Overview of Wastes from Health Care Activities

UNEP IETC Osaka, Japan

19 July 2012
Susan Wilburn, Technical Officer

Public Health and Environment

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Public health and environment

Key Points
Of the total amount of waste generated by health-care activities, about 80% is general waste. The remaining 20% is considered hazardous material that may be infectious, toxic or radioactive. Every year an estimated 16 000 million injections are administered worldwide, but not all of the needles and syringes are properly disposed of afterwards. Health-care waste contains potentially harmful microorganisms which can infect hospital patients, healthcare workers and the general public.

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Public health and environment

What is health-care waste?

Health-care waste includes all the waste generated by health-care establishments, research facilities, and laboratories. In addition, it includes the waste originating from minor or scattered sources--such as that produced in the course of health care undertaken in the home (dialysis, insulin injections, etc.).

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Public health and environment

Categories of health care waste

Sharps: Used or unused sharps
e.g. hypodermic, intravenous or other needles; auto-disable syringes; syringes with attached needles; infusion sets; scalpels; pipettes; knives; blades; broken glass

Infectious: Infectious waste is material suspected to contain

pathogens (bacteria, viruses, parasites or fungi) in sufficient concentration or quantity to cause disease in susceptible hosts. This category includes: waste contaminated with blood or other body fluids,
cultures and stocks of infectious agents from laboratory work, waste from infected patients in isolation wards; dressings, bandages and other material

contaminated with blood or other body fluids

Pathological: Human tissues, organs or fluids; body parts;

fetuses; unused blood products
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Categories of waste (cont)

Pharmaceutical : Pharmaceuticals that are expired or no
longer needed; items contaminated by or containing pharmaceuticals; Cytotoxic waste containing substances with genotoxic properties waste containing cytostatic drugs (often used in cancer therapy) genotoxic chemicals)

Chemical: Waste containing chemical substances

(e.g. laboratory reagents; film developer; disinfectants that are expired or no longer needed; solvents; waste with high content of heavy metals, e.g. batteries; broken thermometers and blood pressure gauges)

Radioactive: Waste containing radioactive substances

(e.g. unused liquids from radiotherapy or laboratory research; contaminated glassware, packages, or absorbent paper; urine and excreta from patients treated or tested with unsealed radionuclides; sealed sources)
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General definition and characteristics

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Health Care Waste

Improper management of health care waste can have both direct and indirect health consequences for health personnel, community members and the environment. Direct consequences when disposable materials (especially syringes) are intentionally re-used Indirect consequences in the form of toxic emissions from inadequate burning of medical waste, or the production of millions of used syringes in a period of three to four weeks from an insufficiently well planned mass immunization campaign
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Health Care Waste Management Exposed groups and associated risks

Health-care workers UK 96 to 2004, 2140 reported occupational exposures to bloodborne viruses. 21% of the injuries occurring during the disposal process (Gabriel 2009)

Waste handlers Study in Mexico city showed that out of 69 interviewed waste handlers 34% (13) reported 22 needle stick injuries between them during the first 12 months and 96% had seen needles and syringes in waste (Thompson et al, 2010).
Scavengers retrieving items from dumpsites In Pakistan on average scavenger boys who were going through medical waste, for collection and resale, experienced three to five needle stick injuries a day (Altaf and Mujeed 2002)
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Children who may come into contact with contaminated waste Dozen of children in Sadr City, largest suburb of Baghdad, have been admitted to hospitals with symptoms of infectious diseases due to contact with waste (Integrated Regional Information Networks, 2007). Communities living near landfill and waste sites or near treatment facilities Low income households are more likely to live close to waste sites resulting in more direct contact with health care waste (Appleton and Ali, 2000) Local populations affected by the utilization of products recycled from health care waste and the reuse of untreated medical equipment In India more than 30% of the injections administered each year were carried out using re-used or inadequately sterilized medical equipment and that nationally, 10% of health care facilities sold used syringes to waste pickers (IndiaCLEN 2004).

