Incineration: Public Health

Impact, Climate Change

Implications and the Ebola
Crisis
Health Care Without Harm &
University of the Philippines College of Public Health
Cocoon Hotel, Quezon City, Philippines
January 28, 2015
Jorge Emmanuel

Precautionary Principle

Embodied in international law (UN

Framework Convention on Climate Change,
Stockholm Convention on Persistent
Organic Pollutants, Rio Declaration, etc.)

Requires that precautionary measures

be taken when an activity threatens
serious harm to human health and the
environment, when the balance of
scientific evidence suggests a
relationship between the activity and
harmful effects

Medical Waste Incineration (MWI)

is a major global source of Dioxins
Europe: 62% of dioxin emissions due to 4 processes,
including MWI
Belgium: MWI accounts for 14% of dioxin emissions
Denmark: MWI is 3rd or 4th largest dioxin source of 16
process groups
Thailand: MWI - highest dioxin source by far of 7 sources
tested
United States:
MWIs third largest source of dioxins: 17% of total
dioxins in 1995
Drop in dioxin emissions from MWI in part due to shift
to non-incineration methods: 2470 g TEQ/yr in 1987 to
477 g TEQ/yr in 1995
Canada:
MWI - largest dioxin source in Ontario province

Dioxins
Short term for polychlorinated dibenzo-pdioxins and dibenzofurans
Family of 210 compounds
Among the most toxic compounds known
to humans
> The most toxic is
2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD)

Persistence of Dioxins
in the Environment
Environmental half-life on surface soil:
9 to 15 years
Environmental half-life in subsurface soil:
25 to 100 years
Volatilization half-life in a body of water:
more than 50 years

Dioxins are Toxic at Extremely Low

Concentrations

Lowest observable adverse effect levels

from animal studies:

Doses at which increased abortions, severe

endometriosis, decreased off-spring survival, etc. are
seen in Rhesus monkeys at 3.5-4 years:
0.000 000 64 mg/kg/day
Dose at which cancer is found in rats at
104 weeks: 0.000 007 1 mg/kg/day

US EPA cancer potency factor (2002):

(0.000 000 000 001 g TEQ/kg/day)-1

Health Effects Related to Dioxin

Classified as a known human carcinogen by

IARC in 1997

Cancers linked to dioxins:

Chronic lymphocytic leukemia (CLL)
Soft-tissue sarcoma
Non-Hodgkins lymphoma
Respiratory cancer (of lung and bronchus,
larynx, and trachea)
Prostate cancer

Health Effects Related to Dioxin

Developmental Effects
Birth defects
Alteration in reproductive systems
Impact on childs learning ability and attention
Changes in sex ratio (fewer male births)
Immune System Impacts
Suppression of the immune system
Increased susceptibility to disease
Male and Female Reproductive Effects

Other Toxic
Pollutants
from
Incineration

Other Organic
Compounds

Trace Metals
including
Lead,
Cadmium,
Mercury

Dioxins &
Furans

Acid Gases
Carbon
Monoxide

Particulate
Matter

Toxic
Incinerator
Ash

Epidemiological Studies related to

health effects of incineration
STUDY SUBJECTS

CONCLUSIONS REGARDING
ADVERSE HEALTH EFFECTS

REFERENCE

Residents living
within 10 km of an
incinerator, refinery,
and waste disposal site

Significant increase in laryngeal

cancer in men living with closer
proximity to the incinerator and
other pollution sources

P. Michelozzi et al.,
Occup. Environ. Med., 55,
611-615 (1998)

532 males working at

two incinerators from
1962-1992

Significantly higher gastric cancer

mortality

E. Rapiti et al., Am. J.

Ind. Medicine, 31, 659-661
(1997)

Residents living
around an incinerator
and other pollution
sources

Significant increase in lung cancer

related specifically to the
incinerator

A. Biggeri et al. Environ.

Health Perspect., 104, 750754 (1996)

