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HEALING WITHOUT HARM REDUCING EXPOSURE TO ENDOCRINE DISRUPTORS IN HOSPITALSPILOT PROJECT AT PIERRE BOUCHER HOSPITAL’S NEONATAL UNIT

SYNERGIE SANTÉ ENVIRONNEMENT

–Non-profit founded in 2006 by health care professionals–Administered by a board of directors from a health care network.–Mission : Support health facilities in reducing their environmental impact

and improving their environmental practices by applying the principles of environmental health and sustainable development.Services: Status reports, development of policies and action plans, training, pilot project implementation, implementation of participatory action plans–Membership: 19 health institutions (CISSS, CIUSSS, CHU) members, ie 41

hospitals, 147 shelters and 98 CLSCs, 5 educational institutions and 2 associations (1 purchasing group and 1 union)

CANADIAN COALITION FOR GREENHEALTH CARE

–Non-profit created in 2001 by health care organisations

–Administered by a board of directors from a health care network.

–Mission: The Canadian Coalition for Green Health Care enables the health care sector to lead the integration of environmentally responsible practices into the delivery of health care.

–Services: resources, pilot projects, webinars, workshops, training, Green Health Digest, Research projects, onsite energy services.

–Membership: represents 40% of hospital beds across Canada

SAFER CHEMICAL PROJECT OBJECTIVES• Reduce toxic and hazardous waste generated by health care facility

(HCF) operations to water through:– Identification, evaluation and implementation of innovative, safer chemical

technologies and product use strategies.• Reduction target:

–250 kgs of toxics and other waste per year to water• Use of project results:

–Develop best practices to reduce chemicals in HCFs –Share key successes and lessons learned

PROJECT ACTIVITIES

• Engage HCFs willing to pilot new safer chemical systems & strategies

PROJECT ACTIVITIES• Engage technical partners to provide information on purchasing, technological systems,

infection control and safer chemicals for health care– Class 1 Inc

•Shared expertise on UV disinfection

– Crothall Healthcare •Provided labour and testing for aqueous ozone pilot at Lower Mainland Health Organizations

– Coalition for Healthcare Acquired Infection Reduction (CHAIR)•Shared expertise on health care infection reduction

– Tersano•Provided 2 Aqueous Ozone units and training for St Martha’s Hospital pilot•Provided information for pilot at Lower Mainland Health Organizations

PROJECT ACTIVITIES

• Background research• Establish baselines

–Chemical/product purchasing, use, and waste generation

• Complete pilot projects with final evaluation• Share findings and recommendations

SAFER CHEMICAL PROJECT COLLABORATORS

Lower Mainland Health Organizations, BC

St. Martha's Regional Hospital, NS

THIS PROJECT WAS UNDERTAKEN WITH THE FINANCIAL SUPPORT OF

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ENDOCRINE DISRUPTORS

Lise Parent, Ph.D.Petya Grigorova, Ph.D.TÉLUQ UNIVERSITY

RESULTS OF THE TESTS ON THE SAMPLES Tests sanguins1,1,1-Trichloroéthane1,1,2-Trichloroéthane1,1-Dichloroéthène1,2,4-Triméthylbenzène1,2-Dichlorobenzène1,2-Dichloroéthane1,2-Dichloropropane1,3- Dichlorobenzène1,3,5- Triméthylbenzène1,4- DichlorobenzèneAldrineArgentArsenicBenzèneBérylliumBismuthBPC 101BPC 128BPC 138BPC 163BPC 183BPC 187BPC Aroclor 1260BPC-105BPC-118BPC-153BPC-156BPC-170BPC-180

BPC-28BPC-52BPC-99BromodichlorométhaneCadmiumChlorobenzèneChloroformeCis-1,2-DichloroéthèneCis-nonachloreCobaltCuivreDibromochlorométhaneDichlorométhaneDithiophosphate de

diéthyleDithiophosphate de

diméthyleÉtainÉthylbenzèneHexachlorobenzèneLithiumManganèseMercureMéta-xylènesMirexMolybdèneMTBENickelOxychlordane

p,p'-DDEp,p'-DDTPara-xylènePBBPBDÉ 100PBDÉ 153PBDÉ 47PBDÉ 99Phosphate de diéthylePhosphate de diméthylePlombSéléniumStyrolèneSulfonate de perfluorooctaneTellureTétrachloroéthaneTetrachloroéthylèneTétrachlorure de carboneThalliumThiophosphate de diéthyleThiophosphate de diméthyleToluèneToxaphène 26Toxaphène 50Trans-1,2-dichloroéthèneTrans-nonachloreTrichloroéthèneUraniumZinc

