Guide for Hospital Staff in Caring for Persons with Allergies/Sensitivies

[Guest guest]

Guide for Hospital Staff in Caring for Persons with Allergies/Sensitivies

Canadian Society for Environmental Medicine

Discussion Draft

September, 1997

Using this guide:

Issues pertaining to each hospital department are presented on separate

sheets which may be posted on department bulletin boards. A full copy of the

guide may be kept in each department for ready reference and/or can be

available from the Inservice Education Coordinator on request.

Introduction:

People with environmental sensitivities, including allergic (atopic)

reactions, may present at hospital not only for treatment of reactions, but

also

for injuries, acute or chronic illnesses, and surgery.

Contending with adverse reactions is time consuming and disconcerting for

caregivers. This guide is designed to assist hospital staff in each

department to meet the needs of those with allergies and other sensitivities,

to

prevent reactions, minimize discomfort, decrease cost/length of hospital

stay, and increase the likelihood of successful outcome.

Sensitivities to a wide variety of environmental exposures, singly or in

combination, at levels tolerated by the majority of the population, may

manifest as symptoms/signs with a spectrum of severity and related to any body

system. Such exposure related symptoms wane after varying lengths of time

when the exposure(s) cease(s). (1-6)

When persons with sensitivities are in hospital, it may be difficult or

impossible to determine whether onset or exacerbation of symptoms is related

to the condition precipitating the admission, illness apprehensiveness,

provocative agents in the air, food or water, one particular medication, drug

combinations, or overlap of any of these factors.

Patients' needs vary widely. Not all the following measures need to be

taken for every patient. Nevertheless, it may be advantageous to institute

as many as possible to minimize the necessity for special adjustments for

each atopic or sensitive patient. An additional benefit will be lowered

pollutant exposures and better indoor air quality for all patients and staff,

including those with unrecognized sensitivities.

Administrative Services:

Scent-free Policy

Establish and maintain a 'Scent-free environment Program' for all hospital

personnel, patients and visitors.

Designate a staff member, usually the Inservice Education Coordinator, to

be responsible for development and maintenance of the program. Development

would include reviewing references (e.g. 1 - 12), working with Public

Relations on preparation of in=house communication materials (16), and seeking

input from hospital staff on inservice education and implementation issues.

Maintenance would include educating new employees about the program,

periodically updating staff, meeting on request with inpatients with

allergies/sensitivities.

Assign day-to-day management responsibility to an employee in each of the

following departments: Administration, Public Relations, Engineering and

Maintenance, Housekeeping, Laundry, Dietary, Medical/Surgical, Emergency, and

Operating Room.

Pest Management Policy

Since pesticides and herbicides are toxic compounds, alternative pest

management strategies, which avoid the use of such agents altogether, are

preferable (12) (17). At the very least, admitting staff should notify

maintenance that no pesticide or herbicide spraying will occur indoors or

outdoors

during a sensitive patient's stay in hospital.

Clean Room

A private room is a medical necessity if it is not possible to protect the

patient's space from roommates' toiletries, visitors and flowers. Being

a medical necessity, it should not be charged to the patient.

Ideally, certain rooms, for example infection control rooms, can be

designated and maintained as 'clean rooms'. It is important to locate 'clean

rooms' away from exhaust vents, parking lots, truck delivery areas,

incinerators, laundry rooms, laboratories, and areas recently or regularly

sprayed

with pesticides.

New buildings or recently renovated rooms usually have heightened levels

of volatile organic compounds (VOCs) from offgassing building materials or

paints, and should be avoided for sensitive patients. Synthetic materials

in new furnishings also off gas VOCs whereas metal or non-preserved hardwood

does not.

Admission Planning

Designate admissions staff to be responsible for facilitating admission

arrangements for patients with sensitivities. Duties would include answering

telephone inquiries, mailing out information about hospital policies for

dealing with sensitivities, and arranging preadmission meetings when

necessary to make appropriate preparations. such meetings allow the patient ,

accompanied by a supportive relative or friend, to outline his/her special

needs to the pertinent hospital personnel who will be responsible for his/her

care (e.g. staff physicians(s), nursing supervisor(s), head housekeeper,

dietitian).

