Download Slide 1

Bridging Health Care Practice with
Environmental Health Advocacy
Leadership in Human and
Environmental Health
Karen Bowman, MN, RN, COHN-S
WSNA Environmental Health Specialist
Pollution During Fetal
Development
• Every person born in the
world today is exposed to
persistent bioaccumulating
toxins.
• U.S. industries
manufacture and import
approximately 86,000
chemicals, 3,000 of them
at over a million pounds
per year.
1
Chemical Policy Reform and the Toxic
Substance Control Act (TSCA) 1976
• Regulates the
introduction of new or
already existing
chemicals (PBTs)
• It grandfathered most
existing chemicals
Hazard Communications
OSHA 1910.1200/WAC 296-800-170
Right to Know
• OSHA has estimated that
more than 32 million
workers are exposed to
650,000 hazardous
chemical products in more
than 3 million American
workplaces.
• This poses a serious
problem for exposed
workers and their
employers.
http://www.lni.wa.gov/Safety/Topics/AtoZ/Hazcom/default.asp
Pharmaceuticals
All Other Chemicals
Rigorous pre-market testing with
oversight by the FDA
No requirement for original research
or any pre-market testing
Full disclosure of pre-market testing
results
No requirement of disclosure for
research and development
Disclosure of information about drug
interactions
No requirements for disclosure
regarding chemical interactions
Comprehensive drug labeling
regarding efficacy and specific side
effects
Inadequate requirement for labeling
about specific human health threats
(thwarting informed decision making)
A system for reporting unexpected
side effects
No system for reporting health effects
associated with chemicals,
household or personal care products,
pesticides, drinking water, air
pollution, or any other chemical
exposures in our homes, schools, or
communities
A mechanism for recall
No specific mechanism for recall
Sattler, Barbara
BODY BURDEN PROFILE:
Pollution in Newborns
A benchmark investigation of industrial
chemicals, pollutants, and pesticides in human
umbilical cord blood
Though scientists once thought
that the womb protected
developing babies from pollution, a
new study of umbilical cord blood
from newborns found an average
of 200 industrial chemicals,
pesticides and other pollutants in
10 newborns. Of 287 chemicals
detected, 180 have been linked to
cancer, 217 are neurotoxins and
208 are linked to birth defects.
Representing over 3
million nurses
Representing over
75,000 strong
7
WSNA Environmental Health Action Plan
• Inform the organization/constituents and community about environmental
health issues
• Chemical Policy Reform and Persistent bioaccumulating toxins (PBT)
• Form strategic alliance with local env. health advocacy groups
• Develop a step-system approach for nurses to engage in env health issues
at their own level
• Model leadership in political activism; grassroots activism, lobbying etc
• Goal: Support environmental health policy
8
The Toxic-Free Legacy Coalition
and more than 50 other organizations in Washington State
working together to eliminate persistent toxic chemicals
9
Human & Environmental Health
“Conditions that ensure that all living
things have the best opportunity to
reach and maintain their full genetic
potential.”
S. Gilbert (1999)
What are Persistent Bioaccumulating
Toxins (PBT)
• PERSISTENT- stay around in the environment,
wildlife, and in people’s bodies for long periods of
time
• BIOACCUMULATIVE- build up in the food chain,
increase in concentration as they move up the food
chain
• TOXIC- extremely toxic in small amounts, causing
health problems such as birth defects and diseases
such as cancer
s.diver, inharmsway 110503
Persistent Toxic Pollution Cycle
s.diver, inharmsway 110503
Contamination and Recontamination of Our
Waterways
Duwamish River Superfund Site
• Cleanup completed in 2004
• Phthalate recontamination detected
in 2005 from stormwater runoff
Commencement Bay
• $103 million Superfund Cleanup
• Phthalate recontamination
ongoing
Water and Health
PCBs & PBDEs in Puget Sound Wildlife
• Puget Sound Chinook - higher PCB &
PBDE levels than other West Coast
salmon
• Puget Sound harbor seals - higher PCB levels than Georgia Basin seals
- levels of PBDEs doubling every 4 yrs
• Southern resident Orcas have 3x more
PCBs and 4x more PBDEs than Northern
residents.