Poussière4-nonylphenolnonylphenol monoethoxylatenonylphenol diethoxylate4-octylphenoloctylphenol monoethoxylateoctylphenol diethoxylate4-tert-methylbutylphenolα-chlordane (alpha-chlordane)γ-chlordane (gamma-chlordane)2-bis(4-chlorophenyl)-1,1,1-

trichloroethane4,4-DDTdiazinondicofol + 4,4’-dichlorobenzophenone(breakdown product)dieldrinmethoxychlorpentachloronitrobenzenepentachlorophenolcis-permethrintrans-permethrinpiperonyl butoxidepropoxurperfl uorooctanoic acidperfl uorooctanyl sulfonatedimethyl phthalatediethyl phthalatedi-n-propyl phthalate

diisobutyl phthalatedi-n-butyl phthalatebutylbenzyl phthalatedi(2-ethylhexyl) phthalate[bis(2-ethylhexyl)phthalate]2,2’,4,4’-tetrabromodiphenyl

ether2,2’4,4’,5-pentabromodiphenyl

ether 2,2’,4,4’,6-pentabromodiphenyl

ether2,2’, 4,4’, 5,5’-hexabromodiphenyl

ether2,2’,4,4’5,6’-hexabromodiphenyl

ether2,2’,3,4,4’,5’,6-heptabromodiphenyl

etherdecabromodiphenyl ethermonobutyltindibutyltintributyltintetrabutyltindioctyltintricyclohexyltintriphenyltin

BODY BURDEN IS A TERM THAT REFERS TO THE TOTAL ACCUMULATION OF TOXINS IN YOUR BODY

• Is it normal to have all of these substances in our bodies? • Even babies have been found to have a body

burden at birth• This has been detected even in very remote

geographical areas ….

WHAT IS A TOXIC SUBSTANCE?

• The obvious, with immediate effects: poison, corrosive, irritant• The less obvious, with effects that can appear

later on: carcinogenic, teratogenic, mutagenic

ENDOCRINE DISRUPTORS?

ENDOCRINE DISRUPTOR

• Exogenous substance that alters the function(s) of the endocrine system and causes adverse health effects in an individual or his progeny

An ED disrupts the hormonal message and causes health problems to an individual or their children

THE ENDOCRINE SYSTEM

THE INFLUENCE OF HORMONES IS VERY IMPORTANT FROM THE FIRST MOMENTS OF YOUR LIFE AND ONWARDS

–Fetus development

–Childbirth

–Lactation

–Growth

–Puberty

–Reproduction

HORMONES PLAY A PART IN OUR DAILY ACTIVITIES

FEMINIZED FISH

• In the St. Lawrence River and elsewhere in the world, more and more male fish also have...ovaries!

HEALTH PROBLEM TO BE LINKED TO THE ED• Infertility

• Changes in the males / females ratio

• Miscarriage

• Low Birth Weight

• Sexual Anomalies

• Early Puberty

• Behavioral Disorders

• Increased rates of other cancers

• Immune system alteration

• Obesity

ENDOCRINE DISRUPTORS DURING DEVELOPMENT

This is the latest report published by the World Health Organization and the United Nations Environment Program

The report states that exposure to endocrine disruptors during development is considered to be a significant risk factor for developing a chronic disease

http://www.who.int/ceh/publications/endocrine/en/index.html

State of the science of endocrine disrupting chemicals - 2012An assessment of the state of the science of endocrine disruptors prepared by a group of experts for the United Nations Environment Programme (UNEP) and WHO

http://www.who.int/ceh/publications/endocrine/en/index.html

TESTICULAR CANCER IN NORTHERN EUROPEAN COUNTRIES

1989-1994 1998-2003

State of the science of endocrine disrupting chemicals - 2012An assessment of the state of the science of endocrine disruptors prepared by a group of experts for the United Nations Environment Programme (UNEP) and WHO

http://www.who.int/ceh/publications/endocrine/en/index.html

SOME CONCLUSIONS

• Everyone is exposed to ED• Rapid increase in chronic diseases (and those related to ED =

underestimated)• Can epidemiological studies link ED exposure to diseases• Critical periods of exposure: fetal, neonatal and puberty

CHALLENGES POSED BY ED

• Effects at very low doses• The effect is not the same depending on the moment of life

when the exposure occurs•Multiple exposures daily•Misunderstood interactions (cocktail effect)• Effects are not visible immediately (transgenerational effects)

CHALLENGES POSED BY ED

• Effects at very low doses• The effect is not the same depending on the moment of life

when the exposure occurs•Multiple exposures daily•Misunderstood interactions (cocktail effect)• Effects are not visible immediately (transgenerational effects)

DO WE NEED TO WORRY ABOUT OUR CHILDREN?• They are more vulnerable

–They are more exposed than adults

–Eat, drink and breathe more frequently ...

