• Clinical and Experimental Pediatrics
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• v.63 no.7
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• pp.251-258
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• 2020

Exposure to environmental factors can cause interstitial lung diseases (ILDs); however, such types of ILDs are rare. From 2007 to 2011, an ILD epidemic occurred in South Korea owing to inhalational exposure to toxic chemicals in humidifier disinfectants (HDs). HD-associated ILDs (HD-ILDs) are characterized by rapidly progressing respiratory failure with pulmonary fibrosis and a high mortality rate of 43.8%-58.0%. Although 18.1%-31.1% of the general population used HDs, only a small proportion of HD users were diagnosed with HD-ILDs. This finding suggests that investigation of the pathophysiologies underlying HD-ILDs is needed in addition to the identification of susceptibility to HD-ILDs. Further, there have been several concerns regarding the diverse health effects of exposure to toxic chemicals in HDs, including those that have not been identified, and long-term prognoses in terms of pulmonary function and residual pulmonary lesions observed on follow-up chest images. In this review, we summarize the clinical features, pathologic findings, and changes in radiologic findings over time in patients with HD-ILDs and the results of previous experimental research on the mechanisms underlying the effects of toxic chemicals in HDs. Studies are currently underway to identify the pathophysiologies of HD-ILDs and possible health effects of exposure to HDs along with the development of targeted therapeutic strategies. The experience of identification of HD-ILDs has encouraged stricter control of safe chemicals in everyday life.

• Journal of Environmental Health Sciences
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• v.45 no.4
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• pp.340-357
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• 2019

The purpose of this paper is to help develop a comprehensive understanding of the humidifier disinfectant disaster from diverse perspectives based on a critical review of the relevant academic research papers published so far in the fields of both natural and social science. The authors reviewed pertinent articles in the six academic areas of law, social science, humanities, medicine, toxicology, and environmental health. A proper understanding of the issue of humidifier disinfectant is a challenging task because diverse aspects of it have become related over the more than two decades since such products were first released to the market in 1994. Technical and esoteric issues such as the complex system for relief and compensation for health damages and the approval of chemical toxicity are known to be major impediments to viewing the bigger picture regarding this tragedy. The authors believe that experts need to consider a comprehensive perspective going beyond their individual research arena to gain a better understanding of this issue, especially since it was an alarm signal on ethics and the role of experts and scholars in Korean society. Besides the two professors arrested by the prosecutor's office, it should be remembered that medical doctors recommended patients use humidifiers and disinfectants, and the media was inactive in reporting on this issue. Furthermore, the current paucity of examination of the social and political implications of this tragedy calls for more active engagement by researchers in the humanities and social sciences. In this regard, this paper is a work of self-examination and self-criticism by the authors that could resonate with the overall academic community.

• Environmental Engineering Research
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• v.18 no.4
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• pp.253-257
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• 2013

Exposure assessment for three major active ingredients used for humidifier disinfectants, polyhexamethylene guanidine (PHMG), oligo(2-(2-ethoxy)ethoxyethyl guanidinium chloride (PGH), and 5-chloro-2-methylisothiazol-3(2H)-one/2-methylisothiazol-3(2H)-one (CMIT/MIT) mixture, was conducted in a bedroom using an air sampler for a refined risk assessment. The experimental site was selected to reflect consumer exposure conditions. Aerosols formed by a humidifier were sampled during 8 hr at 7.5 L/min. Absorbed PHMG and PGH by the sampler were quantified using a spectrophotometric method, and high performance liquid chromatography-ultraviolet detection was used for CMIT/MIT. Three exposure scenarios were assumed for adding humidifier disinfectants to the humidifier water at 1, 2, and 10 times the volume recommended by the product suppliers, and the humidifier was on at its maximum rate of producing aerosols in order to consider reasonable worst-cases. The sampled mass of PHMG and PGH ranged 200 to $2,800{\mu}g$ and 140 to $1,900{\mu}g$, respectively, under different exposure conditions, whereas the absorbed mass of CMIT/MIT was barely detected at the detection limit of 0.11/0.29 mg/L, only at 10 times the recommended level. The resulting risk quotients for PHMG and PGH ranged 1,400 to 20,000 and 1,000 to 13,000, indicating that health risks could be significant. For CMIT/MIT mixture, risk quotients were much smaller than estimated by assuming that they are conservative in the indoor environment, probably due to oxidative reactions. The refined exposure assessment presented here may provide a useful tool for assessing risks posed by active ingredients in spray-type biocidal products.

• Health Policy and Management
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• v.30 no.4
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• pp.444-450
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• 2020

Background: In this study, we compared the incidents of humidifier disinfectants and incidents of mild hepatitis in Japan to highlight the differences in government response in the health care field in terms of "chain of responsibility". Methods: We examined whether the three mechanisms of action and the chain of responsibility hypothesis were applied to compare the cases of Korea and Japan. The incident of Japan occurred in 1987 in Misawa city, Aomori prefecture. In the 1990s, the safety of blood products increased dramatically. However, relief for infected victims was neglected. Green Cross did not notify the parties. In Korea, in the spring of 2011, a number of lung disease patients were accidentally admitted to a hospital in Seoul, and a female patient with respiratory failure symptoms expired. The Korea Centers for Disease Control and Prevention conducted animal tests and the Ministry of Health and Welfare issued an order for forced collection of humidifier disinfectants. Results: In the case of Japan, the Ministry of Health and Welfare had to take responsibility for follow-up measures such as the investigation of the cause, so it was tied to a "chain of responsibility". However, in the case of Korea, the Ministry of Health and Welfare was free from the chain. Conclusion: Through the comparison between the cases of Japan and Korea, we confirmed that whether or not a government organization chooses to conceal responsibility depends on its past behavior, which is whether it is free from the chain of responsibility or not. Therefore, it was reaffirmed that an organization (ministry or department) free from the chain of responsibility must exist within the government.

