Healthcare facilities have always been massive consumers of cleaning products, from endless supplies of hand sanitizer and soap for healthcare workers to products used to sanitize equipment and disinfect surfaces and patients’ rooms. But the arrival of the Covid-19 pandemic took cleaning products to new heights, both inside healthcare facilities and out in the community.

Now it’s not just patient rooms but also the waiting room that’s regularly wiped down. It’s not just the school clinic but every classroom surface in a school that’s regularly disinfected. Movie theaters, post offices, coffee shops, and just about every place you might go, signs are letting you know about the extra deep cleaning that occurs there.

It’s worth considering: what kinds of chemical fumes are we all inhaling, and what type of health risks might come with them? One of the more significant concerns is whether exposure to these cleaning products could increase the risk of asthma or chronic obstructive pulmonary disease (COPD) or worsen existing cases, either in nurses or their patients or families, because of increased cleaning in places like schools. Research to date suggests a risk exists, but it’s difficult to quantify since it’s unclear how many cleaning products are being used, which ones are being used, and what the health effects of those specific products might be.

A 2019 study involving more than 73,000 female nurses found that exposure to cleaning products and disinfectants was linked to a 25% to 38% increased risk of COPD, even after considering whether the nurses smoked or had asthma. Even more recently, a systematic review from May analyzed 14 studies that examined the risk of obstructive respiratory diseases in healthcare workers exposed to cleaning products. The study found that nurses were 1.7 times more likely in general to develop asthma compared to people in other occupations. Nurses were 1.4 times more likely to develop asthma if exposed to cleaning and disinfecting surfaces and 1.3 times more likely if exposed to disinfecting instruments. The risk more than doubled if the exposure was to bleach.

“Although the overall evidence was rated as low, the limitations found in this review hint at a potential underestimation of the real risk,” the authors wrote. “These findings highlight the need for reinforced prevention practices with regard to healthcare workers.”

But the evidence isn’t clear-cut. A separate study from January 2020 found no connections between the risk of asthma and nurses’ exposure to disinfectants. That said, the study focused on nurses in the later stages of their careers, which means it could miss problems in nurses who left their career early due to disability or to conditions like asthma or COPD that disinfectants further agitated.

The bottom line is that we still don’t have good information on how much these cleaning products — especially their increased use since the pandemic began — are affecting anyone’s risk of chronic respiratory conditions. To make matters more difficult, many people don’t even know what’s in the products they’re using.

For example, a recent study surveyed 1,555 staff members from K-12 schools in Indiana, Kentucky, and Ohio to learn about their use of disinfectants to reduce Covid-19 transmission. Nearly half of the respondents (46%) said they used cleaning products to disinfect surfaces more than four times a day, and only 11% said they did not clean and disinfect school surfaces at all. Yet 60% of the respondents said they used at least one product they could not identify. Only one in four respondents received Safety Data Sheets to guide them in safely using cleaning products, and only one in three had received training on using products safely and effectively. Most (78%) did not wear gloves when using the products.

Fortunately, most also said they did not experience any health effects after using the products, but 6% did report health effects, including burning eyes, headache, nausea, skin irritation, and respiratory or breathing issues, and 21% of respondents said they didn’t know if they experienced health effects or not. That makes sense since some health issues might only appear after months or years of exposure. “Vapors can remain in the air long after a surface is dry, and chemicals such as quats leave residue after drying that can become a long-term exposure pathway via dust,” the authors noted.

Most cleaning products do not list all their ingredients because they aren’t required to. The FDA only regulates food, drinks, and drugs meant to be ingested, so FDA requirements for listing ingredients don’t apply to cleaning products. The Environmental Protection Agency (EPA) defines cleaners, sanitizers, and disinfectants differently, and the agency does require manufacturers to list any active disinfectants or potentially harmful ingredients in a product. However, that requirement typically only applies if the ingredient is known to be hazardous. In theory, a company could add a scent to their product intended to make it smell a certain way and not be required to list what chemicals it included because it’s neither a disinfectant nor known to be harmful.

All of this leads to an obvious question: What do we do? Avoiding disinfecting surfaces is not an option, but the Occupational Safety and Health Administration (OSHA) recommends reducing workers’ exposure to potentially hazardous cleaning chemicals.

Here are some of their suggestions:

• Don’t assume a product is safer or better for the environment simply because “green” appears on the label. Instead, look for “certified green cleaners,” which must meet specific criteria by different certifying agencies. The EPA has more information on those products here.

• Review the Safety Data Sheets on each product or chemical you use or hear of patients, teachers, and other community members using. Ensure that your colleagues know the risks of certain products and how to protect themselves, and educate your patients about the same risks and precautions.

• Never mix cleaning products without checking to be sure it’s safe, and never mix products containing bleach and ammonia.

• Ensure that instructions for proper dilution of products are posted and available to everyone who uses the products.

• Ensure that personal protection equipment, such as gloves and goggles, are available close by the cleaning equipment and that signs remind workers to use the PPE.

• Ensure all cleaning products are appropriately and accurately labeled, including any risks they may pose.

• Be sure areas that require regular cleaning have adequate ventilation, or talk to your supervisor about addressing places that don’t have it.

Nurses can take many of these steps on their own at work, and they can discuss them with patients or with community members, such as school teachers and coffee shop owners. Some steps might require nurses to discuss the issue with a supervisor or management. In all cases, being aware of the potential risks and taking steps to ameliorate them can keep nurses and others in the community healthier.