Cleaning agents, COVID and child health

By Patrick Hicks, Caseng Zhang, Kaden Lam, Alvaro Osornio, and Anne Hicks

In 2021, disinfection and sanitization are more important than ever. When choosing products, parents, schools, and health agencies need to balance hygiene with the potential harms from children’s exposure to disinfecting cleaning agents, especially with enhanced cleaning regimens. Cost, availability, human resources and existing regimens, particularly in schools and other public spaces, also need to be considered.

Following harmful exposure to disinfecting cleaning agents, respiratory symptoms are often a primary complaint. Considering the high prevalence of childhood asthma, the consequences of exposure to disinfecting cleaning agents must be considered. This blog reviews common disinfecting cleaning agents: how they work, efficacy against COVID-19, and potential hazards and health concerns, especially related to asthma.

Types of Disinfecting Cleaning Agents

Note: All are irritants to skin and should be handled as such. 

Alcohols

Typical alcohols include isopropyl alcohol (isopropanol) and ethyl alcohol (ethanol). While both have similar structures and properties, upon contact with skin, isopropanol evaporates much faster than ethanol. Most hand sanitizers contain isopropanol.

Ethanol in cleaning products is NOT safe for human consumption. Ingestion of alcohol-based products may cause liver and kidney damage.

Alcohols effectively sanitize skin and surfaces by denaturing proteins and the lipid cell membrane. A combination of water and alcohol is more effective against bacteria and viruses than pure alcohol: 60%-80% alcohol is ideal, while effectiveness falls off steeply above 90% and below 50%. Although alcohols are moderately effective fungicidal agents, they are not effective sporicides.

Alcohol is effective against COVID-19, and is the standard recommended disinfectant by the Centers for Disease Control (U.S.) for health care settings and the basis for the majority of hand sanitizers.

Repeated use of alcohol-based sanitizers on skin can cause irritation, drying, itchiness, and rashes. Lower alcohol concentrations may decrease skin irritation. Alcohol is highly flammable and should be kept clear of fire hazards. Additionally, alcohols can cause hardening of rubber and plastic instruments from continuous exposure.

Recall: Some agents, added intentionally or present as contaminants, are unhealthy and have been recalled in Canada. They include methanol, ethyl acetate and 1-propanol. Any hand sanitizer products with these ingredients should not be used, particularly by children.

Chlorine Compounds

Typical chlorine compound cleaners are hypochlorites in the form of sodium hypochlorite (bleach) and calcium hypochlorite (bleaching powder). They are mostly used in liquid form, but toxic fumes also form during regular use.

The exact mechanism by which chlorine compounds kill microbes is unclear. Chlorine compounds are extremely effective against bacteria, fungi, viruses, spores, and mycobacteria. They can effectively clean surfaces that may have been exposed to COVID-19 as well as many other pathogens. They are for surface use only and should never be used on skin, ingested or inhaled. 

Applying chlorine on surfaces generates vapor/fumes, and these compounds are caustic. They cause burning and irritation when exposed to skin or when inhaled and can result in burns or permanent eye damage. Exposure to these compounds can cause headaches, nausea, and dizziness. Long-term exposure to hypochlorite has been demonstrated to cause new cases of asthma, and exposure can also trigger asthma exacerbations in people with existing asthma. Swallowing bleach can damage the gastrointestinal mucosa and cause esophageal strictures, perforation and other significant permanent damage to the gastrointestinal tract. It is important to keep bleach away from children to prevent accidental ingestion. Chlorine causes bleaching (loss of colour) in fabrics and in high concentrations can be corrosive to metal.

Peroxides

Hydrogen peroxide is the most widely used peroxide for cleaning purposes and is often an alternative to bleach.  It can also be used to disinfect wounds but is not generally used for hand washing. Peroxides are mostly used in liquid form. Toxic fumes form during regular use.

Hydrogen peroxide is effective against bacteria, yeast, fungi, spores, and viruses. There is also evidence for its use as a surface disinfectant against COVID-19. Hydrogen peroxide is a reactive compound that can lose its efficacy but is stable when stored in dark- coloured containers. 

Hydrogen peroxide irritates the skin and mucous membranes--eyes, nose, and throat--through physical contact or inhalation. Still, hydrogen peroxide is considered less likely to cause an asthma exacerbation and is recommended by the CDC as a surface cleaner against COVID-19 for people with asthma, including children.

Aldehydes

Formaldehydes and glutaraldehydes are most frequently used for disinfecting medical instruments. While they are mostly used in liquid form, toxic fumes also form during regular use.

