Exposures and controls in my workplace

I work at SFO Medical Clinic. I think for the most part, biological exposures are the greatest concern as I am sure it is in most healthcare settings. We have an x-ray machine in the clinic, so radiological exposures might be another concern. Additionally, the clinic is in an airport and we can sometimes smell the fumes from the airplanes in the clinic. I think this could be considered a chemical exposure.

The nurses are well-trained to triage and assess the symptoms of a person who presents in the clinic. If there is a chance that the patient might be contagious, he/she is put into an exam room immediately so that they are not sitting in the waiting room with other patients. We also have a negative pressure exam room that can be used to isolate the contagious individual. We regularly (especially after a possibly contagious person presents in the clinic) use Super Sani-Cloth to wipe down the check-in and check-out desks, clipboards, and pens that the patients use. As far as radiation exposure, the x-ray technicians are well-trained to protect themselves. There is also a light outside of the x-ray room that is lit when an image is being shot so that someone outside in the hallway does not enter. The smell of airplane fumes in the clinic occurs once in a while, but the airport does not do anything to prevent it nor do we do anything in response to the fumes.

From the lecture, we learned about the hygiene hierarchy of controls. Obviously the best and most effective control is to eliminate the hazard completely. In the case of biological exposures or even radiological exposures (x-ray in this case), it is impossible to remove these exposures in a healthcare setting. Clinics and hospitals exist to treat people who are sick. We use x-rays as a tool to treat people. We cannot eliminate these exposures here. The most obvious controls we must exercise in this setting are administrative controls and personal protective equipment, which is what I believe is currently being done in my workplace.

Asbestos and Mesothelioma

Asbestos is a natural mineral that is heat and chemical resistant which has made it useful in many products. Insulation is one product where asbestos has been used. Asbestos becomes a problem when disturbed or damaged as asbestos fibers are released into the air and people inhale or ingest them.

Since the 1920s, asbestos has been linked to serious health effects, one of which is mesothelioma. There are 3,000 new cases of mesothelioma diagnosed each year. Symptoms include chest pain, shortness of breath, fatigue, and persistent cough, among other things. These symptoms do not show up until 10-50 years after exposure. Despite the growing knowledge of the harm of asbestos exposure, the use of asbestos boomed between the 1930s to 1970s. High risk occupations for asbestos exposure include: construction workers, manufacturing and industrial workers, automotive manufactures and mechanics, and shipyard workers.

Asbestos is not currently banned in the United States. The organizations that oversee and enforce asbestos regulations are the Environmental Protection Agency, the Occupational Safety and Health Administration and the Mine Safety and Health Administration. Attempts made to ban asbestos in the past were unsuccessful. The Clean Air Act was amended to include asbestos as an air pollutant in 1970. In the same decade, the Toxic Substances Control Act gave the EPA the authority to regulate toxins, asbestos included. In 1980, the Comprehensive Environmental Response, Compensation and Liability Act began Superfund sites. In 1989, the EPA rolled out the Asbestos Ban and Phase-Out Rule, which was overturned by the Fifth Circuit Court of Appeals in 1991. In most recent attempts, under the Frank R. Lautenberg Chemical Safety for the 21st Century Act of 2016, the EPA selected asbestos as one of ten chemicals for risk assessment increasing hopes for a ban. Under the Trump Administration this past summer, however, the EPA proposed the Significant Use Rule, which would allow the use of asbestos with approval from the EPA.

While no ban currently exists to protect against asbestos and its harmful health effects, there are federal and state laws that dictate how asbestos must be removed and disposed of. Certified asbestos professionals are trained and licensed to follow the strict guidelines for asbestos removal and disposal. In my opinion, this does not truly protect people from the exposure to asbestos.

All information came from the Mesothelioma + Asbestos Awareness Center. For more information, visit https://www.maacenter.org

WHO and the occupational health of health workers

WHO writes "protecting the occupational health of health workers is critical to having an adequate workforce of trained and health health personnel." I really like this quote. The health of health workers is so important because they take care of people who are sick. In the healthcare setting, workers are exposed to biological hazards like TB, Hepatitis, HIV/AIDS, and others. WHO reported that 37% of hepatitis B among health workers resulted from workplace exposure and that only 20% of health workers in some places in the world are vaccinated. The WHO Global Plan of Action encourages members to create national programs for occupational health among health workers and for WHO to create national hepatitis B immunization campaigns.

