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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