A Clean Production Action Report Chemical Footprint of Products Commonly Used in Pediatrics Departments

Mark S. Rossi, PhD and Wanda Ratliff, MS

Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms

Mark S. Rossi, PhD and Wanda Ratliff, MS December 5, 2017

Clean Production Action is a solutions focused non-profit organization that advances safer alternatives to hazardous chemicals through its BizNGO, Chemical Footprint Project (CFP), and GreenScreen® programs.

www.cleanproduction.org ii | Clean Production Action

Contents

v Acknowledgments

1 Executive Summary

Chapter 1 9 Bringing Chemical Footprinting to Health Care

Chapter 2 13 Method for Chemical Footprinting Products Used in Health Care

14 2.1 Chemicals of High Concern (CoHCs) and Potential for Exposure

15 2.2 Inventory of Products Commonly Used in Pediatric Patient Rooms and List of Priority Products

17 2.3 Supplier Survey

18 2.4 Supplier Responses

Chapter 3 21 Results

21 3.1 Medical Supplies

23 3.2 CoHCs in Medical Supplies

26 3.3 Personal Care Products

27 3.4 Disinfectants & Cleaning Products

27 3.5 Furnishings

28 3.6 CoHCs in Pediatric Products

Chapter 4 31 Recommendations

34 Endnotes Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | iii

FIGURES

2 Figure ES-1. Number of Products Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

3 Figure ES-2. Number of Medical Supplies Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

4 Figure ES-3. Chemicals of High Concern (CoHCs) in Medical Supplies Commonly Used in Pediatric Patient Rooms and the Number of Products that Contained Them

4 Figure ES-4. Number of Personal Care Products Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

21 Figure 1. Number of Products Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern

22 Figure 2. Number of Medical Supplies Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

23 Figure 3. Number of IV Products Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

23 Figure 4. Number of Enteral Products Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

23 Figure 5. Number of Respiratory Therapy Products Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

24 Figure 6. Chemicals of High Concern (CoHCs) in Medical Supplies Commonly Used in Pediatric Patient Rooms and the Number of Products that Contained Them

24 Figure 7. Number of Products Containing Polyvinyl Chloride (PVC) and Other Chemicals of High Concern (CoHCs) in Medical Supplies Commonly Used in Pediatric Patient Rooms

26 Figure 8. Number of Personal Care Products Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

27 Figure 9. Number of Disinfectants and Cleaning Products Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

27 Figure 10. Number of Products Commonly Used in Pediatric Patient Rooms that Contained Antibacterials and Antimicrobials

28 Figure 11. Number of Furnishings Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

29 Figure 12. Chemicals of High Concern (CoHCs) and the Number of Products in Pediatric Patient Rooms that Contained Them iv | Clean Production Action

About the Authors

Mark S. Rossi, PhD Executive Director, Clean Production Action Part of the Clean Production Action team since 2004, Mark has the unique ability to bring together diverse groups and achieve innovative outcomes. In 2006, he founded BizNGO, a collaboration of organizations who work together to advance safer chemicals and sustainable materials. Mark is the co-author of GreenScreen® for Safer Chemicals. Launched in 2007, GreenScreen is now the gold standard in hazard assessment tools. In 2014, he co-founded the Chemical Footprint Project. Mark’s career includes stints at Tellus Institute, the Toxics Use Reduction Institute, and Health Care Without Harm. His doctorate is in Environmental Policy from MIT.

Wanda J. Ratliff, MS Consultant to Clean Production Action Wanda has over 20 years’ experience in corporate environmental management and consulting. She has served as a Vice President at Haley & Aldrich, a national environmental and engineering consulting firm based in Boston, and as an expert witness and provided litigation support on a number of complex environmental cases. As a consultant to Clean Production Action since 2016, Wanda has collaborated with strategic partners on GreenScreen, prepared alternatives assessments, and con- ducted Chemical Footprint Project work to benchmark corporate progress toward the use of safer chemicals. She is also an Authorized Greenscreen Practitioner.TM Wanda earned her Master of Science degree in Geochemistry from Louisiana State University. Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | v

Acknowledgments

We are very thankful to the three health care organizations and the group purchasing organization that made this study possible. Kyle Tafuri and pediatric nurses at Hackensack Meridian Health, Lauren Bulin and pediatric nurses at Dignity Health, and staff at a third health care organization and a group purchasing organization (both of which chose to remain anonymous) were all incredibly helpful in identifying products with the greatest use and potential for exposure in pediatric departments. Mary Ellen Leciejewski and Lauren Bulin of Dignity Health along with the staff at the anonymous organizations provided invaluable data, contacts, insights, guidance, and feedback, all of which were essential to the research and writing of the results. Alison Poor of Clean Production Action provided much needed support with references. Ellen Goldberg of Clean Production Action lent us her copy editing skills. And David Gerratt of DG Communications provided the design of the report.

Design Illustration Photography David Gerratt Monty Lewis © Thinkstockphoto NonprofitDesign.com lewisarts.com unless otherwise noted CHEMICAL FOOTPRINT Medical Supplies 101 Products with 45% no CoHCs 55% 84 Products that contain CoHCs

CHEMICAL FOOTPRINT CHEMICAL FOOTPRINT Cleaning Personal Care 2 34 Products with Products with 28% no CoHCs 32% no CoHCs 72% 68% 5 CHEMICAL FOOTPRINT 16 Products that Products that contain CoHCs Furnishings contain CoHCs 18% 2 Products with no CoHCs 82% 9 Products that contain CoHCs

CHEMICAL FOOTPRINT Patient ROOM 139 Products with 45% no CoHCs 55% 114 Products that contain CoHCs Executive Summary

For medical products that contain chemicals of high concern, are there alternatives in the marketplace? Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 1

Executive Summary

azardous chemicals in products and frequently around the body (e.g., cleaning supply chains are catalyzing health and disinfecting products used in patient rooms). care organizations, retailers, and For this study, the chemical footprint of a pediatric other businesses to ask their suppliers product was defined by the presence of chemicals Hwhether their products and manufacturing of high concern in a product. This study demon- operations use these chemicals and whether strates how to chemical footprint products in safer alternatives are available.1 This study was health care and how chemical footprinting can designed to assess the chemical footprint of inform purchasing decisions in health care. products commonly found in a hospital pediatric patient room. Pediatrics was chosen for evaluation Method because of the well-recognized greater sensitivity The chemical footprinting of products in a of children to exposure to toxic chemicals than pediatric patient room involved: adults. • Specifying the list of chemicals of high “Chemical footprinting” is the process of concern (CoHCs). These chemicals represent evaluating the presence of hazardous chemicals the “chemical footprint” of a product. in products, manufacturing processes, supply • Developing criteria for prioritizing products chains, and/or packaging.2 Chemical footprints based on potential for exposure. provide baseline data, be they the number of • Inventorying products commonly used in chemicals of high concern in products and/or a pediatric patient room and developing a their mass, for evaluating performance and list of priority products based on potential benchmarking progress away from hazardous for patient exposure. chemicals to safer alternatives.3 This chemical • Confirming product details, including footprint study focused on products commonly supplier catalog numbers, with purchasing used in a pediatric patient room that have staff at two hospitals. the potential for moderate or higher patient • Sending surveys to 62 suppliers requesting exposure because they are in the body (e.g., information on CoHCs in 358 priority nasogastric and endotracheal tubes), on the products. body (e.g., bracelets, soaps, or tape), or used Three health care organizations participated at various levels in this study. One health care organization and its group purchasing organi- zation participated in all aspects of the study. This study demonstrates how Another health care organization participated in to chemical footprint products in collecting information by telephone interviews with pediatric nursing, procurement, and envi- health care and how chemical ronment, health, and safety (EH&S) staff; iden- tifying priority products; sending the survey footprinting can inform purchasing to suppliers; and reviewing the responses. A decisions. third health care organization hosted an on-site survey of products in a pediatric patient room that included interviews with pediatric nursing, 2 | Clean Production Action

are illustrative, not definitive, of the chemical footprint of products in a pediatric patient room. Over half of the 253 pediatric products evaluated did not Findings Fifty suppliers replied with data on 253 products contain chemicals of high concern commonly found or used in a pediatric patient room. The products covered four categories of (CoHCs). products: medical supplies (185 products), personal care products (50 products), furnishings (11 prod- ucts), and cleaning or disinfecting products (seven products). Over half of the 253 pediatric procurement, and environment, health, and products evaluated did not contain chemicals of safety (EH&S) staff. high concern (CoHCs). Specifically, 114 products Pediatric products with moderate to higher contained CoHCs (45%) and 139 products did potential exposure were identified and suppliers not contain CoHCs (55%) (see Figure ES-1). were surveyed concerning CoHCs in their prod- In the Medical Supplies category, IV products, ucts. For this study, CoHCs were defined as those enteral feeding products, respiratory therapy substances with potential to cause adverse health products, and catheters had the greatest number effects to people or the environment, and have of products containing CoHCs. These products been prioritized for reduction by health care accounted for 82% of the medical supplies with organizations. CoHCs included the carcinogenic CoHCs (see Figure ES-2). and reproductive/developmental toxicants on Reflecting the disposable nature of single-use the California Proposition 65 list; latex; and medical supplies, the primary CoHCs found in persistent, bioaccumulative, and toxic (PBT) this category were polyvinyl chloride (PVC) substances (see Section 2 for details). The survey was sent to 62 suppliers repre- senting 358 products from two health care orga- nizations, with 50 suppliers responding with answers for 253 products. The data were com- Reflecting the disposable nature bined into one dataset to protect the anonymity of single-use medical supplies, the of the health care organizations and their sup- pliers. Due to the number of products for which primary CoHCs found in this category suppliers did not reply (155 products had no reply), the combining of the products into a were PVC plastic, phthalates, BPA, single data set did not result in an overstate- and other Prop 65 chemicals. ment of the chemical footprint of a representa- tive patient room. Note the data provided below

