chemicals healthcare_faye ferrer_philippines.pdf
DESCRIPTION
Presentation made during the Green Hospitals Asia Conference 2013, held on October 15, 2013 in Quezon City, Philippines.TRANSCRIPT
UNEP-SAICM Project on Chemicals Substitution and Management in the Health Sector
The Philippines Experience
Faye V. Ferrer Safer Chemicals Campaigner
Health Care Without Harm Asia
Chemical Substitution and Management in the Health Care Sector
• A project of HCWH Asia and UNEP-SAICM Quick Start
Programme (QSP)
• Four pilot hospitals in the Philippines and Argentina
• One and half years of implementation
• Three major components:
1. Identification of priority health care chemicals for substitution and/or management
2. Test a model for substitution and/or management
3. Educate health care workers and other stakeholders
International Agreements on Chemicals
International Agreements
Environmental Focus
Rotterdam Convention
Pesticides and industrial chemicals - To promote shared responsibility and cooperative efforts in the international trade of certain hazardous chemicals and to contribute to the environmentally sound use of those hazardous chemicals.
Stockholm Convention
POPs (Persistent organic pollutants) - To protect human health and the environment from chemicals that remain intact in the environment for long periods, become widely distributed geographically, accumulate in the fatty tissue of living organisms and are toxic to humans and wildlife.
Basel Convention
Hazardous wastes - To protect human health and the environment against the adverse effects resulting from the generation, management, transboundary movements and disposal of hazardous and other wastes.
Montreal Convention
Substances - To reduce the production and consumption of ozone depleting substances in order to reduce their abundance in the atmosphere, and thereby protect the earth’s fragile ozone layer.
World Health Organization
Chemicals - To protect human health from the harmful effects of improperly managed chemicals through multisectoral action.
International Agreements on Chemicals
International Agreements
Priority Lists
World Health Organization
10 chemicals of major public health concern: Arsenic, Asbestos, Benzene,
Cadmium, Dioxin and dioxin-like substances, Fluoride, Lead, Mercury, Pesticides, Air Pollution.
Rotterdam Convention
• Industrial chemicals (Asbestos, Actinolite, Amosite, Anthophyllite, Crocidolite, Tremolite, Polybrominated biphenyls (PBB), Hexabrominated biphenyls, Octabrominated biphenyls, Decabrominated biphenyls, Polychlorinated biphenyls (PCB), Polychlorinated terphenyls (PCT), etc.); • Pesticides and chemicals like Mercury compounds including inorganic
mercury compounds, alkyl mercury compounds and alkyloxyalkyl and aryl mercury compounds
Stockholm Convention
• 12 initial POPs or “Dirty Dozen” (Aldrin, Chlordane, DDT, Dieldrin, Endrin, Heptachlor, Hexachlorobenzene, Mirex, Toxaphene, Polychlorinated biphenyls (PCB), Polychlorinated dibenzo-p-dioxins (PCDD), and Polychlorinated dibenzofurans (PCDF). PCDD - emitted mostly from the burning of hospital, municipal, and hazardous wastes. PCDF - produced unintentionally from many of the same processes that produce dioxins, detected in emissions from waste incinerators .
