Highlights
- •Children in childcare settings are vulnerable to environmental health risks.
- •Evidence-based guidelines are needed regarding surface disinfection in child care.
- •Currently recommended disinfectants do not disinfect against all child care–relevant organisms.
- •Peroxide products have less potential for respiratory toxicity than bleach or quats.
Background
Children in child care settings have a high infectious burden. They are frequently
exposed to sanitizing and disinfecting agents, whose toxicities have not been studied
in these settings. Current guidance on the preferred disinfection agents for child
care is vague.
Methods
This article combines 2 different sources of information: the Environmental Protection
Agency registration data on the efficacy of hospital-grade disinfectants and a review
of the research on the toxicities of the most common of these disinfectants to summarize
information that could be used for more evidence-based early care and education disinfection
regulations and guidelines.
Results
Coverage of these organisms varied both between disinfectant classes (defined by active
ingredient), as well as within classes. The 3 most common active ingredients in the
database—quaternary ammonias, bleaches, and hydrogen peroxides—had 251, 63, and 31
products, respectively. Quaternary ammonias and bleaches are both known asthmagens,
with the potential for toxic gas release when mixed. Quaternary ammonias may also
cause reproductive toxicity. Disinfectant-grade peroxides have relatively low inhalational
toxicity.
Conclusions
A clear rationale is needed to establish policies for determining preferable disinfection
products for use in child care settings, based on efficacy against relevant pathogens,
toxicity, ease of use, and cost. When other factors are equal, the use of peroxide-based
disinfectant products is recommended to minimize inhalational toxicity.
Key Words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of Infection ControlAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Volatile organic compounds and particulate matter in child care facilities in the District of Columbia: results from a pilot study.Environ Res. 2015; 146 (116-4)
- Infectious diseases and daycare and preschool education.J Pediatr Rio J. 2007; 83: 299-312
- American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education.Caring for our children. 3rd ed. Elk Grove Village (IL): American Academy of Pediatrics, 2011: 613
- Reducing Environmental Exposures in Child Care Facilities.Environmental Law Institute. 2015; : 1-153
American Academy of Pediatrics. Nutrition Supervision. In: Holt K, Wooldridge N, Story M, Sofka D, eds. Bright Futures: Nutrition, 3rd Edition. Elk Grove Village, (IL): American Academy of Pediatrics; 2011. p. 17-111.
- Environmental exposures in Early Childhood Education Environments.in: California Air Resources Board. California Air Resources Board. California Environmental Protection Agency. 2012: 1-423 (Available from:)
- Quantitative assessment of airborne exposures generated during common cleaning tasks: a pilot study.Environ Health. 2010; 9: 76
- Hygienic conditions in child-care facilities in North Carolina and South Carolina: an integrated microbial and observational study.Am J Infect Control. 2014; 42: 781-786
- Effect of fecal contamination on diarrheal illness rates in day-care centers.Am J Epidemiol. 1993; 138: 243-255
- Reducing absenteeism from gastrointestinal and respiratory illness in elementary school students: a randomized, controlled trial of an infection-control intervention.Pediatrics. 2008; 121: e1555-e1562
- Effect of cleaning and disinfection of toys on infectious diseases and micro-organisms in daycare nurseries.J Hosp Infect. 2015; 89: 109-115
- Effect of antibacterial home cleaning and handwashing products on infectious disease symptoms: a randomized, double-blind trial.Ann Intern Med. 2004; 140: 321-329
- Domestic use of bleach and infections in children: a multicentre cross-sectional study.Occup Environ Med. 2015; 72: 602-604
