Chronic Disease amp Chronic Disease amp Environmental Environmental
ToxinsToxinsEmerging Links Emerging Links
Jenny E Jenny E Pompilio MDPompilio MD
wwworegonpsrorgwwworegonpsrorg
Goals TodayGoals Today
Summarize areas of concerns about Summarize areas of concerns about Environmental ToxinsEnvironmental Toxins
Healthy People 2010Healthy People 2010 CDCrsquos Natrsquol Report on Human Exposure CDCrsquos Natrsquol Report on Human Exposure Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos Women of Child-bearing Age and Women of Child-bearing Age and
MercuryMercury Oregon Climate Oregon Climate Everyday practiceEveryday practice
Chronic Disease a Chronic Disease a SnapshotSnapshot
1 overall killer in US (7 of 10 deaths 1 overall killer in US (7 of 10 deaths per year)per year)
~90-100 million Americans (13 of ~90-100 million Americans (13 of population) population)
gt75 of US $14 trillion medical care gt75 of US $14 trillion medical care costs costs
Account for 13 of the years of potential Account for 13 of the years of potential life lost before age 65 life lost before age 65
Modifiable Risk Factors amp Modifiable Risk Factors amp Death Death
United States 2000United States 2000Percentage of all deathsPercentage of all deathsTobacco use 181Tobacco use 181
Poor dietlack of exercise 166Poor dietlack of exercise 166
Alcohol use 35Alcohol use 35
Infectious agents 31Infectious agents 31
Pollutantstoxins 23Pollutantstoxins 23
Motor vehicle crashes 18Motor vehicle crashes 18
Firearms 12Firearms 12
Risky sexual behavior 08Risky sexual behavior 08
Illicit drug use 07Illicit drug use 07
JAMA 2004 291 1238-45
Poor environmental quality accounts Poor environmental quality accounts for 25 of all preventable world for 25 of all preventable world
illnessillness
WHO 1997
Environmental Illness a Environmental Illness a SnapshotSnapshot
Environmental illness Environmental illness in US childrenin US children
$55 billionyear$55 billionyear Lead poisoningLead poisoning
AsthmaAsthma
CancerCancer
Developmental DisabilitiesDevelopmental Disabilities
EHP 2002 110 (7) 721-728
Healthy People 2010Healthy People 2010
National objectivesNational objectives Most significant Most significant
preventable preventable threats to health threats to health amp goals to reduce amp goals to reduce themthem
Includes Includes environmental environmental health objectiveshealth objectives
Providers role in Providers role in preventionprevention
Healthy People 2010 Toxic Healthy People 2010 Toxic WastesWastes
Lower elevated blood lead levels to Lower elevated blood lead levels to 11
Minimize risks from hazardous sitesMinimize risks from hazardous sites Reduce pesticide exposuresReduce pesticide exposures Reduce toxic pollutants produced Reduce toxic pollutants produced
disposed of treated or used for disposed of treated or used for energy recoveryenergy recovery
Increase recycling of solid waste to Increase recycling of solid waste to 3838
State of Knowledge Our State of Knowledge Our Chemical EnvironmentChemical Environment
gt80000 chemicals in gt80000 chemicals in Federal inventoryFederal inventory
2000 to 3000 NEW 2000 to 3000 NEW chemicals per yearchemicals per year
gt4 billion lbs released gt4 billion lbs released into environment yearly into environment yearly 72 million lbs of 72 million lbs of recognized carcinogens recognized carcinogens
Basic Screening Basic Screening Information Data Set Information Data Set (SIDS) avg $205000 per (SIDS) avg $205000 per chemicalchemical
Hazard Data - Chemicals Hazard Data - Chemicals Produced Produced
gt 1 Million PoundsYear gt 1 Million PoundsYear
0 10 20 30 40 50 60 70 80 90 100
Percentage Tested
Acute Toxicity
Environmental Fate
Ecotoxicity
Mutagenicity
Chronic Toxicity
ReproductiveToxicity
Full Set of BasicToxicity Tests
Medical WasteMedical Waste
6000 US hospitals~2 million 6000 US hospitals~2 million tons waste per year tons waste per year
Clinics and doctorsrsquo offices add 700000 Clinics and doctorsrsquo offices add 700000 tonstons
EPA regulations weak-HCWHh2eEPA regulations weak-HCWHh2e 850000 tons incinerated850000 tons incinerated
Pollutants inc dioxin Hg cadmium Pollutants inc dioxin Hg cadmium and Pband Pb
Segregation amp alternatives to Segregation amp alternatives to incineration incineration would cost 93 would cost 93 centspatientdaycentspatientday
Our Chemical EnvironmentOur Chemical Environment
1305 Superfund sites1305 Superfund sites 25002500 are are eligible eligible gt80kgt80k hazardous sites hazardous sites knownknown
~11 million people live within 1 mile~11 million people live within 1 mile ~25 live within 4 miles~25 live within 4 miles OR ranks 24OR ranks 24-12 Superfund sites-12 Superfund sites 3 in PDX3 in PDX Harbor Oil Portland Harbor Oil Portland
Harbor Harbor McCormick amp Baxter McCormick amp Baxter Creosoting Co Creosoting Co
Multnomah amp Washington CoMultnomah amp Washington CoShared Pollutants 2002Shared Pollutants 2002
Links to Disease Links to Disease
Methanol (gt240k lbs)Methanol (gt240k lbs)
StrongStrong ATN amp vision problems ATN amp vision problems
GoodGood Pancreatitis amp Pancreatitis amp Parkinsonrsquosmovement disorders Parkinsonrsquosmovement disorders
Ammonia (gt100k lbs)Ammonia (gt100k lbs)
StrongStrong Asthma acutechronic bronchitis Asthma acutechronic bronchitis olfactory disorders amp rhinitis olfactory disorders amp rhinitis
GoodGood Pulmonary edema Pulmonary edema
Links to Disease contLinks to Disease cont
Xylene (gt95k lbs) amp Toluene (gt83k lbs)Xylene (gt95k lbs) amp Toluene (gt83k lbs) GoodGood Scleroderma arrhythmias menstrual Scleroderma arrhythmias menstrual
do cognitive impairment hearing loss amp do cognitive impairment hearing loss amp fetal death (miscarriagestillbirth)fetal death (miscarriagestillbirth)
Glycol Ethers (gt20k lbs)Glycol Ethers (gt20k lbs) StrongStrong Reduced male fertility abnormal Reduced male fertility abnormal
sperm (morphology motility amp count) amp fetal sperm (morphology motility amp count) amp fetal death (miscarriagestillbirth) death (miscarriagestillbirth)
GoodGood ATN reduced female fertility general ATN reduced female fertility general congenital and craniofacial malformationscongenital and craniofacial malformations
National Report on Human National Report on Human Exposure to Environmental Exposure to Environmental
Chemicals Chemicals (CDC 705)(CDC 705)
Random selection from NHANES Random selection from NHANES surveysurvey
148 chemicals from 2001-2002 inc 148 chemicals from 2001-2002 inc data on 116 chemicals from 1999-data on 116 chemicals from 1999-20002000
Criteria for chemical inclusion Criteria for chemical inclusion wide exposure wide exposure serious health effects serious health effects adequate blood amp urine samples adequate blood amp urine samples efficacy of attempts to reduce efficacy of attempts to reduce
exposure exposure availability of reliable bio-monitoring availability of reliable bio-monitoring
methodmethod
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Goals TodayGoals Today
Summarize areas of concerns about Summarize areas of concerns about Environmental ToxinsEnvironmental Toxins
Healthy People 2010Healthy People 2010 CDCrsquos Natrsquol Report on Human Exposure CDCrsquos Natrsquol Report on Human Exposure Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos Women of Child-bearing Age and Women of Child-bearing Age and
MercuryMercury Oregon Climate Oregon Climate Everyday practiceEveryday practice
Chronic Disease a Chronic Disease a SnapshotSnapshot
1 overall killer in US (7 of 10 deaths 1 overall killer in US (7 of 10 deaths per year)per year)
~90-100 million Americans (13 of ~90-100 million Americans (13 of population) population)
gt75 of US $14 trillion medical care gt75 of US $14 trillion medical care costs costs
Account for 13 of the years of potential Account for 13 of the years of potential life lost before age 65 life lost before age 65
Modifiable Risk Factors amp Modifiable Risk Factors amp Death Death
United States 2000United States 2000Percentage of all deathsPercentage of all deathsTobacco use 181Tobacco use 181
Poor dietlack of exercise 166Poor dietlack of exercise 166
Alcohol use 35Alcohol use 35
Infectious agents 31Infectious agents 31
Pollutantstoxins 23Pollutantstoxins 23
Motor vehicle crashes 18Motor vehicle crashes 18
Firearms 12Firearms 12
Risky sexual behavior 08Risky sexual behavior 08
Illicit drug use 07Illicit drug use 07
JAMA 2004 291 1238-45
Poor environmental quality accounts Poor environmental quality accounts for 25 of all preventable world for 25 of all preventable world
illnessillness
WHO 1997
Environmental Illness a Environmental Illness a SnapshotSnapshot
Environmental illness Environmental illness in US childrenin US children
$55 billionyear$55 billionyear Lead poisoningLead poisoning
AsthmaAsthma
CancerCancer
Developmental DisabilitiesDevelopmental Disabilities
EHP 2002 110 (7) 721-728
Healthy People 2010Healthy People 2010
National objectivesNational objectives Most significant Most significant
preventable preventable threats to health threats to health amp goals to reduce amp goals to reduce themthem
Includes Includes environmental environmental health objectiveshealth objectives
Providers role in Providers role in preventionprevention
Healthy People 2010 Toxic Healthy People 2010 Toxic WastesWastes
Lower elevated blood lead levels to Lower elevated blood lead levels to 11
Minimize risks from hazardous sitesMinimize risks from hazardous sites Reduce pesticide exposuresReduce pesticide exposures Reduce toxic pollutants produced Reduce toxic pollutants produced
disposed of treated or used for disposed of treated or used for energy recoveryenergy recovery
Increase recycling of solid waste to Increase recycling of solid waste to 3838
State of Knowledge Our State of Knowledge Our Chemical EnvironmentChemical Environment
gt80000 chemicals in gt80000 chemicals in Federal inventoryFederal inventory
2000 to 3000 NEW 2000 to 3000 NEW chemicals per yearchemicals per year
gt4 billion lbs released gt4 billion lbs released into environment yearly into environment yearly 72 million lbs of 72 million lbs of recognized carcinogens recognized carcinogens
Basic Screening Basic Screening Information Data Set Information Data Set (SIDS) avg $205000 per (SIDS) avg $205000 per chemicalchemical
Hazard Data - Chemicals Hazard Data - Chemicals Produced Produced
gt 1 Million PoundsYear gt 1 Million PoundsYear
0 10 20 30 40 50 60 70 80 90 100
Percentage Tested
