Exencephaly

Polyvinyl Chloride (PVC) is a plastic that emits poisons while its being manufactured, while its incinerated and sometimes during medical usages. PVC items are pervasive in health care, one quarter of all plastic medical products is made of it. These items include IV and blood bags, enterai feeding devices, tubing, endotracheal tubes ,oxygen tents, mattress covers, packaging, basins, hemodialysis equipment, patient i.d. bracelets ,bedpans, respiratory therapy products, catheters, thermal blankets, lab equipment and medical gloves. Non-medical hospital uses for PVC are found in office supplies and hospital building materials. Health concerns with PVC result from two toxic chemicals with which it is associated.

Dioxins are a group of persistent and very toxic chemicals that are the by-products of PVC production. In addition, they are released into the air in emissions from municipal solid waste and industrial incinerators, including hospital incinerators. When released into the air they may be transported long distances, even around the globe. Like mercury, dioxin bioaccumulates up the food chain. Contamination in the food chain begins with dioxin particles in water or soil and then proceeds to fish and livestock, ultimately reaching humans through the food we eat.

When dioxin is consumed by humans, in the form of beef, fish, and dairy products, it is stored in the fatty tissue-it is lipophilic. Human babies who are breastfed, and for whom it can be said are at the very top of the food chain, receive 10% of their lifetime exposure to dioxin from their mother's fat-laden milk. As nurses, we should continue to advocate that women breast feed, as we concurrently advocate for policies and practices that will decrease the dioxin levels in our environment.

Studies of humans occupationally exposed have shown dioxins to be associated with cancers of the lung, thyroid gland, hematopoietic system, and liver, as well as connective and soft tissue sarcoma (Thornton et al., 1996). According to the Environmental Protection Agency (EPA) draft report on dioxin's health effects, the levels of dioxinlike compounds found in the general population may cause a lifetime cancer risk as high as lin 1,000. This is 1,000 times higher than the generally "acceptable" risk of one in a million.

In addition to dioxin's carcinogenicity status, it is also a known endocrine disruptor, a chemical that mimics or otherwise disrupts normal hormone activity.

Endocrine disruption can occur at extremely small doses of exposure. "Human studies designed to examine reproductive or developmental effects of dioxin exposure have produced mixed results... Nevertheless, there is now sufficient evidence to conclude that dioxin is probably a cause of some birth defects. There is also evidence that testosterone levels are depressed in occupationally-exposed workers, and thyroid hormone is depressed in infants exposed at ambient levels through breast feeding." (Schettler et al, 2000).

There is another toxic chemical associated with the use of PVC. Because PVC is very brittle, plasticizers are added for flexibility and softness. Di(2-ethylhexyl) phthalate (DEHP) is a common plasticizer in PVC. By weight, DEHP comprises 20-40% of the PVC products on average. However, this additive does not actually bond with the PVC and is subject to leaching, or breaking free from the PVC under certain conditions. Conditions that promote this leaching include heating the product and when the medical device contacts fluids. DEHP migrates into a variety of fluids including blood, plasma, and total parenteral and enterai nutrition solutions. During medical interventions that require long-term IV interaction such as blood transfusions, hemodialysis or extracorporeal membrane oxygenation (ECMO), DEHP exposure is significantly enhanced due to the increased exposure time. Pediatric exposures are of the greatest concern. Sick newborns and infants face the greatest risk of exposure from medical interventions and may also be the most vulnerable to the toxic effects of DEHP because of their stage in human development. A NICU infant may come into contact with this chemical from a variety of sources, resulting in the infant receiving what amounts to a megadose.

While there are no human studies of DEHP, animal studies indicate that the liver, kidneys, heart, lungs and reproductive organs are those organs that are particularly at risk for damage. On the basis of these animal studies, the U.S. Food and Drug Administration (FDA), in 2001, released a safety assessment of DEHP in PVC devices, concluding that, the following medical procedures posed a risk to patients: adults and infants undergoing ECMO; infants undergoing exchange transfusions; all patients receiving enterai nutrition; infants receiving total parenteral nutrition; adults undergoing cardiopulmonary bypass; and nursing infants of mothers on hemodialysis. (A summary of this assessment can be found on the HCWH web site at: http://www.noharm.org/library/docs/Going_Green_3_A_Summary_of_the_FDA_Safety_As.pdf

In addition, the National Toxicology Program expressed concern about DEHP exposure among three groups of patients including: critically ill infants, healthy infants and toddlers, and babies of pregnant or lactating women. (A summary of this report can also be found on the HCWH web site at (http://www.noharm.org/ library/docs/Going_Green_3_7_A_Summary_of_the_NTP_Expert_Pa.pdf Actions

The solution for these problems is to establish and implement PVC reduction programs in healthcare facilities, this process can include these steps: (1) establish a PVC reduction policy, (2) educate staff, (3) collect data, (4) identify PVC- and DEHP- free alternatives and (5) develop and implement a PVC reduction plan.