People living within

7.5 km of 72
incinerators

Risks of all cancers and specifically

of stomach, colorectal, liver, and
lung cancer increased with closer
proximity to incinerators

P. Elliott et al., Br. J.

Cancer, 73, 702-710 (1996)

Epidemiological Studies related to

health effects of incineration
STUDY SUBJECTS

CONCLUSIONS REGARDING
ADVERSE HEALTH EFFECTS

REFERENCE

122 workers at an
industrial incinerator

R. Wrbitzky et al., Int. Arch.

Occup. Environ. Health, 68,
13-21 (1995)

176 incinerator workers

employed for more than
a year from 1920-1985

Higher levels of lead, cadmium, and

toluene in the blood, and higher levels
of tetrachlorophenols and arsenic in
urine
Excessive deaths from ischemic heart
disease and lung cancer among workers
employed for at least 1 year; significant
increase in deaths from ischemic heart
disease among workers employed for
more than 30 years or followed up for
more than 40 years

Mothers living close to

incinerators and
crematoria in Cumbria,
England, from 1956 to
1993

Increased risk of lethal congenital

anomaly, in particular, spina bifida and
heart defects around incinerators, and
increased risk of stillbirths and
anacephalus around crematoria

T. Drummer, H. Dickinson
and L. Parker, Journal of
Epidemiological and
Community Health, 57,
456-461 (2003)

P. Gustavsson, Am. J. Ind.

Medicine, 15, 129-137
(1989)

Best Available Techniques under the

Stockholm Convention

BAT air emissions performance level:

0.1 nanograms I-TEQ/Normal cubic meter at

11% oxygen

BAT wastewater performance level for

effluents from treatment of gas treatment
scrubbers:
0.1 nanograms I-TEQ/liter

To be achieved by a suitable combination of

primary and secondary measures

Best Available Techniques under the

Stockholm Convention

Primary measures (partial list)

Introduction of waste at 850C or higher;

automation to avoid introducing waste below
850C
Control of oxygen input
Minimum residence time of 2 seconds at 1100C
in the secondary chamber after last addition of
air and 6% O2 by volume (for waste with >1%
halogenated substances)
On-line monitoring for combustion control (T,
oxygen, carbon monoxide, dust), and regulation
from a central console.

Best Available Techniques under the

Stockholm Convention

Secondary measures
Dedusting
Fabric filter operating below 260C
Ceramic filter used between 800 to
1000C
Cyclones for pre-cleaning
Electrostatic precipitators around
450C
High performance adsorption units
with activated carbon

Best Available Techniques under the

Stockholm Convention

Secondary measures
Techniques for further
emission reduction

Catalytic oxidation
Gas quenching
Catalyst-coated fabric filters
Different types of wet or dry
adsorption systems using mixtures
of activated charcoal, coke, lime and
limestone solutions

Best Available Techniques under the

Stockholm Convention

Monitoring
Routine monitoring of: CO, oxygen,
particulate matter, HCl, SO2, NO2, HF, air
flows, temperatures, pressure drops, and pH
Periodic or semi-continuous measurement of:
polychlorinated dioxins and furans

Stringent emission limits

All reference conditions: 273K, 101.3kPa, 11% O2, dry; Small 200 lbs/hr, medium > 200 to 500 lbs/hr, and large > 500 lbs/hr.
For half hour averages, at least 97% of concentrations must meet the first value and 100% must meet the second value.

