1. An occupational journal critique by: Ashley L. Azor EOHS 5307 December 15,2014 SHORT-TERM RESPIRATORY EFFECTS OF CLEANING EXPOSURES IN FEMALE DOMESTIC CLEANERS MEDINA-RAMÓN ET AL. 2006 EUR RESPIR J 2006; 27:1196-1203 DOI: 10.1183/09031936.06.00085-405

2. RATIONALE Recent studies have found an increased risk of asthma & other respiratory Sx in cleaning workers especially in female domestic cleaning workers. Irritants from cleaning products associated with higher risk of asthma & chronic bronchitis Sx

3. HYPOTHESIS Exposure to irritant cleaning products may aggravate a pre-existing obstructive lung disease in female domestic cleaners.

4. STUDY DESIGN Panel study was used in the present study. Panel study is a particular design of longitudinal study( cohort) STUDY SAMPLE female domestic cleaners age 31-66 yrs. Recruited from participants of case-control study nested within large population –based cross-sectional survey in Cornella ( Spain) Selected if reported: current asthma Sx being woken by shortness of breath in last 12 months, or chronic bronchitis Sx such as cough and/or bringing up phlegm on most days at least 3 months each year during population based survey Exclusion criteria: Illiteracy or otherwise unable to complete a diary

5. DAILY DIARY RECORDS FOR 2 WEEKS ( TRAINED RESEARCH NURSE INSTRUCTED PARTICIPANTS ON DIARY COMPLETION & USING PEAK FLOW METER How were they measured? ConfoundersExposuresOutcomes Self-reportRespiratory medications, respiratory infection, & cigarettes smoked Cleaning products and tasks, number of hours worked ( in home & at work) URT Sx: blocked nose, throat irritation, watery eyes LRT Sx: chest tightness, wheezing, & S.O.B., cough Analyses: Summed up scores of mild/mod/severe sx vs. none/very mild Mini-wright peak flow meter Peak Expiratory Flow ( PEF) Recorded 3x/day: after rising, lunch, before sleep. Analyses: highest of the 3 measurement for each occasion

6. METHODS OF DATA ANALYSIS: Mixed Regression models were used to assess the daily changes in Sx and PEF associated with specific cleaning exposures. ( used to model individual change across time and repeated measures ) All models had a random intercept for each individual( differences of levels between each individual in comparison with others) Models were adjusted for the presence of cofounders ( respiratory infection, maintenance RX, smoking, and age)

7. METHOD OF DATA ANALYSIS ( CONT.) Assessment of short-term effects of cleaning exposures on URTs and LRTs were based on binary outcomes obtained by dichotomizing the respective symptom severity scores using a cut off point of two ( based off sums of multiple scores of Respiratory severity Sx) Association between each cleaning exposures and Peak Expiratory Flow were assessed using PEF at night and PEF in the morning of the following day as continuous variables ( previously stated the highest PEF at each occasion was used for analyses)

8. METHODS OF ANALYSIS ( CONT.) in the analysis of URTs and LRTs, exposure variables that showed a p-value of <0.1 in the separate models were included in the same model in order to account for the simultaneous exposure to several products.

9. RESULTS: LRT Sx were more common on working days,predominantly associated W/Ex to diluted bleach, degreasing sprays/atomisers, and air fresheners. Associations with URT Sx and PEF were less apparent. URT Sx, there was no association with working days.

10. SIGNIFICANT OR’S AND COEFFICIENTS( CLEANING EXPOSURES& TASKS, DAILY REPORTED SX, HRS. WORKED, AND PEF) URTsLRTsPEF at nightPEF following morning Daily time cleaning ( 4-8h) 1.02.0-0.91.0 Cleaning tasks( vacuuming) 2.0 -3.92.0 Cleaning products ( bleach) 1.83.5 1.7 *cleaning products ( ammonia) 1.81.6-9.4-1.2 Cleaning products( degreasing spray/atomizers 2.26.96.0-2.9 Cleaning products( air fresheners/atomi zers) 1.27.87.9-4.1

11. STRENGTHS AND LIMITATIONS: Study design and population ( inclusion and exclusion criteria) were well defined. Exposure and outcome measures were well defined. Rationale was clearly stated. Tables displayed results well and was easy to interpret.

12. STRENGTHS AND LIMITATIONS ( CONT.) : Discussion explained the results further and included the author’s thoughts on the strengths and limitations of the present study. Temporality could not be determined because of prevalent cases. Likelihood of under reporting in diary logs could have biased results, introduction information bias Results not representative of general population

13. INFORMATION BIAS? presence/absence of exposure which minimized exposure misclassification multiple exposures could lead to spurious associations, biasing away from the null.

14. SELECTION BIAS: For the sake of the research hypothesis and study design I do not think selection bias occurred, nor was it mentioned.

15. CRITERIA FOR CAUSALITY: Strength of Association TemporalityBiological Gradient Biological Plausibility Consistency Exposure( cleaning products/task ) ✔✗✔✗✔ Outcome( Respiratory Sx/ PEF) ✔✗✔✗✔

16. FURTHER RESEARCH: Further research is needed to distinguish between new onset of respiratory tract issues of the upper and lower in domestic cleaning workers and already cases. As well as investigate between short and long term effects of irritant cleaning products in other cleaning staff and the general population. Although just as expensive as a panel study, cohort study design with baseline measurements to be obtained from new hires and use of repeated measures.