- Maintaining health by balancing microbial exposure and prevention of infection: the hygiene hypothesis versus the hypothesis of early immune challenge.J Hosp Infect. 2013; 83: S29-S34
- Inactivation of Burkholderia pseudomallei on environmental surfaces using spray-applied, common liquid disinfectants.Lett Appl Microbiol. 2015; 61: 418-422
- The effectiveness of three home products in cleaning and disinfection of Staphylococcus aureus and Escherichia coli on home environmental surfaces.J Appl Microbiol. 2015; 119: 1245-1252
- How are children different from adults?.Environ Health Perspect. 1995; 103: 7
- Physician reports of work‐related asthma in California, 1993–1996.Am J Ind Med. 2001; 39: 72-83
- Cleaning and asthma characteristics in women.Am J Ind Med. 2014; 57: 303-311
- Asthma and occupation in the 1958 birth cohort.Thorax. 2013; 68: 365-371
- Relationships between asthma and work exposures among non-domestic cleaners in Ontario.Am J Ind Med. 2009; 52: 716-723
- Work-related asthma among health care workers: surveillance data from California, Massachusetts, Michigan, and New Jersey, 1993–1997.Am J Ind Med. 2005; 47: 265-275
- Characterization of cleaning and disinfecting tasks and product use among hospital occupations.Am J Ind Med. 2015; 58: 101-111
- Agents and trends in health care workers' occupational asthma.Occup Med (Lond). 2013; 63: 513-516
- Occupational risk factors and asthma among health care professionals.Am J Respir Crit Care Med. 2007; 175: 667-675
- A review on human health perspective of air pollution with respect to allergies and asthma.Environ Int. 2013; 59: 41-52
- Association between cleaning-related chemicals and work-related asthma and asthma symptoms among healthcare professionals.Occup Environ Med. 2012; 69: 35-40
- Asthma among workers in healthcare settings: role of disinfection with quaternary ammonium compounds.Clin Exp Allergy. 2014; 44: 393-406
- Occupational exposure and new-onset asthma in a population-based study in Northern Europe (RHINE).Ann Occup Hyg. 2013; 57: 482-492
- Late Breaking Abstract - Occupational exposure to disinfectants and COPD incidence in US nurses: a prospective cohort study.Eur Respir J. 2017; 50
- Domestic use of hypochlorite bleach, atopic sensitization, and respiratory symptoms in adults.J Allergy Clin Immunol. 2009; 124 (731-8)
- Cleaning sprays, household help and asthma among elderly women.Respir Med. 2014; 108: 171-180
- Domestic use of cleaning sprays and asthma activity in females.Eur Respir J. 2012; 40: 1381-1389
- Fragrance materials in asthma: a pilot study using a surrogate aerosol product.J Asthma. 2013; 50: 975-982
- Effect of exposure to detergents and other chemicals on biomarkers of pulmonary response in exhaled breath from hospital cleaners: a pilot study.Int Arch Occup Environ Health. 2012; 85: 389-396
- House cleaning with chlorine bleach and the risks of allergic and respiratory diseases in children.Pediatr Allergy Immunol. 2007; 18: 27-35
- Poverty, dirt, infections and non-atopic wheezing in children from a Brazilian urban center.Respir Res. 2010; 11: 167
- The use of household cleaning products during pregnancy and lower respiratory tract infections and wheezing during early life.Int J Public Health. 2013; 58: 757-764
- Current use of room disinfectants and allergic symptoms at the age of 4 years.J Allergy Clin Immunol. 2009; 123: 1176-1178
- Do indoor chemicals promote development of airway allergy?.Indoor Air. 2007; 17: 236-255
- Indoor residential chemical emissions as risk factors for respiratory and allergic effects in children: a review.Indoor Air. 2007; 17: 259-277
- Influence of host and environmental factors on wheezing severity in infants: findings from the PARIS birth cohort.Clin Exp Allergy. 2012; 42: 275-283
- Frequent use of chemical household products is associated with persistent wheezing in pre-school age children.Thorax. 2005; 60: 45-49
US EPA OOCSAPP. Product Performance Test Guidelines: Disinfectants for Use on Hard Surfaces—Efficacy Data Recommendations. Available from: nepis.epa.gov/Exe/ZyPURL.cgi?Dockey=P100LBNA.TXT. Accessed September 30, 2016.
