• Journal of Environmental Health Sciences
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• v.47 no.4
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• pp.310-319
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• 2021

Background: Humidifier disinfectant exposure is an ongoing issue, and there is still considerable related controversy. Various approaches are needed to secure scientific evidence on the extent of the victims' damages and for the determination of appropriate compensation. Objectives: The purpose of this study was to assess the association between humidifier disinfectant (HD) use and academic achievement in Korean children. Methods: This study used data from the 8th Panel Study on Korean Children in 2015. For the final study, 1,598 cases were used. T-tests and multiple linear regression analyses were conducted to determine whether the use of humidifier disinfectant is a factor that affects academic ability. Results: Children in groups using humidifier disinfectant showed statistically significantly lower scores in all areas of language, including reading, speaking and writing, and statistically lower scores in all areas of mathematics, including counting, addition and subtraction. In the multiple regression analysis results, which control for the effects of various demographic/social variables, the use of humidifier disinfectants showed statistically significant beta coefficients (β: -0.357, p<0.001), negatively affecting children's language ability. As for the 'math' variable, which was created by combining counting, addition, and subtraction scores, the use of humidifier disinfectants as independent variables also showed statistically significant beta coefficients (β: -0.200, p<0.001), negatively affecting children's math ability. Conclusions: The results of the study showed that depending on whether or not humidifier disinfectants were used, there are differences in children's language abilities, such as reading, speaking, and writing, as well as in their mathematical abilities, such as counting, adding, and subtracting numbers. These findings are thought to serve as a scientific basis for extending the perspective from health effects to more diverse areas of demographic and social impact related to humidifier disinfectant damage and compensation.

• Journal of Environmental Health Sciences
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• v.46 no.4
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• pp.433-443
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• 2020

Objective: This study aimed to introduce the use of humidifier disinfectant (HD) in hospitals based on an on-site investigation. Methods: A preliminary survey and on-site investigation of HD use were conducted in 23 hospitals. Among them, one hospital without previous information on HD use was selected for a pilot investigation; 22 hospitals were selected based on previous documents and exposure statements from parliamentary investigation and exposure assessment regarding HD. Descriptive statistics were used to present distribution and characteristics of HD purchase and HD use in hospitals. Also, details on interviews from the on-site investigation were described. Results: Among the 23 hospitals, a total of ten were confirmed to have purchased and used an HD (nine hospitals) or HD-like product (one hospital). For the purchased HD products, four hospitals reported 'Aekyung Gaseupgi Mate', two hospitals reported 'Oxy Ssakssak New Gaseupgi Dangbun', and one hospital reported 'Homeplus Gaseupgi Chungjungje' (one hospital used three kinds of HD products). One hospital reported an HD-like product and four hospitals were 'Unknown'. For the number of HD products purchased, five hospitals reported '100 or less', two hospitals reported 'More than 100', and three hospitals were 'Unknown'. For each of the ten hospitals, we described detailed characteristics of HD purchase and its exposure status obtained through on-site investigation, including the purchase volume (i.e., number of products), exposure space (i.e., patient's room, staff space), and exposure period. Additionally, a comparison of on-site investigation and parliamentary investigation or exposure assessment regarding HD was reported. Conclusion: This study introduced detailed cases of HD purchase and HD use in hospitals based on an on-site investigation, and our findings revealed a possibility of a considerable volume of HD exposure in various multiuse facilities, including hospitals.

• Journal of Environmental Health Sciences
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• v.46 no.3
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• pp.335-343
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• 2020

Objectives: The Korean Ministry of Environment has identified cases of people suspected of suffering lung disease potentially caused by polyhexamethylene guanidine (PHMG) used in humidifier disinfectants (HDs). Exposure assessment for the HDs was conducted using a questionnaire during face-to-face interview. The main purposes of this study were to develop a methodology to effectively classify levels of exposure to HDs based on a questionnaire. Methods: We first identified the overall participants' exposure characteristics by HD exposure levels; Second, we selected misclassified subjects and investigated characteristics of overestimated and underestimated subjects, focusing on exposure cases to PHMG-containing HDs. An inhalation reference concentration (RfC) for PHMG was produced on the basis of inhalation toxicity values. We made a cross-tabulation of the exposure classes (Exposure classes 1-to-4) by clinical classes based on the RfC. When the value of the exposure class minus the clinical class was 0 or 1, we assumed these were true values. When the value was ≥2 and ≤ -2, we assigned these cases to the overestimation group and underestimation group, respectively. Results: The overestimated group may have already recovered and responded excessively due to psychological anxiety or in order to receive compensation. On the other hand, relatively high mortality rates and surrogate responses for those under 10 years of age may have resulted in inaccurate exposure assessment for underestimated groups. For the characteristics of exposure, it was shown that for the underestimated group, the exposure was relatively weaker than the overestimated group, even though a high overall clinical rating was determined. Conclusions: This study may suggest ways to reduce bias and overcome the limitations of current HD exposure assessment.

