Managing Medical Waste

1. Managing Medical Waste Session 5: Infection Control Basics

2. Learning Objectives • Understand that most hospital waste materials are not more dangerous than household waste, but keeping used sharps and needles from staff and public access is a priority • Learn ways to minimise waste • Know the criteria for safe management of sharps

3. Part I: Health Care Waste Overview

4. Definitions of Waste Health care waste • All types of waste from all health care activities Hazardous health care waste • Waste that presents a health hazard of some kind • Note: Most health care waste is no more hazardous than household waste

5. Flammable Toxic - mutagenic, cytotoxic, teratogenic, etc Reactive Allergen, contact sensitiser Explosive Infectious Radioactive Corrosive Caustic Alcohol Cancer chemotherapy, tar-based products Sulphuric acid, chlorine powder Glutaraldehyde Picric acid, fertiliser, ammonia TB cultures Barium enema, X-rays Bleach Lye Types of Hazards to Consider

6. Infectious hazard: Anatomic waste Laboratory cultures Sharps Live viruses Corrosive, teratogenic, reproductive hazard: Heavy metals Pesticides Cleaning products Pressurised containers Mercury Cancer therapy Hazardous Health Care Waste

7. Yes! IF needles and syringes are scavenged and re-used, then many diseases can be spread Keep used sharps and syringes out of public access No! Most medical waste does not have more germs than household waste It causes visual pollution, generates fear, but unless re-use of sharps occurs, medical waste causes little disease Is Health Care Waste an Important Source of Infectious Disease?

8. Then Why does this Waste Matter? • Sharps injuries may harm workers and communities • Medical waste potentially impacts patients, workers, community, and economy because of the volume and permanence of waste

9. Health Care Institutions Generate about 3.5 kg of Waste per Bed per Day Health care waste may: • Contain infectious organisms, including drug resistant ones • Place cancer causing agents into air or ground water • Cause radiation-related illnesses • Contribute to global warming harm atmosphere (CFC containing refrigerant gas) • Cause injury (sharps, explosion) • Cause congenital defects or stillbirth, prematurity, infertility

10. Which Waste to Address First? • IC Committees should START with infectious waste, especially used sharps and microbiological culture waste

11. How to Safely Dispose of Infectious Sharps • Do not recap sharps before disposal • Dispose of sharps at the point of use in a leak proof puncture proof container • Avoid handling, emptying or transferring used sharps between containers • Autoclave highly infectious waste before disposal • Control public access to syringes and medical equipment • Shred, encapsulate and bury according to national legislation

12. For Non-Infectious Hazardous Waste, the Risks Depend on: • Severity of acute or chronic exposure • Duration of exposure • Frequency of exposure • Concentration agent (1% versus 50%) • Individual vulnerability including pregnancy, weight • Route of exposure (skin, respiratory, oral, etc.) • Steps taken to protect (PPE, relieved from immediate contact etc.)

13. Who is at Risk? • Doctors - anesthesiologists, pathologists • Nurses - oncology nurses, OT, ER • Hospital support staff - X-ray assistants, pharmacy, morgue, and lab staff • Cleaning staff - those cleaning sewage lines • General public - those using sharps found in the waste

14. Anesthetic gases Glutaraldehyde Formaldehyde/formalin Cancer therapeutic agents Ethylene Oxide Radiation Asbestos Blood contaminated sharps Bleach Solvents (xylene, toluene, acetone, ethanol) Pesticides, fungicides Heavy metals (mercury, chronium, cobalt, cadmium, arsenic, lead) Latex Strychnine and cyanide Common Hazards

15. 12 Steps to Manage Hazardous Wastes before Disposal 1. Know what hazards you have 2. Purchase smallest quantity needed, and don’t purchase hazardous materials if safe alternative exists **Use mercury-free thermometers

16. 12 Steps to Manage Hazardous Wastes (cont’d) 3. Limit use and access to trained persons with personal protective gear

17. 4. Use Engineering Controls such as Ventilation, Hoods for Select Hazards

18. 5. Get Rid of Unnecessary Stuff • Don’t accumulate unneeded products • Don’t let peroxides and oxidising agents turn into bombs Photo of bomb robot called into hospital to dispose of picric acid.

19. 6. Label with Agent, Concentration and Hazard Warnings • Examples of hazard labels:

20. 7. Communicate about Workplace Hazards • Job description • Posters on doors • Labels on hazards • Give feedback on use of PPE and disposal in evaluation • Role model safe use and disposal • Contact point who is responsible

21. 8. Recycle Products When Possible

23. Group Discussion: Recycling • Why should recycling be promoted? • Which products can be safely and cost effectively recycled in your facility?