Public Relations:

Background

Over the last two decades, many countries, including Canada, Have noted an

increase in childhood asthma (24) which may be related to ground level

ozone and fine particles(25). Children are known to be more vulnerable to

environmental pollutants than adults (26). Significant associations have been

found between respiratory (27) and cardiac (28) admissions to Ontario

hospitals and ozone- sulphate air pollution levels, with even very low levels

of pollutants increasing admissions(27). Association has also been noted

between ozone levels and asthma emergency department visits in St. John, NB

(29). It is unknown what percentage of the population develops symptoms in

response to low level exposures to pesticides, herbicides, perfumes,

cleaning products, paints, etc., as prevalence studies have not been mounted.

Many communities in North America have banned the use of pesticides for

cosmetic purposes. Hospitals such as IWK Children's (Halifax) have developed

guidelines and promotional material to implement a scent free policy (16).

Popular press reports have indicated that some government departments, some

schools, some churches, and the State of California have instituted

fragrance free zones.

In House Communications

Develop employee information/reminders (fact sheet, newsletter, posters,

buttons, telephone script) regarding a scent-free environment policy.

Assist department heads to arrange program orientation sessions for all current

staff, including training staff how and when to courteously and sensitively

approach visitors whose fragrance is having a negative effect on those

around them. Arrange for information and training support for maintenance

staff regarding pest management. Facilitate orientation of all new employees

on an ongoing basis.

External Communications

Develop scent-free environment logo, brochures, posters, fact sheet,

promotional display, external advertisements, notices in hospital's external

publications (annual report and newsletters), notices in other external

newsletters and local newspapers, notice to physicians, and notice to all

patients in pre-admission packages. Facilitate training of staff to use a

prepared telephone script alerting prospective patients and visitors to the

hospital's scent-free policy.

Engineering and Maintenance

Clean Room location

Since new buildings or recently renovated rooms usually have heightened

levels of volatile organic compounds from off gassing building materials or

paints, which should be avoided for sensitive patients, it is important to

collaborate with the designated 'Scent free Environment Program' employee in

Administration when building/renovating must take place. Then, necessary

adjustments may be made to accommodate the needs of persons with

allergies/sensitivities. It is also important to ensure that 'clean rooms' are

located away from exhaust vents, parking lots, truck delivery areas,

incinerators, laundry rooms, laboratories, and areas which have recently been

sprayed

with pesticides.

Ventilation/cooling System

Ventilation ductwork should be cleaned regularly to remove dust and other

debris, and mechanical systems checked to ensure continuous delivery of an

adequate supply of fresh air (9, 10) to 'clean rooms'. Cooling systems

should be well maintained to prevent contamination and aerosolization of

organisms (11).

Windows

Given the imperfections of ventilation/cooling systems, and the

possibilities for inadvertent exposures, windows should preferably open to allow

extra intake of fresh air and escape of accumulated volatiles. If windows are

sealed, or must be kept closed because of pollens or air pollution, it is

especially important that an air purification system be available in the

room. Such a device should contain a HEPA (High Efficiency Particulate Air)

filter, and a charcoal absorbent (coconut seems to be best tolerated).

Flooring

Preferably, the floor of the sensitive patient's room should be smooth and

more than six months old. No wax should be used on it or floors in the

vicinity.

Shower

A filter should be installed on the shower head to prevent exposure to

both chemical and biological aerosols produced during showering.

Paint

When a designated 'clean room' needs painting, a nontoxic solvent free

paint should be used.

Pesticides/herbicides

If an alternative pest management strategy is not operational, admitting

should make arrangements with maintenance that no spraying will occur

indoors or outdoors during a sensitive patient's stay in hospital.

Housekeeping

No Scents Personnel Policy

Housekeeping staff should not wear any perfume, cologne, or aftershave, or

scented hairspray, deodorant, lotion or cream.

