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: cephed04@yahoo.com

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

ramcharitra1@yahoo.com

cephed04@yahoo.com