• Journal of Environmental Health Sciences
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• v.48 no.3
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• pp.183-194
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• 2022

Background: No study has examined the regulatory factors associated with fatal health problems due to the use of humidified disinfectants (HD) in South Korea. Objectives: This study aimed to identify and discuss the deficiencies and limitations found in the Toxic Chemical Control Acts (TCCA) that failed to prevent the health risk of chemicals in HD products. Methods: The South Korean TCCA was reviewed focusing on acts in operation from 1994 through the end of 2011, the period when HD was allowed in manufacturing and marketing. Results: The TCCA was the act intended to regulate the toxicity of chemicals in HD products. We found the TCCA to lack three key legal clauses which would have been essential to controlling the health risk of HD. First, there was the exemption of toxic and hazard testing for existing chemicals, including chloromethylisothiazolinone (CMIT), methylisothiazolinone (MIT), and benzalkonium chloride (BKC). Secondly, there were no articles requiring industry to provide animal inhalation test result for polymers such as polyhexamethylene guanidine (PHMG) and Oligo(2-)ethoxyethoxyethyl guanidine chloride (PGH). Finally, there was a lack of articles on examining the risk of products as well as on addressing changes in the usage of products. These articles were found to be generally provided in the US Toxic Substance Chemical Act (TSCA) and the EU Registration, Evaluation and Authorization of Chemicals (REACH). Conclusions: In conclusion, the Ministry of Environment of South Korea had not updated key articles for regulating hazardous chemicals, causing large-scale health problems due to HD which had been fundamentally addressed in chemical-related acts in other countries.

• Journal of Environmental Health Sciences
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• v.45 no.5
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• pp.559-560
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• 2019

• Journal of Environmental Health Sciences
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• v.45 no.3
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• pp.273-284
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• 2019

Objective: This study was performed to estimate the number of those who used humidifier disinfectants (HDs) and experienced health effects from exposure to HDs in Korea between 1994 and 2011. Methods: A nationwide interview survey was conducted for the representative sample to identify the proportion of those who used HDs among the general population (n=3,001). Another online survey was conducted for those exposed to HDs to find the proportion of those who experienced health effects among those who were exposed to HDs (n=3,993). Statistics for population size by region and year (1994-2011) were used to estimate the cumulative number of those exposed to HDs and those who experienced health effects. In terms of the proportion of those exposed to HDs, those less than 30 years of age were excluded due to an issue related to information bias. Various approaches for estimation included the capture-recapture method for estimation of those who experienced health effects. Results: The cumulative proportion of those exposed to HDs was 6.7% among the general population, and the proportion of those who experienced health effects among those who were exposed to HDs was 13.9%. Based on these factors, it was estimated that 3.5 to 4.0 million people were exposed to HDs and 350 to 400 thousand experienced health effects at least requiring visiting a hospital. Conclusion: It is suggested that a nationwide representative sample may be essential for population size estimation of those exposed to environmental risk factors and of those who experienced health effects.

• 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.42 no.6
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• pp.365-374
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• 2016

Objectives: Studies are needed to examine the characteristics of health effects reported by people who used humidifier disinfectant (HD), including the distribution of victims. Methods: We analyzed the distribution of health effects including lung injury that were asserted by a total of 699 individuals who registered with the first through third national programs to determine health effects associated with the use of HD. Results: We found that HD-associated lung injury (HDLI) occurred every year from 2002 through 2011, and in 2011 for 37.2% (n=96) of the total of 258 clinically evaluated HDLI victims. More than half of the victims responded that they were victimized between 2010 and 2011. This was consistent among all classifications by sex, age, HD brand and HD chemical ingredient. Conclusion: This study assumed that the major reason for the outbreak of the health effect between 2010 and 2011 could be the variations in concentrations and physical properties related to polyhexamethylene guanidine (PHMG). Further studies are necessary to examine if some factors related to the chemical disinfectants contained in HD brands may have caused the massive outbreak of health effects including HDLI.

• Journal of Environmental Health Sciences
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• v.38 no.6
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• pp.503-509
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• 2012

Objectives: This study was performed in order to evaluate the generation characteristics of airborne bacteria and fungi while operating a household humidifier, in consideration of user habits. Methods: Microbial samples were collected in a closed chamber with a total volume of 2.76 $m^3$, in which a humidifier was operated according to experimental strategies. A cultivation method based on the viable counts of mesophilic heterotrophic bacteria and fungi was performed. Experimental strategies were divided into three classes: the type of water in the water reservoir (tap water, cooled boiled water); the frequency of filling the reservoir (refill every day, no refill); and the sterilization method (sterilization function mode, humidifier disinfectants). Results: Significant increases in the concentration of airborne bacteria were observed while the humidifier was in operation. The concentration had increased to 2,407 $CFU/m^3$ by 120 hours when tap water filled the reservoir without any application of sterilization, while for cooled boiled water, it was merely 393 $CFU/m^3$ at a similar time point. Usages of disinfectant in the water tank were more effective in decreasing bioaerosol generation compared to sterilization function mode operation. Generation characteristics of airborne fungi were similar to those of bacteria, but the levels were not significant in all experiments. Calculated exposure factor can be used as an indicator to compare biorisk exposure. Conclusion: This study identified the potential for bioaerosol generation in indoor environments while operating a household humidifier. User practices were critical in the generation of bioaerosol, or more specifically, airborne bacteria. Proper usage of a humidifier ensures that any biorisks resulting from generated bioaerosol can be prevented.