Acute Toxicity
Environmental Fate
Ecotoxicity
Mutagenicity
Chronic Toxicity
ReproductiveToxicity
Full Set of BasicToxicity Tests
Medical WasteMedical Waste
6000 US hospitals~2 million 6000 US hospitals~2 million tons waste per year tons waste per year
Clinics and doctorsrsquo offices add 700000 Clinics and doctorsrsquo offices add 700000 tonstons
EPA regulations weak-HCWHh2eEPA regulations weak-HCWHh2e 850000 tons incinerated850000 tons incinerated
Pollutants inc dioxin Hg cadmium Pollutants inc dioxin Hg cadmium and Pband Pb
Segregation amp alternatives to Segregation amp alternatives to incineration incineration would cost 93 would cost 93 centspatientdaycentspatientday
Our Chemical EnvironmentOur Chemical Environment
1305 Superfund sites1305 Superfund sites 25002500 are are eligible eligible gt80kgt80k hazardous sites hazardous sites knownknown
~11 million people live within 1 mile~11 million people live within 1 mile ~25 live within 4 miles~25 live within 4 miles OR ranks 24OR ranks 24-12 Superfund sites-12 Superfund sites 3 in PDX3 in PDX Harbor Oil Portland Harbor Oil Portland
Harbor Harbor McCormick amp Baxter McCormick amp Baxter Creosoting Co Creosoting Co
Multnomah amp Washington CoMultnomah amp Washington CoShared Pollutants 2002Shared Pollutants 2002
Links to Disease Links to Disease
Methanol (gt240k lbs)Methanol (gt240k lbs)
StrongStrong ATN amp vision problems ATN amp vision problems
GoodGood Pancreatitis amp Pancreatitis amp Parkinsonrsquosmovement disorders Parkinsonrsquosmovement disorders
Ammonia (gt100k lbs)Ammonia (gt100k lbs)
StrongStrong Asthma acutechronic bronchitis Asthma acutechronic bronchitis olfactory disorders amp rhinitis olfactory disorders amp rhinitis
GoodGood Pulmonary edema Pulmonary edema
Links to Disease contLinks to Disease cont
Xylene (gt95k lbs) amp Toluene (gt83k lbs)Xylene (gt95k lbs) amp Toluene (gt83k lbs) GoodGood Scleroderma arrhythmias menstrual Scleroderma arrhythmias menstrual
do cognitive impairment hearing loss amp do cognitive impairment hearing loss amp fetal death (miscarriagestillbirth)fetal death (miscarriagestillbirth)
Glycol Ethers (gt20k lbs)Glycol Ethers (gt20k lbs) StrongStrong Reduced male fertility abnormal Reduced male fertility abnormal
sperm (morphology motility amp count) amp fetal sperm (morphology motility amp count) amp fetal death (miscarriagestillbirth) death (miscarriagestillbirth)
GoodGood ATN reduced female fertility general ATN reduced female fertility general congenital and craniofacial malformationscongenital and craniofacial malformations
National Report on Human National Report on Human Exposure to Environmental Exposure to Environmental
Chemicals Chemicals (CDC 705)(CDC 705)
Random selection from NHANES Random selection from NHANES surveysurvey
148 chemicals from 2001-2002 inc 148 chemicals from 2001-2002 inc data on 116 chemicals from 1999-data on 116 chemicals from 1999-20002000
Criteria for chemical inclusion Criteria for chemical inclusion wide exposure wide exposure serious health effects serious health effects adequate blood amp urine samples adequate blood amp urine samples efficacy of attempts to reduce efficacy of attempts to reduce
exposure exposure availability of reliable bio-monitoring availability of reliable bio-monitoring
methodmethod
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Chronic Disease a Chronic Disease a SnapshotSnapshot
1 overall killer in US (7 of 10 deaths 1 overall killer in US (7 of 10 deaths per year)per year)
~90-100 million Americans (13 of ~90-100 million Americans (13 of population) population)
gt75 of US $14 trillion medical care gt75 of US $14 trillion medical care costs costs
Account for 13 of the years of potential Account for 13 of the years of potential life lost before age 65 life lost before age 65
Modifiable Risk Factors amp Modifiable Risk Factors amp Death Death
United States 2000United States 2000Percentage of all deathsPercentage of all deathsTobacco use 181Tobacco use 181
Poor dietlack of exercise 166Poor dietlack of exercise 166
Alcohol use 35Alcohol use 35
Infectious agents 31Infectious agents 31
Pollutantstoxins 23Pollutantstoxins 23
Motor vehicle crashes 18Motor vehicle crashes 18
Firearms 12Firearms 12
Risky sexual behavior 08Risky sexual behavior 08
Illicit drug use 07Illicit drug use 07
JAMA 2004 291 1238-45
Poor environmental quality accounts Poor environmental quality accounts for 25 of all preventable world for 25 of all preventable world
illnessillness
WHO 1997
Environmental Illness a Environmental Illness a SnapshotSnapshot
Environmental illness Environmental illness in US childrenin US children
$55 billionyear$55 billionyear Lead poisoningLead poisoning
AsthmaAsthma
CancerCancer
Developmental DisabilitiesDevelopmental Disabilities
EHP 2002 110 (7) 721-728
Healthy People 2010Healthy People 2010
National objectivesNational objectives Most significant Most significant
preventable preventable threats to health threats to health amp goals to reduce amp goals to reduce themthem
Includes Includes environmental environmental health objectiveshealth objectives
Providers role in Providers role in preventionprevention
Healthy People 2010 Toxic Healthy People 2010 Toxic WastesWastes
Lower elevated blood lead levels to Lower elevated blood lead levels to 11
Minimize risks from hazardous sitesMinimize risks from hazardous sites Reduce pesticide exposuresReduce pesticide exposures Reduce toxic pollutants produced Reduce toxic pollutants produced
disposed of treated or used for disposed of treated or used for energy recoveryenergy recovery
Increase recycling of solid waste to Increase recycling of solid waste to 3838
State of Knowledge Our State of Knowledge Our Chemical EnvironmentChemical Environment
gt80000 chemicals in gt80000 chemicals in Federal inventoryFederal inventory
2000 to 3000 NEW 2000 to 3000 NEW chemicals per yearchemicals per year
gt4 billion lbs released gt4 billion lbs released into environment yearly into environment yearly 72 million lbs of 72 million lbs of recognized carcinogens recognized carcinogens
Basic Screening Basic Screening Information Data Set Information Data Set (SIDS) avg $205000 per (SIDS) avg $205000 per chemicalchemical
Hazard Data - Chemicals Hazard Data - Chemicals Produced Produced
gt 1 Million PoundsYear gt 1 Million PoundsYear
0 10 20 30 40 50 60 70 80 90 100
Percentage Tested
Acute Toxicity
Environmental Fate
Ecotoxicity
Mutagenicity
Chronic Toxicity
ReproductiveToxicity
Full Set of BasicToxicity Tests
Medical WasteMedical Waste
6000 US hospitals~2 million 6000 US hospitals~2 million tons waste per year tons waste per year
Clinics and doctorsrsquo offices add 700000 Clinics and doctorsrsquo offices add 700000 tonstons
EPA regulations weak-HCWHh2eEPA regulations weak-HCWHh2e 850000 tons incinerated850000 tons incinerated
Pollutants inc dioxin Hg cadmium Pollutants inc dioxin Hg cadmium and Pband Pb
Segregation amp alternatives to Segregation amp alternatives to incineration incineration would cost 93 would cost 93 centspatientdaycentspatientday
Our Chemical EnvironmentOur Chemical Environment
1305 Superfund sites1305 Superfund sites 25002500 are are eligible eligible gt80kgt80k hazardous sites hazardous sites knownknown
~11 million people live within 1 mile~11 million people live within 1 mile ~25 live within 4 miles~25 live within 4 miles OR ranks 24OR ranks 24-12 Superfund sites-12 Superfund sites 3 in PDX3 in PDX Harbor Oil Portland Harbor Oil Portland
Harbor Harbor McCormick amp Baxter McCormick amp Baxter Creosoting Co Creosoting Co
Multnomah amp Washington CoMultnomah amp Washington CoShared Pollutants 2002Shared Pollutants 2002
Links to Disease Links to Disease
Methanol (gt240k lbs)Methanol (gt240k lbs)
StrongStrong ATN amp vision problems ATN amp vision problems
GoodGood Pancreatitis amp Pancreatitis amp Parkinsonrsquosmovement disorders Parkinsonrsquosmovement disorders
Ammonia (gt100k lbs)Ammonia (gt100k lbs)
StrongStrong Asthma acutechronic bronchitis Asthma acutechronic bronchitis olfactory disorders amp rhinitis olfactory disorders amp rhinitis
GoodGood Pulmonary edema Pulmonary edema
Links to Disease contLinks to Disease cont
Xylene (gt95k lbs) amp Toluene (gt83k lbs)Xylene (gt95k lbs) amp Toluene (gt83k lbs) GoodGood Scleroderma arrhythmias menstrual Scleroderma arrhythmias menstrual
do cognitive impairment hearing loss amp do cognitive impairment hearing loss amp fetal death (miscarriagestillbirth)fetal death (miscarriagestillbirth)
Glycol Ethers (gt20k lbs)Glycol Ethers (gt20k lbs) StrongStrong Reduced male fertility abnormal Reduced male fertility abnormal
sperm (morphology motility amp count) amp fetal sperm (morphology motility amp count) amp fetal death (miscarriagestillbirth) death (miscarriagestillbirth)
GoodGood ATN reduced female fertility general ATN reduced female fertility general congenital and craniofacial malformationscongenital and craniofacial malformations
National Report on Human National Report on Human Exposure to Environmental Exposure to Environmental
Chemicals Chemicals (CDC 705)(CDC 705)
Random selection from NHANES Random selection from NHANES surveysurvey
148 chemicals from 2001-2002 inc 148 chemicals from 2001-2002 inc data on 116 chemicals from 1999-data on 116 chemicals from 1999-20002000
Criteria for chemical inclusion Criteria for chemical inclusion wide exposure wide exposure serious health effects serious health effects adequate blood amp urine samples adequate blood amp urine samples efficacy of attempts to reduce efficacy of attempts to reduce
exposure exposure availability of reliable bio-monitoring availability of reliable bio-monitoring
methodmethod
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Modifiable Risk Factors amp Modifiable Risk Factors amp Death Death
United States 2000United States 2000Percentage of all deathsPercentage of all deathsTobacco use 181Tobacco use 181
Poor dietlack of exercise 166Poor dietlack of exercise 166
Alcohol use 35Alcohol use 35
Infectious agents 31Infectious agents 31
Pollutantstoxins 23Pollutantstoxins 23
Motor vehicle crashes 18Motor vehicle crashes 18
Firearms 12Firearms 12
Risky sexual behavior 08Risky sexual behavior 08
Illicit drug use 07Illicit drug use 07
JAMA 2004 291 1238-45
Poor environmental quality accounts Poor environmental quality accounts for 25 of all preventable world for 25 of all preventable world
illnessillness
WHO 1997
Environmental Illness a Environmental Illness a SnapshotSnapshot