Comparison of Capital Costs

Incinerators with Air Pollution Control

Autoclaves

Some Trends: Medical Waste Incineration (MWI)

600

554

Canada

Germany
MWIs

400
200
0
0
1984

2002
200
MWIs

On-Site MWIs

United States

Portugal

50
40
30
20
10
0

40

1
1995

Ireland
150

150
100
50

0
1990s

2005

2004

Non-Incineration Treatment Options

Treatment technologies

Autoclaves- various sizes

Autoclaves with shredders
Hybrid autoclaves
Continuous steam treatment systems
Batch microwave units
Continuous microwave units
Frictional heating units

Medical Waste Management is not a

Technology but a System

Waste Classification
Waste Segregation
Waste Minimization
Containerization
Color Coding
Labeling, Signage
Handling
Transport
Storage
Treatment
Final Disposal
Contingency Plans
Wastewater Treatment

Policies, Roles and

Responsibilities
Written Procedures
Plans & Roadmap
Training

Periodic, multi-level training

Certification

Organization

HCWM committee, HCWM

coordinator

System of Monitoring,
Evaluation & Improvement
Champions, Incentives

Allocating Human &

Financial Resources

India Project (2010-2012)

King George Medical University Hospital:

3000 bed in low-income state, 50 departments
No healthcare waste management, no segregation
Infectious waste thrown on the floor and swept up
periodically by cleaning staff
Infectious waste transported in leaking bicycle carts
Waste dumped at uncontrolled dump sites
in the hospital grounds (scavengers)
Some waste burned in makeshift incinerator

India Project
Dramatic change to a model facility for HCWM
HCWM program sparked development of infection control
program
Active HCWM committee, committed hospital leadership
Strong environmental champions among the staff
Introduction of color-coded segregation bins,
posters, training
Vastly improved internal transport system and
addition of a waste tracking and CCTV system
On-site storage/treatment facility with autoclave & shredder
Post-treatment materials recovery and recycling of plastics,
glass, etc. provides revenues to the hospital
Video documentary
www.gefmedwaste.org

Kyrgyzstan Project (2005-2013)

One of the poorest of the former Soviet
countries
PROBLEM before the project:

No national regulations on medical waste

Little or no segregation of waste
Some hospitals treated infectious waste with
hypochlorite
Many needle-stick injuries and occupational
health issues
Most waste was either dumped untreated
along with regular waste or burned in open
pits

Approach

National assessment (2004)

Developed a model with stakeholder
participation included reusable containers,
waste minimization, and recycling (20052006)
Tested and refined the model at selected
hospitals (2006)
Worked on national regulations
Expanded model nationwide training, local
organization, technology deployment,
monitoring (2007-2013)

Autoclave-based Technology

Results (as of end of 2013)

All hospitals in the country (> 25 beds), all
primary health centers, and many private
clinics use the model (67% of hospital beds)
Hospitals found an average 33% cost savings
compared to previous system of
hypochlorite treatment
Needle-stick injuries and cuts and
occupational exposures were reduced
Every hospitals generated revenue from sale
of recycled plastic and metal

Advantages of re-designing healthcare waste

management around a steam-based technology

The color-coded container can now be reusable Get

rid of the single-use color-coded plastic bags and boxes.

Previously infectious materials can be recycled if they are

properly segregated, sterilized and crushed/shredded.

Expand recycling and waste minimization to recyclable and

compostable non-infectious non-hazardous materials.

Promote segregation to maximize the advantages of steambased technologies.

Shift from a waste management framework to a

resource management framework.

Highlights of the Ebola Crisis

Up to 90% case fatality rate
No know cure
Entire communities were wiped out
One town alone in Sierra Leone has 1,455 orphans

Highlights of the Ebola Crisis

People started dying in the streets in major cities

Hospitals and clinics treating Ebola patients were
overwhelmed some driven away, others on the floor
All schools and businesses shut down, economy ground
to a halt

Highlights of the Ebola Crisis

Doctors, nurses, nurses aides, ambulance

drivers, and burial workers started dying
As of December, 570 doctors, nurses, health
workers have died
Sierra Leone only had 95 doctors and 991
nurses nationwide

Ebola Waste Project (2014)

21296 Ebola cases so far
8,420 deaths so far
Mostly in 3 countries:
Liberia, Guinea, and
Sierra Leone
Problem: What to do with highly infectious
waste at Ebola Treatment Centers?