I work at an urgent care clinic at San Francisco International Airport. Though I do not do direct patient care, I can be exposed to biological hazards and psychological hazards in this setting. Before I was hired to work at the clinic, I had to undergo a pre-employment physical where I had to provide my vaccination history and have titers drawn to confirm my vaccinations. Apparently, this may not be routine in all parts of the world given the statistic of hepatitis B vaccination rate being only 20% in some places. I am glad we have an international organization, WHO, to help advocate for and protect the health of health workers.

http://www.who.int/occupational_health/topics/hcworkers/en/

MSDS and ToxNet

I work in the front office at an urgent care clinic, so my exposure to chemicals is not very high. One thing we use often in the front office is the Super Sani-Cloth Germicidal Wipe to disinfect desk tops, keyboards, telephones, clipboards, and pens. The wipes contain a mixture of chemicals that include: Isopropyl Alcohol, n-Alkyl (60% C14, 32% C16, 5% C12, 5% C18) dimethyl benzyl ammonium chlorides, and n-Alkyl (68% C12, 32% C14) dimethyl ethylbenzyl ammonium chlorides. Using the MSDS I answered the following questions:

• What are the health risk associated with this chemical?
• The product is flammable and can cause serious eye irritation.
• Is the chemical a carcinogen?
• The product is not considered carcinogenic.
• What personal protective equipment or special precautions should be taken when working with this chemical?
• PPE include eye protection as appropriate, disposable protective gloves as appropriate, and suitable respiratory equipment if insufficient ventilation.
• When using the product, one should not eat, drink, or smoke. One should wash his or her hands after using product.
• If this is a chemical found in your workplace, what training/education were you given about any risks associated with this chemical?
• I do not believe I was given any training/education for the use of these wipes. I remember being told that there is a 2 minute dry time and maybe I was told to use gloves but I honestly can't remember. I read the bottle the wipes come in, use gloves when using the product, and wash my hands immediately after use. I think there needs to be training or reminders for safely using this product. I've observed coworkers use this product with their bare hands and I've also watched a coworker use the product to clean ink off of one of the desk tops where soap and water probably would have been sufficient. 

I noticed on the MSDS under Toxicological Information that "not available" or "not applicable" was listed next to the specifics for skin corrosion/irritation (ex: exposure minutes) and for respiratory or skin sensitization. Using TOXNET, I looked up isopropyl alcohol which is the major chemical component in the wipes. Though the major risks of the wipes listed on the MSDS were its flammability and serious eye irritation, there were many other adverse health effects listed on TOXNET. These included central nervous depression, liver, kidney, cardiovascular depression, brain damage, drowsiness, coma and respiratory depression, irritation of mucous membranes and eyes, among other things. It was surprising to me that the MSDS made the product seem safer than it might actually be.

Heavy Metals

Perhaps the most surprising and interesting to me was the link Needleman pointed out between lead exposure and behavior. One case-control study found that arrested and convicted youths were at higher risk of delinquency associated with bone lead concentrations (OR = 4). Another study found a fourfold increase in homicide rates in U.S. counties with the highest air lead levels. It sort of makes me wonder if we should convict people and assign punishment the same way knowing this information. What was also very persuasive was the cost-benefit analysis for removing lead hazards in homes that were built before lead-based paints were banned in 1971. It would cost $33.7 billion over 30 years, which is a lot of money, but the benefit would equate to $61.7 billion, nearly double the expense. That seems well worth the investment.

In the short article on the outbreak of childhood lead poisoning in Nigeria, I was glad to read that there was local involvement at every step of the intervention because that is so important for success. Another key feature of the intervention was the implementation of safer mining practices which helps to ensure safety and health in the future.

Green Chemistry

While phasing out and getting rid of toxins and pollutants in our environment is very important, research and formulation of safe alternatives is also necessary. This is where green chemistry comes in. I actually first heard about green chemistry when I was looking for a topic to write about for my literature review. I came across an article on mussels, specifically their byssal threads which they use to attach themselves to rocks and other mussels, and their implications for green chemistry and synthesizing polymers and adhesives. 

