Brief Report: Respiratory Illness Associated with Boot Sealant Products --- Five States, 2005--2006

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During February 2005--February 2006, six regional poison control centers in five states were consulted regarding 172 human and 19 animal (i.e., pet cat or dog) exposures to shoe or boot leather protection or sealant products resulting in respiratory illness. One product was associated with 126 cases of human illness and another product with seven cases. An ongoing investigation, begun in December 2005, is being conducted by the poison centers. The majority of cases occurred in Michigan, where poison control centers are collaborating with the Michigan Department of Community Health to further document exposures and adverse health effects from the products. Results of the investigation of the 150 cases reported during 2005 underscore the continuing need to assess the magnitude of the problem, evaluate the toxic etiology of the products involved, and determine how to prevent further cases of illness resulting from use of the products.

A case was defined as a report to a poison control center of illness after exposure to an aerosol agent used for waterproofing boots or shoes; reports were made directly by persons exposed, by family members or friends, or by health-care facilities where persons sought treatment. Specific illness symptoms were not required to meet the case definition.

During 2005, the number of cases increased substantially with the onset of winter. One case was reported in February and one in July; five were reported in August, four in September, 11 (7%) in October, 36 (24%) in November, and 92 (61%) in December (Figure). Eighty-four (56%) cases were reported in Michigan, 25 (17%) in Indiana, 19 (13%) in western Pennsylvania, 12 (8%) in central Ohio, and 10 (7%) in Kentucky.

Ages of the 150 patients ranged from one to 70 years (median: 33 years); 33 (22%) were aged <18 years. Among the patients, 50% were the persons in their households who most used the product; however, persons who did not use the product also were affected. The product was sprayed indoors in 131 (87%) of 150 cases; 19 (13%) of the patients were exposed when the product was used outdoors. No evidence was observed that substance abuse was related to the exposures. Investigators determined that sprayed shoes and boots brought into the home from garages or outdoors continued to be a source of exposure to both humans and pets as the product evaporated. Five occupational exposures occurred, four while spraying clothing items at work and one while demonstrating a product to a customer. Preexisting respiratory risk factors were identified in 40 (27%) of the 150 patients: asthma (13 [8%]) and smoking (27 [18%]).

A total of 144 patients were symptomatic, including 137 (95%) who reported symptoms of respiratory illness; all were encouraged to seek medical care. Among those who were symptomatic, the most common symptoms were cough [(113 patients [78%])] and dyspnea [(86 [60%])]. Eighty (56%) were known to have been evaluated in hospitals or hospital emergency departments, including 15 (10%) who were admitted and had hospital stays of up to 5 days. Pulse oximetry of patients evaluated in hospitals ranged from 61% to 100% (median: 94.9%). Chest radiographs were positive for infiltrates in 13 of 47 patients for whom this finding was recorded. Eight patients met the case definition for chemical pneumonitis (i.e., bilateral infiltrates suggestive of chemical pneumonitis and pulse oximetry <95% on room air). One person lost consciousness and was in respiratory distress, but recovered; no human patient died.

Among 134 persons whose treatment was known, treatment consisted of bronchodilators alone in 28 (21%) patients, bronchodilators plus corticosteroids in 13 (10%) patients, and no intervention other than oxygen in 69 (51%) patients. The duration of illness was determined on the basis of last follow-up and ranged from 0.25--360 hours (median: 17.6 hours) in 116 patients for whom duration could be evaluated.

Among the 19 pets with illness, four were evaluated by veterinarians. Reported symptoms for the animals included dyspnea (13 [68%]), cough (three), and vomiting (three). Chest radiographs were positive for infiltrates in one animal, and one cat met the case definition for chemical pneumonitis. Treatment included bronchodilators in one animal, corticosteroids in one animal, diuretics with anti-inflammatory agent in one animal, and no treatment other than oxygen and supportive care in 12 (8%) animals. Two cats died from respiratory failure.

Two products were primarily associated with the 150 cases of human illness, both manufactured by Assured Packaging (Mississauga, Ontario, Canada) and distributed by the Manakey Group LLC (Grand Rapids, Michigan). Use of Jobsite Heavy Duty Bootmate was cited by patients in 126 (84%) cases. Rocky Boot Weather and Stain Protector was named in seven (5%) cases. The two Assured Packaging products consist of 45% heptane, 20%--30% petroleum distillates, 25%--30% isobutane propellant, 5%--10% propane propellant, 0.33% fluoropolymer, and 0.33% silicone. Neither the product labels nor the material safety data sheets for the products list fluoropolymer or silicone. Previous outbreaks of acute pulmonary illness associated with exposure to waterproofing agents have implicated fluoropolymer/hydrocarbon-based products (1--4).

The Consumer Product Safety Commission is evaluating these exposures and boot sealant products. Local health departments and emergency departments were alerted to report cases to their regional poison centers. The American Association of Poison Control Centers has instituted 13 new product codes and three new generic codes for waterproofing agents to enable all poison centers to conduct surveillance on exposures more readily.

On January 3,2006, at the request of the Michigan Department of Community Health, Manakey Group issued a recall of Jobsite Heavy Duty Bootmate and Rocky Boot Weather and Stain Protector from store shelves, but not from consumers' homes. During January--February 2006, 22 additional exposures were reported to the six regional poison centers. Among callers asked, all purchased the product before the recall date. No product defect has been identified. Consumers should be encouraged to use all products for waterproofing shoes and boots as directed, to apply them outdoors, and to leave the sprayed shoes and boots and any contaminated clothing outdoors until all fumes have dissipated.

Reported by: S Smolinske, PharmD, S White, MD, GP Daubert, MD, Children's Hospital of Michigan Regional Poison Control Center, Detroit; R Didrichsons, B Eisenga, MD, DeVos Children's Hospital Regional Poison Center, Grand Rapids, Michigan; J Mowry, PharmD, Indiana Poison Center, Indianapolis; R Mrvos, E Krenzelok, PharmD, Pittsburgh Poison Center, Pennsylvania; M Casavant, MD, D Baker, PharmD, Central Ohio Poison Center, Columbus; HA Spiller, MS, Kentucky Regional Poison Center, Louisville.

This report is based, in part, on technical assistance provided by A Bronstein, MD, Rocky Mountain Poison and Drug Center, Denver, Colorado; T Litovitz, MD, National Capital Poison Center, Washington DC; and M Lai, MD, American Association of Poison Control Centers, Washington DC. Assistance with the investigation was provided by M Stanbury, Div of Environmental and Occupational Epidemiology, Michigan Dept of Community Health, Lansing, Michigan; and G Liss, MD, Occupational Health and Safety Branch, Ontario Ministry of Labour, Toronto, Canada.

Brief Report: Respiratory Illness Associated with Boot Sealant Products --- Five States, 2005--2006

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