www.jped.com.br
ORIGINAL
ARTICLE
Use
of
sanitizing
products:
safety
practices
and
risk
situations
夽
Ana
Aurélia
Rocha
da
Silva
a,b,∗,
Raquel
Souza
Passos
a,b,
Luiz
Alberto
Simeoni
c,
Francisco
de
Assis
Rocha
Neves
c,
Elisa
de
Carvalho
a,baHospitaldeBasedoDistritoFederal,Brasília,DF,Brazil
bHospitaldaCrianc¸adeBrasília,Brasília,DF,Brazil
cHealthSciences,UniversidadedeBrasília(UnB),Brasília,DF,Brazil
Received13May2013;accepted21August2013 Availableonline25December2013
KEYWORDS Caustics; Corrosive;
Accidentprevention; Riskgroups;
Sanitizingproducts
Abstract
Objectives: to evaluate the handling and risk factors for poisoning and/or digestive tract
injuriesassociatedwiththeuseofsanitizingproductsathome.
Methods: interviewswereconductedin419householdsfromdifferentregions,collecting
epi-demiological data fromresidentsandriskhabits relatedto theuseandstorageofcleaning products.
Results: sanitizingproductsconsideredtobeahealthriskwerefoundin98%ofthehouseholds
where the researchwas conducted,andin 54%ofcases, theywere storedin placeseasily accessible tochildren. Lyewas found in19%,followed by illicitproducts in39%ofhomes. In13%ofhouseholds,peopleproducedsoap,andin12%theystoredproductsinnon-original containers.Theuseofillicitproductsandthemanufactureofhandmadesoapwereassociated withlowereducationallevelofthehouseholdownersandwiththeregionsandsocioeconomic classeswithlowerpurchasingpower.
Conclusions: riskpracticessuchasinadequatestorage,manufacturing,anduseofsanitizing
productsbythepopulationevidencetheneedforpublichealthpolicies,includingeducational measures,asameansofpreventingaccidents.
©2013SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Allrightsreserved.
夽 Pleasecitethisarticleas:SilvaAA,PassosRS,SimeoniLA,NevesFA,CarvalhoE.Useofsanitizingproducts:safetypracticesandrisk
situations.JPediatr(RioJ).2014;90:149---54. ∗Correspondingauthor.
E-mail:[email protected](A.A.R.d.Silva).
PALAVRAS-CHAVE Cáusticos;
Corrosivos; Prevenc¸ãode acidentes; Gruposderisco; Produtossaneantes
Usodeprodutossaneantes:práticasdeseguranc¸aesituac¸õesderisco
Resumo
Objetivos: avaliaraformadeutilizac¸ãoeosfatoresderiscoparaintoxicac¸õese/oulesõesdo
tratodigestórioassociadosaousodosprodutossaneantesnodomicílio.
Métodos: foramrealizadasentrevistasem419domicíliosdediferentesregiões,
estabelecendo-se dados epidemiológicos dos moradores e hábitos de risco relacionados à utilizac¸ão e armazenamentodosprodutosdelimpeza.
Resultados: dosdomicíliosondefoirealizadaapesquisa,haviaprodutossaneantesconsiderados
deriscoem98%,sendoqueem54%doscasos,elesestavamarmazenadosemlocaisdefácil acessoparacrianc¸as.Asodacáusticaestavadisponívelem19%eosprodutos‘‘clandestinos’’em 39%dasmoradias.Em13%dosdomicílioshaviaohábitodefazersabãoeem12%dearmazenar osprodutosforadaembalagemoriginal.Ousodeprodutosclandestinoseafabricac¸ãoartesanal desabãoestavamassociadosàbaixaescolaridadedasdonasdascasaseàsregiõeseàsclasses econômicasdepoderaquisitivomaisbaixo.
Conclusões: práticasderiscocomo armazenamento,fabricac¸ãoeutilizac¸ãoinadequadosde
produtossaneantespelapopulac¸ãoestudadaapontamparaanecessidadedepolíticasdesaúde pública,incluindomedidaseducacionais,comoformadeprevenc¸ãodeacidentes.
©2013SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Todososdireitos reservados.