Walls, Furniture, and Floors

Use only unscented disinfectants to wash walls and furniture prior to

admission of a sensitive patient. Hydrogen peroxide (3% w/v) or benzalkonium

chloride (Zephiran Aqueous Solution 1:750) are usually well tolerated.

Clean the sensitive patient's room first each a.m.

Damp dust using a clean cloth supplied by the hospital laundry (washed

three times in plain water after regulation hospital laundering).

Damp mop using a designated m op moistened only with water.

Never apply wax to a designated 'clean room', and avoid waxing

neighbouring floors during a sensitive patient's admission.

Bathroom

Prior to a sensitive patient's admission, clean the bathroom thoroughly

with 3% boric acid (Borax) in water (to remove moulds and fungi). Detach any

bathroom deodorizer and thoroughly scrub the wall behind for removal of

all deodorant residues on the tile and in the mortar. Thereafter use only

baking soda and water or tolerated cleaning products supplied by the patient.

 

Operating Room

Use only unscented disinfectants to wash walls and floor of OR prior to

surgery for a sensitive patient. Boric acid aqueous solution, which is

nonodorous, is active against enterobacteria (18), and pseudomonas aeruginosa

(19). In combination with quaternary ammonium compounds, it is active

against fungi (20) and, with chlorine, against poliovirus (21), thus reducing

the

amount required of these volatile, and often less tolerated, substances.

Laundry

No Scents Personnel Policy

Laundry staff should not wear any perfume, cologne, or aftershave, or

scented hairspray, deodorant, lotion or cream, to avoid transfer of any of

these products to the clean linen.

Washing

Cotton bedclothes, drapes and cleaning cloths should be washed three times

in plain water after regulation hospital laundering.

Storage

A supply of appropriately washed linens should be stored in a designated

cupboard away from other linens. These linens can possibly be kept in the

designated 'clean rooms'.

Alternative Arrangements

If these measures are insufficient to meet a particular sensitive

patient's needs, or are impractical in certain circumstances, the patient may

need

to supply his/her own laundered bedding from home, using such products as

Nature Clean laundry soap or Tide Free unscented detergent.

Dietary Staff

Food:

Preadmission Planning

Persons with sensitivities may need to consult with the dietitian prior to

admission to discuss the availability and preparation of foods which are

tolerated.

Type of Food

Since allergens may lurk as hidden ingredients in mixtures (12) it is

generally desirable to use plain, tolerated foods. Persons with sensitivities

usually tolerate organically grown and additive free foods best.

Availability

The patient may be asked to provide his/her own organically grown or

difficult to procure foods, if the admission is elective, and the patient is

able to obtain these foods prior to admission. For emergency use, it is

desirable to store a small quantity of organic and unusual foods, and to learn

where fresh supplies may be obtained on fairly short notice. Arrangements

need to be made for the labeling and storage of these foods, and a separate

area designated for their preparation, to prevent mixing with other foods.

Water

A reverse osmosis water filter or distilled drinking water should be

available in the hospital. However, the patient may either supply his/her own

tolerated water in glass jugs (to be refrigerated), or bring a portable

water filter.

Medical/Surgical and Emergency Staff

Emergency Admissions

At least one room should be designated as a 'clean room' in the emergency

department, and suitably prepared (see Housekeeping guidelines).

Patient's Room

A private room is a medical necessity and should be so ordered, if it will

be impossible to protect the patient's space from roommates' toiletries,

visitors and flowers. Being a medical necessity, it should not be charged

to the patient.

A notice should be placed on the patient's closed door warning about what

exposures are to be avoided, for example, " SENSITIVITIES - no perfumes,

tobacco smoke, alcohol swabs, flowers, potted plants, or -----------

permitted in this room " .

I may be necessary to restrict visitors.

Freshly printed books/magazines/newspapers should not enter the room

unless the patient indicates the inks will not be bothersome.

Keep windows closed if the patient is allergic to a pollen which is in

season.

Permit the patient to use his/her own portable air cleaner as needed (if

hospital and CSA approved), or have one available.