Figure ES-1.Number of Products Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

Medical Supplies 101 84

Personal Care Products 34 16 2 Furnishings 9 2 n No CoHCs n Yes CoHCs Cleaning Products 5 Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 3

Figure ES-2.Number of Medical Supplies Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

IV Products 32 36

Enteral Products 10 14

Respiratory Products 7 13 n No CoHCs n Yes CoHCs

Urinary Catheters 2 9

Miscellaneous* 5

Needles & Syringes 25 3 1 Patient Bracelets 3 1 Suction Tips–Yankauer 1

Baby Bottles & Nipples 15

Exam Gloves 6

Tape 2 *Miscellaneous = blood pressure cuff (1), electrode (1), & infant heel warmers (3)

plastic, phthalates (DIDP, DBP, and DEHP),4 Bisphenol A (BPA), and other California Prop-osition 65 (Prop 65) chemicals, including IV products, enteral feeding products, respiratory monomers and solvents. These four chemicals/ chemical classes accounted for 91% of the CoHCs therapy products, and catheters were the medical reported in medical supplies (see Figure supplies with the greatest number of products ES-3, p. 4). Of the 63 medical supply products with PVC, containing CoHCs. 37 contained phthalates, five contained BPA, three contained antibacterials/antimicrobials, and 20 contained other Prop 65 chemicals including monomers and solvents. Note that some PVC medical supplies contained multiple of Prop 65 monomers and solvents. All of the CoHCs; for example, both phthalates and Prop respiratory therapy products with CoHCs con- 65 monomers and solvents. tained PVC and the phthalate DEHP. The urinary Medical supplies with the greatest number catheters contained DEHP (four products) and of PVC- and phthalate-containing products were: unspecified phthalates (one product). The needles a) IV solutions with 12 products; b) respiratory and syringes contained DEHP at approximately therapy masks with seven products; c) urinary 200 parts per million (ppm) as a mixture or catheters with five products; and d) needles contaminant with a non-phthalate plasticizer. and syringes with three products. For these four The personal care category included 50 prod- categories of medical supplies, all 27 of the PVC ucts with 34 (68%) of the products containing no products contained phthalates. The IV solutions CoHCs and 16 (32%) of the products containing contained the phthalate DBP, along with a range one or more CoHC (see Figure ES-4, p. 4). Lotions, 4 | Clean Production Action

ointments, lip balms, diapers, shampoo caps, For every personal care product that con- and personal care bags—along with the majority tained a CoHC, there was at least one product of skin wipes and oral care products—did not that did not contain a CoHC. This finding high- contain CoHCs. The dominant CoHCs reported lights that health care organizations can procure in personal care products were antibacterials and functionally appropriate personal care products antimicrobials in soaps and washes, hand sani- that contain no CoHCs. tizers, and skin wipes (12 products); and latex (six Reflecting the demands of protecting against products). Other CoHCs reported in personal bacterial and viral infections in health care, care products were phthalates in hand sanitizers surface disinfectants and germicidal wipes are and the Prop 65 chemical, benzophenone in soap. likely to contain CoHCs. The three surface

Figure ES-3.Chemicals of High Concern (CoHCs) in Medical Supplies Commonly Used in Pediatric Patient Rooms and the Number of Products that Contained Them

Polyvinyl Chloride (PVC) 63

Phthalates (DEHP, DIDP, DBP, 44 and not specified)

Other Prop 65 Monomers, 24 Solvents, etc.

Bisphenol A (BPA) 8

Latex–Natural Rubber 7

Antimicrobials/Antibacterials 5 25

Perfluorinated Chemicals (PFCs) 2 3

Figure ES-4.Number of Personal Care Products Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

Soap & Body Wash 1 6

Hand Sanitizer 1 4

Wash Cloths 2 2 n No CoHCs n Yes CoHCs

Skin Prep 2 2

Skin Wipes (incl. baby wipes) 4 1

Oral Care 6 1

Miscellaneous* 7

Lotion, Ointments, & Lip Balm 11

* Miscellaneous = diapers (5), shampoo cap (1), & personal care bag (1) Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 5

Photo courtesy of Dignity Health disinfectants included in this survey all con- tained antibacterials/antimicrobials, and a cloth used with the disinfectants included the Prop For every personal care product that contained 65 chemical, titanium dioxide. Similarly, both germicidal wipes contained antibacterials/ a CoHC, there was at least one equivalent product antimicrobials as well as latex. Only the general that did not contain a CoHC. purpose cleaners did not contain any CoHCs, including no antibacterials and antimicrobials. The furnishings category included cribs, crib mattresses, beds, bed mattresses, and other patient furniture. In total, 11 products were in- included the greatest number of CoHCs, including: cluded in the survey, with all of the products PVC; halogenated and non-halogenated flame except crib mattresses containing CoHCs. All retardants; heavy metals; persistent, bioaccumu- four cribs contained PVC and antibacterials/ lative and toxic (PBT) substances; substances antimicrobials, while the crib mattresses con- on the European Union Restriction of Hazardous tained no CoHCs. The other patient room Substances (RoHS) Directive; BPA; phthalates; furniture, stool and overbed table, included and Prop 65 solvents. Bed mattresses also con- PVC (overbed table), BPA (stool), halogenated tained a wide range of CoHCs, including: PVC, flame retardants (overbed table), heavy metals halogenated and non-halogenated flame retar- (stool and overbed table), and other Prop 65 dants, heavy metals, perfluorinated compounds chemicals (overbed table). (PFCs), BPA, phthalates, and other unspecified Patient beds were the most complex product Prop 65 chemicals. included in the entire survey, and the only prod- Overall, the dominant CoHCs identified in uct that contained electrical equipment. Not pediatric products were PVC, phthalates, anti- surprising, given their complexity, patient beds bacterials/antimicrobials, Prop 65 monomers 6 | Clean Production Action

and solvents, latex, and BPA. Together these six chemicals/chemical classes accounted for 85% of the reported instances of CoHCs in pedi- For the 114 products that contained atric products. An interesting finding is that CoHCs the question is, are there antibacterials and antimicrobials are being added to a range of products that come into alternatives on the market that patient skin contact, including IV arm restraints, patient bracelets, cribs, and wash cloths. do not contain CoHCs? A number of products featured one or more supplier selling one product with CoHCs while another supplier sold a comparable product without CoHCs: For the 114 products that contained CoHCs the • enteral feeding tubes: some contained PVC question is, are there alternatives on the market while others contained no CoHCs; that do not contain CoHCs? Specific product • IV arm restraints: some contained PVC categories in need of research on alternative while others contained no CoHCs; products are: • IV catheters: some contained BPA or PVC • IV products (including administration/ while others contained no CoHCs; extension sets, connectors, and tubing), • skin prep: some contained latex while others • enteral and total parenteral nutrition contained no CoHCs; (TPN) products, • all of the following products featured some • catheters, suppliers selling the product with antibacterials/ • blood tubing, antimicrobials and others selling the equiva- • respiratory therapy products, lent product with these CoHCs: • personal care products (skin wipes, hand – soaps and body washes, sanitizers, soaps/body washes), and – hand sanitizers, • cleaning products (general purpose/facility – patient bracelets, cleaners; surface cleaners). – wash cloths, and – skin wipes. Given the general connections between PVC, phthalates, and other Prop 65 chemicals, health These products represent potentially quick care organizations could take a major step opportunities for substitution. For other products towards reducing their chemical footprint by containing CoHCs, alternatives may be available avoiding PVC-based products where feasible. but will require further research. A second research need is for the product categories where some products contained Opportunities for Next Steps CoHCs and other similar products did not This first chemical footprint of products used in contain CoHCs. The research question: are the pediatric patient rooms demonstrated how health products meeting the same specifications and care organizations can measure their chemical functional uses? The next research step for these footprint at the departmental level and identified products is to gather data on the specific end products that contain or do not contain CoHCs. uses of those products and determine whether For the participating organizations it provides they can be substituted without offsetting a baseline chemical footprint for a pediatric required levels of performance. patient room—the number of products that con- With alternative products identified that do tain CoHCs. For other health care organizations, not contain CoHCs, health care organizations it provides an indicator of the types of products will have the chemical information they need to likely to contain CoHCs on their shelves. With replace the products. With data on number of chemical footprint data in hand, health care products with CoHCs and information on the organizations can measure their progress in availability of safer alternatives, health organiza- reducing their footprint. tions will be prepared to engage suppliers in Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 7