Communities impacted by pollution from poorly operated incinerators Research suggests that population living within 3 km of old incinerators saw an increase of 3.5% in the risk of contracting cancer (Porta et al, 2009)
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Process of HC Waste management

Waste classification Waste segregation Waste minimization Containerization Color coding Labeling and signage Handling Transport Storage Treatment Final disposal of waste.

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Waste management hierarchy

Most preferable Prevent Reduce Reuse Recycle Recover Treat Dispose Least preferable
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Waste segregation is key

Careful segregation and separate collection of hospital waste is the key to safe, sound management of healthcare waste. Segregation can substantially reduce the quantity of health-care waste that requires specialized treatment.
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Public health and environment

Segregation of health-care waste (continued)

In any area that produces hazardous waste hospital wards, treatment rooms, operating theatres, laboratories, etc.
bins plus separate sharps container will be needed.

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Public health and environment

Segregation of health-care waste

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Public health and environment

Sharps waste
Sharps are items that can cause cuts or puncture wounds, including: needles, hypodermic needles,

scalpel and other blades,

knives, infusion sets,

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saws,
broken glass, and pipettes

Public health and environment

Sharp waste management

Sharps Handling Recommendations Do not recap needles Never pass used sharps from one person to another Locate needle destroyer and container near the point of generation to have good visibility Sharps should be disposed of in puncture-resistant sharps containers

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Public health and environment

Highly hazardous healthcare waste

Highly hazardous healthcare wastes, which should be given special attention, includes
highly infectious non-sharp waste such as laboratory supplies, highly infectious physiological fluids, pathological and anatomical waste, stools from cholera patients, and sputum and blood of patients with highly infectious diseases such as TB and HIV/AIDS. They also include large quantities of expired or unwanted pharmaceuticals and hazardous chemicals, as well as all radioactive or genotoxic wastes.

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Sub-categories of hazardous waste: Infectious waste and highly infectious waste

Infectious waste includes: cultures and stocks of infectious agents from laboratory work; waste from surgery and autopsies on patients with infectious diseases; waste from infected patients in isolation wards; waste that has been in contact with infected patients undergoing haemodialysis; infected animals from laboratories; any other instruments or materials that have been in contact with infected persons or animals.
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Infectious waste management

Infectious waste should go into yellow leak-proof plastic bags or containers. Bags and containers for infectious waste should be marked with the international infectious substance symbol

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Public health and environment

Sub-categories of hazardous waste: Chemical waste and pharmaceutical Chemical waste consists of waste
discarded solid, liquid, and gaseous chemicals, for example from diagnostic and experimental work and from cleaning, housekeeping, and disinfecting procedures.

Pharmaceutical waste includes expired, unused, spilt, and contaminated pharmaceutical products, drugs, vaccines, and sera that are no longer required and need to be disposed of appropriately.
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Chemical and pharmaceutical waste management

Small amounts of chemical or pharmaceutical waste may be collected together with infectious waste.
Large quantities of chemical waste should be packed in chemical-resistant containers.

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The identity of the chemicals should be clearly marked on the containers: hazardous chemical wastes of different types should never be mixed.

Radioactive waste
The waste produced by health-care and research activities involving radionuclides, and related activities such as equipment maintenance, storage, etc., can be classified as follows:
sealed sources; spent radionuclide generators; low-level solid waste, e.g. absorbent paper, swabs, glassware, syringes, vials; residues from shipments of radioactive material and unwanted solutions of radionuclides intended for diagnostic or therapeutic use; liquid immiscible with water, such as liquid scintillation-counting residues used in radioimmunoassay, and contaminated pump oil; waste from spills and from decontamination of radioactive spills; excreta from patients treated or tested with unsealed radionuclides; low-level liquid waste, e.g. from washing apparatus; gases and exhausts from stores and fume cupboards.

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Public health and environment

General healthcare waste

General healthcare waste, similar or identical to domestic waste, including materials such as packaging or unwanted paper. 7590% of waste generated by healthcare facilities falls into this category.

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General waste management

This waste is generally harmless and needs no special handling; and General health-care waste should join the stream of domestic refuse for disposal. Bags and containers for general healthcare waste are black.

