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Environmental and Health Issues and Recommendations  Less Hazardous:
Purchasing medical devices that do not contain mercury reduces the release of mercury into the environment.
- Choose medical supplies that do not contain mercury.
 End-of-Life Management
Discarded thermometers, sphygmomanometers (blood pressure monitors), esophageal dilators and weighted tubing that contain mercury are regulated as hazardous waste under the Department of Toxic Substances Control's (DTSC) Universal Waste program.
- Reduce end-of-life management costs by purchasing medical supplies that do not contain mercury.
See the Introduction for complete descriptions of these environmental and health issues.
BACKGROUND AND ENVIRONMENTAL AND HEALTH ISSUES [1]
Mercury can be found in many common health care devices, from fever thermometers, blood pressure cuffs, and esophageal dilators, to mercury-containing motion switches, fluorescent light bulbs, and cleaning solutions. Mercury is also found in laboratory chemicals and measurement devices. When mercury-containing devices are improperly disposed of (in red bags or down the drain, for example), they can cause significant human health and environmental problems. [2]
Hospitals are a significant source of mercury arriving at publicly owned treatment works (POTW), contributing 5 -10 percent of the total mercury in wastewater, according to a recent study by the Association of Metropolitan Sewerage Agencies. Mercury enters hospital wastewater from disposal of laboratory chemicals, dental services, and cleanup of broken mercury-containing devices such as thermometers and blood pressure cuffs. [3]
Environmental and Health Issues
Incineration
When mercury-containing waste is incinerated, the mercury is vaporized into the air. According to the United States Environmental Protection Agency (USEPA), medical waste incinerators are the fourth largest source of mercury to the environment. [4] Additionally, medical and municipal waste incinerators are responsible for 30 percent of the total mercury emissions to air. [5]
Landfill
When mercury-containing devices are disposed in the landfill, mercury can reenter the environment through gases released by landfills and through leaching into the ground water. USEPA estimates that for the year 2000, mercury fever thermometers contributed to 17 tons of mercury in U.S. municipal solid waste. [6] The estimated quantity of mercury is expected to decline due to passage of legislation SB 633.
Water Releases
When mercury-containing waste (including fixatives, medicine, cleaning solutions) are dumped down the drain, the mercury eventually returns to the water supply, and is converted to methylmercury by bacteria. Methylmercury bioaccumulates in aquatic animals, and the concentrations can increase by a million fold in animals at the top of the food chain. [7]
Human Health Implications
The primary pathway for mercury to impact human health is through eating mercury-contaminated fish. California and 41 other states post fish consumption advisories because of widespread mercury contamination. As a reproductive toxin and a potent neurotoxin, mercury affects the brain and the central nervous system. Pregnant women, women of childbearing age, and small children are at greatest risk. Mercury can cross the placenta and cause irreparable neurological damage to the fetus. A National Academy of Sciences report from July 2000 showed that 60,000 babies born in the United States each year are at risk of neurological damage due to their mothers eating mercury-contaminated fish. [8]
What to look for: Look for medical supplies that do not contain mercury.
LAWS AND GUIDELINES
California
Statute
The California Mercury Reduction Act of 2001 (SB 633, Sher, Chapter 656, Statutes of 2001) prohibits any person, except as specified, on and after July 1, 2002, from selling at retail or supplying a mercury fever thermometer, as defined, to a consumer or patient in the state, except by a prescription.
Federal
Under certain Federal environmental statutes, such as the Clean Air Act, Clean Water Act, and Resource Conservation and Recovery Act, the USEPA has the responsibility to develop regulations to control some mercury emissions to air, water, or from wastes and products.
On June 24, 1998, the American Hospital Association (AHA) and the USEPA signed a landmark agreement identifying goals to reduce the impact of health care facilities on the environment.
Other States
More than a dozen states have passed comprehensive legislation aimed at reducing the amounts of mercury in their states. Health Care Without Harm-an international health care coalition-promotes the passing of ordinances and resolutions banning the manufacture, sale, and distribution of mercury-containing devices. Such legislation supports mercury elimination practices already in place all over the country, from local mercury fever thermometer exchanges to major health care institutions' efforts to replace their mercury-containing devices with effective and safer alternatives.
PERFORMANCE
Two independent studies have found significant accuracy problems associated with mercury thermometers, with 53 percent of new mercury thermometers inaccurate by at least ± 0.1 degree C. [9] The American Society for Testing and Materials (ASTM) standard for glass/mercury medical thermometers specifies a maximum allowable error of ± 0.1 C in the cited range. [10]
A study of 444 mercury sphygmomanometers (blood pressure monitors) found accuracy problems, with 55 percent showing zero level between 10 and 20 mm Hg (mercury), and 38 percent had dirty columns that obscured readings. [11]
Peer-reviewed studies show that electronic and aneroid sphygmomanometers (non-mercury) are accurate within acceptable clinical practice limits if calibrated regularly according to manufacturer directions. [12] Mercury-free blood pressure measuring devices have been used by most major medical facilities and accepted by medical personnel for many years.