Environmental illness Environmental illness in US childrenin US children
$55 billionyear$55 billionyear Lead poisoningLead poisoning
AsthmaAsthma
CancerCancer
Developmental DisabilitiesDevelopmental Disabilities
EHP 2002 110 (7) 721-728
Healthy People 2010Healthy People 2010
National objectivesNational objectives Most significant Most significant
preventable preventable threats to health threats to health amp goals to reduce amp goals to reduce themthem
Includes Includes environmental environmental health objectiveshealth objectives
Providers role in Providers role in preventionprevention
Healthy People 2010 Toxic Healthy People 2010 Toxic WastesWastes
Lower elevated blood lead levels to Lower elevated blood lead levels to 11
Minimize risks from hazardous sitesMinimize risks from hazardous sites Reduce pesticide exposuresReduce pesticide exposures Reduce toxic pollutants produced Reduce toxic pollutants produced
disposed of treated or used for disposed of treated or used for energy recoveryenergy recovery
Increase recycling of solid waste to Increase recycling of solid waste to 3838
State of Knowledge Our State of Knowledge Our Chemical EnvironmentChemical Environment
gt80000 chemicals in gt80000 chemicals in Federal inventoryFederal inventory
2000 to 3000 NEW 2000 to 3000 NEW chemicals per yearchemicals per year
gt4 billion lbs released gt4 billion lbs released into environment yearly into environment yearly 72 million lbs of 72 million lbs of recognized carcinogens recognized carcinogens
Basic Screening Basic Screening Information Data Set Information Data Set (SIDS) avg $205000 per (SIDS) avg $205000 per chemicalchemical
Hazard Data - Chemicals Hazard Data - Chemicals Produced Produced
gt 1 Million PoundsYear gt 1 Million PoundsYear
0 10 20 30 40 50 60 70 80 90 100
Percentage Tested
Acute Toxicity
Environmental Fate
Ecotoxicity
Mutagenicity
Chronic Toxicity
ReproductiveToxicity
Full Set of BasicToxicity Tests
Medical WasteMedical Waste
6000 US hospitals~2 million 6000 US hospitals~2 million tons waste per year tons waste per year
Clinics and doctorsrsquo offices add 700000 Clinics and doctorsrsquo offices add 700000 tonstons
EPA regulations weak-HCWHh2eEPA regulations weak-HCWHh2e 850000 tons incinerated850000 tons incinerated
Pollutants inc dioxin Hg cadmium Pollutants inc dioxin Hg cadmium and Pband Pb
Segregation amp alternatives to Segregation amp alternatives to incineration incineration would cost 93 would cost 93 centspatientdaycentspatientday
Our Chemical EnvironmentOur Chemical Environment
1305 Superfund sites1305 Superfund sites 25002500 are are eligible eligible gt80kgt80k hazardous sites hazardous sites knownknown
~11 million people live within 1 mile~11 million people live within 1 mile ~25 live within 4 miles~25 live within 4 miles OR ranks 24OR ranks 24-12 Superfund sites-12 Superfund sites 3 in PDX3 in PDX Harbor Oil Portland Harbor Oil Portland
Harbor Harbor McCormick amp Baxter McCormick amp Baxter Creosoting Co Creosoting Co
Multnomah amp Washington CoMultnomah amp Washington CoShared Pollutants 2002Shared Pollutants 2002
Links to Disease Links to Disease
Methanol (gt240k lbs)Methanol (gt240k lbs)
StrongStrong ATN amp vision problems ATN amp vision problems
GoodGood Pancreatitis amp Pancreatitis amp Parkinsonrsquosmovement disorders Parkinsonrsquosmovement disorders
Ammonia (gt100k lbs)Ammonia (gt100k lbs)
StrongStrong Asthma acutechronic bronchitis Asthma acutechronic bronchitis olfactory disorders amp rhinitis olfactory disorders amp rhinitis
GoodGood Pulmonary edema Pulmonary edema
Links to Disease contLinks to Disease cont
Xylene (gt95k lbs) amp Toluene (gt83k lbs)Xylene (gt95k lbs) amp Toluene (gt83k lbs) GoodGood Scleroderma arrhythmias menstrual Scleroderma arrhythmias menstrual
do cognitive impairment hearing loss amp do cognitive impairment hearing loss amp fetal death (miscarriagestillbirth)fetal death (miscarriagestillbirth)
Glycol Ethers (gt20k lbs)Glycol Ethers (gt20k lbs) StrongStrong Reduced male fertility abnormal Reduced male fertility abnormal
sperm (morphology motility amp count) amp fetal sperm (morphology motility amp count) amp fetal death (miscarriagestillbirth) death (miscarriagestillbirth)
GoodGood ATN reduced female fertility general ATN reduced female fertility general congenital and craniofacial malformationscongenital and craniofacial malformations
National Report on Human National Report on Human Exposure to Environmental Exposure to Environmental
Chemicals Chemicals (CDC 705)(CDC 705)
Random selection from NHANES Random selection from NHANES surveysurvey
148 chemicals from 2001-2002 inc 148 chemicals from 2001-2002 inc data on 116 chemicals from 1999-data on 116 chemicals from 1999-20002000
Criteria for chemical inclusion Criteria for chemical inclusion wide exposure wide exposure serious health effects serious health effects adequate blood amp urine samples adequate blood amp urine samples efficacy of attempts to reduce efficacy of attempts to reduce
exposure exposure availability of reliable bio-monitoring availability of reliable bio-monitoring
methodmethod
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Poor environmental quality accounts Poor environmental quality accounts for 25 of all preventable world for 25 of all preventable world
illnessillness
WHO 1997
Environmental Illness a Environmental Illness a SnapshotSnapshot
Environmental illness Environmental illness in US childrenin US children
$55 billionyear$55 billionyear Lead poisoningLead poisoning
AsthmaAsthma
CancerCancer
Developmental DisabilitiesDevelopmental Disabilities
EHP 2002 110 (7) 721-728
Healthy People 2010Healthy People 2010
National objectivesNational objectives Most significant Most significant
preventable preventable threats to health threats to health amp goals to reduce amp goals to reduce themthem
Includes Includes environmental environmental health objectiveshealth objectives
Providers role in Providers role in preventionprevention
Healthy People 2010 Toxic Healthy People 2010 Toxic WastesWastes
Lower elevated blood lead levels to Lower elevated blood lead levels to 11
Minimize risks from hazardous sitesMinimize risks from hazardous sites Reduce pesticide exposuresReduce pesticide exposures Reduce toxic pollutants produced Reduce toxic pollutants produced
disposed of treated or used for disposed of treated or used for energy recoveryenergy recovery
Increase recycling of solid waste to Increase recycling of solid waste to 3838
State of Knowledge Our State of Knowledge Our Chemical EnvironmentChemical Environment
gt80000 chemicals in gt80000 chemicals in Federal inventoryFederal inventory
2000 to 3000 NEW 2000 to 3000 NEW chemicals per yearchemicals per year
gt4 billion lbs released gt4 billion lbs released into environment yearly into environment yearly 72 million lbs of 72 million lbs of recognized carcinogens recognized carcinogens
Basic Screening Basic Screening Information Data Set Information Data Set (SIDS) avg $205000 per (SIDS) avg $205000 per chemicalchemical
Hazard Data - Chemicals Hazard Data - Chemicals Produced Produced
gt 1 Million PoundsYear gt 1 Million PoundsYear
0 10 20 30 40 50 60 70 80 90 100
Percentage Tested
Acute Toxicity
Environmental Fate
Ecotoxicity
Mutagenicity
Chronic Toxicity
ReproductiveToxicity
Full Set of BasicToxicity Tests
Medical WasteMedical Waste
6000 US hospitals~2 million 6000 US hospitals~2 million tons waste per year tons waste per year
Clinics and doctorsrsquo offices add 700000 Clinics and doctorsrsquo offices add 700000 tonstons
EPA regulations weak-HCWHh2eEPA regulations weak-HCWHh2e 850000 tons incinerated850000 tons incinerated
Pollutants inc dioxin Hg cadmium Pollutants inc dioxin Hg cadmium and Pband Pb
Segregation amp alternatives to Segregation amp alternatives to incineration incineration would cost 93 would cost 93 centspatientdaycentspatientday
Our Chemical EnvironmentOur Chemical Environment
1305 Superfund sites1305 Superfund sites 25002500 are are eligible eligible gt80kgt80k hazardous sites hazardous sites knownknown
~11 million people live within 1 mile~11 million people live within 1 mile ~25 live within 4 miles~25 live within 4 miles OR ranks 24OR ranks 24-12 Superfund sites-12 Superfund sites 3 in PDX3 in PDX Harbor Oil Portland Harbor Oil Portland
Harbor Harbor McCormick amp Baxter McCormick amp Baxter Creosoting Co Creosoting Co
Multnomah amp Washington CoMultnomah amp Washington CoShared Pollutants 2002Shared Pollutants 2002
Links to Disease Links to Disease
Methanol (gt240k lbs)Methanol (gt240k lbs)
StrongStrong ATN amp vision problems ATN amp vision problems
GoodGood Pancreatitis amp Pancreatitis amp Parkinsonrsquosmovement disorders Parkinsonrsquosmovement disorders
Ammonia (gt100k lbs)Ammonia (gt100k lbs)
StrongStrong Asthma acutechronic bronchitis Asthma acutechronic bronchitis olfactory disorders amp rhinitis olfactory disorders amp rhinitis
GoodGood Pulmonary edema Pulmonary edema
Links to Disease contLinks to Disease cont
Xylene (gt95k lbs) amp Toluene (gt83k lbs)Xylene (gt95k lbs) amp Toluene (gt83k lbs) GoodGood Scleroderma arrhythmias menstrual Scleroderma arrhythmias menstrual
do cognitive impairment hearing loss amp do cognitive impairment hearing loss amp fetal death (miscarriagestillbirth)fetal death (miscarriagestillbirth)
Glycol Ethers (gt20k lbs)Glycol Ethers (gt20k lbs) StrongStrong Reduced male fertility abnormal Reduced male fertility abnormal
sperm (morphology motility amp count) amp fetal sperm (morphology motility amp count) amp fetal death (miscarriagestillbirth) death (miscarriagestillbirth)
GoodGood ATN reduced female fertility general ATN reduced female fertility general congenital and craniofacial malformationscongenital and craniofacial malformations
National Report on Human National Report on Human Exposure to Environmental Exposure to Environmental
Chemicals Chemicals (CDC 705)(CDC 705)
Random selection from NHANES Random selection from NHANES surveysurvey
148 chemicals from 2001-2002 inc 148 chemicals from 2001-2002 inc data on 116 chemicals from 1999-data on 116 chemicals from 1999-20002000
Criteria for chemical inclusion Criteria for chemical inclusion wide exposure wide exposure serious health effects serious health effects adequate blood amp urine samples adequate blood amp urine samples efficacy of attempts to reduce efficacy of attempts to reduce
exposure exposure availability of reliable bio-monitoring availability of reliable bio-monitoring
methodmethod
