Health and Safety Practices Survey of Healthcare Workers

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Chemical Sterilants

Here you will learn what we found regarding chemical sterilants and relevant/related standards and guidelines to reduce exposure.


Chemical sterilants are used in healthcare to chemically treat surgical instruments and medical supplies to ensure infectious pathogens are not transmitted to patients. Common chemical sterilants used in healthcare1 include:

  • Ethylene oxide (EtO)
  • Hydrogen peroxide gas plasma (HPGP)
  • Vaporized hydrogen peroxide
  • Immersion and vapor phase peracetic acid

This study focused on sterilization systems using EtO and HPGP.

Acute exposure2 to EtO has been associated with:

  • Respiratory irritation
  • Headache
  • Nausea
  • Shortness of breath

Chronic EtO exposure2 has been linked to:

  • Cancer
  • Reproductive effects
  • Mutagenic changes
  • Neurotoxicity
  • Sensitization

Acute exposure3 to HPGP may cause:

  • Upper respiratory tract irritation
  • Skin irritation, when there is contact with liquid solutions

Chronic HPGP exposure has been associated with mutagenic changes in animals.4

This study was conducted to:

  1. Assess compliance with elements of OSHA’s EtO standard5 and EPA’s requirement6 for use of a single chamber process for EtO
  2. Assess adherence to exposure control and practice guidelines for HPGP
  3. Characterize the extent EtO and HPGP sterilization systems are used

Eligible respondents included those who reported using EtO or HPGP in the seven days prior to the survey. Most worked in the central sterile supply department of hospitals and included central supply processing technicians and sterile processing technicians. The reported findings exclude respondents who worked in non-hospital settings due to small sample size.

Best practices and study findings

Overall, findings from this survey show:

  1. Compliance with OSHA’s EtO standard relative to training and availability of standard procedures was good but not universal.
  2. Separate EtO sterilization and aeration units were still being used nearly one year after EPA prohibited their use.
  3. EtO use appears to have diminished in favor of HPGP which affords higher throughput and minimal regulatory constraints.
  4. Training and availability of standard procedures for HPGP was good but not universal. Healthcare employers and employees share responsibility for ensuring compliance with OSHA’s EtO standard, EPA’s single chamber requirement for EtO, and exposure control and precautionary guidelines for HPGP.
What we found What employers/employees should do
6% of EtO respondents and 8% of HPGP respondents said that they had not received initial training on safe handling procedures. Employees should be trained on the hazards of EtO and HPGP prior to working with these sterilants.5,7
4% of EtO respondents and 9% of HPGP respondents said that standard procedures were not available. Ensure standard operating procedures for the safe use of these sterilants are available to employees.5,7
5% of respondents using EtO operated separate sterilization and aeration units. Hospital employers need to use a single chamber sterilization process for EtO6 (i.e., sterilization and aeration takes place in one unit). EPA prohibited the use of separate units in March 2010 to eliminate EtO exposure during transfer of loads from the sterilizer to the aerator.

Comparative use of EtO vs HPGP

This survey suggests that use of EtO has diminished in favor of HPGP. 84% of survey respondents used HPGP, 38% used EtO, and 22% used both types of sterilization systems (this survey is not necessarily representative of all healthcare workers who use chemical sterilants).


1 Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

2 OSHA. Health and safety topics: Ethylene oxideexternal icon

3 Mastrangel G, Zanibellato R, Fadda E,  Lange JH, Scoizzato L, Rylander R. [2009] Exposure to hydrogen peroxide and eye and nose symptoms among workers in a beverage processing plant. external icon Ann Occup Hyg 53(2):161–165.

4 Driessens N, Versteyhe S, Ghaddhab C, Burniat A, De Deken X, Van Sande J, Dumont JE, Miot F, Corvilain B.[2009] Hydrogen peroxide induces DNA single- and double-strand breaks in thyroid cells and is therefore a potential mutagen for this organexternal icon. Endocr Relat Cancer. 16(3):845-56. doi: 10.1677/ERC-09-0020

5 OSHA Ethylene Oxide Standard 1910.1047external icon

6 U.S. Environmental Protection Agency. Ethylene oxide (EtO): hospitals and healthcare facilities must use a single chamber when sterilizing medical equipment with EtOexternal icon

7 OSHA Hazard Communication Standard 1910.1200external icon

Survey and report

To request a copy of this survey, please email

Journal articleexternal icon

Page last reviewed: October 16, 2018