evaluating, selecting, and purchasing alternative products that do not contain CoHCs while meet- ing performance requirements and price points. Together suppliers and health A step along this path would be to set goals for care organizations can advance the reducing the chemical footprint by percent or number of products per year. use of green chemistries that are Measuring and reducing chemical footprints requires the collection, management, and safe and healthy for people and analysis of data that are not the expertise of most health care organizations. The following the planet. actions would simplify the process for all health care organizations interested in tracking and reducing CoHCs in products: The chemical footprinting of products commonly • CoHCs: Agree to a common list of CoHCs used in pediatrics reveals a clear set of next for health care. steps that will enable health care organizations • Reporting: Require suppliers to (or prefer to reduce known chemicals of concern to human suppliers that) report chemical ingredients health and the environment in products they use to a common template. every day beyond what is required by regulations. • Certification: Use a third-party certification Additionally the research highlights the impor- of products, such as GreenScreen® Certified, tance of suppliers knowing the chemicals in their that identifies products that do not contain products and putting into place policies and pro- CoHCs. Such a certification would greatly cedures to identify and reduce CoHCs. Together simplify communication between suppliers suppliers and health care organizations can and health care organizations on the presence advance the use of green chemistries that are or absence of CoHCs in products. safe and healthy for people and the planet. Bringing Chemical Footprinting 1to Healthcare Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 9

chapter 1 Bringing Chemical Footprinting to Health Care

hemicals are the foundation of our referred to as a “plasticizer,” DEHP can be found materials economy. Part of all products, in PVC plastic products used in health care. be they liquid, gas, or solid, chemicals Animal studies reveal DEHP to be toxic to the are the building blocks of the products reproductive system, causing adverse effects Cwe use every day. Yet, all chemicals are not to the testes and liver.5 The U.S. National Toxi- created equal. Some are inherently safe while cology Program concluded in 2006 that “There others are inherently hazardous to human health is serious concern that certain intensive medical or the environment. Water, known by the chemical treatments of male infants may result in DEHP formula H20, is an inherently safe chemical— exposure levels that adversely affect development we drink it, bathe in it, and it comprises approxi- of the male reproductive tract.” 6 In 2002, the U.S. mately 60% of our body weight. Other chemicals Food and Drug Administration (FDA) released are not so healthy or essential to life. a public health notification concerning DEHP in Di(2-ethylhexyl)phthalate (DEHP) is an PVC medical devices and pinpointed concerns example of an inherently hazardous chemical with DEHP exposure to the male fetus, male that is widely found in health care. The primary neonate, and peripubertal (time around puberty) end use of DEHP is to make polyvinyl chloride male during procedures posing the highest risk (PVC or “vinyl”) plastic flexible. Technically of exposure to DEHP, including total parenteral 10 | Clean Production Action

nutrition (TPN) in neonates and enteral nutrition to toxic chemicals are important causes of in neonates and adults.7 France restricted the disease and dysfunction in children and also in use of DEHP in certain medical devices in 2015.8 adults, and that diseases caused by chemicals The presence of hazardous chemicals such as can successfully be prevented, thus saving lives, DEHP in products is leading health care organi- enhancing the quality of life, reducing health zations, retailers, and other purchasers to ask care and education costs, and increasing their suppliers whether the products they pur- national productivity.”13 chase contain hazardous chemicals and to prefer In this study the chemical footprint is the products made with inherently safer chemicals.9 products that contain chemicals of high concern Business and health care leaders are striving to (CoHCs) in a pediatric patient room. By identify- know the extent to which hazardous chemicals ing hazardous chemicals in products used in a are in the products they purchase and use every pediatric patient room, chemical footprinting day. The identifying, tracking, and measuring can help health care providers identify products of hazardous chemicals in products is part of a to avoid (those that contain hazardous chemicals) new trend called “chemical footprinting.”10 and prefer (those that do not contain hazardous chemicals). While the level of exposure to haz- ardous chemicals in any one product may be quite small, the cumulative effect of constant “Chemical footprinting” is the process of evaluating exposure to small levels of hazardous chemicals the presence of hazardous chemicals in products, could cause adverse health effects, especially for children. As researchers from the Emma manufacturing processes, supply chains, and/or Children’s Hospital in Amsterdam concluded, the “increased knowledge of the greater sensi- packaging. tivity of the unborn baby, the infant and the child, has led to general recognition that a higher degree of precaution is now needed in regulating for multiple stressors on the young.”14 Thus avoid- “Chemical footprinting” is the process of ing hazardous chemicals in pediatric products evaluating the presence of hazardous chemicals represents a preventative action, preventing in products, manufacturing processes, supply the potential for adverse effects from quite small chains, and/or packaging.11 Chemical footprints but cumulative levels of exposure to known haz- provide data, be they the number of chemicals ardous chemicals among vulnerable populations. of high concern in products and/or their mass, This chemical footprint study focused on for evaluating performance and benchmarking products commonly used in a pediatric patient progress away from hazardous chemicals to room that have the potential for patient exposure safer alternatives.12 because they are in the body (e.g., nasogastric This study was designed to assess the chemi- tubes and various catheters), on the body (e.g., cal footprint of products commonly found in a bracelets, soaps, or tape), or used frequently hospital pediatric patient room. Pediatrics was around the body (e.g., cleaning and disinfecting chosen for evaluation because of the well-recog- products used in patient rooms). This study nized greater sensitivity of children to exposure provides both an example of how to chemical to toxic chemicals than adults. As the environ- footprint products in the health care setting mental health researchers Philip Landrigan and and how chemical footprinting can be used to Lynn Goldman summarized: “early life exposures inform purchasing decisions in health care. Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 11 Method for Chemical Footprinting Products 2Used in Health Care Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 13

chapter 2 Method for Chemical Footprinting Products Used in Health Care

he chemical footprinting of products Three health care organizations participated in a pediatric room involved: at various levels in this study. One health care • Specifying the list of chemicals organization and its group purchasing organi- of high concern (CoHCs). These zation participated in all aspects of the study. Tchemicals represent the “chemical footprint” Another health care organization participated in of a product. collecting information by telephone interviews • Developing criteria for prioritizing products with pediatric nursing, procurement, and envi- based on potential for exposure. ronment, health, and safety (EH&S) staff; iden- • Inventorying products commonly used in a tifying priority products; sending the survey pediatric patient room and developing a list to suppliers; and reviewing the responses. A of priority products based on potential for third health care organization hosted an on-site patient exposure. survey of products in a pediatric patient room • Confirming product details, including that included interviews with pediatric nursing, supplier catalog numbers, with purchasing procurement, and environment, health, and staff at two hospitals. safety (EH&S) staff. Specific products were iden- • Sending surveys to 62 suppliers requesting tified and suppliers were surveyed concerning information on CoHCs in 358 priority CoHCs in products identified in pediatric rooms products. in two of the three health care organizations.

Method for Chemical Footprinting Products Used in Health Care

Photo courtesy of Dignity Health 14 | Clean Production Action

2.1 Chemicals of High Concern 5. Phthalates (including DEHP and nine other (CoHCs) and Potential for Exposure phthalates): homogenous material in the This study surveyed suppliers on the presence of product contains greater than or equal to 12 chemicals/classes of CoHCs in their products. 1,000 ppm of phthalates.20 The 12 chemicals/classes of CoHCs were identi- 6. California Proposition 65 (Prop 65) chemicals: fied on the basis of similar criteria that have the product contains any intentionally added been applied in the health care sector, including chemical listed under Prop 65. Practice Greenhealth’s Standardized Environ- 7. Antimicrobial and antibacterial agents: the mental Questions for Medical Products15 and product contains intentionally added anti- microbial/antibacterial agents to reduce surface pathogens. 8. Persistent, bioaccumulative, and toxic (PBT) The 12 chemicals/classes of CoHCs were identified chemicals: homogenous material in the product on the basis of similar criteria that have been contains greater than or equal to than 1,000 ppm of a PBT.21 applied in the health care sector, including 9. Non-halogenated flame retardants: non- electronic homogeneous material contains Practice Greenhealth’s Standardized Environmental greater than or equal to 1,000 ppm of any Questions for Medical Products and Kaiser chemical or chemical compound for which the functional use is to resist or inhibit the Permanente’s Sustainability Scorecard for spread of fire, including but not limited to phosphorous- and nitrogen-based chemicals. Medical Products. 10. Metals: product contains mercury, lead, cadmium, or organotin compounds (see endnote for specified thresholds).22 Kaiser Permanente’s Sustainability Scorecard 11. Perfluorinated chemicals (PFCs): product for Medical Products.16 The rationale for this contains stain- or water-repellant treatments decision was that since many suppliers have that contain a perfluorinated compound. been socialized to these chemicals by Practice 12 Latex: product contains latex. Latex is includ- Greenhealth and other health care organizations, ed as a CoHC because of the concerns with it would be easier for suppliers to answer a sur- latex allergy in the health care sector, which vey concerning the presence of these chemicals can in the most severe cases lead to anaphy- in their products. The 12 chemicals/classes of lactic shock. CoHCs and the thresholds for reporting the chemicals in products are as follows: These 12 chemicals/chemical classes were 1. Substances listed on the European Union’s adopted as the CoHCs list for this study. This list Restriction of Hazardous Substances (EU of chemicals includes close to 1,000 chemicals RoHS) Directive for Electrical and Electronic that are carcinogens, reproductive toxicants, Equipment and above the regulatory require- endocrine disruptors, or PBTs. ments specified by RoHS.17 “Pediatric products” include products used 2. Bisphenol A (BPA): homogenous material in pediatric patient (0-18 years of age) rooms. in the product contains greater than or equal To determine the potential for patient exposure to 1,000 ppm of intentionally added BPA and to a product, the following criteria were used: related structural or functional analogues.18 • Higher potential for exposure: products and/ 3. Polyvinyl Chloride (PVC): product contains or their packaging (for example, saline solution any PVC. in plastic IV bag) have the potential for inter- 4. Bromine- and chlorine-based compounds: nal bodily contact (including oral, inhalation, homogenous material in the product contains ingestion, intravenous, and enteral). Examples greater than or equal to 1,000 ppm of bromine of products with higher potential for pediatric and chlorine-based compounds.19 patient exposure included IV lines and bags, Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 15

