Mercury and PBT Reduction in Healthcare The Campaign for Environmentally Responsible Health Care Health Care Without Harm

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.

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

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

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

International Joint Commission 6th 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. “

National Mercury Combustion Sources USEPA 1997

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

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

Obstacles to Mercury Elimination Reluctance to change Lack of awareness of alternatives and economics Minimal understanding of the human and environmental impacts

Hospital Mercury Current and Historical Use Batteries Fluorescent Lights Mercury containing devices Dental Amalgam Lab Chemicals Pharmaceutical products Preservatives Housekeeping supplies

Mercury-free Thermometer

Mercury-free Sphygmomanometer

Mercury-free Sphygmomanometers 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

Mercury-free Sphygmomanometers 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?

Zenkers and B5 Traditionally used in histopathology labs Can be phased out to mercury free alternatives –Duluth hospitals –Kaiser

B5 Filtration

Mercury Filter Wastes

B5 Hazardous Waste

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 ppb. All B5 should be sent to a mercury refiner.

Alternative to Mercury Fixatives Formalin Zn Formalin –Anatech ANATECH IBF –Surgipath St Mary’s Duluth Clinic

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

Phased Mercury Elimination Discontinue purchase of mercury containing equipment Replace Hg equipment Educate employees Child birth education Mercury free fixatives Fluorescents management Clean traps Housekeeping supplies Mechanical switches

Making Medicine Mercury Free Pledge program for hospitals and clinics <500 facilities Non regulatory Voluntary compact with community National Institutes of Health Beth Israel Deaconess Medical Center: Boston, MA Kaiser Permentente, Catholic Healthcare West Facilities

St. Mary’s Medical Center Developed a Zero Discharge team Current mercury use and management practices documented through a written survey Performed wastewater monitoring and reagent analysis

Mercury Elimination Task Force Understand sources Understand fate in the environment Employee education Mercury elimination policy

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

US Dioxin Emission Estimates From Sources USEPA 1998

Inventory of Sources of Dioxin in the United States USEPA, 1998

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

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 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

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

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

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

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

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

Dioxin (PVC) Reduction and Elimination Resolutions American Public Health Association Minnesota Medical Association Minnesota Public Health Association Catholic Healthcare West Maine Hospital Association

PVC/DEHP Reduction Policies NICU in Boston requests DEHP-free products CMA DEHP resolution CHW requests disclosure of PVC in products

Persistent Toxic Cycle