• Journal of Environmental Health Sciences
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• v.43 no.4
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• pp.247-256
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• 2017

Objectives: The deaths of Korean victims exposed to the disinfectant CMIT/MIT have remained unresolved. This is mainly due to a lack of concordance between the few available toxicity tests and the abundant epidemiological data, making it difficult to establish a cause-and-effect relationship. Therefore, this study was carried out to investigate any potential associations between CMIT/MIT exposure and death. Methods: Groups of experimental and control C57BL/6 mice were instilled (in the trachea) with chloromethylisothiazolinone/methylisothiazolinone (CMIT/MIT) using a visual instillobot. CMIT/MIT was instilled over a period of three days and eight weeks, respectively, to achieve acute and chronic exposures. A threshold dose-response model was applied for estimating the threshold level as one line of evidence for a causal association between CMIT/MIT and death. Results: An acute exposure of 1.2 mg ai/kg/day of CMIT/MIT was estimated to reflect the threshold for death. The dose-response curve with this threshold showed a very steep slope and a narrow range of CMIT/MIT exposures. The narrow range of CMIT/MIT exposures, in particular, indicated an evident boundary between survival and death, thus implicating a strong causal association. A similar threshold dose-response relationship observed following acute exposure was also seen following chronic exposure to CMIT/MIT. Airborne disinfectant exposure was visible as minimal or mild lung damage with no fibrosis, as shown by histopathological tests. However, many observations are considered to be functional respiratory tract or lung failure due to death, as observed in necropsies of the mice that died due to CMIT/MIT exposures. Conclusions: There are two strong lines of evidence for a causal association between death and CMIT/MIT exposure: 1) The threshold dose-response curve, with a very steep slope and a narrow range of CMIT/MIT exposures showing a visible boundary between survival and death; and 2) many cases of functional respiratory or lung failure.

• Journal of Environmental Health Sciences
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• v.46 no.5
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• pp.495-503
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• 2020

Objective: This study aimed to compare the characteristics of humidifier disinfectant-like products (HD-like products) and humidifier disinfectant products (HD products) and introduce actual cases of the usage of HD-like products in hospitals based on an on-site investigation. Methods: The characteristics, chemical components, and usage of HD-like products (Hichlor or Biospot) and HD products (N-with) containing NaDCC (sodium dichloroisocyanurate) were compared. In the process of conducting the on-site investigation, four hospitals were identified as previously using HD-like products. Each on-site investigation to identify the use of HD-like products was composed of four parts: 1) hospital infection control guidelines, 2) manual for humidifiers in patient's rooms, 3) interviews with nursing staff, infection managers, and purchase managers, 4) searching on the product purchase system. Results: Although HD-like products (Hichlor and Biospot) and HD products (N-with) were sold for different usage purposes, they were all white-colored and coin-shaped foaming tablets with the same chemical component, NaDCC. The manual for using HD-like products and HD products was similar (inserting the tablet in a humidifier container with water). Among the four hospitals, one had used Hichlor in the same manner as HD (N-with) by inserting a tablet in 1L of water in a filled humidifier container and Biospot as a kind of detergent for humidifier container cleaning. Another two hospitals had used Biospot and/or Aniosyme as a kind of detergent for humidifier container cleaning. The other hospital had used unknown product in the same manner as N-with, so we thus assumed it was either an HD products (N-with) or HD-like products (Hichlor, Biospot). Conclusion: This study raises the possibility of the development of adverse health effects similar to exposure to an HD-products when exposed to an HD-like products and the possibility of further use in other medical institutions or multi-use facilities. Therefore, an expansion of the investigation is needed in order to confirm whether there have been similar cases in the past.

