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United Nations Environment Programme P .O. Box 30552 Nairobi, 00100 Kenya Tel: (254 20) 7621234 Fax: (254 20) 7623927 E-mail: uneppubunep web: unep unep U n i t e d n a t i o n s e n v i r o n m e n t P r o g r a m m e Com Pendi Um of t e Chnologies for t reatment / d estr UCtion of h ealth Care WasteCopyright United Nations Environment Programme, 2012 This publication may be reproduced in whole or in part and in any form for educa- tional or non-profit purposes without special permission from the copyright holder, provided acknowledgement of the source is made. UNEP would appreciate receiv- ing a copy of any publication that uses this publication as a source. No use of this publication may be made for resale or for any other commercial purpose whatsoever without prior permission in writing from the United Nations Environment Programme. Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the United Na- tions Environment Programme concerning the legal status of any country, territory, city or area or of its authorities, or concerning delimitation of its frontiers or boundar- ies. Moreover, the views expressed do not necessarily represent the decision or the stated policy of the United Nations Environment Programme, nor does citing of trade names or commercial processes constitute endorsementAcknowledgement This document was written by Dr. JORGE EMMANUEL, Consultant, under the overall guidance and supervision of Surya Prakash Chandak, Senior Programme Officer, International Environmental Technology Centre, Division of Technology, Industry or waste generated in research related to the aforementioned activities; or waste generated in the production or testing of biologicals. 2 1.2 SOURCES OF HEALTHCARE WASTE Some regulations define healthcare waste as waste generated by hospitals, clinics, biomedical laboratories and other specific sources associated with human or animal health care. Below is a list of known and potential sources of healthcare waste: Hospitals, medical centers, and polyclinics Clinics, diagnostic facilities, dialysis centers and other specialized outpatient treatment facilities Primary health centers, rural health stations, basic health units, or health posts Maternity centers or birthing facilities Physicians offices Dental clinics and offices Medical laboratories, biomedical laboratories and research centers, biotechnology laboratories, nuclear medicine laboratories Blood banks, blood collection centers, and blood transfusion centers Nursing homes for the elderly, long-term residential care facilities for the chronically ill, and hospices for the terminally ill Pharmacies and dispensaries, drug stores, pharmaceutical manufacturing facilities Alternative medicine treatment facilities (e.g., acupuncture centers) Veterinary hospitals, veterinarians clinics, and veterinary offices Animal research and testing centers, and animal quarantine stations Home health care settings Health facilities, infirmaries, clinics, or health stations in colleges and universities, childrens schools and summer camps, military establishments, police stations, prisons, and commercial or industrial establishments Emergency service facilities (ambulance stations, paramedic units, rescue operations) Coroners or medical examiners facilities, forensic pathology or autopsy laboratories, and crime laboratories Drug addiction rehabilitation centers Funeral homes and mortuaries Tattoo and cosmetic ear piercing establishments Health and quarantine stations in airports, ports, and immigration/customs facilities First-aid posts. The bulk of healthcare waste is generally produced by hospitals. Health-related facilities in the United States can be categorized according to 15 types of sources. Hospitals, which comprise only 1% of all health-related facilities, account for 71% of the total healthcare waste generated annually. Doctors offices, nursing homes, 1 Adapted from Chapter 2, Safe management of waste from health-care activities, World Health Organization, Geneva, Switzerland (upcoming edition). 2 See, for example, definitions in the Bio-medical Waste (Management and Handling) Rules, Second Amendment, Ministry of Environment and Forests, India, 2000pendium of Technologies for the Treatment/Destruction of Healthcare Waste 4 clinics, and medical labswhich together make up 36% of the total facilitiescontribute 22% of the healthcare waste (see Figure 1). 3 Figure 1.1 Typical Contributions of Different Health Facilities to Total Healthcare Waste Generated The pattern shown in Figure 1.1 above is expected in most countries, in which large hospitals produce the majority of healthcare waste even though they account for a small percentage of healthcare establishments, while small health centers, clinics, primary health stations, doctors offices, etc. comprise the majority of health facilities but produce a smaller portion of the total healthcare waste stream. Although it is effective to focus initially on waste management practices in hospitals, the large number of primary health facilities should not be ignored. 