Health Care Without Harm Environmentally Responsible Management of Health-Care Waste With a Focus on Immunization Waste Working Draft, October 2002 Comments and suggestions on the document are welcome. Send comments to: <firuzeh@essential.org> Health Care Without Harm 1755 S Street NW, Suite 6B Washington, DC 20009 USA

Waste Management Strategies First Things First Eliminate unnecessary injections Product selection and purchasing Workers as the front-line of defense Rigorous training Immunization Segregation is key Proper containerization, secure transport & storage Non-burn treatment technologies Proper disposal

Guidelines Guidelines for Central Planners Guidelines for Local Managers Practical Procedures Treatment and Disposal Options Guidelines are adapted from valuable existing documents: Management of wastes from immunization campaign activities (UNICEF) Safe Management of Wastes from Health Care Activities (WHO) First, do no harm (SIGN, draft 2002)

Toxic Pollutants From Medical Waste Incinerators Air Emissions trace metals: As, Cd, Cr, Cu, Hg, Mg, Ni, Pb acid gases: HCl, SO2, NOx dioxins & furans, including 2,3,7,8-tetrachlorodibenzo-p-dioxin other organic compounds: benzene, toluene, xylenes, chlorophenols, vinyl chloride, polycyclic aromatic hydrocarbons, etc. carbon monoxide particulate matter pathogens (under conditions of poor combustion) Ash Residues: metals, dioxins & furans, other organics Medical waste incinerators are a major source of dioxins & mercury in the environment.

Health Impacts of Incinerator Emissions Incinerator emissions have been linked to: lung, laryngeal, stomach and other cancers ischemic heart disease urinary mutagens and promutagens elevated blood levels of various toxic organic compounds and metals

Stockholm Convention on POPs Stockholm Convention on Persistent Organic Pollutants (POPs Treaty) Adopted in May 2001 Article 5: countries will take measures to further reduce releases of POPs with the goal of ultimate elimination Annex C First in the list of POPs from unintended production: Dioxins and Furans Source with the potential for comparatively high formation and release of dioxins and furans: Medical Waste Incinerators

De Montfort Combustion Efficiencies* Organic Emissions are 20 to 400 times above the South African limit India S. Africa * Organic Emission Fraction = 1 - Combustion Efficiency Field Test: DM1, DM2, DM3, DM4 ; Lab Test: DM5, DM6

De Montfort Incinerator Does Not Meet Environmental Standards Fails to meet combustion temperatures limits Fails to meet residence time requirements Exceeds opacity limits Fails to meet combustion efficiency standards Exceeds limits on particulate matter Exceeds some limits on metals Violates stack height requirements without modification Has no pollution control, no controls on temperature and air input, no safe ash removal system Could release significant quantities of dioxins, furans, mercury and other toxic pollutants

Summary of Field Investigations Incinerators (1-2 yrs old) poorly maintained & operated Broken ash doors and/or chamber doors, heavily corroded, clogged air vents, sharps waste around incinerator, etc. All waste burned including … PVC plastics (e.g., IV bags) and mercury thermometers Non-infectious, recyclable and compostable waste (despite segregation practices or policies) Large quantities of unburned material in the ash Ash improperly disposed of in every case Smoke visible from incinerators; in some cases, smoke coming out of chamber door and air inlets Incinerators near populated areas

Heavy Smoke From Incinerator Operator Using Motorcycle Helmet Courtesy of P. Madhavan

Soot & Molten Plastic (?) Coming Out of Ash Door Courtesy of Bradley Hersh

Undestroyed Needles On the Ground Around Incinerator Courtesy of Shibu K. Nair

Problems of Promoting Incineration Results in Adverse Health Impacts on Health Workers and Communities Pollutes the Environment Weakens Enforcement of Environmental Laws Threatens Worker Safety Undermines Good Waste Management Practices Promotes Dumping of Obsolete Technologies Hampers Deployment of Cleaner Technologies

Low-Cost Options CE Cement Encasing EI Encapsulation With Immobilizing Materials BP Waste Burial Pit or Sharps Pit With Concrete Cover PU Portable Autoclave or Microwave ND Point-of-Use Needle Destruction Technologies ND/m Mechanical Needle Destruction CT Storage, Transport and Centralized Treatment TG Traditional Grinders S Shredders or Hammermills Disposal in Sanitary Landfill Burial in Restricted Sites

Decision Tree 2

Cement Encasing

Encapsulation With Immobilizing Materials

Sharps Waste Burial Pit With Concrete Cover

Basic Autoclave (Simple Retort Design)

Estimates for Cement Encasing Trench volume and cement needed for DTP-HepB-Hib vaccination waste Number of children targeted for vaccination 100 1,000 5,000 10,000 Number of safety boxes 8 75 377 753 Volume of sharps waste (cubic meters) 0.04 0.042 2.12 4.25 Trench volume (cubic meters) 0.08 0.85 8.49 Amount of cement needed (kg) 10 96 478 955 Approximate cost of cement, lime, and sand (US $) $5 $43 $215 $430  

Comparative Costs for Treating 50,000 Syringes

Capital Costs to Treat 1,600 kg/day of Medical Waste in a Region

Health Care Without Harm Environmentally Responsible Management of Health-Care Waste With a Focus on Immunization Waste Working Draft, October 2002 Comments and suggestions on the document are welcome. Send comments to: <firuzeh@essential.org> Health Care Without Harm 1755 S Street NW, Suite 6B Washington, DC 20009 USA