Tutoring the Textile Industry on Risky Flame Retardants
An industry group welcomes a Duke researcher to explain the troubling legacy of chemicals intended to to make materials fire resistant
By Catherine Clabby
Before environmental chemist Heather Stapleton briefed a roomful of textile industry professionals about how people get exposed to potentially harmful flame retardants, she acknowledged the obvious.
“I just want to thank the organization for this invitation to this meeting,” the Duke University assistant professor Thursday told members of the Association of Textile, Apparel & Materials Professionals gathered in Cary for two days this week. “It’s a very different venue and a very different group of people than I normally interact with.”
“I know this can be a very controversial issue. There are hundreds of different fire retardants on the market. And there is really more of an environmental concern for a handful of them,” she said. “That is where most of my research has fallen.”
With that, Stapleton launched into summaries of a long list of experiments she and the members of her laboratory have conducted in recent years. They’ve been looking at a subset of fire-supressing chemicals that can easily shed potentially toxic small-molecule chemicals inside our homes, directly onto our bodies and even into indoor air.
That’s a concern, Stapleton said, because these chemicals—designed to keep working for years, long enough to deter fire in long-lasting products—don’t break down easily. Some accumulate over time within people, increasing the levels and length of exposure a child or adult experiences over time.
Stapleton has focused much of her research on a flame-retardant mixture called PentaBDE (PBDE), manufacture of which was phased out in the United States in 2004 but remains in many home products, including those containing polyurethane foam. Animal studies indicate it may be toxic to the human liver, the thyroid and impair normal neurological development.
She is also interested in the chemicals developed to replace PBDE since the phase-out, the make-up of which have not always been disclosed for “proprietary” reasons; those include tris (1,3-dichloro-2-propyl) phosphate (TDCPP). Animal studies suggest this new flame retardant harms brain cells, disrupts normal hormone messaging, and hinders normal reproduction.
Through highly technical detective work with sensitive instruments, Stapleton has found flame retardants in car seats, portable crib mattresses, baby carriers, changing table pads, nursing pillows and high chairs. She also has found them in camping tents. Some of the househould discoveries came from samples she and colleagues at Duke have collected and analyzed for free as part of a research project. Her research team has also documented the chemical’s presence in household dust, as well as human blood and the urine of pregnant women.
Stapleton explained all this near the end of the two-day conference called Shining a Light on Flammability in Textile Applications.
For much of the meeting, which drew participants from multiple states, Central America, South America and Europe, the focus was on less controversial topics, including fire science, new protective clothing for firefighters, and laundering effects on flame retardant materials.
Thursday afternoon was reserved for items producing more friction within the industry. In addition to Stapleton’s research, participants heard about stepped up federal regulation of chemicals that could, in time, limit the use of some flame retardants. They also were briefed on court cases brought against manufacturers using California’s Proposition 65, a “right to know” law that requires manufacturers of consumer products to notify consumers when some potentially cancer-causing chemicals are contained in products beyond a certain threshold.
A bill to ban some flame retardants in North Carolina has been introduced several times in recent years without making much progress in the General Assembly.
Bert Truesdale, a senior director at TenCate Protective Fabrics in Georgia and an organizer of the meeting, said Thursday’s talks were vital for a diverse industry that wants to be educated about everything relevant to its practices. “It helps us understand the priorities,” he said.
Making changes in materials used in manufacturing isn’t always simple, stressed Maggie Baumann, a marketing advisor to FRX polymers, based in Massachusetts.
“There is always a trade off when you make change in a formula. It can be difficult to maintain the performance standards in the products,” she said.
FRX has developed a different approach to producing flame retardants, one that embeds that ability into stable polymers instead of using easy-to-escape compounds like those Stapleton studies. Trouble is, they are more expensive.
New regulations may nudge the industry into using these more expensive components, she said.
Away from her presentation, Stapleton said she considers wider potential costs when it comes to the chemicals that she studies. Her research shows that children, particularly infants, have the highest exposure to potentially toxic flame retardants. Infants, she has concluded, are more sensitive to exposure to these chemicals and more research is needed to detect whether their exposures are linked to neurodevelopmental disorders, such as attention deficit, autism and cancer.
But before she stepped away from the podium, Stapleton offered one bit of advice from the research realm to the industry people who listened politely to her technical talk.
Her recommendation was to always think about exposure.
“Risk is a function of exposure and toxicity,” she said. “If there are ways to reduce the emission of these chemicals, that would reduce the risk.”
Tainted Waters: New Drinking Water Threat Concerns Scientists, Officials
A coalition of researchers, utilities and state regulators have made progress tracking an unregulated and unwelcome contaminant in river water feeding drinking water supplies. Can they stop it?
By Catherine Clabby
When the EPA ordered drinking water systems nationwide to test their water for a long list of unregulated contaminants, North Carolina water systems scored high on tests most systems would wish to fail.
Some of the highest levels nationally of a likely cancer-causing chemical 1,4 dioxane were detected in North Carolina water systems in the Cape Fear River Basin, which supplies water to more than 120 public water systems used by 1.5 million residents.
Finding the human-made substance, used in many types of manufacturing, was unwelcome for two big reasons. Long-term exposure to 1-4 dioxane, even at very low levels, likely causes cancer, the EPA says. And conventional water treatment technologies cannot remove it.
“If you ask me about my biggest concern in drinking water in North Carolina right now, it’s 1-4 dioxane” says Tom Reeder, Assistant Secretary for the Environment at the state Department of Environmental Quality.
Welcome to the complex reality of emerging threats to surface waters, the streams, rivers and lakes that supply most of the drinking water North Carolinians consume. Research has improved our ability to understand and detect such risks.
Problem is, eliminating them is never simple.
Detective work over two years by North Carolina State University researchers, water utility managers and the DEQ has pinpointed three likely “hot spot” sources of 1,4-dioxane contamination in the Cape Fear basin. Levels of discharge into the basin have fallen. But the substance is not yet evicted.
And no one expects this will be the last challenging water pollutant to float our way.