3 Medical Waste IncineratorsBackground Information for Proposed Guidelines: Industry Profile Report for New and Existing Facilities, EPA-453/R-94-042a, U.S. Environmental Protection Agency, Washington, DC, 1994pendium of Technologies for the Treatment/Destruction of Healthcare Waste 5 2 HEALTH AND ENVIRONME NTAL IMPACTS OF HEALTHCARE WASTE Various reports have highlighted the dangers of improper disposal of healthcare waste. A systematic review of healthcare waste management in 40 low- and middle-income countries revealed substantial problems in urban regions in Africa, Asia, and the Middle East exacerbated by increasing quantities of healthcare waste and improper treatment and disposal. The study noted that in addition to the deleterious health effects of incinerator emissions and ash, many incinerators were antiquated and dysfunctional and, as a consequence, infectious waste was often discarded with municipal waste or openly burned. 4 A study by the World Health Organization (WHO) on the hazards of healthcare waste concluded that in developing countries where the waste is discarded without treatment in open dump sites, the health impacts are significant due to scavenging, the lack of personal protective equipment among waste workers, and the limited availability of immunization. 5 In Pakistan, scavenger boys sorting through medical waste for collection and resale experienced on average three to five needle-stick injuries a day. 6 In Mexico City, an interview of 69 sanitation workers revealed that 34% experienced between one to five needle-stick injuries in the previous year and 96% reported seeing needles and syringes in the waste. 7 At Sadr City Hospital in Iraq, a pediatrician reported dozens of children admitted with symptoms of infectious diseases due to contact with waste, including hospital waste. 8 A study that included field work in Pakistan and Bangladesh concluded that the urban poor are potentially at the greatest risk, in particular, waste pickers involved in collecting recyclables for selling to recycling establishments. 9 As part of WHOs Global Burden of Disease Project, Prss-Ustn et al. estimated that in the year 2000, about 16,000 hepatitis C infections, 66,000 hepatitis B infections, and 1,000 HIV infections may have occurred worldwide among healthcare workers due to occupational exposure to sharps injuries. 10 Among the recommended primary preventive measures is the proper management of sharps waste. Another impact of healthcare waste on health and the environment relates to the use of old or poorly functioning medical waste incinerators that do not meet international standards. A medical waste incinerator releases a wide variety of pollutants including particulate matter such as fly ash; heavy metals (arsenic, cadmium, chromium, copper, mercury, manganese, nickel, lead, etc.); acid gases (hydrogen chloride, hydrogen fluoride, sulfur dioxides, nitrogen oxides); carbon monoxide; and organic compounds like benzene, carbon tetrachloride, chlorophenols, trichloroethylene, toluene, xylenes, trichloro-trifluoroethane, polycyclic aromatic hydrocarbons, vinyl chloride, etc. 11 Pathogens can also be found in the solid residues and in the exhaust of poorly designed and badly operated incinerators. 12 In addition, the bottom ash residues are generally contaminated with leachable organic compounds, such as dioxins, and heavy metals and have to be treated as hazardous waste. 4 M.O. Harhay, S.D. Halpern, J.S. Harhay and P.L. Olliaro, Tropical Medicine and International Health 14 (11), 14141417 (2009). 5 I.F. Salkin and M.E. Kennedy, Review of Health Impacts From Microbiological Hazards in Health-Care Waste, World Health Organization, Geneva, Switzerland, 2001. 6 A. Altaf and S.A. Mujeeb, Unsafe disposal of medical waste: a threat to the community and environment., Journal of the Pakistan Medical Association, 52 (6), 232 (2002). 7 B. Thompson, P.L. Moro, K. Hancy, I.R. Ortega-Snchez, J.I. Santos-Preciado, C. Franco-Paredes, B.G. Weniger, and R.T. Chen, Needlestick injuries among sanitation workers in Mexico City, Rev Panam Salud Publica 27 (6), 467-468 (2010). 8 Integrated Regional Information Networks, Iraq: Medical waste a growing health hazard, April 2007. 9 J. Appleton and M. Ali, Healthcare or Health Risks? Risks from Healthcare Waste to the Poor, WELL (Water and Environmental Health at London and Loughborough), Water Engineering and Development Centre, Loughborough University, Leicestershire (2000). 10 A. Prss-Ustn, E. Rapiti, and Y. Hutin, American Journal of Industrial Medicine 48 (6), 482-490 (2005). 11 J. Emmanuel, Best Environmental Practices and Alternative Technologies for Medical Waste Management, presented at the Eighth International Waste Management Congress and Exhibition, Kasane, Botswana, June 25-28, 2007. 