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Public health and environment1|

Overview of Wastes fromHealth Care Activities

UNEP IETC Osaka, Japan

19 July 2012

Susan Wilburn, Technical Officer

Public Health and Environment


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Key Points

Of the total amount of waste generated by health-careactivities, 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 areadministered 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, health-care workers and the general public.


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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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Categories of health care waste

Sharps: Used or unused sharpse.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 containpathogens (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 materialcontaminated 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 nolonger 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 haveboth direct and indirect health consequences for health

personnel, community members and the environment.

Direct consequences when disposable materials (especiallysyringes) are intentionally re-used

Indirect consequences in the form of toxic emissions frominadequate burning of medical waste, or the production ofmillions of used syringes in a period of three to four weeksfrom an insufficiently well planned mass immunizationcampaign


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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 bloodborneviruses. 21% of the injuries occurring during the disposal process(Gabriel 2009)

Waste handlersStudy in Mexico city showed that out of 69 interviewed waste handlers34% (13) reported 22 needle stick injuries between them during thefirst 12 months and 96% had seen needles and syringes in waste(Thompson et al, 2010).

Scavengers retrieving items from dumpsitesIn Pakistan on average scavenger boys who were going throughmedical waste, for collection and resale, experienced three to fiveneedle 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 beenadmitted to hospitals with symptoms of infectious diseases due to contactwith 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 sitesresulting in more direct contact with health care waste (Appleton and Ali,2000)

Local populations affected by the utilization of products recycled fromhealth care waste and the reuse of untreated medical equipment

In India more than 30% of the injections administered each year werecarried out using re-used or inadequately sterilized medical equipment andthat 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 incineratorssaw 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 hierarchyMost preferable

Least preferable

Prevent

Reduce

Reuse

Recycle

Recover

Treat

Dispose


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Waste segregation is key

Careful segregation and separate

collection of hospital waste is the key

to safe, sound management of health-care waste.

Segregation can substantially reduce

the quantity of health-care waste thatrequires specialized treatment.


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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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Segregation of health-care waste


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Sharps wasteSharps are items that can cause

cuts or puncture wounds,

including:

needles,

hypodermic needles,

scalpel and other blades,

knives,

infusion sets,

saws,

broken glass,

and pipettes


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Sharp waste management

Sharps Handling Recommendations

Do not recap needles

Never pass used sharps from one

person to another

Locate needle destroyer andcontainer near the point of

generation to have good visibility

Sharps should be disposed of in

puncture-resistant sharps

containers


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Highly hazardous healthcare wasteHighly 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 diseasessuch 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 internationalinfectious substance symbol


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Sub-categories of hazardous waste:

Chemical waste and pharmaceutical

waste Chemical waste consists ofdiscarded solid, liquid, andgaseous chemicals, forexample from diagnostic andexperimental work and from

cleaning, housekeeping, anddisinfecting procedures.

Pharmaceutical waste includesexpired, unused, spilt, and

contaminated pharmaceuticalproducts, drugs, vaccines, andsera that are no longer requiredand need to be disposed ofappropriately.


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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.

The identity of the chemicals

should be clearly marked on the

containers: hazardous chemical

wastes of different types should

never be mixed.


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Radioactive wasteThe 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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General healthcare waste

General healthcare

waste, similar or

identical to domestic

waste, includingmaterials 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 areblack.


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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.

l f


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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 passiveventilation reduce energy use

Tropical gardens, irrigated by

recycled water, provide fresh fruits

and vegetables for staff and patients

G i h lth t b fit f


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Greening health sector: co-benefits for

patients, health workers and climate

mitigation

Chemical hazards:

Capture and reuse

of waste anesthetic

gases: reproductive

hazards and potent

GHGases*

*Estimated to have a globalwarming potential of 500-3700 X CO2

"Risking their health while

caring for others:

Reproductive health

hazards of germ-killers"NIOSH, Harvard School of Public

Health and Brigham & Women's

Hospital surveyed of 7,000 women

nurses and found numerous potentialoccupational chemical exposures that

doubled or tripled miscarriage risk.

Lawson C et al. Am J Obstet Gynecol.2011 Dec 30Ryan, SM, Nielsen CJ. Global warming potential of

inhaled anaesthetics: application to clinical use.