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Environmental Illness a Environmental Illness a SnapshotSnapshot
Environmental illness Environmental illness in US childrenin US children
$55 billionyear$55 billionyear Lead poisoningLead poisoning
AsthmaAsthma
CancerCancer
Developmental DisabilitiesDevelopmental Disabilities
EHP 2002 110 (7) 721-728
Healthy People 2010Healthy People 2010
National objectivesNational objectives Most significant Most significant
preventable preventable threats to health threats to health amp goals to reduce amp goals to reduce themthem
Includes Includes environmental environmental health objectiveshealth objectives
Providers role in Providers role in preventionprevention
Healthy People 2010 Toxic Healthy People 2010 Toxic WastesWastes
Lower elevated blood lead levels to Lower elevated blood lead levels to 11
Minimize risks from hazardous sitesMinimize risks from hazardous sites Reduce pesticide exposuresReduce pesticide exposures Reduce toxic pollutants produced Reduce toxic pollutants produced
disposed of treated or used for disposed of treated or used for energy recoveryenergy recovery
Increase recycling of solid waste to Increase recycling of solid waste to 3838
State of Knowledge Our State of Knowledge Our Chemical EnvironmentChemical Environment
gt80000 chemicals in gt80000 chemicals in Federal inventoryFederal inventory
2000 to 3000 NEW 2000 to 3000 NEW chemicals per yearchemicals per year
gt4 billion lbs released gt4 billion lbs released into environment yearly into environment yearly 72 million lbs of 72 million lbs of recognized carcinogens recognized carcinogens
Basic Screening Basic Screening Information Data Set Information Data Set (SIDS) avg $205000 per (SIDS) avg $205000 per chemicalchemical
Hazard Data - Chemicals Hazard Data - Chemicals Produced Produced
gt 1 Million PoundsYear gt 1 Million PoundsYear
0 10 20 30 40 50 60 70 80 90 100
Percentage Tested
Acute Toxicity
Environmental Fate
Ecotoxicity
Mutagenicity
Chronic Toxicity
ReproductiveToxicity
Full Set of BasicToxicity Tests
Medical WasteMedical Waste
6000 US hospitals~2 million 6000 US hospitals~2 million tons waste per year tons waste per year
Clinics and doctorsrsquo offices add 700000 Clinics and doctorsrsquo offices add 700000 tonstons
EPA regulations weak-HCWHh2eEPA regulations weak-HCWHh2e 850000 tons incinerated850000 tons incinerated
Pollutants inc dioxin Hg cadmium Pollutants inc dioxin Hg cadmium and Pband Pb
Segregation amp alternatives to Segregation amp alternatives to incineration incineration would cost 93 would cost 93 centspatientdaycentspatientday
Our Chemical EnvironmentOur Chemical Environment
1305 Superfund sites1305 Superfund sites 25002500 are are eligible eligible gt80kgt80k hazardous sites hazardous sites knownknown
~11 million people live within 1 mile~11 million people live within 1 mile ~25 live within 4 miles~25 live within 4 miles OR ranks 24OR ranks 24-12 Superfund sites-12 Superfund sites 3 in PDX3 in PDX Harbor Oil Portland Harbor Oil Portland
Harbor Harbor McCormick amp Baxter McCormick amp Baxter Creosoting Co Creosoting Co
Multnomah amp Washington CoMultnomah amp Washington CoShared Pollutants 2002Shared Pollutants 2002
Links to Disease Links to Disease
Methanol (gt240k lbs)Methanol (gt240k lbs)
StrongStrong ATN amp vision problems ATN amp vision problems
GoodGood Pancreatitis amp Pancreatitis amp Parkinsonrsquosmovement disorders Parkinsonrsquosmovement disorders
Ammonia (gt100k lbs)Ammonia (gt100k lbs)
StrongStrong Asthma acutechronic bronchitis Asthma acutechronic bronchitis olfactory disorders amp rhinitis olfactory disorders amp rhinitis
GoodGood Pulmonary edema Pulmonary edema
Links to Disease contLinks to Disease cont
Xylene (gt95k lbs) amp Toluene (gt83k lbs)Xylene (gt95k lbs) amp Toluene (gt83k lbs) GoodGood Scleroderma arrhythmias menstrual Scleroderma arrhythmias menstrual
do cognitive impairment hearing loss amp do cognitive impairment hearing loss amp fetal death (miscarriagestillbirth)fetal death (miscarriagestillbirth)
Glycol Ethers (gt20k lbs)Glycol Ethers (gt20k lbs) StrongStrong Reduced male fertility abnormal Reduced male fertility abnormal
sperm (morphology motility amp count) amp fetal sperm (morphology motility amp count) amp fetal death (miscarriagestillbirth) death (miscarriagestillbirth)
GoodGood ATN reduced female fertility general ATN reduced female fertility general congenital and craniofacial malformationscongenital and craniofacial malformations
National Report on Human National Report on Human Exposure to Environmental Exposure to Environmental
Chemicals Chemicals (CDC 705)(CDC 705)
Random selection from NHANES Random selection from NHANES surveysurvey
148 chemicals from 2001-2002 inc 148 chemicals from 2001-2002 inc data on 116 chemicals from 1999-data on 116 chemicals from 1999-20002000
Criteria for chemical inclusion Criteria for chemical inclusion wide exposure wide exposure serious health effects serious health effects adequate blood amp urine samples adequate blood amp urine samples efficacy of attempts to reduce efficacy of attempts to reduce
exposure exposure availability of reliable bio-monitoring availability of reliable bio-monitoring
methodmethod
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Healthy People 2010Healthy People 2010
National objectivesNational objectives Most significant Most significant
preventable preventable threats to health threats to health amp goals to reduce amp goals to reduce themthem
Includes Includes environmental environmental health objectiveshealth objectives
Providers role in Providers role in preventionprevention
Healthy People 2010 Toxic Healthy People 2010 Toxic WastesWastes
Lower elevated blood lead levels to Lower elevated blood lead levels to 11
Minimize risks from hazardous sitesMinimize risks from hazardous sites Reduce pesticide exposuresReduce pesticide exposures Reduce toxic pollutants produced Reduce toxic pollutants produced
disposed of treated or used for disposed of treated or used for energy recoveryenergy recovery
Increase recycling of solid waste to Increase recycling of solid waste to 3838
State of Knowledge Our State of Knowledge Our Chemical EnvironmentChemical Environment
gt80000 chemicals in gt80000 chemicals in Federal inventoryFederal inventory
2000 to 3000 NEW 2000 to 3000 NEW chemicals per yearchemicals per year
gt4 billion lbs released gt4 billion lbs released into environment yearly into environment yearly 72 million lbs of 72 million lbs of recognized carcinogens recognized carcinogens
Basic Screening Basic Screening Information Data Set Information Data Set (SIDS) avg $205000 per (SIDS) avg $205000 per chemicalchemical
Hazard Data - Chemicals Hazard Data - Chemicals Produced Produced
gt 1 Million PoundsYear gt 1 Million PoundsYear
0 10 20 30 40 50 60 70 80 90 100
Percentage Tested
Acute Toxicity
Environmental Fate
Ecotoxicity
Mutagenicity
Chronic Toxicity
ReproductiveToxicity
Full Set of BasicToxicity Tests
Medical WasteMedical Waste
6000 US hospitals~2 million 6000 US hospitals~2 million tons waste per year tons waste per year
Clinics and doctorsrsquo offices add 700000 Clinics and doctorsrsquo offices add 700000 tonstons
EPA regulations weak-HCWHh2eEPA regulations weak-HCWHh2e 850000 tons incinerated850000 tons incinerated
Pollutants inc dioxin Hg cadmium Pollutants inc dioxin Hg cadmium and Pband Pb
Segregation amp alternatives to Segregation amp alternatives to incineration incineration would cost 93 would cost 93 centspatientdaycentspatientday
Our Chemical EnvironmentOur Chemical Environment
1305 Superfund sites1305 Superfund sites 25002500 are are eligible eligible gt80kgt80k hazardous sites hazardous sites knownknown
~11 million people live within 1 mile~11 million people live within 1 mile ~25 live within 4 miles~25 live within 4 miles OR ranks 24OR ranks 24-12 Superfund sites-12 Superfund sites 3 in PDX3 in PDX Harbor Oil Portland Harbor Oil Portland
Harbor Harbor McCormick amp Baxter McCormick amp Baxter Creosoting Co Creosoting Co
Multnomah amp Washington CoMultnomah amp Washington CoShared Pollutants 2002Shared Pollutants 2002
Links to Disease Links to Disease
Methanol (gt240k lbs)Methanol (gt240k lbs)
StrongStrong ATN amp vision problems ATN amp vision problems
GoodGood Pancreatitis amp Pancreatitis amp Parkinsonrsquosmovement disorders Parkinsonrsquosmovement disorders
Ammonia (gt100k lbs)Ammonia (gt100k lbs)
StrongStrong Asthma acutechronic bronchitis Asthma acutechronic bronchitis olfactory disorders amp rhinitis olfactory disorders amp rhinitis
GoodGood Pulmonary edema Pulmonary edema
Links to Disease contLinks to Disease cont
Xylene (gt95k lbs) amp Toluene (gt83k lbs)Xylene (gt95k lbs) amp Toluene (gt83k lbs) GoodGood Scleroderma arrhythmias menstrual Scleroderma arrhythmias menstrual
do cognitive impairment hearing loss amp do cognitive impairment hearing loss amp fetal death (miscarriagestillbirth)fetal death (miscarriagestillbirth)
Glycol Ethers (gt20k lbs)Glycol Ethers (gt20k lbs) StrongStrong Reduced male fertility abnormal Reduced male fertility abnormal
sperm (morphology motility amp count) amp fetal sperm (morphology motility amp count) amp fetal death (miscarriagestillbirth) death (miscarriagestillbirth)
GoodGood ATN reduced female fertility general ATN reduced female fertility general congenital and craniofacial malformationscongenital and craniofacial malformations
National Report on Human National Report on Human Exposure to Environmental Exposure to Environmental
Chemicals Chemicals (CDC 705)(CDC 705)
Random selection from NHANES Random selection from NHANES surveysurvey
148 chemicals from 2001-2002 inc 148 chemicals from 2001-2002 inc data on 116 chemicals from 1999-data on 116 chemicals from 1999-20002000
Criteria for chemical inclusion Criteria for chemical inclusion wide exposure wide exposure serious health effects serious health effects adequate blood amp urine samples adequate blood amp urine samples efficacy of attempts to reduce efficacy of attempts to reduce
exposure exposure availability of reliable bio-monitoring availability of reliable bio-monitoring
methodmethod
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Healthy People 2010 Toxic Healthy People 2010 Toxic WastesWastes
Lower elevated blood lead levels to Lower elevated blood lead levels to 11
Minimize risks from hazardous sitesMinimize risks from hazardous sites Reduce pesticide exposuresReduce pesticide exposures Reduce toxic pollutants produced Reduce toxic pollutants produced
