Environmentally Responsible Management of Health-Care Waste With a Focus on Immunization Waste Comments and suggestions on the document are welcome. Send.

Environmentally Responsible Management of Health-Care Waste

With a Focus on Immunization Waste

Comments and suggestions on the document are welcome. Send comments to: <[email protected]>

Working Draft, October 2002

Health Care Without Harm

1755 S Street NW, Suite 6B

Washington, DC 20009

USA

Waste Management Strategies

• First Things First Eliminate unnecessary injections Product selection and purchasing Workers as the front-line of defense

Rigorous training Immunization

Segregation is key Proper containerization, secure transport &

storage Non-burn treatment technologies Proper disposal

Guidelines

Guidelines for Central Planners Guidelines for Local Managers Practical Procedures Treatment and Disposal Options

Guidelines are adapted from valuable existing documents:• Management of wastes from immunization campaign

activities (UNICEF)• Safe Management of Wastes from Health Care Activities

(WHO)• First, do no harm (SIGN, draft 2002)

Toxic Pollutants From Medical Waste Incinerators

• Air Emissions– trace metals: As, Cd, Cr, Cu, Hg, Mg, Ni, Pb– acid gases: HCl, SO2, NOx– dioxins & furans, including 2,3,7,8-tetrachlorodibenzo-p-dioxin – other organic compounds: benzene, toluene, xylenes,

chlorophenols, vinyl chloride, polycyclic aromatic hydrocarbons, etc.

– carbon monoxide– particulate matter– pathogens (under conditions of poor combustion)

• Ash Residues: metals, dioxins & furans, other organicsMedical waste incinerators are a major source of

dioxins & mercury in the environment.

Health Impacts of Incinerator Emissions

• lung, laryngeal, stomach and other cancers

• ischemic heart disease

• urinary mutagens and promutagens

• elevated blood levels of various toxic organic compounds and metals

Incinerator emissions have been linked to:

Stockholm Convention on POPs

• Stockholm Convention on Persistent Organic Pollutants (POPs Treaty)

• Adopted in May 2001• Article 5: countries will take measures to further reduce

releases of POPs with the goal of ultimate elimination• Annex C

– First in the list of POPs from unintended production: Dioxins and Furans

– Source with the potential for comparatively high formation and release of dioxins and furans: Medical Waste Incinerators

Field Test: DM1, DM2, DM3, DM4 ; Lab Test: DM5, DM6

0

0.005

0.01

0.015

0.02

0.025

0.03

0.035

0.04

0.045

DM1 DM2 DM3 DM4 DM5 DM6

Org

anic

Em

issi

on

Fra

ctio

n

Series1

India

S. Africa

De Montfort Combustion Efficiencies*

* Organic Emission Fraction= 1 - Combustion Efficiency

Organic Emissions are 20 to 400 times above the South African limit

De Montfort Incinerator Does Not Meet Environmental Standards

Fails to meet combustion temperatures limitsFails to meet residence time requirementsExceeds opacity limitsFails to meet combustion efficiency standardsExceeds limits on particulate matterExceeds some limits on metalsViolates stack height requirements without modificationHas no pollution control, no controls on temperature and air input, no safe ash removal systemCould release significant quantities of dioxins, furans, mercury and other toxic pollutants

Summary of Field Investigations

• Incinerators (1-2 yrs old) poorly maintained & operated– Broken ash doors and/or chamber doors, heavily corroded,

clogged air vents, sharps waste around incinerator, etc.

