Integrated Pest Management (IPM) in the Health Care Setting

1. 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.

2. 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

3. Common Hospital Pests • Flies • Cockroaches • Ants • Spiders • Rodents • Weeds • Plant insects

4. Common Sites of Pest Infestations • Cafeterias • Loading Docks • Storage Areas • Bathrooms • Waste disposal areas • Patient rooms

5. 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

6. A pesticide product contains: Active ingredients “Inert” ingredients Synergists Contaminants and impurities Metabolites What is in a Pesticide?

7. 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.

8. 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 Health Effects of Pesticides

9. 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

10. 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

11. 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.

12. 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.

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

14. 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 Hospital Pesticide Use Survey

15. 37 Most Commonly Used Pesticides • 62% are insecticides • 27% are herbicides • 8% are rodenticides • 3% are fungicides

16. Most Commonly Used Insecticides at Surveyed Hospitals Pyrethroids Carbamates Botanicals Inorganics Synergists Others Organophosphates

17. 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

18. 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

19. 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.

20. 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.

21. 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

22. 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

23. 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

24. 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.

25. 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.

26. Key Elements of an IPM Program • Pest Prevention • Monitoring • Education • Record Keeping • Least Hazardous Approach to Pests • Pesticide Use Notification

27. IPM Techniques Eliminate Food - Restrict Entry - Control Habitat • Sanitation • Vacuuming • Pest-proofing waste disposal • Structural maintenance • Mechanical traps Inspect - Detect - Correct

28. 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

29. Flies - Safer Management • Sanitation • Exclusion • Flypaper • Fly swatters • UV light traps indoors • Traps with non-toxic attractants outdoors

30. 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

31. 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

32. 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)) Least Hazardous Pesticides

33. 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

34. San Francisco General Hospital Massachusetts General Hospital Oregon Health and Science University Brigham and Women’s Hospital Hackensack University Medical Center Veterans Hospitals Examples of Hospital IPM Programs

35. 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

36. 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

37. 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 IPM Implementation

38. For More Information • Healthy Hospitals, Controlling Pests Without Harmful Pesticides, by Kagan Owens, Beyond Pesticides, 2003 • www.beyondpesticides.org • www.noharm.org

39. Integrated Pest Management (IPM) in the Health Care Setting For more information: Ann McCampbell, MD Ph: (505) 466-3622 E-mail: DrAnnMc@aol.com ***Adapted from presentation given by Kagan Owens of Beyond Pesticides at CleanMed 2004.