Risk of Asthma Symptoms among Workers in Health Care Settings

Risk of Asthma Symptoms among Workers in Health Care Settings

Mustafa Al-Zoughool Rana Al-Mistneer

Department of Community and Environmental Health, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Available online: 
| Citation



Prevalence of asthma is quite high in health care settings due to exposure to a wide variety of substances, including cleaning products, latex, medicines, ammonia and solvents. In this cross-sectional study, participants completed a validated questionnaire about their occupation, asthma diagnosis, variability of asthma symptoms at and away from work, and exposure to individual substances in the workplace. Work-related asthma symptoms (WRAS) were defined based on a set of criteria. Principal component analysis (PCA) was conducted to classify different substances into exposure patterns. Multivariable logistic regression analysis was used to evaluate the association between self-reported exposures to substances and asthma outcomes among health care workers. PCA revealed two factors: factor 1 (metal dust, metal fumes, solvents, cleaning agents, ammonia, glues) and factor 2 (disinfectants, latex, medicines). Exposure to factor 1 agents was associated with increased risk of WRAS (crude odds ratio (OR) 5.52, 95% confidence intervals (CI) 2.72–11.19), while exposure to factor 2 agents was associated with non-significant lower risk of WRAS (crude OR 0.58, 95% CI 0.3–1.14). Adjusting by confounders such as parent’s allergy and history of asthma, or smoking, did not appreciably change the ORs. Some agents were associated with increased risk of WRAS, while the lack of association with the exposure to other set of chemicals may be attributed to a number of factors, including healthy worker effect.


chemical exposures, disinfectants, health care, solvents, work-related asthma symptoms


[1] Loyo-Berríos, N.I., Irizarry, R., Hennessey, J.G., Tao, X.G. & Matanoski G., Air pollution sources and childhood asthma attacks in Catano, Puerto Rico. American Journal of Epidemiology, 165(8), pp. 927–935, 2007. DOI: 10.1093/aje/kwk088.

[2] Kemp, J.P., Comprehensive asthma management: guidelines for clinicians. Journal of Asthma, 35, pp. 601–620, 1998. DOI: 10.1172/JCI114338.

[3] Eder, W., Ege, M.J. & von Mutius E., The asthma epidemic. New England Journal of Medicine, 355(21), pp. 2226–2235, 2006. DOI: 10.1056/NEJMra054308.

[4] van Schayck, O.C., Global strategies for reducing the burden from asthma. Primary Care Respiratory Journal, (2), Vol. 22(no2), pp. 239–243. 2013. DOI: 10.4104/pcrj.2013.00052.

[5] Balmes, J., Becklake, M, Blanc, P, Henneberger, P, Kreiss, K, Mapp, C, Milton, D, Schwartz, D., Toren, K. & Viegi, G., Environmental and occupational health assembly, American Thoracic Society. American Thoracic Society statement: Occupational contribution to the burden of airway disease. American Journal of Respiratory and Critical Care Medicine, 167(5), pp. 787–97, 2003.

[6] Buck, R.G., Miles, A.J. & Ehrlich, R.I., Possible occupational asthma among adults presenting with acute asthma. South African Medical Journal, 90 (9), pp. 884–888, 2000. DOI: org/10.1164/rccm.167.5.787.

[7] Jeebhay, M.F. & Quirce, S., Occupational asthma in the developing and industrialised world: A review. International Journal of Tuberculosis and Lung Disease, 11(2), pp. 122–133, 2007.

[8] McHugh, M.K., Symanski, E., Pompeii, L.A. & Delclos, G.L., Prevalence of asthma by industry and occupation in the U.S. working population. American Journal of Industrial Medicine, 53(5), pp. 463–475, 2010. DOI: 10.1002/ajim.20800.

[9] Hayes, J.P. & Fitzgerald, M.X., Occupational asthma among hospital health care personnel: A cause for concern? Thorax, 49(3), pp. 198–200, 1994. DOI: 10.1136/thx.49.3.198.

[10] White, G.E.1., Mazurek, J.M. & Moorman, J.E., Asthma in health care workers: 2008 and 2010 Behavioral risk factor surveillance system asthma call-back survey. Journal of Occupational and Environmental Medicine, 55(12):1463–1468, 2013. DOI: 10.1097/JOM.0000000000000006.

