Mercury poisoning

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Mercury poisoning
Classification and external resources
Elemental mercury
ICD-10 T56.1
ICD-9 985.0
DiseasesDB 8057
MedlinePlus 002476
eMedicine emerg/813 
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Mercury poisoning (also known as mercurialism, hydrargyria, Hunter-Russell syndrome, or acrodynia when affecting children) is a disease caused by exposure to mercury or its toxic compounds. Mercury is a cumulative heavy metal poison which occurs in its elemental form, inorganically as salts, or organically as organomercury compounds; the three groups vary in effects due to differences in their absorption and metabolism, among other factors.[1] However, with sufficient exposure all mercury-based toxic compounds damage the central nervous system and other organs or organ systems such as the liver or gastrointestinal tract.

Symptoms typically include sensory impairment (vision, hearing, speech), disturbed sensation and a lack of coordination. The type and degree of symptoms exhibited depend upon the individual toxin, the dose, and the method and duration of exposure.

Due to its toxicity, there have been campaigns in many countries to ban mercury altogether.

Contents

[edit] Signs and symptoms

Common symptoms include peripheral neuropathy (presenting as paresthesia or itching, burning or pain), skin discoloration (pink cheeks, fingertips and toes), edema (swelling), and desquamation (dead skin peels off in layers).

Because mercury blocks the degradation pathway of catecholamines, epinephrine excess causes hyperhidrosis (profuse sweating), tachycardia (persistently faster-than-normal heart beat), mercurial ptyalism (hypersalivation) and hypertension (high blood pressure). Mercury is thought to inactivate S-adenosyl-methionine, which is necessary for catecholamine catabolism by catechol-o-methyl transferase.

Affected children may show red cheeks and nose, erythematous lips (red lips), loss of hair, teeth, and nails, transient rashes, hypotonia (muscle weakness), and photophobia. Other symptoms may include kidney disfunction (e.g. Fanconi syndrome) or neuropsychiatric symptoms (emotional lability, memory impairment, insomnia).

Thus, the clinical presentation may resemble pheochromocytoma or Kawasaki disease.

An example of desquamation of the hand of a child with severe mercury poisoning acquired by handling elemental mercury is this photograph in Horowitz, et al (2002).[2]

[edit] Causes

Mercury poisoning is caused by sufficient exposure to elemental mercury or mercury compounds. The consumption of fish is by far the most significant source of ingestion-related mercury exposure in humans, although plants and livestock also contain mercury due to bioaccumulation of mercury from soil, water and atmosphere, and due to biomagnification by ingesting other mercury-containing organisms.[3] Exposure to mercury can occur from breathing contaminated air,[4] or from improper use or disposal of mercury and mercury-containing objects, for example, after spills of elemental mercury or improper disposal of fluorescent light bulbs.[5]

Human-generated sources such as coal plants emit approximately half of atmospheric mercury, with natural sources such as volcanoes responsible for the remainder. An estimated two-thirds of human-generated mercury comes from stationary combustion, mostly of coal. Other important human-generated sources include gold production, non-ferrous metal production, cement production, waste disposal, crematoria, caustic soda production, pig iron and steel production, mercury production (mostly for batteries), and biomass burning.[6]

Mercury and many of its chemical compounds, especially organomercury compounds, can also be readily absorbed through direct contact with bare, or in some cases (such as dimethyl mercury) insufficiently protected, skin. Mercury and its compounds are commonly used in chemical laboratories, hospitals, dental clinics, and facilities involved in the production of items such as fluorescent light bulbs, batteries, and explosives.[7]

[edit] Toxic effects

Mercury damages the central nervous system, endocrine system, kidneys, and other organs, and adversely affects the mouth, gums, and teeth. Exposure over long periods of time or heavy exposure to mercury vapor can result in brain damage and ultimately death. Mercury and its compounds are particularly toxic to fetuses and infants. Women who have been exposed to mercury in pregnancy have sometimes given birth to children with serious birth defects (see Minamata disease).

Mercury exposure in young children can have severe neurological consequences, preventing nerve sheaths from forming properly. Mercury inhibits the formation of myelin, the building block protein that forms these sheaths.[8]

There is some evidence that mercury poisoning may predispose to Young's syndrome (men with bronchiectasis and low sperm count).[9]

Mercury poisoning's effects partially depend on whether it has been caused by exposure to elemental mercury, inorganic mercury compounds (as salts), or organomercury compounds.

