Healthcare Waste Management in Lebanon Samar Khalil 6 June, 2012

Outline Types of Healthcare Wastes AGENDA Sub headline Types of Healthcare Wastes Impact of Mismanagement of Healthcare Waste Healthcare waste management in Lebanon Legal Framework

Hazardous Infectious Waste Hazardous Non- Infectious Waste Types of Healthcare Wastes AGENDA Sub headline 1 2 Hazardous Infectious Waste 3 Hazardous Non- Infectious Waste Non- Hazardous Waste Paper Food Packaging Plastics Glass Sharps (needles) Waste contaminated with blood and body fluids Used X-ray fixer solution Amalgam (containing silver and mercury) X-ray developer Lead foils, shields and aprons Cleaners for X-ray developer systems Chemiclave/Chemical sterilant solutions Disinfectants, cleaners and other chemicals Example text

Wastes that need special treatment Types of Healthcare Wastes AGENDA Sub headline 4 5 Wastes that need special treatment Radioactive Waste Expired Pharmaceuticals Pathological waste Cytotoxic waste Sharps (needles) Waste contaminated with blood and body fluids Example text

Exposure to hazardous infectious waste Impact of Mismanagement of Healthcare Waste Occupational & Public Health Risks Occupational & Public Health Risks Exposure to hazardous infectious waste AIDS; Gastroenteric infections; Respiratory infections; Ocular infection; Genital infections; Skin infections; Anthrax; Meningitis; Haemorrhagic fevers; Septicaemia; Bacteraemia; Candidaemia; Viral hepatitis A, B and C

Impact of Mismanagement of Healthcare Waste Occupational & Public Health Risks Occupational & Public Health Risks Source: Safe management of wastes from health-care activities/ Chapter 3: Health Impacts of Health-care waste – WHO Geneva 1999.

Exposure to hazardous non- infectious waste Exposure to Mercury vapors Impact of Mismanagement of Healthcare Waste Occupational & Public Health Risks Occupational & Public Health Risks Exposure to hazardous non- infectious waste Intoxication; Burns; Injuries to the skin, the eyes, or the mucous membranes of the airways; Mercury waste: Inhalation of mercury vapor leads to damage in the central and peripheral nervous systems, lungs, kidneys, skin and eyes. It also affects the immune system and is mutagenic. Exposure to Mercury vapors

Mercury level in dentists’ hair Impact of Mismanagement of Healthcare Waste Impact of Mismanagement of Healthcare Waste Occupational & Public Health Risks Occupational & Public Health Risks Occupational & Public Health Risks Mercury level in dentists’ hair Among ninety-nine dentists in Beirut, 25.25% had a mercury level above the safe baseline of 5 µg/g. Of those, 7.07% had a concentration approximately 10 µg/g. Example text Harakeh, S., Sabra, N., Kassak, K., & Doughan, B. (2002). Factors Influencing Total Mercury Levels Among Lebanese Dentists. The Science of Total Environment .

Impact of Mismanagement of Healthcare Waste AGENDA Sub headline Indirect Risks Via the Environment 1 2 3 Soil Pollution Air Pollution Water Pollution Leakage of contaminants into the soil as a result of: Inappropriate disposal of mixed Healthcare and Municipal waste. Indiscriminate dumping of incinerator ash containing toxic heavy metals such as Mercury. Open burning of healthcare waste especially that containing plastics (PVC) release of carcinogens such as Dioxins and Furans. Surface water contamination due to: Runoff from indiscriminate dumping. Direct discharge of untreated waste water. Ground water contamination due to: Leakage from inadequate disposal sites. Example text

Healthcare Waste Management Lebanon Current Situation The quantity of infectious healthcare waste generated per day is estimated at 8,200 kg/day. The quantity of infectious healthcare waste generated per bed per day is estimated at 1 kg. Cost of transportation and treatment of infectious healthcare waste in Lebanon ranges between 0.55- 0.75 USD/Kg.