Tracking a contaminant
The U.S. Safe Drinking Water Act requires the EPA to compile a list of unregulated but emerging contaminants of concern every five years. Larger water systems must then look for those contaminants. Knowing the distribution and amounts of water contaminants helps EPA prioritize new regulations.
EPA included 1,4-dioxane because animals develop nasal cavity, liver and gall bladder tumors after exposure in laboratory studies. Useful as a solvent, a production ingredient for aluminum containers, and sometimes produced as a byproduct, 1,4-dioxane is present in the manufacture of a long list of products. Paint strippers and dyes, prescription medicines and the polyethylene terephthalate (PET) plastics used to make bottles and polyesters are among them.
While EPA does not regulate 1,4-dioxane, it has calculated that long-term exposure to concentrations at .35 parts per billion (ppb) could increase the risk of cancer in one out of 1 million people. North Carolina has calculated that the same concentration poses the same risk in waterways feeding water supplies.
Higher concentrations would pose higher risks.
People are most likely to be exposed to 1,4-dioxane in drinking water. That fact that most water systems don’t have the costly water treatment technologies that can successfully remove the human-made compound made finding the source in the Cape Fear River a priority.
In 2013, NC State University water quality researcher Detlef Knappe’s lab was dropping brown glass bottles in Cape Fear basin waters to collect samples and test for contaminants on the EPA list. When a water testing laboratory contact tipped the environmental engineering researcher that some North Carolina water systems were finding elevated levels of 1,4-dioxane, Knappe decided to look for that too.
Screening for tiny amounts of chemicals in the changing composition and flow levels of streams and rivers is not simple. Rainy periods can drop concentrations while dry periods can raise them; varying amounts of waste get released into streams and rivers from day to day. The first analytic approach Knappe used in surface waters — no EPA-approved method yet exists — didn’t make foolproof measurements, but it was evidence that 1,4-dioxane or something resembling it was present in open waters.
In 2014 Knappe approached drinking water utilities and the state Department of Environmental Quality with his team’s evidence that 1,4-dioxane was present in basin waterways feeding public drinking water supplies. The groups joined forces to track down the source. With fast-track grants awarded quickly by the National Science Foundation and the Urban Water Consortium, funded by North Carolina water utilities, Knappe and DEQ started systematic sampling for 1,4-dioxane in the Cape Fear River basin water.
“There was an expectation that we needed to do something instead of waiting for the state or federal government to figure out what to do. That didn’t seem like the right thing,” says Mick Noland, the chief of operations at Fayetteville’s water system where testing has turned up 1,4-dioxane levels as high as 8.8 parts per billion, 25 times higher than the EPA’s level of concern.
Knappe’s laboratory developed a faster and more sensitive testing method and focused its sampling on 40-plus sites in the Haw and Deep rivers, the upper reaches of the Cape Fear basin closer to the N.C. State campus. The DEQ water sciences program sampled 12 sites lower in the Cape Fear River, but also with overlap to make sure the measurements of 1,4-dioxane in river water were consistent.
By 2015 Knappe’s lab had pinpointed three likely 1,4-dioxane sources: wastewater released from communities near the basin’s headwaters in Reidsville, Asheboro and Greensboro. Since 1,4-dioxane is not used in wastewater treatment, it was likely that industries in these communities were discharging 1,4-dioxane into their sewer pipes.
To track down potential sources of 1,4-dioxane in their wastewater, Reidsville, Asheboro, and Greensboro water managers surveyed their commercial clients to see if they used 1,4-dioxane or sampled the wastewater lines serving such customers, looking for the highest concentrations. Each identified businesses using the chemical. With no stick of state or federal rules limiting the release of 1,4-dioxane into municipal sewers, the water systems approached the businesses with the problem.
In Asheboro sampling turned up one source: StarPet Inc., a local plant that produces food-grade plastic stock and is owned by Indorama Ventures in Thailand, which describes itself as a leading global manufacturer of Polyethylene Terephthalate (PET). StarPet has been highly cooperative about finding a way to stem the flow, says Michael Rhoney, Asheboro’s water resources director. StarPet is waiting for directions from the city on how to best pretreat its discharges, Rhoney said.
By surveying, Reidsville has identified two potential sources, Unifi, Inc., a Greensboro-based manufacturer of polyester and nylon yarns with other North Carolina plants in Madison and Yadkinville, as well as DyStar, owned by Kiri Holding Singapore and a producer of dyes and other chemicals. “They are looking at ways to remove it from their raw material so they can have their finalized products be the same,” said Kevin Eason, the city’s director of public works.
Steve Drew, director of water resources in Greensboro would not disclose the name of the company his water system has identified as a potential 1-4-dioxane emitter, saying an exemption to state public records law related to billing allows him to shield its identity.
“Right now it’s more of a ‘please’ and ‘thank you’ environment. We want to work with them to give them time to do good work without the risk of feeling villainized for not doing something they were not required to do,” Drew says.
North Carolina Health News has filed a state’s freedom of information query to obtain the company’s identity.
Keeping it going
DEQ isn’t finished assessing the scale of 1,4-dioxane contamination in North Carolina waters feeding drinking water supplies. Reeder, the assistant secretary, says DEQ intends to require water utilities discharging wastewater to monitor for the compound and report the results.
State environmental regulators are still sampling in the Cape Fear basin and are applying for nearly a quarter of a million dollars in grant money from the National Fish and Wildlife Foundation to continue testing there for the 1,4-dioxane and another chemical called bromide. They want to look for both in the Neuse and Yadkin river basins.
While DEQ has labelled waters below the Reidsville, Asheboro and Greensboro wastewater release sites 1-4-dioxane “hot spots,” that does not mean they are the only source in the Cape Fear River basin. Water samples taken downstream from one abandoned mill also found elevated levels. Groundwater polluted by 1,4-dioxane reaching stream and river water might carry the contaminant, too.
Knappe says he favors swift action to stop 1-4-dioxane discharges into North Carolina waters. While a better understanding of its health threats are recent, the compound may have been reaching Cape Fear River drinking water taps for decades, he said. UNC researchers reported detecting it in unspecified amounts in the Haw River in the 1980s. And if EPA decides to regulate it in drinking water, that could take years.
