Integrated Pest Management (IPM) in the Health Care Setting

Ann McCampbell, MD Healthy Environments in Health Care Workgroup Health Care Without Harm July 9, 2004

***Adapted from presentation given by Kagan Owens of Beyond Pesticides at CleanMed 2004.

Why Look at Hospital Pest Management Practices?

•Hospitals are intended to be places of health and healing, yet many hospitals use pesticides that can harm patients and staff •Hospital environments need to be free of hazardous pesticides as well as pests

Common Hospital Pests

 Flies  Cockroaches  Ants  Spiders  Rodents  Weeds  Plant insects

Common Sites of Pest Infestations

 Cafeterias  Loading Docks  Storage Areas  Bathrooms  Waste disposal areas  Patient rooms

What is a Pesticide?

 Chemicals designed to kill or repel insects, plants and animals that are undesirable or threaten human health  Pesticides include: – Herbicides (weedkillers) – Insecticides (bug sprays) – Fungicides – Rodenticides – Other

What is in a Pesticide?

 A pesticide product contains: – – Active ingredients “Inert” ingredients – Synergists – Contaminants and impurities – Metabolites

U.S. EPA

 U.S. EPA states: “By their very nature, most pesticides create some risk of harm to humans, animals and the environment …”

- U.S. EPA, What is a Pesticide?, 2002.

Health Effects of Pesticides

 Acute adverse effects – Nausea & vomiting – – – – – – Headaches Rashes Dizziness Aching joints Flu-like symptoms Asthma trigger  Linked to chronic effects – Cancer – – – – Birth defects Genetic damage Neurological problems Development of chemical sensitivities

Vulnerable Populations

 Particularly vulnerable populations: – Pregnant women – Infants and children – Elderly – Those with compromised immune, respiratory or nervous systems – Those with allergies or sensitivities to pesticides

Pesticides and Cancer

 Non Hodgkin’s lymphoma has been linked to the use of the herbicide 2,4-D  Children living in households where insecticides are used suffer elevated rates of leukemia, brain cancer and soft tissue sarcoma

American Medical Association

“Particular uncertainty exists regarding the long-term health effects of low dose pesticide exposure… Considering [the] data gaps, it is prudent … to limit pesticide exposures … and to use the least toxic chemical pesticide or non chemical alternative.”

- AMA, Council on Scientific Affairs. 1997.

Department of Veteran Affairs

“Pest management in health care facilities differs from control practices in other institutions. The effect on patients in various stages of debilitation and convalescence, and in varied physical and attitudinal environments, requires that a cautious policy be adopted concerning all uses of pesticides.

The use of any pesticide establishes a risk of uncertain magnitude.” -

Department of Veteran Affairs. 1986. Pest Management Operations, Chapter 2. Environmental Management Service.

Pesticide Regulation Insufficient

 Pesticide registration does not equal safety  Cumulative and synergistic effects not tested  Risk benefit assessment  Toxicity testing only on active ingredient  Inadequate testing for impacts on vulnerable populations

Hospital Pesticide Use Survey

 100% use chemical pesticides  73% hire a pest control company to manage the majority of structural (indoor) pests  36% hire a pest control company to manage the majority of outdoor pests on hospital grounds

37 Most Commonly Used Pesticides

 62% are insecticides  27% are herbicides  8% are rodenticides  3% are fungicides

Most Commonly Used Insecticides at Surveyed Hospitals 30% 25% 20% 15% 10% 5% 0% 26% 13%

Organophosphates Organophosphates

13% 9% 9%

Inorganics

9% 21%

37 Most Commonly Used Pesticides

Health Effects:  16 are likely, probable or possible carcinogens  13 are linked to birth defects  15 are reproductive toxins  22 are neurotoxins  18 cause kidney or liver damage  28 are irritants

Pyrethroids Are Not Flowers

 Neurotoxic  Burning of skin, dizziness, headache, vomiting, muscle twitching, seizures  Endocrine-disruptors  Possible human carcinogens  Toxic synergist PBO (piperonyl butoxide)  Deltamethrin persists for years in environment

Ontario College of Family Physicians

 “The literature does not support the concept that some pesticides are safer than others;”  “Exposure to all the commonly used pesticides … has shown positive associations with adverse health effects.”  “Our message to patients should focus on reduction of exposure to all pesticides …”

- Ontario College of Family Physicians, Pesticides Literature Review, April 23, 2004.

What is Integrated Pest Management (IPM)?

 IPM is a pest management strategy that focuses on long-term prevention and suppression of pest problems through nontoxic means such as: – – – – – Sanitation Structural maintenance Mechanical/physical controls Cultural practices Biological controls  Pesticides are used only as a last resort.

