DOH Administrative Order No. 21, s.2008 - Gradual Phase-Out of Mercury in All Philippine Health Care Facilities and Institutions
Department of Health
OFFICE OF THE SECRETARY
2/F Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Trunk Line 743-8301; Direct Line: 711-9501; Fax: 743-1829; 743-1786
URL: http://www.doh.gov.ph; e-mail: osec@doh.gov.ph
April 28, 2008
ADMINISTRATIVE ORDER
No. 2008-0021
| SUBJECT: | Gradual Phase-Out of Mercury in All Philippine Health Care Facilities and Institutions | |
I. RATIONALE/BACKGROUND
Mercury is a naturally-occuring heavy metal. At ambient temprature and pressure, mercury is a silvery-white liquid that readily vaporizes and may stay in the atmosphere for up to a year. When released to the air, mercury is transported and deposited globally. Mercury ultimately accumulates in lake bottom sediments, where it is transformed into its more toxic organic form, methyl mercury, which accumulates in fish tissue.
Mercury is highly toxic, especially when metabolized into methyl mercury. It may be fatal if inhaled and harmful if absorbed through skin. Around 80% of the inhaled mercury vapor is absorbed in the blood through the lungs. It may cause harmful effects to the nervous, digestive, respiratory, immune systems and to the kidneys, besides causing lung damage. Adverse health effects from mercury exposure can be: tremors, impaired vision and hearing, paralysis, insomnia, emotional instability, developmental deficits during fetal development, and attention deficit and developmental delays during childhood.
In 1991, the World Health Organization (WHO) concluded that a safe level of mercury exposure, below which no adverse effect, has never been established.
Several European countries Sweden, France, Denmark and Norway, have also banned mercury-containing thermometers from as early as 1991. A European wide resolution on the issue of mercury is pending.
In the United States, hospitals have significantly reduced the amount of mercury found in facilities and are demonstrating a clear preference for safe alternatives. Many hospitals across the country have taken steps to address the issue, including labelling mercury-containing devices and phasing out their purchase in favo or safer, equally effective alternatives. More than 1,000 hospitals across the US have pledged to virtually eliminate mercury medical device and more than 90% of pharmacy chains have stopped selling mercury fever thermometers. Three of the five largest health care group purchasing organizations in the US now have mercury-free purchasing policies.
On 25 January 2006, at the opening of the Southeast Asian Conference on Mercury in Health care held at the Philippine Heart center, the Department of Health pronounced the gradual elimination of mercury-use in the Philippine health care system.
The Department of Health (DOH) provides the following policies and guidelines for the gradual phase-out of mercury in all Philippine health care facilities pursuant, among others, the following laws, rules and regulations:
| o | "Toxic Substances and Hazardous Nuclear Wastes Control Act of 1990" (Republic Act 6969); | |
| o | Procedural Manual for Title III: Hazardous Waste Management;
Management of Chemicals and Toxic Substances (Implementing Rules and Regulationsfor Title II, DENR A.O. 92-29); | |
| o | "Chemical Control Order for Mercury and Mercury Compounds" Implementing Rules and Regulations under DENR A.O. 97-38); Clean Water Act of 2004, (Republic Act No. 9275); | |
| o | "Revised Rules and Regulations Governing the Registration, Licensure and Operation of Hospitals and Other Health Care Facilities in the Philippines" (DOH Aministrative Order 70-A as amended); | |
| o | Hospital Licensure Act (Republic Act 4226) The COnsumer Act of the Philippines of the Department of Trade and Industry (DTI), covering various chemicals, Article 10-Injurious, Dangerous & Unsafe Products (RA 7394) |
II. SCOPE AND COVERAGE
These policies and guidelines shall apply to all Health care Facilities as defined by this document.
III. DEFINITION OF TERMS
1. Health Care Facilities mean any of the following:
| a. | HOSPITALS - places devoted primary to the maintenance and operation of facilities for the diagnosis, treatment and acre of individuals sufering from illness, disease, injury or infirmity or in need of obstetrical or other medical and nursing care. The term "hospital" shall also be construed as any institution, building or place where there are installed beds or cribs or bassinets for twenty-four hour use or longer by patients in the treatment of diseases, diseased-condition, injuries, deformities or abnormal physical or mental states, maternity cases, and sanitorial or sanitarial care infirmities, nurseries, dispensaries, and such other means by which they may be designated. |
| b. | INFIRMARY - a health facility that provides emergency treatment and care to the sick and injured, as well as clinical care and management to mothers and newborn babies. |
| c. | BIRTHING HOME - a health facility that provides maternity services on pre-natal and post-natal care, normal spontaeneous delivery and care of newborn babies. |
| d. | CLINIC - shall mean a place in which patients avail of medical consultations or treatment on an out-patient basis and shall include the following: d.1 Medical d.2 Ambulatory d.3 Dialysis d.4 Health care Centers and Dispensaries d.5 Surgical d.6 Alternative Medicine d.7 Dental d.8 Other clinical facilities not mentioned above that require a license/certification/accreditation from DOH. |
2. Mercury - means any substance containing element mercury, either in pure form, as metallic salts or organometallic compounds.
3. Mercury Audit - a mercury audit aims to identify all the uses and sources of mercury, and the amount present in the facility.
