DR. aparna sharma dept. Of community medicine m. S. Ramaiah medical college, msrit post, bangalore



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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1.NAME OF THE CANDIDATE AND ADDRESS

DR.APARNA SHARMA

DEPT. OF COMMUNITY MEDICINE

M.S. RAMAIAH MEDICAL COLLEGE, MSRIT POST, BANGALORE

2.NAME OF THE INSTITUTION

M.S. RAMAIAH MEDICAL COLLEGE

M.S.RAMAIAH NAGAR,

BANGALORE-560054

3.COURSE OF STUDY AND SUBJECT

M.D.(COMMUNITY MEDICINE)

4.DATE OF ADMISSION TO COURSE

12-06-2013

5.TITLE OF THE TOPIC

MERCURY AUDIT IN HEALTH CARE SETTINGS OF BANGALORE

6. Brief resume of the intended work

INTRODUCTION

Mercury is a toxic heavy metal which is widely dispersed in nature. Most human exposure results from fish consumption or dental amalgam. Mercury occurs in several chemical forms, with complex pharmacokinetics. The clinical impact of smaller mercury exposures remains controversial1.

Being the only common liquid metal, its usefulness stems from its unique combination of weight, ability to flow, electrical conductivity, chemical stability, high boiling point and relatively low vapor pressure. For centuries, mercury was the ideal choice for use in medical devices that measure temperature (thermometers) and pressure (sphygmomanometers), and in other applications where density and flexibility were needed (esophageal dilators). In addition to above, mercury-containing devices and materials have been an integral part of Health Care Facility (HCF) operations for decades, for many other applications.2

Mercury poisoning has an adverse effect on the human nervous system and other body systems. Being a neurotoxin, it affects the nervous system primarily. The ‘mad hatters’ of the 19th century suffered from mercury poisoning. The Minamata tragedy which occurred due to dumping of mercury compounds by a petrochemical and plastic manufacturing unit in a small fishing village in Japan had affected 2,200 people of which over 1,000 died. Since then, mercury in the environment has been a focus of attention all across the globe especially for its health and environment risks.3

According to W.H.O policy paper, health-care facilities are one of the main sources of mercury release into the atmosphere .They are also responsible for mercury pollution taking place in water bodies from the release of untreated wastewater. Dental amalgam contains as much as 45-55% mercury. In 1991, the World Health Organization confirmed that mercury contained in dental amalgam is the greatest source of mercury vapour in non-industrialized settings. 4

The following lists show some of the common uses of mercury that may be found in hospitals.

Medical uses:


  1. Thermometers

  2. Sphygmomanometers (blood pressure monitors)

  3. Esophageal dilators (also called bougie tubes)

  4. Cantor tubes and Miller Abbott tubes (used to clear intestinal obstructions)

  5. Feeding tubes

  6. Dental amalgam

  7. Laboratory chemicals (fixatives, stains, reagents, preservatives)

  8. Batteries

  9. Pharmaceutical preservatives

Non-medical uses common in medical settings:

  1. Cleaning solutions with caustic soda or chlorine that were contaminated with mercury during the production process

  2. Batteries

  3. Fluorescent lamps and high-intensity discharge lamps

  4. Non-electronic thermostats

  5. Pressure gauges

  6. Some electrical switches used for lights and appliance 5


6.1 Need for the study

Doctors, nurses and other medical staff work with mercury-based products on a routine basis and are in danger of inhaling toxic vapour when breakages or leakages occur. Mercury free alternatives are available for almost all the products. Many countries across the world have shifted to mercury free alternatives and have proper mercury management policies.3.

It is therefore pertinent to have an effective mercury elimination program suitable for Indian health care settings to reduce mercury pollution as well as reduce the health hazards related to mercury spills. Hence this study, aims at assessing the levels of mercury in the selected hospitals of Bangalore and also to measure the awareness amongst Health care professionals regarding this.

6.2 Review of literature

In a study conducted by Toxics Link, a N.G.O., in Delhi it was found that nearly 70 thermometer breakages take place each month in a 300 to 500 bedded hospital. Data also shows that an average-sized hospital annually releases 3 kg of mercury in the environment. The dental wing of both the hospital also had very high level of mercury (3.11 µg/m3). The levels were also high in maternity and general wards thus posing substantiation risk to new born babies and patients.6

A study conducted in 12 cities by Toxic Links found the awareness on ill effects of mercury containing products to be quite low among doctors, retailers and customers. However they had issues with the use of mercury free products i.e. accuracy, availability and quality which act as hindrances to their willingness to shift. 7

In a multi-centric study conducted in New Delhi, Haryana and Uttar Pradesh, India to assess the awareness about mercury toxicity and the knowledge of proper handling and disposal of mercury-containing items in health care set–up, a questionnaire-based survey was carried out amongst health care professionals in government and corporate hospitals, overall awareness was found to be more in corporate sector.8



6.3 Research question:

What is the current status of mercury usage in health care settings?



6.4 Aim: To conduct mercury audit in health care settings of Bangalore.

6.5 Objective:

  1. To conduct a methodical examination and review of mercury containing equipment in hospitals care settings.

  2. To assess knowledge, attitude and practice regarding mercury management, hazards due to mercury and acceptance of mercury containing equipment amongst health care professionals.

