Virginia Research Day 2021

CHANGES IN USE OF QUATERNARY AMMONIUM COMPOUND (QAC) DISINFECTANTS IN DENTAL CLINICS DUE TO THE COVID-19 PANDEMIC Brooke D Burwell 1 , Alekhya Peruri 1 , Hannah L Paros 1 , Richard Antoun 1 , Caroline G Horne 1 , Rachel A Hall 1 ,

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Tyler Steve 1 , Chang Xu 1 , Theresa J McCann 1 , Terry C Hrubec 1 1. Edward Via College of Osteopathic Medicine, VA Campus, Blacksburg, VA

HYPOTHESIS

ABSTRACT Dental Healthcare Professionals are continuously in contact with disinfecting chemicals throughout their work day. With the onset of the COVID-19 pandemic, changes in use of disinfecting products must be examined. SAR-CoV-2 can linger on surfaces for up to three days, making consistent disinfection of communal surfaces vital. Of the 516 disinfecting products listed by the United States Environmental Protection Agency that are effective against SARS-CoV-2, 241 contain a Quaternary Ammonium Compound (QAC) as an active ingredient. Since their discovery in 1915, QACs have been used in a variety of products including detergents, emulsifying agents, deodorizers, hair products, and surface disinfectants. Though long believed to be harmless, QAC exposure has been linked to asthma and contact dermatitis in humans, and developmental, reproductive and immune toxicity in animals. Recent studies have shown that 80% of the population contains QAC residues in their blood, and these are correlated in a dose dependent manner with markers of inflammation and inhibition of mitochondrial function. Since the onset of the COVID-19 pandemic, indoor exposure to QACs has increased. Given the increased use of disinfectants in healthcare facilities, it is likely that workers have been increasingly exposed to these potentially harmful disinfectant products. This study aims to assess the changes in disinfection products and procedures in dental healthcare settings in response to the COVID-19 pandemic. Dental offices are unique in that patients must remove their masks to be treated, which puts individuals at a higher risk of transmission of the virus. Dental offices will be contacted and surveyed about changes in disinfectant product use within different areas of their practice including the waiting area and patient rooms. This will be conducted on a national basis with the aim of contacting 500 different offices. 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. We hypothesize that the use of disinfectants that contain QACs has increased due to the COVID-19 pandemic. This research was funded in part by VCOM. METHODS Selecting the States • Five states were selected as representative of the USA based on their rankings using 28 selected 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). Disinfectant Questionnaire • The survey was designed to identify in any changes made to the classes of disinfectants used (quaternary ammonia, bleach, hydrogen peroxide or phenol) or disinfection practices due to the COVID-19 pandemic. • The finalized survey was compiled into a Qualtrics survey with both an internal version for calling and an external version for emailing. Contacting the States • The dental practices were identified by each state’s Department of Health website. • The offices were randomized to prevent any bias in calling order. • Each office was called and asked to complete a survey either over the phone or by email.

RESULTS

It was hypothesized that the use of disinfectants that contain QACs has increased due to the COVID-19 Pandemic.

Preliminary Results of Phone Calls

Arizona Michigan Florida Total

Total Phone Calls Made

103

22

21

146

Total Responses Response Rate

20

4

0

24

RESULTS

19% 18% 0% 16.40%

Practices using Contracted Disinfect Service

5

1

0

6

TYPES OF DISINFECTANTS USED IN DENTAL OFFICES BEFORE COVID-19

Cavicide/Caviwipes (QAC + isopropanol) Bleach Based Products

Ammonium Based

QAC Based

Unknown/Unnamed Disinfectant Type

TYPES OF DISINFECTANTS USED IN DENTAL OFFICES AFTER COVID-19

All application methods increased with the greatest increase in wiping

Cavicide/Caviwipes (QAC + Isopropanol) Bleach Based

CONCLUSIONS

Ammonium Based

QAC Based

Unknown/Unnamed Disinfectant Type

ACKNOWLEDGEMENTS • Hora PI, Pati SG, McNamara PJ, Arnold WA. 2020. Increased use of quaternary ammonium compounds during the sars-cov-2 pandemic and beyond: consideration of environmental implications. Environmental Science & Technology Letters, 7:622-631. DOI: 10.1021/acs.estlett.0c00437 • Zheng G, Filippelli GM, Salamova A. 2020. Increased Indoor Exposure to Commonly Used Disinfectants during the COVID-19 Pandemic. Environmental Science & Technology Letters 2020 7 (10), 760-765. DOI: 10.1021/acs.estlett.0c00587 • This project was funded in part by VCOM. • We are grateful to the practices for taking time to complete the survey. Future research • The long-term goal of this research is to contact at least 500 practices to get more accurate results. • Paired t-tests would be used to compare the practices to see if QAC exposure or toxicity has increased with COVID • Due to the COVID-19 pandemic, most of the dental offices that were surveyed had adjusted their disinfectant practices. • A disinfectant that contains QACs was determined to be used by most of the dental offices.

Hydrogen Peroxide Based

Overall quaternary ammonia containing disinfectants use stayed the same but there was an addition of hydrogen peroxide and an unknown/other disinfectant

Changes in Dental Offices' Disinfectant Practices Due to COVID-19 Arizona Michigan Total Practices with Changed Disinfectant Protocols 11 3 14 (78%) Practices with Disinfection Occurring More Often 11 2 13 (72%) Practices with Altered Disinfectant Types 2 2 4 (22%) Practices with Altered Disinfectant Concentrations 1 0 1 (5%)

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