Knowledge and awareness of mercury disposal among health care providers

Mercury is considered to be a powerful neurotoxin which leads to mercury poisoning. Mercury can harm us in many ways. Mercury vapour can harm the nervous system in newborn babies and can further lead to cough, tremor and irritability. Being a healthcare provider, it is necessary to know about mercury spill management. To assess the awareness and knowledge of mercury spill management among healthcare providers, an online based survey was created using google forms. The students were asked to answer 10 questions based on mercury spill management and its usefulness. 100 students actively participated in the survey. Correlation analysis was done by chi square test using SPSS software. The results were analysed by Spss software. From the correlation, only 18% of the students in first year, 6% of the students in second year, 2% of the students in third year, 4% of the students in fourth year and 5% of the students in final year were aware of the side effects of mercury with the p value of 0.879 which is statistically insignificant . Similarly, 26% of the first year students, 7% of the second year students, 4% of the third year students, 8% of the fourth year students and 7% of the final year students were aware that hypochlorite solution is used to wipe the mercury spill with p value of 0.323 which is statistically insignificant. On analysing the data it was found that healthcare providers had only little knowledge on mercury spill management. Many healthcare providers were aware of the side effects of mercury and some students were aware of its management. This survey in the current scenario is of utmost importance to reduce exposure of mercury among healthcare providers.


INTRODUCTION
Mercury is found in a variety of medicinal devices. Mercury is considered as a powerful neurotoxin which leads to mercury poisoning (Clevenger et al., 1997). Mercury vapour can harm our system in newborn babies and can lead to cough,irritability and memory loss, so protection against it is a must (Rennie, 1999). Salts of mercury are corrosive to eyes,nose and GIT (Clarkson and Magos, 2006). Nature of mercury is that it forms small globules on exposure. Mercury is not absorbed readily from skin and it does evaporate at room temperature. Inhalation of mercury vapour is very harmful and can lead to death in severe cases (Langley, 2013).
Mercury spill kit is used to avoid the exposure of mercury spills (Baughman, 2006). Mercury spill management is carried out in implementation mercury disposal practice to help minimise the exposure of workers, patients and environment to toxic      mercury (Azziz-Baumgartner, 2007). Mercury spill kits are essential for mercury spill and breakages. It is mandatory for each medical personnel to have two or three kits and should be replaced once after use (Goldman and and, 2001). Management of mercury includes constructing safe mercury storage facilities, adopting preventive measures, safe handling procedures, mercury spill cleanup kits and also use of proper PPE during spill cleanup      cleanup (Spiegel and Veiga, 2010). There are four major steps in mercury spill management which are evacuating the area immediately, putting on face masks, changing clothes which have spilled on them and removing jewellery (Ishigaki and Yanase, 2016).
Dental professionals are exposed to mercury on a daily basis. Dental amalgam, thermometer and sphygmomanometer used by medicinal staff contain mercury in them (Babu, 2011). Mercury spill management includes use of personal protective equipment, covering the papilloma with newspaper or blotting paper, wiping the spill with hypochlorite solution and spills should be placed in biohazards bag and safe disposal (Ceaser, 2003). Educating healthcare providers about the protocol for mercury devices, mercury spill management and its disposal is necessary.  Numerous researches have been conducted by our team in various ields. Studies have been conducted in cancer biology, which includes breast cancer (Gan, 2019), hepatic carcinoma (Jainu et al., 2018), laryngeal cancer (Wang, 2019), oral cancer (Rengasamy, 2018;G and R, 2018), and thyroid cancer (Ma, 2019) etc. Studies are also focussed on metabolic disorders (Ponnulakshmi et al., 2019;Shukri, 2016), herbal medicines (Chen, 2019;Menon et al., 2016), active constituents (Li, 2020;Mohan et al., 2015), nanoparticles (Wu, 2019;Ke, 2019) and protein characterization (Rengasamy, 2016). The aim of the research was to assess and improve the knowledge about mercury spill management among healthcare providers to overcome the hazards to mercury spill.

MATERIALS AND METHODS
The study was conducted among healthcare providers in Chennai. The sample size was 100. The survey was conducted through an online basis and the questions asked were close ended questions. Questions included in the survey were based on mercury spill management and its hazards. A questionnaire composed of 10 questions (Figure 1) was prepared and circulated using an online platform google forms. The responses were collected and analysed. Correlation analysis was done by chi square test using SPSS software. Method of representation of data was done using bar graphs. Statistical software used was Spss. Statistical test used was the chi square test.