Initial Solution: Incineration

Heavy black smoke and high levels of HCl
and dioxins
Strong opposition by nearby communities
No technical support provided

Initial Solution: Incineration

Toxic exposures to incinerators and burn

barrels

Initial Solution: Incineration

Problems
PPE has a seam coating that melts at 98C
PPE has flash ignition point of 343C
PPE material has a heat release capacity of about
1560 J/g-K self-sustaining combustion
PPE has a heating value of 46.3 MJ/kg (same as gasoline)

Non-Incineration Solution

Autoclaves by Africans for Africa

Uses mechanical controls instead of computer controls
easier to fix
Rides through power outages that are common in Africa
Uses steam ejectors instead of vacuum pumps less
maintenance problems, waste volume reduced by 40-60%
Installs in one day
Exceeded international
standards by an order
of magnitude

Autoclaving

Ebola is destroyed by autoclaving in seconds

No smoke, no dioxins, no HCl, no toxic air
pollutants
Safe for workers with PPE
Special barrel trolley protects workers from Ebola
exposure
Cheaper than an incinerator

When barrel is full, take to autoclave

Place waste inside stainless steel
barrel and close the lid

Slide barrel into autoclave

Start heating, multi-vacuum and

sterilization cycles

Barrel and trolley are ready to pick

up more waste

www.medi-clave.co.za

Close sliding door

Unlock & rotate barrel to dump

treated waste at the bottom

When finished, open door and

remove sterilized barrel

Recommendations
Do not use the Ebola crisis as an excuse
to bring back incineration.
Incinerators bring with them heavy health
and environmental costs.
Incinerators are not needed to destroy
Ebola.
Autoclaves are now being used effectively
in the Ebola-affected countries.

Photos of the Ebola Work

Photos of the Ebola Work

Photos of the Ebola Work

Global Carbon Dioxide Levels

CO2 levels reached 400 ppm

for the first time in human history
on May 9, 2013

Sources: National Oceanic and Atmospheric Administration, US Department of Commerce; Scripps

Institution of Oceanography

Multiple Indicators of Global Climate Change

Source: Climate Change

2013: The Physical Science
Basis, Working Group I
contribution to the IPCC
Fifth Assessment Report,
September 2013.

Global Temperature Projections

Source: U.S. Climate Change Impacts
in the United States, U.S. Global
Change Research Program, U.S.
Government, 2009.

B1
A2
A1FI

Source: World Development Report:

Development and Climate Change,
The World Bank, 2010

Some Consequences of Global

Warming

Global rise in sea level (1870-2008, and 2100 projection)

Source: Rahmstorf S. et al. 2012: Environ Res

Lett 7 044035

A 40-inch sea level rise is projected

to inundate 5,000 hectares of
Manila Bays coast and affect 2.5
million people.
-- Hulme, M and Sheard, N. 1999:
Climate Research Unit, Norwich

Climate Change Impacts in Southeast Asia (IPCC 4th

Assessment and ADB Reports)

Increased coastal hazard due to larger

tidal variations and intense typhoons
coupled with increased rainfall
More land loss and coastal erosion
due to sea level rise
Bleaching of coral reefs
from higher temperatures
and ocean acidification
Desiccation and shrinkage of freshwater wetlands
More salt-water intrusion affecting coastal freshwater
and groundwater resources due to sea level rise

Sources: Climate Change 2007: Impacts, Adaptation and Vulnerability, Working Group II Contribution to the Fourth Assessment, IPCC Report,
2007; The Economics of Climate Change in Southeast Asia: A Regional Review, Asian Development Bank, April 2009

Climate Change Impacts in Southeast Asia

(IPCC 4th Assessment and ADB Reports)

Increase in precipitation extremes

(torrential rains) in the monsoon season
and with tropical cyclones
Increase in runoff and soil erosion
More areas affected by floods
Changed patterns of runoff & river flows
More heat waves and droughts
that may intensify water shortage
and reduce hydroelectric power
Possible shorter growing seasons

