Page 1 of 224

1










Page 2 of 224

2
FOREWORD

Way back in 2004, in the capacity of District Surgeon, I, suggested then Medical
Superintendent, DHQ Hospital Jhang that the hospital should buy an incinerator for waste
disposal. To my surprise Late Dr. Ajmal Ahmdani came up with a big no. He said
Never think of buying an incinerator, it is more a harm than help. You should go for
Autoclave. A totally unexpected answer I was never ready to accept. Look at the
person. He seems totally ignorant. But I did not have enough knowledge to prove my
point. I decided to study the literature to find arguments for proving my point. I searched
books, internet and all available resources. I lost and Dr. Ahmdani won the debate. Now I
had already developed interest in the subject. Literature consistently advocated Autoclave
for the predisposal management of Hospital waste. Then I visited World Wild Life Fund
office in Lahore, where, I was told about presentation of a doctor named Sudheer Joseph
from St. Stephens Hospital, Delhi. I contacted the doctor; planned the trip and visited the
hospital in Nov. 2006. In New Delhi I had the opportunity to visit the central waste
disposal facility managed by the private company Synergy. The facility was catering for
1500 hospitals and was located outside Delhi 3Km away from all the residential areas. A
local NGO with the name of Toxic Links helped me a lot. After that visit I read the
literature again and things became clear in my mind. I realized that very few people in
Pakistan have the idea about waste management. On my return I sought appointment with
Dr. Shagufta ShahJahan, now Director General Environment and discussed the idea of
NO BURNING WASTE with her. She listened to me patiently and finally agreed with
my point. With her help my name was included in WHO collaborated project being run
under Dr. Shakeela Zaman, then Director Health Services Academy Islamabad. In One
and half year after surveys and workshops a national plan was prepared for waste
management in Pakistan. Meanwhile National Programme for Hepititis Control sent a
team to Jhang. This comprised Dr. Rustam and Dr. Mumtaz. I discussed the syringe
disposal programme (Indian model) with them and they liked it very much.
Now the Healthcare waste management became my passion and I founded a society
called Waste Watch &Works in Jhang. 15 clinics participated in our syringe disposal
programme.
When you started discussion some hear, out of them few listen and very few act. It is
amazing that Dr. Mazhar ul Khaliq caught the point and started studying about the
subject. He went forward and decided to write a book. Not an easy decision but finally
the product has come in our hands.
At this point of time when Pakistan is seriously considering Healthcare Waste
Management, the problem needs an exhaustive theoretical workup before launching a
comprehensive plan for the country. In order to understand the depth of subject we
should try to take a multidimensional view of current state of affairs in the World with
particular reference to its application in Pakistan.
1. Paradigm Shift: In the last decade there has been global concern about
incineration hazards due to toxic emissions like DIOXIN & FURANS

and high
Capitol and recurring costs for minimizing the pollution problems in this system
of Healthcare Waste Management. Therefore developed countries started
adopting alternative methods e.g. Autoclaving, Microwaving and Chemical
Disinfection.

Page 3 of 224

3
2. Difference in Circumstances: Third World Countries have limited Resources and
other operational constraints along with peculiar circumstances making it
impossible to replicate the exact models of HCWM of developed nations.
3. Questionable Compliance: New patterns of HCWM e.g. reduction and
segregation of hazardous waste necessitate change in the attitude of the people,
which is a big undertaking in a society of relatively low literacy rate with
longstanding ignorant practices.
Thus,
In PAKISTAN we need to:-
1. Benefit from the research and experiences of developed countries with
customization of methods to fit in our environment.
2. Study HCWM practices in developing countries. In this respect the closest
country with similar environment is India.
In INDIA:-
The country is updating the system of HCWM.
They have started alternative techniques like CHEMICAL DISINFECTION
and AUTOCLAVING.
PVC and other plastics are not incinerated and only body parts are incinerated.
Central Facilities have been developed in many cities. These cater for many
hospitals and are located outside the cities. These have INCINERATOR,
AUTOCLAVES, SHREDDERS and EFFLUENT TREATMENT PLANTS.
SEGREGATION with color coding is being adhered to. They are using four
colors for incinerator, autoclave, recyclable and common waste respectively
with separate system for sharps. *Pictures of St. Stephens Hospital Delhi.
They are considering MERCURY free environment.
The hospitals are establishing EFFLUENT TREATMENT PLANTS.
This Book is going to fill the gap of reference material locally written on the subject and
will be useful to individuals (doctors & Allied personnel) as well as institutions.

