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Waste recycling
Only 15% of the hospital waste stream is classified regulated or potentially infectious, and must be handled as such. The majority of hospital waste is similar to that found in an office building or hotelmostly paper, cardboard, metal and food waste. Much of this waste can be diverted from landfills and can reduce waste disposal costs through waste recycling.

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Examples of Reuse, Recycle of Waste, Water

Thailand GREEN & CLEAN Hospitals

Biogas from food waste used for hospital cooking Recycling plastic IV bottles

India Bhopal Sambhavna Trust Clinic

Harvests rainwater for hospital use Solar water heaters and passive ventilation reduce energy use Tropical gardens, irrigated by recycled water, provide fresh fruits and vegetables for staff and patients
Public health and environment

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Greening health sector: co-benefits for patients, health workers and climate mitigation
Chemical hazards:
"Risking their health while Capture and reuse caring for others: of waste anesthetic Reproductive health gases: reproductive hazards of germ-killers"

hazards and potent GHGases* *Estimated to have a global

warming potential of 5003700 X CO2
Ryan, SM, Nielsen CJ. Global warming potential of inhaled anaesthetics: application to clinical use. International Anesthesia Research Society, July 2010, 27 | Public health and environment 111(1).

NIOSH, Harvard School of Public Health and Brigham & Women's Hospital surveyed of 7,000 women nurses and found numerous potential occupational chemical exposures that doubled or tripled miscarriage risk.
Lawson C et al. Am J Obstet Gynecol. 2011 Dec 30

. . . Examples of mercury elimination

New Delhi, India: the citys public health system is substituting mercury in its hospitals. To date 12 hospitals are in the process of substitution. (Poster from campaign on right) Sao Paulo, Brazil: more than 100 private hospitals and 34 public hospitals have gone mercury-free Mexico City, Mexico: The health secretariat announced in September 2009 that its system of 28 hospitals and more than 200 health clinics would join the WHOHCWH Initiative and phase out mercury-based medical devices.

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Global Policy and Driving forces

SIXTY-THIRD WORLD HEALTH ASSEMBLY (WHA63.25) Agenda item 11.18 - Improvement of health through safe and environmentally sound waste management The Libreville Declaration on Health and Environment in Africa: Framework for Health Care Waste Management (Douala 2010) Global Alliance for Vaccines and Immunization 72 countries receiving support for health care waste WHO Safe Management of Wastes from Health-care activities Second edition - September 2012

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Public health and environment

Special Rapporteur on hazardous waste, The improper management and disposal of medical waste has an adverse impact on the enjoyment of human rights in many countries.
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Public health and environment

Refers to the Stockholm Convention on POPs Source with the potential for comparatively high formation of dioxins & furans: Medical Waste Incinerators
40,000 times higher than emission limits set forth.

Sept 2011 A/HRC/18/31

Despite major driving forces - HCWM remains weak

Lack of existing policies developed and implemented at country level Resources are mobilized but remains limited and not in phase with the magnitude of the public health problem Difficulty to find ways or platform to influence decision, e.g.: how long needle removers will remain as a Yes or No decision while it is introduced in some countries without safety guaranties Mass campaigns are to be prepared long in advance to ensure that the strategy on site will be able to safely handle huge amounts of waste

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Public health and environment

Affordable technologies for waste treatment are not developed in and for low income countries and are mostly geared towards industrialized countries Low cost technologies are often not environmentally friendly and safe In low income countries the trade-off is between direct health risks / indirect health risks related to poor strategy or environmental pollution
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Supply Chain
Look for solutions to reduce waste to contribute to improving some of the health care waste management problem countries face Ultimately, the waste management problem must be addressed at all levels, from upstream technology development to downstream waste minimization and management, to ensure that health care can be delivered without side effects on health care workers, communities, or the environment

Improvements made by countries by adopting purchase policies that consider the waste stream
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Public health and environment

Health waste management

Some 25% of health waste is hazardous developing countries are most at risk due to poor waste management practices. Energy benefits of energy-waste systems are clear but may involve a health

penalty (e.g. emissions of dioxins, pollutants) - Environmental benefits of mechanical/thermal treatment (e.g. microwaving/autoclaving) are also clear energy aspects needs more exploration.