International Anesthesia Research Society, July 2010,

111(1).
http://www.who.int/water_sanitation_healthhttp://www.who.int/water_sanitation_health


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. . . Examples of mercury elimination

New Delhi, India: the citys public healthsystem is substituting mercury in itshospitals. To date 12 hospitals are inthe process of substitution. (Poster

from campaign on right)

Sao Paulo, Brazil:more than 100 privatehospitals and 34 public hospitals havegone mercury-free

Mexico City, Mexico:The health secretariatannounced in September 2009 that its

system of 28 hospitals and more than200 health clinics would join the WHO-HCWH Initiative and phaseoutmercury-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 andenvironmentally 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

WHOSafe Management of Wastes from Health-care activitiesSecond edition - September 2012


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Special Rapporteur on hazardous waste,

The improper

management and

disposal of medical

waste has an

adverse impact on

the enjoyment of

human rights inmany countries.

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 thanemission limits set forth.

Sept 2011 A/HRC/18/31


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Despite major driving forces - HCWM

remains weak

Lack of existing policies developed and implemented at countrylevel

Resources are mobilized but remains limited and not in phase with

the magnitude of the public health problemDifficulty to find ways or platform to influence decision, e.g.: howlong needle removers will remain as a Yes or No decision while it isintroduced in some countries without safety guaranties

Mass campaigns are to be prepared long in advance to ensure thatthe strategy on site will be able to safely handle huge amounts ofwaste


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Affordable technologies for waste treatment arenot developed in and for low income countriesand are mostly geared towards industrializedcountries

Low cost technologies are often notenvironmentally friendly and safe

In low income countries the trade-off is betweendirect health risks / indirect health risks related topoor strategy or environmental pollution


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Supply Chain

Look for solutions to reduce waste to contribute to improvingsome of the health care waste management problem countriesface

Ultimately, the waste management problem must be addressed at

all levels, from upstream technology development to downstreamwaste minimization and management, to ensure that health carecan be delivered without side effects on health care workers,communities, or the environment

Improvements made by countries by adopting purchase policiesthat consider the waste stream


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Health waste managementSome 25% of health waste is hazardousdeveloping countries are most at

risk due to poor waste management practices.

Energy benefits of energy-waste systems are clearbut may involve a healthpenalty (e.g. emissions of dioxins, pollutants)

- Environmental benefits of mechanical/thermal treatment (e.g.microwaving/autoclaving) are also clearenergy aspects needs more

exploration.

Hydroclave: for health waste steam sterilization and

griding/volume reduction - GuyanaOpen health waste incineration pit Haiti

T l t t W t S it ti H i d h lth


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Tools to support Water, Sanitation, Hygiene and health

care waste interventions in settingsWORLDHEALTH ORGANIZATION

Safe health-carewaste management

POLICY PAPER

1- Unsafehealth-carewastemanagementleadstodeathanddisability

Health-careactivitiesleadtothe productionof wastethatmay leadto adversehealtheffects. Mostof this wasteis not moredangerous thanregular householdwaste. However,sometypes of health-carewasterepresent ahigher risk tohealth. Theseincludeinfectious waste(15%t o25% of totalhealth-care waste)amongwhich aresharps waste (1%),bodypart waste (1%), chemicalor pharmaceutical waste (3%), andradioactiveandcytotoxic wasteor brokenthermometers (less than1%).

Sharps waste, although produced insmallquantities,is highly infectious.Poorlymanaged,they expose health-

careworkers,waste handlers and the communityto infections. Contaminatedneedles andsyringes representaparticular threat andmay bescavengedfrom wasteareas anddump sitesand be reused. WHOhas estimatedthat,in 2000,injectionswithcontaminatedsyringescaused: 21millionhepatitis Bvirus(HBV) infections(32%of allnewinfections); twomillionhepatitis Cvirus (HCV) infections (40%of allnew infections); 260000HIV infections (5% of allnewinfections).

Epidemiologicalstudiesindicatethata personwhoexperiencesoneneedle-stick injuryfrom aneedle usedonaninfectedsourcepatient has risks of 30%,1.8%,and 0.3% respectivelyto becomeinfectedwithHBV,HCVandHIV. In2002,the results of aWHOassessmentconductedin22 developingcountriesshowedthattheproportionof health-carefacilitiesthatdonot use proper wastedisposalmethods ranges from 18%to64%.