- Ability of cleaning-disinfecting wipes to remove bacteria from medical device surfaces.Am J Infect Control. 2015; 43: 1331-1335
- Update: Bleach-free Disinfection and Sanitizing for Child Care.San Francisco Asthma Task Force. 2013; 2013 (Available from:) (. Accessed September 30, 2016): 1-70
Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Recommendations for Care of Children in Special Circumstances: Children in Out of Home Child Care. In: Red Book, 30th Edition (2015). Management and Prevention of Illness. Elk Grove Village (IL): American Academy of Pediatrics; 2015:134-136.
FOIA Request Results, request # EPA-HQ-2016-010386. EPA US Sep26, 2016. Available from: https://foiaonline.regulations.gov/foia/action/public/view/request?objectId=090004-d280e525f0. September 30, 2016.
- Chlorine gas inhalation: human clinical evidence of toxicity and experience in animal models.Proc Am Thorac Soc. 2010; 7: 257-263
- Persistent asthma after inhalation of a mixture of sodium hypochlorite and hydrochloric acid.Chest. 1994; 105: 1895-1896
- Chlorine-induced injury to the airways in mice.Am J Respir Crit Care Med. 2003; 168: 568-574
- Halogenated volatile organic compounds in chlorine-bleach-containing household products and implications for their use.Atmospheric Environ. 2014; 92: 376-383
- VOC exposures in California early childhood education environments.Indoor Air. 2016; 121 (a160-13)
- Exaggerated responses to chlorine inhalation among persons with nonspecific airway hyperreactivity.Chest. 1996; 109: 331-337
- Airway response to chlorine inhalation (bleach) among cleaning workers with and without bronchial hyperresponsiveness.Am J Ind Med. 2011; 54: 293-299
- Asthma, chronic bronchitis, and exposure to irritant agents in occupational domestic cleaning: a nested case-control study.Occup Environ Med. 2005; 62: 598-606
- Chronic low dose chlorine exposure aggravates allergic inflammation and airway hyperresponsiveness and activates inflammasome pathway.PLoS ONE. 2014; 9e106861
- Occupational risk factors for asthma among nurses and related healthcare professionals in an international study.Occup Environ Med. 2007; 64: 474-479
- Short-term respiratory effects of cleaning exposures in female domestic cleaners.Eur Respir J. 2006; 27: 1196-1203
- Cleaning products and short-term respiratory effects among female cleaners with asthma.Occup Environ Med. 2015; 72: 757-763
- Work-related asthma among professional cleaning female workers.Arch Environ Occup Health. 2017; 72: 53-60
- Airway dysfunction in swimmers.Br J Sports Med. 2012; 46: 402-406
- Prevalence and characteristics of asthma in the aquatic disciplines.J Allergy Clin Immunol. 2015; 136: 588-594
- Asthma is more prevalent in elite swimming adolescents despite better mental and physical health.Scand J Med Sci Sports. 2012; 22: 362-371
- Airway dysfunction and inflammation in pool- and non-pool-based elite athletes.Med Sci Sports Exerc. 2012; 44: 1433-1439
- Swimming facilities and work-related asthma.J Asthma. 2015; 52: 52-58
- Occupational asthma caused by chloramines in indoor swimming-pool air.Eur Respir J. 2002; 19: 827-832