Page 4 of 224

4
INTRODUCTION

In a developing country like Pakistan, the need for a proper Hospital Waste Management
System was long over due. With the given limited physical, human and financial
resources we have the target of improving health conditions countrywide. The importance
of reliable database for planning and management of hospital waste cannot be
overemphasized.
It is a matter of pleasure that we have prepared this important national issue by writing a
book on Hospital Waste Management. This book would not only provide informations
about our needs for prevention of ever growing burden of communicable diseases by a
prompt mechanism of hospital waste management but would also enable to reader to
redefine and prioritize our this health problem on rationale estimates. The author of the
book is directly involved in the management of hospital waste at the institute of cardilogy
Multan as chairman of the hospital waste management committee. In this book the reader
will find basic knowledge about hospital waste & its management according to the
international standards with available scarce resources in a country like Pakistan.
It is my pleasure to extend my personal appreciations for Dr. Mazhar-Ul-Khaliq for the
splendid work in accomplishing this highly extensive and invaluable task.


Dr.Mohammad Mohsin Khan
M.B.B.S., MPH.,PhD
Approved PhD Supervisor
Higher Education Commission
Government of Pakistan



















Page 5 of 224

5


DEDICATED TO MY FATHER

ABDUL KHALIQ
&
MY DAUGHTER
AYESHA MAZHAR
































Page 6 of 224

6



1.1 - INTRODUCTION

Dealing with waste is a challenge common to all human societies.
Nature makes no waste: in healthy ecosystems, one species waste becomes
food for the next, in an endless cycle. Modern societies interrupt this cycle in
three ways.
First, technology has created a wide range of substances that do
not exist in nature. Human discards are thus increasingly comprised of plastics,
metals, and natural materials laced with hazardous substances (for example,
bleached and inked paper), which, in many cases, are difficult or impossible for
natural ecosystems to break down.
Second, industrial societies use and dispose of much more material
per person than their predecessors, and than their counterparts in the less
industrialized world.
Third, rapid population growth increases the number of people and
the total amount of waste generated. As a result, the global ecosystem is
overwhelmed, both quantitatively and qualitatively, with what we discard.
Ultimately, human societies rely on the natural environment for all their material
needs, including food, clothing, shelter, breathable air, drinkable water, and raw
materials for manufacturing and construction. At the same time, all human
discards go to the environment.
When humans were few and of limited technological capability, we
could afford to ignore the relationship between these two processes. Now that we
dominate the global ecosystem, that is no longer the case. At the same time that
we are confronted with rapid destruction and growing scarcity of natural
resources deforestation, declining fisheries, contaminated groundwater, and

Page 7 of 224

7
so on we are producing ever-larger quantities of waste that is more hazardous
than ever.

1.2 - WASTE
Waste is defined as material which no longer has any value to its
original owner, and which is discarded. Wastes are those materials no longer
required by an individual , institution or industry and thus are regarded as by
products or end products of the production & consumption process respectively.

NATIONAL DEFINITION OF WASTE
According to Pakistan Environmental Protection Act - 1997, "waste"
means any substance or object which has been, is being or is intended to be,
discarded or disposed of, and includes liquid waste, solid waste, waste gases,
suspended waste, industrial waste, agricultural waste, nuclear waste, municipal
waste, hospital waste, used polyethylene bags and residues from the incineration
of all types of waste.

Figure 1 - Open area waste site.



Page 8 of 224

8

The main constituents of waste in urban areas are organic waste
(Including kitchen waste and garden trimmings), paper, glass, metals and
plastics. Ash, dust and street sweepings can also form a significant portion of the
waste. Waste is generated by a range of stakeholders including: pedestrians,
households, businesses, markets, industries and healthcare facilities.
Therefore solid waste can also include toxic waste (e.g. chemicals from industry),
biological waste (e.g. dressings from hospitals) and occasionally feaces (e.g.
from nappies). These hazardous wastes require specialized treatment and
disposal, not discussed in this technical brief.
The source of waste often determines its quantities and
characteristics. In developing countries waste generated from various sources
is often combined at collection and disposal, so due care required to ensure the
health and safety of those involved in waste management.