feeding tubes, nasal cannula, and baby Products excluded from the inventory were bottle nipples. food products, pharmaceuticals, surgically • Moderate potential for exposure: products implanted devices, built-environment products and/or their packaging have the potential for (for example, flooring, wall finishes, wall guards, external bodily contact (dermal exposure) or casework, ceiling materials, windows and other inhalation and frequent or extended duration fixed/non-moveable items), and products not exposure. Examples of products with moder- related to direct patient treatment (for example, ate potential for pediatric patient exposure office supplies typically found at a nurses station). included hand soap, skin sanitizers, diapers, Fixed built environment products were excluded and surface disinfectants used in patient because the focus of this research was on products rooms. that procurement staff could address in the • Lower potential for exposure: products and/or near term, versus requiring room renovations. their packaging have the potential for only Pharmaceuticals and surgically implanted external bodily contact (dermal), infrequent devices were excluded because these product exposure, and short duration exposure. Ex- selections are clinical decisions. Food products amples of products with lower potential for were excluded because food selection varies exposure included IV pumps, patient monitor widely across health care facilities and patient screens, blood collection vials, bedpans, and dietary needs. urine specimen containers. 2.2 Inventory of Products Using these exposure criteria, the study iden- Commonly Used in Pediatric tified and included products with moderate to Patient Rooms and List higher potential for pediatric patient exposure, of Priority Products while those with lower potential exposure were To inventory products commonly used in identified and excluded. Input from nursing, pediatric patient rooms we reviewed pediatric procurement, and EH&S staff was critical to department purchasing records from two hospitals; understanding products of greatest use and conducted on-site inventories at two hospitals; potential for moderate or more exposure. and interviewed nursing, procurement, and 16 | Clean Production Action

EH&S staff at three hospitals (two on-site and Second, we conducted on-site visits to two one by telephone). pediatric departments. We inventoried supply First, we reviewed the department of pedi- and patient rooms, and interviewed pediatric atrics purchasing records from one health care nursing, procurement, and EH&S staff to identify organization. From these records, five general products with the greatest potential for patient product categories were identified for inventory: and staff exposure. At one hospital we completed • personal care products, including hand an in-depth inventory of products commonly sanitizers, shampoos, toothpastes, and wash used and found in a pediatric patient room. cloths; The on-site visits resulted in the elimination • cleaning and disinfectant products used on of one product category, durable medical equip- a daily basis to clean or disinfect surfaces ment, due to lower potential for patient expo- in patient rooms; sure. The medical equipment category had the • furnishings that can be moved in and out lowest potential for direct patient exposure of patient rooms including beds, cribs, among all the products found in the patient and mattresses; rooms. Since medical equipment may off-gas • medical supplies including enteral feeding hazardous chemicals from the housings (such as tubing, intravenous (IV) administration flame retardants) and wires (such as phthalates), sets, and nasal cannula; and the hazardous chemicals in these products is • medical equipment including patient worth follow-up research. monitors and IV pumps. After the removal of the medical equip- ment category, approximately 1,300 products These five categories included thousands of remained on the product inventory. The list was individual products. further reduced when products were screened Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 17

for their potential for moderate or higher potential for exposure. Using the priority product list from one health care organization, Critical data needs in assessing the chemical a second health care organization used annual footprint of products in health care organizations usage purchase data and discussion with department of pediatrics staff to identify 75 are: a) accurate information on the products in products with moderate or higher potential use; and b) having the most up-to-date supplier for exposure. In total, we identified 358 priority products from 62 suppliers. name, product catalog number, and contact 2.3 Supplier Survey information for each product. We worked with two health care organizations and a group purchasing organization to survey suppliers on the presence or absence of CoHCs (see Section 2.1 for the list of CoHCs) in their information was missing by model name and products. The survey was sent in Microsoft number. A letter from the health care organiza- Excel format and included instructions, a survey tion, or health care organization and group sheet for supplier responses, and a list of abbre- purchasing organization, accompanied the viations. The instructions sheet outlined the survey, explained the project, and authorized instructions for completing the survey. The us to collect the product information on their instructions included specific criteria for each behalf. The letter and survey were sent to 62 of the 12 chemicals/classes of CoHCs. In the suppliers representing 358 products. survey, an answer of “no” meant the product Critical data needs in assessing the chemical did not meet the criteria and “yes” meant the footprint of products in health care organizations product met the criteria. For example, a supplier are: a) accurate information on the products in would answer “no” if the product contained use; and b) having the most up-to-date supplier the phthalate DEHP because it did not meet name, product catalog number, and contact the phthalate-free goal for products or “yes” information for each product. Lessons learned if the product did not contain any phthalates in data collection were the importance of both because it met the phthalate-free goal. “bottom-up” and “top-down” data collection Suppliers were also asked to provide a methods. “Bottom-up” data collection encom- description of the product and to answer two passes on-site visits to confirm which products additional questions: 1) is the product designed are indeed in use in a facility. On-site visits or sized for pediatric use; and 2) did the supplier are important because procurement databases conduct an assessment to identify the presence may not be comprehensive and facilities may of all of the CoHCs in the product. In total the purchase products off-contract. survey had 19 fields: manufacturer name, manu- “Top-down” data collection encompasses facturer catalog number, manufacturer product using product information in a procurement description, extended manufacturer product database. Using the procurement database is description, specified use in a department of quicker than the bottom-up method because pediatrics, 12 chemicals/classes of chemicals, supplier name, product catalog number, and list of Proposition 65 chemicals specified by contact information are readily at-hand. Due Chemical Abstract Services Registry Number to mergers and acquisitions and changes in pro- (CASRN) if present in the product, and curement, products on the shelf may be harder chemical inventory. to find in the procurement database, thereby The same survey format was sent to every making the contacting of suppliers more supplier, though each supplier received a challenging. specific list of products that was unique to itself. The combination of on-site visits (bottom-up) Products were specified by product description with procurement database information (top-down) and manufacturer catalog number, and if that provided a comprehensive vantage point into the 18 | Clean Production Action

products in use and supplier contact information. 18 suppliers reporting Prop 65 chemicals in their Support of unit-level staff and procurement staff products, 10 provided CASRNs, one provided was and will be critical to any efforts in chemical CASRNs for some of its products, and seven footprinting products in health care. did not provide any CASRN. Of the 18 suppliers that reported no CoHCs 2.4 Supplier Responses in their products: Sixty-two suppliers were contacted to provide • two answered incorrectly by inverting the information on chemicals in 358 products. Of the response options; 62 suppliers contacted, 50 suppliers responded • two did not complete chemical inventories to the survey for 253 of the products. Of the for all of their products, raising the question, 50 suppliers that responded to the survey, nine how do they definitively know their products suppliers reported data for some, but not all do not contain CoHCs if they have not of their products. Some of these nine suppliers, completed an inventory for CoHCs; and rather than provide partial information, only • 14 answered the questions correctly and provided data for products for which it could reported completing chemical inventories provide complete and accurate information, and for their products – indicating that these for the remaining products provided no data. surveys were of a higher quality. Of the 50 suppliers that responded to the survey: Of the 31 suppliers that reported CoHCs in • 18 reported having no CoHCs in their their products: products, • four answered incorrectly by inverting • 31 reported having CoHCs in their products, answers or answered only a few of the 12 ques- and tions related to CoHCs, and did not complete • one answered only a few of the questions chemical inventories of their products; (making it impossible to know whether or • four answered that their product contained not its product contained CoHCs or not). BPA, phthalates, or brominated/chlorinated chemicals but then answered that their product We assessed the quality of the supplier responses did not contain Prop 65 chemicals; and with four metrics, and found the quality among • of the remaining 23: and between suppliers to be quite mixed. First, – three did not complete chemical inventories some suppliers answered incorrectly by inverting for their products; the response options and answering “yes” where – two did not have complete information “no” belonged and vice-versa (see Section 2.2 for on Prop 65 chemicals—these two suppliers description of the appropriate survey responses). seemed to know the limits of their knowl- In these cases, suppliers were contacted and edge of chemicals in their products as they the responses updated. Second, some suppliers could not definitively state that their prod- answered only a few, as opposed to all, of the ucts did not contain Prop 65 chemicals 12 questions related to CoHCs. Third, suppliers (an indicator of high quality responses); incorrectly or incompletely answered the ques- – eight reported Prop 65 chemicals in their tion concerning Prop 65 chemicals. For example, products, listed the Prop 65 chemicals, some suppliers answered that their product con- and completed chemical inventories of tained BPA, phthalates, or brominated/chlorinated their products (indicators of high quality chemicals, but then answered that their product responses); and did not contain a Prop 65 chemical despite these – 10 reported no Prop 65 chemicals in chemicals being listed under Prop 65. This is also their products and reported that they had an indicator that the supplier did not understand complete chemical inventories of their the Prop 65 list. Also, if a product contained a products (their responses seemed be Prop 65 chemical, the supplier was requested to of high quality). provide the CASRN for that chemical. Of the Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 19

