.05 (0.99-1.14) 1.00 (1.00-1.01) Usual Cough 1.01 (1.00-1.02) 0.88 (0.63-1.04) 1.00 (0.99-1.01) Shortness of Breath on Level Ground* 1.01 (1.00-1.02) 1.04 (0.97-1.11) 1.00 (0.99-1.01) Wheeze, previous 12 months 1.00 (0.99-1.01) 1.00 (0.91-1.08) 1.00 (0.99-1.01) Awaken from chest tightness, previous 12 months 1.00 (0.53-2.34) 0.99 (0.90-1.07) 1.00 (0.99-1.00) Asthma Medication Use 1.01 (1.00-1.02) 1.01 (0.90-1.11) 1.00 (0.99-1.01) Asthma-like Symptoms 1.00 (1.00-1.01) 0.99 (0.92-1.05) 1.00 (0.99-1.01) * 95% confidence intervals are displayed in parentheses. ** The odds ratios represent the change for every parts per billion change in exposure measurements. An odds ratio greater than one indicates an increase in symptoms for an increase in exposure. Exposures that were significantly associated with work-related acute symptoms at p 

< 0.05 are noted in bold.
Page 42 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

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Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018) Page 43

Keywords: North American Industry Classification System 622110 (General Medical and 

Surgical Hospitals), Pennsylvania, peracetic acid, hydrogen peroxide, acetic acid, disinfectant, sporicidal agent
Page 44 Health Hazard Evaluation Report 2015-0053-3269 (Revised 09/2018)

The Health Hazard Evaluation Program investigates possible health hazards in the workplace 

under the authority of the Occupational Safety and Health Act of 1970 (29 U.S.C. § 669(a)

(6)). The Health Hazard Evaluation Program also provides, upon request, technical assistance 

to federal, state, and local agencies to investigate occupational health hazards and to prevent 

occupational disease or injury. Regulations guiding the Program can be found in Title 42, Code 

of Federal Regulations, Part 85; Requests for Health Hazard Evaluations (42 CFR Part 85).

Disclaimer 

The recommendations in this report are made on the basis of the findings at the workplace 

evaluated and may not be applicable to other workplaces.

Mention of any company or product in this report does not constitute endorsement by the 

National Institute for Occupational Safety and Health (NIOSH).

Citations to Web sites external to NIOSH do not constitute NIOSH endorsement of the 

sponsoring organizations or their programs or products. NIOSH is not responsible for the 

content of these Web sites. All Web addresses referenced in this document were accessible as 

of the publication date.

Acknowledgments

Desktop Publisher: Tia McClelland

Site Visit: Brie Hawley, Megan Casey, Michael Beaty, Randy Boylstein, Kristin Cummings, 

Matt Duling, Ethan Fechter-Leggett, Reid Harvey, Alyson Johnson, Robert B. Lawrence, Tia 

McClelland, Christopher Mugford, Randall Nett, Anand Ranpara, Marcia Stanton, M. Abbas 

Virji, and Sandy White.

Availability of Report

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The state and local health department and the Occupational Safety and Health Administration 

Regional Office have also received a copy. This report is not copyrighted and may be freely 

reproduced.

This report is available at http://www.cdc.gov/niosh/hhe/reports/pdfs/2015-0053-

3269revised092018.pdf.

All other HHE Reports may be found at http://www2a.cdc.gov/hhe/search.asp. 

Recommended citation for this report:

NIOSH [2018]. Evaluation of exposure to a new cleaning and disinfection product and 

symptoms in hospital employees. By Hawley B, Casey M, Cummings K, Edwards N, 

Johnson A, Cox-Ganser J. Morgantown, WV: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, National Institute for Occupational 

Safety and Health, NIOSH HHE Report No. 2015-0053-3269 (revised 09/2018).
To receive documents or other information about

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