cephed`s mercury free health care system development in nepal · atomic weight: 200.59(2)g·mol−1...
TRANSCRIPT
Mercury Free Health Care
System Development in Nepal (Feasibility study , Piloting & Strategy development )
Ram Charitra Sah
Executive Director /Environment Scientist
Center for Public Health and Environmental Development
(CEPHED),
Nayabasti, Imadol-5, Lalitpur, Kathmandu, Nepal.
Tel.Fax: 977-1-5201786
Email: [email protected]
National Workshop on Health Care Waste Management and Mercury Free Health Care System in Nepal
January 13 – 14, 2011 , Hotel Everest , New Baneshwar, Kathmandu
Center for Public Health and Environmental
Development
(CEPHED)
Goal: Improved environment management and public health.
Vision: Bridging people with science and technology for healthy living and environment safety.
Mission: Acts as bridging forum between people with science and technologies to made access to new scientific knowledge, technologies and safety measures of environment and public health sector through research, coordination, capacity building and policy dialogue.
Workıng area: Natural Resource Mgmt., Envıronment Cons., Chemical management, Environmental pollution, and Publıc Health etc.
Members/Partner Organization: SA Regional Hub, IPEN, HCWH, GAIA, Zero Mercury , CHE,
Contents of Presentation
� Mercury and Its Impacts
� Study and Results
� Orientation and Capacity building program
� Feasibility Study Mercury Free Health Care
� Mercury Free Health Care Strategy Devt.
� Conclusion and Recommendation
� Radio Jingle and Video Documentary
Mercury: 200Hg80
� Mercury is a chemical element that occurs in
nature and can be found almost everywhere in
the environment. Mercury is only metal which is
liquid at ordinary temperature; in fact it is liquid
at 298 Kelvin. Mercury is sometimes called
quicksilver because of its silvery-white
appearance. It is naturally occurring heavy,
odorless, lustrous liquid metal found in three
forms: metallic; inorganic and organic.
MERCURY (Hg)
Color: Silvery
Atomic Number: 80
Atomic Weight: 200.59(2) g·mol−1
Density: 13.534 g·cm−3
Melting point: - 38.83 °C,
Boiling point: 356.73 °C,
Mercury is Quick Silver
Impacts of Mercury
� Mercury is highly toxic in all its elemental, inorganic and organic forms.
� It readily absorbed through skin and reaches to the brain crossing over skin
and blood brain barrier.
� It may fatal if inhaled and harmful if absorbed through skin.
� It causes harmful effects to the nervous, digestive, respiratory, immune
systems, kidneys and lung damage.
� Exposure to it may result tremors, impaired vision and hearing, paralysis,
insomnia, emotional instability.
� It also causes developmental deficits during pregnancy and childhood
(WHO 2005).
� A drop of mercury enough to cause contamination of a ponds (>8 ha )
beyond expectable level of fish consumption.
Mercury Impact Episodes � The hazards of methylmercury poisoning in 1956 , Minamata, Japan. Ill, or died,
after eating the fish and shellfish in Minamata Bay. Some 35000 people affected.
More than half of whom have now died.
� Another modern mercury tragedy occurred in Iraq in 1971, when 6,500 people
were hospitalized and more than 400 died after eating wheat grain treated with a
methylmercury fungicide.
� Several serious incidents of mercury contamination occurred in Canada
soon after the Minamata and Nigata cases.
� A study of 180 dentists by researchers at the Glasgow Royal Infirmary in
Scotland found the dentists had up to four times the normal level of
mercury in their urine and nails and had more kidney disorders and
memory lapses than the general public.
� In a study involving 45 women dentists and 31 dental nurses, a positive
association was found between elevated mercury levels and incidence of
malformations and aborted pregnancies.
� In Nepal , Chronic headache from dental amalgam, mercury poisoning
from breakage of thermometer, death in case of mercury use to abort
pregnancy etc has been already happened.
185 Reported Mercury Poisoning Cases in
Nepal
CEPHED INITIATIVES� Sector wise study and inventory
� Production of IEC materials and Dissemination
� Development of Mercury Spill toolkit and distribution and
Demonstration.