Eight suppliers had very high quality responses: • Suppliers need data management systems they provided detailed information on Prop 65 in place to routinely, consistently, and quickly chemicals by CASRN, their responses on BPA/ respond to information requests. Suppliers phthalates aligned with their responses on Prop for which this was the first time they received 65, and in some cases they noted chemicals such a request typically lacked the systems below the reporting thresholds. For example, to respond. They indicated that it requires a the reporting threshold for phthalates is greater great deal of time to obtain responses for the than or equal to 1,000 ppm, but at least one hundreds of chemicals included in the survey. company noted that its products contained Some are just beginning to establish data- approximately 200 ppm of DEHP even though bases for such information. it uses a non-phthalate plasticizer in its products. • Suppliers would benefit from a single list of In addition to the eight outstanding respondents, CASRNs to report on with a uniform reporting two other companies were generally comprehen- threshold (to the fullest extent possible). sive though they either lacked data on all products Ideally, if there was one list that was har- or provided a generic list of Prop 65 chemicals monized across health care organizations by CASRN that might be in the product. it would make the task of collecting and The wide variation in supplier responses reporting chemical data comparatively to the surveys, from no response to detailed easier for suppliers. responses highlights a few opportunities for • The survey should include a question that improvement: asks how companies determine whether • Suppliers need to be trained in how to re- CoHCs are in their products. For example, spond to the survey, including understanding is the supplier responses based on product the threshold levels associated with CoHCs, testing, a chemical inventory, and/or which can range from being present at any certifications from suppliers? level for PVC to greater than or equal to 1,000 ppm for phthalates. The above caveats highlight the limits to the data reported by suppliers and detailed in the next section. 3Results Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 21

chapter 3 Results

lean Production Action in partnership with two health care providers requested data on 358 products from 62 suppliers. IV products, enteral feeding products, respiratory Fifty suppliers replied with data on therapy products, and catheters were the medical Cwhether chemicals of high concern (CoHCs) are contained in 253 products commonly used supplies with the greatest number of products in pediatric departments. The data from the two containing CoHCs. health care providers were combined into one dataset to protect the anonymity of the health care organizations and their suppliers, and because the number and type of products varied 3.1 Medical Supplies widely between the two organizations. The data Reflecting their dominance in the patient room, provided below are illustrative, not definitive, medical supplies included the largest number of of the chemical footprint of products in a products (185) in the survey. Eighty-four (45%) pediatric room. of these products contained one or more CoHC, Products were divided into four categories: while the remaining 101 (55%) products contained medical supplies (185 products), personal care no CoHCs. The largest categories of products products (50 products), furnishings (11 products), without CoHCs were needles and syringes, in and cleaning products (seven products). Overall, which 90% of the products (25 of 28 products) 114 products contained CoHCs (45%) and 139 contained no CoHCs, and baby bottles and nipples, products did not contain CoHCs (55%) (see in which none of the 15 products contained Figure 1). CoHCs (see Figure 2). Needles and syringes Note that in the descriptions that follow contained three products with PVC, residual DEHP of CoHCs in products, suppliers are required from a non-phthalate plasticizer, and latex. to report CoHCs in the product as well as the IV products, enteral feeding products, res- packaging. For example, for IV solutions, sup- piratory therapy products, and catheters were pliers reported whether the containers used the medical supplies with the greatest number of to package the solutions contained CoHCs, as products containing CoHCs. Together these four well as chemicals in the solutions themselves. subcategories accounted for 69 of the medical

Figure 1.Number of Products Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

Medical Supplies 101 84

Personal Care Products 34 16 2 Furnishings 9 2 n No CoHCs n Yes CoHCs Cleaning Products 5 22 | Clean Production Action

Figure 2.Number of Medical Supplies Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

IV Products 32 36

Enteral Products 10 14

Respiratory Products 7 13 n No CoHCs n Yes CoHCs

Urinary Catheters 2 9

Miscellaneous* 5

Needles & Syringes 25 3 1 Patient Bracelets 3 1 Suction Tips–Yankauer 1

Baby Bottles & Nipples 15

Exam Gloves 6

Tape 2 *Miscellaneous = blood pressure cuff (1), electrode (1), & infant heel warmers (3)

supply products with CoHCs. Other products contained PVC (three products) as well as with CoHCs included: needles and syringes, DEHP and antibacterials/ antimicrobials in patient bracelets (identification, allergy alert, two products. Three of the eight other catheters and fall risk), blood tubing, suction tips, blood contained PVC and/or BPA. Accessories includ- pressure cuffs, ECG electrodes, and infant ed securement devices for catheters, three of heel warmers. which contained CoHCs including perfluorinated IV products were the largest medical supplies compounds (PFCs—two products), BPA (one subcategory, with 68 products, including: IV product), and unspecified Prop 65 chemicals solutions, administration/extension sets, arm (one product). None of the central venous restraints, connectors, and catheters. Thirty six of catheters contained CoHCs. the IV products contained CoHCs (see Figure 3). Enteral products included 24 feeding tubes, All 12 of the IV solution containers contained feeding sets, and oral/enteral syringes. Of the CoHCs, including PVC, the phthalate DBP, and 20 enteral feeding tubes and sets, 14 contained Prop 65 monomers and solvents. Eight of the CoHCs, including ten products with PVC, six nine IV administration/extension sets contained products with phthalates, and one product with PVC; and among those eight products with PVC, BPA (see Figure 4). Three of the 10 PVC feeding three contained BPA and a mix of Prop 65 mono- tubes were nasogastric tubes made with DEHP. mers and solvents, two contained DEHP, one Three other feeding tube products contained contained an unspecified phthalate and latex, phthalates in an external sheath that is not one contained BPA and latex, and one contained intended to come into contact with the patient. only PVC. Four of the five irrigation/flush solutions None of oral/enteral syringes contained CoHCs. and their containers contained the phthalates The third largest category of medical supplies DBP and DEHP, but surprisingly did not include with CoHCs was respiratory therapy products, PVC. The three arm restraints with CoHCs in which 13 of the 20 products contained CoHCs Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 23

Figure 3. Number of IV Products Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

IV Solutions 12

Admin/Extension Sets 1 8

n No CoHCs Irrigation/Flush Solutions 1 4 n Yes CoHCs

Arm Restraints 6 3

Accessories 6 3

Catheters–Other 5 3

Tubing 2

Connectors 5 1

Catheters–Central Venous 8

(see Figure 5). All of the respiratory therapy Figure 4. Number of Enteral Products Commonly Used products with CoHCs contained PVC and in Pediatrics Patient Rooms that Contained and Did Not the phthalate DEHP. Contain Chemicals of High Concern (CoHCs) Unlike the central venous catheters, which had no CoHCs, nine of the 11 urinary catheters Enteral 6 14 had CoHCs, including PVC (five products), Feeding Tubes latex (two products), DEHP and unspecified Enteral/ 4 n No CoHCs n Yes CoHCs phthalates (five products), and other Prop 65 Oral Syringes chemicals (two products). Among the miscellaneous other products: three of four patient bracelets (ID, allergy alert, and fall risk) contained CoHCs, including Figure 5. Number of Respiratory Therapy Products antibacterials/antimicrobials (three products) Commonly Used in Pediatric Patient Rooms that Contained and PVC (one product); one of the two Yankauer and Did Not Contain Chemicals of High Concern (CoHCs) suction tips contained PVC; a blood pressure Masks–Aerosol, Oxygen, cuff and ECG electrode contained PVC; and 3 7 Respirator, & Tracheal all three infant heel warmers contained a Prop 65 monomer. Cannula (with tubing) 6 n No CoHCs Cannula Fixation Device 4 3.2 CoHCs in Medical Supplies & Tracheal Tube Collar n Yes CoHCs The medical supplies product category is dominated by single use, disposable products made from plastic, and the CoHCs found in medical supplies are reflective of these materials. Eighty four of the 185 medical supply products contained CoHCs. The primary CoHCs found in medical supplies were PVC, phthalates (DIDP, DBP, and DEHP),23 BPA, and other Prop 65 24 | Clean Production Action

Figure 6. Chemicals of High Concern (CoHCs) in Medical Supplies Commonly Used in Pediatric Patient Rooms and the Number of Products that Contained Them

Polyvinyl Chloride (PVC) 63

Phthalates (DEHP, DIDP, DBP, 44 and not specified)

Other Prop 65 Monomers, 24 Solvents, etc.

