Tragedy in Poultry Plants

The Washington Post, Seattle Times, Daily Herald and other news papers ran a story on April 25th about the tragic story of Jose Navarro a USDA inspector at the Murray's Chicken poultry processing plant in South Fallsburg, in upstate New York who died at age 37 because of lung damage caused by exposure to antimicrobial chemicals (primarily chlorine and peracetic acid) that were used to sanitize the birds. According the Daily Herald

"Several months before he died, he coughed up blood, but it "self-resolved," according to the autopsy report. Then on Nov. 19, 2011, he began coughing up blood and went to the hospital, where his lungs continued to hemorrhage. He died a week later after his lungs and kidneys failed, the autopsy report said."

While Mr Navarro was an extreme case, chemical exposure in the poultry plant was not uncommon. The article went on to say that

"more than two dozen USDA inspectors and poultry-industry employees described a range of ailments they attributed to chemical exposure, including asthma and other severe respiratory problems, burns, rashes, irritated eyes, sinus ulcers and other sinus problems."

According to the Daily Herald, Murray's denied that chemical exposure was the cause of the death, but the OSHA report cited chemicals as the suspected cause of the workers' ailments. During the investigation at the plant, inspectors and plant workers offered a raft of complaints. They said they suffered from irritation to their respiratory system, two reported "coughing up blood," and still others had "various skin diseases."

OSHA was apparently unable to provide direct cause and effect between inhalation of the chlorine and peracetic acid vapors since the concentrations were low on the day that OSHA inspected the plant, but OSHA officials issued a hazard alert letter, showing they had concerns about the use of chemicals and made a series of recommendations to improve conditions at the plant. OSHA placed the following summary on its website:

The U.S. Department of Labor's Occupational Safety and Health Administration has cited MB Consultants Ltd., doing business as Murray's Chickens, for eight alleged violations of workplace safety and health standards at the company's South Fallsburg chicken processing facility. Proposed fines total $67,600 following a November 2011 inspection by OSHA's Albany Area Office. OSHA found ... the company failed to ... provide workers with information and training on specific hazards involving disinfectants and other chemicals used in work areas. These conditions resulted in citations for six serious violations. A serious violation occurs when there is substantial probability that death or serious physical harm could result from a hazard about which the employer knew or should have known. The citations carry $32,600 in proposed fines. ...

The chlorine and peracetic acid were used as antimicrobials and they perform an essential function. The overriding concern in the food industry is food safety from pathogens in the food that potentially can cause food poisoning, death. The statistics for food poisoning in the US are startling:

• Salmonella poisoning is the most common type of food poisoning. It causes 40 percent of food poisoning cases. There were 7,800 reported cases of Salmonella poisoning in 2012, with 33 deaths.
• Campylobacter, a type of bacteria that is spread through chicken and unpasteurized milk and cheese, is becoming more common. In 2012, 7,000 people were sickened by Campylobacter, and six died.
• Vibrio infections – caused by contaminated seafood spread via warm sea water – have increased 43 percent. In 2012, there were 193 cases of Vibrio infections and six deaths.
• Approximately one in six Americans (48 million people) is sickened by foodborne illnesses every year, and about 3,000 die.
• Roughly 128,000 people are hospitalized annually for foodborne illnesses.
• There are two major groups of foodborne illnesses — 31 known pathogens were predicted to cause 9.4 million illnesses in 2011. About 55,961 people would be hospitalized, and 1,351 would die due to one of these known pathogens.
• “Unspecified pathogens” were predicted to cause 38.4 million illnesses, hospitalize 71,878, and kill 1,686 people in 2011.

Sometimes food poisoning reaches the headlines. We remember the two children who died and over 400 people sickened from e-coli tainted hamburgers from a Jack-in the Box restaurant in Tacoma, Washington and the three people died and over 500 were sickened with hepatitis A after an outbreak at a Chi-chis's restaurant in Pennsylvania.

The healthcare industry faces many of the same issues as food. In healthcare, hospital acquired infections are major problem for the healthcare industry where every year nearly two million hospital-acquired infections claim roughly 100,000 lives and add $45 billion in costs. Unfortunately, in their efforts to make patient care paramount, employee health and safety has not always been a priority, as the NIOSH NORA Report recently stated

The HCSA sector is burdened by the historical and entrenched belief that patient care issues supersede the personal safety and health of workers and that it is acceptable for HCSA workers to have less than optimal protections against the risks of hazardous exposures or injuries.

The food processing industry, especially animal slaughter has historically been a dangerous place to work, but the industry has made great progress in recent years to reduce its accident rate. For example, the Poultry processing’s 2011 rate of 5.8 non-fatal injuries and illnesses per 100 full time workers per year represents a 74 percent decrease from 1994 (the oldest data available on the BLS website), when the recorded rate was 22.7. Though greatly improved, animal slaughter still represents a hazardous workplace, compared to 3.5 for all industry.