“Industry is constantly producing different chemicals,” Knappe says. “We need to go beyond what EPA is regulating to stay ahead of it.”
He is tracking water contamination by bromide, a by-product of drinking water disinfecting that can boost the supply of cancer-causing contaminants in water as well as perfluoroalkyl substances, compounds found on nonstick cookware and stain-resistant coatings, too.
Knappe says what he’d most like to see is a voluntary end to the release of the compound into waterways used for drinking water supplies. If that does not occur, an existing North Carolina law intended to limit health-threatening contamination of waterways that feed drinking water supplies should be deployed, he said.
Reeder agrees that North Carolina has the regulatory authority to limit 1,4-dioxane discharges within a statute that says toxic substance concentrations in drinking water (and fish) cannot exceed levels that protect people’s health.
Required monitoring in discharge permits is an initial step to find contamination sources. Once those are certain, DEQ could determine acceptable discharge limits that are informed by health risks, though not everyone may support the restrictions.
“I believe that the administrative code gives us the ability to regulate a potential carcinogen,” Reeder says. “There might be some people who disagree.”
High Death Rates in Cancer ‘Hotspots’ Across NC
In parts of North Carolina, people die from cancers at much higher rates. Some cancers have been linked to malnutrition, race and poverty while others don’t have clear risk factors.
By Minali Nigam
Cancer has been the leading cause of the death in North Carolina since 2009, when it surpassed heart disease as the Grim Reaper’s best friend here.
Combining death rates from all types of cancer, in 2013 North Carolina saw 167.7 deaths out of 100,000 people, which is about the national average.
But there are pockets of the state where death rates are considerably higher than average, and one of the worst areas, not just in the state but in the country, is in northeast North Carolina, said Sam Cykert, UNC-Chapel Hill’s director of health and clinical informatics.
Researchers at UNC have been looking at survival outcomes for adults with one type of blood cancer called acute myeloid leukemia (AML). In a study, published in June, they found three “hotspots” associated with higher death rates from AML including parts of northeastern North Carolina, a region near Greenville, and a region in northern Wake County, extending into Durham.
“Our study wasn’t able to pick out the exact reasons for this,” said Ashley Freeman, a clinical fellow at UNC and one of the study’s authors. “But it was interesting to note that it wasn’t a simple relationship with race or income level, education level and things like that.”
“We believe this means there’s something more complex going on with the local health care structure and possibly at the provider level that’s affecting outcome for patients.”
A complex disease
Each type of cancer has its own “complex mechanisms” and can present differently from patient to patient, and even from state to state, said Andrew Olshan, the director of the epidemiology department for UNC’s Gillings School of Global Public Health.
“Different cancers have different risk factors and some are definitely driven by things that are linked with socioeconomic status and poverty,” he said, “Some cancers don’t follow that pathway.”
For example, people in geographic areas with high death rates from colorectal cancer, Olshan said, often don’t get the screening and treatment to remove the cancer, a result of inadequate access to healthcare facilities.
AML is a cancer that follows a different pathway.
“AML is a pretty rare disease so not every physician out there is going to be familiar with the treatment, diagnosis and follow-up,” said Freeman. It’s important to have specialists who know what they’re seeing.”
So it was hard to draw a straight line between the location and the reason why more people died in that place from AML, Freeman said. But the study did find one high-risk region having fewer general practitioners and radiation oncologists.
“It may be that there are less services available in those areas and may be affecting things like referrals,” to the correct specialist, she said.
North Carolina is uniquely positioned because there are three National Cancer Institute (NCI) centers, said UNC cancer epidemiology researcher Anne Marie Meyer. She was also involved with the AML study.
Meyer says some states don’t even have cancer centers. Yet, even though North Carolina has several NCI cancer centers, “we still see patients in the state who aren’t being referred.”
Part of the problem, she said, could be that doctors in rural areas are overwhelmed by diseases such as Type II diabetes, heart failure and stroke and they fail to refer patients to specialists.
“In the AML context, timing is of the essence, with regard to getting a patient diagnosed and into care and into intensive chemotherapy,” Meyer said.
According to the American Cancer Society, “this leukemia can progress quickly if not treated and would probably be fatal in a few months.”
“Some patients who have preventable and treatable cancers are missed. It’s really a function of not only demographics and [socioeconomics], but also health care infrastructure that’s available in specialty care,” Meyer said.
‘Moving the dial’
Doctors, state legislators and cancer survivors came together over the past several years to help write the North Carolina Comprehensive Cancer Control Plan for 2014 to 2020. The plan addresses ongoing healthcare needs and treatments for six different types of preventative cancers that are linked to factors such as tobacco use, poverty and health care coverage.
“When we look at breast, cervical and colon cancer, even after we control for race and poor insurance coverage, we still see inequalities that are potentially geographic in nature,” said Meyer.
“What this tells us is cancer is a complex disease,” she said.
In an effort to reduce geographic cancer disparities in the state, the cancer control plan calls for early detection through routine screenings, partnerships with transportation, employment and housing services for underserved patients, and education programs.
“We are trying to move the dial in North Carolina to lessen mortality and lessen disparities by region, by racial ethnic group, etc.,” said Olshan.
One clear intervention is screening for colorectal cancer, he said.
“It’s a tractable problem and among the most common cancer,” which is why research is targeting a more precise definition of colorectal cancer hotspots and increase screening in those areas.
People don’t have access to the services needed to get colonoscopies to more patients. “We’re not going to go in overnight and obviously reduce poverty” and other barriers to screening, Olshan said.
“We have to work with the health department, healthcare providers, a whole variety of network groups… It’s clearly a multidisciplinary approach to try and implement an intervention and spread the dissemination of a proven intervention like screening.”
Dispatch From the International AIDS Conference: Social Media, Isolation and Risky Behavior
Lee Storrow, the head of the NC AIDS Action Network, is in Durban, South Africa for the 2016 International Conference on AIDS to present his own research. This week, NC Health News will be featuring some stories from Lee about the conference and where North Carolina fits into the global fight against HIV/AIDS.