Bisphenol A (BPA) 8

Latex–Natural Rubber 7

Antimicrobials/Antibacterials 5

Perfluorinated Chemicals (PFCs) 2 3

chemicals, including monomers and solvents. methylene chloride (5 products), acrylonitrile These four chemicals/chemical classes accounted (4 products), and 1,3-Butadiene (three products). for 91% of the CoHCs reported in medical sup- Of the 63 medical supply products with PVC, plies (see Figure 6). Chemicals included among 37 contained phthalates, five contained BPA, the Prop 65 monomers and solvents were benzene, three contained antibacterials/antimicrobials, toluene, methylene chloride, acrylonitrile, 1,3- and 20 contained other Prop 65 chemicals includ- butadiene, styrene, ethylbenzene, and vinyl ing monomers and solvents; in addition, five chloride. The Prop 65 monomers and solvents products contained latex. Note that some PVC reported in medical supplies included: benzene medical supply products contained multiple (12 products), toluene (12 products), vinyl CoHCs; for example, both phthalates and Prop chloride (12 products), ethyl acrylate (12 products), 65 monomers and solvents.

Figure 7. Number of Products Containing Polyvinyl Chloride (PVC) and Other Chemicals of High Concern (CoHCs) in Medical Supplies Commonly Used in Pediatric Patient Rooms

IV–Solutions 12 12 12

Enteral–Feeding Tubes 10 3

IV–Admin/Extension Sets 8 2 4 3 5 n PVC n Antimicrobials Respiratory Therapy– 7 7 n Latex Masks n BPA Respiratory Therapy– 6 n Phthalates Cannulas n Other Prop 65 Urinary Catheters 5 5 1

IV–Catheters, Connectors, & Tubing 5 1 1 2

Needles & Syringes 3 3 3

Miscellaneous* 7 3 3

*Miscellaneous = arm restraints (3), blood pressure cuff (1), bracelet (1), ECG (1) & suction tip (1) Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 25

Figure 7 highlights the PVC medical supplies and their associated CoHCs for nine categories of medical supplies. Phthalates were most widely If health care suppliers eliminated PVC and found with PVC products because manufacturers add phthalates to PVC to make it flexible; PVC its associated CoHCs from the medical supplies is inherently a rigid plastic. Manufacturers add reviewed in this survey, health care organizations softening agents, technically known as plasticizers, to PVC to make it flexible. Phthalates are the would eliminate 75% of the CoHCs in medical most widely used plasticizer in PVC. Medical supplies with the greatest number supplies. of PVC- and phthalate-containing products were: a) IV solutions (12 products); b) res- piratory therapy masks (seven products); c) urinary catheters (five products); and d) Interesting to note is that BPA, which is needles and syringes (three products). The commonly added to PVC in manufacturing, IV solutions contained the phthalate DBP, along was only reported in five of the 63 medical sup- with a range of Prop 65 monomers and solvents. ply products containing PVC: four IV admin sets All of the respiratory therapy products with and one IV connector. Verification that flexible CoHCs contained PVC and the phthalate DEHP. PVC products do not contain BPA is important The urinary catheters contained DEHP (four given that BPA is a common additive in PVC products) and unspecified phthalates (one manufacturing. product). The needles and syringes contained Among the 21 medical supply products that DEHP at approximately 200 ppm as a mixture contained CoHCs, but not PVC, were: or contaminant with a non-phthalate plasticizer. • irrigation flush solutions (four products with For the five categories of medical supplies DBP and DEHP, but not PVC); with PVC that were not dominated by phthal- • infant heel warmers (three products with Prop ates, the products contained a mix of phthalates, 65 monomer); BPA, antimicrobials, and/or other Prop 65 chem- • IV accessories (two products with PFCs and icals and latex. Respiratory therapy cannulas one product with BPA); and were the only category of PVC medical supply • patient bracelets (two products contained products that did not contain phthalates (see antibacterials/antimicrobials). Figure 7). 26 | Clean Production Action

Figure 8. Number of Personal Care Products Commonly Used in Pediatric Patient Rooms that Contained and Did Not Contain Chemicals of High Concern (CoHCs)

Soap & Body Wash 1 6

Hand Sanitizer 1 4 n No CoHCs n Yes CoHCs Wash Cloths 2 2

Skin Prep 2 2

Skin Wipes (incl. baby wipes) 4 1

Oral Care 6 1

Miscellaneous* 7

Lotion, Ointments, & Lip Balm 11

* Miscellaneous = diapers (5), shampoo cap (1), & personal care bag (1)

If health care suppliers eliminated PVC and its two products contained antibacterials/ associated CoHCs from the medical supplies antimicrobials. reviewed in this survey, health care organizations Skin preparation products contained latex could eliminate 75% CoHCs in medical supplies. in two of the four products. Skin wipes included antibacterials/antimicrobials in one product. 3.3 Personal Care Products And oral care included one product with latex. The personal care category included 50 products The dominant CoHCs reported in personal with 34 (68%) of the products containing no CoHCs care products were antibacterials and anti- and 16 (32%) of the products containing one or microbials in soaps and washes, hand sanitizers, more CoHC (see Figure 8). Lotions, ointments, and skin wipes (12 products) and latex (six lip balms, diapers, shampoo caps, and personal products). The latex reported in body washes, care bags—along with the majority of skin wipes soap, and toothpaste requires follow-up with sup- and oral care products—did not contain CoHCs. pliers to know if the latex is in the product or the Soap and body wash products contained packaging. Other CoHCs reported with personal the most CoHCs in the personal care products care products were phthalates in hand sanitizers category, with six of seven products contain- and the Prop 65 chemical, benzophenone in soap. ing CoHCs: five of the products contained anti- Antibacterials and antimicrobials were the bacterials/antimicrobials, and three of those dominant CoHCs across the personal care products. products contained latex; and an additional product contained the Prop 65 chemical ben- zophenone. One soap and body wash product did not contain any CoHCs. For every personal care product Hand sanitizers followed a similar path as the soap and body wash products, with four of the category that contained a CoHC, five products containing CoHCs. All four hand there was at least one product sanitizers with CoHCs contained antibacterials/ antimicrobials, and two of those four products that did not contain a CoHC. contained phthalates. Wash cloths contained a mix of no CoHCs (two products) and CoHCs— Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 27

Yet for every personal care product category that contained a CoHC, there was at least one product that did not contain a CoHC, thereby Antibacterials and antimicrobials are being highlighting the potential for health care organi- zations to procure personal care products that added to a range of products that come into contain no CoHCs. patient skin contact, including IV arm restraints, 3.4 Disinfectants & Cleaning patient bracelets, cribs, and wash cloths. Products The seven disinfectant and cleaning products included in the survey consisted of three surface disinfectants, two germicidal wipes, and two general purpose cleaners (see Figure 9). Figure 9. Number of Disinfectants and Cleaning Products Reflecting the demands of protecting against Commonly Used in Pediatric Patient Rooms that Contained bacterial and viral infections in health care, and Did Not Contain Chemicals of High Concern (CoHCs) surface disinfectants and germicidal wipes are likely to contain CoHCs. The three surface dis- Disinfectants 3 infectants included in this survey all contained antibacterials/antimicrobials, and a cloth used Germicidal Wipes 2 with the disinfectants included the Prop 65 chemical, titanium dioxide. Similarly, both General Purpose 2 Cleaners germicidal wipes contained antibacterials/ n No CoHCs n Yes CoHCs antimicrobials as well as latex. Only the general purpose cleaners did not contain any CoHC, including no antibacterials and antimicrobials. Figure 10. Number of Products Commonly Used Infection concerns are driving the use of in Pediatric Patient Rooms that Contained Antibacterials antibacterials and antimicrobials in many health and Antimicrobials care products care beyond surface disinfectants. Antibacterials and antimicrobials were reported in over 20% of the products that contained Soap & Body Washes 5 CoHCs, reaching beyond the disinfectants. Beyond surface disinfectants and cleaning prod- Hand Sanitizers 4 ucts, antibacterials and antimicrobials are being added to a range of products that come into Cribs 4 patient skin contact, including IV arm restraints, Disinfectants 3 patient bracelets, cribs, and wash cloths. Figure 10 lists the 26 products identified in this survey Patient Bracelets 3 of pediatric products that contained antibacterials and antimicrobials. For every product listed in Germicidal Wipes 2 Figure 10, except cribs, surface disinfectants, and germicidal wipes, alternative products Wash Cloths 2 were identified that did not contain CoHCs, including antibacterials and antimicrobials. IV Arm Restraints 2

