Virginia Research Day 2021

CHANGES IN USE OF QUATERNARY AMMONIUM COMPOUND (QAC) DISINFECTANTS IN PRIVATE PRACTICE CLINICS DUE TO THE COVID-19 PANDEMIC Richard Antoun 1 , Caroline G Horne 1 , Rachel A Hall 1 , Tyler Steve 1 , Chang Xu 1 , Brooke D Burwell 1 , Alekhya Peruri 1 , Theresa J McCann 1 , Terry C Hrubec 1 1. Edward Via College of Osteopathic Medicine, VA Campus

With the onset of the COVID-19 pandemic, disinfection procedures and products within healthcare facilities have been widely re-evaluated and adjusted. With the ability of SAR-CoV-2 to persist on surfaces for up to 3 days and for viral particles to be shed by asymptomatic persons, regular disinfecting of common areas is essential for infection control. Of the 516 products listed by the United States Environmental Protection Agency (EPA) as effective against SARS-CoV-2, 241 products contain a Quaternary Ammonium Compound (QAC) as the active ingredient. Since their discovery in 1915, QACs have increased in use and application. QACs are active ingredients in a wide variety of consumer and industrial products, including surface disinfectants, detergents, emulsifying agents, deodorizers, and hair products. QAC based disinfectants are often used in preference to other disinfectants due to their low cost, non-corrosive properties, and perceived safety. Though widely considered safe, QACs have been linked to medical complications with continued exposure. Asthma and contact dermatitis have been associated with QAC contact in people, and animal studies have identified developmental, reproductive and immune toxicity. Evaluation of population wide exposure has found that 80% of individuals contain QAC residues in their blood, with markers of inflammation & mitochondrial function varying in a dose dependent manner with blood QAC concentration. Recent studies have found that the COVID-19 pandemic has increased indoor exposure to QAC compounds. Our study will assess the changes in disinfectant procedures and product usage in medical office settings to determine if there is an increased use of QAC containing compounds. The project will focus on disinfection procedures in patient exam and waiting rooms in response to the COVID-19 pandemic. Approximately 500 medical offices will be surveyed throughout the United States by telephone. Offices will be asked an IRB approved standardized set of questions regarding the types of disinfectants being used, changes in cleaning products due to the COVID-19 pandemic, as well as changes in the frequency of cleaning/disinfecting procedures during the pandemic. Descriptive statistics with means and proportions will be used to describe the data. Normality and distribution of data will be assessed. Paired t-tests or non-parametric equivalents will be used to compare changes in disinfection practices. All analyses will be 2-tailed with statistical significance set at p<.05, and 95% confidence intervals will be provided for outcomes. • Disinfection guidelines have been established by the Center for Disease Control (CDC) to reduce spread of SARS-CoV-2 virus responsible for COVID-19 pandemic. 1 • Of the 531 disinfectants approved by the United States Environmental Protection Agency (EPA) for use against COVID, 245 contain quaternary ammonium compounds (QACs); a common ingredient found in medical, residential, and industrial products. 2 • QACs can cause asthma, contact dermatitis, ocular inflammation, and hypersensitivities. 3 • More recently, studies have shown that QACs cause birth defects, infertility, and alter cellular inflammation, mitochondrial function and lipid homeostasis in animals. 3 • These toxic effects may be seen in humans as well. 3 • This study was conducted to determine if changes in disinfection practices in medical settings due to COVID-19 have potentially increased exposure to QAC containing disinfectants.

Private Practice Characteristics Pennsylvania Arizona

Total

Called

21

2 0 1 1

23

Responded to survey

3 0

3 1

Declined

No answer % Response

18

19

14.3%

0%

13.0%

Rural

2 0 1

- - -

Suburban

Urban

Both practices increased wiping, while only one increased spraying. There was no change in mopping or soaking.

● With the COVID-19 pandemic, several changes in disinfection protocols have been put in place within private practice offices. ● With changes in disinfection protocols, health care workers may be exposed to increased levels of disinfection products, many of which have known adverse health effects. ● Small sample size notwithstanding, within our study, an increase in wiping and spraying of disinfectants relative to pre-pandemic levels is evident. ● Spray disinfectants have a higher potential for inhalation and can cause adverse lung reactions such as asthma, chronic obstructive pulmonary disease (COPD) and fibrosis. Additional Considerations This work is ongoing with the goal of 500 completed survey responses.

With only two responses to the survey, it is difficult to make any conclusions about disinfectant choices.

• Survey design : A Qualtrics survey was developed to determine if the types of disinfectants and or disinfection procedures have changed due to the pandemic. • Information about the type of practice and disinfection procedures areas within the practice was collected. • Geographic Selection : To obtain results that could represent the country as a whole, five states were selected based on their rankings using 28 selected current metrics of health and demographic data compiled by the Kaiser Family Foundation. The three states immediately below and three states immediately above the national average were identified for each metric. The incidence of the identified states was ranked and states with the highest rankings were selected: Pennsylvania (score 9), Arizona (score 8), Florida (score 8), Illinois (score 7), Michigan (score 7). • Medical Practice Selection: Practices were selected from an online COVID-19 Atlas identifying all practices available for testing and/or treatment of COVID-19. 4 Practice order was randomized to minimize bias when contacting. • Practices were contacted by phone or email. In total, the target is for 500 responses to the survey.

1. “Cleaning and Disinfection of Environmental Surfaces in the Context of COVID-19: Interim Guidance.” World Health Organization , 15 May 2020, pp. 1–8., doi:WHO reference number: WHO/2019-nCoV/Disinfection/2020.1. 2. “Disinfectants Pesticides.” EPA - List N Disinfectant Table , Environmental Protection Agency, cfpub.epa.gov/giwiz/disinfectants/index.cfm. 3. Hrubec, Terry C., et al. “Altered Toxicological Endpoints in Humans with Quaternary Ammonium Compound Exposure.” MedRxiv , Cold Spring Harbor Laboratory Press, 1 Jan. 2020, www.medrxiv.org/content/10.1101/2020.07.15.20154963v1. 4. University of Chicago. “US Covid Atlas.” GeoDa on Github , geodacenter.github.io/covid/map.html#.

We hypothesize that the use of disinfectant practices have increased in medical offices throughout the nation due to the COVID-19 pandemic, and this has resulted in an increased use of QAC containing products.

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