2- Health-carewastemanagementmayalso represent a riskto health

Health-carewaste management options may themselves leadto risks to health andno perfect readi lyachievable solution to manage health-carewaste exists. Health-care waste,whether generated atsmaller ruralclinics or larger facilities,can bemanaged where adequatewell-operatedinfrastructuresexist. However, thevolumesof waste generatedwithinlarge facilitiesand targetedpublic efforts (e.g., immunization campaigns) aremorechallenging, particularlyin developing countrieswhereresources maybe limited.In these difficultsituations for whichwaste disposaloptionsare limited,small-scaleincinerators havebeen usedand arestillusedasan interim solution inless developedand transitionalcountries.However, small-scaleincinerators oftenoperateatt emperatures below800degreesCelsius.This mayleadt othe productionof dioxins,furans or othertoxic pollutants as emissions and/or in bottom/flyash. Transportto centraliseddisposalfacilities may alsoproducehazardsto health-carehandlers,if notsafely managed.

3 Balancingriskstomakesoundpolicydecisionsin health-carewastemanagement

In additionto risks tohealthfrom infectious agents,long-term low-levelexposure of humans todioxinsandfurans maylead toimpairmentof theimmune system,and impaireddevelopmentof thenervous system,theendocrinesystem andthe reproductivefunctions.Short-term highlevel exposuremay resultin skinlesionsandalteredliver function.

TheInternational Agencyfor Researchon Cancer (IARC) classifies dioxins as a known humancarcinogen.However, most of the evidence documentingthe toxicity of dioxinsand furans is based uponstudies ofpopulationsthat havebeen exposedto highconcentrations of dioxinseither occupationallyor throughindustrialaccidents.Thereis littleevidenceto determinewhether chronic low-levelexposuretodioxinsand furans causescancer inhumans.Overall, itis notpossibletoestimate theglobalburden of diseasesfrom exposureto dioxinsandfurans becauseof largeareas of uncertainty.

Inthe last 10years, theenforcement of stricteremissionstandards for dioxinsandfurans bymany countriessignificantlyreducedthe releaseof these substancesintotheenvironment

*.

*Standards:0.1ng TEQ/m

3 (ToxicityEquivalence)inEuropeto0.1ngto 5ngTEQ/m

3 inJapanaccordingto

incinerator capacity.

WORLDHEALTH ORGANIZATION

Mercury inHealth Care

POLICY PAPER

1- BackgroundMercuryis anaturallyoccurring heavymetal. At ambient temperaturea ndpressure, mercuryis asilvery-whitel iquidthat readi l yvapor izes andmaystayintheatmosphereforuptoa year. Whenreleasedtotheai r , mercury

is transported and depositedglobally. Mercuryultimately accumulates in lakeb ottom sediments, whereit istransformedinto its moretoxic organic form, methylmercury, whichaccumulates infishtissue.

Mercuryis highlytoxic, especiallywhenmetabolized intomethyl mercury. It maybefatal if inhaled andharmfulifabsorbedthrough theskin. Around 80% of theinhaledmercuryvapour is absorbedinthebloodthroughthe

lungs. It maycause harmfulef fects tothe nervous, digestive,respirato ry, immunesystems andtothe kidneys,besides causinglung damage. Adversehealth effectsfrom mercuryexposurecan be: tremors, impairedvisionand hearing, paralysis, insomnia, emotional instability, developmental deficits during fetal development, and

attentiond eficit andde velopmentaldelays during childhood. Recent studies suggest thatmercury mayhave nothresholdbelowwhichsomeadverseeffects donot occur.

2- Contribution fromthe health-carese ctorand RegulationHealth-carefacilities areoneof themainsources of mercuryrelease intothe atmospherebeca useof emissionsfrom theincineration of medicalwaste. TheEnvironment Minister of theCana dianprovince of Ontariodeclared

onDecember 2002 thatemissions from incinerators werethe fourth-largest sourceof mercury.IntheUni tedStates, accordingto US Envi ronmentalProtectionAgency(EPA) in a1997report, medicalwasteincinerators mayhave beenrespo nsiblefor as muchas 10%of allmercuryair releases.

Health-carefacilities are alsoresponsiblefor mercurypollution taking placeinwate r bodies from therelease of

untreatedwastewater. Accordingto a1999report, heal th-carefaci l iti es mayalso havebeenresponsiblefor asmuchas 5%of allmercuryreleases inwastewat er. Environment Canadaestimates that morethan one-third ofthemercury loadinsewage systems i s due todentalpractice.