By Lee Storrow
The poster presentation section at the International Conference on AIDS is overwhelming. The five sections line the perimeter of the second floor of the convention center, a space twice the size of Raleigh’s Halifax Mall. Hundreds of posters are on display each day.
You can read the details of the results on LaGrand’s abstract here.On Tuesday, I spoke with Dr. Sara LeGrand, Assistant Research Professor of Global Health at the Duke Global Health Institute. She was presenting her research on whether the use of social networking (Facebook, Instagram) and dating/hook-up sites (Grindr, Jack’d) in young black men who have sex with men (MSM) in North Carolina could predict whether these men felt socially isolated.
The study reveals that young black MSM are, indeed, using social networking accounts and using those accounts may reduce these men’s feelings of social isolation.
Across the survey of N.C. teens, participants reported an average of 7.35 hours of Internet use per day and the average number of social networking platforms – such as Facebook or Grindr – that participants used was 3.62. The study found that the more social network sites used translated into decreased feelings of social isolation, as well as increased searching for sex partners online.
“I think the results of this study are especially important for young people in rural areas of North Carolina who often face greater stigma around their sexuality,” said Dr. LeGrand.
There’s been a lot of chatter about the rise of dating and hook-up apps and their potentially negative role in changing the nature of gay sex. At the same time, gay men in rural parts of North Carolina have limited support systems and often live in homophobic environments. If Grindr can provide even a limited outlet to remind a closeted gay man that he is not alone, it might be beneficial.
Dating and hook-up apps aren’t going away any time soon. HIV prevention advocates need to think about how to harness those apps to disseminate positive prevention messages and build support systems for those most at risk.
Study: North Carolina Minors Have Easy Online Access to E-Cigs
Despite legislators’ and parents’ efforts, kids have no problem buying electronic cigarettes online.
By Bradley Allf
Gone are the days of the Marlboro Man, but the tobacco industry is finding new ways to lure young people. Though today’s youth smoke far fewer cigarettes than their counterparts did 20 years ago, an emerging market for electronic cigarettes is providing a new outlet for nicotine use among young people.
Despite a state law prohibiting the sale of these products to people younger than 18, a study by UNC-Chapel Hill researchers found that North Carolina minors can easily obtain electronic cigarettes over the internet.
“E-cigarettes,” as they are called, are a group of various battery-operated devices that allow users to inhale nicotine vapor.
Originally promoted as smoking cessation devices, the products are now exploding in popularity among teens, many of whom have never smoked conventional cigarettes. One recent study found that high school seniors are now twice as likely to use e-cigarettes as conventional cigarettes. Of the estimated 4.7 million middle and high-school students in the US that used tobacco products in 2015, 3 million were e-cigarette users.
The e-cigarette business, almost nonexistent 10 years ago, has burgeoned into a multi-billion-dollar industry. Effective policies have struggled to keep pace, leading one FDA official to label the market the “wild, wild West.”
North Carolina, for its part, outlawed the sale of e-cigarettes to minors in 2013. Researcher Rebecca Williams from UNC-Chapel Hill wanted to find out how effective this law was in preventing minors from purchasing e-cigarettes online.
To test this, her team recruited 11 teenagers from 14 to 17 years old to try to purchase e-cigarettes over the internet. The research is described in an article in JAMA Pediatrics.
The team identified 98 online e-cigarette vendors for the study. They then allowed the 11 teens, under supervision, to attempt to buy e-cigarette products from the different vendors.
Of the 98 purchase attempts, only 5 failed due to age-verification requirements.
In fact, more than 80 percent of vendors either did not attempt to verify age, or used clearly ineffective means of verifying age, such as offering a check box. The only consistently effective age-verification techniques that Williams and her team found were requirements to enter a date of birth in conjunction with a social security number.
Williams is a researcher at the UNC Lineberger Comprehensive Cancer Center and Center for Health Promotion and Disease Prevention. She has done similar studies on youth access to conventional cigarettes and anticipated these results.
“The rate of success with e-cigarettes is similar to what we found with cigarettes,” she said. “So it didn’t surprise me at all that it was easy to buy e-cigarettes online for teens.”
So why aren’t online vendors following North Carolina law? Williams explains that part of the issue is jurisdictional.
“When you’re making an online purchase, where is that purchase taking place? Is it taking place where the person who is ordering is located? Is it where the website is hosted? Is it where the business is located?” she asked. “Those all may be in different states and different countries.”
It can be tough to know where exactly the boundaries of enforcement fall when dealing with online purchases. It is also exceedingly difficult to track down these vendors, many of whom operate internationally.
Better than cigarettes?
According to a report released by the American Heart Association last year, “[e]- cigarettes are mostly unregulated and their health effects are not fully known, especially when associated with long-term use.”
Research on the effects of traditional cigarettes accumulated over decades. However, because e-cigarettes sprang quickly onto the US market in 2007, there hasn’t been enough time for researchers to determine how e-cigarettes affect the human body.
Despite this, there are already some known risks associated with e-cigarettes. One instance concerns the chemicals used to flavor the vapor. While these chemical products are approved by the Food and Drug Administration for ingestion, they have not been approved for inhaling.
“Safe to ingest does not mean safe to vaporize and inhale,” Williams says. “When they vaporize a product at a high temperature, it creates more and more dangerous chemicals that can be damaging to lung tissue and other tissue.”
Chemicals such as diacetyl (butter or popcorn flavor) and cinnamaldehyde (cinnamon flavor), both of which are found in many e-cigarette flavorings, pose known health risks.
In addition, nicotine itself is highly addictive and can have long-term consequences for brain development, particularly for young people.
Taken together, these health risks have many people concerned.
“I think we know they’re not safe and we’re still finding out how unsafe they are,” says Peg O’Connell of the North Carolina Alliance for Health. “I think that’s the public health message.”
At the national scale, the FDA announced in May that it will begin regulating the sale of e-cigarettes in August. This policy was partially informed by the Internet Tobacco Vendors Study, which based its suggestions on the research findings of Williams and her team.
Williams believes this is a step in the right direction. She said a national policy would address some of the jurisdictional problems associated with having different regulations in different states. She hopes that the FDA will end up enacting strict age-verification requirements for online vendors at both the point of order and the point of delivery to keep minors from getting access to e-cigarettes.
