Integrated Pest Management (IPM) in the Health Care Setting

Ann McCampbell, MDHealthy Environments in Health Care Workgroup Health Care Without HarmJuly 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

Risk benefit assessment

Toxicity testing only on active ingredient

Cumulative and synergistic effects not tested

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

26%

13% 13%

9% 9% 9%

21%

0%

5%

10%

15%

20%

25%

30%

Pyrethroids Organophosphates Carbamates Botanicals Inorganics Synergists Others (<5% each)Pyrethroids

Organophosphates

Carbamates Botanicals Inorganics Synergists Others

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))

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

Hospital Pesticide Use Notification

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: DrAnnMc@aol.com

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