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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 WPSR Advocacy for Health - Slide 1 Presentation Transcript

  • 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. 1
    U.S. industries manufacture and import approximately 86,000 chemicals, 3,000 of them at over a million pounds per year.
  • 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 CommunicationsOSHA 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.
  • Pharmaceuticals All Other Chemicals
    Sattler, Barbara
  • Representing over 3 million nurses
    Representing over 75,000 strong
  • 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
  • The Toxic-Free Legacy Coalition
    and more than 50 other organizations in Washington State
    working together to eliminate persistent toxic chemicals
  • 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
    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)
    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
    Environment – up to decades
    Humans – half-life 7 years
    carcinogen, reproductive toxicant, endocrine disruptor
  • Di-ethylhexyl phthalate (DEHP)
    Phthalate Plasticizer
    2 million tons/year
    Ubiquitous exposure
    General Uses
    Building materials
    Medical Devices
  • 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
    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
    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.
    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
    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, 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
    Chromosome abnormalities
    Prostate, breast cancer
    Onset of puberty
    Long-term memory formation
    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
    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