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MERCURY
Why Are We Concerned ?
Elemental
Liquid metal
Inorganic salts
Mercuric chloride
Organic
Methyl, ethyl, dimethyl Phenyl organic groups
Mercury cycle
Emitted from human activities & natural sources Circulates in the atmosphere from 6 months to 1 years Deposited back into land or bodies of water
Minamata disease: 2,265 cases confirmed in Minamata, Japan as of March 2001 Effects:
Constriction of visual fields Irregular gait Loss of muscular coordination Loss of speech, hearing, and taste Emotional disturbance Living wooden dolls
Minimata 2011
g/l
15-300
15-30 g/l
30-50
30-50 g/l
% Faroe Island Children with Per cent of children with low test scores age 7 years lowest scores at at age 7 years
30
20
10
40
60
80
100
120
140
160
70
I.Q.
130
57% INCREASE
IN
4 million "gifted"
160
70
I.Q.
130
Public Health and Economic Consequences of Methyl Mercury Toxicity to the Developing Brain
Leonardo Trasande, Philip J. Landrigan, and Clyde Schechter Mount Sinai School of Medicine, New York, New York, USA Environ Health Perspect 113:590596 (2005).
$1.3 billion
each year is attributable to mercury emissions from U.S. power plants.
Photo: Illinois State Geological Survey
Thermometers Sphygmomanometers Dental amalgam Gastrointestinal tubes Laboratory chemicals Pharmaceutical products Electrical applications Medical waste incineration, open burning, burning in barrels, gasification, pyrolysis, etc.
Fever Thermometers
WHO/OMS
Use: Fever thermometers measure human body temperature including oral, rectal, or auxiliary (armpit). Mercury content: Content ranges from 0.5 to 3 grams. Alternatives: Mercury-free alternatives include digital, alcohol, and glass gallium-indium-tin thermometers. Other alternatives include ear canal thermometers and flexible forehead thermometers. These alternatives can be as accurate as mercury thermometers, and are easier to read.
Russia (0.180) and China (0.152):highest level per capita in grams of mercury per person per year
In 2005, 200.9 tons of mercury was consumed by medical thermometer manufacturers in China. 40.3% was exported. In 2002, 25.579 metric tons of mercury was consumed by the one medical thermometer manufacturer in Russia .
Mercury Thermometers
Breakage
Thermometer Breakage
An example glass thermometer containing 1 gram of mercury A broken thermometer will release mercury which will evaporate and to a concentration of 22.2 mg/m3 in the air measured in a in a 15 square meter, three meter high room. China's provision of mercury maximum allowable concentration in indoor air is 0.01 mg/m3 and in US workplaces the PEL is 0.1 mg/M3 & STEL is 0.03 mg/M3.
Xueyu Li , Global village of Beijing: 12-20-2007
Young Children have been poisoned after less than 2 weeks exposure to mercury vapor from a bedroom carpet after a single thermometer broke.
Poisindex, 2010
http://www.noharm.org/europe/issues/toxins/mercury/resources.php
Fever Thermometers
WHO/OMS
Use: Fever thermometers measure human body temperature including oral, rectal, or auxiliary (armpit). Mercury content: Content ranges from 0.5 to 3 grams. Alternatives: Mercury-free alternatives include digital, alcohol, and glass gallium-indium-tin thermometers. Other alternatives include ear canal thermometers and flexible forehead thermometers. These alternatives can be as accurate as mercury thermometers, and are easier to read.
Accuracy Issues
http://www.sustainablehospitals.org/cgi-bin/DB_Report.cgi?px=W&rpt=Cat&id=15
Detailed Study of Non-Mercury Alternatives 8 U.S. Army Corps of Engineers, Baltimore District as an Environmental Attribute HQ Defense Logistics Agency January 2005
Cost Issues
WHO-HCWH Global Initiative to Substitute Mercury-Based Medical Devices in Health Care A Two-Year Progress Report Published by the World Health Organization and Health Care Without Harm (Discussion Draft ) - 2010
Reducing Mercury in Health Care Setting: A case study of Four Hospitals in Delhi, India, Toxics Link 2009
Sphygmomanometers
WHO/OMS
Internal Medicine Residency: 1975 1978 Attending Physician Internal Medicine: 1979 Emergency Room: 1979 1980 Inpatient Internal Medicine: 1975 - 2009 Outpatient Internal Medicine: 1975 President of the Medical Staff: 2001-2005 Professor of Internal Medicine Fellow American College of Physicians Officer County and State Medical Societies
Hypertension
It is surprising that nearly 100 years after it was first discovered, and the subsequent recognition of its limited accuracy, the Korotkoff technique for measuring blood pressure has continued to be used without any substantial improvement.
