HOSPITAIS SAUDÁVEIS Sao Paulo, Brazil 12 November 2010 Susan Wilburn.pdf · HOSPITAIS SAUDÁVEIS Sao Paulo, Brazil 12 November 2010. Geneva, Switzerland and the United Nations. Regional

GO GREEN FOR HEALTH!

Susan Wilburn, MPH, BScNursing

Interventions for Healthy Environments

HOSPITAIS SAUDÁVEIS

Sao Paulo, Brazil

12 November 2010

Geneva, Switzerland

and the United Nations

Regional Office of the World

Health Organization

System of

the UNPAHOInter-American

System

Specialized

Health Agency for

the Organization

of American

States

http://en.wikipedia.org/wiki/Image:LogooasENG.png

http://en.wikipedia.org/wiki/Image:Flag_of_the_United_Nations.svg

12 November 20104 |

Outline

Global Burden of Disease from Environmental Exposures

Environmental health in health care setting

Occupational health of health workers

Climate Change and Health: Leading by example

12 November 20105 |

Public Health and Environment:

preventing disease through healthier environments

Reduce 25% of the global burden of

disease

Promote a healthier environment

– intensify primary prevention and

– influence public policies in all

sectors, so as to

– address the root causes of

environmental threats to health

Health impact assessment and

environmental burden of disease

Environmental health of the health

sector

Occupational health

Chemical Safety

Water, sanitation and health

Children's environmental health

Air pollution (in and outdoors)

Radiation safety

Climate change and health

12 November 20106 |

12 November 20107 |

Go Green for Health!

First do no harm and leading by

example

Climate Mitigation

– Energy efficiency

– Green building design

– Alternative energy generation

– Transportation

– Food

– Waste

– Water

Chemical Safety

– Pesticides

– Disinfectants and sterilants

– Mercury elimination

– Dioxin

Occupational health of health

workers

12 November 20108 |

Resolution WHA 60.26 from 2007

Workers’ Health: Global Plan of Action

Bring occupational health care to those in biggest need:

• Work towards coverage of all workers with essential interventions and basic occupational health services

• Develop human resources for occupational health:

• Train primary care practitioners

• Attract and retain human resources for workers' health

• Build capacities for basic occupational health services

Provide occupational health care for health-care workers:

• Global campaign for immunization against Hepatitis B

• National programmes for occupational health and safety of healthcare workers

12 November 20109 |

Report of the Commission on the Social Determinants of

Health and its Knowledge Network on Employment Conditions

"Social injustice is killing people on a grand scale."

Improve Daily Living Conditions

Tackle the Inequitable Distribution of Power, Money and Resources

Measure and Understand the Problem and Assess the Impact of Action

www.who.int/social_determinants/final_report/en/index.html

Knowledge Network on

Employment Conditions

Fair Employment & Decent Work

– Action Area 3: Improve working

conditions for all workers to

reduce exposure to material

hazards, work-related stress, and

health-damaging behaviours.

12 November 201010 |

Health Workers

59.2 million full-time paid health workers worldwide1

21.7 million healthcare workers in the Americas1

Women represent 70% of the health workforce2

57 countries have a critical shortage of health human

resources1

– Without a healthy, safe and motivated workforce the

public health goals of the countries cannot be met

– Working conditions have an impact on the workforce and

quality of patient care

1 WHO 2006; 2 Cameron 2006

http://creative.gettyimages.com/source/Search/100','40','1','


Global shortage of health workers

57 countries, 36 of which are in Africa

Distribution of the global health workforce


Sub-Saharan Africa:

11% of the world's population, 25% of the global burden of disease,

3% of the world's health workers, <1% of global health expenditure

Distribution of health workers by level of health and burden of disease,

WHO regions

0

5

10

15

20

25

30

35

0 5 10 15 20 25 30 35 40 45

% of global workforce

% o

f g

lob

al b

urd

en

of

dis

ease Africa

South-East Asia

Eastern Mediterranean

Western Pacif ic

EuropeAmericas


Global crisis health care workforce shortage

push and pull mechanisms

Working conditions including occupational health are an important push factor for migration and leaving the profession

