Mercury and PBT Reduction in Healthcare

1
Mercury and PBT Reduction in Healthcare
Health Care Without Harm
The Campaign for Environmentally Responsible
Health Care
2
The Mission of Health Care Without Harm

• To transform the health care industry so it is
  no longer a source of environmental harm by
  eliminating pollution in health care practices
  without compromising safety or care.

3
HCWH

• International coalition for environmentally
  responsible healthcare
• 320 member organizations in 30 countries
• ANA, CHW, CHE, APHA, SHA, OCEH!

4
HCWH Initiatives

• Participation in H2E
• Mercury Workgroup
• Making Medicine Mercury Free
• Roundups, Pharmacies
• PVC/DEHP Workgroup
• Alternative Technologies
• International
• Green Buildings
• SHEA, CleanMed
• Maine MOU

5
The Nasty Nine

• Chlordane
• Dieldrin
• DDT and its breakdown products
• Hexachlorobenzene (HCB)
• Mercury
• Octachlorostyrene (OCS)
• PCBs
• 2,3,7,8 TCDD (Dioxin)
• Toxaphene

6
International Joint Commission6th Biennial
Report, 1992

• We conclude that persistent toxic substances are
  too dangerous to the biosphere and to humans to
  permit their release in any quantity.

7
National Mercury Combustion Sources USEPA 1997
8
Ethical Considerations

• Fish consumption advisories in 40 states
• 5 million people regularly eat contaminated fish
  from the Great Lakes
• CDC - 1 in 10 women of childbearing age are at
  risk of having newborns with neurological
  problems

9
Economic Considerations

• Clean up costs
• Butterworth Hospital
• New Hampshire Hospital
• Potential regulatory costs
• 300 ppt pretreatment level in Duluth, MN
• Hazardous waste/training costs
• JAHCO compliance

10
Obstacles to Mercury Elimination

• Reluctance to change
• Lack of awareness of alternatives and economics
• Minimal understanding of the human and
  environmental impacts

11
Hospital Mercury Current and Historical Use

• Batteries
• Fluorescent Lights
• Mercury containing devices
• Dental Amalgam

• Lab Chemicals
• Pharmaceutical products
• Preservatives
• Housekeeping supplies

12
Mercury-free Thermometer
13
Mercury-free Thermometer
14
Mercury-free Thermometer
15
Mercury-free Sphygmomanometer
16
Mercury-freeSphygmomanometers

• Aneroid most common
• Eliminates risk of mercury-spill and associated
  training costs
• Journal of Human Hypertension
• Study of 444 Hg units..the majority had serious
  problems which would give rise to major errors in
  bp measurement
• Mayo Study aneroids provide accurate pressure
  measurements Arch Intern Med March 2001

17
Mercury-freeSphygmomanometers

• NIH/Mayo/ etc
• Ask proper ?s
• What is reputation of supplier?
• What type of testing?
• What is calibration warranty?
• Will the manufacturer dispose of Hg units?
• Is cuffing system latex free?

18
Zenkers and B5

• Traditionally used in histopathology labs
• Can be phased out to mercury free alternatives
• Duluth hospitals
• Kaiser

19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
(No Transcript)
23
B5 Filtration
24
Mercury Filter Wastes
25
B5 Hazardous Waste
26
Used B5 Management

• Some Histopathology texts recommend precipitation
  of B5 to remove mercury.
• Precipitated B5 supernatant may contain 25 ppm of
  mercury.
• one liter discharge in 20,000 gal (75,000 l) flow
  will exceed WLSSD pretreatment limit of 0.300
  ppb.
• All B5 should be sent to a mercury refiner.

27
Alternative to Mercury Fixatives

• Formalin
• Zn Formalin
• Anatech 1-800-ANATECH
• IBF
• Surgipath 1-800-225-3035
• St Marys Duluth Clinic
• 218-726-4000

28
Historical Sources of Mercury

• Located in the wastewater piping infrastructure
  from historical use
• builds up in low points and in biomass lining
  piping
• traps are the big easy

29
Phased Mercury Elimination

• Mercury free fixatives
• Fluorescents management
• Clean traps
• Housekeeping supplies
• Mechanical switches

• Discontinue purchase of mercury containing
  equipment
• Replace Hg equipment
• Educate employees
• Child birth education

30
Making Medicine Mercury Free

• Pledge program for hospitals and clinics lt500
  facilities
• Non regulatory
• Voluntary compact with community
• National Institutes of Health
• Beth Israel Deaconess Medical Center Boston, MA
  
• Kaiser Permentente, Catholic Healthcare West
  Facilities

31
St. Marys Medical Center

• Developed a Zero Discharge team
• Current mercury use and management practices
  documented through a written survey
• Performed wastewater monitoring and reagent
  analysis

32
Mercury Elimination Task Force

• Understand sources
• Understand fate in the environment
• Employee education
• Mercury elimination policy

33
Innovators

• Looking at mercury-free preservatives
• Historical sources
• Letters of support for mercury disclosure
• Roundups
• Signing MMMF pledge

34
US Dioxin Emission Estimates From Sources USEPA
1998
35
Inventory of Sources of Dioxin in the United
States USEPA, 1998
36
Medical Waste and Dioxin

• created as an unwanted byproduct during processes
  that involve chlorine, heat and organic matter
• As compared to solid waste, medical waste
  contains a high percentage of Polyvinyl chloride
  (PVC) plastic
• PVC is more than 50 chlorine

37
Daily Dioxin Intake

• According to the EPA, the average levels of
  dioxin in all Americans is at or approaching
  levels where we can expect to see a variety of
  health effects
• EPA also estimates that adults consume 300-600
  times the daily safe dioxin intake levels
• Children consume 50 times more than the safe
  adult levels
• EPA draft reassessment includes breast fed
  infants as highly exposed population

38
Health Effects Associated with Dioxin and
Dioxin-like Chemicals USEPA 1994

• Hormonal changes
• Decreased fertility
• Endometriosis
• Ovarian dysfunction
• Altered immune response

• Reduced sperm count
• Decreased testis size
• Feminization of hormonal and behavioral responses

39
Dioxin Elimination Strategies

• Educate your organization
• start with small pilot projects
• end medical waste incineration and use
  alternative treatment technologies
• purchase PVC alternatives when available
• request alternatives from your general purchasing
  organization

40
Chlorine Free Alternatives Exist For

• IV bags
• PVC containers
• Vinyl shower curtains
• Chlorine bleach and cleaning products
• Vinyl patient id bracelets
• Chlorine bleached paper products
• Vinyl body bags

41
DEHP (di-2-ethylhexyl Phthalate)

• Listed on draft US EPA, RCRA, PBT list
• plasticizer that makes rigid PVC flexible 40
  avg up to 80 by weight
• DEHP
• does not bind to PVC
• Leaches into liquids,Off-gasses into air
• used in all disposable, flexible medical PVC
  products

42
National Toxicology Program Expert Panel on
Phthalate Esters

• Serious concern about DEHP exposures in the
  treatment of critically ill infants
• Concern about DEHP exposures in infants and
  toddlers
• Concern about DEHP exposures in pregnant women

43
Dioxin (PVC) Reduction and Elimination Resolutions

• American Public Health Association
• Minnesota Medical Association
• Minnesota Public Health Association
• Catholic Healthcare West
• Maine Hospital Association

44
PVC/DEHP Reduction Policies

• NICU in Boston requests DEHP-free products
• CMA
• DEHP resolution
• CHW requests disclosure of PVC in products

45
Persistent Toxic Cycle