Locally, North Carolina health organizations are working on a number of fronts to enact policies designed to stem the rising number of young people who are using e-cigarettes.
O’Connell is working with the North Carolina Alliance for Health to bring back the state’s formerly award-winning youth tobacco prevention program. According to O’Connell, education initiatives such as the state’s previous anti-tobacco effort may be effective in keeping e-cigarettes away from minors.
The Orange County Board of Health, in concert with the Orange County Board of Commissioners and counties across the state, has been advocating other e-cigarette control policies.
Orange County health educator Coby Jansen Austin said those two bodies support a public policy of giving jurisdictions the right to raise the minimum sale age for tobacco and e-cigarettes from 18 to 21.
According to Austin, policy actions make a real difference in decreasing the number of young people who start using tobacco products.
“What we know has worked in tobacco control and contributed to a lot of the drop in tobacco use that we’ve seen over the last five or six decades are some of the policies around tobacco,” she says. “And so I think the FDA regulations are a good example of where we have the appropriate research and we take appropriate policy actions. It’s not just about education and sharing information, though those are also components.”
Correction: This article originally stated the research was published in the Journal of the American Medical Association.
Study Finds Encouraging Surgical Outcomes at Critical Access Hospitals
By Taylor Sisk
On the heels of a report warning that more than a third of the nation’s critical access hospitals are in danger of closure comes some encouraging news. A new study indicates certain procedures are being performed in these small hospitals more safely and at a lower cost than in larger institutions.
A University of Michigan team of researchers looked at four common surgeries – appendectomy, gall bladder removal, hernia repair and removal of all or part of the colon – and found no statistically significant difference in 30-day mortality rates between critical access and other hospitals.
Further, critical access hospitals experienced serious complications in performing these procedures 6.4 percent of the time as compared with 13.9 percent of the time in other hospitals.
CAHs also billed Medicare an average of $1,400 less for the procedures.
CAHs serve many of the nation’s remotest regions. By definition, they have fewer than 25 beds and are more than 35 miles from the next nearest hospital. They must maintain an average length of stay of 96 hours or less for acute-care patients and provide 24-hour emergency-care services. In return, they receive preferential reimbursement from Medicare, which covers more of their costs.
There are 1,284 CAHs throughout the country; North Carolina has 20.
Doing what they should
The Michigan researchers examined more than 1.6 million Medicare-beneficiary admissions to 828 CAHs and 3,676 other hospitals. Their results were published last week in the Journal of the American Medical Association.
The researchers found that patients who had any of the four types of operations at CAHS tended to be healthier upon admission than patients treated for the same procedures at other hospitals. They said this indicated CAH surgeons appropriately selected patients who they felt would be most likely to have positive outcomes, while sending higher-risk patients to larger hospitals.
“From a surgical standpoint, these hospitals appear to be doing exactly what we would want them to be doing: common operations on appropriately selected patients who are safe to stay locally for their care,” lead author Andrew Ibrahim said in a release.
That said, even after correcting for differences in health status at the time of the operations, the CAHs had equal or better outcomes.
‘On the firing line’
In rural communities throughout the country, small hospitals in general, and critical access hospitals in particular, are facing mounting challenges including reduced reimbursements; aging, declining populations; and difficulties recruiting health care professionals.
“Critical access hospitals are on the firing line. They’re in the middle of the target,” Alvin Hoover, past chairman of the American Hospital Association’s Small or Rural Governing Council and current board chair of the Mississippi Hospital Association, said in a recent interview. “It’s hard for me to understand why you want to target those guys, because if you look at the cost of care, they do it cheaper than anybody else.
“If you can keep that person home, right there in that local community, your cost of treatment of that pneumonia patient, [for example], is going to be way less than it is if you have to send them to the big university.”
The outcomes found in this research, the study’s authors write, should “inform legislators about the valuable role critical access hospitals provide in the U.S. health care system.”
New Testing Technique Could Make Identifying Potentially Hazardous Chemicals Easier
Recent work in finding more efficient ways of testing chemicals is almost more important than the potential hazards of the chemicals themselves.
By Catherine Clabby
When UNC-Chapel Hill scientists spilled commonly used fungicides onto mouse brain cells, genes inside those cells changed. Activity levels among some of the genes shifted to distinctive patterns observed in the brains of people with autism.
First hear this: No one has proven that a class of popular crop-field fungicides causes brain damage. For starters, mouse brain cells are not human brain cells (though they are more alike than many people know). And cell studies don’t prove that chemical X produces human brain abnormality Y.
That said, the recently published research is compelling evidence that the potential of human health risks from a popular class of farm fungicides may merit closer study.
“There are so many questions to be answered,” said UNC cell biologist Mark Zylka, who led the chemical-screening project. “Do these chemicals get in the blood? Do they get into the brain? If so, in what concentrations?
Despite uncertainties about a real-world risk, Zylka is confident there is promise in the technique used to make this headline-grabbing discovery. The approach is a step forward in the scientific quest to more rapidly screen chemicals for potential impacts on human health, this time in the brain.
Trial and error
The breadth and accuracy of toxicology studies are vital in today’s chemical-laden world. Their results strongly influence government rulings on safe and unsafe levels of the tens of thousands of manufactured chemicals registered for use in the United States alone.
For nearly 100 years, many toxicology studies exposed mice or other lab animals to chemicals to see if they do harm. Damage to skin, disruption of reproduction and the growth of tumors all flag concerns.
But it isn’t always clear how to extrapolate data from one strain of mice to diverse populations of people. And animal studies can’t clarify precisely how chemicals affect functioning in cells, information that both help prevent and treat illness.
Several federal research agencies, particularly those located in North Carolina, are promoting newer toxicology screens. These use automated laboratory tools, computer analysis and plates of cells or tissues as research subjects to help predict ways that compounds might affect people and the environment.
Automated cell-based screenings broaden the number of chemical targets that can be screened and pick up the pace of studies because they can be cheaper and quicker than animal-based tests, said Scott Auerbach, a molecular toxicologist at the National Toxicology Program in Research Triangle Park.
