30 October 2011

Mercury Instrument: Health Aspects

Carolyn VickersPublic Health and Environment

David WoodImmunization, Vaccines and Biologicals

Mercury Instrument: Health Aspects

Carolyn VickersPublic Health and Environment

David WoodImmunization, Vaccines and Biologicals

30 October 2011

Presentation OutlinePresentation Outline

Role of the health sector in addressing the health impacts of mercury, with some WHO examples

Addressing health in the mercury instrument

INC2 request for information on mercury in pharmaceuticals. UNEP(DTIE)/Hg/INC.3/6 Annex 1: Mercury in human vaccine preservatives

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Role of the health sector in addressing health impacts of mercury

Role of the health sector in addressing health impacts of mercury

1. Providing the health evidence and raising public awareness about the health implications of mercury exposure

2. Setting health-based guidelines and targets for mercury exposure

3. Providing clinical management and educating health workers

4. Reducing health sector use of mercury-added products

5. Working with other sectors in advocating effective health-positive interventions and safer alternatives, with special emphasis on vulnerable populations

6. Sharing knowledge and participating in international mechanisms to solve problems

7. Assessing impacts of policies through monitoring and evaluation

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Health in the mercury instrumentHealth in the mercury instrument

Objective: protect human health and environment by reducing mercury

releases .

In subsistence fishing populations, between 1.5/1000 and 17/1000 children showed cognitive impacts

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Greatest health gains will be made by addressing the main sources of mercury

Greatest health gains will be made by addressing the main sources of mercuryUNEP para 29 study

Coal combustion in power plants and industrial

boilers

Non-ferrous metals

Large scale gold production

Cement production

Waste incineration

Residential heating/other combustion

Pig iron and steel, secondary steel

Mercury production

Artisanal and small-scale gold production

Chlor alkali industry

Other waste

Dental amalgam (cremation)

Other

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Corresponding to these annexes in the draft text

Corresponding to these annexes in the draft text

A. Supply

E. ASGM

F. Emissions

OtherC. Products

D. Manufacturing Processes

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Coal-fired power plantsCoal-fired power plants

Coal consumption has significant detrimental health impacts.

While moving to cleaner energy sources, BAT to reduce mercury emissions must also address other coal pollution, including PM10 which is a major cause of premature death.

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Residential Coal Combustion for Cooking & Heating Improving health through cleaner household energyResidential Coal Combustion for Cooking & Heating Improving health through cleaner household energy

Problem: Incomplete combustion of coal in households for cooking and heating releases indoor high levels of mercury, sulfates, high levels of carbon monoxide and other health damaging pollutants.

Interim solutions for health:

Coal stoves with flues (e.g. chimneys)

Improved coal stoves

Coal processing (e.g. briquetting)

Ultimate solutions for health:

Clean fuels (e.g. Liquefied Petroleum Gas, biogas)

Advanced biomass stoves (e.g. fan-assisted gasifier stoves) where appropriate

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ASGMASGM

17% of emissions to air, plus additional emissions and personal exposures of serious concern

All-hazard industry management practices are needed, to prevent exposure to mercury and other hazards.

Multi-stakeholder approaches, e.g. national Task Force established to address Zamfara lead poisoning outbreak due to ASGM.

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Health sector use of mercury: Dental amalgam

Health sector use of mercury: Dental amalgam

Almost all countries use dental amalgam: Alternatives are more expensive and have technical limitations

WHO 2009 technical meeting, co-supported by UNEP, recommended a phase down be pursued by:

– Promoting disease prevention and alternatives to amalgam

– Research and development of cost-effective alternatives

– Education of dental professionals and raising public awareness

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Mercury thermometers and blood pressure measuring devices (BPMD)

Mercury thermometers and blood pressure measuring devices (BPMD)

Breakage results in exposure of patients, health care workers, etc and creates hazardous waste

WHO recommends use of mercury-free thermometers and BPMD in health-care and domestic settings.

Validated and affordable alternatives are available, including for calibration in clinical setting.