Inequities and "unfair" recruiting: 45 % of new graduates in Swaziland leave the country

25% of Nurses in Zambia died in one year

IMF Structural readjustments require cuts in social spending: nurses in Kenya, Tanzania and Zimbabwe are unemployed despite need

UK “ethical recruiting” guidelines were effective for first year only

New Code of Practice for Migration


Extent to which H&S concerns influence nurses employment decisions

( 2001 ANA/Nursing World On-Line Health & Safety Survey n = 4826)

Not at all

12%

Great Extent

Moderate Extent

LimitedExtent

31%

26%31% 88% state that H&S

concerns influencetheir decision tocontinue in nursing.


Hazards to health care workers

Hepatitis B, C

Anesthetics

Cytotoxic drugs

Latex

Mercury

Radiation

Noise

Repetitive movements

Heat

SARS

TB

HIV/AIDS

Rubella

MeaslesJob Insecurity

Workload Technology

Sodium hypochlorite

Influenza

Glutaraldehyde

Heavy lifting

Handling patients

Occupational &

environmental

risk factors

Physical/Ergonomic Chemical

Biological

Pesticides

Organizational,

Psychosocial

Violence

Tuberculosis

Ethylene

oxide


Hierarchy of Controls

Most effective

Least effective

Elimination

Substitution

Engineering Controls

Administrative Controls

Work Practice Controls

Personal Protective Equipment


Complete removal of a hazard from the work area

Preferred method to control hazards and should be selected

whenever possible

EXAMPLE:

Elimination

Needleless IV Systems

“Latex Free”

Environment


Kazakhstan: Doctors, and

a Medical Procedure, on Trial in Kazakhstan

"It's insane. This kid needed no blood”,

Dr. Michael O. Favorov, CDC's Central Asia

program director who headed the outbreak

investigation, said of one HIV-infected infant. The

eight-month-old was given 25 unnecessary blood

transfusions, according to court documents.

Ilan Greenberg, New York Times (20.03.07)


Replacing a conventional material or process with a less harmful alterative.

EXAMPLE:

– Glutaraldehyde – typically used as a cold sterilant to disinfect heat-sensitive equipment such as endoscopes, can cause asthma, conjunctivitis, & dermatitis. Less toxic disinfectants are equally effective and reduce the potential for adverse effects.

Substitution


Removing or isolating a hazard through technology.

This measure focuses on the source of the hazard or the pathway of

transmission.

EXAMPLE:

Engineering Controls

Ceiling-Mounted Lift


Policies aimed at limiting worker exposure to a hazard, typically

accomplished through work assignments

EXAMPLE:

– Workplace Violence: To prevent a patient from assaulting a nurse, staff

members may work in pairs when providing care to or transporting a

patient on a psychiatric unit. The presence of multiple staff members may

discourage patients from attacking.

Administrative Controls


Reduce exposure to occupational hazards through the behavior of workers.

Example:

Work Practice Controls

Prohibiting Recapping

Used/Contaminated

Needles

Pouring cleaning agents

instead of spraying them to

avoid airborne exposure


Clothing & equipment designed to be a barrier between worker and

hazard

Least effective measure of control

Should be last option when trying to reduce worker exposure, since it

doesn’t control the hazard itself

EXAMPLE:

Personal Protective Equipment

Gowns, gloves, masks, and

eye shields when caring for

a patient with SARS

Adapting the definition from the

Safe Injection Global Network (SIGN):

“A safe health care practice does no

harm to the recipient, does not expose

the provider to any avoidable risk, and

does not result in any waste that is

dangerous for other people”


“Be sure to secure your own oxygen mask first before helping another.”


Occupational Exposure to Bloodborne Pathogens

Acidentes de trabalho com material biológico

Situação Mundial

2 million exposures per year

In Healthcare workers:

37% of Hepatitis B

39% of Hepatitis C

4.4% of HIV

Are due to needlestick injuries

Although only 1,000 hcw deaths per year from occupational HIV, all can and should be prevented!