AVAILABILITY
Mercury-free medical supplies are available from a variety of manufacturers. A list of resources is provided on page eight in "Eliminating Mercury in Hospitals," USEPA Environmental Best Practices for Health Care Facilities, November 2002.
The Sustainable Hospitals Program (SHP) provides technical support and lists of alternative products to the health care industry for selecting products and work practices that eliminate or reduce occupational and environmental hazards, maintain quality patient care and contain costs. They support and collaborate with health care institutions, clinicians, unions representing health care practitioners, students, and government, as well as environmental and health care advocacy groups.
COST
Note: The following discussion on cost is general and is not meant to reflect specific contracts or to supersede existing mandates or policies.
Although individual mercury-free products may cost more than conventional products, the overall costs associated with mercury products are much higher. A "mercury management policy" and spill response plan must be developed for facilities that use mercury-containing devices. Employees who clean up mercury spills must receive annual training and the proper equipment. Health care facilities using mercury-containing products must face these additional costs. When spills do occur, not only is there the risk of occupational exposure, but also cleanup costs often amount to thousands of dollars. Mercury disposal is expensive and few disposal options are truly risk free. Mercury-contaminated waste that is handled by a hazardous waste hauler can end up in a hazardous waste incinerator, resulting in mercury emissions to the environment. [13]
Health care facilities can avoid the mercury risk altogether by using non-mercury alternatives. Safe, effective alternatives exist for nearly all traditional health care uses of mercury, from temperature and blood pressure measurement to fixatives used in the lab.
Because of health and safety considerations and the environmental impact of mercury, any hospital that stores and uses mercury-containing devices within its facility is required by federal regulations to be prepared to handle mercury spills. [14]
SPECIFICATIONS
California
The Procurement Engineering Team of the Procurement Division of the Department of General Services develops and reviews specifications for statewide commodity standards and information technology. If you have questions regarding developing specifications, contact the team.
Tips for Writing Specifications
Sample Language
INFORM, Inc. is an independent nonprofit research organization that examines the effects of business practices on the environment and on human health. Its goal is to identify ways of doing business that ensure environmentally sustainable economic growth. INFORM's reports are used by government, industry, and environmental leaders around the world.
Recommended specification from INFORM:
"As part of [state's] efforts to reduce the use and disposal of mercury and mercury containing products, the [state] has determined that any contracts resulting from this solicitation must meet the following requirements:
- In their response, Bidders must offer mercury-free alternatives to all products which contain intentionally added mercury (mercury added products) where such alternatives exist.
- Should such alternatives not be available, bidders must submit with their response a list of products without mercury-free alternatives and an explanation of why alternatives are not available.
- Following a contract award, contractors must not sell any mercury added products, even if they have received a direct request from a contract user, unless they have submitted a written request and received written prior approval from the [procurement office].
"Additionally, it is desirable that Bidders offer:
- A proposal for a collection system to ensure recycling or proper disposal of mercury for any product containing mercury offered for sale on this contract when no mercury-free alternative is available. This includes any mercury containing batteries (such as button batteries) that may be sold with equipment such as electronic thermometers.
- A proposal on the type of mercury reduction and/or elimination training for contract users that would be offered by the bidder.
- A description of any other efforts that the bidder would undertake as part of this contract to reduce/eliminate the sale and use of mercury containing products, as well as any mercury reduction efforts being undertaken or proposed by the bidder which are not related to this contract.
- Identification of products which contain mercury (when no mercury-free alternatives are available) to contract users at the time of purchase and delivery. This language can also be adapted if other mercury-containing components are required.
"The [purchasing office] reserves the right to remove products from this contract that have been deemed hazardous and/or unacceptable by federal/state/agency regulations and/or guidelines for their agencies or affiliate departments."
Other Specifications
Massachusetts Request for Response (RFR) HSP16 for Medical and Surgical Supplies (mercury section on page 12).
Massachusetts restricts the sale of mercury-containing products, allowing vendors to sell them only when no mercury-free substitute is available. Since spring 2001, no vendor has sold any mercury-containing product to the state. Note that in these specifications, "mercury-labeled" means "mercury-added."
United States Environmental Protection Agency Database of Environmental Information for Products and Services (Search "healthcare products")
This database contains contract language, specifications, and policies created and used by federal, state, and local governments and others to buy environmentally preferable products and services.