I think the 12 principles of green chemistry are great because they focus on using renewable sources to synthesize chemicals that are not toxic to humans or the environment, do not accumulate in the environment, and minimizes waste. It basically is everything current industry is not. Reading the 12 principles, I am reminded of the precautionary principle. This is how we ought to do research and create chemicals, with safety and health of both humans and the environment as a forethought not afterthought. After watching the video on the Great Pacific Garbage Patch, I was amazed. I was mostly amazed that it is known that plastics persist and do not degrade and thus accumulate, this had to have been known when plastic was first created. Where did scientists and industry think all the plastics would end up? Was that ever discussed as a pitfall?

Six Chemical Classes

I really enjoyed watching Green Chemical Policy Institute's video series on the six chemical classes approach. It was very informative and well done. I chose to further look into phthalates. Using Biomonitoring California's Phthalates Fact Sheet, I learned that phthalates are found in a variety of products that most people use daily. These include: school lunchboxes, backpacks, food packaging and containers, gloves, fragrances (perfume, lotion, deodorants, etc.), nail polish, and medications among other things. Phthalates can disrupt hormones, fetal, infant, and child development, and decrease fertility. The CDC found 13 phthalate metabolites in the urine of participants in 2003-2004 NHANES. They found that phthalates exposure is widespread in the U.S., which is not surprising considering all the items that phthalates are present in, some of which are listed above. To add, adult women have higher levels of phthalate metabolites in their urine than men. According to Green Chemical Policy Institute, to limit exposure to harmful phthalates, one can use glass food containers, avoid plastics with recycle codes 3 to 7, eat less canned and packaged foods, wash hands before eating and drinking, and opt for fragrance-free personal care products.

An Ideal Chemical Policy

I really like the six reforms under the Louisville Charter for Safer Chemicals, which are:

1. require safer substitutes and solutions
2. phase out persistent, bioaccumulative, or highly toxic chemicals
3. give the public and workers the full right-to-know and participate
4. act on early warnings
5. require comprehensive safety data for all chemicals
6. take immediate action to protect communities and workers

In my opinion, these reforms would all be included in an ideal chemical policy. I especially like the consideration of the precautionary principle, or preventing harm before it happens. When dealing with chemicals for which health effects may only be seen many years after exposure, it is important to take the precautionary approach. If a policy that proposes the aforementioned reforms is ever passed in the United States, I fear that it won't be enough to protect U.S. consumers considering many products and food items are imported from other countries. So, a truly ideal chemical policy would be one that includes these reforms at an international level, like the Stockholm Convention. This would ensure better health and safety for all people. In watching the short video, The Pesticide Trap, I was stunned as I watched a man spray harmful pesticides on his cotton crops with no protective gear and his clothing drenched in the pesticide. I became even more upset when I learned that the man could not read the pesticide container nor did he understand the symbols on the container and thus did not know the adverse health effects of exposure. This scenario could be avoided if an international chemical policy existed that would, for instance, give workers the right-to-know (Reform No. 3) and protect workers (Reform No. 6). 

Chemical Policy Reform

The Louisville Charter for Safer Chemicals outlines six necessities for a revamped chemical policy for better regulation of harmful chemicals in the United States. I really liked all six principles, but chose to read more on "Require Safer Substitutes and Solutions." This principle simply stands by "No Data, No Market." It is rather incredible that this is not already in place, it is common sense and really the way it ought to be. This principle would require manufacturers to submit the health and safety information for their chemical product before it is allowed to stay on the market or enter the market. This would apply to all chemicals, including the 69,000 chemicals that were put on the market prior to 1979, that were "grandfathered" under the Toxic Substance Control Act enacted in 1976. Before reading the background paper for this reform, I thought one potential pushback by manufacturers would be high costs. The background paper, however, reported that costs would be minimal for industries. In fact, the estimated cost for compliance with Europe's REACH (Registration, Evaluation and Authorization of Chemicals) program was less than 0.15% of the chemical industry's sales revenue over an 11 year period. That is a lot lower than I would expect. That is very little money spent upfront for better health outcomes and money saved in the long run.