1.3 - TYPES OF WASTE:-
Wastes can be divided into many different types which include
Solid Wastes
Liquid Wastes
Gaseous Wastes
Hazardous Wastes
Radioactive Wastes
Medical Wastes

All the industrial, municipal and Medical wastes consist of the above mentioned
types.





Page 9 of 224

9

1.3.1 - SOLID WASTE
Waste materials which contain less than 70% water contents.
Solid waste generation in Pakistan ranges between 0.283 to 0.612 kg/capita/day
and the waste generation growth rate is 2.4% per year.
Source: - (Draft Environmental Assessment Report, Stockholm, November, 1993).
Pakistan generates 47,920 tons of solid waste per day.
Urban waste: 19,190 tons
Rural waste: 28,730 tons
The industries of chemicals, fertilizers, tanneries, textile units produce
21,173 tons of toxic waste.
Collection efficiency of solid wastes is about 54% in the urban centers.

TYPES OF SOLID WASTE:-
Solid waste can be classified into different types depending on their
source for example:-
Municipal Waste
Industrial Waste
Hospital Waste

MUNICIPAL WASTE:-
Municipal Solid Waste (MSW) is useless or unwanted material
discarded as a result of human or animal activity. Most commonly it is solids,
semisolids or liquids in containers thrown out of houses, commercial or
industrial premises.
Municipal Solid Waste Management (MSWM) is the generation,
separation, collection, transfer, transportation and disposal of waste in a way
that takes into account public health, economics, conservation, aesthetics, and
the environment, and is responsive to public demands.

Page 10 of 224

10

SOURCES OF MSW
Houses: Appliances, newspapers, clothing, disposable tableware, food
packaging, cans, bottles, food scraps, yard trimming.
Commercial buildings: Corrugated boxes, food wastes, office paper, and
disposable tableware.
Institutions: Office paper, cafeteria and restroom waste, classroom wastes,
yard trimmings.
Industries: Corrugated boxes, lunchroom wastes, and office papers, wood
pallets.
Municipal solid waste consists of household waste, construction
and debris, and waste from streets. This garbage is generated mainly from
residential and commercial places. With the change in lifestyle and food habits,
the amount of municipal solid waste has been increasing rapidly.
GARBAGE: THE FOUR BROAD CATEGORIES
Organic waste:
Waste from kitchen, vegetables, flowers, leaves, fruits etc
.

Toxic waste:

Used & expired medicines, paints, chemicals, bulbs, spray cans, fertilizer
and pesticide containers, batteries, shoe polish.
The importance placed upon waste and toxicity minimization in the health care
sector is reflected in a 1997 memorandum of understanding between the
American Hospital Association and USEPA (US environmental protection
agency). This agreement includes a commitment to reduce total waste by one-
third by the year 2005 and by 50 percent by 2010; to virtually eliminate mercury-
containing waste by 2005; and to minimize the production of persistent,
bioaccumulative, and toxic (PBT) pollutants.

Page 11 of 224

11


Recyclable:
Paper, glass, metals, and plastics, etc.

Soiled Waste:
Hospital waste such as cloth soiled with blood and other body fluids.

TABLE 1 - CONTRASTS TYPICAL WASTE CHARACTERISTICS IN LOW &
HIGH INCOME COUNTRIES
Low Income Country High income Country
Generation per household 0.5 Kg 2 Kg
Density 500 Kg cubic meter 100 Kg per cubic meter
Composition
Organic Up to 80% 30%
Paper 5% 40%
Metals Less than 1% 10%
Plastics Less than 1% 2%
Glass Less than 1% 10%
Moisture Contents High Low

INDUSTRIAL WASTE:-
Unwanted materials from an industrial operation; may be liquid,
sludge, solid, or hazardous waste.
FACT SHEET OF INDUSTRIAL CHEMICALS
MANAGEMENT IN PAKISTAN

Our industry imports chemicals worth Rs. 4,500 million and dyes/colors
worth Rs. 5,000 million every year.
Over 500 types of chemicals are being imported in the country for use in
different processing industries.
Local production of chemicals is limited to only a few categories viz. Soda
Ash, sulphuric acid, caustic soda, chlorine, fertilizers, pesticides,
paint/varnishes and polishes and creams.
Import data of 1997-98 indicates that industry imported
3,000 tones of formic acid (a carcinogenic chemical),
2,052 tons phenols,

