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
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,
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 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
Import of Mercury (Kg)
150
160
140
Kilograms
120
100
80
60
40
22
12
20
0
2005/6
20006/7
Physical Years
2007/8
Thermometer and Hg contains
Articles
Pressure Measuring Equipment in 2006/7 : 8165 unit
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 UTubes
3-12 mg
Linear Fluorescent
Lamps
3-12 mg
Mercury Vapour
Lamps
25-225 mg
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 ?
(75-
???
..
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.
Frequency
Breakage
Health
of
management
hazards
Cleaning
S.No. District
Spill
Name of
Collected/
Hospital
Handled
1
Norvic
kept in dustbin
incineration
2
Paropakar
Maternity
do not know
kept in dustbin
Sarvanga
do not know
kept in separate
container
2 times a day
Health
problem
B&B
kept in sharp
bucket
incineration
3 times a day
cancer
3
Lalitpur
4
5
6
Bhaktapur
skin burn
2 times a day
not known
Korea-Nepal
Friendship
By paper
incineration
6/6 hours
tissue
damage
Bhaktapur
By paper
kept in dustbin
2 times a day
cancer
Selected 20 Dental Hospitals & Clinics
Facilities
Locations
No. of site
Shine and Smile Dental Clinic
Puja Dental Clinic
R.T Dental Clinic
Himalaya Dental Clinic
Advanced Oral Dental Hospital
Oral Dental Clinic
Arniko Dental Clinic
Bhaktapur
Bhaktapur
Bhaktapur
Bhaktapur
Bhaktapur
Thimi
Thimi
Korea Nepal Friendship Hospital
Thimi
Baneshwor Dental Clinic
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
Suresh Dental Clinic
Satdobato Dental Clinic
Lagankhel Dental Clinic
Lalitpur
Lalitpur
Lalitpur
Lalitpur
4 in Lalitpur
Jaya Dassheel Dental Clinic
Community Dental Clinic
Kritipur
Kritipur
2 in Kritipur
5 in Bhaktpur
3 in Thimi
6 in Kathmandu
Details of Hospitals/Clinics
Facilities
Shine and Smile Dental Clinic
Puja Dental Clinic
R.T Dental Clinic
Himalaya Dental Clinic
Advanced Oral Dental Hospital
Oral Dental Clinic
Arniko Dental Clinic
Korea Nepal Friendship Hospital
Baneshwor Dental Clinic
Om Dental Clinic
Samaj Dental Clinic
Helping Hands Community Dental Hospital
Himal Dental Hospital
Om Shai Dental Clinic
Lagankhel Polyclinic
Suresh Dental Clinic
Satdobato Dental Clinic
Lagankhel Dental Clinic
Jaya Dassheel Dental Clinic
Community Dental Clinic
Number of Staffs
Doctor Assistant WM
3
1
1
1
2
_
3
1
1
4
2
_
2
1
_
2
1
_
5
3
1
2
2
_
1
2
_
4
1
_
13
15
3
4
2
1
10
18
2
1
1
_
3
6
_
1
2
_
2
1
_
3
2
_
2
1
_
3
2
_
Hg Based Equipment
Others Thermometer Barometer Sphy.
1
yes
no
no
_
no
no
no
_
no
no
no
2
yes
yes
yes
_
no
no
no
_
no
no
no
_
yes
no
yes
_
yes
yes
yes
_
yes
no
yes
1
yes
yes
yes
_
yes
no
no
_
yes
yes
yes
3
yes
yes
yes
_
no
no
no
1
no
no
no
_
yes
yes
yes
1
no
no
yes
_
yes
yes
yes
_
no
yes
yes
1
no
no
yes
mercury use No. of patients filled
(gm/month) with amalgam/month
60
15
6
25
30
125
10
40
35
140
52
210
75
300
33
130
56
225
22
90
30
120
28
110
225
900
30
120
2
5
38
150
15
60
38
150
18
70
25
100
Awareness and Training about Hg
Awareness
Training
15 (75%) Dental
clinics are aware
about the health
impact of Hg
5 (25%)Dental clinics
are unaware about
the health impact of
Hg
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
80
% of the Students
70
60
50
40
30
20
BA
LHSS
MVS
BBBS
GEMS
KC
NC
BIC
PA
0
HIC
10
Name of Institutions
Touched
Inhaled
Taken on Paper or Plate
Played
Others
Maximum Percentage of studied Studnets among slected academic
institution (School & Colleges) in Kathmandu VAlley
70
70
60
50
40
40
32
28
30
18
20
10
0
Touched
Inhaled
Taken on Plate
or Paper
Played
Others
Policy of Mercury Import in Nepal
S.No.
Chemicals
Category
Permission required or not
1
Mercury
Hazardous
2
Mercuric Oxide
Hazardous
3
Mercuric Chloride
Hazardous
4
Mercurous Chloride
Hazardous
5
Mercuric Iodide
Hazardous
6
Mercurous Iodide
Hazardous
7
Mercuric Sulphide
Hazardous
8
Mercuric Sulphate
Hazardous
9
Mercurous Sulphate
Hazardous
10
Mercuric Nitrte
Hazardous
11
Mercurous Nitrate
Hazardous
12
Mercuric Cynide
Hazardous
13
Mercuric Cynide Oxide
Hazardous
14
Mercuric Fluminate
Hazardous
15
Mercuric Thiocynate
Hazardous
16
Phenyl Mercury acetate
Hazardous
Source: Department of Custom, Government of Nepal 2007
Not required
Not required
Not required
Not required
Not required
Not required
Not required
Not required
Not required
Not required
Not required
Not required
Not required
Not required
Not required
Not required
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 Analysis
Maternity 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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
National policy/guidelines/acts/regulation development.
Proper training and education programs
Pilot demonstration programs
Arrangement of disposal landfill site
Supply of mercury free equipments
Develop national act for mercury free
Guidelines to use, sell, dispose of mercury and mercury containing
products.
Gradually replace and stop importing mercury base equipments.
Making plan which can replace mercury gradually.
Discover other alternative for dental filling and educate people about health
impact
Awareness to all
Remove all mercury instruments
Ban of importing mercury based instruments and promote import of digital
one.
Suggestion for Hospital Management
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Proper awareness and supply of alternatives
Strict regulation for discard the mercury base equipments and have
alternative supply for that
Arrangement of disposal sites
Hospital should initiate supply of mercury free products
Hospital level guidelines to following the national law
Make a plan to make hospital mercury free
Making good guidelines and policy
Buy new and latest validated and certified mercury free instruments
Gradually shift from mercury to digital one
Remove all mercury and replace by digital instruments
Bring mercury free equipments only.
Supply of digital instruments in every wards
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 Filling
Ask 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
Available and
Reduced use
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
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
[email protected]
[email protected]