Legal Framework AGENDA Sub headline Laws Law 64/1988: Conservation of the environment against pollution from hazardous waste and hazardous materials Law 387/1994: Ratification of Basel Convention on the Control of Trans- boundary Movements of Hazardous Wastes and their Disposal 1 The law punishes crimes related to breaching of the terms of the various stages of management of hazardous waste. Sanctions include responsible and people who know about the crime and refrain from reporting it to concerned authorities. Sanctions range from payment of fines to death penalty. 2 Controls trans-boundary movements of hazardous waste (including hazardous healthcare waste). The only legitimate trans-boundary shipments of hazardous waste are exports from countries without facilities, or expertise to dispose safely of certain wastes, to countries which have both facilities and expertise.

Legal Framework AGENDA Sub headline Laws Law 432/2002: Ratification of Stockholm Convention on Persistent Organic Pollutants Law 444/2002: Protection of the environment 3 Eliminate dangerous POPs, starting with the 12 worst. Support the transition to safer alternatives. Target additional POPs for action. Cleanup old stockpiles and equipment containing POPs. Work together for a POPs-free future. 4 The precautionary principle. The principle of preventive action. The polluter pays principle. The principle of avoiding degradation of natural resources.

Legal Framework Decrees, Decisions & Circulars AGENDA Sub headline Decrees, Decisions & Circulars Decree 13389/2004: Determining the types of waste from healthcare facilities and their disposal Decision 52/1/1996: Standards and Limits for the Prevention of Air Water and Soil Pollution Standards for water. Standards for wastewater. Standards for air emissions. 2 1 Defines the types of HCW; Requires proper waste segregation and waste minimization; Sets some guidelines for the collection, storage, treatment and disposal of the different types of wastes; Requires an EIA study for licensing HCWT facilities. Gave HCF 120 days for compliance with the decree. Decision 8/1/2001: Standards for air emissions, liquid effluents, and waste water treatment plants 3 Standards for wastewater. Standards for air emissions. Circular 11/1/2011: Trimestrial Report for Infectious Healthcare Waste Treatment Unifies the trimestrial reports submitted by HCWT facilities to the Ministry of Environment. 4

THANK YOU! For further information: www.gefmedwaste.org Contact: s.khalil@moe.gov.lb

Introduction to the Project Pilot Facilities Demonstrating Best Techniques & Practices for Reducing HCW to Avoid Releases of Dioxins and Mercury AGENDA Sub headline Introduction to the Project Pilot Facilities

Intro to the Project Introduce and Evaluate the Use of Mercury-Free Devices India Tanzania Philippines Vietnam Lebanon Senegal Latvia Argentina Update Policies Develop Training Material & disseminate information Establish Model Facilities Objective To demonstrate and promote best practices and techniques for health-care waste management in order to minimize or eliminate releases of persistent organic pollutants and mercury to the environment Evaluate Available Non-Incineration Treatment Technologies

Model Facilities Baseline Assessment Policies and Procedures Update Onsite survey conducted at both model facilities 1 Policies and Procedures Update Waste Management Program Organizational structure and resources’ allocation Policies & Procedures Waste Handling Capacity Building 2 Mercury Phaseout Comparative Evaluation of Mercury Free Thermometers Policies and Procedures Replacement of thermometers 3

THANK YOU! For further information: www.gefmedwaste.org Contact: s.khalil@moe.gov.lb

1 Challenges Opportunities Challenges for the Management of Healthcare Waste in Lebanon AGENDA Sub headline Challenges Opportunities 1 Lack of national expertise in HCWM Lack of infrastructure for disposal of some types of HCW (cytotoxics, chemicals, etc...) Low level of legal enforcement (though improving) Lack of national strategies and plans for the management of chemical and hazardous wastes. Lack of national capacity for the testing and laboratory analysis of dioxins. Lack of national standards in relation to dioxins emission limit values in residues and air. Replication at the national level Setting legal framework for compliance with HCWM guidelines, and standards. Coordination with different stakeholders (ie.: MoPH: accreditation & licensing ) Certification of HCWM personnel Coordination with the academic sector (i.e.: integration of a HCWM module in the curricula)

THANK YOU! For further information: www.gefmedwaste.org Contact: s.khalil@moe.gov.lb