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  • How and why did WSNA get involvedA few definitions so we’re all on the same pageDiscuss health effects of( 3) toxic chemicalsPhthalates and PVC Bisphenol AHealth Care Professionals and Advocacy
  • Organotins: Highly toxic chemicals comprising tin combined with organic molecules, used in antifouling paints such as tributyl tin.
  • Suggests that manufacturers consider eliminating DEHP in certain devices that can result in high aggregate exposures for sensitive patient populations such as neonates
  • The effect of priming solutions and storage time on plasticizer migration in different PVC tubing types--implications for wet storage of ECMO systems. (2009)The wet priming of extracorporeal membrane oxygenation systems and storage of these systems for rapid deployment is common practice in many clinical centers.This storage policy is, however, seen by many to be controversial due to the potential adverse effects associated with the migration of the di(2-ethylhexyl) phthalate plasticizer (DEHP) from the polyvinyl chloride (PVC) circuit tubing and issues surrounding the maintenance of sterility. This study was performed to evaluate the effects of both short and long-term storage and priming fluid type on plasticizer migration from four commonly used PVC tubes in extracorporeal membrane oxygenation therapy circuits. The four tubes incorporating three plasticizers, two DEHP, one tri(2-ethylhexyl) trimellitate (TOTM), and one dioctyl adipate (DOA) were exposed to each of the three priming fluids for a period of 28 days. Samples were taken at time intervals of 1, 4, 8, 24, and 48 hours, followed by samples at 7, 14, and 28 days. Each sample was processed using a spectrophotomer and the concentration of plasticizer leaching into each solution at each time-point determined. There was a time dependent increase in plasticizer leached from each tube. The migration was greatly affected by both the priming fluid and tubing type. The migration of DEHP was higher than that of TOTM and DOA over both the short and long-term exposure levels. Plasticizer migration occurs from all of the tubes tested over the long term. The TOTM and DOA tubes performed better than the DEHP counterparts in the short term. Selection of priming fluid has a major bearing on plasticizer migration with significant lipid and protein containing fluids promoting higher migration than simple sodium chloride .9% solution prime. The results suggest that DOA tubing and sodium chloride. 9% solution priming fluid should be selected if wet primed perfusion circuits are to be used over short terms of storage.
  • NHANES:The National Health and Nutrition Examination Survey (NHANES) is a survey research program conducted by the National Center for Health Statistics (NCHS) to asses the health and nutritional status of adults and children in the United States, and to track changes over time. ...en.wikipedia.org/wiki/NHANES“NHANES 1999-2003 Survey: The current NHANES survey began in 1999. We have obtained DNA from whole blood specimens obtained from 8,000 subjects aged 20 yrs and older. ...www.oege.org/populationstudies.shtml
  • Glue curronidation
  • Bisphenol A (BPA) is a widespread estrogenic chemical used in the production of polycarbonate, and epoxy resins lining food and beverage cans and in dental sealants. During fetal life the intrauterine environment is critical for the normal development, and even small changes in the levels of hormones, such as estradiol or estrogen-mimicking chemicals, can lead to changes in brain function and consequently in behavior. We review here a series of ethological studies on the effects of maternal oral exposure during the last part of gestation (prenatal exposure) or from gestation day 11 to postnatal day 7 (perinatal exposure) to a low, environmentally relevant dose of BPA (10 microg/kg bw/day) on behavioral responses of CD-1 mouse offspring. We examined both male and female offspring and found that maternal exposure to BPA affected: (1) behavioral responses to novelty before puberty and, as adults; (2) exploration and activity in a free-exploratory open field; (3) exploration in the elevated plus maze and (4) sensitivity to amphetamine-induced reward in the conditioned place preference test. A consistent effect of the maternal exposure to BPA is that in all these different experimental settings, while a significant sex difference was observed in the control group, exposure to BPA decreased or eliminated the sex difference in behavior. In addition, exposure of female mice to BPA in both adulthood or during fetal life altered subsequent maternal behavior. These findings, together with those from other laboratories, are evidence of long-term consequences of maternal exposure to low-dose BPA at the level of neurobehavioral development.