- An outbreak of swimming-pool related respiratory symptoms: An elusive source of trichloramine in a municipal indoor swimming pool.Int J Hyg Environ Health. 2015; 218: 386-391
- Lung function in volunteers before and after exposure to trichloramine in indoor pool environments and asthma in a cohort of pool workers. BMJ Open. 2012; 2 (e000973-3)
- Is there a potential link between indoor chlorinated pool environment and airway remodeling/inflammation in swimmers?.Expert Rev Respir Med. 2012; 6: 469-471
- Chlorinated pool attendance, atopy, and the risk of asthma during childhood.Environ Health Perspect. 2006; 114: 1567-1573
- Infant swimming practice, pulmonary epithelium integrity, and the risk of allergic and respiratory diseases later in childhood.Pediatrics. 2007; 119: 1095-1103
- Impact of chlorinated swimming pool attendance on the respiratory health of adolescents.Pediatrics. 2009; 124: 1110-1118
- Swimming pool attendance is related to asthma among atopic school children: a population-based study.Environ Health. 2015; 14: 37
- Swimming pool-induced asthma.J Investig Allergol Clin Immunol. 2011; 21: 240-241
- Indoor swimming pool attendance and respiratory and dermal health in schoolchildren–HITEA Catalonia.. Respir Med. 2014; 108: 1056-1059
- Swimming pool attendance and respiratory symptoms and allergies among Dutch children.Occup Environ Med. 2012; 69: 823-830
- Potential carcinogenic hazards of non-regulated disinfection by-products: haloquinones, halo-cyclopentene and cyclohexene derivatives, N-halamines, halonitriles, and heterocyclic amines.Toxicology. 2011; 286: 1-19
- Household cleaning product-related injuries treated in US emergency departments in 1990-2006.Pediatrics. 2010; 126: 509-516
Goldberg B. Dozens of children at N.J. daycare center accidentally drink bleach. Reuters 2014:1-3. Available from: https://www.reuters.com/article/us-usa-new-jersey-bleach/dozens-of-children-at-n-j-day-care-center-accidentally-drink-bleach-idUSKBN0H628020140911. Accessed September 30, 2016.
- Acute occupational disinfectant-related illness among youth, 1993–1998.Environ Health Perspect. 2003; 111: 1654-1659
- Benzalkonium chloride (BAC) and dimethyldioctadecyl-ammonium bromide (DDAB), two common quaternary ammonium compounds, cause genotoxic effects in mammalian and plant cells at environmentally relevant concentrations.Mutagenesis. 2007; 22: 363-370
- Exposure to common quaternary ammonium disinfectants decreases fertility in mice.Reproduct Toxicol. 2014; 50: 163-170
- Susceptibility of antibiotic-resistant cocci to biocides.J Appl Microbiol. 2002; 92
- Strong irritants masquerading as skin allergens: the case of benzalkonium chloride.Contact Derm. 2004; 50: 213-217
- Work-related asthma in France: recent trends for the period 2001–2009.Occup Environ Med. 2012; 69: 391-397
- Asthma related to cleaning agents: a clinical insight.BMJ Open. 2013; 3 (e003568-8)
Culver A, Geiger C, Simon D. Safer Products and Practices for Disinfecting and Sanitizing Surfaces. City and County of San Francisco: SF Environment 2014:1-58. Available from: https://sfenvironment.org/sites/default/files/fliers/files/sfe_th_safer_products_and_practices_for_disinfecting.pdf Accessed September 30, 2016.
