Faye Ferrer Health Care Without Harm Asia Philippines

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

Policy Reference for Chemicals

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

Chemicals in Health Care

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.

Activities with Pilot Hospitals

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.

Educational Workshop with Stakeholders

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

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.

Maraming Salamat! Thank you!

Faye V. Ferrer

+63 2 0920.9327151 faye@no-harm.org