Wisconsin Statewide Contract for Medical/Surgical and Related Products (Contract Number: 15-47598-201)
Wisconsin restricts the sale of mercury-containing thermometers and blood pressure equipment, and reserves the right to remove other mercury-containing items from the contract.
VENDORS
Also see lists of alternative products.
California State Contracts
The California Strategic Sourcing Initiative (CSSI) allows the State of California to purchase the best products and best services for the best value. Some CSSI contracts pertain to medical supplies. Go to CSSI's News and Events Web page and select the "Contract Key Dates" link. This link connects to the latest information about tentative award dates for upcoming contracts. Please note that these contract award dates are subject to change.
The use of these contracts are mandatory for all State departments except when they purchase from a California-certified Small Business Enterprise or a California-certified Disabled Veteran Business Enterprise, in cases of emergency, or as identified in the contract.
The California Multiple Award Schedules (CMAS)
The California Multiple Award Schedules (CMAS) contracts are established using products, services and prices from already existing competitively assessed and cost compared multiple award contracts. The products, services, and prices are primarily from the federal General Services Administration (GSA) multiple award schedule program, but not exclusively. To these products, services, and prices, the Department of General Services (DGS) adds California contract terms and conditions and procurement codes and policies and establishes a totally independent California contract.
The contracts are utilized statewide by both California state and local government agencies under delegated authority from the DGS. Agencies make best value purchasing decisions according to their own business needs such as price, warranty, and supplier performance.
To search for vendors of medical supplies, visit the CMAS Basic Search Web page; click on "View Products/Services;" select the appropriate product description from the Product/Service Description list; then follow the directions at the top of the Web page to continue with your search.
Local agencies may use State procurement contracts.
SUCCESS STORIES
Mercury Elimination Leadership Program (HELP)
The Mercury Elimination Leadership Program (HELP) provides local training, onsite assistance, and state awards recognizing hospitals reaching the national goal of eliminating mercury from hospitals by 2005. As of October 2005, sixty-four acute care California hospitals have reached the goal of virtual mercury elimination and one hundred seventy-six have pledged to reach this goal.
Hospitals for a Healthy Environment (H2E)
Each year, H2E recognizes the efforts and achievements of Partner health care facilities and Champions of H2E with national recognition. The application process is simple, and the benefits of national recognition are many.
RESOURCES AND WEBSITES
California Integrated Waste Management Board (CIWMB)
Sacramento, CA
(916) 341-6000
The CIWMB's mission is to reduce waste, promote the management of all materials to their highest and best use, and protect public health and safety and the environment, in partnership with all Californians.
Health Care Without Harm (HCWH)
Arlington, VA
(703) 243-0056
Health Care Without Harm is an international coalition of hospitals and health care systems, medical professionals, community groups, health-affected constituencies, labor unions, environmental and environmental health organizations and religious groups.
Hospitals for a Healthy Environment (H2E)
Washington, DC
(800) 727-4179
The H2E is a voluntary program designed to help health care facilities enhance work place safety, reduce waste and waste disposal costs, and become better environmental stewards and neighbors.
INFORM
New York, NY
(212) 361-2400
INFORM, Inc. is an independent nonprofit research organization that examines the effects of business practices on the environment and on human health.
Mercury Elimination Leadership Program (HELP)
(800) 700-5854 or (916) 322-3670
The HELP program provides local training, onsite assistance, and state awards recognizing hospitals reaching the national goal of eliminating mercury from hospitals by 2005.
HELP is a joint effort of the Department of Toxic Substances Control, the Department of Health Services, the California Healthcare Association, USEPA Region IX, Hospitals for a Healthy Environment (H2E), California Water Environment Association (CWEA), and Publicly Owned Treatment Works (POTW). This joint effort is supporting the national goal set by the American Hospital Association (AHA) and the USEPA to virtually eliminate health care wastes that contain mercury by the year 2005.
Minnesota Pollution Control Agency (MPCA)
St. Paul, MN
(651) 296-6300 or (800) 657-3864
Many businesses use products containing mercury, but may not realize it. Learn why mercury is a concern, how to properly manage mercury, and what alternative products exist.
The MPCA Business Assistance program provides the following services: phone assistance and referrals, printed materials, workshops and presentations, financial assistance, facilitation, and recognition and promotion of success stories.
Office of the Federal Environmental Executive (OFEE)
Washington, DC
(202) 564-1297
As part of its broader mission to promote sustainable environmental stewardship throughout the federal government, the OFEE promotes the acquisition of recycled-content, environmentally preferable, and biobased products. Visit the OFEE's Web site for "Priority Chemicals - Mercury" for information on mercury. Additionally, the Web site highlights success stories in environmental procurement, recycling, and waste prevention.