RESULTS AND DISCUSSION
The response of the survey was collected and tabulated in the form of bar graphs. When inquired about the awareness of the mercury spill management among healthcare providers, 98% of the participants responded. Correlation analysis was done by chi square test using SPSS software. It was disappointing to ind that healthcare providers had mere knowledge about the mercury spill management.
The response of the survey was collected and the table later in the form of a bar graph. It was disappointing to know the healthcare providers had very little knowledge about mercury spill management and its uses. The questions were many focused on mercury spill management, its uses and hazards of mercury spills. In the present study, 71.6% of the students were aware that mercury is used in a variety of medicine and devices while 28.4% of the healthcare providers were not aware of it [ Figure 2]. The x axis represents the uses of mercury and y axis represents the number of responses. 71.6% were aware and 28.4% was not aware.
In the current study 8.8% of the healthcare providers believed that mercury vapours causes cough, while 31.4% believe that it causes irritability, 25.5 % of the students believed that mercury vapour causes memory loss, while 34.3 % believes all three cough, irritability and memory loss [ Figure 3]. The X axis represents side effects of mercury and Y axis represents the number of responses. 8.8% cough, 31.4% irritability, 25.5% memory loss and34.3% believe all of the above.
64.7% of the students believe that mercury is easily absorbed in the skin, while the other 35.3% believe that mercury does not get absorbed in the skin [ Figure 4]. The axis represents the nature of mercury and Y axis represents the number of responses. 64.7% of them believe it absorbs in the skin and 35.3% opposes it. 60.8% of the healthcare providers were aware of mercury spill management while 39.2% were not of mercury spills management [ Figure 5]. The X axis represents the awareness and Y axis represents the number of responses. 60.8% of them were aware and 39.2% of them were not aware.
7% of the students believed that we are supposed to wipe the mercury spill with alcohol, while 34.3% of the students believe the phenyl was used to write the mercury spill and 52% were aware hypochlorite solution is used to wipe the mercury spill 7 % of students believed neither alcohol, phenols or hypochlo-rite solution is used [ Figure 6]. The X axis represents the cleaning of mercury spill and Y axis represents number of respiratory.7% believes with alcohol, 34.3% believes phenyl, 52%believes hypochlorite solution and 7% believes none of the above.
12.7% of the students believed that mercury seen only in dental amalgam while 40.2% believed that mercury is seen in sphygmomanometer, 16.7% believe in thermometer and only 30.4% of the study where are there that mercury is found in dental amalgam, sphygmomanometer and thermometer [ Figure 7]. The X axis represents the materials in which mercury is found and Y axis represents the number of responses.12.7% believed dental amalgam, 40.2% believes sphygmometer, 16.7% thermometer and 30.4%believes all of the above.
In the current study for the prevention of exposure to mercury spill, 10.8% believes PPE, 29.4 % believes mercury spill management and 59.8% believes both [ Figure 8]. The X axis denotes the materials by which materials by which exposure of mercury can be prevented and Y axis denotes the number of response.10.8% believes PPE, 29.4 % believes mercury spill management and 59.8%believes both.
For the corrosiveness of mercury, 31.4% believe skin, 63.7% nose and 4.9% believes teeth [ Figure 9]. The X axis represents the part affected due to the corrosive nature of mercury and Y axis represents the number of responses.31.4% believe skin, 63.7% nose and 4.9% believes teeth.
For the awareness of the protocol for mercury spill management, 43.1% of the students were aware and 56.9% were not aware [ Figure 10]. The X axis represents the awareness and Y axis represents the number of responses. 43.1% saids yes and 56.9% says no.
For the training in mercury spill management, 50% of the dental students have been trained and 50% has not been trained [ Figure 11]. The X axis represents the training awareness while Y axis represents the number of responses. 50% of the dental students have been trained and 50% have not been trained.
Chi square test was done in comparison with the gender of the respondents. The graph showed only 18% of the females and 17% of the males were aware of the side effects of mercury Figure 12 shows that The X axis represents gender while Y axis represents the number of responses. Blue colour denotes cough, green colour denotes irritability, beige colour denotes memory loss and purple colour denotes all of the above. Majority of the females (18 partici-pants) were aware that cough, irritability and memory loss are the side effects of mercury spill. However the difference in awareness among males and females is not statistically signi icant.