Guth, J. H., Denison, R. A., & Sass, J. (2005). Background paper for reform no. 5 of the Louisville Charter for Safer Chemicals. The Louisville Charter. Retrieved from https://smartpolicyreform.org/the-charter/background-papers-for-the-louisville-charter/background-paper-5

Pesticides: What's on my Food

Using whatsonmyfood.org, I looked up the pesticides that could have been present in one of my meals yesterday. I ate at Gen Korean BBQ for lunch and had rice, beef, green onion, bell peppers, corn, and zucchini. The food items with the most number of potential pesticide residues were sweet bell pepper (53), green onion (31), and rice (15). Just seeing the number of pesticides that I could have been exposed to in just one meal makes me feel nauseated. Among the pesticide residues, every toxin was present...carcinogens, hormone disruptors, neurotoxins, developmental or reproductive toxins, and bee toxins. This information is disgusting and overwhelming. After this, I may consider eating out less and cooking at home more. I can limit my exposure to these harmful toxins by buying organic and ensuring proper food preparation. In terms of public health, we absolutely need policy to regulate what is being used on our food. Just like with the safety of personal care products available to consumers where I assumed ingredients were tested and deemed safe before they were allowed on the market, I assumed the same of food. So, as we work towards and until we have good policy, the public health community can raise awareness of the absent policy and guidelines around the use of pesticides on food and teach people to make healthier choices like buying organic or choosing conventional foods that have lower pesticide residues.

My Topic of Interest: Climate Change and Homelessness

I decided to pursue an MPH because I am passionate about and interested in working with people experiencing homelessness. So, for my literature review, I am looking into the effect of climate change on the homeless population. We know that with climate change we will see an increase in extreme weather events. It is important to understand the challenges associated with extreme heat and cold that affect the health of the homeless population. 

Some of the agencies that are concerned with homelessness include: U.S. Department of Health & Human Services (federal), U.S. Department of Housing and Urban Development (federal), Health Care for the Homeless (national) and at the local levels there are many smaller organizations. In the Bay Area, a few organizations include: Catholic Charities of San Francisco, Catholic Charities of the East Bay, Bay Area Rescue Mission, Dorothy Day House, Glide Memorial Church, Winter Nights Shelter, among others.

The National Institutes of Health's Role

The National Institutes of Health, whose role is to conduct research, is comprised of 27 Institutes and Centers. One is the National Institute of Environmental Health Sciences (NIEHS), established in 1966. Their mission is "to discover how the environment affects people in order to promote healthier lives." Their research incorporates epidemiological studies, toxicological studies, and intervention and prevention studies. They study a wide range of environmental exposures including air pollution, climate change, lead exposure, asbestos exposure, carcinogens, among many others. All research studies and findings are available to the general public.

For more information, click here:

National Institute of Environmental Health Sciences

My Local Environmental Services

Looking at the Alameda County Public Health Department's list of programs and services, I have identified several environmental services. As I was going through the list, the obvious environmental programs and services were Asthma Start Program, Lead Poison Prevention, Tobacco Control Program, and Wildfire Smoke. Before taking this class and learning about the breadth of environmental health, I would not have identified any additional environmental programs. However, knowing what I know now, I would also include the following in that list: Emergency Preparedness - Public Health Emergency Preparedness (PHEP); Equity, Social & Health; and MRSA - Methicillin-resistant Staphylococcus Aureus. I chose to include Emergency Preparedness because with climate change we will see an increase in extreme weather events prompting weather-related emergencies across the country. We have already begun seeing this. I chose to include Equity, Social & Health because I learned that hazardous environmental exposures disproportionately affect poor and minority neighborhoods. And lastly, I included MRSA as an environmental program in light of what I learned last week about the use of antibiotics in livestock and its contribution to antibiotic resistance.

Alameda County also has an Environmental Health Department. Looking at their list of programs on their website, I found the most interesting to be the Healthy Nail Salon Recognition. I get my nails done every 4-6 weeks, so this program jumped out at me right away. This program recognizes salons that use safer products and practices. They also have a nail technician certification project. Looking at the salons on the list, my usual nail salon is not listed. This may prompt me to choose a different salon in the future, one that is on the list.

Obesogens

Using Seasonal Food Guide, I was amazed to find a large variety of food available in California this time of year. The list of produce available in California in early October includes: apples, avocados, cabbage, carrots, cauliflower, corn, cucumbers, eggplant, garlic, grapes, green beans, lettuce, melons, and the list goes on. I am not sure if the variety is this large in other states, but think of all the meal possibilities with this many produce options. Though it would take more planning to create meals using what is in season, I think it is a great way to eat healthier and support a healthy environment. I recently joined a CSA and am pleased with the quality of the produce I received in my first box and look forward to creating delicious seasonal meals.

