UNIVERSITY OF AALBORG, SEPTEMBER 2009 “ERASMUS TEACHING STAFF VISIT” - SEMINAR A

1. UNIVERSITY OF AALBORG, SEPTEMBER 2009“ERASMUS TEACHING STAFF VISIT” - SEMINAR A MEDICAL WASTE Sources, Production Rates, and main Characters Salvatore Nicosia, Assoc. Prof. in Environmental Engineering DIIAA, Dipartimento di Ingegneria Idraulicaed Applicazioni Ambientali, Università di Palermo Viale delle Scienze, 90128 Palermo(nicosia@idra.unipa.it)

2. Classesafter the EuropeanRegulations - 1 European Commission Decision of 3 May 2000 (…) establishing a list of wastes (…) (2000/532/EC) EWC – European Waste Catalogue 2

3. Classes after the European Regulations- 2 EWC – European Waste Catalogue – Abstract CLASS 15 - WASTE PACKAGING; ABSORBENTS, WIPING CLOTHS, FILTER MATERIALS AND PROTECTIVE CLOTHING NOT OTHERWISESPECIFIED 15 01 Packaging 15 01 02 Plastic packaging 15 01 03 Wooden packaging 15 01 04 Metallic packaging 15 01 05 Composite packaging 15 01 06 Mixed packaging 15 01 07 Glass packaging 15 01 08* Packaging containing residues of - or contaminated by - dangerous substances 15 02 Absorbents, …, wiping cloths and protective clothing 15 02 02* Absorbents, …, wiping cloths, protective clothing contaminated by dangerous substances 15 02 03 Absorbents, …, wiping cloths and protective clothing other than those mentioned in 15 02 02 3

4. Classesafter the EuropeanRegulations - 3 EWC – European Waste Catalogue – Abstract CLASS 18 - WASTES FROM HUMAN OR ANIMAL HEALTH CARE AND/OR RELATED RESEARCH (except kitchen and restaurant wastes not arising from immediate health care) 18 01 Wastes from natal care, diagnosis, treatment or prevention of disease in humans 18 01 01 Sharps (except 18 01 03) 18 01 02 Body parts and organs including blood bags and blood preserves (except 18 01 03) 18 01 03* Waste whose collection and disposal is subject to special requirements in view of the prevention of infection 18 01 04 Waste … not subject to special requirements … (e.g. dressings, …, linen, disposable clothing, diapers) 18 01 06* Chemicals consisting of, or containing, dangerous substances 18 01 07 Chemicals other than those mentioned in 18 01 06 18 01 08* Cytotoxic and cytostatic medicines 18 01 09 Medicines other than those mentioned in 18 01 08 18 01 10* Amalgam waste from dental care 4

5. Classesafter the EuropeanRegulations- 4 EWC – European Waste Catalogue – Abstract CLASS 18 - WASTES FROM HUMAN OR ANIMAL HEALTH CARE AND/OR RELATED RESEARCH (except kitchen and restaurant wastes not arising from immediate health care) 18 02 Wastes from research, diagnosis, treatment or prevention of disease involving animals (much as above) CLASS 09 - WASTES FROM THE PHOTOGRAPHIC INDUSTRY 09 01 Wastes from the photographic industry 09 01 01* Water-based developer and activator solutions 09 01 03* Solvent-based developer solutions 09 01 04* Fixer solutions 09 01 05* Bleach solutions and bleach fixer solutions 5

6. Source and nature of the risks from medical waste (EU) (*) provided that cannulae and needles have been removed and that bags have been cleared of organic liquids. Containers of anti-blastic or radioactive medicines excluded. Under the general condition that they do not originate from isolation wards. 6

7. Source and nature of the risks from medical waste (UNEP & WHO – “Guidance Manual for Health-Care Waste Management in Sub-Saharan Countries”) 7

8. A possible correspondence between WHO and EU definitions 8

9. Generation Rates, 1 – The variables Rates depend • primarily, on the nature of the medical cares that are given in each Department making up the whole structure; • strongly, also, on the manner in which medical, assistant and auxiliary staff daily handle and make up the waste. Examples of data sources World, broadly averaged : • WHO- Safe management of wastes from health-care activities. Chapter 2- Definition and characterization. Geneva, 1999. National: • APAT – Agenzia per la Protezione dell’Ambiente Valutazioni quali-quantitative sulla produzione e gestione dei rifiuti speciali sanitari.Rome, 2008 (www.apat.it). Local: • Liberti et al., in Waste Mgmt & Res., 1994 and 1996 9

10. Generation Rates, 2 – Unit Production Indexes • PU1 is the Unit Production Index referred to occupied sleeping accommodation: where MR is the quantity of waste produced in one year (kg/year). PU1represents the quantity of waste produced daily per sleeping accommodation on duty (year average). • PU2 is the Unit Production Index referred to number ofhospitalisations: where R is the number of hospitalisations in one year (or any given time span). PU2represents the average quantity of waste produced per patient admitted. 10