Introduction
Poisonings areresponsible for high morbidity and mortal-ity in childhood. An unsafe environment is a risk factor forinjuriesandpoisoninginchildren.1Accidentalingestion of caustic substances, which are found in many cleaning products,are amongthe majorinjuries resulting froman unsafeenvironment,particularlyindevelopingcountries,1,2 wherethesecasesareoftenunderreported.Sanitizing prod-uctsare‘‘substances or preparations intended for use on objects,fabrics,inanimatesurfaces,andenvironmentswith the purpose of cleaning, disinfecting, disinfesting, sani-tizing, deodorizing, and odorizing, as well as disinfection of water for human consumption, horticultural produce, and pools’’, comprising: 1) cleaning products in general, andsimilar;2) disinfectants,sterilizing agents,sanitizers, deodorizers, and disinfectants used in water for human consumption, horticultural produce, and pools, and 3) insecticides.3
Despitetheunderreporting,therehavebeenreports,in Brazilandacrosstheworld,ofcasesofhumanpoisoningand serious injuries caused by sanitizing products. Records of theAmericanAssociationofPoisonControlCenters(AAPCC) evidencethatin2009,therewere2,479,355casesofhuman poisoning;cleaning products wereresponsiblefor 212,616 (7.4%)ofallcasesandfor125,394(9.3%)ofthetotalcases inchildrenyoungerthan5years,secondonlytocosmetics (13.0%)andanalgesics(9.7%).4
InBrazil,datafromtheNationalPoisonand Pharmacolog-icalInformation System(SistemaNacional deInformac¸ões Tóxico Farmacológicas - SINITOX) evidence that, in 2009, therewere reports of 100,391 casesof human poisoning; 10,675 (10.63%) of them were caused by sanitizing prod-ucts,andhalf(5,091) ofthe casesoccurredwithchildren youngerthan5years.5Brazilian andglobaldataconfirma higherprevalenceofsuchaccidentsinchildrenyoungerthan 5yearsandinmales.2,6,7
Among the sanitizing products, those containing caus-ticsubstances mustbe emphasized,astheycauseserious injuries to the digestive tract, which can lead to an increasedrisk for developing esophageal cancer.8 In addi-tion,theingestionofcausticproductsremainstheleading causeofsevereesophagealstenosisinchildren, represent-ingthesecondleadingcauseofesophagealreplacementin thisagegroup,9withgreaterdifficultyregardingthedilating therapyandahigherrateofrecurrencewhencomparedto othertypesofesophagealstenoses.10
In pediatric patients, most cases occur by accident. Thestorage ofcleaningproductsininadequateplacesand the way they are used have been identified as possible risk factorsfor these accidents tooccur.11 Mostaccidents occur at home12,13 and at relatives’ homes,12 where chil-dren areexposedtoimproperlystoredtoxicsubstances.14 Other sociodemographic conditions associated with inges-tion of caustic substances have been identified, such as: lowmaternaleducationallevel,largefamilies,maternalage youngerthan30years,andworkingmother.12
InBrazil,therehavebeennostudiesthatdemonstrated howtheseproductsareusedinthehouseholdoridentified risk factors for poisoning and/or injuries of the digestive tract.Thus,thecurrentstudyaimedtoassesstheuseand storageofhouseholdsanitizingproductsbythepopulation of the Federal District,according toitsdifferent regions, socioeconomicclasses,andeducationallevelsregardingthe presenceorabsenceofchildren.
Methods
ThisresearchwasconductedintheFederalDistrict(Brazil), a regionthathas apopulation of 2,570,160inhabitants.15 The sample was calculated to be representative of this
population, based on the number of households per
Coordination Secretariat of the Federal District --- (Secre-tariade Planejamento e Coordenac¸ão do Distrito Federal ---SEPLAN) andbythePlanaltoCentral Development Com-pany(Companhia doDesenvolvimento doPlanalto Central --- CODEPLAN) in 2004 as it represented, at the time of thesamplecalculation,thelatestcensusofthenumberof householdsintheFederalDistrict.Intheend,thetotal sam-pleconsistedof419householdsdistributedover27ARsof theFederalDistrict.