Climate Change Impacts in Southeast Asia

(ADB Report)

Possible drop in agricultural productivity, increase in

crop stress and reduced yields in the Philippines
(versus increased rice yields in Indonesia and
Malaysia)
Graph from: The Economics of Climate
Change in Southeast Asia: A Regional
Review, Asian Development Bank, April
2009

Philippines

Climate Change Impacts in Southeast Asia

(IPCC 4th Assessment and ADB Reports)

Possible increased intensity and spread of forest fires

Disappearing endemic flora and fauna due to changes in

rainfall patterns and climate-related pest infestation (e.g.,
Philippine teak trees [Tectona philippinensis])

Landward migration of mangroves and tidal wetlands (which

will be constrained by human infrastructure)

Possible increased outbreaks

of malaria and dengue

Socioeconomic Impacts of Climate Change

More deaths, destruction and loss of livelihoods due to intense

typhoons, landslides and flash floods

Economic losses due to the impact of water shortage on crops,

especially rice, corn, sugarcane and coconut

Reduced production of fish and marine products due to changes in

ocean circulation, seawater temperature, etc.

Greater food insecurity due to lower agricultural and fish yields,

and worsening social inequality

Higher morbidity & mortality due to thermal stress, vector-borne

(malaria, dengue) and water-borne diseases

Loss in GDP
Philippines, Indonesia, Thailand
& Vietnam (left) vs global (right)
GDP loss projection
[ADB Report, 2009]

Projected Timing of Climate Change

When will the climate change to a state continuously

outside the bounds of historical variability?

Unprecedented climates will occur earliest in the tropics

and among low-income countries .

Collaborative study by
(University of Hawaii at
Manoa and University of
Ryukus, Okinawa)

Source: C. Mora et al., The projected timing of climate departure from recent
variability, Nature 502, 183-187 (10 December 2013).

CONCLUDING SLIDES

Likely Consequences of a Return to Incineration

More health facilities will ignore segregation
and waste minimization
Incinerators will not meet increasingly
stringent dioxin standards due to cost
dioxins released during transient conditions
Dioxin limits will not be enforced due to
cost, lack of enforcement mechanisms, and
inability to test in-country (or unqualified
labs will manipulate results)
Dioxins will impact the health of current
and future generations

Concerns regarding pyrolysis, gasification,

waste-to-energy plants

Technology issues (see my Youtube videos)

High levels of furans and other pollutants
Lack of monitoring and enforcement
Very high costs
(W2E plant closures due to less waste)
TECHNOLOGIES THAT REQUIRE WASTE AS
INPUT TO OPERATE AND MAKE A PROFIT
ENCOURAGE MORE CONSUMPTION
OF MATERIALS, MORE USE OF ENERGY,
AND THE GENERATION OF MORE WASTE

VISION OF AN ALTERNATIVE PATH

Conservation of earths resources
Towards Zero-Waste
Renewable clean energy

If we install roof-top solar panels on 6 million

homes, we can generate the equivalent of all of
the countrys annual electricity consumption.
(California added 6 GW
in rooftop solar alone
in 2013)

My dream / my vision:
Most homes, schools, government
offices, and commercial and industrial buildings
have rooftop
. solar PVs.
Large-scale concentrated solar and wind farms and other clean
renewable sources provide the bulk of grid power.
Reforestation is successful, mangrove forests protect more coastal areas,
and urban centers have more green spaces.
Communities, especially on the coasts and flood plains, are resilient to climate change and no
one dies during intense typhoons, storm surges, and flash floods.
The agricultural, fisheries, and other sectors have adapted to climate change; no one goes
hungry, and everyone has access to quality health care.
The air is cleaner, cars run on solar, and cities are healthier and more livable.
There is greater social equity and the country follows a green,
low-carbon, climate-resilient path of development.
There is a critical mass of professionals, researchers
and educators committed to sustaining
this vision.