[edit] Elemental mercury

Quicksilver (liquid metallic mercury) is poorly absorbed by ingestion and skin contact. It is hazardous due to its potential to release mercury vapour. Animal data indicate that less than 0.01% of ingested mercury is absorbed through the intact gastrointestinal tract; though it may not be true for individuals suffering from ileus. Cases of systemic toxicity from accidental swallowing are rare, and attempted suicide via intravenous injection does not appear to result in systemic toxicity.[10] Though not studied quantitatively, the physical properties of liquid elemental mercury limit its absorption through intact skin and in light of its very low absorption rate from the gastrointestinal tract, skin absorption would not be high.[11] Some mercury vapour is absorbed dermally but uptake by this route is only approximately 1% of that by inhalation.[12]

In humans, approximately 80% of inhaled mercury vapour is absorbed via the respiratory tract where it enters the circulatory system and is distributed throughout the body.[13] Chronic exposure by inhalation, even at low concentrations in the range 0.7–42 μg/m3, has been shown in case control studies to cause effects such as tremors, impaired cognitive skills, and sleep disturbance in workers.[14][15]

[edit] Inorganic mercury compounds

Mercury occurs inorganically as salts such as mercury(II) chloride. Mercury salts primarily affect the gastro-intestinal tract and the kidneys, and can cause severe kidney damage; however, as they can not cross the blood-brain barrier easily, mercury salts inflict little neurological damage without continuous or heavy exposure.[16] As two oxidation states of mercury form salts (Hg+ and Hg2+), mercury salts occur in both mercury(I) (or mercurous) and mercury(II) (mercuric) forms. Mercury(II) salts are usually more toxic than their mercury(I) counterparts because their solubility in water is greater; thus, they are more readily absorbed from the gastrointestinal tract.[16]

[edit] Organic mercury compounds

Compounds of mercury tend to be much more toxic than the element itself, and organic compounds of mercury are often extremely toxic and have been implicated in causing brain and liver damage. The most dangerous mercury compound, dimethyl mercury, is so toxic that even a few microliters spilled on the skin, or even a latex glove, can cause death.[17][18]

Methyl mercury is the major source of organic mercury for all individuals.[19] It works its way up the food chain through bioaccumulation in the environment, reaching high concentrations among populations of some species. Larger species of fish, such as tuna or swordfish, are usually of greater concern than smaller species. The U.S. Food and Drug Administration (FDA) and the U.S. Environmental Protection Agency (EPA) advise women of child-bearing age, nursing mothers, and young children to completely avoid swordfish, shark, king mackerel and tilefish (golden bass), to limit consumption of albacore ("white") tuna to no more than 6 oz (170 g) per week, and of all other fish and shellfish to no more than 12 oz (340 g) per week.[20] However, there is no evidence that moderate consumption of fish in the U.S. poses a significant health hazard.[citation needed] A 2006 review of the risks and benefits of fish consumption found that for adults the benefits of one to two servings of fish per week outweigh the risks, even (except for a few fish species) for women of childbearing age, and that avoidance of fish consumption could result in significant excess coronary heart disease deaths and suboptimal neural development in children.[21]

Ethylmercury is a breakdown product of the antibacteriological agent ethylmercurithiosalicylate, which has been used as a topical antiseptic and a vaccine preservative (further discussed under Thiomersal below). Its characteristics have not been studied as extensively as methyl mercury. It is cleared from the blood much more rapidly, with a half-life of 7 to 10 days, and it is metabolized much more quickly than methyl mercury. It probably does not have methyl mercury's ability to cross the blood-brain barrier via a transporter, but instead relies on simple diffusion to enter the brain.[19]

Other exposure sources of organic mercury include phenylmercuric acetate and phenylmercuric nitrate. These were used in indoor latex paints for their anti-mildew properties, but were removed in 1990 because of cases of toxicity.[19]

[edit] Treatment

The standard of care for mercury poisoning is chelation therapy using DMSA (in U.S.), DMPS and alpha lipoic acid (ALA) (in Europe, Russia and former Soviet republics). A study of workers involved in the production of mercurous chloride, showed that the sodium salt of 2,3-dimercapto-1-propanesulfonic acid (DMPS) was effective in lowering the body burden of mercury and in decreasing the urinary mercury concentration to normal levels.[22]

Alternative medicine makes use of these same substances along with others, such as vitamin C (ascorbic acid), EDTA and "high sulfur foods". However, it has been shown that inorganic mercury (Hg2+) bound to EDTA (a necessary step in EDTA-induced mercury chelation) forms a complex (HgEDTA) that is "potentially injurious to the neuronal cytoskeleton".[23]

Some of the toxic effects of mercury are in some cases partially or wholly reversible, either through specific therapy or through natural elimination of the metal after exposure has been discontinued. However, heavy or prolonged exposure can do irreversible damage, particularly in fetuses, infants, and young children.