[11] Bang, K., Hnizdo, E. & Doney, B., Prevalence of asthma by industry in the US population: a study of 2001 NHIS data. American Journal of Industrial Medicine, 47, pp. 500–508, 2005. DOI: 10.1002/ajim.20170.

[12] Karjalainen, A., Kurppa, K., Martikainen, R. et al., Work is related to a substantial portion of adult-onset asthma incidence in the Finnish population. American Journal of Respiratory and Critical Care Medicine, 164, pp. 565–568, 2001. DOI: 10.1164/ajrccm.164.4.2012146.

[13] Kogevinas, M., Zock, J-P., Jarvis, D. et al., Exposure to substances in the work-place and new-onset asthma: an international prospective population-based study [ECRHSII]. Lancet, 370, pp. 336–341, 2007. DOI: 10.1016/S0140-6736(07)61164-7.

[14] Liss, G.M., Buyantseva, L., Luce, C.E. et al., Work-related asthma in health care in Ontario. American Journal of Industrial Medicine, 54, pp. 278–284, 2011. DOI: 10.1002/ajim.20935.

[15] Syabbalo, N., Occupational asthma in a developing country. Chest, 99(2), pp. 528, 1991. DOI: 10.1378/chest.99.2.528-a.

[16] Delclos, G.L., Arif, A.A., Aday, L., Carson, A., Lai, D., Lusk, C., Stock, T., Symanski, E., Whitehead, L.W, Benavides, F.G. & Antó, J.M., Validation of an asthma questionnaire for use in healthcare workers. Occupational and Environmental Medicine, 63 (3), pp. 173–9, 2006. DOI: 10.1136/oem.2005.021634.

[17] Antonini, J.M., Lewis, A.B., Roberts, J.R. & Whaley, D.A., Pulmonary effects of welding fumes: review of worker and experimental animal studies. American Journal of Industrial Medicine, 43, pp. 350–360, 2003. DOI: 10.1002/ajim.10194.

[18] Hannu, T., Piipari, R., Kasurinen, H., Keskinen, H., Tuppurainen, M. & Tuomi, T., Occupational asthma due to manual metal-arc welding of special stainless steels. European Respiratory Journal, 26(4), pp. 736–739, 2005. DOI: 10.1183/09031936.05.00130504.

[19] Keskinen, H., Kalliomäki, P-L. & Alanko, K., Occupational asthma due to stainless steel welding fumes. Clinical Allergy, 10, pp. 151–159, 1980. DOI: 10.1016/0091-6749(78)90072-6.

[20] Jaakkola, J.J., Piipari, R. & Jaakkola, M.S., Occupation and asthma: A population-based incident case-control study. American Journal of Epidemiology 158(10), pp. 981–987, 2003. DOI: 10.1093/aje/kwg238.

[21] Lai, C.Y., Lai, C.H., Chuang, H.C., Pan, C.H., Yen, C.C., Lin, W.Y., Chen, J.K., Lin, L.Y. & Chuang, K.J., Physicochemistry and cardiovascular toxicity of metal fume PM2.5: A study of human coronary artery endothelial cells and welding workers. Scientifc Reports, 19, pp. 335–15, 2016. DOI:10.2147/IJN.S52239.

[22] Cavallari, J.M. et al., PM2.5 metal exposures and nocturnal heart rate variability: a panel study of boilermaker construction workers. Environmental Health, 7(36), 2008. DOI: 10.1093/jat/29.8.814.

[23] Chan-Yeung, M. & Malo, J.L., Aetiological agents in occupational asthma. European Respiratory Journal, 7, pp. 346–371, 1994. DOI: 10.1183/09031936.94.07020346.

[24] Huang et al., Association between concentrations of metals in urine and adult asthma: A case-control study in Wuhan, China. PLoS One, 11(5), e0155818, 2016. DOI: 10.1371/journal.pone.0155818.t006.

[25] Novey, H.S., Habib, M. & Wells, I.D., Asthma and IgE antibodies induced by chromium and nickel salts. Journal of Allergy and Clinical Immunology, 72 (4), pp. 407–12, 1983. DOI: 10.1016/0091-6749(83)90507-9.

[26] Dumas, O., Donnay, C., Heederik, D.J., Héry, M., Choudat, D., Kauffmann, F. & Le Moual, N., Occupational exposure to cleaning products and asthma in hospital workers. Occupational and Environmental Medicine, 69(12), pp. 883–889, 2012. DOI: 10.1136/oemed-2012-100826.

