Title: Mercury and PBT Reduction in Healthcare
1Mercury and PBT Reduction in Healthcare
Health Care Without Harm
The Campaign for Environmentally Responsible
Health Care
2The 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.
3HCWH
- International coalition for environmentally
responsible healthcare - 320 member organizations in 30 countries
- ANA, CHW, CHE, APHA, SHA, OCEH!
4HCWH Initiatives
- Participation in H2E
- Mercury Workgroup
- Making Medicine Mercury Free
- Roundups, Pharmacies
- PVC/DEHP Workgroup
- Alternative Technologies
- International
- Green Buildings
- SHEA, CleanMed
- Maine MOU
5The Nasty Nine
- Chlordane
- Dieldrin
- DDT and its breakdown products
- Hexachlorobenzene (HCB)
- Mercury
- Octachlorostyrene (OCS)
- PCBs
- 2,3,7,8 TCDD (Dioxin)
- Toxaphene
6International 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.
7National Mercury Combustion Sources USEPA 1997
8Ethical 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
9Economic 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
10Obstacles to Mercury Elimination
- Reluctance to change
- Lack of awareness of alternatives and economics
- Minimal understanding of the human and
environmental impacts
11Hospital Mercury Current and Historical Use
- Batteries
- Fluorescent Lights
- Mercury containing devices
- Dental Amalgam
- Lab Chemicals
- Pharmaceutical products
- Preservatives
- Housekeeping supplies
12Mercury-free Thermometer
13Mercury-free Thermometer
14Mercury-free Thermometer
15Mercury-free Sphygmomanometer
16Mercury-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
17Mercury-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?
18Zenkers and B5
- Traditionally used in histopathology labs
- Can be phased out to mercury free alternatives
- Duluth hospitals
- Kaiser
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23B5 Filtration
24Mercury Filter Wastes
25B5 Hazardous Waste
26Used 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.
27Alternative to Mercury Fixatives
- Formalin
- Zn Formalin
- Anatech 1-800-ANATECH
- IBF
- Surgipath 1-800-225-3035
- St Marys Duluth Clinic
- 218-726-4000
28Historical 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
29Phased 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
30Making 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
31St. 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
32Mercury Elimination Task Force
- Understand sources
- Understand fate in the environment
- Employee education
- Mercury elimination policy
33Innovators
- Looking at mercury-free preservatives
- Historical sources
- Letters of support for mercury disclosure
- Roundups
- Signing MMMF pledge
34US Dioxin Emission Estimates From Sources USEPA
1998
35 Inventory of Sources of Dioxin in the United
States USEPA, 1998
36Medical 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
37Daily 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
38Health 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
39Dioxin 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
40Chlorine 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
41DEHP (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
42National 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
43Dioxin (PVC) Reduction and Elimination Resolutions
- American Public Health Association
- Minnesota Medical Association
- Minnesota Public Health Association
- Catholic Healthcare West
- Maine Hospital Association
44PVC/DEHP Reduction Policies
- NICU in Boston requests DEHP-free products
- CMA
- DEHP resolution
- CHW requests disclosure of PVC in products
45Persistent Toxic Cycle