International Agreements on Chemicals
International Agreements
Priority Lists
Basel Convention
•Wastes to be controlled: Y1 Clinical wastes from medical care in hospitals, medical centers and clinics, Y13 Wastes from production, formulation and use of resins, latex, plasticizers, glues/adhesives,
Y16 Wastes from production, formulation and use of photographic chemicals and processing materials Y29 Mercury; mercury compounds, •Wastes which may contain either inorganic or organic constituents:
A4020 Clinical and related wastes arising from medical, nursing, dental, veterinary, or similar practices, and wastes generated in hospitals or other facilities during the investigation or treatment of patients, or research projects
Montreal Convention
• Chlorofluorocarbon, Halons, Other fully halogenated CFCs, Hydrochlorofluoro carbons, Hydrobromofluoro carbons, used in propellants in medicinal aerosols; also used as solvents, degreasing agents, cleaning agents • 1,1,1-Trichloroethane (Methyl chloroform), used as photographic film
cleaner
Philippine Policies and Circulars on Chemicals
1. Republic Act 6969 An Act to Control Toxic Substances and Hazardous and Nuclear Wastes,
Providing Penalties for Violations Thereof, and for Other Purposes
2. Department of Health Administrative Order 2008-0021 Gradual Phase-out of Mercury in All Philippine Health Care Facilities and
Institutions
3. Department of Health Memorandum 2010-0269 Instructions for DOH Healthcare Facilities for the Disposal of Mercury
Lamps in Accordance with Administrative Order No. 0021 s. 2008 on the Gradual Phase-out of Mercury in All Philippine Health Care
Facilities and Institutions
4. Joint DTI-DENR-DA-DOF-DOH-DILG-DOLE-DOTC Administrative Order No. 01 Series of 2009 The Adoption and Implementation of the Globally Harmonized System of
Classification and Labeling of Chemicals (GHS)
Philippine Policies and Circulars on Chemicals
5. Department of Environment and Natural Resources Memorandum Circular 2002-12 Delegation of Authority to the Environmental Management Bureau
Regional Offices to Issue "Permit to Transport“ for Hazardous Wastes, and "Certification" and "Importation Clearance" for Chemicals and Chemical Substances
6. Department of Environment and Natural Resources Administrative Order 1998-58 Priority Chemical List
7. Department of Environment and Natural Resources Administrative Order 1997-38
Chemical Control Order for Mercury and Mercury Compounds
Philippine Policies and Circulars on Chemicals
8. Department of Environment and Natural Resources Administrative Order 2005-05
Toxic Chemical Substances for Issuance of Chemical Control Orders (Cadmium Compounds, Lead Compounds, Arsenic Compounds, Vinyl
Chloride, Benzene, and Chromium)
9. Department of Environment and Natural Resources Administrative Order 2000-18
Chemical Control Order for Ozone Depleting Substances (ODS)
10.Department of Environment and Natural Resources Memorandum Circular 2005-23
Registration of Dealers, Re-Sellers and Retailers of Ozone Depleting Substances (ODS)
11.Environmental Management Bureau Memorandum Circular 2003-011 Scope of Compliance Monitoring for Industrial Chemicals and Toxic
Substance Under Title II
Initial List of Hazardous Chemicals in HeaIth Care
Hospital Uses Health and Environmental Concerns
Disinfectants & Sterilants
• Glutaraldehyde is a potent occupational skin irritant and causes asthma.
• Ethylene oxide is flammable and explosive, a probable human carcinogen, a toxic air contaminant, and an ozone depleter.
• Chemicals designed to kill biological organisms like pesticidal cleaners can be very toxic to humans and ecosytems.
Initial List of Hazardous Chemicals in HeaIth Care
Hospital Uses Health and Environmental Concerns
Cleaning Agents
• Chlorine bleach (sodium hypochlorite), can in some circumstances liberate chlorine gas, a respiratory irritant and sensitizer.
• Surfactants such as alkylphenol ethoxylates degrade into nonylphenol, which is toxic to aquatic wildlife; ethanolamines can cause asthma.
• Some cleaners may contain chemicals that cause cancer, reproductive disorders, respiratory ailments, eye and skin irritation, central nervous system impairment, etc.
Initial List of Hazardous Chemicals in HeaIth Care
Hospital Uses Health and Environmental Concerns
Laboratory Chemicals
• Toluene is neurodevelopmental toxicant. • Formaldehyde is a carcinogen. • Laryngitis, bronchitis or bronchial pneumonia, conjunctivitis may be
developed through chronic exposure to laboratory chemicals.
Initial List of Hazardous Chemicals in HeaIth Care
Hospital Uses Health and Environmental Concerns
Medical Devices
• PVC manufacture and incineration generate dioxins, chlorinated organochlorines.