And fear/stigma affects care and migration

WHO Environmental Burden of Disease, 2003

Risk of Virus Transmission

Following Percutaneous Injury

Virus Chance of HCW InfectionHBV 6 – 30 out of 100 people

HCV 3 – 10 out of 100 people

HIV 1 out of 300 people


Hierarquia dos controles aplicados ao risco de

exposição a patógenos transmissíveis pelo sangue

Elimination or substitution of sharp (eliminate

unnecessary injections, jet injectors,

needleless IV systems, blunt suture needles)

Engineering Controls (A-D syringes, safer

needle devices, sharps containers)

Administrative (policies and training

programmes)

Work Practice Controls (Universal

Precautions, no recapping, provision &

placement & removal of sharps containers)

Personal Protective Equipment (gloves,

masks, gowns, etc)

See www.who.int/hiv/pub/prev_care/healthservices/en/index.html

Annex 4

Eliminação do perigoEliminação total

de um perigo da área de trabalho. A

eliminação constitui o método

preferencial de controlo dos riscos,

devendo ser seleccionado sempre que

possível. Exemplos: remoção de

objectos cortantes e perfurantese

agulhas e eliminação de todas as

injecções desnecessárias. Algumas seringas e agulhas podem ser substituídas

por dispositivos de injecção sem agulha.

Controlos técnicos Controlos que isolam ou

removem um perigo de um local de trabalho.

Controlos administrativos Políticas que

visam limitar a exposição ao perigo,tais como

as precauções universais

Controlos relativos às práticas de trabalho

Equipamento de protecção individual (EPI)

http://www.who.int/hiv/pub/prev_care/healthservices/en/index.html


Decline in HBV Cases Among Healthcare

Workers Following Vaccination

0

4'000

8'000

12'000

16'000

20'000

1983 1991 1995

OSHA mandates HBV vaccination

17,000

800

This regulation had the greatest impact in eliminating

HBV transmission among healthcare workers.

Mahoney F et al. Archives of Int Med 157 (1997): 2601-2603


But . . . Over 80% of Healthcare Workers Remain

Unimmunized in many parts of the world

Despite 95% Efficacy

of HBV

Immunization


Fraction of HCV, HBV, HIV by Region


WHO-ICN Protecting Healthcare Workers –

Preventing Needlestick Injuries project

Prevention of needlestick injuries in health care workers, to prevent infection with HIV and Hepatitis B and C, a collaborative effort lead by WHO and ICN, in close coordination with ILO

Pilot in South Africa, Tanzania, and Vietnam resulting in development of new tool kit, expansion throughout southern Africa, Egypt and Venezuela

Key elements– National collaborative planning (OH, NNA,

MOH)

– Assessment of products, practices then implement surveillance

– Needlestick prevention committee (using data for prevention)

– IEC, control measures, supplies (sharps containers, PPE, safer devices)

– HBV Immunization, PEP and Treatment


Hepatitis B Immunization Campaign –

Peru goes first


Protecting health-care workers in Egypt


REPORTING IS IMPORTANT including near misses

Reporting Ensures

Proper treatment & follow-up

Financial compensation, if necessary

Engineering or procedure changes


Dramatic increase in incidence of Tuberculosis

Incidência Estimada de Tuberculose por 100.000 Habitantes em

Países Africanos em 1990 e 2005Dados da Organização Mundial da Saúde - Fonte: Chaisson et al 2008


Estimated HIV prevalence in new TB cases, 2006

No estimate

0–4

20–49

50 or more

5–19

HIV prevalence in

TB cases, (%)

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the

part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning

the delimitation of its frontiers or boundaries.

Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

WHO 2006. All rights reserved


Joshi et al. PLoS Med 2006

Health care workers are at risk of infection

and TB disease


Joint WHO-ILO-UNAIDS policy guidelines

for improving health worker access to HIV

and TB prevention, treatment and care

• Reinforce existing joint

guidelines and update

with new guidelines for

TB infection prevention

and control, 3 I’s

(intensified case finding,

IPC, Isoniazid preventive

therapy

• Links to global framework

for national occupational

health programmes for

health workers

• 2 year development with

30 countries participating

in process (Presentations

on systematic review and

14 statements in French)

• 21 countries surveyed

• Expert guidelines and

tripartite review

• Launch 25 November

2010 in Geneva



Health Care Workers

Chemical Hazards

Latex allergies

– gloves

Ethylene oxide

– sterilization

Nitrous oxide

– anesthesia

Toxic chemicals

– Disinfectants

– Drug handling: antineoplastic and antiretroviral

– Lab workers: formalin

– Mercury

– Cleaning agents

NURSES’ HEALTH

A Survey on Health & Chemical Exposure

The 2006 online survey was designed to assess the relationships between nurses' health and their exposures to 11 different common health care hazards.

• Impact: – Support for the launch of

the NIOSH Occupational Exposure Survey

– Highlighted NORA and European Respiratory Disease research linking health workers to asthma

http://www.nursingworld.org/

http://nursingworld.org/

http://images.google.com/imgres?imgurl=http://www.amia.org/meetings/f06/images/umaryland.jpg&imgrefurl=http://www.amia.org/meetings/f06/nisymposium.asp&h=58&w=105&sz=2&hl=en&start=4&tbnid=TZutawh8nup3ZM:&tbnh=46&tbnw=84&prev=/images?q=university+of+maryland+school+of+nursing&gbv=2&hl=en&ie=UTF-8

Some of the Known Hazards

• Chemotherapeutic Drugs

• Mercury

• Waste Anesthetic Gases

• Laser & Electrocautery Smoke

• Disinfecting and Sterilizing Agents

– Glutarlaldehyde and Ethylene Oxide

• Pesticides, Cleaners & Fragrances

• Latex products

Reasons to Eliminate

Glutaraldehyde

• Potent occupational skin irritant and sensitizer

• Causes occupational asthma

• Employees, patients and visitors may be needlessly exposed in patient rooms or clinic areas where soak pans are not covered

• Exposure limits set by regulators make substitution a practical option

Nurses’ Survey Finding ~

Sterilization & Disinfectant Agents

Glutaraldehyde

• 52 percent of more than

1,500 nurses surveyed

reported on-the-job

exposures. Nurses with

frequent, long-term

exposures to glutaraldehyde

(at least weekly for at least

ten years) reported 46

percent higher rates of

asthma than other nurses.

http://images.google.com/imgres?imgurl=http://www.emsdiasum.com/microscopy/products/chemicals/images2/16300.jpg&imgrefurl=http://www.emsdiasum.com/microscopy/products/chemicals/glutaraldehyde.aspx&h=158&w=240&sz=10&hl=EN&start=3&tbnid=ZUxTmUdkS907bM:&tbnh=72&tbnw=110&prev=/images?q=glutaraldehyde+&gbv=2&hl=EN&sa=G

Royal College of Nurses (RCN)

Case Study in Advocacy• RCN identifies nurses with asthma related to exposure to

glutaraldehyde

• RCN represents nurses before compensation board to provide benefits

• RCN works to achieve safe exposure limits in 1999 (0.05 ppm) and to identify alternatives

• RCN educates occupational health representatives about the hazard and alternatives in 2000.

• RCN receives best practice award from National Health Trust for implementation of alternatives

• Manufacturer pulls glutaraldehyde off the market in the UK in 2002

Alternatives to Glutaraldehyde

• Substitute peracetic Acid/hydrogen

peroxide(H2O2)

• Sterris

• Sterrad

• CIDEX OPA Solution (0.55% ortho-

phthalaldehyde)

Nurses’ Survey Finding ~

Sterilization & Disinfectant Agents:

Ethylene Oxide

• 29 percent of more than 1,500 nurses surveyed reported on-the-job exposures. Nurses with frequent, long-term exposures to ethylene oxide (at least weekly for at least ten years) reported 45 percent higher rates of asthma than other nurses.