� Awareness raising and Capacity building (5 R/20 Districts
and many health care facilities)
� Feasibility study for mercury free health care system
� Strategy development for Mercury free health care system
� Piloting Mercury Free Health care service delivery from
Propkar Maternity and Stupa Community Hospital. Soon
start with Kanti Children Hospital
0
20
40
60
80
100
120
140
160
2005/6 20006/7 2007/8
22
12
150Kilograms
Physical Years
Import of Mercury (Kg)
Thermometer and Hg contains
Pressure Measuring Equipment in 2006/7 : 8165 unit
Articles Mercury
Contains
Fever
Thermometer
0.5 grams
Laboratory
Thermometer
5 grams
Industrial
Thermometer
5 grams
Thermostat 3 grams
Sphygmomanome
ter
20 – 60
grams
Mercury Spillage
Articles Mercury Contains
Compact
Fluorescent Lamp
1-25 mg
Fluorescent U-
Tubes
3-12 mg
Linear Fluorescent
Lamps
3-12 mg
Mercury Vapour
Lamps
25-225 mg (75-
1500Watt)
Question to the Importer, Promoter, Distributor, Marketing
and Advertising Agencies :
1. How much Mercury does your Products Contains ?
2. What is your plan for management of these products at
the end of life?
3. What are the basis of Claiming CFL as Environmental
Friendly ?
???..
Mercury in Tube light & CFL
Equipment Types and Thermometer
Breakage (Per year)
� Kanti Children , Annual purchasing =900 +
� Stupa Community Hospital =144
� Propkar Maternity and Women's
Hospital=333
� Bir Hospital =1200
Spill collection/handling,
breakage management.
S.No. DistrictName of
Hospital
Spill
Collected/
Handled
Breakage
management
Frequency
of
Cleaning
Health
hazards
1 Norvic kept in dustbin incineration skin burn
2
Paropakar
Maternity do not know kept in dustbin 2 times a day not known
3 Lalitpur Sarvanga do not knowkept in separate
container 2 times a day
Health
problem
4 B & B
kept in sharp
bucket incineration 3 times a day cancer
5 BhaktapurKorea-Nepal
Friendship By paper incineration 6/6 hours
tissue
damage
6 Bhaktapur By paper kept in dustbin 2 times a day cancer
Selected 20 Dental Hospitals & ClinicsFacilities Locations No. of site
Shine and Smile Dental Clinic Bhaktapur 5 in BhaktpurPuja Dental Clinic Bhaktapur
R.T Dental Clinic Bhaktapur
Himalaya Dental Clinic Bhaktapur
Advanced Oral Dental Hospital Bhaktapur
Oral Dental Clinic Thimi3 in Thimi
Arniko Dental Clinic Thimi
Korea Nepal Friendship Hospital Thimi
Baneshwor Dental Clinic Kathmandu
6 in Kathmandu
Om Dental Clinic Kathmandu
Samaj Dental Clinic Kathmandu
Helping Hands Community Dental Hospital Kathmandu
Himal Dental Hospital Kathmandu
Om Shai Dental Clinic Kathmandu
Lagankhel Polyclinic Lalitpur 4 in Lalitpur
Suresh Dental Clinic Lalitpur
Satdobato Dental Clinic Lalitpur
Lagankhel Dental Clinic Lalitpur
Jaya Dassheel Dental Clinic Kritipur 2 in Kritipur
Community Dental Clinic Kritipur
Doctor Assistant WM Others Thermometer Barometer Sphy.
Shine and Smile Dental Clinic 3 1 1 1 yes no no 15 60
Puja Dental Clinic 1 2 _ _ no no no 6 25
R.T Dental Clinic 3 1 1 _ no no no 30 125
Himalaya Dental Clinic 4 2 _ 2 yes yes yes 10 40
Advanced Oral Dental Hospital 2 1 _ _ no no no 35 140
Oral Dental Clinic 2 1 _ _ no no no 52 210
Arniko Dental Clinic 5 3 1 _ yes no yes 75 300
Korea Nepal Friendship Hospital 2 2 _ _ yes yes yes 33 130
Baneshwor Dental Clinic 1 2 _ _ yes no yes 56 225
Om Dental Clinic 4 1 _ 1 yes yes yes 22 90
Samaj Dental Clinic 13 15 3 _ yes no no 30 120
Helping Hands Community Dental Hospital 4 2 1 _ yes yes yes 28 110
Himal Dental Hospital 10 18 2 3 yes yes yes 225 900
Om Shai Dental Clinic 1 1 _ _ no no no 30 120
Lagankhel Polyclinic 3 6 _ 1 no no no 2 5
Suresh Dental Clinic 1 2 _ _ yes yes yes 38 150
Satdobato Dental Clinic 2 1 _ 1 no no yes 15 60
Lagankhel Dental Clinic 3 2 _ _ yes yes yes 38 150
Jaya Dassheel Dental Clinic 2 1 _ _ no yes yes 18 70
Community Dental Clinic 3 2 _ 1 no no yes 25 100
mercury use
(gm/month)
No. of patients filled
with amalgam/month Facilities
Number of Staffs Hg Based Equipment
Details of Hospitals/Clinics
Awareness and Training about Hg
Awareness
� 15 (75%) Dental
clinics are aware
about the health
impact of Hg
� 5 (25%)Dental clinics
are unaware about
the health impact of
Hg
Training
� 7 (35%)Dental clinics
have taken training on
handling of Hg
� 13 (65%) Dental clinics
were untrained on
handling of Hg
� Other than public health
background personnel
were also engaged in
amalgam preparation.