“The idea is to get us closer more quickly to the things that we should be looking at. Potentially no stone will get left unturned,” said Auerbach, whose program is part of the Toxicology in the 21st Century initiative. So is the National Institute of Environmental Health Sciences, where NTP is based; the Food and Drug Administration; and other federal agencies.
Environmental Protection Agency staff in RTP, also Tox21 participants, compiled nearly 300 chemicals that Zylka’s team screened. Those included pesticides, fungicides, herbicides and compounds used to make plastics, among others.
The UNC researchers employed genomic sequencing tools to capture changes in gene activity in its mouse neurons after they were dosed.
The rates at which genes direct the production of proteins in different types of cells is essential to health. Overactive or underactive genes are less likely to produce the amount of proteins that cells require to grow or function normally.
Increasingly, genetic studies are linking patterns of abnormal gene activity to specific illnesses and disorders. Differences detected in brain cells of people with autism, for instance, include reduced activity of genes involved in transmission of signals between neurons and increased activity among genes involved in immune responses.
Zylka’s team found that exposure to fungicides called quinone outside inhibitors produced those very types of changes in the mouse neurons, in addition to other effects. Among the fungicides screened were pyraclostrobin, trifloxystrobin, famoxadone and fenamidone, agricultural chemicals modeled after an antifungual chemical forest mushrooms emit to protect themselves.
Agricultural chemical companies in North Carolina – BASF, Bayer and Syngenta – are among the producers of products using this class of fungicides. With names such as Cabrio, Reason and Abound, they suppress damaging fruit rot, mold, mildew and other blights on everything from berries to lettuce and nuts and improve farmers’ yields.
In food-crop fields and other agricultural settings, these types of fungicides work by impairing structures inside fungi cells called mitochondria. The structures are important in cells of many organisms because they produce the chemical energy cells can use to power many activities.
In their paper, Zylka’s team cites FDA and U.S. Department of Agriculture data showing that residue from quinone outside inhibitors has been detected on food, including spinach and apples, but in extremely tiny amounts measured in parts per million. Federal studies have documented residue from this class of fungicides on food, particularly leafy green vegetables.
Darren Wallis, a Bayer spokesman, said his company is committed to producing safe products that must undergo rigorous testing before release and are monitored by the company and regulatory agencies around the world once in circulation. Bayer scientists, he said, will certainly review the UNC findings and assess if any next steps are needed.
“The people of Bayer take our jobs of creating products to help improve the lives of people, plants and animals very seriously,” Wallis said.
Effects from exposure to chemicals released into the environment is an active area in autism research. Evidence exists, for instance, that pregnant women living close to farmlands and exposed to a limited number of pesticides are at increased risk of giving birth to children who will be diagnosed with autism, one clue that exposures may increase risk of the disorder.
Given indications that prenatal exposures play a role in autism, good research that sheds light on how chemicals affect neurons is needed, said Geraldine Dawson, director of the Center for Autism and Brain Development at Duke University, who was not involved in the UNC study.
“Zylka and his team have developed a really efficient way to test how a wide range of toxins influence the expressions of genes involved in neuronal development and function,” Dawson said. ”This high-throughput approach will be critical for identifying which combinations of toxins are associated with increased risk.”
Because of what they saw in the brain cells exposed to fungicides, the expanded use of the compounds and their detection on food, the UNC scientists in their paper called for “greater scrutiny” on the fungicides’ effects outside cells too.
There is now reason to observe effects on brains, they said, and behavior.
Though Zika Unlikely a Risk in N.C., Local Efforts Are Scaling Up
Research and response teams in North Carolina are preparing.
By Rose Hoban
It’s cold in North Carolina right now. So people aren’t sitting on their porches swatting at mosquitoes.
But even when the weather warms up and the local bloodsucking bugs start flying, the question for many people is: Is it possible to get the Zika virus in North Carolina?
The answer, according to researchers from UNC-Chapel Hill, is, essentially, “No.”
“There’s not zero risk of anything, but I wouldn’t worry about transmission of Zika in the U.S.,” said Aravinda de Silva, an infectious-disease researcher at UNC who specializes in dengue virus, another mosquito-borne virus in the same family as Zika.
Though there are mosquitoes in the U.S. capable of carrying Zika, de Silva said there’s an exceedingly slim chance of someone in this country getting Zika from a mosquito.
There have been small outbreaks of dengue in Key West and along the Texas-Mexico border. But da Silva said Zika diagnoses in the U.S. will overwhelmingly come from travelers who bring it home from their Caribbean or Latin American vacation.
“Let’s put the U.S. aside for a moment. There’s more globally; all these people living in endemic areas,” he said. “There are huge populations living in these large urban centers, millions and millions of people who are at risk of getting dengue, and those same populations are at risk of getting Zika.”
“If it wasn’t for the microcephaly, it wouldn’t be unique,” said UNC infectious-disease specialist David Weber, referring to a strongly suspected link between Zika infection in pregnant women in Brazil and a sharp uptick in a birth defect known as microcephaly.
“Otherwise, [Zika] is just a mild illness, which is why there’s been so little research,” he said.
According to da Silva and Weber, who both presented last week, researchers from the university are mobilizing to study the disease.
Even as the UNC researchers were presenting, a study was released in the New England Journal of Medicine showing direct links between even mild Zika infections in pregnant women and the birth defect. What is disturbing to the authors of that study was that only about a third of the women tested actually had a fever; the rest never knew they were sick.
Air conditioning and window screens
Zika is closely related to dengue, which has been spreading widely in Latin America and the Caribbean for the past few years. Commonly known as “breakbone fever,” dengue usually causes mild fever. But in a limited percentage of patients, its muscle and joint pains can be just plain awful.
Yet out of the estimated 390 million cases of dengue worldwide in 2013, only 794 were diagnosed in the U.S. Most of those were travelers who acquired the disease while abroad.
There has been some local transmission in the U.S., but the spread has been limited. Even in places in the U.S. like Key West and along the Texas-Mexico border where there are the right kind of mosquitoes – namely, Aedes aegypti and Aedes albopictus – and the weather is warm enough, there’s reduced risk of those bugs actually carrying disease from one person to another.