(Pearson chi square value= 0.935, p value 0.427 (> 0.05) is statistically not signi icant.. The association shows that 29% of the males and 24% of the females were aware that hypochlorite solution is used to wipe the mercury spill Figure 13 shows that X axis represents gender and Y axis represents the number of responses. Blue colour denotes the alcohol, green colour denotes phenyl, beige colour denotes hypochlorite solution and purple colour denotes none of the above. Majority of the males (29 participants) were aware that sodium hypochlorite is used for cleaning mercury spill. However the difference in knowledge between the male and female is not statistically signi icant. Pearson chi square test value is 0.800, p value is 1.006 (>0.05) which is statistically not signi icant. The association showed that 29% of the females and 30% of the males were aware that the exposure to mercury can be reduced by using PPE and mercury spill management Figure 14 shows that The X axis represents the gender and Y axis represents the number of responses. Blue denotes PPE, green denotes mercury spill management and beige denotes both. Majority of the males (30 participants) were aware about the measure to avoid exposure to mercury spill. However the difference in knowledge between the male and female is not statistically signi icant. Pearson chi square test 0.173, p value is 3.507 (>0.05) which is statistically not signi icant. The association graph shows that only 17% of the females and 14% were aware that mercury is corrosive to skin Figure 15 shows that The X axis represents the gender and Y axis represents the number of responses. Blue denotes the skin, green denotes the nose, beige denotes teeth. Majority of the males (24 participants) responded that mercury is more toxic to teeth. .However the difference is not statistically signi icant. Pearson chi square value is 0.612, p value is 0.982 (>0.05) which is statistically not signi icant. The correlation shows that 37% of the male and 35% of the females were aware of the mercury spill management Figure 16 shows that The X axis represents the gender and Y axis represents the number of responses. Blue denotes the yes and green denotes no. Majority of males (37 participants) were aware about mercury spill management.However the difference in awareness between the male and female is not statistically signi icant. Pearson chi square test 0.172, p value is 0.137 (>.05) which is statistically not signi icant. Association graph depicts that only 30% of the females and 33% of the males were trained in mercury spill management Figure 17 shows that The X axis represents the gender and Y axis represents the number of responses. Blue denotes the yes and green denotes no. However the difference in awareness between the male and female is not statistically signi icant. Pearson chi square test 0.007, p value is 0.189 (>.05) which is statistically not signi icant.
Mercury is the neurotoxin which is used in medicine and devices. Medicinal personals, especially dentists deal with mercury regularly (Boening, 2000). Mercury as such is not absorbed in the skin but inhalation of its vapour is harmful (Andreescu, 2017). Use of PPE, safe disposal using hypochlorite solutions are some of the precautions for mercury spill management. Mercury is a very toxic substance, people can be exposed to it in many ways (Baughman, 2006). There are many sideeffects of mercury, in serious condition it can lead to death also. Mercury causes skin rashes, eye irritation and lung damage (Melville, 1936). Mercury spill in water leads to mercury laced ish and meat. Foetus and children are more susceptible towards mercury spill (Zahir, 2005). Among dentists, greatest potential hazard results from contamination of hands after working with fresh amalgam and mercury metal. Unawareness of dentists about mercury could be hazardous (Buchwald, 1972). Amalgam has shown to be the most versatile and durable of all restorative materials used in dental treatments. Each practitioner should realise the potential hazards associated with mercury and should practise good mercury hygiene measures (Perim and Goldberg, 1984). Mercury containing a thermometer and sphygmomanometer is preferred for medicinal use. Educating health personnel and public about correct handling of mercury and its management is necessary (Halder, 2015;Wang, 2019). Mercury spill has a signi icant impact on public health and economic value. Safe handling of mercury is of utmost importance and securely storing mercury is also necessary (Zeitz et al., 2002).

CONCLUSIONS
From the study it is evident that the healthcare providers had very little knowledge on mercury spill management, despite the fact that they deal with mercury every day. The chi square analysis showed that males were more aware about the corrosiveness of mercury and the management of mercury spill. Hence it is of utmost importance to enhance the awareness on spill management among the healthcare providers. This study will establish a future scope by creating awareness among the gen-eral population to reduce the risk of mercury spills.

ACKNOWLEDGEMENT
The author expresses their sincere thanks to Saveetha Dental College for extending full support to complete this study.