Effectiveness against COVID-19 can be assumed due to their known virucidal activity, despite a lack of specific evidence. Aldehydes are used to clean surfaces or disinfect objects, but not on humans. Formaldehyde is often released from new materials such as upholstery, carpet, drywall, and wood. It has been linked to respiratory irritation in these settings and children will often complain of sore throat and burning eyes.

Formaldehyde is considered a potential carcinogen, and ingestion can be fatal. It is highly reactive and irritates skin and mucous membranes, including those in the eyes, nose and throat. It also triggers asthma-like symptoms and can increase sensitivity to aeroallergens in people with existing allergies, contributing to asthma exacerbations. Glutaraldehyde is irritating to the eyes, throat, and nose and can also cause shortness of breath. 

Iodine Compounds

Primarily used as an antiseptic on skin, iodine compounds can also be used to disinfect medical equipment. While mostly used in liquid form, toxic fumes also form during regular use.

Iodine compounds have been shown to kill bacteria, mycobacteria, and viruses, as well as certain fungi after prolonged exposure. There is evidence that this disinfectant is effective against COVID-19. Iodine can be used to disinfect surfaces and skin but should not be ingested or otherwise used internally.

Exposure can cause irritation and burns to the skin, eyes, nose and throat. Caution and proper protection must be used when handling iodine compounds. Although they can be used to disinfect skin, the area should be cleaned after use. Short-term exposure to fumes can result in headaches. Ingestion can cause nausea, vomiting, diarrhea, and abdominal pain.

Phenols

Phenols, a common hospital disinfectant used on surfaces and noncritical medical devices, are mostly used in liquid form but release toxic fumes.

Phenolic products kill bacteria, fungi, viruses, and mycobacteria, and have shown effectiveness against COVID-19 in vitro. 

Phenolic compounds can cause severe burns. Fumes released during use and direct contact can also irritate mucus membranes in the nose, throat and lungs, and cause pulmonary edema after extended exposure. Other side effects after short-term exposure include headaches, fatigue, dizziness, and peripheral cyanosis (blue skin or lips), liver, kidney, and nervous system damage. Phenols should be handled as potential carcinogens.

Quaternary ammonium compounds

Commonly used for environmental sanitation such as disinfection of noncritical surfaces, as well as medical equipment that comes into contact with intact skin. Common quaternary ammonium compounds include benzalkonium chloride and are sold to the public as cleaning agents. They are mostly used in liquid form, but toxic fumes also form during regular use.

Quaternary ammonium compounds kill bacteria, fungi, and enveloped viruses. Quaternary ammonium compounds are effective against COVID-19. 

Exposure can result in mucous membrane irritation, including the nose, throat and lungs. Quaternary ammonium compounds are toxic when ingested and long-term chronic exposure is not recommended as potential health impacts are unknown.

Choosing a disinfecting cleaning agent

When choosing a disinfecting cleaning agent, it is important to consider when to use a disinfectant and when a cleaning agent such as soap and water or detergent would be better. With this in mind, important factors such as individual and group health, cost, and efficacy are important considerations.

Minimizing the risk of side effects secondary to disinfecting cleaning agents

• Use all cleaning agents as per instructions. If equally effective, lower-risk products cannot be substituted, products that cause respiratory or mucus membrane irritation should be used in a well ventilated area to minimize potential health effects.
• Cleaning agents and disinfectants should be used by adults only. Children, especially those with asthma, should avoid exposure and stay in another room, if possible.
• Identify areas that require disinfection. Use milder agents such as soap and water where possible, such as in low-touch and low-risk areas.
• If someone experiences respiratory or other health symptoms, they should leave the area where they noted the trigger and seek treatment if necessary. 
• Contact 911 for medical emergencies. 

Although the COVID-19 pandemic may present additional challenges to children with asthma and other respiratory conditions and their families, safety precautions can minimize potential health effects. It is important for schools, daycares and other places where children are regularly present are aware of the efficacy and impact of specific cleaning agents.

Patrick Hicks is an undergraduate student at the University of Alberta, Caseng Zhang is an undergraduate student at McMaster University, Kaden Lam is an undergraduate student at the University of Calgary, Alvaro Osornio is a Professor of Pediatrics at the University of Alberta, and Anne Hicks is Assistant Professor, Pediatric Respiratory Medicine at University of Alberta.

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The information on this blog should not be used as a substitute for medical care and advice. The views of blog writers do not necessarily represent the views of the Canadian Paediatric Society.