[edit] Prevention and regulation

Mercury poisoning can be prevented (or minimized) by eliminating or reducing exposure to mercury and mercury compounds. To that end, many governments and private groups have made efforts to avoid common hazards or to ban mercury altogether. For example, the export from the European Union of mercury and some mercury compounds will be prohibited from 2011-03-15.[24] The variability among regulations and advisories is at times confusing for the lay person as well as scientists.

Country Regulating agency Regulated activity Medium Type of mercury compound Type of limit Limit
US OSHA occupational exposure air elemental mercury Ceiling (not to exceed) 0.1 mg/m³
US OSHA occupational exposure air organic mercury Ceiling (not to exceed) 0.05 mg/m³
US FDA drinking water inorganic mercury Maximum allowable concentration 2 ppb (0.002 mg/L)
US FDA eating sea food methyl mercury Maximum allowable concentration 1 ppm
US EPA drinking water inorganic mercury Maximum contaminant level 2 ppb (0.002 mg/L)

[25]

[edit] Occurrences of mercury poisoning

  • The phrase mad as a hatter is likely a reference to mercury poisoning, as mercury-based compounds were once used in the manufacture of felt hats in the 18th and 19th century. (The Mad Hatter character of Alice in Wonderland was almost certainly inspired by an eccentric furniture dealer, not by a victim of mercury poisoning.)[26]
  • An early scientific study of mercury poisoning was in 1923-6 by the German inorganic chemist, Alfred Stock, who himself became poisoned, together with his colleagues, by breathing mercury vapour that was being released by his laboratory equipment — diffusion pumps, float valves, and manometers — all of which contained mercury, and also from mercury that had been accidentally spilt and remained in cracks in the linoleum floor covering. He published a number of papers on mercury poisoning, founded a committee in Berlin to study cases of possible mercury poisoning, and introduced the term micromercurialism.[27]
  • The term Hunter-Russell syndrome derives from a study of mercury poisoning among workers in a seed packing factory in Norwich, England in the late 1930s who breathed methylmercury that was being used as a seed disinfectant and preservative.[28]
  • From 1932 to 1968 methyl mercury was released into the sea around the city of Minamata in Kumamoto prefecture, Japan. The toxin bioaccumulated in fish, which when eaten by the local population caused the largest case of mercury poisoning known. Minamata disease and a second outbreak Niigata Minamata disease caused the deaths of over 1000 people and permanently disabled a great many more.
  • Widespread mercury poisoning occurred in rural Iraq in 1971-1972, when grain treated with a methyl mercury-based fungicide that was intended for planting only was used by the rural population to make bread, causing at least 6530 cases of mercury poisoning and at least 459 deaths (see Basra poison grain disaster).[29]
  • On August 14, 1996, Karen Wetterhahn, a chemistry professor working at Dartmouth College, spilled a small amount of dimethylmercury on her latex glove. She began experiencing the symptoms of mercury poisoning five months later and, despite aggressive chelation therapy, died a few months later from brain malfunction due to mercury intoxication.[17][18]
  • In April of 2000, Alan Chmurny attempted to kill a former employee, Marta Bradley, by pouring mercury into the ventilation system of her car.[30]
  • The first emperor of unified China, Qin Shi Huang Di, was driven insane and killed by mercury pills intended to give him eternal life.
  • On March 19, 2008, Tony Winnett, 55, inhaled mercury vapors while trying to extract gold from computer parts, and died ten days later. His Oklahoma residence became so contaminated that it would have to be gutted.[31][32]

[edit] Acrodynia epidemic

Acrodynia is a type of mercury poisoning in children characterized by pain and pink discoloration of the hands and feet. The word is derived from the Greek, where ακρος means high (as in:in an extremity) and οδυνη means pain. As such, it might be (erroneously) used to indicate that a patient has pain in the hands or feet. However, acrodynia is a disease rather than a symptom.[2] Also known as pink disease, erythredema, Selter's disease, or Swift-Feer disease, acrodynia was relatively commonplace amongst children in the first half of the 20th century.[33] Initially, the cause of the acrodynia epidemic among infants and young children was unknown; however, mercury poisoning, primarily from calomel in teething powders, began to be widely accepted as its cause in the 1950s and 60s.[33] The prevalence of acrodynia decreased greatly after calomel was excluded from most teething powders in 1954.[33]

