Ethylene Oxide (EtO) gas is a highly volatile and widely used industrial chemical used in the production of plastics, textiles, antifreeze, and to sterilize medical devices. It has been used for decades in the chemical industry, with numerous case reports documenting adverse health effects resulting from occupational exposure, ranging from respiratory irritation, elevated risk of cancer, and neurologic sequelae. More recently, in 2016, the U.S. Environmental Protection Agency (EPA) cited that EtO gas is more toxic than previously estimated, and emerging data indicate those residing near EtO-emitting facilities are also at risk of adverse health effects. According to the FDA, approximately 50 percent of sterile medical devices in the U.S. are sterilized with EtO. Hundreds of facilities in a variety of chemical sectors nationwide emit EtO, as well as an unknown number of warehouses storing EtO-treated medical devices that emit this chemical through off-gassing. Therefore, the very product used to sterilize critical medical equipment can also pose a danger to people who live, work, or attend school near these facilities where EtO is emitted.
This is concerning as the industrial facilities actively emitting EtO into the air and storage warehouses passively emitting this chemical are often located near densely populated areas, putting a myriad of community members at risk. As with other toxic environmental exposures, marginalized communities – those with economically and socially disadvantaged populations, face a higher burden of exposure to EtO gas. As a case in point, in the state of Illinois, there were two areas of the state with active EtO-emitting facilities prior to 2019 – in Willowbrook, a suburb of Chicago, and northern Lake County, IL. Following the release of the U.S. EPA report and various news articles highlighting the increased risk posed by community-level exposure, there was a public outcry, strong community organization, and political pull from several Illinois legislators to abruptly close the EtO-emitting facility in Willowbrook. Despite similar community organization, two EtO-emitting facilities remain active in Lake County, IL. The difference is evident not just by geographic location, but by social and economic differences between the two communities. This phenomenon is not unique to Illinois, as several articles highlight the environmental justice concerns posed by exposure to EtO gas (Wood & Howarth, 2024).
As a bright spot and glimmer of hope for reducing this hazardous environmental exposure, Recent Rulemaking by the US EPA in 2024, under the Biden administration, sought to limit EtO gas exposure to community members. This updated rule under the Clean Air Act sought multiple protections including expanded air monitoring, installing available technology to reduce emissions, and seeking viable alternatives to EtO gas. While not unexpected but still disappointing, the Trump administration has sought to reverse this new rule through Presidential Proclamation before it goes into effect in 2026, citing that there is no viable alternative to EtO gas and the medical industry being dependent on sterilized medical equipment to prevent interruptions in medical care.
This new executive order offers more questions than answers. First, these exemptions to the new rule were only granted for some and not all EtO-emitting facilities. It appears these dozens of facilities granted exemptions are scattered throughout the United States and not all are necessarily tied to facilities for the sole purpose of medical sterilization. It is supposed that the industrial sites granted exemptions had directly sought out exemptions by the Trump administration. Second, this order supposes that the technology needed to reduce EtO emissions is not available, despite reports that this technology is readily available and already installed in many EtO-emitting facilities.
While the importance of EtO gas in the sterilization of medical devices and chemical industry can be acknowledged, there is a way to proceed forward to protect the health of our community members while balancing the bottom line of the chemical and medical industries. First, the rulemaking under the Biden administration called for the use of available technology to reduce emissions. The cost of this installation can be substantial however it has already been successfully implemented in multiple facilities. Additionally, states could pursue incentives for companies as part of community health benefits. Second, alternatives to sole reliance on EtO gas for medical sterilization can be explored. Practice Greenhealth, a leading sustainable health care organization which delivers environmental solutions to more than 1,700 hospitals and health systems in the United States and Canada, has worked with 256 hospitals moving away completely from ethylene oxide to safer sterilization alternatives without compromising infection prevention for patients, employees, and visitors. In the 256 hospitals, alternatives to EtO used are include steam sterilization (84% of facilities), low temperature hydrogen peroxide gas plasma (44% of facilities), peracetic acid (16% of facilities), ozone plasma (4% of facilities) and other alternatives (4% of facilities).
While federal progress stalls on protecting communities from EtO exposure, nurses can still take action. We can still advocate at the state and county level for strong local health protections and continue to elevate the health effects of EtO in our workplaces, hospitals, clinics and communities. We can educate ourselves and colleagues about local sources of EtO exposure and most importantly as nurses we can continue to advocate for our patients who remain impacted by exposure to EtO. Reports like Invisible Threat, Inequitable Impact by the Union of Concerned Scientists have aggregated information on commercial ethylene oxide sterilizers.
The EPA’s decision under the last administration, to require facilities to reduce EtO emissions, came after decades of communities and workers shouldering the burden of harmful exposure. Community members and workers should not have to carry the burden of ensuring that facilities control cancer-causing air emissions. ANHE urges you to contact your elected officials in the U.S. Congress and urge them to support EPA to vigorously oppose rollbacks to the ethylene oxide commercial sterilizer rule which will expose communities to more ethylene oxide. Tell them why preventing exposure to ethylene oxide is important to the health of you and your community.
Linda O’Kelley, PhD, RN
Dr. Linda O’Kelley holds a PhD in Nursing Science from Rush University. Her research focuses on the health impacts of toxic environmental exposures, utilizing large datasets to link biomarkers of exposure with measurable health outcomes. Passionate about both advocacy and protecting the environment, Dr. O’Kelley also engages in advocacy work related to climate change and clean air legislation. In addition to her research and advocacy efforts, she works as a NICU nurse in Evanston, IL.