• All waste burned including …– PVC plastics (e.g., IV bags) and mercury thermometers– Non-infectious, recyclable and compostable waste (despite

segregation practices or policies)

• Large quantities of unburned material in the ash• Ash improperly disposed of in every case• Smoke visible from incinerators; in some cases, smoke

coming out of chamber door and air inlets• Incinerators near populated areas

Heavy Smoke From IncineratorOperator Using Motorcycle Helmet

Courtesy of P. Madhavan

Courtesy of Bradley Hersh

Soot & Molten Plastic (?) Coming Out of Ash Door

Undestroyed Needles On the Ground

Around Incinerator

Courtesy of Shibu K. Nair

Problems of Promoting Incineration

• Results in Adverse Health Impacts on Health Workers and Communities

• Pollutes the Environment

• Weakens Enforcement of Environmental Laws

• Threatens Worker Safety

• Undermines Good Waste Management Practices

• Promotes Dumping of Obsolete Technologies

• Hampers Deployment of Cleaner Technologies

Low-Cost Options

CE Cement EncasingEI Encapsulation With Immobilizing MaterialsBP Waste Burial Pit or Sharps Pit With Concrete CoverPU Portable Autoclave or MicrowaveND Point-of-Use Needle Destruction TechnologiesND/m Mechanical Needle DestructionCT Storage, Transport and Centralized Treatment

TG Traditional GrindersS Shredders or Hammermills

Disposal in Sanitary LandfillBurial in Restricted Sites

Decision Tree 2

Regional sanitary or engineered landfill

available?

Electricity available?

Off-Site

Yes No

Electricity available?

Yes Yes NoNo

CT-S-landfill**CT-TG-landfillCT-EI-landfillCT-large CE or BP in restricted area of landfillPU-S-landfillPU-TG-landfillPU-EI-landfillPU-CE or BP in restricted area of landfillND-EI-landfillND-CE or BP in restricted area of landfill

Large CE at restricted area of landfillLarge BP at restricted area of landfillEI-landfillND/m-EI-landfillND/m-CE or BP at restricted area of landfill

CT-S-large CE at restricted siteCT-S-large BP at restricted siteCT-TG-large CE at restricted siteCT-TG-large BP at restricted siteCT-EI-burial at restricted sitePU-S-CE or BP at restricted sitePU-TG-CE or BP at restricted sitePU-CE or BP at restricted siteCE at restricted siteBP at restricted siteEI-burial at restricted siteND-EI, CE or BP at restricted site

CE at restricted siteBP at restricted siteEI-burial at restricted siteND/m-EI, CE or BP at restricted site

medical wasteand/or sharpscontainers

soil covercement m ixture

Cement Encasing

Cem ent

Sharps waste

Drum

Soil

Encapsulation With Immobilizing Materials

security fencecement cap

50 cm of soil coverearth mound to keepwater out of the pit

sharps containers

soil

Sharps Waste Burial Pit With Concrete Cover

SafetyValve

ReleaseValve

Insulation

ChargingDoor

Steam

SteamTrap

Thermocouple

Regulator

Valve

SteamInlet

Basic Autoclave (Simple Retort Design)

Estimates for Cement EncasingTrench volume and cement needed for DTP-HepB-Hib vaccination waste

Number of children targeted for vaccination

100 1,000 5,000 10,000

Number of safety boxes 8 75 377 753

Volume of sharps waste (cubic meters) 0.04 0.042 2.12 4.25

Trench volume (cubic meters) 0.08 0.85 4.25 8.49

Amount of cement needed (kg) 10 96 478 955

Approximate cost of cement, lime, and sand (US $)

$5 $43 $215 $430 

Comparative Costs for Treating 50,000 Syringes

0

1000

2000

3000

4000

5000

6000

7000

CE BP PU ND De Mft Sicim

US

$ (

es

tim

ate

d)

Recurrent Costs for50,000 Syringes

Capital Costs

Capital Costs to Treat 1,600 kg/day of Medical Waste in a Region

0

20000

40000

60000

80000

100000

120000

140000

160000

Centralized Autoclave-Shredder

De Montfort Incinerators(74)

Sicim Incinerators (15)

Ca

pit

al C

os

t E

sti

ma

tes

(U

S $

)

Environmentally Responsible Management of Health-Care Waste

With a Focus on Immunization Waste

Comments and suggestions on the document are welcome. Send comments to: <[email protected]>

Working Draft, October 2002

Health Care Without Harm

1755 S Street NW, Suite 6B

Washington, DC 20009

USA