“This has mostly to do with lifestyle factors such as air conditioning and window screens, which limit the spread of mosquito-borne viruses here,” said Helen Lazear, a UNC microbiologist who studies mosquito-borne diseases, during last week’s presentation.
In a recent Key West dengue outbreak, there were only 28 confirmed cases of locally transmitted disease between August 2009 and March 2010.
More than the U.S.
Lazear floated the suspicion that prior infection with dengue, as is common in Brazil and other countries where Zika is currently raging, can actually make Zika cases worse.
According to Lazear and da Silva, Zika triggers the immune response created after a person has gotten dengue.
“Unfortunately, dengue and Zika are too close and it’s very difficult with the [existing test] to see whether someone is having a dengue or a Zika infection,” da Silva said.
That makes it harder for researchers to actually confirm that a patient has Zika while they’re still sick. Instead, the best diagnosis is made using sensitive DNA-based testing; but that’s expensive and needs to be done in a lab.
UNC researcher Sylvia Becker-Dreps, who has been doing epidemiology research in Nicaragua for a decade, will be leading a collaboration between UNC and a university in that country to study Zika.
“Right now, it’s mostly a naîve population; they’re only starting to get their first cases, something between 300 and 600 cases detected in Nicaragua,” Becker-Dreps said.
The idea is to help the government with its response, but resources in that country are poor and Becker-Dreps said the ministry of health is only testing every tenth blood sample it receives.
She said one of the most important things to do is monitor what happens with pregnant women as the disease spreads across Nicaragua.
“The rainy season begins in May,” she said. “So the epidemic is only arriving now in Nicaragua. Then wait nine months and see.”
It’s important to understand what’s happening with Zika now, da Silva said, because inevitably the disease will make the jump to Asia, with its megacities of tens of millions of people.
“You have huge populations living in these large urban centers, millions and millions of people who are at risk of getting dengue, and those same populations are at risk of getting Zika,” he said.
Even if only a small proportion of pregnancies in Zika-infected women in those megacities end with babies having birth defects, it could still be tens of thousands of cases.
Closer to home, state public health officials are leveraging the publicity around Zika to beef up their surveillance and response capacity around bug-borne diseases.
North Carolina was one of the only states in the country to have a small cadre of entomologists, embedded in the Division of Public Health, to track mosquito-borne diseases and other diseases carried by bugs, known as “vector-borne” diseases.
But the vector-borne disease branch was eliminated during budget cutting in 2010 and 2011.
Now the Division of Public Health is looking for two entomologists, one to be based in Raleigh and the other to do fieldwork throughout the state, according to Danny Staley, who heads the division.
Essentially, that’s the same level of staffing as in the older program.
Staley said a number of counties, including New Hanover and Brunswick, have active vector-control programs. Those counties have historically been mosquito hot spots.
Staff go out, either in response to complaints or to known hot spots, he said, and look for birdbaths or containers with larvae.
Staley said spraying has fallen out of favor as the preferred method of mosquito control. Instead, public health interventions are more targeted: Teams go to hot spots, look for larvae, trace the feeding patterns of the mosquitoes and monitor what happens after they apply larvacide or drain waters.
“You can have three or four broods coming off of one container in a day,” Staley said.
He said the newly hired state-level entomologists will coordinate with local departments and will track what’s happening statewide to prepare for “new and novel viruses that are coming our way.”
“Last year, it was chikungunya; a few years earlier, it was West Nile virus,” Staley said.
As happens often in public health efforts, funds get cut when there’s no disease activity; then when there’s an outbreak, agencies scramble to rebuild.
“I will say that North Carolina is not unique in this situation,” Staley said. “In Florida and other states, there are similar situations; programs that were once very popular have faded.”
The entomologist job postings closed last week. Staley said the division is “aggressively” moving to get the new hires in place before North Carolina’s mosquitoes get active.
Distant Echoes of Slavery Affect Breast-feeding Attitudes of Black Women
Black women have some of the lowest rates of breast-feeding. One midwife found some surprising reasons why that might be so.
By Rose Hoban
As certified nurse-midwife Stephanie Devane-Johnson works with her patients in Greensboro, she talks to them about a lot of health issues. But for her pregnant clients, one of the biggest topics is breast-feeding.
“I’m asking about whether they’re going to breast-feed or bottle-feed,” Devane-Johnson said. “If they say they’re going to bottle feed, I say, “What about breast-feeding?’’
But to her frustration, for many black women breast-feeding their babies isn’t the first option.
National data show that only about 59 percent of black women breast-feed, compared to 79 percent of whites and 80 percent of Hispanic women. In North Carolina, those rates are even lower: Only about 44 percent of black mothers breast-feed.
This led Devane-Johnson to explore why more black women aren’t breast-feeding.
Some of the answers she found were surprising: The echoes of slave women being forced to give up their milk still resounded. And black women didn’t talk to their sisters, daughters and granddaughters about how to feed their babies; the bottle was just assumed.
And for some women, breast-feeding was a “white thing.”
As part of her research for a doctoral degree at the UNC-Chapel Hill School of Nursing, Devane-Johnson held focus groups to ask black women about breast-feeding. She presented her research at the annual UNC-Chapel Hill Minority Health Conference, held last week at the Friday Center in Chapel Hill.
Devane-Johnson described how she recruited 39 women ranging in age from 18 to 89 years old and asked them what conversations they’d had with family members.
Turns out, many hadn’t had conversations at all.
“In the formula-feeding group, it was just assumed,” she said.
She said some women who had breast-fed said it was a topic that couldn’t be addressed in their families.
“If they did breast-feed, they didn’t breast-feed at, say, their aunt’s house, [because] they would tell them, ‘You can’t do that in my house. Breast-feeding is nasty,’” Devane-Johnson said. “You don’t talk about ‘boobies,’ because breasts are sometimes seen as sexual and not as functional.”
And then there was the enduring legacy of slavery.
“There were some older black women who wanted to disassociate themselves from the past, from slavery and the wet-nursing,” she said, explaining that often young slave women were impressed into giving their milk to white infants.