Open health waste incineration pit Haiti

Hydroclave: for health waste steam sterilization and griding/volume reduction - Guyana

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Public health and environment

Tools to support Water, Sanitation, Hygiene and health care waste interventions in settings
Safe health-care waste management
WORLD HEALTH ORGANIZATION

POLICY PAPER
1 - Unsafe health-care waste management leads to death and disability
Health-care activities lead to the production of waste that may lead to adverse health effects. Most of this waste is not more dangerous than regular household waste. However, some types of health-care waste represent a higher risk to health. These include infectious waste (15% to 25% of total health-care waste) among which are sharps waste (1%), body part waste (1%), chemical or pharmaceutical waste (3%), and radioactive and cytotoxic waste or broken thermometers (less than 1%). Sharps waste, although produced in small quantities, is highly infectious. Poorly managed, they expose healthcare workers, waste handlers and the community to infections. Contaminated needles and syringes represent a particular threat and may be scavenged from waste areas and dump sites and be reused. WHO has estimated that, in 2000, injections with contaminated syringes caused: 21 million hepatitis B virus (HBV) infections (32% of all new infections); two million hepatitis C virus (HCV) infections (40% of all new infections); 260 000 HIV infections (5% of all new infections). Epidemiological studies indicate that a person who experiences one needle-stick injury from a needle used on an infected source patient has risks of 30%, 1.8%, and 0.3% respectively to become infected with HBV, HCV and HIV. In 2002, the results of a WHO assessment conducted in 22 developing countries showed that the proportion of health-care facilities that do not use proper waste disposal methods ranges from 18% to 64%.

2 - Health-care waste management may also represent a risk to health

Health-care waste management options may themselves lead to risks to health and no perfect readily achievable solution to manage health-care waste exists. Health-care waste, whether generated at smaller rural clinics or larger facilities, can be managed where adequate well-operated infrastructures exist. However, the volumes of waste generated within large facilities and targeted public efforts (e.g., immunization campaigns) are more challenging, particularly in developing countries where resources may be limited. In these difficult situations for which waste disposal options are limited, small-scale incinerators have been used and are still used as an interim solution in less developed and transitional countries. However, small-scale incinerators often operate at temperatures below 800 degrees Celsius. This may lead to the production of dioxins, furans or other toxic pollutants as emissions and/or in bottom/fly ash. Transport to centralised disposal facilities may also produce hazards to health-care handlers, if not safely managed.

3 Balancing risks to make sound policy decisions in health-care waste management

In addition to risks to health from infectious agents, long-term low-level exposure of humans to dioxins and furans may lead to impairment of the immune system, and impaired development of the nervous system, the endocrine system and the reproductive functions. Short-term high level exposure may result in skin lesions and altered liver function. The International Agency for Research on Cancer (IARC) classifies dioxins as a known human carcinogen. However, most of the evidence documenting the toxicity of dioxins and furans is based upon studies of populations that have been exposed to high concentrations of dioxins either occupationally or through industrial accidents. There is little evidence to determine whether chronic low-level exposure to dioxins and furans causes cancer in humans. Overall, it is not possible to estimate the global burden of diseases from exposure to dioxins and furans because of large areas of uncertainty. In the last 10 years, the enforcement of stricter emission standards for dioxins and furans by many countries * significantly reduced the release of these substances into the environment .
*

Standards: 0.1 ng TEQ/m (Toxicity Equivalence) in Europe to 0.1 ng to 5 ng TEQ/m in Japan according to incinerator capacity.