• DEHP, an additive to PVC, can damage the liver, kidneys, lungs and reproductive system, particularly developing testes, according to animal studies.
• In animal studies, BPA is associated with alteration in breast, prostate, and brain development, changes in behavior, and susceptibility to breast and prostate cancer. Human studies find a direct association with risk of diabetes and heart disease.
Initial List of Hazardous Chemicals in HeaIth Care
Hospital Uses Health and Environmental Concerns
Waste disposal by incineration
• Dioxin is a known human carcinogen, and can cause birth defects, learning disabilities, endometriosis, infertility, suppressed immune function, reduced IQ and hyperactive behavior in children. It bioaccumulates in people & wildlife.
• Incinerator emissions can include carcinogenic, mutagenic and reproductive toxicants, asthmagens and respiratory irritants.
General Profile of Pilot Hospitals
Name of facility Romblon Provincial Hospital
St. Paul Hospital Tuguegarao
Type of hospital Public secondary Private tertiary
Bed capacity 75 beds 120 beds
Occupancy rate 60% per year, about 550 outpatients per month
63.49% per year, about 4,336 outpatients per month
Administration Operated by the Provincial Government of Romblon
One of the 13 health care ministries under the Saint Paul de Chartres - Philippines
Location Odiongan, Romblon which is an island province in South Luzon
Tuguegarao City, capital of Cagayan which is a peninsula in North Luzon
Hospital Walk Through
Purpose:
1. To conduct a general inventory of chemicals being used in the pilot hospitals and document their storage and disposal systems. 2. To identify chemicals of concern for substitution.
Dental room of Romblon Provincial Hospital Central sterile supply of St. Paul Hospital Tuguegarao
Hospital Walk Through
Areas visited:
Operating room, Delivery room, Endoscopy unit, Dialysis unit, Dental room, Laboratory, Radiology, Central Sterile room, Supply room, Housekeeping, and Linen room.
Operating room complex (top) and Endoscopy unit (bottom) Laboratory and Central supply room of Romblon Provincial Hospital of St. Paul Hospital Tuguegarao
Orientation Seminar on Chemicals
• Target audience are the end-users of chemical products but also attended by other hospital staff to have an institutional wide understanding of the project.
Hospital staff from different departments of St. Paul Hospital and nearby hospitals from Tuguegarao City.
Observation of Hospital Procedures
• To better understand written hospital policies as actual procedures are carried out, and served as a venue to validate processes, identify gaps, and give initial feedbacks.
OR staff of St. Paul Hospital Tuguegarao demonstrating cleaning of used surgical instruments.
Focus Group Discussions
• A more in-depth but direct gathering of information from hospital staff on their knowledge and understanding of the hospital’s infection control, chemical and hospital waste management systems.
Focus group discussion with first batch of staff from Romblon Provincial Hospital
Major Findings from Focus Group Discussions
RPH Strengths: 1. There are policies and programs on infection control
and waste management. 2. Has created a Chemicals Management Committee.
RPH Issues and Concerns: 1. No specific policies and procedures on purchase,
handling and disposal of chemicals. 2. Infection Control Committee not active. 3. Lack of budget to implement some projects. 4. Lack of manpower to focus on other projects.
Major Findings from Focus Group Discussions
SPHT Strengths: 1. There are policies and programs on infection control and
waste management. 2. Active Infection Control Nurse (not Committee). 3. Management is supportive of the projects of the Infection
Control Nurse.
SPHT Issues and Concerns: 1. No specific policies and procedures on purchase, handling
and disposal of chemicals. 2. No Chemicals Management Committee. 3. Only the Infection Control Nurse implements the projects
on infection control.
Chemicals of Concern
Glutaraldehyde used for disinfection of surgical instrument and endoscopes.
Sodium hypochlorite used for cleaning of rooms and work areas.