This process is described in the document Setting Healthcares Environmental Agenda (SHEA, 2000).

The Hospitals for a Healthy Environment, Health Care Without Harm, and Sustainable Hospitals websites all have excellent guidance for reducing PVC use in hospitals, with valuable information on the alternatives. They also provide comprehensive guidance on waste reduction. see: _http://www.h2e-online.org/, and www.noharm.org and www.sustainablehospitals .org

On the topic of PVC, the ANA has again taken a leadership role, publishing press releases and statements to educate nurses on the environmental problems with which it is associated. For further resources from the ANA intended to help nurses act to reduce the toxic pollution created as a health care industry byproduct the reader is referred to the RNnoharm/Pollution Prevention web page on the ANA web site: http://www.nursingworld.org/rnnoharm and http://nursingworld.org/mods/mod370/ehhcs.pdf

Examples:

DEHP Plasticized PVC Products in the NICU

Feeding Related Products Intravenous Products

Breast milk delivery tube IV bags

Enterai feeding bags IV tubing

Lipid extension tubes Red blood cell bags

NG tubes

Tubing for breast pumps Sources of Dermal Exposure

Exam gloves

Respiratory Therapy Products Patient ID bracelets

ET tubes and trach tubes

Humidifier (sterile water bags, tubing) Other Potential

PVC Products

Oxygen masks and tubing Drainage tubes and bags

Resuscitators, O2 reservoir bags Isolette portal covers

Suction tubing Mattress covers

Ventilator tubing Flooring and wall covering

Ostomy and neuro shunt bags

Umbilical vessel catheters

[Sources: Sustainable Hospital Project, 2000, "Alternative Products," see: http://www.uml.edu/centers/LCSP/hospitals/ (Lowell: Sustainable Hospitals Project, UMASS Lowell); and Tickner, et al., 1999, The Use of Di-2-Ethylhexyl Phthalate in PVC Medical Devices: Exposure Toxicity, and Alternatives (Lowell: Lowell Center for Sustainable Production, UMass Lowell)]

Relevant Animal Studies regarding DEHP exposures and toxic effects:

Animal Species Target Organ Effect

Rat Testes Disorganization of seminiferous tubule structure in male offspring, sertoli cell vacuolation, atrophy of seminiferous tubules, loss of spermato genesis, testicular an epididymalatrophy, testicular agenesis, hemorrhagic testes, and hypospadias

Rat Ovaries Suppressed or delayed ovulation, suppressed estradiol production, poly cystic ovaries

Human neonate Lungs Respiratory distress, pathological changes resembling hyaline membrane disease

Rat Heart Decreased heart rate and blood pressure

Rat Kidneys Reduction in creatinine clearance, cystic changes

Mouse Fetus/embryo Fetal death, exencephaly, open neural tubes, reduced pup size

Monkey Liver Abnormalities in histology, reduced liver function

Table adapted from Table 1. Toxicity of DEHP to Various Organ Systems, p. 3, in Neonatal Exposure to DEHP and Opportunities for Prevention, Mark Rossi, 2000.

To download the entire report with full scientific references, see: _http://www.noharm.org/library/docs/ Neonatal_Exposure_to_DEHP_di-2-ethylhexylphth .pdf

References:

Setting Healthcares Environmental Agenda (SHEA), (October, 2000) [On-line]. Available (page 30) http://www.noharm.org/library/docs/Setting_Healthcares_Environmental_Agenda .pdf

Schettler, T, Stein, J, Reich, E, & Valenti, M. (2000). In Harms Way: Toxic threats to child development, GBPSR. Thornton, J., McCally, M. & Orris, P. (1996). Hospital and plastics. Public Health Reports, 11, 298-313.

by Barbara Saltier, RN, DrPH & Marian Condon, RN, MS

About the Authors:

Barbara Sattler, RN, DrPH is the Director of the Environmental Health Education Center at the University of Maryland School of Nursing. Bsattler@son.umaryland.edu www.enviRN.umaryland.edu

Marian Condon, RN, MS is a graduate of the Community/Public Health Masters program at the University of Maryland and currently works as a Research Project Manager at the Occupational Health Program at the University of Maryland School of Medicine.

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