11. Generation Rates, 3 – an overview (after WHO, 1999 – rearranged) 11

12. Generation Rates, 4 – National data from Italy (APAT) 12

13. Methods for surveying and monitoring • Generally speaking, distinct records (*) should be kept of: • municipal-like HCW; • Non-HazardousHCW; • Hazardous – Non InfectiousHCWand • Hazardous – InfectiousHCW. From the recorded data, Unit Production Indexes can be calculated. ( slide 11) • Caution: distribute over the whole park of beds on duty - or over the total medical services given - the amount of waste generated by the labs, divided and associated to similar types produced in the Departments. (*) see among others the broad and thorough Report edited by Simeone, M. G., and coworkers: Il sistema di contabilità dei rifiuti sanitari: una indagine conoscitiva.APAT, Rome (Italy), 2003. 13

14. Generation Rates, 5 – basical everyday’s questions • Do the wastes that are dropped and sealed in the special bins really belong all to the type 18 01 03* (Waste whose collection and disposal is subject to special requirements in view of the prevention of infection)? • Is it sure that it is not being added any non-infectious waste such as type 18 01 04 (Waste … not subject to special requirements …, e.g. dressings, plaster casts, linen, disposable clothing, diapers) or 18 01 09 (Medicines other than … 18 01 08)? • Maybe also types 15 01 02 (Plastic packaging) and 15 01 07 (Glass packaging) are being un-necessarily associated to supposed infectious waste? • Are any leftovers being mixed with supposed infectious waste? • How much do the wastes really weigh? 14

15. Case study: a survey carried out in Palermo, 1 In order to obtain detailed information on generation rates a monitoring work was recently carried out in two major Hospitals in Palermo. The monitoring work consisted in weighing the hazardous waste containers coming from medical care filled up in departments purposely chosen for 15 days. The Departments selected were 4 per hospital, and the same in both hospitals: • General and Emergency Surgery, • 1st Resuscitation, • Emergency Room (in Hospital B has 8 beds), • Oncological DH (= Haematology for Hospital B). 15

16. Table 1 -HCW production: quantities and classes. Hospitals HCW Production [kg] HCW-NH [%] HCW-H [%] Non-Infectious Infectious Hospital A (year 2005) 424.766 2,1 4,0 93,9 Hospital B (year 2006) 133.921 0,04 8,25 91,71 A survey in two Hospitals in Palermo, 2 Some results were rather surprising Wastes labelled as Non-Hazardous are the least of all the fractions! Nearly all Wastes labelled as Hazardous are supposed to be Infectious! 16

17. A survey in two Hospitals in Palermo, 3 Other results for infectious waste are aligned with national statistics (*) relevant for Day Hospital / Day Surgery Departments 17

18. Reasonable values would be (as experimentally determined by APAT, Italy): Why are the apparent densities of Infectious Waste so low? 18

19. We are drawn to suppose that insufficient care is often put by personnel in filling up the bags and cans. 60 dm3 capacity 1/3 full; real waste density 300; apparent density 100! 19

20. Are we able to verify the results? A material balance helps. • Containers cannot be inspected. • So we must make resort to indirect measures and calculations. Liquids exchange Sorted Wastes to treatment and disposal Hospital’s Pharmacy or Procurement Office Medicines, remedies etc. Departments, Laboratories 20

21. How can we forecast the amount and composition of waste? Two examples • A catheter bag weighs 100 g at the purchase • When completely full, it weighs 500 + 100 g • Expected amount of plastics (kg) = N pieces x 0.1 • Expected amount of liquids (kg) = N pieces x 0.5 • An infusion bag weighs 560 g at the purchase • When completely empty, it weighs 60 g • Expected amount of plastics (kg) = N pieces x 0.06 • Expected amount of liquids (kg) = 0 Of course the personnel need clear directions to dispose of used medical devices in the right box among the infectious / non infectious one! 21

22. A common spreadsheet, once entered the data, makes the calculations for us… … down to the results ( slide 25) 22

23. Among hundreds of items purchased by Hospitals, diapers are critical • for their enormous number in hospitals • for the big gain in water content  increased weight after use • (+ 60% and more) • for the high probability that they are dropped in the infectious waste bag even when not prescribed. 23

24. Example of composition of assumed infectious waste when no source - separated collection of glass and plastics is made Without liquids Including liquids 24

25. Correspondence between experimental weighings and forecasts on the short period (a few maonths)is likely not to be perfect 25

26. Concluding remarks • Actually, Health Care Wastes are not huge amounts and are not all infectious • There are enormous margins for a sound management of them; container labelling, staff training etc are the premise for a proper, affordable disposal • Glass separation at the source gives the benefits of recycle (if there are factories for it in the Country!) and of reduction of the amounts in weight and in volume • Plastics separation gives similar benefits, but subtracts Thermal Value to the waste. Therefore, when infectious waste is to be incinerated, auxiliary fuel is required • Incidentally, in the debate about incineration in Europe, USA, Canada, Australia, plastics separation is claimed, although no chlorinated polymers are involved in medical devices. 26