7. Material and methods

7.1 Study setting- Health care settings which will include both medical and dental hospitals

7.2 Study unit – Health care settings

7.3 Inclusion criteria: Health care settings who are willing to participate in the study.

7.4 Exclusion criteria: Health care settings which have completely phased out mercury from their hospitals.

7.5 Study Design- Cross sectional study

7.6 Study period- January 2014 to December 2014

7.7 Sample Size-A study conducted in New Delhi in 2007 by a NGO Toxics Links observed that an average-sized hospital annually releases 3 kg of mercury in the environment. They reported that an average sized hospital in Delhi may record a breakage rate of 70 thermometers in a month8.

In the present study expecting similar results assuming 20 % variation with 95% confidence level and 6% relative precision, the study requires minimum 43 health care settings.



7.8 Sampling technique- Proportion probability sampling technique will be adopted. Proportionate to each category of hospital i.e. small, medium, large and dental teaching colleges, random sampling will be done based on number of hospitals in Bangalore.

7.9 Study Methodology– Proportion probability sampling method will be employed. The health care settings will be divided into the following categories: small, medium, large and dental teaching hospitals. Samples will be drawn proportionately from these categories employing random sampling.

Necessary permission will be sought from the concerned authorities in the respective health care setting before commencing the study.

Mercury Assessment in the health care facilities will be done by creating a “map” of the facility listing departments where mercury containing items is anticipated and a “checklist” of the items and their approximate mercury contents, by weight will be noted. The data will be recorded in an Excel spreadsheet. Any other item containing mercury, and not on the check-list, will be added to the list, as and when they are come across.

A pre- designed, semi-structured, pilot -tested questionnaire will be administered in the health care settings to measure the knowledge, attitude and practice regarding mercury management, health hazards related to mercury and the acceptance of mercury free equipment amongst the health care personnel.



7.10 Statistical analysis-

•Qualitative data like baseline information and distribution of responses to various items of the questionnaire will be expressed in frequency and percentages.

•Quantitative data like quantum of mercury, awareness level scores will be expressed in mean and standard deviation.

•Chi-square test of significance will be applied to test for differences in proportion.



7.11 Does the study require any investigations or interventions to be conducted on patients or other humans or animals?

No

8. REFERENCES



  1. Bernhoft R. Mercury toxicity and treatment: a review of the literature. Journal of environmental and public health. 2011; 2012. Available from URL: http://www.ncbi.nlm.nih.gov/pubmed/22235210/ [Accessed 4th Oct 2013].

  2. Babu JC. Environmentally Sound Management of Mercury Waste in Health Care Facilities. Centre for Pollution Control Board, India. 2010. Available from URL: http://cseindia.org/userfiles/Guidelines_For_Mercury.pdf [Accessed on 29th Oct. 2013].

  3. Agarwal A. Moving Towards Mercury-Free Health Care: Substituting Mercury-Based Medical Devices in India. Toxics link. 2009.

  4. World health organization. Mercury in health care, Policy Paper. 2005: WHO/SDE/WSH/05.08. Available from URL: http://www.who.int/water_sanitation_health/medicalwaste/mercurypolpap230506.pdf [Accessed 4th Oct 2013].

  5. Mercury Waste Virtual Elimination Model Plan. Maryland: U.S. Army public health command. 2010.113 p. Report No.: TG No.333. Available from URL: http://phc.amedd.army.mil/PHCResourceLibrary/FinalHospitalMercuryReductionPlan21Oct2010agg.pdf. [Accessed 1st Nov. 2013].

  6. Pastore P, Singh R, Jain N. Mercury in hospital indoor air: staff and patients at risk. New Delhi, India : Toxic links.2007

  7. Toxic Links and Health Care without Harm. Market study on alternatives of mercury measuring devices in health care in India. New Delhi, India: Toxic Links.2010.

  8. Halder N, Peshin S, Pandey R, Gupta Y. Awareness assessment of harmful effects of mercury in health care set-up in India: A survey-based study. Toxicology and industrial health. 2013; 29 (9). Available from URL: http://tih.sagepub.com/content/early/2013/05/21/0748233713488237.abstract/ [Accessed 4th Oct 2013].





9.SIGNATURE OF THE CANDIDATE

10.REMARKS OF THE GUIDE: Mercury is a very useful metal which is used widely in health care settings in our country but at the same time a very toxic substance with very toxic consequences to health care personnel. The present study will help in building evidence regarding its usage and explore for alternate replacements.


11.NAME AND DESIGNATION OF

(IN BLOCK LETTERS)

11.1. GUIDE: DR.T. HEMANTH, M.D.

PROFESSOR ,

DEPT OF COMMUNITY MEDICINE

MSRMC, BANGALORE-54

11.2 SIGNATURE

11.3. CO-GUIDE DR. ARJUNAN ISAAC, M.D.

ASSOCIATE PROFESSOR ,

DEPT OF COMMUNITY MEDICINE

MSRMC, BANGALORE-54

11.4 SIGNATURE


11.5. HEAD OF THE DEPARTMENT DR. S.P. SURYANARAYANA , M.D

PROFESSOR AND HEAD,

DEPT OF COMMUNITY MEDICINE

MSRMC, BANGALORE-54

11.6. SIGNATURE

12. REMARKS OF CHAIRMAN & PRINCIPAL

12.1 SIGNATURE




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