Cotton mattress pad and/or double bottom sheets should serve to protect

from the plastic mattress cover for most sensitive patients, but occasionally

the patient may supply his/her own aluminum sheeting (Mylar - Canadian

Tire) to cover the mattress if plastic is intolerable.

Staff

Medical staff should not wear any scented products to work (e.g. perfume,

cologne, aftershave, or scented hairspray, deodorant, lotion or cream).

Staff should not wear freshly dry cleaned clothing, or clothes laundered

with perfumed detergent and/or fabric softener. They should also not use

perfumed soaps, or highly perfumed shampoos.

Generally, NO SCENTS MAKES GOOD SENSE.

No one who has recently smoked, or is wearing smoke laden clothing, should

come near the patient. If possible, non-smoking staff should be

designated for sensitive patients.

If the patient is allergic to animal dander(s), staff wearing clothing

which has had contact with animals should not go near the patient.

Patient Care

It is exhausting and demoralizing for the patient to have to explain

sensitivities to EVERYONE. Ensure ALL staff are informed of the patient's

needs

by posting the Medical/Surgical and emergency Staff Guidelines on the

patient's chart. If needed, the Inservice Education coordinator may be asked

to brief staff and answer their questions/concerns.

Encourage patient to shower first in the morning, if s/he must use a

common shower room.

Hydrogen peroxide (3% w/v) or benzalkonium chloride (Zephiran Aqueous

Solution 1:750) are generally tolerated disinfectant swabs whereas alcohol or

iodine preparations are often not. A 3% boric acid aqueous solution has

been reported effective and well tolerated for wound disinfection (22).

Although individual sensitivities vary, and patients may wish to supply

their own tolerated products, the following unscented grooming aids (there

may well be others) have generally been tolerated by sensitive patients.

Staff may wish to use them themselves. Brand names are registered trademarks.

 

Deodorants - Tom' Unscented, Crystal Rock, Speed Stick Unscented

Moisturizing Creams (may be used for body rubs) - Clinique, Marcelle,

Almay, Glaxol Base, Lubriderm Unscented, New Debut Moisturizing Lotion

Fragrance Free with Collagen and UV Sunscreen. Some individuals may not

tolerate

any petroleum based creams. They may tolerate olive, jojoba, or almond oil.

 

Powders - The patient may have found tapioca, arrowroot or cornstarch

tolerable. Most commercial powders contain cornstarch, which would be

unsuitable for corn sensitive patients.

Shampoos - Nature Clean, Clinique, Almay, Pure Essentials Fragrance Free

Soaps - Ivory bars or liquid, Pears unscented, Neutragena unscented, pure

glycerine or Castile from health food stores, several Soap Factory soaps,

Nature Clean All Purpose Cleaner (can be used as a liquid soap, cleaner or

shampoo as necessary), Nature Clean bar soap, Pure and Simple soap from

N.E.E.D.S.

Medications, General Principles

 

1. An Adverse Reaction History Form (Appendix a) (13) should be completed

by the patient, perhaps with the assistance of his/her physician, and

placed at the front of the patient's chart on admission.

2. Sensitive patients may require and may be able to metabolize much less

than the usual drug dosages. They also may develop new sensitivities

rapidly. Therefore, it is essential to consult with the referring physician

and the patient on which medications at which dosages were previously used

successfully. Also, sensitive patients are often reluctant to risk a new

medication exposure when they are ill, and will be much reassured if they and

their doctor are consulted first, and, if a new medication must be used,

they are told that precautions will be taken (see the following items in this

section).

3. Start with a fraction of the lowest dose recommended in the CPS (half

dose for most sensitive patients, quarter dose for the exquisitely

sensitive by history), and build the dosage as tolerated to the bare minimum

required.