In both healthcare and the food industry, antimicrobial chemicals are one of the most effective means to reduce the risk of infection. These chemicals are used to destroy a broad range of pathogens and so exposure of these chemicals to workers is potentially hazardous and can lead to serious injury or as in the case of Mr. Navaro, death. The chemicals provide an essential function preventing infections in healthcare and food poisoning in the food supply, but the danger they present to workers is real and they must be used safely.

Safe use means that there must be sufficient engineering controls and PPE in place to prevent exposure, continuous gas monitoring to ensure that airborne concentrations are at safe levels and employee training to know what to do in the case of a chemical leak or other exposure. Several studies have shown that worker safety improves patient safety and that investing in workplace safety helps the bottom line several times over. Improving safety in healthcare and the food industry not only helps meet the legal duty of employers to provide a safe work environment under the 1970 Occupational Safety and Health Act (section 5), but it will also improve both food safety and patient safety.

Simple Human Error Leads to Ethylene Oxide Release from Sterilizer

We received a call this morning that there had been an ethylene oxide release from a hospital sterilizer. Sterile processing staff at a large hospital placed a load into one of their three ethylene oxide sterilizers and started the cycle. A short while later the cycle aborted and while trying to identify the problem, one of the staff members unexpectedly opened the door.

The ChemDAQ ethylene oxide monitors immediately went into alarm and the two employees rapidly left the room. They and the rest of sterile processing evacuated the department until the monitors showed it was safe for them to return. In addition to the two women in the sterilization room, the other four workers in the department were all sent to the emergency room for evaluation. Fortunately, it appears that everyone was able to get out quickly enough that no-one suffered adverse symptoms from exposure to ethylene oxide.

The cause of the problem was later found to have been due to a simple human error. The manufacturer's service technician had been on-site earlier that day to do the regular preventative maintenance and when he was finished, he forgot to switch the sterilizer back from service mode to normal mode. In service mode the cycles times are short and the door locks are apparently disabled.

This incident shows the importance of being aware that even well designed, well maintained equipment can and sometimes does fail because of a simple human error that any of us could have made.

This blog has railed against the use of badges for ethylene oxide monitoring in healthcare as being ineffective. If these two workers had not evacuated after the sterilizer door was opened, then their exposure to ethylene oxide would have been considerably higher and it would have made no difference whether they were wearing a badge or not. Fortunately for the staff at this hospital, they were protected by a ChemDAQ monitoring system.

Exposure Limits for Peracetic Acid

As a manufacturer of gas monitors, one of the questions that we face is where to set the alarm limits. The ChemDAQ Steri-Trac^® monitor has two instantaneous alarms (high and low) which respond to the current concentration of the target gas and the ChemDAQ DAQ^® computer, in addition to data collection, reports etc., calculates time weighted averages and provides alarms based on these time weighted average exposure (TWA).

For a vapor such as hydrogen peroxide, which has an OSHA permissible exposure limit (PEL) of 1 ppm (8 hr TWA), the DAQ has an 8 hour TWA of 1 ppm. There is no OSHA short term exposure limit for hydrogen peroxide and so the DAQ does not have a STEL alarm.

For vapors such as peracetic acid for which there are no OSHA PELs, alternative exposure limits must be sought. The first step is look to see if there are any ACGIH threshold limit values (TLV) or other recognized exposure standard. The ACGIH does not have a TLV for peracetic acid, but it has proposed a short term exposure limit (STEL) of 0.4 ppm. In the absence of recognized exposure limits, one looks for published studies and reviews of published studies.

Recently Pechacek, Maier and Haber reviewed a range of studies of the health effects of exposure to peracetic acid and came up with several recommendations. The authors are with Ecolab, one of the largest suppliers of peracetic acid and TERA, a non-profit organization dedicated to solving problems associated with public health.

The authors' first recommendation is that neither a ceiling limit nor a STEL on its own is appropriate since

" PAA is an irritant that can cause cytotoxicity. Insufficient dose-response information is available to ensure that the absence of a sensory response also protects from accumulating subclinical cytotoxic responses." The authors go on to comment that the combination of 8 hr TWA and STEL is valuable. This conclusion may have significance to the ACGIH proposed STEL for peracetic acid.

In addition to recommending the use of both an 8 hr TWA and STEL, Pechacek et al calculated a value for the 8 hr TWA occupational exposure limit based on published reports of 0.26 to 1.56 mg/m3, which corresponds to a concentration range of 0.08 to 0.5 ppm.

The ChemDAQ DAQ calculates both the STEL and the 8 hour TWA, and the ChemDAQ alarm limits are set at 0.4 and 0.2 ppm respectively, both within the range recommended by Pechacek, Maier and Haber.