  • Mice—neonatal and pre-pubertal exposure to BPA via lactation resulted in increased numbers and faster development of tumors in mammary glands of female offspring after exposure to a carcinogen (DMBA) in adulthood(Jenkins, Environ Health Perspect, 2009)
  • NTP, National Toxicology Program CERHR, Center for the Evaluation of Risks to Human Reproduction
  • What is a Children’s Environmental Health Advocates? We’re everyday citizens, nurses, doctors, mothers, scientists, ministers, grandmothers telling our stories, showing support and being active participants in helping to change thinking about environmental exposures and the strong links to disease.We advocate for: A child’s fundamental right to be born without toxics in their bodies and to grow up in a healthy environment. Leavingour children a legacy of fresh air, clean water, thriving wildlife, and healthy bodies - a Toxic-Free Legacy.
  • Download the entire Guide to Choosing Safer Products (pdf) or download individual sections below.Table of Contents (pdf)Section A: Introductory DocumentsRationale for a Comprehensive Chemicals Policy in Health Care (pdf)Explanation of a Comprehensive Chemicals Policy in Health Care (pdf)Section B: Policies and Plans for ImplementationDeveloping a Written Institutional Chemicals Policy (pdf)Developing a Written Plan of Action to Implement an Institutional Chemicals Policy (pdf)Key Issues for Implementation of a Comprehensive Chemicals Policy Program (pdf)Section C: Implementation StrategiesSupply Chain Implementation Strategy (pdf)Advocacy Implementation Strategy (pdf)Occupational Health Implementation Strategy (pdf)Section D: AppendicesAnnotated List of Chemical Lists for Targeted Chemicals Strategy (pdf)Check-list for Chemicals Policy Implementation (pdf)
  • WPSR Advocacy for Health - Slide 1

    1. 1. Bridging Health Care Practice with Environmental Health Advocacy<br />Leadership in Human and Environmental Health<br />Karen Bowman, MN, RN, COHN-S<br />WSNA Environmental Health Specialist<br />
    2. 2. Pollution During Fetal Development<br />Every person born in the world today is exposed to persistent bioaccumulating toxins. 1<br />U.S. industries manufacture and import approximately 86,000 chemicals, 3,000 of them at over a million pounds per year. <br />
    3. 3. Chemical Policy Reform and the Toxic Substance Control Act (TSCA) 1976<br />Regulates the introduction of new or already existing chemicals (PBTs)<br />It grandfathered most existing chemicals<br />
    4. 4. Hazard CommunicationsOSHA 1910.1200/WAC 296-800-170<br />Right to Know<br />OSHA has estimated that more than 32 million workers are exposed to 650,000 hazardous chemical products in more than 3 million American workplaces. <br />This poses a serious problem for exposed workers and their employers. <br />http://www.lni.wa.gov/Safety/Topics/AtoZ/Hazcom/default.asp<br />
    5. 5. Pharmaceuticals All Other Chemicals<br />Sattler, Barbara<br />
    6. 6.
    7. 7. Representing over 3 million nurses<br />Representing over 75,000 strong<br />7<br />
    8. 8. WSNA Environmental Health Action Plan<br />Inform the organization/constituents and community about environmental health issues<br />Chemical Policy Reform and Persistent bioaccumulating toxins (PBT)<br />Form strategic alliance with local env. health advocacy groups<br />Develop a step-system approach for nurses to engage in env health issues at their own level <br />Model leadership in political activism; grassroots activism, lobbying etc<br />Goal: Support environmental health policy<br />8<br />
    9. 9. The Toxic-Free Legacy Coalition<br />and more than 50 other organizations in Washington State<br />working together to eliminate persistent toxic chemicals<br />9<br />
    10. 10. Human & Environmental Health<br />“Conditions that ensure that all living things have the best opportunity to reach and maintain their full genetic potential.”<br />S. Gilbert (1999)<br />
    11. 11. What are Persistent Bioaccumulating Toxins (PBT)<br />PERSISTENT- stay around in the environment, wildlife, and in people’s bodies for long periods of time<br />BIOACCUMULATIVE- build up in the food chain, increase in concentration as they move up the food chain<br />TOXIC-extremely toxic in small amounts, causing health problems such as birth defects and diseases such as cancer<br />s.diver, inharmsway 110503<br />