Skin Wipes 1 3.5 Furnishings (incl. baby wipes) The furnishings category included cribs, crib mattresses, beds, bed mattresses, and other patient furniture (a stool and an overbed table). In total, 11 products were included in the survey, 28 | Clean Production Action

halogenated and non-halogenated flame retar- dants, heavy metals, PBTs, EU RoHS chemicals, BPA, phthalates, and Prop 65 solvents. Bed mat- tresses also contained a wide range of CoHCs, including PVC, halogenated and non-halogenated flame retardants, heavy metals, PFCs, BPA, phthal- ates, and other unspecified Prop 65 chemicals. Electric beds, due to the complexity of materials and electronic and electrical components, are likely to contain CoHCs. The question then is not, “Does the bed contain CoHCs?” The ques- tions should be, “What is the chemical footprint of this bed? How many CoHCs does a bed con- tain and what is the mass of CoHCs in this bed?” Suppliers of complex products such as beds should report the chemical footprint—the count and mass of CoHCs—of their products. Then suppliers can quantitatively report reductions and health care organizations can benchmark Figure 11. Number of Furnishings Commonly Used products and track reductions in CoHCs in in Pediatric Patient Rooms that Contained and Did Not complex products such as patient beds. Contain Chemicals of High Concern (CoHCs) 3.6 CoHCs in Pediatric Products The dominant CoHCs in pediatric products are Cribs 4 PVC, phthalates, antibacterials/antimicrobials, Prop 65 monomers and solvents, latex, and BPA. Stool & 2 Overbed Table n No CoHCs Together these six chemicals/chemical classes n Yes CoHCs accounted for 89% of the reported instances of Beds 2 CoHCs in pediatric products (see Figure 12). Since Prop 65 chemicals overlap with nearly Bed Mattress 1 every group except PVC and latex, they are not

Crib Mattresses 2 listed in their entirety in Figure 12. Rather, Figure 12 lists phthalates, BPA, heavy metals, EU RoHS directive chemicals, PBTs, PFCs, and bromine-/ chlorine-containing compounds separately from with all of the products except crib mattresses Prop 65. The remaining Prop 65 chemicals are containing CoHCs (see Figure 11). disaggregated in Figure 12 into two groups: a) All four cribs contained PVC and antibacterials/ monomers and solvents; and b) “unspecified” or antimicrobials, while the crib mattresses contained “not listed elsewhere.” Respondents to the survey no CoHCs. The other patient room furniture, were asked to list Prop 65 chemicals by CASRN, stool and overbed table, included PVC (overbed but in some cases they did not do so. When this table), BPA (stool), halogenated flame retardants occurred, we referred to this as an “unspecified” (overbed table), heavy metals (stool and overbed Prop 65 chemical. “Not listed elsewhere” chemicals table), and other Prop 65 chemicals (overbed are Prop 65 chemicals that did not fall within any table). other category listed in Figure 12. We categorized Patient beds were the most complex product those chemicals, such as benzophenone, as included in the entire survey, and the only product Prop 65 “not listed elsewhere.” that contained electrical equipment. Not surpris- Suppliers and health care organizations ingly, given their complexity, patient beds included would substantially reduce CoHCs in products the greatest number of CoHCs, including: PVC, by avoiding where possible products that do not Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 29

Figure 12. Chemicals of High Concern (CoHCs) and the Number of Products in Pediatric Patient Rooms that Contained Them

Polyvinyl Chloride (PVC) 70

Phthalates (DEHP, DIDP, DBP, 55 and not specified)

Antibacterials/Antimicrobials 26

Prop 65–Monomers & Solvents 19

Latex–Natural Rubber 15

Bisphenol A (BPA) 11

Prop 65–Unspecified or 10 Not Listed Elsewhere Heavy Metals (Cadmium, Lead, 4 Mercury or Organotin)

Bromine-/Chlorine-based Compounds 3

Perfluorinated Chemicals (PFCs) 3 A number of products featured one or more

Non-Halogenated Flame Retardants 2 supplier selling one product with CoHCs while another supplier or two sold a comparable EU Restriction of Hazardous 1 Substances (RoHS) product without CoHCs. Persistent, Bioaccumulative 1 & Toxic (PBTs)

contain PVC, phthalates, and antibacterials/ • all of the following products featured antimicrobials. Since PVC and phthalates are some suppliers selling the product with anti- typically linked together, and the Prop 65 mono- bacterials / antimicrobials and others selling mers and solvents are heavily associated with the equivalent product without these chemicals: the PVC products, avoiding PVC-based products – soaps and body washes, would significantly reduce CoHCs in pediatric – hand sanitizers, products, especially medical supplies. – patient bracelets, A number of products featured one or more – wash cloths, and supplier selling one product with CoHCs while – skin wipes. another supplier or two sold a comparable product without CoHCs: These products represent potentially quick • enteral feeding tubes: some contained opportunities for substitution. For other products PVC while others contained no CoHCs; containing CoHCs, alternatives may be available • IV arm restraints: some contained PVC but will require further research. while others contained no CoHCs; Overall this generalized chemical footprint • IV catheters: come contained BPA or of a pediatric patient room indicated that PVC while others contained no CoHCs; approximately 45% of the products are likely to • skin prep: some contained latex while contain CoHCs. The specific percentages will others contained no CoHCs; vary depending on the health care system and its purchasing practices. Recommendations: 4Where do we go from here? Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 31

Recommendations: chapter 4 Where do we go from here? Recommendations

his first chemical footprint of products used in a pediatric patient room revealed a number of opportunities for action. This research demonstrates how health care Specifically, this research demonstrates organizations can measure and reduce their Thow health care organizations can measure and reduce their chemical footprints, highlights the chemical footprints, highlights the need to perform need to perform additional research to fill data gaps, and identify products that do not contain additional research to fill data gaps, and identify chemicals of high concern (CoHCs), and clarifies products that do not contain chemicals of high the value of investing in systemic initiatives that will enable the rapid measurement and concern (CoHCs). reduction of chemical footprints.

Measure Chemical Footprint Many health care organizations have taken every day. This chemical footprinting research important steps to reducing CoHCs, such as demonstrates that hospitals can measure their BPA, phthalates, brominated flame retardants, chemical footprint, thereby creating a baseline to and PVC in the products they purchase and use which they can measure their progress. Without 32 | Clean Production Action

a baseline metric it is impossible to measure other similar products did not contain CoHCs. progress away from CoHCs to safer alternatives. The research question here is: “are the products This research provides a starting point for un- meeting the same specifications and functional derstanding the chemical footprint of products use?” The next research step for these products commonly used in a pediatric patient room and is to gather data on the specific end uses of those identifies five key steps for measuring the chemical products and determine whether they can be footprint of products in the health care setting: substituted without offsetting required levels 1) identify products to evaluate for CoHCs; of performance. 2) identify annual usage of those products pur- chased; 3) identify list of CoHCs; 4) ask suppliers R educe Chemical Footprint which products contain CoHCs; and 5) compile With alternative products identified that do list of pediatric products that contain and do not not contain CoHCs, health care organizations contain CoHCs. With these data in hand health will have the information they need to replace care organizations can measure their progress products. With data on number of products with in reducing their chemical footprint. CoHCs and information on the availability of safer alternatives, health organizations will be able to engage suppliers in evaluating, selecting, and purchasing alternative products that do not The next research step for these products is to contain CoHCs while meeting performance and gather data on the specific end uses of those products price requirements. A step along this path would be to set goals for reducing the chemical foot- and determine whether they can be substituted print by percent or number of products per year. without offsetting required levels of performance. Systemic Changes Measuring and reducing chemical footprints requires the collection, management, and analysis of data that is not the expertise of most health Identify Safer Alternatives care organizations. The following actions would Two key additional research needs emerged simplify the process for all health care organi- over the course of this study. First is the need to zations interested in tracking and reducing identify alternative products that do not contain CoHCs in products: CoHCs. For the 114 products that contain CoHCs, • CoHCs: Agree to a common list of CoHCs the question is, “are there alternatives on the for health care. A common list of CoHCs will market that do not contain CoHCs?” Specific simplify reporting requirements for suppliers product categories in need of research on and facilitate reductions in these chemicals alternative products are: in the health care sector. Starting points for a • IV products (including administration/ common list of CoHCs include the Chemical extension sets, connectors, and tubing), Footprint Project’s list of CoHCs (which is • enteral and total parenteral nutrition (TPN) based on GreenScreen List Translator™),25 products, Practice Greenhealth’s Standardized Envi- • catheters, ronmental Questions for Medical Products,15 • blood tubing, and Kaiser Permanente’s Sustainability • respiratory therapy products, Scorecard.16 • personal care products (skin wipes, hand • Reporting: Require suppliers to (or prefer sanitizers, soaps/body washes), and suppliers that) report chemical ingredients • cleaning products (general purpose/facility to a common template. An example from the cleaners and surface cleaners). building sector is the Health Product Declara- tion Collaboration’s HPD Open Standard,26 A second research need is within product categories which many building product manufacturers where some products contained CoHCs and use to report all chemicals in their products Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 33

to interested purchasers. A model template for reporting chemical ingredient informa- tion would provide suppliers and health care A model template for reporting chemical ingredient organizations with a common platform for infor-mation would provide suppliers and health filing and sharing chemical ingredient information. care organizations with a common platform for filing • Certification: A third-party certification of products that meet the criteria for absence and sharing chemical ingredient information. of CoHCs in products would greatly simplify communication between suppliers and health care organizations. Suppliers could use the recognition of a certification to highlight that The chemical footprinting of products commonly they know the chemicals in their products and used in pediatric patient rooms reveals a clear that their products do not contain CoHCs, set of next steps that will enable health care while health care organizations could simply organizations to reduce CoHCs in products they ask for certified products—thereby eliminating use every day beyond what is required by regu- the need to specify and track CoHCs in the lations. Additionally the research highlights the products from suppliers. The GreenScreen importance of suppliers knowing the chemicals Certified™ Standard for Textile Chemicals27 in their products and putting into place policies is an example of a certification program and procedures to identify and reduce CoHCs. that could be readily applied to health care Together suppliers and health care organizations products. can advance the use of green chemistries that are safe and healthy for people and the planet. 34 | Clean Production Action