disposed of treated or used for disposed of treated or used for energy recoveryenergy recovery
Increase recycling of solid waste to Increase recycling of solid waste to 3838
State of Knowledge Our State of Knowledge Our Chemical EnvironmentChemical Environment
gt80000 chemicals in gt80000 chemicals in Federal inventoryFederal inventory
2000 to 3000 NEW 2000 to 3000 NEW chemicals per yearchemicals per year
gt4 billion lbs released gt4 billion lbs released into environment yearly into environment yearly 72 million lbs of 72 million lbs of recognized carcinogens recognized carcinogens
Basic Screening Basic Screening Information Data Set Information Data Set (SIDS) avg $205000 per (SIDS) avg $205000 per chemicalchemical
Hazard Data - Chemicals Hazard Data - Chemicals Produced Produced
gt 1 Million PoundsYear gt 1 Million PoundsYear
0 10 20 30 40 50 60 70 80 90 100
Percentage Tested
Acute Toxicity
Environmental Fate
Ecotoxicity
Mutagenicity
Chronic Toxicity
ReproductiveToxicity
Full Set of BasicToxicity Tests
Medical WasteMedical Waste
6000 US hospitals~2 million 6000 US hospitals~2 million tons waste per year tons waste per year
Clinics and doctorsrsquo offices add 700000 Clinics and doctorsrsquo offices add 700000 tonstons
EPA regulations weak-HCWHh2eEPA regulations weak-HCWHh2e 850000 tons incinerated850000 tons incinerated
Pollutants inc dioxin Hg cadmium Pollutants inc dioxin Hg cadmium and Pband Pb
Segregation amp alternatives to Segregation amp alternatives to incineration incineration would cost 93 would cost 93 centspatientdaycentspatientday
Our Chemical EnvironmentOur Chemical Environment
1305 Superfund sites1305 Superfund sites 25002500 are are eligible eligible gt80kgt80k hazardous sites hazardous sites knownknown
~11 million people live within 1 mile~11 million people live within 1 mile ~25 live within 4 miles~25 live within 4 miles OR ranks 24OR ranks 24-12 Superfund sites-12 Superfund sites 3 in PDX3 in PDX Harbor Oil Portland Harbor Oil Portland
Harbor Harbor McCormick amp Baxter McCormick amp Baxter Creosoting Co Creosoting Co
Multnomah amp Washington CoMultnomah amp Washington CoShared Pollutants 2002Shared Pollutants 2002
Links to Disease Links to Disease
Methanol (gt240k lbs)Methanol (gt240k lbs)
StrongStrong ATN amp vision problems ATN amp vision problems
GoodGood Pancreatitis amp Pancreatitis amp Parkinsonrsquosmovement disorders Parkinsonrsquosmovement disorders
Ammonia (gt100k lbs)Ammonia (gt100k lbs)
StrongStrong Asthma acutechronic bronchitis Asthma acutechronic bronchitis olfactory disorders amp rhinitis olfactory disorders amp rhinitis
GoodGood Pulmonary edema Pulmonary edema
Links to Disease contLinks to Disease cont
Xylene (gt95k lbs) amp Toluene (gt83k lbs)Xylene (gt95k lbs) amp Toluene (gt83k lbs) GoodGood Scleroderma arrhythmias menstrual Scleroderma arrhythmias menstrual
do cognitive impairment hearing loss amp do cognitive impairment hearing loss amp fetal death (miscarriagestillbirth)fetal death (miscarriagestillbirth)
Glycol Ethers (gt20k lbs)Glycol Ethers (gt20k lbs) StrongStrong Reduced male fertility abnormal Reduced male fertility abnormal
sperm (morphology motility amp count) amp fetal sperm (morphology motility amp count) amp fetal death (miscarriagestillbirth) death (miscarriagestillbirth)
GoodGood ATN reduced female fertility general ATN reduced female fertility general congenital and craniofacial malformationscongenital and craniofacial malformations
National Report on Human National Report on Human Exposure to Environmental Exposure to Environmental
Chemicals Chemicals (CDC 705)(CDC 705)
Random selection from NHANES Random selection from NHANES surveysurvey
148 chemicals from 2001-2002 inc 148 chemicals from 2001-2002 inc data on 116 chemicals from 1999-data on 116 chemicals from 1999-20002000
Criteria for chemical inclusion Criteria for chemical inclusion wide exposure wide exposure serious health effects serious health effects adequate blood amp urine samples adequate blood amp urine samples efficacy of attempts to reduce efficacy of attempts to reduce
exposure exposure availability of reliable bio-monitoring availability of reliable bio-monitoring
methodmethod
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
State of Knowledge Our State of Knowledge Our Chemical EnvironmentChemical Environment
gt80000 chemicals in gt80000 chemicals in Federal inventoryFederal inventory
2000 to 3000 NEW 2000 to 3000 NEW chemicals per yearchemicals per year
gt4 billion lbs released gt4 billion lbs released into environment yearly into environment yearly 72 million lbs of 72 million lbs of recognized carcinogens recognized carcinogens
Basic Screening Basic Screening Information Data Set Information Data Set (SIDS) avg $205000 per (SIDS) avg $205000 per chemicalchemical
Hazard Data - Chemicals Hazard Data - Chemicals Produced Produced
gt 1 Million PoundsYear gt 1 Million PoundsYear
0 10 20 30 40 50 60 70 80 90 100
Percentage Tested
Acute Toxicity
Environmental Fate
Ecotoxicity
Mutagenicity
Chronic Toxicity
ReproductiveToxicity
Full Set of BasicToxicity Tests
Medical WasteMedical Waste
6000 US hospitals~2 million 6000 US hospitals~2 million tons waste per year tons waste per year
Clinics and doctorsrsquo offices add 700000 Clinics and doctorsrsquo offices add 700000 tonstons
EPA regulations weak-HCWHh2eEPA regulations weak-HCWHh2e 850000 tons incinerated850000 tons incinerated
Pollutants inc dioxin Hg cadmium Pollutants inc dioxin Hg cadmium and Pband Pb
Segregation amp alternatives to Segregation amp alternatives to incineration incineration would cost 93 would cost 93 centspatientdaycentspatientday
Our Chemical EnvironmentOur Chemical Environment
1305 Superfund sites1305 Superfund sites 25002500 are are eligible eligible gt80kgt80k hazardous sites hazardous sites knownknown
~11 million people live within 1 mile~11 million people live within 1 mile ~25 live within 4 miles~25 live within 4 miles OR ranks 24OR ranks 24-12 Superfund sites-12 Superfund sites 3 in PDX3 in PDX Harbor Oil Portland Harbor Oil Portland
Harbor Harbor McCormick amp Baxter McCormick amp Baxter Creosoting Co Creosoting Co
Multnomah amp Washington CoMultnomah amp Washington CoShared Pollutants 2002Shared Pollutants 2002
Links to Disease Links to Disease
Methanol (gt240k lbs)Methanol (gt240k lbs)
StrongStrong ATN amp vision problems ATN amp vision problems
GoodGood Pancreatitis amp Pancreatitis amp Parkinsonrsquosmovement disorders Parkinsonrsquosmovement disorders
Ammonia (gt100k lbs)Ammonia (gt100k lbs)
StrongStrong Asthma acutechronic bronchitis Asthma acutechronic bronchitis olfactory disorders amp rhinitis olfactory disorders amp rhinitis
GoodGood Pulmonary edema Pulmonary edema
Links to Disease contLinks to Disease cont
Xylene (gt95k lbs) amp Toluene (gt83k lbs)Xylene (gt95k lbs) amp Toluene (gt83k lbs) GoodGood Scleroderma arrhythmias menstrual Scleroderma arrhythmias menstrual
do cognitive impairment hearing loss amp do cognitive impairment hearing loss amp fetal death (miscarriagestillbirth)fetal death (miscarriagestillbirth)
Glycol Ethers (gt20k lbs)Glycol Ethers (gt20k lbs) StrongStrong Reduced male fertility abnormal Reduced male fertility abnormal
sperm (morphology motility amp count) amp fetal sperm (morphology motility amp count) amp fetal death (miscarriagestillbirth) death (miscarriagestillbirth)
GoodGood ATN reduced female fertility general ATN reduced female fertility general congenital and craniofacial malformationscongenital and craniofacial malformations
National Report on Human National Report on Human Exposure to Environmental Exposure to Environmental
Chemicals Chemicals (CDC 705)(CDC 705)
Random selection from NHANES Random selection from NHANES surveysurvey
148 chemicals from 2001-2002 inc 148 chemicals from 2001-2002 inc data on 116 chemicals from 1999-data on 116 chemicals from 1999-20002000
Criteria for chemical inclusion Criteria for chemical inclusion wide exposure wide exposure serious health effects serious health effects adequate blood amp urine samples adequate blood amp urine samples efficacy of attempts to reduce efficacy of attempts to reduce
exposure exposure availability of reliable bio-monitoring availability of reliable bio-monitoring
methodmethod
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Hazard Data - Chemicals Hazard Data - Chemicals Produced Produced
gt 1 Million PoundsYear gt 1 Million PoundsYear
0 10 20 30 40 50 60 70 80 90 100
Percentage Tested
Acute Toxicity
Environmental Fate
Ecotoxicity
Mutagenicity
Chronic Toxicity
ReproductiveToxicity
Full Set of BasicToxicity Tests
Medical WasteMedical Waste
6000 US hospitals~2 million 6000 US hospitals~2 million tons waste per year tons waste per year
Clinics and doctorsrsquo offices add 700000 Clinics and doctorsrsquo offices add 700000 tonstons
EPA regulations weak-HCWHh2eEPA regulations weak-HCWHh2e 850000 tons incinerated850000 tons incinerated
Pollutants inc dioxin Hg cadmium Pollutants inc dioxin Hg cadmium and Pband Pb
Segregation amp alternatives to Segregation amp alternatives to incineration incineration would cost 93 would cost 93 centspatientdaycentspatientday
Our Chemical EnvironmentOur Chemical Environment
1305 Superfund sites1305 Superfund sites 25002500 are are eligible eligible gt80kgt80k hazardous sites hazardous sites knownknown
~11 million people live within 1 mile~11 million people live within 1 mile ~25 live within 4 miles~25 live within 4 miles OR ranks 24OR ranks 24-12 Superfund sites-12 Superfund sites 3 in PDX3 in PDX Harbor Oil Portland Harbor Oil Portland
Harbor Harbor McCormick amp Baxter McCormick amp Baxter Creosoting Co Creosoting Co
Multnomah amp Washington CoMultnomah amp Washington CoShared Pollutants 2002Shared Pollutants 2002
Links to Disease Links to Disease
Methanol (gt240k lbs)Methanol (gt240k lbs)
StrongStrong ATN amp vision problems ATN amp vision problems
GoodGood Pancreatitis amp Pancreatitis amp Parkinsonrsquosmovement disorders Parkinsonrsquosmovement disorders
Ammonia (gt100k lbs)Ammonia (gt100k lbs)
StrongStrong Asthma acutechronic bronchitis Asthma acutechronic bronchitis olfactory disorders amp rhinitis olfactory disorders amp rhinitis
GoodGood Pulmonary edema Pulmonary edema
Links to Disease contLinks to Disease cont
Xylene (gt95k lbs) amp Toluene (gt83k lbs)Xylene (gt95k lbs) amp Toluene (gt83k lbs) GoodGood Scleroderma arrhythmias menstrual Scleroderma arrhythmias menstrual
do cognitive impairment hearing loss amp do cognitive impairment hearing loss amp fetal death (miscarriagestillbirth)fetal death (miscarriagestillbirth)
