Dr Syed Nasir

2013 FOM ASM
Presentation
Dr Syed Nasir

The Respiratory Health of
Cleaners in NHS Highland

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

Previous Research
• Largest data set on cleaners
from ECRHS (European
Community Respiratory Health
Survey) study – 26 centres in
12 countries.
• Spanish EPIASLI, Canadian
cross-sectional surveys.
• Swedish, Singapore, New
Zealand surveys.
Accessed from: http://www.ecrhs.org/ECRHS%20I.htm
• National surveillance schemes
across 4 continents.

NHS Highland Cleaners
• 6% of NHS Highland employees.
Vital in protecting health of
patients and staff.
• Exposure to occupational
respiratory hazards such as
cleaning agents and dust.
• In NHS Highland cleaners had
higher sickness absence and
staff turnover rates than
administrative staff.

NHS Highland features
• Single Health Board with
discrete, standardised
working conditions.
• Covers 40% of Scottish
mainland area in
Northwest.

Objectives
• To estimate the
prevalence of respiratory
symptoms among
cleaners compared with
administrative workers.
• To identify any
associations between
specific occupational
exposures and
respiratory symptoms
among cleaners.

Method
• Cross-sectional postal
questionnaire survey of:
- All NHS Highland cleaners.
- Comparison group of all
NHS Highland
administrative staff.
• 2 nd mailing to nonresponders.

Questionnaire
• Respiratory symptoms
questions from the validated European
Community Respiratory Health Survey
(ECRHS) questionnaire.
• Exposure
asked about history of cleaning work;
cleaning agents; cleaning tasks; duration of
work as a cleaner; cleaning locations and
training on the use of cleaning agents.

Results : Response Rate
• The overall response rate was 56%:
-645/1270 administrative staff (62%).
-216/545 cleaners (40%).

Demographic profiles
• No significant difference between the
groups in terms of the age distribution
(p=0.075) or gender distribution
(p=0.19).
• A significantly greater proportion of
administrative staff were educated
beyond secondary school level
(p

Smoking profiles
• Greater proportion of
cleaners had ever
smoked (52% vs
34%).
• Comparing the packyears
of smoking in the
two groups, cleaners
smoked statistically
significantly more than
the administrative staff
[p=0.003]

Power of study
• 80% power at a 0.05 significance
level, to detect a 9% difference in the
prevalence of asthma or chronic
bronchitis symptoms.
• Greater than the pre-study projection.

Key findings
• After adjusting for age and smoking,
no significant differences were
found in the occurrence of asthma
and chronic bronchitis in cleaners
compared to administrative staff.
• Cleaners had significantly less upper
respiratory tract symptoms
(allergic rhinitis).

Risk of respiratory
symptoms : adjusted odds
ratio
Cleaners
[OR (95%CI)]
Administrative
staff (never
cleaners)
Wheezing with
breathlessness
0.81 (0.44-1.44) 1.0
Ever asthma 0.65 (0.39-1.04) 1.0
Current asthma 1.25 (0.80-1.92) 1.0
Chronic bronchitis 1.26 (0.79-1.97) 1.0
Ever rhinitis 0.59 (0.41-0.86) 1.0

Exposures : Cleaning
agents
• No significantly increased risk of
asthma or chronic bronchitis
symptoms with any of the chlorinecontaining
cleaning agents.

Exposures : Chlorine –
based agents
Cleaning substance
Current asthma
[OR (95%CI])
Actichlor 1.56 (0.73-3.45)
Cleenol bleach 1.11 (0.39-2.81)
Precept 2.13 (0.44-8.13)

Exposures : Cleaning
tasks
• No significantly increased risk with
dusting/polishing furniture or cleaning
up chemical spills of current asthma or
chronic bronchitis.
• Dusting/polishing furniture
-current asthma OR 2.76, 95% CI 0.63 – 12.23
-chronic bronchitis OR 1.07, 95% CI 0.38 – 3.01.
• Cleaning up chemical spills
-current asthma OR 1.37, 95% CI 0.59 – 3.19
-chronic bronchitis OR 1.88, 95% CI 0.86 – 4.10.

Exposures : Cleaning
Areas
• No significantly increased risk in
operating theatres, hospital wards,
kitchens and corridors:
– Asthma [OR 1.11, 95%CI 0.45–3.18]
– Chronic bronchitis [OR 0.95, 95%CI 0.40 – 2.54]

Risk by Geographical Area
• No significantly
increased risk of
current asthma or
chronic bronchitis
symptoms by area
(4 CHPs).

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

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

Hierarchy of Control
ELIMINATION Sprays, Enzymatic/Biological agents, Sanitiser powder,
Fume-emitting Destainer, Bactericidal gel.
Introduction of Steam cleaner using hot water-avoids use
of chemicals.
SUBSTITUTION Lower chlorine concentrations in cleaning agents
ENGINEERING Use of enclosed bucket to dissolve chlorine-based tablet in
tepid water
ADMINISTRATIVE Colour coding of cleaning equipment/areas (NPSA)
Standard Procurement Process
HAI/HEI audits
INFORMATION,
INSTRUCTION,
TRAINING
NHS Highland-wide trainers
Standard training programme for cleaners
Framework of NHS Scotland Policies (Cleaning Services ,
Agenda for Change, Cleaner Education and Training),
Cleanliness Champions
PPE Risk-assessed: Masks, Gloves, Uniform

Other factors
• Median length of service of cleaners (6
years).
• Mean age of cleaners (47.3 years) less
than the peak age for diagnosis of
COPD (>55 years).

Study strengths
• Discrete, well-defined occupational
groups with homogenous working
conditions.
• Groups well-matched by age, gender.
• Unexposed group never employed as
cleaners.
• Validated ECRHS questionnaire.
• Evaluation of exposures (tasks,
substances, locations).

Study weaknesses
• Low response rate in cleaners (40%)
• Responder bias
• Healthy Worker Effect

Conclusion
• No significant increase in the prevalence of lower
respiratory symptoms in NHS cleaners.
• No significantly increased risks of respiratory
symptoms among cleaners:
– in the highest risk areas
– using chlorine-based cleaning agents
– by cleaning tasks
– by geographical division
• Possible explanations: Risk assessment and
controls; Cleaners’ age and length of service.

Any questions?