Reasons to Eliminate

Ethylene Oxide (EtO) • Known human carcinogen and probable

teratogen

• Inhaled EtO can cause nausea, vomiting and

neurological disorders

• In solution EtO can cause severe irritation and

burns to eyes, skin and lungs

• EtO may damage central nervous system,

kidneys, and liver

Alternatives to Ethylene Oxide

• Steris (just in time)

• Sterrad

http://www.sterrad.com/products_&_services/sterrad/index.asp

Latex Allergy

• Up to 12% health care professionals

allergic to latex

• Reactions to latex can range from

dermatitis to anaphylaxis

• Glove powder also problem

• Barrier protection needs

Glove Selection

• Barrier protection

– What is use?

– Viral barrier

– Bacterial barrier

– Chemical barrier

• Durability

Health Effects

– Latex allergy (type I)

– Additives allergy (IV)

– Powder

• Comfort and fit

– Flexibility

– Resilience

Reasons to Control Pesticides,

Cleaners and Fragrances (VOCs)• A surprising number of volatile organic compounds are

found in these chemical products

• VOCs accumulate and can contribute to poor overall indoor air quality (IAQ)

• EPA estimates that poor IAQ is one of the top five public health environmental risks

• Patients are particularly vulnerable to IAQ as they are already physically compromised and/or have chemical sensitivities

• JCI has expressed concern over the increasing number of respiratory problems in HCWs

What We Can Do

• Work with institutions to use the least toxic alternatives, negotiate environmentally preferable product selection

• Ensure Safety Data Sheets are available for all chemicals in use on all units and staff are trained according to the OSHA Right to Know Standard

• Join or start a “Green Team”!

• Encourage the use of EPP

• Help individuals keep away from the most toxic exposures, especially women of childbearing age

What We Can Do (2)

• Learn more!

• Advocate for governmental protections from

toxic chemicals: national and state policies,

exposure limits, precautionary policies

• Work with nursing, medical and other healthcare

associations to advance the goal of a healthy

environment


The face of climate change ?


WHO Climate and Health WHO Executive Board Report 124.R5, 22 January 2009:

Objective 4. Strengthen health systems to cope with the health threats posed by climate change, including emergencies related to extreme weather events and sea-level rise

– Action 4.4: “In addition, the development of programmes for health systems that will contribute to reducing their own greenhouse gas emissions will be supported.”

Objective 1. Advocacy and awareness raising.

“… Improved awareness will help health-sector professionals to provide leadership in supporting rapid and comprehensive strategies for mitigation and adaptation that will both improve health and reduce vulnerability.”

Action 1.1 Development of tools, guidance, information and training packages to support awareness and advocacy campaigns to protect health from climate change at national and regional levels. This action will target different population groups, especially health professionals.

Action 1.2 Develop and run a global awareness-raising and advocacy campaign aiming to put health at the centre of the climate change mitigation and adaptation agenda at the international level.


Policies that cut greenhouse gas emissions

can also reduce:

The 800,000 annual deaths from urban air

pollution, and the 1.5 million from indoor air

pollution

The loss of 1.9 million lives, and 19 million years

of healthy life, from physical inactivity

The 1.2 million deaths and over 50 million injuries

from road traffic accidents

-WHO, 2002, 2006

Highlighting the potential for immediate, local and large health

cobenefits



4. Mitigation: leading by example

Healthy hospitals –healthy planet: How the health sector can

reduce its climate footprint


Seven elements of a climate-friendly hospital

1. Energy efficiency – Reduce hospital energy consumption and costs through efficiency and conservation measures.

2. Green building design – Build hospitals that are responsive to local climate condtions and optimized for reduced energy and resource demands.