Initial Laboratory Testing
Purpose for the Pilot Hospitals:
1. To provide the hospitals with a simple evaluation tool which they can adapt and integrate in their policies on infection control and
purchasing of chemical products. 2. To test possible product alternatives to their current disinfectants.
Other Purpose:
3. To pilot test the protocol. • serves as preliminary study only and is subject for further
improvement and possible scale up • submitted to National Reference Laboratory for review
Preliminary Results:
Noted general trends from testing:
1. Alternatives were found to be as effective with current chemical disinfectants.
2. There were variations on the efficacy of alternatives against prescribed contact time.
3. Vinegar as disinfectant was found to be ineffective. There were still presence of micro organisms between 5 minutes to 2 hours.
Training Course Design
• Short training course on chemical safety and management in a health care setting.
• Developed for hospital workers and other stakeholders.
• Nine (9) modules for varying training needs of participants
• Main methodologies are lecture-discussions, demonstrations and group workshops
• Topics on:
1. Policies and regulations on chemicals 2. Chemicals and health hazards 3. Handling, transport, and disposal of chemicals 4. Prevention of chemical hazards and spills management 5. Material Safety Data Sheet (MSDS) 6. Globally Harmonized System (GHS) 7. Comprehensive chemicals action plan
- the incorporation of all topics into formulation of an institutional Chemicals Safety and Management programs and activities including the formation of a Chemicals Management Committee.
Chemicals Safety and Management Training
• 40 participants from RPH, SPHT, and 27 Metro Manila tertiary hospitals attended the 2-day training.
• Trainees were doctors, nurses, medtechs, engineers, and housekeeping staff who are members of HCWM, Infection Control and Pollution Control committees.
Recommendations from Training Workshop
For Health Care Facilities:
1. Formation of a Chemicals Management Committee (CMC) and align their functions and responsibilities with the existing committees like Health Care Waste Management, Infection Control, or Pollution Control.
2. Implement plans for chemicals safety and management as developed from their group workshops. Immediate activities are: a. Inventory of chemicals; b. Review and revise chemicals storage and disposal procedures; c. Draft guidelines and SOPs following MSDS and GHS; and d. Integrate “green procurement” to purchasing policies.
3. Institutional-wide support for CMC – management to support plans and programs of CMC and, all hospital personnel for compliance and cooperation.
4. Trainings to update and/or enhance knowledge and skills of health care workers on chemical safety and management.
5. Identify best practices of other hospitals and be open for benchmarking.
Recommendations from Training Workshop
For Government Agencies:
1. DENR: Follow-up on the central storage of phased-out mercury devices (could have prevented Fabella hospital spill).
2. DOH: Through PhilHealth, submission of chemicals management plans and availability of MSDS of hospital chemicals as licensing and renewal requirements for hospitals.
3. Testing standards on the efficacy of chemical products including safety evaluation for end-users, general public, and the environment.
4. Inter-agency cooperation on information dissemination and compliance monitoring to GHS labelling of chemical products.
5. Review laws on chemicals and draft Implementing Rules and Regulations for strict compliance of manufacturers and distributors.
6. Trainings on chemicals management including risk assessment.
Recommendations from Training Workshop
For Health Care Without Harm Asia:
1. Assist re-training for other hospital personnel.
2. Assist in identifying best practices on chemicals management.
3. Conduct annual “friendly” hospital visits to monitor progress of plans.
4. Continue collaboration with hospitals, government agencies, and other stakeholders.
5. Continue advocacy work on public and environmental health.
Challenges Ahead
For Project Replication:
1. More hospitals to buy-in to the project as another pilot models
2. Partnership with government agencies and other stakeholders to support project components and activities: a. Database of hospital chemicals; b. Market research for safer alternatives; c. Test standardization for chemical products; and d. Training of health care workers and other stakeholders.
For Policy Development:
1. Inclusion of hazardous health care chemicals in Priority Chemical List and/or issuance of Chemical Control Order.
2. Drafting of national laws, administrative orders, and department memorandum with stricter guidelines on chemicals use, handling, transport, and disposal.