[27] Piirila, P., Hodgson, U., Estlander, T. et al., Occupational respiratory hypersensitivity in dental personnel. International Archives of Occupational and Environmental Health, 75, pp. 209–216, 2002. DOI: 10.1007/s00420-001-0302-4.

[28] Thickett, K.M., McCoach, J.S., Gerber, J.M. et al., Occupational asthma caused by chloramines in indoor swimming-pool air. European Respiratory Journal, 19, pp. 827–832, 2002. DOI: 10.1183/09031936.02.00232802.

[29] Kujala, V.M., Reijula, K.E., Ruotsalainen, E.M. et al., Occupational asthma due to chloramine-T solution. Respiratory Medicine, 89, pp. 693–695, 1995. DOI: 10.1016/0954-6111(95)90137-X.

[30] Matulonga, B., Rava, M., Siroux, V., Bernard, A., Dumas, O., Pin, I, Zock, J.P., Nadif, R., Leynaert, B. & Le Moual, N., Women using bleach for home cleaning are at increased risk of non-allergic asthma. Respiratory Medicine, 117, pp. 264–271, 2016. DOI: 10.1016/j.rmed.2016.06.019.

[31] Rosenman, K.D., Reilly, M.J., Schill, D.P. et al., Cleaning products and work-related asthma. Journal of Occupational and Environmental Medicine, 45, pp. 556–563, 2003. DOI: 10.1097/01.jom.0000058347.05741.f9.

[32] Medina-Ramon, M., Zock, J.P., Kogevinas, M. et al., Short-term respiratory effects of cleaning exposures in female domestic cleaners. European Respiratory Journal, 27, pp. 1196–1203, 2006. DOI: 10.1183/09031936.06.00085405.

[33] Shakeri, M S., Dick, F D. & Ayres, J G., Which agents cause reactive airways dysfunction syndrome (RADS)? A systematic review. Occupational Medicine, 58, pp. 205–211, 2008. DOI: 10.1093/occmed/kqn013.

[34] Arif, A. A. & Delclos, G. L., Association between cleaning-related chemicals and workrelated asthma and asthma symptoms among healthcare professionals. Occupational and Environmental Medicine, 69 (1), pp. 35–40, 2012. DOI: 10.1136/oem.2011.064865.

[35] Medina-Ramón, M., Zock, J.P., Kogevinas, M., Sunyer, J., Torralba, Y., Borrell, A, Burgos, F. & Antó, J.M., Asthma, chronic bronchitis, and exposure to irritant agents in occupational domestic cleaning: A nested case-control study. Occupational Environmental Medicine, 62 (9), pp. 598–606, 2005. DOI: 10.1136/oem.2004.017640.

[36] Arif, A.A., Delclos, G.L. & Serra, C., Occupational exposures and asthma among nursing professionals. Occupational and Environmental Medicine, 66(4), 274–278, 2009. DOI: 10.1136/oem.2008.042382.

[37] Vizcaya, D., Mirabelli, M.C., Gimeno, D., Antó, J.M., Delclos, G.L., Rivera, M., Orriols, R., Arjona, L., Burgos, F. & Zock, J.P., Cleaning products and short-term respiratory effects among female cleaners with asthma. Occupational and Environmental Medicine, 72(11), pp. 757–63, 2015. DOI: 10.1136/oemed-2013-102046.

[38] Ekpanyaskul, C,. Etiological investigation of unintentional solvent exposure among university hospital staff. Indian Journal of Occupational and Environmental Medicine, 14(3), pp. 100–103, 2010. DOI: 10.4103/0019-5278.75699.

[39] Arif, A.A., Whitehead, L.W., Delclos, G.L., Tortolero, S.R. & Lee, E.S., Prevalence and risk factors of work related asthma by industry among United States workers: data from the third national health and nutrition examination survey (1988–1994). Occupational and Environmental Medicine, 59(8), pp. 505–11, 2002. DOI: 10.1136/oem.59.8.505.

[40] Kogevinas, M., Antó, J.M., Soriano, J.B. et al., The risk of asthma attributable to occupational exposures. A population-based study in Spain. American Journal of Respiratory and Critical Care Medicine, 154, pp. 137–143, 1996. DOI: 10.1164/ajrccm.154.1.8680669.