–Play near the ground and dust

–Carry objects and their hands to their mouths

–Their skin is thinner and absorbs more

• They are developing

CHALLENGES POSED BY ED

• Effects at very low doses• The effect is not the same depending on the moment of life

when the exposure occurs•Multiple exposures daily•Misunderstood interactions (cocktail effect)• Effects are not visible immediately (transgenerational effects)

ORIGIN OF DETECTED SUBSTANCESPhtalates

dimethyl phthalate (DMP)diethyl phthalate (DEP)diisobutyl phthalate (DiBP)di-n-butyl phthalate (DBP)butylbenzyl phthalate (BBzP)di(2-ethylhexyl) phthalate[bis(2-ethylhexyl)phthalate] (DEHP)

Styling productsPersonal care productsIndoor air freshenersScented productsContainers and plastic wrapToysBiomedical productsPerfumes and scented products

Composés perfluorés

perfluorooctanoic acidperfluorooctanyl sulfonate

Non-stick frying pansFood packagingFabrics and carpetsBody creamsDental bristlesMedical and sports equipmentAthletic wearElectronic appliances

CHALLENGES POSED BY ED

• Effects at very low doses• The effect is not the same depending on the moment of life

when the exposure occurs•Multiple exposures daily•Misunderstood interactions (cocktail effect)• Effects are not visible immediately (transgenerational effects)

CHALLENGES POSED BY ED

• Effects at very low doses• The effect is not the same depending on the moment of life

when the exposure occurs•Multiple exposures daily•Misunderstood interactions (cocktail effect)• Effects are not visible immediately (transgenerational effects)

EPIGENETIC REPROGRAMMING

Felici, MD & Sala, GL (2015) Epigenetic Reprogramming in the Mammalian Germ Line: Possible Effects by Endocrine Disruptors on Primordial Germ Cells

DOHADWHAT IS IT? •What happens in utero can have

consequences throughout life!• The months we spend in utero are the

most important of our lives!

FACTS…

• ED exposure is a reality

• These products are everywhere in our livesInformation is the first step to protect ourselves

MAKING CHOICES AS A SOCIETY

• Is the onus of responsibility on the consumer?

• Can we demand improved protection?

• How do we stimulate the supply of a safer products?

www.sabotage-hormonal.org

Réseau des femmes en environnementTéléphone : 514 -987-3000 poste 6684Courriel : info@rqfe.org

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HEALING WITHOUT HARM: REDUCING EXPOSURE TO ENDOCRINE DISRUPTORS IN HOSPITALS

PILOT PROJECT AT PIERRE BOUCHER HOSPITAL’S NEONATAL UNIT

Nathalie Robitaille, Assistant Director, SSE

Dre Émilie Fréchette-Pelletier, pediatrician at Pierre-Boucher Hospital (CISSS Montérégie-East)

PILOT PROJECT OBJECTIVES

REDUCE EXPOSURE OF PATIENTS AND STAFF TO SUSPECTED ENDOCRINE DISRUPTING CHEMICALS

(EDCS).

PARTICIPANTS

Pilot Hospital✚ Pierre Boucher Hospital, Longueuil, Quebec ✚ 350 beds✚ Supply department, care team (nurses, respiratory

therapists, doctors), technical services director

Synergie Santé Environnement♻️ Trainee♻️ Assisstant Director

WHY CHOOSE THE NEONATAL UNIT?

• Newborns are more vulnerable to exposure from chemicals • Nouveau-nés sont plus vulnérables à

l’exposition aux substances chimiques : –Fine skin

–Less developed systems

–Per kilogram of weight, newborns eat, breathe and drink more than an adult

POURQUOI AVOIR CHOISI L’UNITÉ DE NÉONATALOGIE

InterestInnovative project

HEALING WITHOUT HARMREDUCING EXPOSURE TO ENDOCRINE DISRUPTORS IN HOSPITALS

Pilot project at the neonatal intermediate care unit. A first in Canada!1. Inventory the products to which babies and mothers are exposed 2. Target substances of concern 3. Establish communication with industries (suppliers & distributors) 4. Know the composition of the products 5. Look for healthy alternatives

ØAll these steps involve a participatory approach and apply the cautionary principle! «Better safe than sorry»