Endnotes

1. For example, see: “Examples of Corporate 9. See note 1 above. Chemicals Policies,” Clean Production Action, 10. Lindsey Konkel, “Chemical Footprinting,” accessed October 31, 2017, https://www.bizngo.org/ Environmental Health Perspectives 123 no. 5 (2015): safer-chemicals/examples-corporate-chemicals- A130-3, https://ehp.niehs.nih.gov/wp-content/up- policies. loads/123/5/ehp.123-A130.alt.pdf. 2. Lindsey Konkel, “Chemical Footprinting,” Envi- 11. See note 2 above. ronmental Health Perspectives 123 no. 5 (2015): A130-3, https://ehp.niehs.nih.gov/wp-content/ 12. See note 3 above. uploads/123/5/ehp.123-A130.alt.pdf. 13. Phillip J. Landrigan and Lynn R. Goldman, Cheri Peele, Sally Edwards, Tim Greiner, “Children’s vulnerability to toxic chemicals: a Mark Rossi, The Chemical Footprint Project challenge and opportunity to strengthen health Survey 2016 Guidance Document (Somerville, and environmental policy” Health Affairs 30 no. MA: Clean Production Action, 2016), https://www. 5 (2011): 842-50, http://content.healthaffairs.org/ chemicalfootprint.org/assess/cfp-tool-guidance- content/30/5/842.full. document-request. 14. Koppe JG1, Bartonova A, Bolte G, Bistrup ML, 3. Mark Rossi, Cheri Peele, Sally Edwards and Tim Busby C, Butter M, Dorfman P, Fucic A, Gee D, Greiner, “Chemical footprinting strides to become van den Hazel P, Howard V, Kohlhuber M, Leijs mainstream with Walmart,” GreenBiz, August 11, M, Lundqvist C, Moshammer H, Naginiene R, 2017, https://www.greenbiz.com/article/chemical- Nicolopoulou-Stamati P, Ronchetti R, Salines G, footprinting-strides-become-mainstream-walmart. Schoeters G, ten Tusscher G, Wallis MK, Zuurbier M., “Exposure to multiple environmental agents 4. Dibutyl phthalate (DBP) (CASRN 84-74-2); and their effect,” Acta Paediatr Suppl. 53 (2006): diisodecyl phthalate (DIDP) (CASRN 68515-49-1 106-13, https://www.ncbi.nlm.nih.gov/ or 26761-40-0); and di-2-ethyl hexyl phthalate pubmed/17000577. (DEHP) (CASRN 117-81-7). 15. “Standardized Environmental Questions for 5. “PUBLIC HEALTH STATEMENT Di(2-ethylhexyl) Medical Products,” Practice Greenhealth, accessed phthalate (DEHP),” Agency for Toxic Substances October 31, 2017, https://practicegreenhealth.org/ and Disease Registry, September 2002, https://www. initiatives/greening-supply-chain/standardized- atsdr.cdc.gov/ToxProfiles/tp9-c1-b.pdf. environmental-questions-medical-products. 6. NTP-CERHR Monograph on the Potential Human 16. “Kaiser Permanente Launches Sustainability Reproductive and Developmental Effects of Di(2- Scorecard for Medical Products,” Kaiser Perman- Ethylhexyl) Phthalate (DEHP) (North Carolina: ente, May 4 2010, https://share.kaiserpermanente. Center for the Evaluation of Risks To Human org/article/kaiser-permanente-launches-sustain- Reproduction, 2006), https://ntp.niehs.nih.gov/ntp/ ability-scorecard-for-medical-products. ohat/phthalates/dehp/dehp-monograph.pdf. 17. Chemicals include cadmium, mercury, lead, 7. “FDA Public Health Notification: PVC Devices hexavalent chromium, and polybrominated Containing the Plasticizer DEHP,” Food and Drug biphenyls, polybrominated diphenyl ethers. Administration, July 12, 2002, https://wayback. archive-it.org/7993/20170111182403/http://www.fda. 18. Structural/functional analogues include: bisphenol gov/MedicalDevices/Safety/AlertsandNotices/ AP, bisphenol AF, bisphenol B (BPB), bisphenol C, PublicHealthNotifications/ucm062182.htm. bisphenol C2, bisphenol E (BPE), bisphenol F (BPF), bisphenol G, bisphenol M, bisphenol S 8. Market surveillance of PVC medical devices pre- (BPS), bisphenol P, bisphenol PH, bisphenol sented DEHP-free (France : Agence Nationale de TMC, bisphenol Z, and 4-cumylphenol (HPP) Sécurité du Médicament, November 2015), http:// or Bisphenol A derived chemicals. ansm.sante.fr/var/ansm_site/storage/original/appli cation/22440dbf7102e0c808d1f298a62fdc2f.pdf. Chemical Footprint of Products Commonly Used in Pediatric Patient Rooms | 35

19. Including but not limited to: tetrabromobisphenol- 22. Lead and lead-containing compounds in con- A (CASRN 79-94-7); hexabromocyclododecane centrations exceeding 40 ppm, mercury and (CASRN 25637-99-4); decaBDE (decabromo- mercury-containing compounds exceeding diphenyl ether) (CASRN 1163-19-5); octaBDE 100 ppm, cadmium and cadmium-containing (octabromodiphenyl ether) (CASRN 32536-52-0); compounds exceeding 100 ppm, Organotin pentaBDE (pentabromodiphenyl ether) (CASRN compounds (e.g. tributyltin (TBT), dibutyltin 32534-81-9); tris (2-chloroisopropyl phosphate) (DBT)) exceeding 100 ppm. (TCPP) (CASRN 13674-84-5); tris(2-chloroethyl) 23. Dibutyl phthalate (DBP) (CASRN 84-74-2); phosphate (TCEP) (CASRN 115-96-8); and diisodecyl phthalate (DIDP) (CASRN 68515-49-1 Dechlorane Plus™ (CASRN 13560-88-9). or 26761-40-0); and di-2-ethyl hexyl phthalate 20. Phthalates include di-2-ethyl hexyl phthalate (DEHP) (CASRN 117-81-7). (DEHP) (CASRN 117-81-7); benzyl butyl phthalate 24. The safety of medical devices containing DEHP (BBP) (CASRN 85-68-7); di-n-hexyl phthalate plasticized PVC or other plasticizers on neonates (DnHP) (CASRN 84-75-3); diisodecyl phthalate and other groups possibly at risk (Luxembourg: (DIDP) (CASRN 68515-49-1 or 26761-40-0); dibutyl Scientific Committee on Emerging and Newly- phthalate (DBP) (CASRN 84-74-2); diisononyl Identified Health Risks, 2016), https://ec.europa.eu/ phthalate (DINP) (CASRN 28553-12-0 and 68515- health/scientific_committees/emerging/docs/ 48-0); Diisobutyl phthalate (DIBP) (CASRN 84-69- scenihr_o_047.pdf. 5); di n-pentyl phthalate (DPENP) (CASRN 131-18- 0); dicyclohexyl (DCHP) (CASRN 84-61-7); and 25. Cheri Peele, Sally Edwards, Tim Greiner, di-n-hexyl phthalate (DHEXP) (CASRN 84-75-3). Mark Rossi, The Chemical Footprint Project Survey 2016 Guidance Document (Somerville, 21. Defined by the U.S. Environmental Protection MA: Clean Production Action, 2016), https://www. Agency (EPA) (see https://www.dtsc.ca.gov/SCP/ chemicalfootprint.org/assess/cfp-tool-guidance- upload/1-L-US-EPA_NWM.pdf and https://www.epa. document-request. gov/toxics-release-inventory-tri-program/persistent- bioaccumulative-toxic-pbt-chemicals-covered-tri); 26. Project Team User Guide: Using Health Product OSPAR Chemicals for Priority Action list (http:// Declaration® Open Standard, version 2.1 (Wakefield, www.ospar.org/work-areas/hasec/chemicals/ MA: Health Product Declaration Collaborative, priority-action); and the United Nations Environ- 2017), https://www.hpd-collaborative.org/hpd-user- ment Programme Stockholm Convention on guide. Persistent Organic Pollutants (http://chm.pops.int/ 27. “GreenScreen Certified™,” Clean Production TheConvention/ThePOPs/ListingofPOPs/ Action, accessed October 31, 2017, https://www. tabid/2509/Default.aspx). greenscreenchemicals.org/certified. www.cleanproduction.org