[41] Karjalainen, A., Kurppa, K., Martikainen, R., Klaukka, T. & Karjalainen J., Work is related to a substantial portion of adult-onset asthma incidence in the Finnish population. American Journal of Respiratory and Critical Care Medicine, 164, pp. 565–568, 2001. DOI: 10.1164/ajrccm.164.4.2012146.

[42] Marcos, C.1., Lázaro, M., Fraj, J., Quirce, S., de la Hoz, B., Fernández-Rivas, M. & Losada, E., Occupational asthma due to latex surgical gloves. Annals of Allergy, 7(3), pp. 319–323, 1991. DOI: 10.1111/j.1365-2222.1997.118-az0114.x.

[43] Delclos, G.L., Gimeno, D., Arif, A.A., Burau, K.D., Carson, A., Lusk, C., Stock, T., Symanski, E., Whitehead, L.W., Zock, J.P., Benavides, F.G. & Antó, J.M., Occupational risk factors and Asthma among Health Care Professionals. American Journal of Respiratory and Critical Care Medicine, 175(7), pp. 667–675, 2007. DOI: 10.1164/rccm.200609-1331OC.

[44] Amr, S. & Suk, W.A., Latex allergy and occupational asthma in health care workers: adverse outcomes. Environmental Health Perspective, 112(3):378–381, 2004.

[45] Weber, D.J, Consoli, S.A. & Rutala, W.A., Occupational health risks associated with the use of germicides in health care. American Journal of Infection Control, 44 (5 Suppl), pp. 85–89, 2016. DOI: 10.1016/j.ajic.2015.11.030.

[46] Vellore, A.D.1., Drought, V.J., Sherwood-Jones D, Tunnicliffe B, Moore V.C, Robertson, A.S. & Burge, P.S., Occupational asthma and allergy to sevoflurane and isoflurane in anaesthetic staff. Allergy, 61(12):1485–6, 2006. DOI: 10.1157/13059846.

[47] Pralong, J.A.1., Cartier, A., Vandenplas O. & Labrecque M. Occupational Asthma: New Low-Molecular-Weight Causal Agents, 2000–2010. Journal of Allergy (Cairo). 597306, 2012. DOI: 10.1093/occmed/kqp168.

[48] Donnay, C, Denis, M.A., Magis, R., Fevotte, J., Massin, N., Dumas, O., Pin, I., Choudat, D., Kauffmann, F. & Le Moual, N., Under-estimation of self-reported occupational exposure by questionnaire in hospital workers. Occupational and Environmental Medicine, 68 (8), pp. 611–617, 2011. DOI: 10.1136/oem.2010.061671.

[49] George, L., Delclos, David, Gimeno, Ahmed A., Arif, Fernando G., Benavides, & JanPaul Zock., Occupational Exposures and Asthma in Health-Care Workers: Comparison of Self-Reports with a Workplace-Specific Job Exposure Matrix. American Journal of Epidemiology, 169 (5), pp. 581–587, 2009. DOI: 10.1093/aje/kwn387.

[50] Zock J.P., Cavallé, N, Kromhout, H., Kennedy, S.M., Sunyer, J., Jaén, A., Muniozguren, N., Payo, F., Almar, E., Sánchez, J.L., Antó, J.M. & Kogevinas, M. Evaluation of specific occupational asthma risks in a community-based study with special reference to single and multiple exposures. Journal of Exposure Analysis and Environmental Epidemiology, 14(5), pp. 397–403, 2004. DOI: 10.1038/sj.jea.7500337.

[51] Liss, G.M., Buyantseva, L., Luce, C.E. et al., Work-related asthma in health care in Ontario. American Journal of Industrial Medicine, 54, pp. 278–284, 2011. DOI: 10.1002/ajim.20935.

[52] Mirabelli, M.C.1., Zock, J.P., Plana, E., Antó, J.M., Benke, G., Blanc, P.D., Dahl-man-Höglund, A., Jarvis, D.L., Kromhout, H., Lillienberg, L., Norbäck, D., Olivieri, M., Radon, K., Sunyer, J., Torén, K., van Sprundel, M., Villani, S. & Kogevinas, M., Occupational risk factors for asthma among nurses and related healthcare professionals in an international study. Occupational and Environmental Medicine, 64, pp. 474–479, 2007. DOI: 10.1136/oem.2006.031203.