HEALING WITHOUT HARMREDUCING EXPOSURE TO ENDOCRINE DISRUPTORS IN HOSPITALS

1. Make an inventory of the products babies are exposed to

HEALING WITHOUT HARMREDUCING EXPOSURE TO ENDOCRINE DISRUPTORS IN HOSPITALS

Know the inventory … 74 products under the magnifying glassDiachylon en tissuThermomètre numérique cliniqueSeringueLunette nasale pour CPAPMicrobore extension setGelée lubrifianteSeringueLingette préopératoirePansement transparent adhésif avec cadre de poseGants chirurgicaux stériles en latex poudrésTubulure à intraveineuseTubulure pour la transfusion sanguineInjection de sodium chloride à 0.9%Nettoyant bébéContenant pour lait maternelFortifiant de lait maternel (poudre)Préparation pour nourrisson à base de lait enrichie de ferPréparation de suivi à base de lait pour prématurésEau stériliséeTétine de biberon (bébés à terme et prématurés)Cache yeuxTéterelleIntraveineuse papillonBrassard à pression

Cathéter d'aspirationCrème pour l'irritation mineure à sévère due à l'incontinenceLotion nettoyante pour les mainsCanule nasale avec tube à oxygèneMasque standard avec crochet taille 1Isolette (incubateur)MatelasMatelasSystème du cathéter IV fermé - deux portsCathéter d'aspiration, contrôle du videDiachylonPoire d'aspirationGel de glucoseMasque à ventilationTubulure, circuit de respiration pédiatriqueInjection de dextrose à 5% dextroseInjection d'eau stérileBallon d'anesthésie avec masqueLingette de bain désinfectanteBracelet d'identificationBouchon de seringueEchantillon de crème pour les mamelonOnguent ophtalmiqueMulti-adaptateur

Electrode (pour électrocardiogramme)SaturomètreCathéter IV radio-opaqueRallonge à tubulure (partie d'un set)Air cushion face maskPVC nasopharyngeal airwayTubulure à oxygèneContenant stérile à prélèvementTubulure à acides aminésOnguent de zincCathéter multi-actionTubulure d'alimentationTubulure avec filtreVentimasqueSeringue de sodium chloride pour rinçageEau stérile pour inhalationGel antimicrobien pour les mainsThermomètreEnsemble et plateau de drain thoraciqueCathéter à succion graduéCathéter ombilicalSonde d'alimentationOral/nasal tracheal tube cufflessSeringue tuberculine

PILOT PROJECT AT PIERRE BOUCHER HOSPITAL’S NEONATAL UNIT

2. TARGET SUBSTANCES OF CONCERN

HEALING WITHOUT HARMREDUCING EXPOSURE TO ENDOCRINE DISRUPTORS IN HOSPITALSTARGET SUBSTANCES OF CONCERN

– Phthalates (Fragrance, DEHP, DiNP, DiDP, DEP, BBP, DiDP, etc.) – Bisphenols (Bisphenol A but also its cousins, Bisphenol S and F)– Brominated flame retardants (PBDEs - polybrominated diphenyl ethers)– Triclosan and triclocarban (antibacterial and antifungal) – Parabens–Mercury– Perfluorinated compounds (perfluocarbons or PFCs) – Formaldehyde

PHTALATES

ØTheir presence in medical products has been known since the late 1960s.

ØDetected in the air administered by oxygen therapy

ØConcentration of DEHP increased from 0.126 mg / L to 0.588 mg / L when the solute is stirred.

ØAcceptable DEHP dose is 0.037 to 0.02mg / kg / day according to European Union Scientific Committee and EPA

References : « The association between phthalate exposure and asthma »

PILOT PROJECT AT PIERRE BOUCHER HOSPITAL’S NEONATAL INTERMEDIATE CARE UNIT3. ESTABLISH COMMUNICATION WITH INDUSTRY (SUPPLIERS & DISTRIBUTORS)

AMDRITMEDCARDINALCOOKCOVIDEN-MEDTRONICDEB-CanadaDRAEGERDUFORT & LAVIGNEFISHER & PAYKELHOSPIRA

JOHNSON & JOHNSONMAXTRECMEDELAMEDIQUEPHILIPSSMITHSTELEFLEXTRUDELWOOD WYANT INC

HEALING WITHOUT HARMREDUCING EXPOSURE TO ENDOCRINE DISRUPTORS IN HOSPITALS

4. KNOW THE COMPOSITION OF THE PRODUCTS

PRODUCT COMPOSITION

• Total number of products with Endocrine Disrupting Chemicals (EDCs) based on their labels = 74– Products containing EDCs= 12

