Fracking and Health: What the Internist Needs to Know

Overview
Why the boom in natural gas drilling?
What is “fracking”?
Describe Concerns
Review current state of knowledge re: human health effects
Environmental health and Exposure studies
Provide general guidance for evaluating patients with potential exposures & concerns

http://wvsoro.org/

Why the boom?
Energy independence
“Greener” than coal or oil
Economic boost
New methods allow for accessing previously inaccessible/uneconomical resources
http://www.whitehouse.gov/sites/default/files/blueprint_secure_energy_future.pdf

Hydraulic Fracturing, aka “Fracking”
Hydraulic fracturing: Process of creating fissures in underground formations to allow natural gas to flow
First use of hydraulic fracturing was in 1947
Current fracking technique first used in natural gas shales in the late 1990s in Texas
Allows extraction of vast amounts of previously inaccessible hydrocarbons
New technique: horizontal drilling
Shale gas typically contains over 90% methane

Animation of process
http://youtu.be/VY34PQUiwOQ

The average depth of a well is
almost 1.5 miles below the earth’s
surface
http://www.youtube.com/watch?v=73mv-Wl5cgg

Materials used
Base Fluid
H20
Proppant
Silica Sand
Chemical Additives
Anti-microbial agents
Clay stabilizer
Corrosion inhibitor
Crosslinker
Gelling Agent
Iron Control
pH Adjusting Agent
Surfactant
Benzene
Thompson Nature 2012, Schmidt EHP 2011
Waste fluid contaminants: Heavy metals, Radiation, Benzene, Ethylene glycol, etc.

Why the concern that this could be bad?
Water contamination
Air contamination
Earth quakes
Radiation exposure
Social disruption
Noise
Traffic
Population influx
Proporty devaluation

Who could face risk?
Workers
Community residents
First responders

Documented Human Health Studies
None
Anecdotal
Dish, TX
Blood & urine: toluene
Pavillion, WY
Colorado RN
http://neinuclearnotes.blogspot.com/2010/08/hydraulic-fracturing.html

Environmental Health = Public Health
World Health Organization
Social determinants of health
The social determinants of health are the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.
“…it should not be concluded that an absence of data implies that no harm is being done.” (Finkel and Hays, Public Health, 2013)
http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/index.html

Exposure studies pertinent to human health
NIOSH Silica Evaluations
NY/PA methane studies
Colorado School of Public Health VOC study
Groat University of Texas study
Colborn & Univ of MO studies on chemicals/endocrine disruptors in water
EPA

NIOSH Field Effort
Assessed health risks to oil & gas workers
Silica air sampling
47% greater than OSHA limit
9% of all samples more than 10x the OSHA limit
79% greater than NIOSH limit
31% of all samples more than 10x the NIOSH limit
Esswein et al, J Occ Env Hyg, 2013

Methane found in well water
Private drinking water wells in northeast PA & NY:
Methane detected in 82% of houses sampled
methane concentration with proximity to nearest fracking site
Carbon dating suggests related to drilling
No evidence of fracturing fluids
Osborn SG et al. PNAS, 2011
Jackson RB et al. PNAS, 2013.

Colorado School of Public Health study
Airborne VOCs at levels 5x higher than EPA level if live within ½ mile of drilling site
Increased Hazard Indices for subchronic non-cancer risks & cumulative cancer risks
McKenzie et al, Science of the Total Environment. 2012

University of Texas Energy Institute Study
No aquifer contamination from fracking
No leakage from fracking at depth
Methane in water wells most likely due to natural sources
Surface spills of fracking fluids likely pose greater risks to groundwater
Groat & Grimshaw. Fact-Based Regulation for Environmental Protection in Shale Gas Development. 2012; http://energy.utexas.edu/

Colborn 2011 MSDS Review
Colborn et al. Human and Ecological Risk Assessment, 2011.