• Journal of Environmental Health Sciences
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• v.44 no.4
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• pp.301-314
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• 2018

Objectives: The aim of this study was to introduce the overall progress of exposure assessment to humidifier disinfectant (HD); to present participants' demographic characteristics, exposure characteristics to humidifier disinfectant, and exposure classification; and furthermore to compare those characteristics between survivors and non-survivors. Methods: An assessment of environmental exposure to HD was conducted using modified HD-specific questionnaires that had been previously validated. We analyzed the data from 4,482 participants who had been potentially exposed to HD and had registered with the KEITI (Korea Environmental Industry & Technology Institute) from September 2016 to May 2018 (the fourth survey). Environmental exposure assessments were performed as follows: 1) contact with participants, 2) environmental exposure assessment though face-to-face interviews, 3) assessment review and coding, and 4) exposure rating. Results: Overall, survivors made up 77.1% (3,457 subjects) and non-survivors made up 22.9% (1,025 subjects). When compared with the survivors, non-survivors had a higher proportion of subjects aged >60 years and subjects who answered as suffering lung damage and having purchased HD because it is "Beneficial to health" (p<0.05). For the exposure characteristics compared to survivors, non-survivors had a higher proportion of cases of distance from humidifier to face being less that one meter and the spray direction being toward the face (p<0.05). Overall, respondents who used the "Oxy Ssak Ssak New Gaseupgi Dangbun", "Aekyung Gaseupgi Mate", "Homeplus Gaseupgi Chungjungje", and "E-Mart Gaseupgi Salgyunje" products made up 66.1, 12.3, 4.0, and 3.6%, respectively, and 72.5% of respondents used products with PHMG as the active chemical. When compared with survivors, non-survivors had a higher proportion of use of "Oxy Ssak Ssak New Gaseupgi Dangbun" but a lower proportion of use of products with CMIT/MIT, PGH, or PHMG as the active chemical. Conclusions: This study provided demographic characteristics and exposure assessment for applicants who have been injured by HD. In spite of the limitations of performing past exposure assessment through a questionnaire survey, such as recall bias, useful results may be obtained by comparing survivors with non-survivors. Further studies such as the exposure rating method and so on are necessary to assess past exposure to HD.

• Journal of Environmental Health Sciences
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• v.45 no.4
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• pp.370-380
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• 2019

Objective: This study was performed to investigate the distribution of individual exposure characteristics according to an exposure assessment classification for humidifier disinfectant and to identify the factors that influence assessment classification. Methods: We examined the exposure characteristics of 4,482 subjects who applied for the 4-1 and 4-2 assessments of environmental exposure to humidifier disinfectant conducted by the Korea Environmental Industry & Technology Institute (KEITI). Environmental exposure assessment classification was assessed using the following seven criteria: 1) Distance from humidifier to face; 2) Spray direction; 3) Time used, daytime 4) Time used, during sleep; 5) Time used, cumulative; 6) Exposure intensity; and 7) Cumulative exposure level. Each criteria was then classified as 'high' or low'. When participants answered for more than four criteria, exposure assessment was determined as 'definite,' 'probable,' or 'possible' depending on the ratio of 'high' responses. If participants' responses were inconsistent, exposure assessment was listed as 'unlikely.' If participants answered for less than four criteria, exposure assessment was considered 'indeterminate.' Results: For the exposure assessment classes, definite was assigned to 38.5% (1,725 subjects), probable assigned to 32.9% (1,474 subjects), 25.0% (1,122 subjects) were assigned to as possible, unlikely assigned to 0.1% (3 subjects), and indeterminate assigned to 3.5% (158 subjects). Overall, participants who used 'Oxy Ssakssak New Gaseupgi Dangbun,' 'Aekyung Gaseupgi Mate,' 'Homeplus Gaseupgi Chungjungje,' and 'E-Mart Gaseupgi Salgyunje' totaled 2,996, 557, 176, and 162 subjects, respectively. There was a statistical difference in the type of humidifier disinfectant products between high-exposed and low-exposed participants. Based on the assessment criteria of humidifier disinfectant exposure, subjects were likely to be in the highly exposed classes (definite and probable) when the subjects were exposed 1) for more than ten hours per day and 2) for more than four hours at night 3) when the total cumulative exposure time was higher than the average, 4) when the direction of humidifier spray was toward the face, 5) when the respiratory position was less than 1 meter of distance from the humidifier, 6) when the concentration of indoor contaminants (ug/m3) was higher than the average exposure intensity, and 7) when overall exposure level ($ug/m3^*hr$) was higher than the average exposure level. Conclusion: This study suggests that each exposure assessment criteria was able to appropriately estimate cumulative exposure levels.