It was assumed that the variances were constant and maximumatthestrata,withaconfidencelevelof95%and amarginoferrorof5%.TheseregionsweregroupedintoI, II,andIIIaccordingtothepercapitaincomeineachregion. IncludedinRegionIweretheregionswherethepercapita incomewashigherthanR$1,000;inRegionII,thoseinwhich theincomerangedfromR$500toR$1,000,andinRegion III,thoseinwhichtheincomewaslessthanR$500.
Ineachselectedhousehold,oneoftheresidentsaged18 yearsorolder,presentattheinterview,answeredquestions from a pre-prepared questionnaire on the use of house-holdsanitizingproductsafterdoubtswereclarifiedandthe informedconsentwassigned.
The questionnaire included questionson:1) thefamily sociodemographicconditions,suchasnumberofindividuals living inthe household,age, andeducationallevel of the respondentandotherfamilymembers;2)theformof stor-age(roomandplace)ofcleaningproducts;3)riskpractices, definedasmakingsoapathome,mixingcleaningproducts, disposalofpackaging,reuseoftheoriginalpackaging,and havinglyeand/orillicitproductsathome;4)knowledgeof the interviewee about the health risksof sanitizing prod-ucts,andthehabitofreadingandfollowingthedirections printedonthelabels.
For theassessment of householdincome, theBrazilian criterion of economic classification(2008) was used.This criteriondivides thepopulation intotheeconomic classes A1,A2,B1,B2,C1,C2,D,andE.Inthisstudy,theclasses A1andA2weregroupedasA,B1andB2classesasB,C1and C2classesasC,andclassesDandEasD/E.
Thesanitizingproductswereclassifiedaccordingtothe risk, usingthecriteria establishedby ANVISA, which clas-sifies products as risk 1 and risk 2. Risk 1 products are those that offer less risk, have a 2 < pH < 11.5 and no corrosivecharacteristics,antimicrobialactivity,insecticide action,arenotbasedonviablemicroorganisms,anddonot containintheirformulationinorganicacidssuchas hydroflu-oric(HF),nitric(HNO3),sulfuricacid(H2SO4),ortheirsalts. Allotherproductsareclassifiedasrisk2.
Forthisstudy,theproductsconsideredtobehealthrisk weremanufacturedproductsclassifiedasrisk2byANVISA, includingacid and alkali-based decrustingand degreasing agents, disinfectants, and bleach, as well as homemade orillicitproducts,forcontainingvariousconcentrationsof lye in their formulas. The storage of these products was considered tobe safewhen theywere stored ina locked cupboardand/or in high place, abovetheeye level ofan adult.
ThisstudywasapprovedbytheResearchEthics Commit-tee(REC)oftheUniversityofBrasília.Datawereanalyzed usingtheStatisticalPackageforSocialSciences(SPSS), ver-sion15.Thelevelofsignificancewassetwithaconfidence intervalof95%.
Results
Thestudyincluded419households,from27ARsofthe Fed-eralDistrict,ofwhich80(19.1%)werelocatedinRegionI, 113(27%)inRegionII,and226(53.9%)inRegionIII.
The number of household members ranged from one to 11, with a mean of 3.8 people per household. There werechildrenin239(57%)households.Oftherespondents, 374 (89%) were females and 45 (11%) were males. There wasafemalehomeownerin 410(97.8%)householdsanda malehomeownerin308(73.5%).Themeanageof respon-dents was 37.3±12.5 years, with a median of 36 years. Among them, 21 (5%) were illiterate, 52 (12.4%) had not finishedelementaryschool,80(19.1%)hadfinished elemen-taryschool,151(36.0%) hadfinishedhigh school,and115 (27.4%),hadacollege/universitydegree.Regardingincome, 61 (14.6%) households belonged to class A, 141 (33.6%) belongedtoclassB,182(43.4%) belongedtoclassC,and 35(8.4%)belongedtoclassD/E.
Of the 419 households assessed, 40% stored sanitizing products in the laundry room,and 38% used the kitchen, and in 228 households (54.4%) the products were stored ineasily accessible places. Astatistically significant asso-ciationwasobservedbetweenthishealth-riskpracticeand thelevelofeducationofthefemalehomeowners, socioeco-nomicclass,andregion;itwasmorecommoninhouseholds wherethehighestlevelofeducationwashighschool,class C (low-income), and in regions II and III (lower income), respectively. Table1 presentsthe data relatedto sanitiz-ingproducts found in the households and how theywere used,andTable2correlatestheriskproductsstoredineasily accessibleplaceswiththepopulation’scharacteristics.