Endocrine Disruptors in Nearby Water
Kassotis et al, Endocrinology, epub ahead of print, Dec 2013

EPA Environmental Health Study
5 States
H20, Air, Soil testing
Waste Water
Analyze well design and construction
Conduct “toxicity tests”
Compare pre-drilling to post-drilling
Thompson Nature 2012; http://www.epa.gov/hfstudy/index.html

Pavillion, WY EPA Sampling
Complaints of taste and odor problems from domestic water wells
Methane found
Well blowout
Casings did not extend through areas of accessible water
EPA. Investigation of Ground Water Contamination Near Pavillion, Wyoming, 2011

Fort Worth, TX-EPA drinking water sampling
12/7/10 – EPA issued “Imminent and Substantial Endangerment Order” to protect drinking water
At least 2 residential wells with extremely high levels of methane
Isotopic analysis concludes source from gas production well
http://yosemite.epa.gov/opa/admpress.nsf/e77fdd4f5afd88a3852576b3005a604f/713f73b4bdceb126852577f3002cb6fb!opendocument Also, AP Photo/LM Otero @ http://www.huffingtonpost.com/2013/01/16/epa-water-contamination-investigation-fracking_n_2484568.html

Potential Human Health Hazards
Health Effect
Irritant Effects
Eye irritation, headaches, sore throat, difficulty breathing, nose bleeds
Exacerbation of asthma & COPD
Silicosis
Malignancy
Heavy metal poisoning
Asphyxiation & explosions in confined spaces; Narcosis
Associated Exposure
VOCs
VOCs, Ozone, Particulate Matter
Silica sand
Benzene
Lead, Uranium, Mercury, etc. – depends on what comes up in the brine
Methane; Hydrogen sulfide

Recommendations for Clinicians
Medical Management
Review of symptoms
Temporal history of symptoms in setting of exposure
Occupational/Environmental History
Do they use well water?
Neighboring industries?
Focus on:
Asthma
Irritant symptoms
ENT
Derm
Hematologic symptoms/labs
Neuro
Renal

Recommendations for Clinicians
Public Health
Respirator fit-testing
Sentinel case or cluster
Report
If questions or concerns contact:
OSHA (1-800-321-6742)
NIOSH (1-888-232-6348)
EPA
National Response Center at 1-800-424-8802.

How can exposures be controlled and health risks minimized?
Occupational
Elimination/substituion
Use silica substitute
Engineering controls
Administrative controls
Personal Protective Equipment
NIOSH-approved Fit-tested Respirator
Community
Increase distance from well sites
SAFE WELL CONSTRUCTION
WASTE WATER MANAGEMENT

EPA Green Completions
Purpose is to reduce VOCs (that combine with other agents, generate NOx, smog, ozone, etc) associated with NGD
Phase 1 – Flare
Phase 2 – Capture gas and make available for use or sale
http://www.texassharon.com/2011/01/01/barnett-shale-who-decides-who-suffers/
http://www.epa.gov/airquality/oilandgas/pdfs/20120417changes.pdf

What regulation exists for these processes or chemicals?
OSHA Standards
Nothing specific to fracturing fluids
EPA
Air: 2012 regulations
VOCs
Methane
Air Toxics
Water
Exempt from Safe Drinking Water Act

Fracking in Maryland
Moratorium until data gathered
Expected Summer 2014
Activists want another 18 months of bar
Supporters warn that Maryland may miss out
Baltimore Sun, 1/8/14

Conclusions: Fracking & Human Health
Fracking to uncover natural gas stores is an expanding industry across the country
Many incompletely understood potential risks to workers and the surrounding community
Lack of transparency heightens public concern
Need for further investigation

FRACKING and the CLINIC
New technology creates opportunities for new, and new ways to get old, occupational & environmental illness
Internists
Be knowledgeable about potential risks
Take the Occupational & Environmental History
Ask about well water
Characterize symptoms based on known and theoretical possibilities for disease
Sentinel case/cluster identification