    12. 12. Persistent Toxic Pollution Cycle<br />s.diver, inharmsway 110503<br />
    13. 13. Contamination and Recontamination of Our Waterways<br />Duwamish River Superfund Site<br /><ul><li> Cleanup completed in 2004
    14. 14. Phthalate recontamination detected in 2005 from stormwater runoff</li></ul>Commencement Bay<br /><ul><li> $103 million Superfund Cleanup
    15. 15. Phthalate recontamination ongoing</li></li></ul><li>Water and Health<br />PCBs & PBDEs in Puget Sound Wildlife<br /><ul><li> Puget Sound Chinook - higher PCB & PBDE levels than other West Coast salmon
    16. 16. Puget Sound harbor seals -
    17. 17. higher PCB levels than Georgia Basin seals
    18. 18. levels of PBDEs doubling every 4 yrs
    19. 19. Southern resident Orcas have 3x more PCBs and 4x more PBDEs than Northern residents.</li></li></ul><li>What’s Going Wrong in Washington State?<br />Washington state - highest rates of breast cancer <br />Washington state has one of the highest rates of multiple sclerosis (MS) in the nation. (http://www.swedish.org/110345.cfm)<br />Childhood brain cancer on the rise<br />17% of school-aged children have learning disabilities<br />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/<br />
    20. 20. Costs of Environmental Diseases<br />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/<br />
    21. 21. Costs of Environmental Diseases<br />Conclusions from the WA state economic study…<br />$1.9 billion = annual cost of these 5 childhood diseases attributable to environmental contaminants<br />If adult and childhood costs are combined,total = $2.7 billion annually<br />This accounts for almost 5% of total health expenditures in Washington state<br />in 2004 dollars, see Kate Davies’ study online at http://washington.chenw.org/RIgroup/<br />
    22. 22. Cause for Concern…Is this a Sustainable Future<br />We’re exposed to many toxic chemicals every day, at or near harmful levels<br />Special concern for toxic exposures during fetal & infant development<br />Rising incidence of environmentally linked diseases<br />PBTs from consumer products and industrial processes build up in our environment and food web, exposing generations to come<br />
    23. 23. Phthalates~ the everywhere chemical<br />
    24. 24. Phthalates and PVC<br />Polyvinyl Chloride (PVC)<br />Dioxin<br />Di-ethylhexyl phthalate (DEHP) <br />
    25. 25. Polyvinylchloride (PVC)<br />Vinyl chloride polymer; VC made from chlorine and ethylene<br />Many applications (building material, furnishings, multiple products)<br />Produced with fillers, stabilizers, pigments, plasticizers, lubricants, flame retardants<br />Stabilizers – lead, cadmium, organotins<br />Plasticizers – phthalates; di-ethylhexyl phthalate (DEHP) used in medical devices<br />
    26. 26. PVC - Disadvantages<br />Cradle to Grave Problems<br />dioxin/furans during production and incineration <br />leaching of plasticizers, stabilizers (often metals) in landfills<br />difficult to recycle<br /><ul><li>Potential impacts on direct patient health and safety – leaching of DEHP</li></li></ul><li>Dioxin <br />Persistent <br />Environment – up to decades<br />Humans – half-life 7 years<br />Bioaccumulative<br />Toxic<br />carcinogen, reproductive toxicant, endocrine disruptor<br />
    27. 27. Di-ethylhexyl phthalate (DEHP) <br />Phthalate Plasticizer<br />2 million tons/year<br />Ubiquitous exposure<br />General Uses<br />Building materials<br />Clothing<br />Packaging<br />Medical Devices<br />Medications<br />
    28. 28. Di-ethylhexyl phthalate (DEHP) in Medical Devices<br />Makes PVC flexible<br />20% - 40 % by weight<br />Leaches from medical devices – not bound to the plastic <br />Leaching increased by lipid-like content of fluids, temperature, agitation, storage time<br />
    29. 29. Sources of Medical Exposure to DEHP<br /><ul><li>Intravenous fluids, medications
    30. 30. Blood transfusions
    31. 31. Extra corporeal membrane oxygenation
    32. 32. Dialysis</li></ul>Surgery, e.g. cardiopulmonary bypass<br />Hyper-alimentation<br />Gloves<br />Gastric feeding, NG tubing<br />Artificial ventilation<br />