Before reading Obesogens: An Environmental Link to Obesity, I had never heard of obesogens. The study of obesogens is new and interesting and has implications for understanding obesity and preventing it. A few obesogens mentioned in the article include: atrazine, DDE, soy phytoestrogen genistein, monosodium glutamate, and bisphenol A (BPA) among others. I was interested in looking into BPA because I see and hear BPA-free a lot, especially regarding reusable water bottles and containers. Using TOXNET, I found a cross-sectional study that looked at the association between BPA exposure and BMI in children. Wang et al. found that the average BPA concentrations in urine and daily intake estimates increased with BMI (2012). The study being cross-sectional, however, cannot presume causation. The same study highlighted that six billion pounds of BPA are produced annually around the world and that BPA is found in household appliances, food packaging, and plastic bottles (Wang et al., 2012). Knowing this and the effect BPA exposure has on BMI raises concern and calls for more research.

Wang, H., Zhou, Y., Tang, C., Wu, J., Chen, Y., & Jiang, Q. (2012). Association between bisphenol A exposure and body mass index in Chinese school children: a cross-sectional study. Environmental Health, 11. Retrieved from http://www.ehjournal.net/content/11/1/79

Use of Antibiotics

Antibiotic resistance is a serious and urgent issue. It is clear that the best way to combat the issue is to stop nontherapeutic uses of antibiotics. As far as I can tell, the Preservation of Antibiotics for Medical Treatment Act (PAMTA) has been introduced in the House in March 2017 and the Prevention of Antibiotic Resistance Act (PARA) was introduced in the Senate in March 2017. Antibiotic resistance is increasing quickly. Antibiotic Resistance 101 highlights a study that found an eight- to sixteen-fold increase of one type of antibiotic resistant bacteria after just 3 years of using a certain type of antibiotic in poultry. Thus, it is paramount to take actions swiftly.

Nearby Livestock May Raise 'Superbug' Risk highlighted the risk of contracting livestock-associated MRSA. It is so scary and concerning that just living near livestock increases your risk of contracting this disease. Speaking to the slow action taken to combat antibiotic resistance I mentioned previously, we should really look at this scenario as a lesson. Without controlling antibiotic resistance, how many more "superbugs" will be born?

It was very surprising to read that there is no difference in the effectiveness of antibiotic vs. non-antibiotic soaps among healthy individuals AND that the use of antibiotic soap among sick individuals, in fact, makes them sicker. I am a total hand washer. I also use Wet Ones or hand sanitizer when soap and water is not available. Reading Scientists Discover That Antimicrobial Wipes and Soaps May Be Making You (and Society) Sick has me rethinking my hand washing behavior and the products I use. 

After reading Antimicrobials in Hospital Furnishings: Do They Help Reduce Healthcare-Associated Infections?, I learned that the use of antimicrobials in furniture has implications for increased antibiotic resistance. At the same time, it seems that there is little to no evidence to support the effectiveness of antimicrobials in furnishings in reducing HAIs. So, I really don't think they should be used.

Industrial Farming

Vanishing of Bees was very enlightening. Before watching the documentary, I did not know about colony collapse disorder nor did I fully appreciate the critical role bees play in the environment. The first thoughts I usually have when thinking about bees are honey and bee stings, pollination does not cross my mind. I learned how important bees are and why colony collapse disorder is so alarming. It is clear that the bees' exposure to systemic pesticides is the cause. Not only does pesticides directly affect us, this is one way it indirectly affects us. With a decline in bees, will eventually come the decline in agricultural yield and thus less food available to feed the population. This is a public health issue.

Dirt! The Movie was very interesting. Before watching this movie, I did not think about the effect pesticides have on the dirt, itself. I more so thought of how pesticides affect the actual plant or crop.  The movie discussed the adverse effects of single-species farming. This type of industrial farming has increased the number of pests and thus the use of pesticides to control these pests. The pesticides, in turn, decreases the quality of the soil. Nitrogen-rich fertilizer is then added to the soil. The nitrogen is only partially absorbed by the plant and the rest eventually gets into rivers and the ocean affecting ocean life. To add, the excess nitrogen results in the production of nitrous oxide, which contributes to climate change. The movie explained this well and has helped me understand the grand effect pesticides have on our environment. The movie also briefly discussed composting. I do not currently compost, I have never composted, and I do not know anyone that composts. I would definitely consider composting in the future now that I understand that it increases sustainability. My apartment building has bins for composting, so I have no reason not to try it.

Using Factory Farm Map, I found that there are no factory farms in Alameda County, CA. Prior to looking this up, I did not know whether or not there were factory farms near me.