wpsr advocacy for health - slide 1
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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. [email protected]