• Journal of Environmental Health Sciences
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• v.45 no.1
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• pp.71-81
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• 2019

Objectives: The lung injuries by exposure to the humidifier disinfectants (HDs) were reported in 2011, Korea. For the HD victims, environmental exposure level and clinical diagnosis were conducted to determine the levels of damage by HDs. Methods: The exposure assessment to the HDs from 1st to 4th questionnaire surveys were carried out for 5,245 victims. And the affecting factors of exposure levels were analyzed by characterizing exposure and demographic information. By using of exposure concentration and cumulative time, exposure levels were classified and compared by percentage of clinical diagnosis classes. The high exposure and low clinical diagnosis rating groups, and low exposure and high clinical diagnosis rating groups were analyzed to overcome the limitation of past exposure assessment such as recall bias. Results: Among the all applicants damaged by the humidifier disinfectants, survivors were 4,028 and the dead were 1,217. And male and female were 2,675, and 2,547, respectively. In case of occurrence age of lung disease, under 10 years was majority age group (1,536) and followed by thirties (917). Pregnant women and fetuses were 339 and 439, respectively. And the damages by exposure to the HDs were concentrated on these susceptible populations in groups with low exposure and high clinical diagnosis rating. On the other hand, the groups classified by high exposure and low clinical diagnosis rating were shown different characterization. Conclusions: The questionnaire survey on past exposure may be uncertain due to recall bias. However, the relationship between classified exposure levels and clinical diagnosis ratings might be shown positive correlation if the exposure assessment errors were analyzed and controlled.

• Journal of Environmental Health Sciences
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• v.47 no.4
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• pp.303-309
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• 2021

Background: Humidifier disinfectant is a biocidal product used in the water tanks of humidifiers to prevent the growth of microorganisms. Although there are a huge number of cases of reported humidifier disinfectant-related health effects across the entire Korean population, their numbers are distributed differently depending on the region. Objectives: This study aimed to investigate the regional distribution of enrollment cases who reported humidifier disinfectant-related health effects. Methods: This study used data on 6,240 subjects who experienced humidifier disinfectant-related health effects and who enrolled their cases which is conducted by the Korea Ministry of Environment. We examined the regional distribution of the enrolled cases based on sixteen administrative divisions and assessed the: 1) crude number; 2) proportional rate; and 3) age-standardized proportional rate of enrollment by region. Results: When we examined the crude number of enrollments by region, the highest number were in Gyeonggi-do Province (n=1,896), followed in order by Seoul (n=1,405), Incheon (n=436) Busan, Daegu, Gyeongsangnam-do Province, Daejeon, Chungcheongnam-do Province, Gyeongsangbuk-do Province, Jeollabuk-do Province, Gwangju, Chungcheongbuk-do Province, Gangwon-do Province, Jeollanam-do Province, Ulsan, and Jeju-do. When we examined proportional rate of the regional enrollment (cases per 100,000 population), Daejeon (n=16.2) was the region with the highest rate, followed in order by Gyeonggi-do Province (n=16.1), Incheon-do Province (n=15.9), Seoul, Daegu, Gwangju, Jeollabuk-do Province, Chungcheongnam-do Province, Busan, Chungcheongbuk-do Province, Gangwon-do Province, Gyeongsanbuk-do Province, Gyeongsangnam-do Province, Ulsan, Jeju-do, and Jeollanam-do Province, which is inconsistent with the order in terms of crude numbers. However, when we examined the age-standardized proportional rate of regional enrollment (cases per 100,000 population), their ranked distribution is consistent with the crude rate. Conclusions: This study observed that the regional distribution of the enrolled cases who reported humidifier disinfectant-related health effects is inconsistent with the regional distribution of the proportional rate of enrollment cases, which may be caused in part by the volume of the inherent population of each region.

• Journal of Environmental Health Sciences
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• v.48 no.6
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• pp.324-330
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• 2022

Background: Lung injuries due to exposure to humidifier disinfectants (HDs) were reported in 2011 in South Korea. As a result of the government's epidemiological investigation and toxicity test study, it was found that HDs caused health damage such as lung disease. Objectives: The purpose of this study was to classify HD exposure ratings and analyze the affecting factors that could identify the relationship with lung disease. Methods: Exposure assessment for HDs was conducted using a questionnaire during face-to-face interviews with the applicants. Ratings of high exposure (Class 1) and low exposure (Class 2) were cross-tabulated with clinical ratings (acceptable and unacceptable). Logistic regression analysis was carried out by setting the clinical rating of lung disease as a dependent variable and the socio-demographic and exposure characteristics obtained through the questionnaire as independent variables. Results: The concentration in air of polyhexamethylene guanidine (PHMG) was 71.96±107.47 ㎍/m³, and the exposure concentration was 15.21±23.28 ㎍/m³ . The exposure rating was overestimated with 97.1% of affected subjects having high exposure using margin of exposure (MOE), but only 9.9% matching the clinical class. In the overestimated group, it could be explained by the fact that the exposure time was long and the subjects had already recovered from damage symptoms. As a result of logistic regression analysis, ten variables were found to be significant influencing factors. Conclusions: A new exposure rating could be calculated based on the MOE, and factors affecting lung disease could be estimated through comparative evaluation with the clinical rating.