[edit] Medical procedures

Because elemental mercury often passes through the GI tract without being absorbed, it was used medically for various purposes until the dangers of mercury poisoning became known. For example, elemental mercury was used to mechanically clear intestinal obstructions (due to its great weight and fluidity), and it was a key ingredient in various medicines throughout history, such as blue mass. The toxic effects often were either not noticed at all, or so subtle or generic that they were attributed to other causes and were not recognized as poisoning caused by mercury. While the usage of mercury in medicine has declined, mercury-containing compounds are still used medically in vaccines and dental amalgam, both of which have been the subject of controversy regarding their potential for mercury poisoning.

[edit] Thiomersal

For more details on this topic, see Thiomersal controversy.

Thiomersal, a preservative that contains mercury, has been added to vaccines to prevent their deterioration since the 1930s.[10] No adverse effects of thiomersal have ever been proven, although some allergic reactions have been noted.[citation needed] Its use in vaccines has been hypothesized as a cause of autistic behaviors.[34][35] This hypothesis is controversial, as much evidence suggests that about 90% of autism is explained by genetics.[36] The hypothesis has not been confirmed by reliable studies.[37] However, organizations such as the American Academy of Pediatrics have recommended that the use of thiomersal be reduced as a precautionary measure. With the exception of some flu vaccines, it is no longer used as a preservative in routinely recommended childhood vaccines in the United States; it is still in limited use as a preservative in multi-dose flu and tetanus vaccines and a few other non-childhood vaccines.[38]

[edit] Dental amalgam

For more details on this topic, see Dental amalgam controversy.

Dental amalgam, an alloy of about 50% elemental mercury, has been used to fill decayed teeth since 1830 in the U.S. Although this amalgam is a source of low-level exposure to mercury, no scientific evidence links it as a cause of clinically significant toxic effects, except for the rare local hypersensitivity reaction. The National Institutes of Health has stated that amalgam fillings pose no personal health risk, and that replacement by non-amalgam fillings is not indicated.[19]

[edit] Cosmetics

Some skin whitening products contain the toxic chemical mercury(II) chloride as the active ingredient. When applied, the chemical readily absorbs through the skin into bloodstream.[39][40] The use of mercury in cosmetics is illegal in the United States. However, cosmetics containing mercury are often illegally imported. Following a certified case of mercury poisoning resulting from the use of an imported skin whitening product, the FDA warned against the use of such products.[41][42][43] Symptoms of mercury poisoning have resulted from the use of various mercury-containing cosmetic products.[44][10][45] The use of skin whitening products is especially popular amongst Asian women.[46] In Hong Kong in 2002, two products were discovered to contain between 9,000 to 60,000 times the recommended dose.[47]

[edit] Fluorescent lamps

Fluorescent lamps contain mercury which is released when bulbs are broken. Mercury in bulbs is typically present as either elemental mercury liquid, vapor or both since the liquid evaporates at ambient temperature.[48] When broken indoors, bulbs may emit sufficient mercury vapor to present health concerns. Breakage of multiple bulbs presents a more significant concern. A 1987 report described a 23-month-old toddler who suffered anorexia, weight loss, irritability, profuse sweating, and peeling and redness of fingers and toes. This case of acrodynia was traced to exposure of mercury from a carton of 8-foot fluorescent light bulbs that had broken in a potting shed adjacent to the main nursery. The glass was cleaned up and discarded, but the child often used the area for play.[49]