- Hydrogen peroxide poisoning.Toxicol Rev. 2004; 23: 51-57
- Hydrogen peroxide 3% exposures.J Toxicol Clin Toxicol. 2008; 34: 323-327
- Asthma caused by peracetic acid-hydrogen peroxide mixture.J Occup Health. 2007; 49: 155-158
- Control of pathogens in biofilms on the surface of stainless steel by levulinic acid plus sodium dodecyl sulfate.Int J Food Microbiol. 2015; 207: 1-7
- Biofilm formation of O157 and non-O157 Shiga toxin-producing Escherichia coli and multidrug-resistant and susceptible Salmonella typhimurium and newport and their inactivation by sanitizers.J Food Sci. 2013; 78: M880-M886
- Impact of biocides on biofilm formation by methicillin-resistant Staphylococcus aureus (ST239-SCCmecIII) isolates.Microbiol Immunol. 2012; 56: 203-207
- Commonly used disinfectants fail to eradicate Salmonella enterica biofilms from food contact surface materials.Appl Environ Microbiol. 2014; 80: 1507-1514
- Product Performance Test Guidelines: Sanitizers for Use on Hard Surfaces—Efficacy Data Recommendations.(Available from:) (Accessed 9/30/2016)
- The effects of cleaning and disinfection in reducing Salmonella contamination in a laboratory model kitchen.J Appl Microbiol. 2003; 95: 1351-1360
- Antimicrobial activity of home disinfectants and natural products against potential human pathogens.Infect Control Hosp Epidemiol. 2000; 21: 33-38
- Laboratory evaluation of large-scale decontamination approaches.J Appl Microbiol. 2012; 112: 874-882
- Sporicidal efficacy of pH-adjusted bleach for control of bioburden on production facility surfaces.J Ind Microbiol Biotechnol. 2013; 40: 601-611
- Evaluation of the efficacy of bleach routinely used in health facilities against Mycobacterium tuberculosis isolates in Ethiopia.Pan Afr Med J. 2015; 21: 317
- Use of a mixture of surrogates for infectious bioagents in a standard approach to assessing disinfection of environmental surfaces.Appl Environ Microbiol. 2010; 76: 6020-6022
- Efficacy of commercially available wipes for disinfection of pulse oximeter sensors.Am J Infect Control. 2016; 44: 304-310
- Inactivation of vegetative bacterial threat agents on environmental surfaces.Sci Total Environ. 2013; 443: 387-396
US EPA. Design for the Environment Antimicrobial Pesticide Pilot Project: Moving Toward the Green End of the Pesticide Spectrum. Available from: https://www.epa.gov/pesticide-labels/design-environment-antimicrobial-pesticide-pilot-project-moving-toward-green-end Accessed September 30, 2016.
U.S. Environmental Protection Agency. Safer Choice Program. EPA's Safer Choice Standard. Available from: https://www.epa.gov/sites/production/files/2013-12/documents/standard-for-safer-products.pdf Accessed September 30, 2016.
Rutala WA, Weber DJ. Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities. Available from: https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines.pdf Accessed September 30, 2016.
- Cleaning and disinfecting environmental surfaces in health care: toward an integrated framework for infection and occupational illness prevention.Am J Infect Control. 2015; 43: 424-434
- Infection Prevention and Control in Childcare Settings [Internet].(Available from)
National Association for the Education of Young Children. Cleaning, Sanitizing, and Disinfecting Frequency Table. Available from: https://www.naeyc.org/sites/default/files/globally-shared/downloads/PDFs/accredita-tion/early-learning/Clean%2C%20Sanitize%2C%20Disinfect%20Table_Oct%202016_1.pdf Accessed September 30, 2016.
Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Recommendations for Care of Children in Special Circumstances: Children in Out of Home Child Care. In: Red Book, 30th Edition (2015). General Practices. Elk Grove Village, IL: American Academy of Pediatrics; 2015. p. 148-52.
- National Institute for Occupational Safety and Health (NIOSH), National Occupational Research Agenda (NORA) Cleaning and Disinfecting in Healthcare Working Group, Braun B, Delclos GL, Fagan K, et al. Cleaning and disinfecting environmental surfaces in health care: toward an integrated framework for infection and occupational illness prevention.Am J Infect Control. 2015; 43: 424-434
Article info
Publication history
Published online: August 29, 2018
Footnotes
☆Funding: This publication was supported by the cooperative agreement award number U61TS000238-04 from the Agency for Toxic Substances and Disease Registry (ATSDR). Its contents are the responsibility of the authors and do not necessarily represent the official views of the Agency for Toxic Substances and Disease Registry (ATSDR).
☆Conflicts of interest: None to report.
Identification
Copyright
© 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc.. All rights reserved.