Dentalamalgam is the most commonlyuseddental fi l l ingmater ial . It i s amixtureof mercuryanda metalal loy.

Thenormalcomposi tionis 45-55%mercury; approximately30%si l verandothermetals suchas copper, ti nandzinc. In 1991,the WorldHeal thOrganizationconfi rmedthatmercurycontainedin dentalamalgam is thegreatest sourceof mercuryvapour innon-industrialized settings, exposingthe concernedp opulationto mercury

levels s igni fi cantlyexceedingthosesetforfoodand for ai r .(Source:http://www.who.int/ipcs/publications/cicad/en/cicad50.pdf )

Accordingto arepo rt submitted tot heOSPAR Commission, in theU nitedKing dom, annually 7.41 tonnes ofmercuryfrom dental amalgam aredischarged to the sewer, atmosphereor land, with another11.5 tonnes sent

forrecyclingordisposedwi ththe c l inicalwastestream. Together, mercurycontainedindentalamalgam andinlaboratoryand medicaldevices, accountforabout 53% of thetota lmercurye missions.

Wasteincineration andcrematoria arealso listed as majorsources of mercuryemissions. Manycountries, suchas Armenia, Cameroon,Ghan a, Honduras, Pakistan, and Peru, recognize the contributions from hospital

thermometers, dental amalgams, hospital wastea nd/or medicalwaste incinerators but lack quantitativedata.Despi tethelack of data, thereis good reasontobel ievethat mercuryreleases from theheal thsector ingeneral

aresubstantial.

Somecountries have restr ic tedthe useof mercurythermometers orhavebannedthem wi thoutprescr iption. A

varietyof associations haveado ptedresolut ions encouraging physicians andh ospitals toredu ceand eliminatetheir useof mercurycontainingeq uipment.

3 Occupationalhea lth hazardThemost commonpotentialmodeof occupationalexposureto mercury is v ia inhalationof metal li c l i quidmercuryvapours. If not cleanedup properly, spills of evensmalla mounts of elementalmercury, suchas from

breakage of thermometers,can contaminateindoor air above recommended limits and leadto serious healthconsequences. Sincemercuryva pour is odourless andcolourless, people can breathemercuryva pourand not

knowit. Forliquid metallic mercury, inhalationis the routeof exposurethat poses thegreatest healthrisk.

WHO core principles

for achieving safe and

sustainable

management

of health-care waste

- Rapid Assessment Tool

- e. Monitoring Tool

http://www.healthcarewaste.org

"Water and Sanitation is one of the primary drivers of public health
http://www.healthcarewaste.org/http://www.healthcarewaste.org/http://www.healthcarewaste.org/http://www.healthcarewaste.org/http://www.healthcarewaste.org/http://www.healthcarewaste.org/http://www.healthcarewaste.org/http://www.healthcarewaste.org/


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Yves CHARTIER

http://www.who.int/water_sanitation_health

http://www.healthcarewaste.org

"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, ahuge battle against all kinds of diseases will be won."

Dr LEE Jong-wook, Director-General, World Health Organization.

For More Information
http://www.who.int/water_sanitation_healthhttp://www.healthcarewaste.org/en/115_overview.htmlhttp://www.healthcarewaste.org/en/115_overview.htmlhttp://www.healthcarewaste.org/en/115_overview.htmlhttp://www.who.int/water_sanitation_healthhttp://www.who.int/water_sanitation_health


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Public health and environment37 |

For More Information

WHO Health in theGreen Economy

www.who.int/hia/green_economy

www.who.int/water_sani

tation_health

http://www.healthcarewa

ste.org

Health care wastewww.gefmedwaste.org

Mercury-free health carewww.mercuryfreehealthcare.org
http://www.who.int/hia/green_economyhttp://www.who.int/hia/green_economyhttp://www.who.int/water_sanitation_healthhttp://www.who.int/water_sanitation_healthhttp://www.mercuryfreehealthcare.org/http://www.mercuryfreehealthcare.org/http://www.mercuryfreehealthcare.org/http://www.mercuryfreehealthcare.org/http://www.who.int/water_sanitation_healthhttp://www.who.int/water_sanitation_healthhttp://www.who.int/water_sanitation_healthhttp://www.who.int/hia/green_economyhttp://www.who.int/hia/green_economy

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