24. 9. Segregate Hazards at the Source • Separate sharps and infectious waste where they are used • This prevents injuries that can occur when people sort the trash after it is disposed • Janitors can reinforce separation of sharps waste disposal by reporting sharps in garbage to Hospital Infection Control Committee members

25. 10. Have Written Policies on Waste Disposal • Sharps and infectious waste • Chemotherapy (cancer) • Heavy metals (batteries) • Chemicals Post brief, colorful instructions on walls to remind workers

26. 11. Minimise the Handling of Wastes • Try to eliminate steps that require hazardous wastes to be touched, sorted, transferred from containers, or handled directly

27. 12. Conduct Walk-Around Interviews • Ask about the hazardous substances staff work with, how they dispose of them, and what they need to be able to dispose of them properly • Have a no-blame philosophy that strives to solve problems, NOT to assign blame

28. Part II: Waste Management Methods

29. Options for Specific Types of Waste • Pharmaceutical • Cytotoxic • Other chemical wastes • Heavy metals • Pressurised containers • Radiation • Infectious

30. Pharmaceutical Waste Small amounts: • Disperse in landfill sites, encapsulate or bury on site • Discharge to sewer • Incinerate Large amounts • Incinerate at high temperatures or encapsulate • LANDFILL IS NOT RECOMMENDED

31. Cytotoxic Waste • NEVER LANDFILL or DISPOSE TO SEWER Disposal Options: • Return to supplier • Incinerate at high temperature • Chemical degradation

32. Chemical Waste - Further Recommendations • Keep different hazardous chemicals separate • Do not dispose into the sewers or street • Do not encapsulate large amounts of disinfectants as they are corrosive and flammable • Do not bury large amounts of chemicals

33. Wastes with Heavy Metals • Wastes with mercury, cadmium, lead, arsenic, strychnine, are poisonous (e.g., thermometers, batteries, lead paints, dyes) • Never incinerate or burn • Never dispose of in municipal landfills Best solution: Avoid purchase OR • Recycle in specialised cottage industry or export to countries with specialised facilities • Encapsulation

34. Pressurised Gas Containers • NEVER INCINERATE • Return undamaged gas cylinders and cartridges to the manufacturer for reuse • Damaged containers: empty completely and crush, landfill

35. Radioactive Waste Use requires a national strategy including: • Appropriate legislation • A competent regulatory organisation • Trained radiation protection officer to monitor exposures • Return to the manufacturer Safe handling and disposal of radioactive waste requires a rigorous and relatively complex management scheme

36. Simple Chemical Disinfection • Requires shredding of waste • May introduce strong chemicals into the environment (chorine bleach turns into dioxin when burned) • Efficiency varies • Only the surface is disinfected • Does not disinfect human tissue • Special disposal required to avoid pollution

37. Waste Disposal Options Include • Disinfection – Autoclaving/ Microwaving, treatment, shredding • Land Disposal • Burial • Encapsulation • Incineration • Inertisation • Managed Land-fill • On-site disposal

38. Infectious Waste: Autoclaving • Pressure and temperature • Holding time • Sterility indicators • Type of waste • Followed by shredding / burial / recycled

39. Commercial Disinfection Systems Shred waste, treat chemically, encapsulate Possible advantages: • Encapsulated residue can be placed in landfill • Environmentally friendly • Easy to operate Possible disadvantages: • Requires specialised operators • May be expensive

40. Burying Inside Hospital Premises Apply the following rules: • Access to the site restricted and controlled If waste is retained on site, ensure rapid burial to isolate from animal or human contact • Only hazardous HC Waste to be buried Management controls on what is dumped • Each deposit covered with soil • Site lined with low permeable material-concrete • Groundwater pollution must be avoided Not recommended for untreated hazardous waste

41. Disposal to Land by Encapsulation • Fill metal or plastic containers to 3/4, add: • plastic foam • bituminous sand • cement mortar • clay material • When dry, label and seal containers and landfill • May be used for sharps, chemicals, drugs etc.

42. Incineration Combustible waste turned to ash at temps >800 C • Reduces volume and weight • Residues are transferred to final disposal site • Treatment efficiency depends on incineration temperature and type of incinerator • Not all wastes can be incinerated • Costs vary greatly according to type of incinerator • Produces combustion gases

43. Do not Incinerate Do not incinerate the following: • Plastics especially halogenated plastics (e.g. PVC) • Pressurised gas containers • Large amounts of reactive chemical waste • Radioactive waste • Silver salts or radiographic waste • Mercury or cadmium • Ampoules of heavy metals

44. Advantages of Incineration of HC Waste: • Good disinfection efficiency • Drastic reduction of weight and volume • Good for chemical + pharmaceutical waste

45. Disadvantages of Incineration of HC Waste: • Doesn’t destroy chemical waste at lower temperature for rotary kiln • Toxic air emissions if no control devices in place • Maintaining temperature levels (and efficiency) in field incinerators is difficult, need to balance loads with non-hazardous materials • High costs for high temperature incineration

46. Land-fill in Municipal Landfills If hazardous health-care waste cannot be treated or disposed elsewhere: • Designate a site for hazardous HC Waste • Limit access to this place • Bury the waste rapidly to avoid human or animal contact • Investigate more suitable treatment methods

47. Because no Disposal Method is Easy or Completely Safe… Prevention is best! • Eliminate purchase by buying safer alternatives • Recycle • Use smallest quantities possible, use with engineering controls and Personal Protective Equipment • Segregate hazards into separate waste streams at source • Supervise disposal using best available ecologic option

48. For More Information: • Safe Management of wastes from health-care activities. Edited by A Prüss, E Giroult, P Rushbrook. Geneva World Health Organisation. 1999. 228 p. Available online. Includes a teachers guide • www.healthcarewaste.org. A website managed by the working group on waste

49. More Free References • http://www.healthcarewaste.org, Health Care Waste Management at a Glance • “First, do no harm.” WHO/V&B/02.26 • Available at www.healthcarewaste.org/linked/onlinedocs/4-bd-704.pdf. Contains information about the disposal options for sharps

50. Thank You!