Circulation. 2005;111:697-716
Gold Standard?
mm Hg = mm Hg BP measurement with Hg = Accurate BP
??
The gold standard for clinical blood pressure measurement has always been readings taken by a trained health care provider using a mercury sphygmomanometer and the Korotkoff sound technique, but there is increasing evidence that this procedure may lead to the misclassification of large numbers of individuals as hypertensive and also to a failure to diagnose blood pressure that may be normal in the clinic setting but elevated at other times in some individuals.
Circulation. 2005;111:697-716
A survey of blood pressure devices used in a large teaching hospital in London in 2000 (n=469 devices) 10% 18% 3 8% 35% - the markings were difficult to read - either an obscured mercury column or faded markings, - were leaking mercury. - had worn out, damaged, or split cuffs - velcro cuffs did not stick well enough to resist bursting apart on inflation above 180 mmHg - cuffs contained the wrong size bladder for the size of the cuff.
Electronic pressure gauges are more accurate and better for Y Tube calibration:
Mercury sphygmomanometers Electronic pressure devices
3 mm Hg variation
Very marked digit preferences were observed for both the conventional and the automatic measurements, being most prominent for the digit "0" (52% and 25%, respectively) followed by a preference for the digit "5" (19% and 15%).
Martin G. Myers
was similar to the mean manual blood pressure taken in duplicate (163 23/86+ 12).
Both values were higher (P< 0.001) than the mean of the next five readings taken with the
automated recorder when the patient was resting quietly alone (142 21/80 12).
Clinical Experience
The experiences of using mercury free blood pressure equipment in the Swedish health care sector.
by Kemi & Milj AB for the Swedish Chemicals Inspectorate. 1992
Since 1992 thermometers and other measuring instruments containing mercury may not be commercially manufactured or sold in Sweden.
All heads of department of clinical physiology in Swedish hospitals were contacted and asked to report their experiences from the phase out of mercury in blood pressure equipment.
Studies
Accuracy of aneroid sphygmomanometer blood pressure recording compared with digital and mercury measurements in
Gill G, Ala L, Gurgel R, Cuevas L. Liverpool School of Tropical Medicine, UK.
Brazil
Digital, mercury and aneroid blood pressure measurements were carried out in 400 South American adults. There was slight under-reading of the aneroid instrument (hypertension prevalence 30%, compared with 32% for digital and mercury) Its robustness and simplicity makes it a suitable alternative to mercury machines in tropical field conditions.
Accuracy of the pressure scale of sphygmomanometers in clinical use within primary care
Andrew J. Coleman, Stephen D. Steel, Mark Ashworth, Sarah L. Vowler and Andrew Shennan
45 general practices within Lambeth, Southwark and Lewisham. A total of 279 sphygmomanometers. Calibrated using an accurate electronic reference pressure sensor.
Accuracy of the pressure scale of sphygmomanometers in clinical use within primary care
Andrew J. Coleman, Stephen D. Steel, Mark Ashworth, Sarah L. Vowler and Andrew Shennan
RESULTS:
17.9% of all surveyed devices gave errors exceeding the +/-3 mmHg threshold. 53.2% of aneroid devices were found to be reading in error by more than +/-3 mmHg compared with 7.8% of the combined population of mercury and automated devices.
Significant differences in the performance of specific models of aneroid, mercury and automated devices were also identified.
Automated non-invasive blood pressure devices: are they suitable for use?
Andrew J. Sims, Julian A. Menes, Derek R. Bousfield, Christopher A. Reay and Alan Murray
Results:
86 companies were found to be actively involved in the supply of 158 different models of automated non-invasive blood pressure device. 54 devices for use on the arm and 62 for use on the wrist We received responses for 61% of the main category arm and wrist devices and 80% of these provided claims for CE marking. Inconsistencies were found between claims for diagnostic suitability and claims for clinical validation.
Conclusions:
A majority of models available on the European Union market were not validated by clinical trial to one of the recognized protocols
Both mercury and aneroid sphygmomanometers have been in use for about 100 years, and when working properly, either gives accurate results. Aneroid sphygmomanometers provide accurate pressure measurements when a proper maintenance protocol is followed.
SUMMARY
When Maintained and Calibrated Properly Nearly All Inter-Device Variability 4mm Hg
Clinical Use of Non Hg Sphygmomanometers Conclusion: Aneroid sphygmomanometers are safe and accurate substitutes for hg devices in clinical practice. The oscillometric method is perhaps the best device for office measurement
SUMMARY
ACKNOWLEGEMENTS
Slides Developed From
Materials of WHO, HCWH, UNEP Colleagues at University of Illinois Postings on the Internet
Thanks to all these colleagues who permitted their slides and materials to be edited by me for presentation
And for support from the:
The United Nations Development Programme Global Environment Facility Global Project on Healthcare Waste