– EDC free products= 18

– Unknown product composition= 44

• Total number of products containing EDCs according to a survey sent to suppliers– Products with unknown compositions = 44

– No answer= 37

– Responses= 7 (Products containing EDCs= 1 | Products without EDCs= 6

• Total number of products containing EDCs at the end of the pilot project = 74– Products containing EDCs = 13

– EDC free products = 24

– Unknown product composition= 37

5.RECHERCHERDESALTERNATIVESSAINES

Ø EVA,silicone,polyethylene,polyurethane,butstudiesarelimited.Ø Siliconeseemstobethebest

alternative

Ø Cyclicolefinpolymers(COP/COC)canalsobeusedasasafealternativetobisphenols.

HEALING WITHOUT HARMREDUCING EXPOSURE TO ENDOCRINE DISRUPTORS IN HOSPITALS

% AVERAGE POURCENTAGE OF PHATALATE PER PRODUCT

Sources: 2004, Health Care Without Harm, Preventing Harm from Phthalates: Avoiding PVC in Hospitals1999, Phthalates in PVC Medical Products from 12 Countries, Greenpeace USA

COMPOSITION OF THE MATERIAL

Ball of anesthesia with mask

ØPercentage of PE weight based on total weight of material 16.6%

Presence of DINP

COMPOSITION OF THE MATERIAL

Nasal Canule and Oxygen TubeØPercentage of EDC weight based

on total weight of material: 26.7%

DEHP presence

COMPOSITION OF THE MATERIAL

IV bagØPercentage of EDC weight based

on total weight of material: 30.7%

PVC

COMPOSITION OF THE MATERIAL

Suction catheter

ØPercentage of EDC weight based on total weight of material: 33.9%

DEHP Presence

COMPOSITION DU MATÉRIEL

Oral / nasal tracheal tube cuffless

ØPercentage of EDC weight based on total weight of material: 27.3%

DEHP presence

COMPOSITION OF THE MATERIAL

NasopharyngealTube

ØPercentage of EDC weight based on total weight of material : 33%

PVC

GLOBAL INITIATIVES FOR ALTERNATIVES TO ENDOCRINE DISRUPTORS

STEPS TAKEN TO LIMIT EDCS IN HOSPITALS

Karolskina University HospitalNeonatal UnitStolkholm, Sweden2014- Complete phase out of PVC

PVC-free blood-bag project (Sweden)• Civil Society Initiative (online petition)• Collaboration between industry and the medical sector (4 European companies)

Hospital of Southern Jutland (Denmark)• Started removal of material containing PVC (2005)

PVC-free NICU of the Vienna Hospitals Association (Austria)• Withdrawal of medical equipment containing PVC for premature infants (2001-2010) (+ 15%)

Clémentville Clinic (France)• Phthalate suppression in medical devices (2010) (+ 5%)

CASE STUDY: KAISER PERMANENTE'S APPROACH

–Health care and insurance - 35 hospitals and more than 400 medical centers - 10.2 million members

–Replacement of PVC in intravenous material (2012)

Asked subcontractor to find material without DEHP

Standardized purchases to reduce costs: change affects 100 tons of medical equipment

Will likely have $ 5 million in savings each year

SIMILAR APPROACHES ELSEWHERE IN THE UNITED STATES

« Safer Chemicals Challenge» A Healthier Hospitals initiative

–Gundersen (Wisconsin)–Advocate Health Care (Illinois)–Dignity Health (Californie)–Innova Health System (Virginie)–Partners Healthcare (Massa- chussetts)–Orlando Health (Floride –Tenet Healthcare (Texas)–Spectrum Health (Michigan)

ØPVC reduction in medical equipmentØMaintenance products without triclosanØElimination of mercury 30% of

purchases to mobilize without toxic substances

)

SIMILAR STEPS IN FRANCE

THE INDUSTRY IS STARTING TO MOVE IN QUEBEC !•Medtronic replaces DEHP with DHET in its products

PEDIATRICIAN CONCLUSION

STEPS TO REDUCE ENDOCRINE DISRUPTING CHEMICALS IN YOUR EVERYDAY LIFE!

READ THE INGREDIENTS!

THANK YOU !

CONTACT INFORMATION

CANADIAN COALITION FOR GREEN HEALTH CARELinda Varangu | linda@greenhealthcare.ca

SYNERGIE SANTÉ ENVIRONNEMENTNathalie Robitaille | nrobitaille@ssequebec.orgJérôme Ribesse | jribesse@ssequebec.org