Overview of Wastes from Health Care Activities UNEP IETC Osaka, Japan 19 July 2012 Susan Wilburn, Technical Officer

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

2. 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, health-care workers and the general public.

3. 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.).”

4. Categories of health care waste • Sharps: Used or unused sharpse.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

5. 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 propertieswaste 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)

6. General definition and characteristics

7. 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

8. Health Care Waste ManagementExposed 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)

9. 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)

10. Process of HC Waste management • Waste classification • Waste segregation • Waste minimization • Containerization • Color coding • Labeling and signage • Handling • Transport • Storage • Treatment • Final disposal of waste.

11. Waste management hierarchy

12. Waste segregation is key • Careful segregation and separate collection of hospital waste is the key to safe, sound management of health-care waste. • Segregation can substantially reduce the quantity of health-care waste that requires specialized treatment.

13. 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. 3 1

14. Segregation of health-care waste

15. Sharps waste • Sharps are items that can cause cuts or puncture wounds, including: • needles, • hypodermic needles, • scalpel and other blades, • knives, • infusion sets, • saws, • broken glass, • and pipettes

16. 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

17. 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.

18. 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.

19. 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

20. Sub-categories of hazardous waste: Chemical waste and pharmaceutical waste • Chemical waste consists of 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.

21. 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. • The identity of the chemicals should be clearly marked on the containers: hazardous chemical wastes of different types should never be mixed.

22. 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.

23. 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.

24. 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.

25. 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.

26. 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 • 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

27. Greening health sector: co-benefits for patients, health workers and climate mitigation Chemical hazards: • Capture and reuse of waste anesthetic gases: reproductive hazards and potent GHGases* *Estimated to have a global warming potential of 500-3700 X CO2 "Risking their health while caring for others: Reproductive health hazards of germ-killers" 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 • Ryan, SM, Nielsen CJ. Global warming potential of inhaled anaesthetics: application to clinical use. International Anesthesia Research Society, July 2010, 111(1).

28. . . . 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 WHO-HCWH Initiative and phase –out mercury-based medical devices.

29. 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

30. 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.” 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

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

32. 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

33. 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

34. 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. • Hydroclave: for health waste steam sterilization and griding/volume reduction - Guyana • Open health waste incineration pit –Haiti

35. Tools to support Water, Sanitation, Hygiene and health care waste interventions in settings • - Rapid Assessment Tool - e. Monitoring Tool • WHO core principles • for achieving safe and sustainable management • of health-care waste • http://www.healthcarewaste.org

36. "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 CHARTIERhttp://www.who.int/water_sanitation_health • http://www.healthcarewaste.org

37. For More Information WHO Health in the Green Economy www.who.int/hia/green_economy www.who.int/water_sanitation_health http://www.healthcarewaste.org Health care waste www.gefmedwaste.org Mercury-free health care www.mercuryfreehealthcare.org