Bridging Health Care Practice with Environmental Health Advocacy

Leadership in Human and Environmental Health

Karen Bowman, MN, RN, COHN-SWSNA Environmental Health Specialist

Pollution During Fetal Development

• Every person born in the world today is exposed to persistent bioaccumulating toxins. 1

• U.S. industries manufacture and import approximately 86,000 chemicals, 3,000 of them at over a million pounds per year.

• Regulates the introduction of new or already existing chemicals (PBTs)

• It grandfathered most existing chemicals

Chemical Policy Reform and the Toxic Substance Control Act (TSCA) 1976

• 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.

Hazard CommunicationsOSHA 1910.1200/WAC 296-800-170

Right to Know

http://www.lni.wa.gov/Safety/Topics/AtoZ/Hazcom/default.asp

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

Pharmaceuticals All Other Chemicals

BODY BURDEN PROFILE:Pollution in NewbornsA 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

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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

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The Toxic-Free Legacy Coalition

and more than 50 other organizations in Washington State

working together to eliminate persistent toxic chemicals

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“Conditions that ensure that all living things have the best opportunity to reach and maintain their full genetic potential.”

S. Gilbert (1999)

Human & Environmental Health

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

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

Contamination and Recontamination of Our Waterways

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

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/

Childhood DiseasesBest Estimate - Proportion of

Disease Attributable to Environmental Contaminants

AsthmaCancer

Lead ExposureBirth Defects

Neurobehavioral Disorders

30%5%

100%2.5%10%

Costs of Environmental Diseases

in 2004 dollars, see Kate Davies’ study online at http://washington.chenw.org/RIgroup/

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

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; di-ethylhexyl 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

• Surgery, e.g. cardiopulmonary bypass• Hyper-alimentation• Gloves• Gastric feeding, NG tubing• Artificial ventilation

Intravenous fluids, medications Blood transfusions Extra corporeal membrane oxygenation Dialysis

Sources of Medical Exposure to DEHP

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

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Schreder, Erika (2006). Pollution in people: A study of toxic chemicals in washingtonians

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, 2008Schettler, 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

Chromosome abnormalities

Prostate, breast cancer

Impaired brain development

Long-term memory formation

Obesity and diabetes

Onset of puberty

Dementia

Hyperactivity

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; 2008Munoz-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.

NTP-CERHR, 2008

CERHR, Center for the Evaluation of Risks to Human Reproduction

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 – Pediatric Tool Kit: http://www.psr.org/resources/pediatric-toolkit.html

• 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. Karen@Karenbowman.com