4. Consult with the hospital pharmacist about the oral medications with

the least fillers and dyes. The medication in coloured capsules may be

emptied into tolerated water or served with food. Pure gelatin capsules may be

used, if tolerated. If necessary, consult with pharmacists with special

interest in the needs of the allergic/sensitive: Kent McLeod, Nutri-Chem

Pharmacy, Ottawa, (613) 820-4200, 1-800-363-6327; Greg Etu, Ottawa Chemists,

(613) 235-3993, 1-800-361-2039; Peter Smith, Smith's Pharmacy, Toronto,

(416) 488-2600, 1-800-361-6624.

5. IV, IM, or SC routes for medications may be better tolerated than PO

because oral medications generally contain more excipients (e.g. fillers,

binders, colours). Whenever available, use preservative-free preparations.

6. The contamination of IV solutions with compounds from the plastic

tubing may be reduced by running 500 ml saline through the tubing and

discarding it. IV medications are best put in glass IV bottles (available from

Abbott) rather than plastic bags.

7. Avoid Dextrose in Water if the patient is corn sensitive; use Normal

Saline or Ringer's Solution instead. Use sterile water if adding high

osmolar ingredients.

8. Avoid combination drug preparations whenever possible.

9. Continue medications only as long as absolutely needed. If patient

initially tolerates a medication well, but after a few days develops puzzling

symptoms, s/he may have lost tolerance.

10. Write orders allowing modus dictum use of medications the patient has

brought with him/her which have been specifically formulated to deal with

his/her sensitivities or to provide specific metabolic support. If there

are concerns, consult with the patient's continuing care physician.

11. Unless there are urgent clinical indications, use antibiotics only

after cultures confirm the need, and then for the shortest possible time.

Consider prophylactic oral treatment with lactobacillus acidophilus and bifidus

(non-dairy, powdered source).

12. Only tolerated water should be used for enemas. A reverse osmosis

water filtration system would be useful to prepare enemas for sensitive

patients.

13. For pain control, if previously acceptable medications are unavailable

or insufficient, and there is no history of adverse reaction, try

preparations, without preservatives, of morphine sulfate or meperidine HCl

(Demerol) IM or IV, possibly with dimenhydrinate (Gravol) IM. Remember to

start

with 1/2 or 1/4 the lowest recommended CPS dose. If not tolerable, TENS,

laser, acupuncture, biofeedback, hypnosis, or other modalities may be useful,

when available, remembering that they must be administered in the patient's

protected environment.

14. For severely ill patients who are medication-intolerant,

administration of Oxygen at 3 liters/minute overnight and/or at 5-6

liters/minute for

two hours in the morning has been observed to improve symptoms and tolerance,

possibly through aiding oxidative metabolic processes (30).

Treatment of Reactions

1. 1. Respond immediately if either patient or health care professional

suspects a reaction. Often, hypersensitive patients have hyperosmia, a

heightened sense of smell, and cacosmia, an acute sense of a sickening smell,

almost instantly upon exposure to a substance that is harmful for them

(1,6). This can serve as an early warning signal of inadvertent provocative

airborne exposures. If a patient says s/he smell something that may

exacerbate symptoms, remove it or the patient IMMEDIATELY. The nursing

supervisor

should be responsible for advising the staff to BELIEVE the patient.

2. A charcoal filled face mask may be applied immediately (patient may

provide his/her own or disposables are available from medical supply

companies - e.g. 3M 9913 Dust-Mist masks).

3. Use standard protocols to treat anaphylactic reactions (23).

For non-anaphylactic reactions, not all the following steps need to be

taken if the reaction can be lessened or stopped quickly.

4. Administer previously prescribed medications that have cleared prior

reactions.

5. Administer Oxygen at 4-6 liters per minute until provoked symptoms

clear, usually about 20 minutes. Since the usual soft plastic masks and

tubing outgas volatile organic compounds, sensitive persons may need to use a

ceramic mask or paper come (unbleached coffee filter) and thick, hard,

hypoallergenic tubing.

If a ceramic mask is used, flow rate will need to be increased to 8 litres

per minute. Patients may sometimes have their own mask and tubing, or

they may be obtained from oxygen supply firms (e.g. Burrows Medical Oxygen

Ltd., Tel. (416) 752-5075 or Medox, Tel. (613) 722-5902). They should be kept

in the patient's room.