Handling of Mercury Spill in School and Colleges
0
10
20
30
40
50
60
70
80
PA
HIC
BIC NC
KC
GE
MS
BB
BS
MV
S
LH
SS
BA
Name of Institutions
% of the Students
Touched Inhaled Taken on Paper or Plate Played Others
0
10
20
30
40
50
60
70
Touched Inhaled Taken on Plateor Paper
Played Others
32
18
70
28
40
Maximum Percentage of studied Studnets among slected academic institution (School & Colleges) in Kathmandu VAlley
Policy of Mercury Import in NepalS.No. Chemicals Category Permission required or not
1 Mercury Hazardous Not required
2 Mercuric Oxide Hazardous Not required
3 Mercuric Chloride Hazardous Not required
4 Mercurous Chloride Hazardous Not required
5 Mercuric Iodide Hazardous Not required
6 Mercurous Iodide Hazardous Not required
7 Mercuric Sulphide Hazardous Not required
8 Mercuric Sulphate Hazardous Not required
9 Mercurous Sulphate Hazardous Not required
10 Mercuric Nitrte Hazardous Not required
11 Mercurous Nitrate Hazardous Not required
12 Mercuric Cynide Hazardous Not required
13 Mercuric Cynide Oxide Hazardous Not required
14 Mercuric Fluminate Hazardous Not required
15 Mercuric Thiocynate Hazardous Not required
16 Phenyl Mercury acetate Hazardous Not required
Source: Department of Custom, Government of Nepal 2007
Policy of Mercury Import in Nepal
Name of Items Policy
Mercury Free
Mercury Compounds Free
Thermometers (all kinds) Free
Sphygmomanometers Free
Fluorescent Lamps Free
Primary cell Batteries Free
Emergency lantern Free
Some Uses of Mercury
National workshop on Mercury
Regional Workshops
IEC Material Production and
Disseminations
Mercury Toolkits Development,
Demonstration and Distribution
SPILL TOOLKITS
DEVELOPMENT
DEMONSTRATION
DISTRIBUTION
20 District Level Awareness and
Capacity building programs
EDR: Morang, Sunsary, Dhankuta, Ilam , Siraha
CDR: Dhanusha, Makwanpur, Kavere, Kathmandu
WDR: Kaski,Palpa, Rupandehi, Tanhu, Baglung,
MWDR: Bardia, Surkhet, Dang
FWDR: Doti, Kanchanpur, Kailali,
1 TOT and 3 Regional Level
Training on HCWM and POPs
Shed Construction for Waste and
Orientation Training for House Keeping
Staffs on HCWM and Mercury
Feasibility Study and Orientation
Number of participants Total
Propkar Maternity and Female
Diseases Hospital
32
Norvic Hospital and Research
Center
9
Stupa Community Hospital 24
Other Health Care Professional
mainly nurses from all regions
20
Surgical Suppliers 4
Total 89
Feasibility study and Orientation
Findings of Feasibility Study
� Willingness: High willingness among all
(up to 89%)
� Constraints: Cost, availability and management of obsolete and existing equipments
� Reason of not shifting : lack of awareness,
high cost of alternatives
� Availability : market have good supply of
accurate non mercury equipments
Economic AnalysisMaternity Hospital
� No. of Beds = 365
� Annual Purchase of Mercury Th. =
333 @ 20 (Rs 6660)
� No. of Ward = 15
� No. of Thermometer in use at a
time = 45
� Digital Th.= 6660/Rs 250 =53
� It will just take less than 2 years to
becomes mercury free.
� With 5 year life span, hospital will
be still making benefit of Rs19980
� No mercury exposure and
pollution.
Stupa Community Hospital
� No. of Beds = 55
� Annual Purchase of Mercury Th.