    33. 33. Public Health Notification (2002)<br />“PVC devices that do not contain DEHP can be substituted, or devices made of other materials … can be used, if available.”<br />FDA recommends alternatives when “high-risk procedures are to be performed on male neonates, pregnant women who are carrying male fetuses, and peripubertal males.” <br />
    34. 34. National Toxicology Program of the US Department of Health 2000<br />In animal studies DEHP had various adverse effects<br />Developing male reproductive system and production of normal sperm<br />Interferes with testosterone synthesis<br />Animal studies are relevant to humans<br />
    35. 35. What are the Possible Health Effects of Phthalates?<br />Reduced testosterone production and anogenital distance <br />Hypospadias <br />Malformed or absent epididymis <br />Decreased sperm count <br />Haden, Megan(2006) Phthalates<br />
    36. 36. Highest Risk of Excessive Exposure to DEHP (may exceed the FDA’s TI)<br />Exchange transfusion in neonates<br />ECMO in neonates<br />Total parenteral nutrition (TPN) in neonates (with lipids in PVC bag)<br />Enteral nutrition in neonates and adults<br />Aggregate dose in patients receiving a heart transplant or undergoing coronary artery bypass graft surgery. <br />Massive infusion of blood into trauma patient <br />Transfusion in adults undergoing ECMO<br />Cumulative exposures from multiple procedures<br />
    37. 37. New Research on Priming Solutions, PVC and implications for ECMO (2009)<br /><ul><li>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. </li></ul>two DEHP<br />one tri(2-ethylhexyl) trimellitate (TOTM),<br />one dioctyl adipate (DOA) <br />Leaching DEHP was higher than TOTM and DOA over both the short and long-term exposure levels.<br />Conclusion: <br />Leaching was greatly affected by both the priming fluid, tubing type and time. <br />J Extra Corpor Technol. 2009 Dec;41(4):199-205.<br />
    38. 38. Phthalates - DEHP Exposure<br />Schreder, Erika (2006). Pollution in people: A study of toxic chemicals in washingtonians<br />
    39. 39. Bisphenol A: Exposures and Effects<br />
    40. 40. Bisphenol A—exposures<br />Widespread in general population<br />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<br />Levels higher in children than adults<br />Schettler, T. (2009) HB 1180_WA_BPA_Hearing_Environmental Health Committee<br />
    41. 41. BPA in blood and breast milk<br />NTP-CERHR, 2008<br />Schettler, T. (2009) HB 1180_WA_BPA_Hearing_Environmental Health Committee<br />
    42. 42. Bisphenol A metabolism<br /><ul><li>Bisphenol A absorbed from intestinal tract
    43. 43. As BPA circulates through the liver, it is ultimately rendered inactive by a process called glucuronidation, which also facilitates excretion
    44. 44. Fetus and infant have undeveloped glucuronidation capacity (months before fully developed)</li></ul>Schettler, T. (2009) HB 1180_WA_BPA_Hearing_Environmental Health Committee<br />
    45. 45. Health questions about BPA: animal and human studies<br />Impaired brain development<br />Hyperactivity<br />Chromosome abnormalities<br />Prostate, breast cancer<br />Onset of puberty<br />Long-term memory formation<br />Dementia<br />Obesity and diabetes<br />
    46. 46. Bisphenol A—toxicity<br />Estrogenic activity through classic estrogen receptor has been known for many years <br />We now know that BPA can also act through other receptors and other mechanisms<br />Therefore, beware when you hear that BPA is only a “weak” estrogenic chemical<br />Concentrate here only on low dose effects <br />Schettler, T. (2009) HB 1180_WA_BPA_Hearing_Environmental Health Committee<br />
    47. 47. Bisphenol A—brain <br />Many rodent studies show that early life exposures to BPA alter behavior<br />Decreased response to novelty<br />A significant sex difference in behavior is decreased or eliminated by BPA exposure<br />(Palanza; Environ Res, 2008)<br /><ul><li>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)</li></ul>Schettler, T. (2009) HB 1180_WA_BPA_Hearing_Environmental Health Committee<br />