What’s Going Wrong in Washington
State?
• Washington state - highest
rates of breast cancer
• Washington state has one
of the highest rates of
multiple sclerosis (MS) in
the nation.
(http://www.swedish.org/110345.cfm)
• Childhood brain cancer on
the rise
• 17% of school-aged
children have learning
disabilities
from “Economic Costs of Diseases and Disabilities Attributable to Environmental Contaminants in Washington State” July 2005 by Kate
Davies, Antioch University http://washington.chenw.org/RIgroup/
Costs of Environmental Diseases
Childhood Diseases
Asthma
Cancer
Lead Exposure
Birth Defects
Neurobehavioral
Disorders
Best Estimate - Proportion of
Disease Attributable to
Environmental Contaminants
30%
5%
100%
2.5%
10%
from “Economic Costs of Diseases and Disabilities Attributable to Environmental
Contaminants in Washington State” July 2005 by Kate Davies, Antioch University
http://washington.chenw.org/RIgroup/
Costs of Environmental Diseases
Conclusions from the WA state economic study…
• $1.9 billion = annual cost of these 5 childhood
diseases attributable to environmental contaminants
• If adult and childhood costs are combined,
total = $2.7 billion annually
• This accounts for almost 5% of total health
expenditures in Washington state
in 2004 dollars, see Kate Davies’ study online at http://washington.chenw.org/RIgroup/
Cause for Concern…Is this a Sustainable
Future
•
We’re exposed to many toxic
chemicals every day,
at or near harmful levels
•
Special concern for toxic
exposures during fetal & infant
development
•
Rising incidence of
environmentally linked diseases
•
PBTs from consumer products and
industrial processes build up in
our environment and food web,
exposing generations to come
Phthalates ~ the everywhere chemical
Phthalates and PVC
• Polyvinyl Chloride (PVC)
–Dioxin
• Di-ethylhexyl phthalate (DEHP)
Polyvinylchloride (PVC)
•
•
•
•
•
Vinyl chloride polymer; VC made
from chlorine and ethylene
Many applications (building
material, furnishings, multiple
products)
Produced with fillers, stabilizers,
pigments, plasticizers, lubricants,
flame retardants
Stabilizers – lead, cadmium,
organotins
Plasticizers – phthalates; diethylhexyl phthalate (DEHP) used in
medical devices
PVC - Disadvantages
• Cradle to Grave Problems
– dioxin/furans during production and
incineration
– leaching of plasticizers, stabilizers
(often metals) in landfills
– difficult to recycle
• Potential impacts on direct patient health and
safety – leaching of DEHP
Dioxin
• Persistent
– Environment – up to decades
– Humans – half-life 7 years
• Bioaccumulative
• Toxic
– carcinogen, reproductive toxicant, endocrine disruptor
Di-ethylhexyl phthalate (DEHP)
•
•
•
•
Phthalate Plasticizer
2 million tons/year
Ubiquitous exposure
General Uses
– Building materials
– Clothing
– Packaging
– Medical Devices
– Medications
Di-ethylhexyl phthalate (DEHP) in
Medical Devices
• Makes PVC flexible
• 20% - 40 % by weight
• Leaches from medical devices – not
bound to the plastic
• Leaching increased by lipid-like
content of fluids, temperature,
agitation, storage time
Sources of Medical Exposure to DEHP




Intravenous fluids, medications
Blood transfusions
Extra corporeal membrane oxygenation
Dialysis
•
•
•
•
•
Surgery, e.g. cardiopulmonary bypass
Hyper-alimentation
Gloves
Gastric feeding, NG tubing
Artificial ventilation
Public Health Notification (2002)
• “PVC devices that do not contain
DEHP can be substituted, or devices
made of other materials … can be
used, if available.”
• FDA recommends alternatives when
“high-risk procedures are to be
performed on male neonates,
pregnant women who are carrying
male fetuses, and peripubertal
males.”
National Toxicology Program of the
US Department of Health 2000
• In animal studies DEHP had various adverse
effects
– Developing male reproductive system and
production of normal sperm
– Interferes with testosterone synthesis
• Animal studies are relevant to humans
What are the Possible Health
Effects of Phthalates?