“Grew up thinking breast-feeding was a white thing.” – focus group participant“That image of a ‘mammy’ when people would say that,” reads one of the quotes Devane-Johnson collected from her focus groups. “It did conjure up those pictures of the women feeding the white babies and all that.”
And the cultural memory had been passed down even to younger women.
“It really was amazing…. In my 18-to-29-year-old breast-feeding group, there was a young lady in there who said, ‘Yeah, the white men used to steal the slaves’ milk,’” she said.
Devane-Johnson explained that often slave women had to be away from their own children, at the cost of their own children’s lives.
“A lot of slave babies died during slavery because they weren’t breast-fed. They were fed concoctions of dirty water and cows milk,” she said. Meanwhile, those children’s mothers were giving white children their milk.
And women reported that oral histories have been reinforced by modern technology.
“These pictures are all on social media,” Devane-Johnson said. “Then someone gets pregnant and people talk about breast-feeding. They’ll say, ‘You don’t have to do that anymore.’”
Teaching for change
There are also societal, economic and practical barriers to breast-feeding, Devane-Johnson said, things she’s working with her patients to change.
For starters, breast-feeding isn’t exactly easy, especially at first.
“When you have a sleep-deprived mom trying to breast-feed at three o’clock in the morning, and a matriarch at home is saying, ‘Get that out of that baby’s mouth and get that baby a bottle,’ it’s very enticing,” she said.
“There was an empowerment in being able to choose that bottle and not say I’m going to be sitting here with the baby attached to me.” – focus group participantBreast-feeding also can be something of a class issue, Devane-Johnson said. For some women, using formula was “empowering.”
“If you’re raised in your thought process, ‘I have a job, I can afford to formula-feed,’ to them breast-feeding is associated with being poor,” she said. “To some black women. Not to all, but to some.”
And using formula means a woman doesn’t have to be “tied down” to their baby.
Devane-Johnson said part of the solution is teaching women about how much healthier breast-fed babies are: Research shows they have lower rates of obesity, fewer colds and lower rates of diabetes later in life.
But there are also workplace barriers to breast-feeding. She said women need coaching to ask their supervisors about accommodations, which are required by state and federal law.
Marva Price, a black nurse who spent years teaching women to breast-feed, discussed how she’s helped women approach that discussion.
“They have to ask for that – if they can take time away,” Price said. “Can they take time away, can they even pump in their work space or go someplace and have a clean place, even a storeroom?”
She said that over the years she’s worked with patients to help them figure out what to do and how to negotiate with their bosses. Then there are logistical issues: a refrigerator to store the milk, a place to store the pump, a quiet, out-of-the-way place to pump.
“It takes a lot of support,” Price said.
NIEHS Looks for Higher Local Profile
By Rose Hoban
If you have ever received an email from anyone at the National Institute of Environmental Health Sciences, the bottom of the email has a statement that starts, “Hopefully, you’ve heard of NIEHS, but if not …”
Brand recognition seems to be a problem for NIEHS, the only one of the National Institutes of Health located outside of the DC metropolitan area.
And, yes, NIEHS is located in North Carolina, in Research Triangle Park. It was actually the first large tenant in RTP, back in the ’60s.
NIEHS leader Linda Birnbaum is determined to raise the organization’s profile in this, its 50th anniversary year. She also wants to get her researchers out into the local community more.
“If you’re going to study the environment, you absolutely have to work with the community,” Birnbaum said at an event held last week.
Birnbaum had come to a monthly meeting of RTP 180, a social, networking and educational TED-like event held at The Frontier, a co-working and event space in RTP. She brought with her several NIEHS grantees to talk about their work.
“Several of our centers are at local universities,” Birnbaum said. Both UNC-Chapel Hill and Duke host Superfund Centers. N.C. State University hosts an environmental health center, and there are multiple grantees at universities throughout North Carolina.
“We spend almost $250 million a year in the local environment,” she said. “We’re a pretty well-kept secret.”
Getting the word out
But if the grantees Birnbaum had with her last week were any indication, NIEHS won’t be a secret for long.
N.C. State researcher Heather Patisaul had the crowd laughing along as she presented on what she’s learned from prairie voles, little mouse-like critters that are actually quite social.
There’s active recruitment in North Carolina for several studies, including the Body Weight and Puberty Study and a study on Bisphenol A exposure, both being conducted on the NIEHS campus in RTP. Patisaul explained how the voles mate for life and are more interested in hanging out with their mates than by themselves or with “an alluring stranger.” That’s more similar to humans than other rodents.
With help from NIEHS, she’s been able to look at the hormones in the voles similar to those in humans and has studied how those hormones get disrupted.
“We can study how a chemical like bisphenol A, or BPA, interacts with the brain and the nervous system to change behavior,” she said.
Another presenter, Dave Peden from UNC, grabbed attention with his description of exactly how air pollution damages the lungs.
Peden, who studies asthma, told the crowd that someone with asthma is more likely to have a delayed reaction to air pollution; attacks come a day or so after exposure. That realization is what led researchers to believe that inflammation is important.
“It takes awhile to make pus in your lungs. There’s an image for you.” he said as people audibly groaned. “If you inhale a particle, it takes awhile for your lungs to get annoyed with it.”
Peden said research shows, for example, that if people are worried about pollution, then exercising in the morning may be better than exercising in the afternoon if you exercise outside, because there’s less pollution in the morning.
“There are things that you do to protect yourself,” he said.
More to come
Event emcee Will Hardison said the 300-some people at last week’s event constituted one of the biggest crowds RTP 180 has attracted, so big that the event ran out of food and beer.
Afterwards, Peden said he thinks it’s important for scientists to get out and talk about their research in ways that are engaging to the public.
If that’s the case, Birnbaum may be calling him again. The Institute is planning a series of events throughout 2016, from a screening of WALL-E at Marbles Kids Museum in Raleigh and Women’s Health Awareness Day events in Durham, both in April, to lectures and symposia scattered throughout the year.
“We’ll be having events all year,” Birnbaum said. “Some of the best ways for me to meet the community is to hold an open forum.”