12 M. Barbeito and M. Shapiro, Microbiological Safety Evaluation of a Solid and Liquid Pathological Incinerator, J. Medical Primatology, 6:264-273, 1977; S. Klafka and M. Tierney, Pathogen Survival at Hospital/Infectious Waste Incinerators, Proceedings: National Workshops on Hospital Waste Incineration and Hospital Sterilization, EPA Office of Air Quality Planning and (footnote continued)COmpendium of Technologies for the Treatment/Destruction of Healthcare Waste 6 A health risk assessment study of small-scale incinerators was commissioned by the World Health Organization and completed in January 2004. 13 The study looked at how small-scale incinerators are operated in the field and their reported emissions of dioxins and furans. Based on this, the study identified three classes: (1) incinerators as best practice, operated and maintained properly using sufficient temperatures, afterburners, and other features to limit concentrations of dioxins; (2) incinerators as expected practice, that is, improperly designed, constructed, operated and maintained; and (3) worst-case incinerators that have no afterburners. The WHO study stipulated three operating scenarios: (1) low usage equivalent to 12 kg/month or 1 hour of operation per month; (2) medium usage equivalent to 24 kg/week or 2 hours of operation per week; and (3) high usage or 24 kg/day or 2 hours of operation per day. The emissions and usage rates were used to estimate uptake rates of dioxins and furans for adults and children via ingestion, and compared them to WHOs provisional tolerable intake rate (1-4 pg TEQ/kg-day) and an exposure level (0.001 pg TEQ/kg/-day) based on the upper bound of US EPAs cancer potency factor for dioxins and furans. The study concluded that ingestion intake rates and carcinogenic risks were unacceptable for the worst-case incinerators even at low usage rates. For the expected usage incinerators, the low usage rates kept intake below the WHO provisional intake levels but de minimis risks based on US EPAs cancer potency factor were exceeded. Similarly, de minimis cancer risks were exceeded by the best practice incinerators at the highest usage. Studies investigating the relationship between human exposures to incinerator emissions and the occurrence of health effects in local populations have been difficult, in part because of confounding factorsespecially in distinguishing the contribution of incineration versus other pollutant sourcesand the complications in measuring highly variable environmental concentrations. In a study of school children living near a wire- reclamation incinerator in Taiwan, Wang et al. concluded that the high air pollution levels in the area near the incinerator were associated with a detrimental effect on lung function in the children. 14 Zmirou et al. concluded that the purchase of respiratory medication decreased as the distance of residences from incinerators increased. 15 In contrast, Gray et al. did not find an adverse effect on the prevalence or severity of childhood asthma among children within a 6-km radius of a sewage sludge incinerator in Sydney, Australia. 16 In a study by Shy et al., no difference was found in acute or chronic respiratory symptoms or lung functions between communities adjacent to medical waste and municipal waste incinerators, and comparison groups away from the incinerators. 17 These conflicting results illustrate the complexity of conducting epidemiological studies of the health impacts of incineration in local populations and the need to increase the power of epidemiological studies by looking at multi-site studies. 18 Despite the uncertainties and at times contradictory results, especially with regards to acute and chronic respiratory disorders, more and more studies in the last two decades indicate a clear association between exposure to incinerator emissions and increased body burdens and adverse health impacts. Various studies in Japan, Spain, and Germany show that incinerator workers or children and other residents living near incinerators have significantly higher blood or urine levels of dioxins, furans, polychlorinated biphenyls, hexachlorobenzene, 2,4/2,5-dichlorophenols, 2,4,5-trichlorophenols, hydroxypyrene, toluene, and tetrachlorophenols compared to control groups or to national averages. 19 Similar studies show a higher prevalence of urinary mutagen and Standards, EPA-450/4-89-002, January 1989; Hospital Medical Waste Incinerator Operation and Maintenance, U.S. Environmental Protection Agency, Office of Air Quality Planning and Standards, March 1989. 13 Assessment of Small-Scale Incinerators for Health Care Waste, S. Batterman, report prepared for the Protection of the Human Environment, World Health Organization, Geneva, January 21, 2004. 14 J.Y. Wang, T.R. Hsiue, and H.I. Chen, Arch. Dis. Child. 67(4): 488-490, 1992. 15 D. Zmirou, B. Parent, and J.-L. Potelon, Rev. Epidem. Sante Publ. 32:391-397, 1984. 16 E.J. Gray, J.K.
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