Itwasobserved thatlye wasusedin 81(19.3%) ofthe 419households,anditwaspurchasedinbulkby22(27.2%) of them. Regarding storage, in 15 households (22.7%) lye wasnotstored at home, andin 26 (32.1%)households, it wasstoredineasilyaccessibleplaces.
Homemadeproducts, which mayalso have lyein their composition,werepresentinalmost40%ofthehouseholds visited.
When comparing the practices that may beassociated withahigherriskofaccidentswiththepresenceofchildren in the 239 households where therewere children, it was observedthatin117households(48.9%),sanitizingproducts werekeptin easily accessibleplaces (p=0.01);40 house-holds (16.7%) had lye (p=0.13) and 72 (30.1%) had illicit products (p=0.46); and 28 households (11.7%) produced soapathome(p=0.46).
Regardingdisposal ofcontainers,in 350(83.5%) house-holds, empty containers were thrown in the trash, in 65 (15.5%)theyweretakentoberecycled,andinfour(0.9%) theyweredisposedinadifferentway.
Through analysis of correspondence using charts (Figs. 1 and2), it is suggested thatfactors suchaslower educationallevel(uptohighschool);belongingtoclassesC andD/E,andlivinginregionsIIandIII(lowerincome),were associatedwithagreater chance of usingillicit products, makingsoapathome,andusinglyeathome.
Table1 Useandstorageofcleaningproducts.
n %
Cleaningproductsfound
Powderedsoap 409 97.6
Detergent 400 95.5
Multi-surfacecleaner 370 88.3
Industrializedsoapbar 362 86.4
Fabricsoftener 133 31.7
Aluminumcleaner 159 37.9
Stainlesssteelcleaner 39 9.3
Bleach 393 93.8
Disinfectants 386 92.1
Ovencleaner 118 28.1
Lye 81 19.3
Others 67 16
Homemadesoap 155 37
Otherillicitcleaningproducts 27 6.4
Roomswherecleaningproductsarestored
Laundryroom 170 40.6
Kitchen 161 38.4
Pantry 53 12.6
Bathroom 29 6.9
Bedroom 15 3.6
Others 22 5.2
Placeofstorageofcleaningproducts
Closedcupboard 176 42
Underthesink 92 21.9
Opencupboard 70 16.7
Lockedcupboard 46 10.9
Floor 14 3.3
Others 21 5
Riskpracticesregardingcleaningproducts
Riskproducts 413 98.6
Productsineasily-accessibleplaces 228 54.4
Illicitproducts 163 38.9
Mixingofcleaningproducts 126 30.1
Soap-making 54 12.9
Keepingproductsinnon-originalcontainers 52 12.4 Reusingcleaningproductcontainers 31 7.4
(10.7%)saidtheydidnotknow.Ofthe419respondents,231 (55%)statedthattheyreadthelabelsoftheseproductsand 209(49.9%)claimedtofollowtheinstructionswrittenonthe labels.
Discussion
Thesociodemographicdataof thestudypopulation,when analyzed,aresuggestiveofarepresentativesampleofthe differentsocialclasses,whoseschoolinglevelswerewithin theestimatedvaluesforthepopulationoftheFederal Dis-trict, according to the census performed by the IBGE in 2010.15
Inthis study,theproducts thatwere mostoften found were: powderedsoap and soap bars, detergents, bleach, anddisinfectants,presentinalmostallhouseholdsinwhich thesurveywasperformed.InthestudybyNickmilderetal, disinfectants werethemost often usedproducts.16 Inthe
studybySawalha,bleachwastheonemostfrequentlyfound (96.7%),followedbyacidproducts(86.4%).11
Itwasobservedthatthelaundryroomwasthemost com-monplacetostoretheseproducts,followedbythekitchen, different from study by Beirens et al., conducted in the Netherlands,inwhichthekitchen(90.9%)wasthemain stor-ageroom.17Inthepresentstudy,itisnoteworthythatover halfoftheproductswerestoredinloworintermediate lev-els,includingthefloorandunderthesink orlaundry tub. AccordingtoSchwartsman,oneofthemainfactorsleading topoisoning in childrenappears to bethe easy accessto toxicsubstances,18oftenstoredincupboardsorundersinks (lowareas).Therefore,itisobservedthathalfofthestudied populationisexposedtoagreaterchanceofaccidents.