3. Alternative energy generation – Produce and/or consume clean, renewable energy onsite to ensure reliable and resilient operation

4. Transportation – Use alternative fuels for hospital vehicle fleets; encourage walking and cycling to the facility; promote staff, patient and community use of public transport; site health-care building to minimize the need for staff and patient transportation

5. Food – Provide sustainably grown local food for staff and patients

6. Waste – Reduce, re-use, recycle, compost; employ alternatives to waste incineration

7. Water – Conserve water; avoid bottled water when safe alternatives exist


Opportunities for Action:

health-care facility examples

Energy efficiency – Reduce hospital energy consumption and costs through efficiency and conservation measures. Brazil: 101 hospitals in Sao

Paulo cut energy use by 25%

Mexico: Centro Medico Nacional La Raza education to turn off lights, computers

Alternative energy generation –Produce and/or consume clean, renewable energy onsite to ensure reliable and resilient operation

– Liberia

– Tanzania (shown – off grid electricity with solar panels)


Green building design – Buildhospitals that are responsive to local climate conditions and optimized for reduced energy and resource demands.

– Italy: Meyer Children`s Hospital consumer 35% less energy for heating and cooling and 36% less electricity than standard

– Singapore: Changi General Hospital saves US$800 000 per year

– Hong Kong: Granthan Hospital Natural Ventiliation for TB control since 1957


Transportation – Use alternative fuels for hospital vehicle fleets; encourage walking and cycling to the facility; promote staff, patient and community use of public transport; site health-care building to minimize the need for staff and patient transportation

UK Addenbrook hospital with interest-free bicycle loans and bus passes reduced cars on hospital campus by 16% and staff car use by 22%

Sweden: « eco-driving » reduced fuel use by 10% among ambulances and 50% less insurance claims


Food, waste, water

Food – Provide sustainably grown local food for staff and patients

Waste – Reduce, re-use, recycle, compost; employ alternatives to waste incineration

Water – Conserve water; avoid bottled water when safe alternatives exist

– India Bhopal Sambhavna Trust Clinic rainwater harvesting


Global Partnership co-led by WHO and HCWH

Component of the UNEP Products Partnership

Goal:

By 2017, to phase out the demand for mercury-containing fever thermometers and sphygmomanometers by at least 70% and to shift the production of all mercury-containing fever thermometers and sphygmomanometers to accurate, affordable, and safer non-mercury alternatives.

1,000 hospitals in Asia, Africa, Latin America moving toward phase-out.

Develop and disseminate global training/train-the-trainers module.


What can nurses and doctors do?

Learn more about the health impact of climate change and prepare yourself, your health system and professional organization to recognize and care for the patients suffering ill effects

Put health in the forefront of climate discussions and negotiations

Advocate for strong national and global climate treaties

Lead by example (mitigate) to reduce your carbon footprint at home and at work


Successes

Get the lead out! Of gasoline resulted in decreased lead levels in children

NR32 enforced 18 Nov 2010

Closure of 700 medical waste incinerators led to reductions in dioxin emissions and body burden

OSHA PEL on EtO

DDT ban resulted in the Bald Eagle’s removal from endangered species list

“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”

Margaret Mead


Strengthening Institutional Capacity

WHO Global Network of CC in Occupational Health

Technical level


• Workers’ Health and Safety in the Health Sector: A Manual for

Managers and Administratorshttp://www.bvsde.ops-oms.org/sde/ops-sde/bv-saludtrab.shtml

• Comprehensive online course for healthcare workers

•Joint ILO/WHO guidelines on health services and HIV/AIDS

•Joint WHO/ILO guidelines for occupational and non-

occupational PEP (HIV)

•HIV and Global Workforce Alliance

•Treat, train and retain initiative

• Geolibrary http://www.uic.edu/sph/glakes

• Preventing Needlestick Injuries Toolkithttp://www.who.int/occupational_health/activities/pnitoolkit/en/index.html

WHO Technical Resources

http://www.bvsde.ops-oms.org/sde/ops-sde/bv-saludtrab.shtml







http://www.uic.edu/sph/glakes

http://www.who.int/occupational_health/activities/pnitoolkit/en/index.html


Obrigada

Thank you

Collaboration, Coordination,

Commitment and Cooperation

[email protected]

Documents

HOSPITAIS SAUDÁVEIS Sao Paulo, Brazil 12 November 2010 Susan Wilburn.pdf · HOSPITAIS SAUDÁVEIS Sao Paulo, Brazil 12 November 2010. Geneva, Switzerland and the United Nations. Regional