Transcript Overview of Wastes from Health Care Activities UNEP IETC Osaka, Japan 19 July 2012 Susan Wilburn, Technical Officer Public Health and Environment 1| Public health and environment.

Overview of Wastes from
Health Care Activities
UNEP IETC Osaka, Japan
19 July 2012
Susan Wilburn, Technical Officer
Public Health and Environment
1|
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.
2|
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.).”
3|
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
4|
Public health and environment
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)
5|
Public health and environment
General definition and
characteristics
6|
Public health and environment
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
7|
Public health and environment
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)
8|
Public health and environment
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)
9|
Public health and environment
Process of HC Waste management
•
•
•
•
•
•
10 |
Waste classification
Waste segregation
Waste minimization
Containerization
Color coding
Labeling and signage
Public health and environment
•
•
•
•
•
Handling
Transport
Storage
Treatment
Final disposal of
waste.
Waste management hierarchy
Most preferable
Prevent
Reduce
Reuse
Recycle
Recover
Treat
Dispose
Least preferable
11 |
Public health and environment
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.
12 |
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.
13 |
Public health and environment
Segregation of health-care waste
14 |
Public health and environment
Sharps waste
•Sharps are items that can cause
cuts or puncture wounds,
including:
15 |
•
needles,
•
hypodermic needles,
•
scalpel and other blades,
•
knives,
•
infusion sets,
•
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
16 |
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.
17 |
Public health and environment
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.
18 |
Public health and environment
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
19 |
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.
20 |
Public health and environment
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.
21 |
Public health and environment
• 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.
22 |
Public health and environment
General healthcare waste
General healthcare
waste, similar or
identical to domestic
waste, including
materials such as
packaging or unwanted
paper. 75–90% of waste
generated by healthcare
facilities falls into this
category.
23 |
Public health and environment
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.
24 |
Public health and environment
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 hotel—mostly paper, cardboard,
metal and food waste.
 Much of this waste can be diverted from landfills and can
reduce waste disposal costs through waste recycling.
25 |
Public health and environment
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
•
•
•
26 |
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
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 city’s 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.
28 |
Public health and environment
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
29 |
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.”
30 |
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
31 |
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
32 |
Public health and environment
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
33 |
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
34 |
Public health and environment
•Hydroclave: for health waste steam sterilization and
griding/volume reduction - Guyana
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 .
*
3
3
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
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.
•WHO core principles
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.
•for achieving safe and
sustainable
management
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.
| Public health
and environment
•of35
health-care
waste
•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
36 |
•http://www.healthcarewaste.org
Public health and environment
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
37 |
Public health and environment