[edit] See also

[edit] References

  1. ^ Sweet LI, Zelikoff JT (2001). "Toxicology and immunotoxicology of mercury: a comparative review in fish and humans". J Toxicol Environ Health B Crit Rev 4 (2): 161–205. doi:10.1080/10937400117236. PMID 11341073. 
  2. ^ a b Horowitz Y, Greenberg D, Ling G, Lifshitz M. Acrodynia: a case report of two siblings. Arch Dis Child 2002; 86: 453. PMID 12023189
  3. ^ United States Environmental Protection Agency (December 1997), Mercury Study Report to Congress, vol. 3, Washington, D.C.: United States Environmental Protection Agency, <http://www.epa.gov/ttn/oarpg/t3/reports/volume3.pdf> 
  4. ^ ToxFAQs: Mercury. Agency for Toxic Substances and Disease Registry (1999-04). Retrieved on 2007-07-25.
  5. ^ Goldman, Lynn R.; Michael W. Shannon and the Committee on Environmental Health (2001-07). "Mercury in the Environment: Implications for Pediatricians". Pediatrics 108 (1): 197-205. 
  6. ^ Pacyna EG, Pacyna JM, Steenhuisen F, Wilson S (2006). "Global anthropogenic mercury emission inventory for 2000". Atmos Environ 40 (22): 4048–63. doi:10.1016/j.atmosenv.2006.03.041. 
  7. ^ United States Environmental Protection Agency (December 1997), Mercury Study Report to Congress, vol. 4, Washington, D.C.: United States Environmental Protection Agency, <http://www.epa.gov/ttn/oarpg/t3/reports/volume4.pdf> 
  8. ^ How Mercury Causes Brain Neuron Degeneration
  9. ^ Hendry WF, A'Hern FPA, Cole PJ. Was Young's syndrome caused by mercury exposure in childhood? BMJ 1993;307:1579-82. PMID 8292944
  10. ^ a b c Clarkson TW, Magos L (2006). "The toxicology of mercury and its chemical compounds". Crit Rev Toxicol 36 (8): 609–62. doi:10.1080/10408440600845619. PMID 16973445. 
  11. ^ ATSDR. 1999. Toxicological Profile for Mercury. Atlanta, GA:Agency for Toxic Substances and Disease Registry.
  12. ^ Hursh JB, Clarkson TW, Miles E, Goldsmith LA (1989). "Percutaneous absorption of mercury vapour by man". Arch. environ. Health 44 (2): 120-127. PMID 2494955. 
  13. ^ Cherian M.G., Hursh J.G., Clarkson T.W. 1978. Radioactive mercury distribution in biological fluids and excretion in human subjects after inhalation of mercury vapor. Archives of Environmental Health 33: 190-214.
  14. ^ Ngim CH, Foo SC, Boey KW, and Keyaratnam J (1992). "Chronic neurobehavioral effects of elemental mercury in dentists". British Journal of Industrial Medicine 49: 782-790. 
  15. ^ Liang YX, Sun RK, Chen ZQ, and Li LH. "Psychological effects of low exposure to mercury vapor: Application of computer-administered neurobehavioral evaluation system". Environmental Research 60: 320-327. 
  16. ^ a b Langford, N.J.; R.E. Ferner (October 1999). "Toxicity of mercury". Journal of Human Hypertension 13 (10): 651-656. 
  17. ^ a b The Karen Wetterhahn story - University of Bristol web page documenting her death, retrieved December 9th 2006
  18. ^ a b OSHA update following Karen Wetterhahn's death
  19. ^ a b c d Clifton JC 2nd (2007). "Mercury exposure and public health". Pediatr Clin North Am 54 (2): 237–69, viii. doi:10.1016/j.pcl.2007.02.005. PMID 17448359. 
  20. ^ What you need to know about mercury in fish and shellfish - Advice for women who might become pregnant women who are pregnant nursing mothers young children. U.S. FDA and U.S. EPA Advisory EPA-823-F-04-009, March 2004.
  21. ^ Mozaffarian D, Rimm EB (2006). "Fish intake, contaminants, and human health: evaluating the risks and the benefits". JAMA 296 (15): 1885–99. doi:10.1001/jama.296.15.1885. PMID 17047219. 
  22. ^ Gonzalez-Ramirez D, Zuniga-Charles M, Narro-Juarez A, Molina-Recio Y, Hurlbut KM, Dart RC, Aposhian HV (1998). "DMPS (2,3-dimercaptopropane-1-sulfonate, Dimaval) decreases the body burden of mercury in humans exposed to mercurous chloride". J Pharmacol Exp Ther 287 (1): 8–12. PMID 9765315. 