4. Alternative to Mercury-containing devices/products - mercury-reduced and mercury-free products that are considered to be viable replacements for mercury-containing devices/products.
5. Hospital Waste Management Committee (HWMC) - means a group in the Health Care Facility with the overall responsibility of ensuring that health care waste management plan are promoted and implemented.
6. Waste Management Officer (WMO) - means a person in the Health Care Facility responsible for the day-to-day operation and monitoring of the waste management system. In cases where the Health Care Facility has no HWMC, the WMO shall be the person to assume the responsibility of ensuring the health care waste management plan of the facility as promoted and implemented.
7. Mercury Minimization Program - means a gradual phase-out plan for MDEP by a Health Care Facility in accordance with Section V and following the management plan described in Annex B of this Administrative Order.
IV. GENERAL PROVISIONS
Recognizing the unnecessary risk posed by the continued use of mercury containing products in the healthcare system, the DOH hereby orders that:
| 1. | All hospitals shall immediately discontinue the distribution of mercury thermometers to patients through the distribution of hospital admission/discharge kits. |
| 2. | All hospitals shall follow the guidelines for the graudal phase-out of mercury in health care facilities described in this document in the timeline specified. |
| 3. | All new Health Care Facilities applying for a License to Operate shall submit an inventory of all mercury-containing devices that will be used in their facilities and a corresponding mercury elimination program. |
| 4. | All other Health Care Facilities other than hospital shall make a Mercury Minimization Program based on the guidelines set by this administrative order. |
V. GUIDELINES FOR THE GRADUAL PHASE-OUT OF MERCURY IN HEALTH CARE FACILITIES
1. In order to ensure safety and contamination control, steps taken towards mercury elimination in facility must be consistent and predetermined. It is therefore a must to involve the whole facility in a dedicated Mercury Management and Minimization Program, with the goal of:
| a. | Raising awareness on the dangers posed by mercury and mercury-containing devices in all health care facilities and institutions. |
| b. | Developing a clear preference for the use of Alternative to Mercury-containing Devices among health care personnel. |
| c. | In the short term, preventing the further release of mercury to the environment through proper disposal. |
2. All Health Care Facilities are hereby tasked to designate a dedicated Mercury Management Team within two months from the issuanceof this order. This team should be directly under the Hospital Waste Management Committee.
For the first 6 months from their inception, the Mercury Management Team should have:
| a. | Conducted a Mercury Audit of their facility (Refer to Annex "A" Sample Mercury Audit Form). This should include an assessment of the cost of switching to alternatives to mercury-containing devices. |
| b. | Developed and managed a Mercury Minimization Program for their facility (Refer to Annex "B" Sample Mercury Minimization Program). |
| c. | Drafted and implemented a purchasing policy that requires vendors to sign a mercury-content disclosure agreement (Refer to Annex "C" Sample Vendor Product Mercury-COntent Disclosure) covering products intended for purchase. A clear preference for Alternatives to Mercury-containing Devices where applicable should be in effect. Efforts should be made to communicate with suppliers about an eventaul mercury-free purchasing policy and to work with staff on finding Alternative to Mercury-containing Devices. |
| d. | Conducted a facility-wide information campaign and employee education on the consequences of continued mercury use. Personnel training on preventing and proper handling of mercury spills should also be accomplished (Refer to Annex "D" How to Handle Mercury Spills). |
| e. | Identified and removed unnecessary practices that promote the use and distribution of mercury-containing medical devices. |
3. Within 24 months from the effectivity of this administrative order, all hospitals should have accomplished the following:
| a. | Fully implemented the Mercury Minimization Program developed for their facility. |
| b. | Switched to alternatives from mercury-containing devices. |
| c. | Developed and implemented a program of waste segregation and recycling to further reduce the mercury waste stream in cases where no alternative products exist. For instance, mercury containing batteries and flourescent light bulbs should be collected and processed for recycling or should be properly stored. |
| d. | Identified a dedicated mercury collection area within the facility |
| e. | Developed a proper temporary mercury storage in the facility inaccessible to the public (Refer to Annex "E" Guidelines for setting up a Proper Temporary Mercury Storage Area). |
| f. | Incorporated a mercury management module in their training program for new personnel. |
| g. | Information materials on mercury are displayed and/or available in their facility for the benefit of their patients and the general public. |
VI. EFFECTIVITY
This order shall take effect 30 days after publication in the Official Gazette and major newspapers and shall supersede all issuance inconsistent herewith.
(Sgd) FRANCISCO T. DUQUE III, MD, MSc
Secretary of Health
TABLE OF CONTENTS
I.
RATIONALE/BACKGROUND
II.
SCOPE AND COVERAGEIII.
DEFINITION OF TERMSIV.
GENERAL PROVISIONSV.
GUIDELINES FOR THE GRADUAL PHASE-OUT OF MERCURY IN HEALTH CARE FACILITIESVI.
EFFECTIVITYANNEXES(Link to downloadable pdf files)"A"Sample Mercury Audit Form"B"Sample Mercury Minimization Program"C"Sample Vendor Product Mercury-Content Disclosure"D"How to Handle Mercury Spills"E"Guidelines for setting up a Proper Temporary Mercury Storage Area | |||||||||||||||||||||||