1. 30 October 2011 Mercury Instrument: Health Aspects Carolyn Vickers Public Health and Environment David Wood Immunization, Vaccines and Biologicals

2. 30 October 2011 Presentation 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

3. 30 October 2011 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

4. 30 October 2011 Health 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

5. 30 October 2011 Greatest health gains will be made by addressing the main sources of mercury UNEP para 29 study

6. 30 October 2011 Corresponding to these annexes in the draft text

7. 30 October 2011 Coal-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.

8. 30 October 2011 Residential 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

9. 30 October 2011 ASGM 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.

10. 30 October 2011 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

11. 30 October 2011 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

12. 30 October 2011 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

13. 30 October 2011 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)

14. 30 October 2011 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

15. 30 October 2011 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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17. 30 October 2011 Thiomersal 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

18. 30 October 2011 Alternative 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

19. 30 October 2011 Thiomersal-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

20. 30 October 2011 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

21. 30 October 2011 WHO 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

22. 30 October 2011 Further Information WHO INC3 Submission: INC3 website WHO chemical safety website www.who.int/ipcs/en/www.who.int/ipcs/en/ Global Tools for substitution of mercury thermometers and BPMD in health care. WHO HCWH project website www.mercuryfreehealthcare.org www.mercuryfreehealthcare.org WHO Immunization, biologicals and vaccines website: www.who.int/immunization/en/ www.who.int/immunization/en/