Glycol Ethers (gt20k lbs)Glycol Ethers (gt20k lbs) StrongStrong Reduced male fertility abnormal Reduced male fertility abnormal
sperm (morphology motility amp count) amp fetal sperm (morphology motility amp count) amp fetal death (miscarriagestillbirth) death (miscarriagestillbirth)
GoodGood ATN reduced female fertility general ATN reduced female fertility general congenital and craniofacial malformationscongenital and craniofacial malformations
National Report on Human National Report on Human Exposure to Environmental Exposure to Environmental
Chemicals Chemicals (CDC 705)(CDC 705)
Random selection from NHANES Random selection from NHANES surveysurvey
148 chemicals from 2001-2002 inc 148 chemicals from 2001-2002 inc data on 116 chemicals from 1999-data on 116 chemicals from 1999-20002000
Criteria for chemical inclusion Criteria for chemical inclusion wide exposure wide exposure serious health effects serious health effects adequate blood amp urine samples adequate blood amp urine samples efficacy of attempts to reduce efficacy of attempts to reduce
exposure exposure availability of reliable bio-monitoring availability of reliable bio-monitoring
methodmethod
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Medical WasteMedical Waste
6000 US hospitals~2 million 6000 US hospitals~2 million tons waste per year tons waste per year
Clinics and doctorsrsquo offices add 700000 Clinics and doctorsrsquo offices add 700000 tonstons
EPA regulations weak-HCWHh2eEPA regulations weak-HCWHh2e 850000 tons incinerated850000 tons incinerated
Pollutants inc dioxin Hg cadmium Pollutants inc dioxin Hg cadmium and Pband Pb
Segregation amp alternatives to Segregation amp alternatives to incineration incineration would cost 93 would cost 93 centspatientdaycentspatientday
Our Chemical EnvironmentOur Chemical Environment
1305 Superfund sites1305 Superfund sites 25002500 are are eligible eligible gt80kgt80k hazardous sites hazardous sites knownknown
~11 million people live within 1 mile~11 million people live within 1 mile ~25 live within 4 miles~25 live within 4 miles OR ranks 24OR ranks 24-12 Superfund sites-12 Superfund sites 3 in PDX3 in PDX Harbor Oil Portland Harbor Oil Portland
Harbor Harbor McCormick amp Baxter McCormick amp Baxter Creosoting Co Creosoting Co
Multnomah amp Washington CoMultnomah amp Washington CoShared Pollutants 2002Shared Pollutants 2002
Links to Disease Links to Disease
Methanol (gt240k lbs)Methanol (gt240k lbs)
StrongStrong ATN amp vision problems ATN amp vision problems
GoodGood Pancreatitis amp Pancreatitis amp Parkinsonrsquosmovement disorders Parkinsonrsquosmovement disorders
Ammonia (gt100k lbs)Ammonia (gt100k lbs)
StrongStrong Asthma acutechronic bronchitis Asthma acutechronic bronchitis olfactory disorders amp rhinitis olfactory disorders amp rhinitis
GoodGood Pulmonary edema Pulmonary edema
Links to Disease contLinks to Disease cont
Xylene (gt95k lbs) amp Toluene (gt83k lbs)Xylene (gt95k lbs) amp Toluene (gt83k lbs) GoodGood Scleroderma arrhythmias menstrual Scleroderma arrhythmias menstrual
do cognitive impairment hearing loss amp do cognitive impairment hearing loss amp fetal death (miscarriagestillbirth)fetal death (miscarriagestillbirth)
Glycol Ethers (gt20k lbs)Glycol Ethers (gt20k lbs) StrongStrong Reduced male fertility abnormal Reduced male fertility abnormal
sperm (morphology motility amp count) amp fetal sperm (morphology motility amp count) amp fetal death (miscarriagestillbirth) death (miscarriagestillbirth)
GoodGood ATN reduced female fertility general ATN reduced female fertility general congenital and craniofacial malformationscongenital and craniofacial malformations
National Report on Human National Report on Human Exposure to Environmental Exposure to Environmental
Chemicals Chemicals (CDC 705)(CDC 705)
Random selection from NHANES Random selection from NHANES surveysurvey
148 chemicals from 2001-2002 inc 148 chemicals from 2001-2002 inc data on 116 chemicals from 1999-data on 116 chemicals from 1999-20002000
Criteria for chemical inclusion Criteria for chemical inclusion wide exposure wide exposure serious health effects serious health effects adequate blood amp urine samples adequate blood amp urine samples efficacy of attempts to reduce efficacy of attempts to reduce
exposure exposure availability of reliable bio-monitoring availability of reliable bio-monitoring
methodmethod
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Our Chemical EnvironmentOur Chemical Environment
1305 Superfund sites1305 Superfund sites 25002500 are are eligible eligible gt80kgt80k hazardous sites hazardous sites knownknown
~11 million people live within 1 mile~11 million people live within 1 mile ~25 live within 4 miles~25 live within 4 miles OR ranks 24OR ranks 24-12 Superfund sites-12 Superfund sites 3 in PDX3 in PDX Harbor Oil Portland Harbor Oil Portland
Harbor Harbor McCormick amp Baxter McCormick amp Baxter Creosoting Co Creosoting Co
Multnomah amp Washington CoMultnomah amp Washington CoShared Pollutants 2002Shared Pollutants 2002
Links to Disease Links to Disease
Methanol (gt240k lbs)Methanol (gt240k lbs)
StrongStrong ATN amp vision problems ATN amp vision problems
GoodGood Pancreatitis amp Pancreatitis amp Parkinsonrsquosmovement disorders Parkinsonrsquosmovement disorders
Ammonia (gt100k lbs)Ammonia (gt100k lbs)
StrongStrong Asthma acutechronic bronchitis Asthma acutechronic bronchitis olfactory disorders amp rhinitis olfactory disorders amp rhinitis
GoodGood Pulmonary edema Pulmonary edema
Links to Disease contLinks to Disease cont
Xylene (gt95k lbs) amp Toluene (gt83k lbs)Xylene (gt95k lbs) amp Toluene (gt83k lbs) GoodGood Scleroderma arrhythmias menstrual Scleroderma arrhythmias menstrual
do cognitive impairment hearing loss amp do cognitive impairment hearing loss amp fetal death (miscarriagestillbirth)fetal death (miscarriagestillbirth)
Glycol Ethers (gt20k lbs)Glycol Ethers (gt20k lbs) StrongStrong Reduced male fertility abnormal Reduced male fertility abnormal
sperm (morphology motility amp count) amp fetal sperm (morphology motility amp count) amp fetal death (miscarriagestillbirth) death (miscarriagestillbirth)
GoodGood ATN reduced female fertility general ATN reduced female fertility general congenital and craniofacial malformationscongenital and craniofacial malformations
National Report on Human National Report on Human Exposure to Environmental Exposure to Environmental
Chemicals Chemicals (CDC 705)(CDC 705)
Random selection from NHANES Random selection from NHANES surveysurvey
148 chemicals from 2001-2002 inc 148 chemicals from 2001-2002 inc data on 116 chemicals from 1999-data on 116 chemicals from 1999-20002000
Criteria for chemical inclusion Criteria for chemical inclusion wide exposure wide exposure serious health effects serious health effects adequate blood amp urine samples adequate blood amp urine samples efficacy of attempts to reduce efficacy of attempts to reduce
exposure exposure availability of reliable bio-monitoring availability of reliable bio-monitoring
methodmethod
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Multnomah amp Washington CoMultnomah amp Washington CoShared Pollutants 2002Shared Pollutants 2002
Links to Disease Links to Disease
Methanol (gt240k lbs)Methanol (gt240k lbs)
StrongStrong ATN amp vision problems ATN amp vision problems
GoodGood Pancreatitis amp Pancreatitis amp Parkinsonrsquosmovement disorders Parkinsonrsquosmovement disorders
Ammonia (gt100k lbs)Ammonia (gt100k lbs)
StrongStrong Asthma acutechronic bronchitis Asthma acutechronic bronchitis olfactory disorders amp rhinitis olfactory disorders amp rhinitis
GoodGood Pulmonary edema Pulmonary edema
Links to Disease contLinks to Disease cont
Xylene (gt95k lbs) amp Toluene (gt83k lbs)Xylene (gt95k lbs) amp Toluene (gt83k lbs) GoodGood Scleroderma arrhythmias menstrual Scleroderma arrhythmias menstrual
do cognitive impairment hearing loss amp do cognitive impairment hearing loss amp fetal death (miscarriagestillbirth)fetal death (miscarriagestillbirth)
Glycol Ethers (gt20k lbs)Glycol Ethers (gt20k lbs) StrongStrong Reduced male fertility abnormal Reduced male fertility abnormal
sperm (morphology motility amp count) amp fetal sperm (morphology motility amp count) amp fetal death (miscarriagestillbirth) death (miscarriagestillbirth)
GoodGood ATN reduced female fertility general ATN reduced female fertility general congenital and craniofacial malformationscongenital and craniofacial malformations
National Report on Human National Report on Human Exposure to Environmental Exposure to Environmental
Chemicals Chemicals (CDC 705)(CDC 705)
Random selection from NHANES Random selection from NHANES surveysurvey
148 chemicals from 2001-2002 inc 148 chemicals from 2001-2002 inc data on 116 chemicals from 1999-data on 116 chemicals from 1999-20002000
Criteria for chemical inclusion Criteria for chemical inclusion wide exposure wide exposure serious health effects serious health effects adequate blood amp urine samples adequate blood amp urine samples efficacy of attempts to reduce efficacy of attempts to reduce
exposure exposure availability of reliable bio-monitoring availability of reliable bio-monitoring
methodmethod
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Links to Disease contLinks to Disease cont
Xylene (gt95k lbs) amp Toluene (gt83k lbs)Xylene (gt95k lbs) amp Toluene (gt83k lbs) GoodGood Scleroderma arrhythmias menstrual Scleroderma arrhythmias menstrual
do cognitive impairment hearing loss amp do cognitive impairment hearing loss amp fetal death (miscarriagestillbirth)fetal death (miscarriagestillbirth)
Glycol Ethers (gt20k lbs)Glycol Ethers (gt20k lbs) StrongStrong Reduced male fertility abnormal Reduced male fertility abnormal
sperm (morphology motility amp count) amp fetal sperm (morphology motility amp count) amp fetal death (miscarriagestillbirth) death (miscarriagestillbirth)
GoodGood ATN reduced female fertility general ATN reduced female fertility general congenital and craniofacial malformationscongenital and craniofacial malformations
National Report on Human National Report on Human Exposure to Environmental Exposure to Environmental
Chemicals Chemicals (CDC 705)(CDC 705)
Random selection from NHANES Random selection from NHANES surveysurvey
148 chemicals from 2001-2002 inc 148 chemicals from 2001-2002 inc data on 116 chemicals from 1999-data on 116 chemicals from 1999-20002000