Sustainable Hospitals Program (SHP)
Lowell, MA
(978) 934-3386
The SHP provides technical support to the health care industry for selecting products and work practices that eliminate or reduce occupational and environmental hazards, maintain quality patient care and contain costs.
United States Environmental Protection Agency (USEPA)
Washington, DC (202) 272-0167
Their mercury site provides a broad range of information: actions by the USEPA and others, including international actions; effects on people and the environment; and how to protect you and your family.
END-OF-LIFE MANAGEMENT
Discarded thermometers, sphygmomanometers (blood pressure monitors), esophageal dilators and weighted tubing that contain mercury are regulated as hazardous waste under the Department of Toxic Substances Control's (DTSC) Universal Waste program. DTSC's Web site provides information about the Universal Waste program, mercury waste classification and management.
[1] Portions of this web page were adapted from the Why Mercury? web page published by the Hospitals for a Healthy Environment. Retrieved December 13, 2005 from http://www.h2e-online.org/about/mercury.htm (offline).
[2] Hospitals for a Healthy Environment. Why Mercury? Web page. December 2005. Available at: http://www.h2e-online.org/about/mercury.htm (offline).
[3] Letter from E. Lowry of the Department of Toxic Substances Control to Publicly Owned Treatment Works. Subject: Participation in California's Mercury Elimination Leadership Program. November 4, 2002. Available at the Department of Toxic Substances Control.
[4] United State Environmental Protection Agency, Mercury Study Report to Congress, Vol. II: An Inventory of Anthropogenic Mercury Emissions in the United States, December 1997, page ES-4. Available at: www.epa.gov/ttn/oarpg/t3/reports/volume2.pdf
[5] Ibid., page ES-4. Available at: www.epa.gov/ttn/oarpg/t3/reports/volume2.pdf
[6] United States Environmental Protection Agency, Characterization of Products Containing Mercury in Municipal Solid Waste in the United States, 1970 to 2000. USEPA, EPA530-R-92-013, April 1992. Available at: www.p2pays.org/ref/03/02026.pdf
[7] Glass et al., 1999; Lores et al., 1998; Miles and Fink, 1998; Monson and Brezonik, 1998; Watras et al., 1998; Mason and Sullivan, 1997. From Water Quality Criterion for the Protection of Human Health: Methylmercury, EPA-823-R-01-001, January 2001, page 6-1 http://www.epa.gov/waterscience/criteria/methylmercury/pdf/merc45.pdf
[8] Committee on Toxicological Effects of Methylmercury, Toxicological Effects of Methylmercury, National Research Council, National Academy Press, Washington, DC:, 2000. Available from: www.nap.edu/books/0309071402/html/
[9] Leick-Rude, M.K. and Bloom, L.F. "A Comparison of Temperature-Taking Methods in Neonates." Neonatal Network. Volume 17, Number 5, 1998, pp. 21-37.
Mayfield, S. R. et al. 1984. "Temperature Measurements in Term and Preterm Neonates." Journal of Pediatrics. Volume 104. Number 2. Pages 271-275 as cited in Leick-Rude, M.K. and Bloom, L.F. 1998.
[10] American Society for Testing and Materials. E667-98 (2003), Specification for Clinical Thermometers, Maximum Self-Registering, Mercury-in-Glass, American Society for Testing and Materials. E1112-00 Standard Specification for Electronic Thermometer for Intermittent Determination of Patient Temperature. Available from: http://www.astm.org/
[11] N.D. Markandu, F. Whitcher, A. Arnold and C. Carney. "The Mercury Sphygmomanometer Should Be Abandoned Before It Is Proscribed." Journal of Human Hypertension. Volume 14, 2000, pp. 31-36.
[12] N.D. Markandu, F. Whitcher, A. Arnold and C. Carney. "The Mercury Sphygmomanometer Should Be Abandoned Before It Is Proscribed." Journal of Human Hypertension. Volume 14, 2000, pp. 31-36.
V.J. Canzanello, P.L. Jensen and G.L. Schwartz, "Are Aneroid Sphygmomanometers Accurate in Hospital and Clinic Settings?" Archives of Internal Medicine, March 12, 2001, pp. 729-731
[13] Hospitals for a Healthy Environment. The Cost of Mercury Management. Why Mercury? Web page. Retrieved December 13, 2005 from http://www.h2e-online.org/about/mercury.htm (offline).
[14] United States Environmental Protection Agency. Eliminating Mercury in Hospitals, United States Environmental Protection Agency Environmental Best Practices for Health Care Facilities, November 2002. Available at United States Environmental Protection Agency.
Special Note: Portions of the Environmentally Preferable Purchasing Best Practices Manual were borrowed or adapted from the Environmentally Preferable Purchasing Guide published by the Solid Waste Management Coordinating Board of Minnesota.
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