Thermometers are cheaper and have a shorter life than BPMD

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Momentum growing to phase out mercury BPMD and thermometers

Momentum growing to phase out mercury BPMD and thermometers

European Union policy; policies in most U.S. States

WHO-HCWH Global Mercury Free Health Care Initiative reports on developing countries:

– Argentina, Philippines, Chile, Mongolia implementing national policies

– India Central Government Health Services Mercury Phase-Out Guidelines included in Indian Public Health Standard

– Major provinces in South Africa and Brazil phasing-out– Implementation in hospitals in many other countries including:

Costa Rica, China, Ecuador, Indonesia, Lebanon, Mexico, Nepal, Thailand, Nicaragua, Tanzania, Vietnam

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New WHO publications since INC1: see UNEP(DTIE)/Hg/INC.3/INF/4 for complete list

New WHO publications since INC1: see UNEP(DTIE)/Hg/INC.3/INF/4 for complete list

Replacement of mercury thermometers and sphygmomanometers in health care (2011)

Future use of materials for dental restoration (2011)

Estimating the Global Public Health Implications of Electricity and Coal Consumption (2010)

Health in the Green Economy: Household Energy Sector in Developing Countries (2011)

Children's Exposure to Mercury Compounds (2010)

Mercury in skin-lightening products: Fact sheet (2011)

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INC2 request for information on mercury in pharmaceuticals

INC2 request for information on mercury in pharmaceuticals

INC2 “information on mercury use in pharmaceuticals, particularly vaccines.”

Vaccines are already highly regulated (by medical health regulators assessing safety, efficacy and quality of medical products before granting marketing authorization/ registration)

WHO TRS 926 (2004)Thiomersal in Vaccines; regulatory expectations

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Thiomersal containing vaccines and global public health

Thiomersal containing vaccines and global public health

Thiomersal containing vaccines are essential medicines

- used in over 120 countries to immunize at least 64% of global birth cohort each year

- protect against four major killers; diphtheria, tetanus, pertussis, and Haemophilus influenzae type b disease

- estimated to avert at least 1 400 000 child deaths per year

Thiomersal-containing vaccines are also used by developed and developing countries to protect their populations against pandemic (influenza) and epidemic (eg meningitis in Africa) threats

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Thiomersal and vaccine safetyThiomersal and vaccine safety

High-quality population-based studies conducted in several countries since 2000 conclusively show that vaccines that contain thiomersal are very safe

There is no credible scientific evidence that thiomersal-containing vaccines cause autism

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Alternative preservativesAlternative preservatives

There is very little evidence that a range of vaccines can be preserved with alternatives such as 2 phenoxyethanol

Extrapolation from a few examples (such as injected poliovirus vaccines) that all vaccines can be switched to an alternative preservative is not supported by evidence

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Thiomersal-free vaccinesThiomersal-free vaccines

Thiomersal-free vaccines would have to be available in 1 or 2 dose presentations, rather than the 10-dose products currently used by most countries

This would double the cost of vaccines and the global immunization effort; as immunization will need to continue in the long term, this will be an additional cost long into the future

A switch to single-dose vials alone would require more raw materials, more energy for manufacturing processes and transport, and more waste

The environmental impact of thiomersal-free vaccines is not negligible

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International distribution of vaccines

International distribution of vaccines

Vaccines that contain thiomersal are manufactured in no more than 40 countries but used in over 120 countries

Vaccines require import permits to be traded across international borders

The introduction of new provisions on vaccines that contain thiomersal will introduce potential technical barriers to trade which may inhibit access to life-protecting products

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WHO response on the use of thiomersal in human vaccinesWHO response on the use of thiomersal in human vaccines

The amount of mercury involved with thiomersal use in vaccines is very small compared to other sources of mercury

There is no evidence that suggests a possible health hazard with the amounts of thiomersal currently used in human vaccines

WHO recommends multi-dose vaccine vials for routine immunization programmes in many countries because they are safe and effective, they limit the required storage capacity and help reduce vaccine costs

Alternative presentations would incur significantly higher costs in manufacturing procedures and new regulatory approvals, thereby limiting the ability to offer affordable vaccines

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Further InformationFurther Information

WHO INC3 Submission: INC3 website

WHO chemical safety website www.who.int/ipcs/en/

Global Tools for substitutionof mercury thermometers and BPMD in health care.

WHO HCWH project website www.mercuryfreehealthcare.org

WHO Immunization, biologicals and vaccines website: www.who.int/immunization/en/