= 144 @ 20 (Rs 2880)
� No. of Ward = 8
� No. of Thermometer in use at a
time = 1 0-15
� Digital Th.= 2880/Rs 250 =12
� It will just take less than 2 years
to becomes mercury free
� With 5 year life span, hospital will
be still making benefit of Rs 6640
� No mercury exposure and
pollution.
Suggestion for Government 1. National policy/guidelines/acts/regulation development.
2. Proper training and education programs
3. Pilot demonstration programs
4. Arrangement of disposal landfill site
5. Supply of mercury free equipments
6. Develop national act for mercury free
7. Guidelines to use, sell, dispose of mercury and mercury containing
products.
8. Gradually replace and stop importing mercury base equipments.
9. Making plan which can replace mercury gradually.
10. Discover other alternative for dental filling and educate people about health
impact
11. Awareness to all
12. Remove all mercury instruments
13. Ban of importing mercury based instruments and promote import of digital
one.
Suggestion for Hospital Management
1. Proper awareness and supply of alternatives
2. Strict regulation for discard the mercury base equipments and have
alternative supply for that
3. Arrangement of disposal sites
4. Hospital should initiate supply of mercury free products
5. Hospital level guidelines to following the national law
6. Make a plan to make hospital mercury free
7. Making good guidelines and policy
8. Buy new and latest validated and certified mercury free instruments
9. Gradually shift from mercury to digital one
10. Remove all mercury and replace by digital instruments
11. Bring mercury free equipments only.
12. Supply of digital instruments in every wards
13. Avoid use of mercury in hospitals
Launching of Mercury Free Health
Care Services (Pilot projects)
Strategy for Mercury free Health care
System : 10 Steps
STEP1. Enact the proper legal instruments (policy, guideline, act and
regulation) of Mercury Free Health Care Services
STEP 2. Make the timeframe for making shift from Mercury base health care
services to non mercury based health care system.
STEP3. Mercury auditing: assess all the possible things containing mercury in
all health care facility and envision of corresponding mercury minimization
program as well as phase out program.
STEP 4. Implement mercury phase out program fitted with this timeframe with
proper progress monitoring with respect to time.
STEP 5. Health care facility should take initiative with concrete decision of
replacing mercury base equipment to non mercury base.
Strategy: 10 steps STEP 6. Develop and adopt the mercury equipment shifting
strategy such as gradual replacement and/or one at a
time replacement.
STEP7. Safe collection, storage and disposal of the
mercury, mercury containing devices and waste.
STEP 8. Promotion of Alternative by government as well as
health care facilities themselves.
STEP 9. Allow to Produce, import, sale and distribution of
only quality and validated alternative products
STEP 10. Continuous awareness and capacity building for
all level health care staffs as well as other auxiliary and
administrative including decision making bodies.
�Use
�Management
�Associated health hazards
�Associated environmental
consequences
�Feasible , economic , reliable,
affordable , available and Beneficial for
Public health and environment OO..
What we do now?
Alternatives 1.Make a Shift
Mercury Thermometer Digital Thermometer
Alternative 2 .Make a Shift Mercury Blood Pressure
measuring devices
Aneroid or Digital Blood
Pressure Devises
Dental FillingAsk for Composite Filling rather Mercury
Filling
Go for Mercury Free Battery
Mercury Containing Cells
Go for
Mercury
Free Cell
Lighting System
High Mercury
Containing Tube light
Low Mercury
Containing CFL tubes
All including
Government
promoting but have
not thought end of
life management
ZERO Mercury
Containing LED Bulbs
Available and
Getting popular
Available and
Reduced use
What we need to do ?
� Adoption of Policy of Mercury Free Health Care
Facility
� Research and awareness Raising
� Phase out of Mercury and mercury based
equipments and chemicals.
� Promotion of Alternatives
� Standard Formulation
� Market monitoring and Quality control .
Mercury is Toxic
Use Mercury Free Products & Chemicals and
stay healthy.
Say no to Mercury !!!
THANK YOU
Remarks by Pilot Program Rep.
� Stupa Community Hospital
� Propkar Maternity Hospital
� Radio Jingle on Mercury
� Video Documentary on Mercury
http://www.zeromercury.org/projects/Nepal.html
www.noharm.org
www.mercuryfreehealthcare.org
www.toxicslink.com
www.no-burn.org
www.env-health.org
http://www.chem.unep.ch/mercury/default.htm
http://europa.eu.int/comm/environment/chemicals/mer
cury/
http://www.toxicteeth.com
For details on Medical and Mercury waste management
Ram Charitra Sah, 01-5201786, 9803047621