- Rapid Assessment Tool - e. Monitoring Tool

Mercury in Health Care

WORLD HEALTH ORGANIZATION

POLICY PAPER

WHO core principles for achieving safe and sustainable management

| Public health and environment of35 health-care waste

1 - Background Mercury is a naturally occurring heavy metal. At ambient temperature and pressure, mercury is a silvery-white liquid that readily vaporizes and may stay in the atmosphere for up to a year. When released to the air, mercury is transported and deposited globally. Mercury ultimately accumulates in lake bottom sediments, where it is transformed into its more toxic organic form, methyl mercury, which accumulates in fish tissue.
Mercury is highly toxic, especially when metabolized into methyl mercury. It may be fatal if inhaled and harmful if absorbed through the skin. Around 80% of the inhaled mercury vapour is absorbed in the blood through the lungs. It may cause harmful effects to the nervous, digestive, respiratory, immune systems and to the kidneys, besides causing lung damage. Adverse health effects from mercury exposure can be: tremors, impaired vision and hearing, paralysis, insomnia, emotional instability, developmental deficits during fetal development, and attention deficit and developmental delays during childhood. Recent studies suggest that mercury may have no threshold below which some adverse effects do not occur.

2 - Contribution from the health-care sector and Regulation

Health-care facilities are one of the main sources of mercury release into the atmosphere because of emissions from the incineration of medical waste. The Environment Minister of the Canadian province of Ontario declared on December 2002 that emissions from incinerators were the fourth-largest source of mercury. In the United States, according to US Environmental Protection Agency (EPA) in a 1997 report, medical waste incinerators may have been responsible for as much as 10% of all mercury air releases. Health-care facilities are also responsible for mercury pollution taking place in water bodies from the release of untreated wastewater. According to a 1999 report, health-care facilities may also have been responsible for as much as 5% of all mercury releases in wastewater. Environment Canada estimates that more than one-third of the mercury load in sewage systems is due to dental practice. Dental amalgam is the most commonly used dental filling material. It is a mixture of mercury and a metal alloy. The normal composition is 45-55% mercury; approximately 30% silver and other metals such as copper, tin and zinc. In 1991, the World Health Organization confirmed that mercury contained in dental amalgam is the greatest source of mercury vapour in non-industrialized settings, exposing the concerned population to mercury levels significantly exceeding those set for food and for air. (Source:http://www.who.int/ipcs/publications/cicad/en/cicad50.pdf) According to a report submitted to the OSPAR Commission, in the United Kingdom, annually 7.41 tonnes of mercury from dental amalgam are discharged to the sewer, atmosphere or land, with another 11.5 tonnes sent for recycling or disposed with the clinical waste stream. Together, mercury contained in dental amalgam and in laboratory and medical devices, account for about 53% of the total mercury emissions. Waste incineration and crematoria are also listed as major sources of mercury emissions. Many countries, such as Armenia, Cameroon, Ghana, Honduras, Pakistan, and Peru, recognize the contributions from hospital thermometers, dental amalgams, hospital waste and/or medical waste incinerators but lack quantitative data. Despite the lack of data, there is good reason to believe that mercury releases from the health sector in general are substantial. Some countries have restricted the use of mercury thermometers or have banned them without prescription. A variety of associations have adopted resolutions encouraging physicians and hospitals to reduce and eliminate their use of mercury containing equipment.

http://www.healthcarewaste.org

3 Occupational health hazard The most common potential mode of occupational exposure to mercury is via inhalation of metallic liquid mercury vapours. If not cleaned up properly, spills of even small amounts of elemental mercury, such as from breakage of thermometers, can contaminate indoor air above recommended limits and lead to serious health consequences. Since mercury vapour is odourless and colourless, people can breathe mercury vapour and not know it. For liquid metallic mercury, inhalation is the route of exposure that poses the greatest health risk.

"Water and Sanitation is one of the primary drivers of public health. I often refer to it as Health 101, which means that once we can secure access to clean water and to adequate sanitation facilities for all people, irrespective of the difference in their living conditions, a huge battle against all kinds of diseases will be won." Dr LEE Jong-wook, Director-General, World Health Organization.

Yves CHARTIER http://www.who.int/water_sanitation_health

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http://www.healthcarewaste.org

For More Information WHO Health in the Green Economy www.who.int/hia/green_ economy www.who.int/water_sani tation_health http://www.healthcarewa ste.org Health care waste www.gefmedwaste.org Mercury-free health care www.mercuryfreehealth care.org
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