6. To try to abort or lessen a reaction when there is no contraindication

to salt intake, administer 1/4 tsp tri-alkaline salts (2 parts sodium

bicarbonate to 1 part potassium bicarbonate to 1 part calcium bicarbonate)

sublingually, and/or 1 tsp orally in a glass of tolerated water, followed by a

glass of water. Alternatively, 1/4 tablet of Alka Seltzer Gold may be kept

sublingually until it dissolves, and/or 1 tablet taken PO dissolved in a

glass of water. If there is no effect, repeat in 20 minutes. Alkaline

salts also act as a mild purgative.

7. Administer previously tolerated antihistamine PO or IM.

8. Give Plain (unflavored) Milk of Magnesia, 30-60 ml with a glass of

tolerated water to purge the bowel of an ingested incitant (may not be

necessary if alkaline salts are given).

Operating Room Staff

1. If a blood transfusion may be necessary, sensitive patients may prefer

(and it may be wise) to collect and store their own blood three weeks

prior to surgery.

2. The surgical scrub can be applied to one area of the patient's

forearm, the tape to another area, a piece of surgical glove, and one suture.

These test areas can be left in place for 48 hours to see if there is any

adverse reaction. If any metals or acrylics are to be use4d, they should be

tested as well.

3. Aerosols should be avoided in the O.R.

4. Whenever possible, regional anesthetics are preferable. Cardiac or

single dose vials of lidocaine HCl (Xylocaine) are generally more tolerable

since they have no preservatives.

5. If general anesthetic is required, schedule the patient first in the

day , so that exposures to antiseptics and anesthetics in the operating and

recovery rooms are minimized.

6. According to Dr. Wm. Rea, Surgeon, Environmental Health Center,

Dallas, Texas, premedication with IM diphenhydramine HCl (Benadryl) and

Atropine

Sulfate Injection is usually tolerated. He has found it helpful to

administer 100% oxygen for 5 minutes prior to inducing anaesthesia with a bolus

of

thiopental sodium (Pentothal). He has found succinylcholine chloride

(Anectine) acceptable to paralyze, and fentanyl citrate (Sublimaze) generally

sufficient to obliterate memory and provide analgesia. If at all possible,

he avoids halogenated hydrocarbon gases(Fluothane, Ethrane) (14).

References:

1. Randolph TG, Human ecology and susceptibility to the chemical

environment (1962), Charles C. Thomas, Springfield, IL.

2. Thomson GM, Report of the ad hoc committee on environmental

hypersensitivity disorders, Ontario Ministry of Health (August, 1985).

3. Cullen MR, workers with multiple chemical sensitivities,

Occupational Medicine, State of the ARt Reviews (October-December 1987) Vol

2/No. 4,

Hanley and Belfus, Inc., Philadelphia.

4. Ashford, NA, Miller CS, Chemical exposures, low levels and high

stakes. (1991) Van Nostrand Reinhold, New York.

5. McLellan R. , Multiple chemical sensitivities (MCS): overview and

future directions, Chronic Diseases in Canada, Supplement, Environmental

Sensitivities Workshop, Ottawa, Ontario, May 24, 1990, 17.

6. National Research Council, Multiple chemical sensitivities,

Addendum to biologic markers in immunotoxicology (1992), National Academy

Press,

Washington, D>C>: 141.

7. Randolph TG, Ecologic orientation in medicine: Comprehensive

environmental control in diagnosis and therapy. annals of Allergy. (1965)

23:7-22.

8. National Research Council, Board of Environmental Studies and

Toxicology. Workshop on health risks from exposure to common indoor household

products in allergic or chemically diseased persons. (July 1, 1987).

9. Norback D, Michel I, widstrom J., Indoor air quality and personal

factors related to the sick building syndrome, Scand J. Work Environ Health

16:121-128 (1990).

10. Dennis PJL, Reducing the risk of legionnaire's disease, Ann Occup

Hyg 34:189-192 (1990).