Itis worthnotingthe highrate ofhomemade products presentinhouseholds,aswellaslye,oftenboughtinbulk(a practiceprohibitedbylaw19)andstoredineasilyaccessible placesinmostcases.
Commonriskpracticeswereobservedinthehouseholds of the Federal District, suchasmixing cleaning products, reuse of the original packaging, and storing products in non-original containers. In the study by Sawalha, which included735households,theseproductswerestoredin sub-optimal places and were within the reach of children. It wasmixedcleaningproducts(22%)inasmallerproportion of cases and, most frequently, reused product containers (20.5%)andstoredtheproductsoutoftheoriginal contain-ers(26.9%).11InthestudybySmolinskeandKaufman,bleach wasstoredinlowplacesin21.8%ofthe357households,and in 19% they stored sanitizing products out of the original container.20
Inapproximatelyhalfofthehouseholdswheretherewere children, therewere sanitizing products ineasily accessi-bleplaces(p=0.01).Thesedataweresimilartothosefrom a study conducted in the city of Porto Alegre, Southern Brazil,where 309parentsof childrentreatedat the pedi-atric clinic ofa universityhospitalwere interviewed,and 184(59.5%)storedtheircleaningproductsinpotentially haz-ardouslocations.21The dataobservedinthepresent study is alsosimilartothoseofthe Instituteof Medicineof the National Academies, according to which over half of the householdsthathadchildrenyoungerthan6yearshad chem-icalsstoredinunlockedcupboards,22andtothatofthestudy byBeirens,inwhichalmostallchildren(99%)were poten-tiallyexposed tocleaning products, which werestored in easilyaccessibleplacesinhalfofthehouseholds.17
Interestingly,althoughmost ofthe respondents consid-eredthatthesanitizingproductswereahealthrisk,there wasalowincidenceofreadingandfollowingthedirections onlabels.Moreover,thesenumbersmaybeevenlower,asa studyperformed inPennsylvaniademonstratedthatofthe 76% of respondents whoclaimedtohave read the labels, lessthan5%hadactuallydoneso.23
Table2 High-riskcleaningproductswithinchildren’sreachandassociationwiththecharacteristicsofthepopulation.
Withinchildren’sreachHigh-riskcleaningproducts
Yesn(%) Total p-value(test)
Femalehomeowner’slevelofschooling(n=410)
Uptohighschool 179(57.2) 313 0.0274(Fisher’sexacttest)
Finishedcollege/university 43(44.3) 97
Malehomeowner’slevelofschooling(n=308)
Uptohighschool 116(53.7) 216 0.1070(Fisher’sexacttest)
Finishedcollege/university 40(43.5) 92
Socioeconomicclass(n=419)
A 27(44.3) 61 0.0011(Chi-squared)
B 63(44.7) 141
C 118(64.8) 182
D/E 20(57.1) 35
Region(n=419)
I 35(43.7) 80 0.0347(Fisher’sexacttest)
II/III 193(56.9) 339
Dimension 1 (27.63%) Dimension 2 (24.04%) Homemade product
Graduated
Soap
Soap
High Low Risk
Did not graduate Lye
Lye
Homemade product
B A
D/EC
a
a 1.5
1.0
1.0 1.5 2.0
0.5
0.5 0.0
0.0 –0.5
–0.5
Figure1 Associationsbetweensocioeconomicclassesandeducationallevelwithriskpractices(soapmaking,useoflye,andillicit products).
Graduated
Region I
Region II e III
Did not graduate
Homemade product Soap Lye
Homemade product
Soap Lye
High Low Risk
a
a
Dimension 1 (39.36%)
Dimension 2 (30.71%)
1.5
1.0
0.5
0.0
1.0 1.5 2.0
0.5 0.0
–0.5
especiallyinlow-incomeareasandwhereeducationallevels arelower,inordertopreventaccidentsinchildhood.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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