Criteria for chemical inclusion Criteria for chemical inclusion wide exposure wide exposure serious health effects serious health effects adequate blood amp urine samples adequate blood amp urine samples efficacy of attempts to reduce efficacy of attempts to reduce
exposure exposure availability of reliable bio-monitoring availability of reliable bio-monitoring
methodmethod
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
National Report on Human National Report on Human Exposure to Environmental Exposure to Environmental
Chemicals Chemicals (CDC 705)(CDC 705)
Random selection from NHANES Random selection from NHANES surveysurvey
148 chemicals from 2001-2002 inc 148 chemicals from 2001-2002 inc data on 116 chemicals from 1999-data on 116 chemicals from 1999-20002000
Criteria for chemical inclusion Criteria for chemical inclusion wide exposure wide exposure serious health effects serious health effects adequate blood amp urine samples adequate blood amp urine samples efficacy of attempts to reduce efficacy of attempts to reduce
exposure exposure availability of reliable bio-monitoring availability of reliable bio-monitoring
methodmethod
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
CDC Report GoalsCDC Report Goals
Which chemicals are present amp Which chemicals are present amp concentrations concentrations
How many people have levels above How many people have levels above known toxicity thresholdsknown toxicity thresholds
Establish reference ranges Establish reference ranges Determine if levels are higher in at Determine if levels are higher in at
risk populations risk populations Track trends over time Track trends over time Set priorities for researchSet priorities for research
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
CDC Report HighlightsCDC Report Highlights
First time data for 38148 chemicalsFirst time data for 38148 chemicals BLL declining 44 of children early BLL declining 44 of children early
1990s 16 of children from 1999-1990s 16 of children from 1999-20022002
Hg in women of childbearing age Hg in women of childbearing age 57 have concerning levels57 have concerning levels
Pyrethroid insecticides (common Pyrethroid insecticides (common home use) 76 of populationhome use) 76 of population
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Highlights contHighlights cont
Levels of 3 toxic pesticides- Levels of 3 toxic pesticides- Aldrin Dieldrin amp Endrin-very low Aldrin Dieldrin amp Endrin-very low
29 Dioxin-like compounds levels are 29 Dioxin-like compounds levels are declining declining
Cadmium 5 population gt20yrs age Cadmium 5 population gt20yrs age levels near toxic limit (kidney dz low levels near toxic limit (kidney dz low BMD)BMD)
Phthalates widespread higher in Phthalates widespread higher in women amp childrenwomen amp children
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Limitations of Current DataLimitations of Current Data
Exposure to chemical mixtures Exposure to chemical mixtures common-research more complexcommon-research more complex
Data available for only minority Data available for only minority single agentssingle agents
Epidemiological amp animal studies Epidemiological amp animal studies often only data availableoften only data available
Result links btw Chronic Diseases amp Result links btw Chronic Diseases amp low dose chronic complex exposures low dose chronic complex exposures hard to ldquoproverdquohard to ldquoproverdquo
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
PROVEN HARM
PARTIALLY PROVEN
NOT YET RECOGNIZED
FOREVER UNRECOGNIZED
THE TOXIC ICEBERG________________________________________
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Oregoniansrsquo HealthOregoniansrsquo Health12 CHEMICALS OF KEY CONCERN12 CHEMICALS OF KEY CONCERN 1048698 1048698 acroleinacrolein 1048698 1048698 benzenebenzene 1048698 1048698 benzo(a)pyrenebenzo(a)pyrene 1048698 1048698 bisphenol-Abisphenol-A 1048698 1048698 brominated flame retardants (BFRs)brominated flame retardants (BFRs) 1048698 1048698 dieseldiesel 1048698 1048698 dioxindioxin 1048698 1048698 formaldehydeformaldehyde 1048698 1048698 leadlead 1048698 1048698 mercurymercury home amp garden pesticideshome amp garden pesticides 1048698 1048698 phthalatesphthalates
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
A 52 yr-old pt co increasing tremor A 52 yr-old pt co increasing tremor On PE the tremor is pill-rolling and On PE the tremor is pill-rolling and resolves with intention +Romberg resolves with intention +Romberg sign unstable tandem gaitsign unstable tandem gait
You make a preliminary diagnosis of You make a preliminary diagnosis of early Parkinsonrsquos diseaseearly Parkinsonrsquos disease
Wife mentions reading about Wife mentions reading about environmental links to PD pt is a environmental links to PD pt is a farmer and has used pesticides for farmer and has used pesticides for years Could this be related to his years Could this be related to his diseasedisease
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
Paraquat rotenone organophosphates Paraquat rotenone organophosphates dieldrin and fungicides maneb amp dieldrin and fungicides maneb amp mancozeb implicatedmancozeb implicated
MPTP a designer heroin-like drug MPTP a designer heroin-like drug causes Parkinsonian syndrome in causes Parkinsonian syndrome in addictsaddicts
Higher incidence in industrialized Higher incidence in industrialized countries greatest risk in rural countries greatest risk in rural areasfarms prolonged pesticide useareasfarms prolonged pesticide use
Case control studies herbicide or Case control studies herbicide or insecticide exposure 3-4x likelyinsecticide exposure 3-4x likely
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Pesticides amp ParkinsonrsquosPesticides amp Parkinsonrsquos
2005 Brown T et al Meta-analysis 2005 Brown T et al Meta-analysis of epidemi-ologic amp toxicologic of epidemi-ologic amp toxicologic studies since 1983 studies since 1983
Verified most of these links noting Verified most of these links noting limitations in study designs limitations in study designs
Conclusion ldquogeneric association btw Conclusion ldquogeneric association btw pesticide exposure amp PD exists but pesticide exposure amp PD exists but is insufficient tohellipconcludehellipa causal is insufficient tohellipconcludehellipa causal relationshiprdquo relationshiprdquo
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Pesticides Genes amp PDPesticides Genes amp PD
Dr W Langston of Parkinsonrsquos Dr W Langston of Parkinsonrsquos Institute ldquoAccelerating Research on Institute ldquoAccelerating Research on Genes and Environment in Genes and Environment in Parkinsonrsquos Diseaserdquo (2005)Parkinsonrsquos Diseaserdquo (2005)
Two PD studies underway one in Two PD studies underway one in pesticide applicators other in two pesticide applicators other in two CA counties with known heavy CA counties with known heavy exposureexposure
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Other Health Impacts of Other Health Impacts of PesticidesPesticides
ArrhythmiasArrhythmiasAsthmaAsthmaLymphomas Brain tumorsLymphomas Brain tumorsAbnormal sperm countsAbnormal sperm countsBirth defects amp developmental delaysBirth defects amp developmental delaysHyperactivity amp behavioral problemsHyperactivity amp behavioral problemsDecreased endurance amp coordinationDecreased endurance amp coordinationNeurocognitive problemsNeurocognitive problemsPeripheral neuropathiesPeripheral neuropathies
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Pesticides a Persistent Pesticides a Persistent ProblemProblem
Major classesMajor classes insecticides fungicides insecticides fungicides herbicides rodenticidesherbicides rodenticides
1997 Market1997 Market US $119 billion World $37 US $119 billion World $37 billionbillion
HistoryHistory synthetic-new to humans amp synthetic-new to humans amp environment since 1940s gt800 licensed environment since 1940s gt800 licensed ldquoactiverdquo ingredientsldquoactiverdquo ingredients
Manufacturers Manufacturers Bayer Aventis other drug Bayer Aventis other drug coco
Inherent toxicityInherent toxicity 140 pesticides considered 140 pesticides considered neurotoxic 37 are used on food ampor feedneurotoxic 37 are used on food ampor feed
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Insecticide Sites of Insecticide Sites of ActionAction
Enzymes
Axonal Membranes
Ions (Na+ K+ Ca++ Cl-)
Enzymes
Neurotransmitters
Organochlorines
Pyrethroids
Casarett and Doullrsquos Toxicology The Basic Science of Poisons 5th Edition Ed Klaassen CD
McGraw-Hill New York 1996 P 649
Organophosphorus and
Carbamate Esters
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Organophosphate PesticidesOrganophosphate PesticidesOccurrence and distribution in surface amp
ground water of the United States 1992-97
httpgawaterusgsgovpublicationsabstractsofr00-187html
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Background Pesticide Background Pesticide Exposures WidespreadExposures Widespread
Reported useReported use 98 of families 80 during 98 of families 80 during pregnancypregnancy
In HumansIn Humans detectable chlorpyrifos detectable chlorpyrifos metabolites in 92 of childrenrsquos 82 of metabolites in 92 of childrenrsquos 82 of adultsrsquo urine samplesadultsrsquo urine samples
In FoodIn Food residues of at least one pesticide on residues of at least one pesticide on 72 fruits amp vegetables72 fruits amp vegetables
In HomesIn Homes 3 to 9 pesticide residues found3 to 9 pesticide residues found
In AirIn Air indoor levels 10-100X higher than indoor levels 10-100X higher than outdooroutdoor
In WaterIn Water gt90 stream samples 50 of gt90 stream samples 50 of wellswells
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Sources of PesticidesSources of Pesticides
Household uses lawn amp garden Household uses lawn amp garden sprays exterminators flea collarssprays exterminators flea collars
Household dust (tracking in on shoes)Household dust (tracking in on shoes)
Public schools hospitals parks Public schools hospitals parks childcare facilitieschildcare facilities
Agricultural uses amp workersrsquo clothesAgricultural uses amp workersrsquo clothes
Non-organic foodsNon-organic foods
Breast milkBreast milk
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Strategies to Reduces Strategies to Reduces Exposure to Home amp Garden Exposure to Home amp Garden