    48. 48. BPA—breast cancer <br />Mice—peri-natal exposure to environmentally relevant doses of BPA permanently changes the architecture of the mammary glands<br />Female offspring have increased numbers of terminal end buds in mammary glands and intraductal hyperplasia ( a risk factor for breast cancer in humans)<br />Vandenberg et al; Repro Toxicol; 2008<br />Munoz-de-Toro; Endocrinology; 2005<br />
    49. 49. BPA—prostate cancer <br />Mice—prenatal exposure to environmentally relevant doses of BPA causes proliferation of ducts and prostatic intraepithelial neoplasia in male offspring (pre-cancerous lesion)<br />Rats—perinatal exposure to BPA increases precancerous lesions and susceptibility to hormonally related adult prostate cancer (Prins, 2008)<br />Schettler, T. (2009) HB 1180_WA_BPA_Hearing_Environmental Health Committee<br />
    50. 50. Bisphenol A—diabetes <br /><ul><li>Bisphenol A causes insulin resistance in mice </li></ul> (Alonso-Magdalena; EHP, 2006; Ropero, Intl J Androl, 2008)<br /><ul><li>Higher BPA concentrations were associated with higher likelihood of having diabetes (OR per 1-SD increase in BPA concentration, 1.39) </li></ul> NHANES ; representative population (Lang et al.; JAMA; 2008)<br />
    51. 51. Bisphenol A—heart disease, human<br />Higher urinary BPA concentrations were associated with higher likelihood of cardiovascular diagnoses <br /> NHANES; representative population<br /> (Lang, et al.; JAMA; 2008)<br />
    52. 52. CERHR—Natl Toxicology Program<br />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.<br />CERHR, Center for the Evaluation of Risks to Human Reproduction<br />NTP-CERHR, 2008<br />
    53. 53. Calling Health Care to Action: Becoming Involved in Improving the Health Care Environment<br />A Template for change<br />
    54. 54. Removing the Barriers-Identifying the Facilitators<br />It’s all about mentoring and support<br />Learning the science and key issues<br />Sharing ideas, knowledge and passions<br />Bridging health care professionals with environmental health advocacy organizations<br />Engaging in health policy<br />Informing legislator<br />Environmental Health Lobby Day<br />WSNA Lobby Day<br />Join WPSR, WSNA or other env. orgs<br />
    55. 55. Health Care Industry:Leading the Way in Chemical Reform<br />Creating a “Will for Change”<br />Leveraging out Health care industry to sway the entire chemical production market<br />Empower Downstream Users to Demand Safer Products in Health Care<br />Collaborate with local and national partners<br />Health professionals can support Chemical Policy Reform by working on an institutional level<br />Safer alternatives<br />Green purchasing<br />Transform institution’s vision, values, and organizational objectives that are consistent with a safer chemicals policy practice<br />
    56. 56.
    57. 57. Nurses and Docs Advocating for Change<br />Advocate for the profession<br />Adopt Safer Products in health care<br />Disaster preparedness and First Receiver Training<br />Increased access and training – PPE (drivers for change)<br />Support TSCA Reform<br />Advocate for change in our communities<br />Deliver the health message related to hazardous chemicals<br />Educate and ask policy makers to adopt safer chemicals legislation<br />
    58. 58. Safety & Environmental health<br />Child Safe Products Act<br />PBDE Bill<br /><ul><li>Safe Baby Bottle Act</li></li></ul><li>A Child’s Right to Reach Their Full Potential<br />
    59. 59. Networking (Resources)<br />Health Care Without Harm, www.hcwh.org<br />Practice Green Health, http://practicegreenhealth.org/<br />Wash Physicians for Social Responsibility www.wpsr.org <br />Pediatric Tool Kit: http://www.psr.org/resources/pediatric-toolkit.html<br />Going Green’s PVC audit tool, www.noharm.org/goinggreen<br />Sustainable Hospitals Project, www.sustainablehospitals.org<br />Toxic Free Legacy, www.toxicfreelegacy.org<br />Washington State Nurses Association. Wsna.org<br />Washington Toxics Coalition www.watoxics.org<br />Environmental Work Group http://www.ewg.org<br />Toxicology made simple <br />A Small Dose of… http://www.asmalldoseof.org/<br />Alliance of Nurses for Environmental Health http://e-commons.org/anhe/<br />Wash State Public Interest Research Group www.washpirg.org<br />Karen Bowman & Assoc., Inc. Karen@Karenbowman.com<br />