  23. ^ Duhr EF, Pendergrass JC, Slevin JT, & Haley BE. HgEDTA complex inhibits GTP interactions with the E-site of brain beta-tubulin. Toxicol Appl Pharmacol. 1993 Oct;122(2):273-80. PMID 8212009
  24. ^ European Parliament (2008-05-21). "Export-ban of mercury and mercury compounds from the EU by 2011". Press release. Retrieved on 2008-06-10.
  25. ^ ATSDR - Mercury - Regulations and Advisories
  26. ^ Waldron HA (1983). "Did the Mad Hatter have mercury poisoning?". Br Med J (Clin Res Ed) 287 (6409): 1961. PMID 6418283. 
  27. ^ Stock, Alfred (1926). "Die Gefaehrlichkeit des Quecksilberdampfes". Zeitschrift für angewandte Chemie 39: 461-466. doi:10.1002/ange.19260391502. 
  28. ^ Hunter, D, Bomford, R R, and Russell, D S (1940). "Poisoning by methylmercury compounds". Quart. J. Med. 9: 193-213. 
  29. ^ Engler, Robert (April 27 1985). "Technology out of Control". The Nation 240. 
  30. ^ Jose Antonio Vargas. "'Mad Scientist': On Court TV, Fatal Chemistry", The Washington Post, 2007-01-26. Retrieved on 2007-01-28. 
  31. ^ Swearengin M. "Man dies from mercury poisoning after trying to extract gold", Durant Daily Democrat, 2008-04-01. 
  32. ^ (Associated Press). "Colbert man dies from mercury poisoning", Tulsa World, 2008-04-01. Retrieved on 2008-04-20. 
  33. ^ a b c Ann Dally (1997). "The Rise and Fall of Pink Disease". Social History of Medicine 10 (2): 291-304. doi:10.1093/shm/10.2.291. 
  34. ^ Bernard S, Enayati A, Redwood L, Roger H, Binstock T (2001). "Autism: a novel form of mercury poisoning" (PDF). Med Hypotheses 56 (4): 462–71. doi:10.1054/mehy.2000.1281. PMID 11339848. 
  35. ^ Mutter J, Naumann J, Schneider R, Walach H, Haley B (2005). "Mercury and autism: accelerating evidence?" (PDF). Neuro Endocrinol Lett 26 (5): 439–46. 
  36. ^ Freitag CM (2007). "The genetics of autistic disorders and its clinical relevance: a review of the literature". Mol Psychiatry 12 (1): 2–22. doi:10.1038/sj.mp.4001896. PMID 17033636. 
  37. ^ Rutter M (2005). "Incidence of autism spectrum disorders: changes over time and their meaning". Acta Paediatr 94 (1): 2–15. PMID 15858952. 
  38. ^ Mercury and vaccines (thimerosal). Centers for Disease Control and Prevention. Retrieved on 2007-12-25.
  39. ^ Counter, S. Allen (Dec 16, 2003), Whitening skin can be deadly, The Boston Globe, <http://www.boston.com/news/globe/health_science/articles/2003/12/16/whitening_skin_can_be_deadly/> 
  40. ^ Mercury in Cosmetic Skin Whitening Creams, <http://www.hgtech.com/Data/Other/Hg%20Cream.htm> 
  41. ^ FDA Proposes Hydroquinone Ban, <http://www.medicinenet.com/script/main/art.asp?articlekey=64167> FDA bans hydroquinone in skin whitening products
  42. ^ Skin-lightening creams face FDA ban: Dermatologists defend treatment, <http://findarticles.com/p/articles/mi_qn4155/is_20070128/ai_n17159064> FDA bans hydroquinone in skin whitening products
  43. ^ NYC Health Dept. Warns Against Use of "Skin-lightening" Creams Containing Mercury or Similar Products Which Do Not List Ingredients, January 27, 2005, <http://www.nyc.gov/html/doh/html/pr/pr008-05.shtml> 
  44. ^ Countera, S. Allen; Leo H. Buchanan. "Mercury exposure in children: a review". 
  45. ^ Mahaffey, Kathryn R., Dynamics of Mercury Pollution on Regional and Global Scales, <http://www.springerlink.com/content/w245027uu23r4381/> 
  46. ^ In a survey, 28% of Koreans and 50% of Philippians say that they use skin whitening products.Skin lightening in Asia? A bright future?, <http://www.synovate.com/knowledge/infact/issues/200406/> 
  47. ^ Bray, Marianne, SKIN DEEP: Dying to be white, CNN, <http://edition.cnn.com/2002/WORLD/asiapcf/east/05/13/asia.whitening/> 
  48. ^ Aucott M, McLinden M, Winka M, 2003, Release of Mercury from Broken Fluorescent Bulbs, J Air Waste Manag Assoc 53:143-151.
  49. ^ Tunnessen WW Jr, McMahon KJ, Baser M (1987). "Acrodynia: exposure to mercury from fluorescent light bulbs". Pediatrics 79 (5): 786–9. PMID 3575038. 

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