• Reduced testosterone
production and
anogenital distance
• Hypospadias
• Malformed or absent
epididymis
• Decreased sperm count
Haden, Megan(2006) Phthalates
Highest Risk of Excessive Exposure to
DEHP (may exceed the FDA’s TI)
• Exchange transfusion in neonates
• ECMO in neonates
• Total parenteral nutrition (TPN) in neonates (with lipids in
PVC bag)
• Enteral nutrition in neonates and adults
• Aggregate dose in patients receiving a heart transplant or
undergoing coronary artery bypass graft surgery.
• Massive infusion of blood into trauma patient
• Transfusion in adults undergoing ECMO
• Cumulative exposures from multiple procedures
New Research on Priming Solutions,
PVC and implications for ECMO (2009)
• Evaluate the effects of both short and long-term
storage and priming fluid type on plasticizer
migration from 4 commonly used PVC tubes in
ECMO therapy circuits.
– two DEHP
– one tri(2-ethylhexyl) trimellitate (TOTM),
– one dioctyl adipate (DOA)
• Leaching DEHP was higher than TOTM and DOA over
both the short and long-term exposure levels.
• Conclusion:
– Leaching was greatly affected by both the
priming fluid, tubing type and time.
J Extra Corpor Technol. 2009 Dec;41(4):199-205.
Phthalates - DEHP Exposure
Figure 1: Levels of DEHP Metabolites in Ten Washingtonians
600
500
ppb
400
MEHHP
MEOHP
300
MEHP
200
100
Schreder, Erika (2006). Pollution in people: A study of toxic chemicals in washingtonians
an
w
m
Bo
re
n
Ka
Al
ly
so
n
Sc
hr
ie
r
so
n
ha
m
no
ria
Ab
ra
D
eb
La
ur
ie
Va
le
ne
r
n
Bi
ll
F
in
kb
ei
Br
ow
s
a
Li
s
H
D
en
is
Ta
m
ay
e
li
zi
o
n
so
aw
Pa
ia
tr
ic
Pa
An
n
H
ol
m
es
D
Re
dd
in
g
0
Bisphenol A: Exposures and
Effects
Bisphenol A—exposures
• Widespread in general population
– 93% of representative study population have
detectable levels of BPA in urine (NHANES,
included no children less than 6 yrs old) National
Health and Nutrition Examination Survey
– Levels higher in children than adults
Schettler, T. (2009) HB 1180_WA_BPA_Hearing_Environmental Health Committee
BPA in blood and breast milk
NTP-CERHR, 2008
Schettler, T. (2009) HB 1180_WA_BPA_Hearing_Environmental Health Committee
Bisphenol A metabolism
• Bisphenol A absorbed from intestinal tract
• As BPA circulates through the liver, it is
ultimately rendered inactive by a process
called glucuronidation, which also facilitates
excretion
• Fetus and infant have undeveloped
glucuronidation capacity (months before fully
developed)
Schettler, T. (2009) HB 1180_WA_BPA_Hearing_Environmental Health Committee
Health questions about BPA: animal
and human studies
Impaired brain development
Hyperactivity
Chromosome abnormalities
Prostate, breast cancer
Onset of puberty
Long-term memory formation
Dementia
Obesity and diabetes
Bisphenol A—toxicity
• Estrogenic activity through classic estrogen
receptor has been known for many years
• We now know that BPA can also act through
other receptors and other mechanisms
• Therefore, beware when you hear that BPA is
only a “weak” estrogenic chemical
• Concentrate here only on low dose effects
Schettler, T. (2009) HB 1180_WA_BPA_Hearing_Environmental Health Committee
Bisphenol A—brain
• Many rodent studies show that early life
exposures to BPA alter behavior
– Decreased response to novelty
– A significant sex difference in behavior is
decreased or eliminated by BPA exposure
(Palanza; Environ Res, 2008)
• New
studies in young monkeys show that BPA
exposure interferes with development of normal nerve
connections in the hippocampus, important for
learning and memory (Leranth, PNAS, 2008)
Schettler, T. (2009) HB 1180_WA_BPA_Hearing_Environmental Health Committee
BPA—breast cancer
• Mice—peri-natal exposure to environmentally
relevant doses of BPA permanently changes
the architecture of the mammary glands
• Female offspring have increased numbers of