11. Rubin C., How to get your lawn and garden off drugs, Friends of the

Earth, 701-251 Laurier Ave. W., Ottawa, Ont., K1P 5J6. (1989).

12. Rinkel HJ, Randolph TG, Zeller M., Food Allergy. (1951) Charles C.

thomas, Springfield, IL.

13. Koski D., Personal communication with past president of CSEM, L.M.

Marshall (August, 1993)

14. Rea WJ., Personal Communication with past president of CSEM, L.M.

Marshall (27 October 1993). Information on surgery to be published in

Chemical Sensitivity, vol. 4, cited in: Table of Contents, Vols I-IV, Chemical

Sensitivity, Vl.1 (1992), Lewis Publishers, Boca Raton, Fla.

15. Cooke M.A., Fragrance: its biology and pathology., J. of Royal

College of Physicians of London, Vol. 28, No. 2, (March/April 1994), p. 133

16. IWK Children’s' Hospital, Halifax N.S., Fragrance free ... that's

for me! Guidelines and promotional material for scent-free environment

policy, (1995).

17. Colborn T., Myers JP., et al., The Wingspread consensus statement.

Appendix, Our stolen future (March, 1996), Penguin Books Ltd.

18. Adarchenko A.A., Krasl'nikov A.P., Sobeschuk O.P. Anevaluation of

the sensitivity to antiseptic preparations of clinical strains of

microorganisms in the family Enterobacteriaceae. Zhurnal Mikrobiologii,

Epidemiologii i Immunobiologii, (1) :23-28, Jan., 1990.

19. Adarchenko A.A., Krasil'nikov A.PL, Sobeschuk O.PL, Antiseptic

sensitivity of clinical strains of Pseudomonas aeruginosa. Antibiotiki i

Khimioterapiia, 34 (12):902-907, Dec., 1989.

20. Szymanski J., Wazny J., Disinfection of wood in mushroom growing

cellars with Mycetox. Roczniki Panstwowego Zakladu Higieny. 46(2):193-197,

1995.

21. Berg G., sanjaghsaz H., wangwongwatana S., Potentiation of the

poliocidal effectiveness of free chlorine by buffer. J. of Virological Methods,

23 (2):179-186, Feb., 1989.

22. Borrelly J., Blech M.F., Grosdidier G., Martin-Thomas C.,

Hartermann P., Contribution of a 3% solution of boric acid in the treatment of

deep

wounds with loss of substance. Annales de Chirugie Plastique et

Esthetique. 36 (1): 65-69, 1991.

23. Canada Communicable Diseae Report (1995; 21:200-203) anaphylazis:

statement on initial management in nonhospital settings. CMAJ, May 15,

1996; 154 (10), 1519-1520.

24. Weiss KB, Gergen PJ, Wagener DK, Breathing better or wheezing

worse? The changing epidemiology of asthma morbidity and mortality. (Rev)

Annu

Rev Public Health 1993: 14:491-513.

25. Bates DV, Observations on asthma. (Rev) Envir Health Perspect 1995;

103 Suppl. 6:243-7.

26. Snodgrass WR, Physiological and biochemical difference between

children and adults as determinants of toxic response to environmental

pollutants, in Guzelian PS, Henry CJ, Olin SS., eds. Similarities and

differences

between children and adults: implications for risk assessment, ILSI Press,

Washington, 1992, 35-42.

27. Burnett R. et al, Effects of low ambient levels of ozone and

sulphates on the frequency of respiratory admissions to Ontario hospitals.

Environmental Research, 65:172-194, 1994.

28. Burnett R. et al, Associations between ambient particulate sulphate

and admissions to Ontario hospitals for cardiac and respiratory diseases,

Amer J Epidemiology, 142 (1): 15-22, 1995.

29. Stieb DM, Burnett RT, Beveridge RC, Brook JR, Association between

ozone and asthma emergency department visits in St. John, NB, Canada.

Environ Health Perspect; 104: 1354-1360, 1996. 30. Maclennan JG, Personal

communication with past president of CSEM, L.M.Marshall, September 16, 1997.