Pesticides in OregonPesticides in OregonPolicy SolutionsPolicy Solutions OR pesticide use reporting system OR pesticide use reporting system
(1999) finally funded 2005(1999) finally funded 2005 Educate homeowners re nontoxic Educate homeowners re nontoxic
options options Enc pet owners to use flea combs and Enc pet owners to use flea combs and
vacuuming to control fleasvacuuming to control fleas Enc public places to use Integrated Enc public places to use Integrated
Pest Management (IPM) ie Pesticide Pest Management (IPM) ie Pesticide Free ParksFree Parks
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
What YOU Can Do about What YOU Can Do about PesticidesPesticides
Advise PatientsAdvise Patients Regularly dustRegularly dust Use Integrated Pest Management Use Integrated Pest Management Cleanremove shoes outsideCleanremove shoes outside Keep contaminated clothes separateKeep contaminated clothes separate Buy sustainably grown foodBuy sustainably grown food Store food in secure nontoxic Store food in secure nontoxic
containerscontainers
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Mercury amp Women of Mercury amp Women of Childbearing AgeChildbearing Age
A 32 yo G0P0 woman of A 32 yo G0P0 woman of childbearing age (WCBA) childbearing age (WCBA) presents for annual PE presents for annual PE
PMH negativePMH negative
Social hx husband is Social hx husband is recreational fisherman recreational fisherman
Contemplating pregnancy Contemplating pregnancy
Should she avoid fish Should she avoid fish because of mercury risks because of mercury risks to the fetusto the fetus
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Mercury amp WCBAMercury amp WCBA
gt10gt10 of WCBA exceed safe limit of of WCBA exceed safe limit of 1ugkgday1ugkgday
5050 of women of women who eat fishwho eat fish exceed exceed limitlimit
5757 of WCBA have Hg levels of WCBA have Hg levels concerning for adverse effects concerning for adverse effects (CDC (CDC Natrsquol Report 0705Natrsquol Report 0705))
Higher risk Higher risk 300 000 childrenyear 300 000 childrenyear subsistence fishers immigrants subsistence fishers immigrants Native AmericansNative Americans
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Mercury amp WCBAMercury amp WCBA
Hg enters tissues variable excretionHg enters tissues variable excretion Breast Milk PCBs DDT amp other Breast Milk PCBs DDT amp other
pesticides dioxins dibenzofurans pesticides dioxins dibenzofurans toxic flame retardants amp heavy toxic flame retardants amp heavy metals (Pb amp Hg) metals (Pb amp Hg)
No bio-accumulation in milk but No bio-accumulation in milk but levels in fish-eaters may exceed levels in fish-eaters may exceed unexposed women by 100x unexposed women by 100x
Scientific evidence indicates Scientific evidence indicates advantages of breast-feeding advantages of breast-feeding outweigh riskshellipoutweigh riskshellip
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Neuro Effects of MercuryNeuro Effects of Mercury
Cerebral palsyCerebral palsy MRDDMRDD disequilibrium ataxiadisequilibrium ataxia hearing lossdeafnesshearing lossdeafness visual visual
impairmentblindnessimpairmentblindness peripheral neuropathyperipheral neuropathy parasthesiasparasthesias tremors seizures tremors seizures abnl reflexes amp muscle toneabnl reflexes amp muscle tone Psychiatric disturbances Psychiatric disturbances
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Mercury a Persistent Mercury a Persistent ProblemProblem
PoisoningsPoisonings Minamata 1950s amp Iraq Minamata 1950s amp Iraq 19711971
Nationally ~Nationally ~160 tons of Hg annually160 tons of Hg annually In OregonIn Oregon ~ ~4500 lbs annually4500 lbs annually Lack of regulationLack of regulation In OR 10 facilities In OR 10 facilities
report Hg release-none has a permit or is report Hg release-none has a permit or is required to monitor emissions by staterequired to monitor emissions by state
Fish AdvisoriesFish Advisories in 2004 45 states had in 2004 45 states had gt2000 warnings Oregon lists advisories gt2000 warnings Oregon lists advisories for 12 water bodies inc Willamette for 12 water bodies inc Willamette
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Atmospheric HgAtmospheric Hg
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
The Mercury CycleThe Mercury Cycle
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
MercuryMercuryDeclining Threshold of Declining Threshold of
HarmHarm
2000199019801970001
01
1
10
100
YEAR
Level associated with harmful effectRegulatory standard (maximum safe exposure or high end exposure from allowed fish contamination)
FDA WHO
EPA
ATSDR
DA
ILY
IN
TA
KE
(mic
rogr
ams
kg
day
Hg)
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Sources of MercurySources of MercuryIndustrial emissions Industrial emissions
coal fired plantscoal fired plantsMunicipal amp medical Municipal amp medical
waste incineratorswaste incineratorsAbandoned Hg amp gold Abandoned Hg amp gold
minesminesNatural off-gassing Natural off-gassing Dental amalgamsDental amalgamsBioaccumulation in Bioaccumulation in
foods esp fishfoods esp fishOld thermometers BP Old thermometers BP
cuffs amp auto cuffs amp auto switchesswitches
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Strategies to Reduce Strategies to Reduce Mercury Pollution in Mercury Pollution in
OregonOregonPolicy SolutionsPolicy Solutions Mercury Solutions Act of 2001Mercury Solutions Act of 2001 Ensure safe collection amp recyclingEnsure safe collection amp recycling Clean up abandoned mines and Clean up abandoned mines and
SuperfundsSuperfunds Reduce Hg emissions from health Reduce Hg emissions from health
care facilitiescare facilities Inc Hg in applicable DEQ air amp Inc Hg in applicable DEQ air amp
water permitswater permits Coal burning power plant Boardman Coal burning power plant Boardman
OR OR Implement OR Executive OrderImplement OR Executive Order
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
What YOU Can Do about What YOU Can Do about MercuryMercury
Advise PatientsAdvise Patients Provide Provide An Expectant Motherrsquos Guide to An Expectant Motherrsquos Guide to
Eating Fish in Oregon (DHS) Eating Fish in Oregon (DHS) in waiting in waiting roomsrooms
Rec WCBA and children avoid fish wHgRec WCBA and children avoid fish wHg Enc WCBA to consume low-fat dietEnc WCBA to consume low-fat diet Recycle old Hg thermometers Recycle old Hg thermometers
thermostats amp fluorescent light tubesthermostats amp fluorescent light tubes Have car checked for Hg switches at Have car checked for Hg switches at
participating auto shop (free participating auto shop (free replacement)replacement)
Use digital thermometers amp thermostatsUse digital thermometers amp thermostats
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
SummarySummary Chronic Diseases are prevalent Toxic Chronic Diseases are prevalent Toxic
exposures are possible exposures are possible preventablepreventable contributorscontributors
Pesticides amp risk of Parkinsonrsquos and Mercury Pesticides amp risk of Parkinsonrsquos and Mercury risks to WCBA are more understood than most risks to WCBA are more understood than most toxins and other chronic diseasestoxins and other chronic diseases
Apparent toxicity at high doses should be a Apparent toxicity at high doses should be a red flag for possible harm from low dose red flag for possible harm from low dose chronic exposureschronic exposures
Since ldquoproofrdquo of harm materializes slowly Since ldquoproofrdquo of harm materializes slowly generations are at risk and may be harmed generations are at risk and may be harmed before adequate regulatory response occursbefore adequate regulatory response occurs
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Kaiser amp HCWHh2eKaiser amp HCWHh2e
Clean Diesel Hospital Zones ProjectClean Diesel Hospital Zones Project Healthy Food in Healthcare InitiativeHealthy Food in Healthcare Initiative Green Building PVC and DEHP free Green Building PVC and DEHP free
NICU NICU Environmentally preferable purchasing Environmentally preferable purchasing
policypolicy Making Medicine Mercury Free Award Making Medicine Mercury Free Award h2e Environmental Leadership Award h2e Environmental Leadership Award
20022002
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
What Can You DoWhat Can You Do
Be aware of environmental toxins amp Be aware of environmental toxins amp their possible links to chronic diseasestheir possible links to chronic diseases
Provide advice amp education on Provide advice amp education on prevention andor minimizing prevention andor minimizing exposures or refer appropriately exposures or refer appropriately
Incorporate environmental questions Incorporate environmental questions into clinical historyinto clinical history
Advocate Advocate wwwenvirohealthactionorgwwwenvirohealthactionorg
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Local AdvocacyLocal Advocacy Oregon Environmental CouncilOregon Environmental Council wwwoeconlineorgwwwoeconlineorg Oregon Collaborative on Health amp Oregon Collaborative on Health amp
EnvironmentEnvironment Healthy Environment ForumsHealthy Environment Forums Oregon Center for Environmental HealthOregon Center for Environmental Health wwworegon-healthorgwwworegon-healthorg Healthcare without HarmHealthcare without Harm Hospitals for Healthy Environment (h2e)Hospitals for Healthy Environment (h2e) Oregon PSROregon PSR wwworegonpsrorgwwworegonpsrorg Environmental Health-In Harmrsquos Way Environmental Health-In Harmrsquos Way
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
wwwhealthandenvironmentorgwwwhealthandenvironmentorg
Conference calls on Conference calls on Environmental HealthEnvironmental Health
CHE Oregon (OEC) CHE Oregon (OEC) Working group on Provider educationWorking group on Provider education Media amp Research GroupMedia amp Research Group
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice
Knowledge - Knowledge - ResponsibilityResponsibility
Hippocratic Oath amp primum non nocere reflect philosophy of prevention and minimizing harm
Precautionary Principle when evidence points toward potentially significant widespread or irreparable harm to health or the environment options to avoid harm should be pursued even if harm is not yet fully understood or proven
Ethical Responsibility to share and use knowledge to prevent and minimize harm
Duty to promote health and well being of patients and community
Possible to be a thoughtful public health advocate in everyday practice