Model Hospital IPM Policy

 Policy Goals To manage pests in a manner that will not harm humans or the environment - To reduce or eliminate the use of toxic pesticides - To provide notification to the hospital community if a pesticide is applied

What IPM Is Not

 Routine use of pesticides (calendar spraying)  Pesticide applications when area occupied or may become so during 24 hours after application  Fogging, bombs, tenting, broadcast and space spraying  Pesticide use for aesthetic reasons

What IPM Is Not

Does not use high hazard pesticides: – U.S. EPA Toxicity Categories I and II – – U.S. EPA Class A, B, C carcinogens California Proposition 65 – – Carbamates, organophosphates, pyrethroids, phenoxy herbicides U.S. EPA List I: Inerts of Toxicological Concern

EPA Recommends IPM

“IPM can reduce the use of chemicals and provide economical and effective pest suppression”

- U.S. EPA, Pest Control in the School Environment: Adopting Integrated Pest Management, 1993.

New York State Attorney General

“IPM will reduce pesticide exposures to patients and to hospital staffers and thus protect health. Additionally, adoption of [IPM] will save money. Pesticides are not cheap. Any approaches that sensibly reduces their use will help to contain hospital costs.” -

Attorney General of New York State, 1995.

Key Elements of an IPM Program

 Pest Prevention  Monitoring  Education  Record Keeping  Least Hazardous Approach to Pests  Pesticide Use Notification

IPM Techniques

Eliminate Food - Restrict Entry - Control Habitat – Sanitation – – – – Vacuuming Pest-proofing waste disposal Structural maintenance Mechanical traps Inspect - Detect - Correct

Eliminate Routine Spraying

 Instead, have contractor or staff perform a pest inspection monthly or quarterly to determine whether pests are present and whether action is needed  When taking action, use the least toxic method that will effectively suppress or eliminate pest populations

Flies - Safer Management

 Sanitation  Exclusion  Flypaper  Fly swatters  UV light traps indoors  Traps with non-toxic attractants outdoors

Cockroaches – Safer Management

        Sanitation Food stored in pest-proof airtight containers Eliminate corrugated cardboard Eliminate moisture sources Block entry points Vacuum Glueboards, pheromone traps Boric acid bait

Weeds, Lawns, and Landscape – Safer Management

        Maintain lawn health (mowing and watering) Pull or cut weeds Corn gluten meal Mulch Physically remove insect pests or knock off with high pressure water Spray plants with soapy water Use beneficial, predatory insects Pest-resistant vegetation

Least Hazardous Pesticides

     Boric acid Insecticidal and herbicidal soaps Diatomaceous earth / silica gel Microbe-based insecticides (B.t.) Parasites and predators    Non-volatile insect and rodent baits in tamper resistant containers Liquid nitrogen (cold treatments) EPA Exempt natural pesticides (FIFRA 25(b))

Hospital Pesticide Use Notification

One of the key elements of an IPM program is to notify patients and staff of pesticide use • Provide written notice and/or post signs 72 hours before an application • Leave signs in place for 72 hours after application • Provide name and phone number of whom to contact for additional information

Examples of Hospital IPM Programs

   San Francisco General Hospital Massachusetts General Hospital Oregon Health and Science University    Brigham and Women’s Hospital Hackensack University Medical Center Veterans Hospitals

IPM Is Cost Effective

 Additional startup costs  Decreases the money spent over long-term  Some activities can be absorbed into existing budget: – Training of maintenance, cleaning and food service staff – Maintenance and structural repair

IPM is Cost Effective

 GSA “IPM can be pragmatic, economical, and effective on a massive scale”  University of Rochester - 50% reduction in material costs and substantial reduction in personnel costs  Monroe County Schools (IN) saves $13,600 annually in pest management costs

IPM Implementation

  Create IPM Policy Establish IPM Coordinator  Create specifications for IPM contracts  Involve hospital staff in the creation and implementation of IPM program: – – – – – Legal and risk management staff Administrators Housekeeping Facilities/maintenance personnel Cafeteria staff

For More Information

 Healthy Hospitals, Controlling Pests Without Harmful Pesticides, by Kagan Owens, Beyond Pesticides, 2003  www.beyondpesticides.org

 www.noharm.org

Integrated Pest Management (IPM) in the Health Care Setting

For more information: Ann McCampbell, MD Ph: (505) 466-3622 E-mail: [email protected]

***Adapted from presentation given by Kagan Owens of Beyond Pesticides at CleanMed 2004.