terminal end buds in mammary glands and
intraductal hyperplasia ( a risk factor for
breast cancer in humans)
Vandenberg et al; Repro Toxicol; 2008
Munoz-de-Toro; Endocrinology; 2005
BPA—prostate cancer
• Mice—prenatal exposure to environmentally
relevant doses of BPA causes proliferation of
ducts and prostatic intraepithelial neoplasia in
male offspring (pre-cancerous lesion)
• Rats—perinatal exposure to BPA increases
precancerous lesions and susceptibility to
hormonally related adult prostate cancer
(Prins, 2008)
Schettler, T. (2009) HB 1180_WA_BPA_Hearing_Environmental Health Committee
Bisphenol A—diabetes
• Bisphenol A causes insulin resistance in mice
(Alonso-Magdalena; EHP, 2006; Ropero, Intl J
Androl, 2008)
• Higher BPA concentrations were associated with
higher likelihood of having diabetes (OR per 1-SD
increase in BPA concentration, 1.39)
NHANES ; representative population
(Lang et al.; JAMA; 2008)
Bisphenol A—heart disease, human
• Higher urinary BPA concentrations were
associated with higher likelihood of
cardiovascular diagnoses
NHANES; representative population
(Lang, et al.; JAMA; 2008)
CERHR—Natl Toxicology Program
• The NTP has some concern for effects on the
brain, behavior, and prostate gland in
fetuses, infants, and children at current
human exposures to bisphenol A.
CERHR, Center for the Evaluation of Risks to Human
Reproduction
NTP-CERHR, 2008
Calling Health Care to Action:
Becoming Involved in Improving the Health Care
Environment
A Template for change
Removing the Barriers-Identifying the
Facilitators
• It’s all about mentoring and
support
– Learning the science and key
issues
– Sharing ideas, knowledge and
passions
– Bridging health care
professionals with
environmental health advocacy
organizations
• Engaging in health policy
• Informing legislator
– Environmental Health Lobby
Day
– WSNA Lobby Day
– Join WPSR, WSNA or other env.
orgs
Health Care Industry:
Leading the Way in Chemical Reform
• Creating a “Will for Change”
– Leveraging out Health care industry to sway the entire chemical
production market
– Empower Downstream Users to Demand Safer Products in Health Care
– Collaborate with local and national partners
• Health professionals can support Chemical Policy Reform by working on
an institutional level
– Safer alternatives
– Green purchasing
– Transform institution’s vision, values, and organizational objectives that are consistent
with a safer chemicals policy practice
Nurses and Docs Advocating for
Change
• Advocate for the profession
– Adopt Safer Products in health care
– Disaster preparedness and First Receiver Training
– Increased access and training – PPE (drivers for change)
– Support TSCA Reform
• Advocate for change in our communities
– Deliver the health message related to hazardous chemicals
– Educate and ask policy makers to adopt safer chemicals
legislation
Safety & Environmental health
• Child Safe Products
Act
• PBDE Bill
• Safe Baby Bottle
Act
A Child’s Right to Reach Their Full Potential
Networking (Resources)
•
Health Care Without Harm, www.hcwh.org
•
Practice Green Health, http://practicegreenhealth.org/
•
Wash Physicians for Social Responsibility www.wpsr.org
•
Going Green’s PVC audit tool, www.noharm.org/goinggreen
•
Sustainable Hospitals Project, www.sustainablehospitals.org
•
Toxic Free Legacy, www.toxicfreelegacy.org
•
Washington State Nurses Association. Wsna.org
•
Washington Toxics Coalition www.watoxics.org
•
Environmental Work Group http://www.ewg.org
•
Toxicology made simple
– A Small Dose of… http://www.asmalldoseof.org/
•
Alliance of Nurses for Environmental Health http://e-commons.org/anhe/
•
Wash State Public Interest Research Group www.washpirg.org
•
Karen Bowman & Assoc., Inc. [email protected]
–
Pediatric Tool Kit: http://www.psr.org/resources/pediatric-toolkit.html