Page 12 of 224

12
4,200 tons isocyanides,
31 tons of mercury,
22,817 tons inks/dyes,
234 tons Arsenic,
1,615 tons chromium salt and so on
Tanneries located in Kasur and Sialkot have been discharging effluent
with chrome concentration
Ranging between 182-222 mg/liter against the standard of 1 mg/liter and
Chemical Oxygen Demand 5,002-7320 mg/liter against limit of 150
mg/liter prescribed in the NEQs.
Biological Oxygen Demand (BOD) of river Ravi has been found as high as
300 mg/liter as compared to acceptable limit of 9 mg/liter
About 3,600 tons per year of chemical fertilizer is produced in the country.
18,000 tons of pesticides are imported every year.
Another serious issue is that of high content of led in petrol which is
presently 0.35 gms/litre as compared to 0-0.15 gms/litre in other countries
of the region.
Pakistan Medical Association has found dangerous levels of lead in blood
samples of traffic police, children and adults in Karachi, Islamabad and
Peshawar cities.
Sulphur in Diesel is also much higher i.e. 1% as compared to 0.05-0.50%
in other countries of the region.
Sulphur in furnace oil is 3% as compared to 0.5% - 1% in other countries
of the region.








Page 13 of 224

13
TABLE 2 WASTE GENERATION ESTIMATE IN DIFFERENT CITIES OF
PAKISTAN
S.No CItIes CeneratIon
Kglclday
Pate Kglhlday Waste
generatIon
Tonslday
Waste generatIon
Tonslyear
1 KarachI 0.613 4.21 6,450 2,345,250
2 Hyderabad 0.563 3.41 75.7 356.131
3 FaIsaIabad 0.31 2.737 24.3 337,370
4 Peshawar 0.48 3.423 80.3 25,35
5 CujranwaaIa 0.46 3.424 824 300,760
6 annu 0.43 2.41 36.0 13,140
7 uetta 0.378 2.646 378.0 137,70
8 SIbbI 0.283 1.86 17 6,205
TotaI

10,414.3 3,601,221

1.3.2 LIQUID WASTE:-
Liquid wastes, originating from a community. They may have been
composed of domestic wastewaters or industrial discharges.

1.3.3 - GASEOUS WASTE:-
Waste in form of gas is called gaseous waste.

1.3.4 HAZARDOUS WASTE:-
Hazardous Waste is a "waste" which because of its quantity,
concentration, or physical, chemical, or infectious characteristics may posses a
substantial or potential hazard to human health or the environment when
improperly treated, stored or disposed of, or otherwise mismanaged; or Cause or
contribute to an increase in mortality, or an increase in irreversible or
incapacitating illness.


Page 14 of 224

14
NATIONAL DEFINITION
Pakistan Environmental Protection Act 1997 defines Hazardous
waste" as waste which is or which contains a hazardous substance, and includes
hospital waste and nuclear waste.
Pakistan Environmental Protection Act 1997 defines " Hazardous
substance" as a substance or mixture of substance, other than a pesticide
which, by reason of its chemical activity is toxic, explosive, flammable, corrosive,
radioactive or other characteristics causes, or is likely to cause, directly or in
combination with other matters, an adverse environmental effect.

1.3.5 RADIOACTIVE WASTE:-
Liquid, solid ,or gaseous waste resulting from mining of radioactive
ore, production of reactor fuel materials, reactor operation, processing of
irradiated reactor fuels, and related operations, and from use of radioactive
materials in research, industry, and medicine.

Figure 2 - Radioactive waste container with symbol




Page 15 of 224

15

These materials contain the unusable radioactive byproducts of the
scientific, military, and industrial applications of nuclear energy. Since its
radioactivity presents a serious health hazard, disposing of such material is a
great problem. Methods of disposal include dumping concrete-encased
containers filled with radioactive waste in the ocean and burying the waste
underground in old salt mines. In 1996 the United States opened a waste
processing plant in Aiken, S.C. at the Savannah River nuclear-weapons complex.
The waste will be converted into cylinders of radioactive glass, which will then be
encased in steel containers that will be stored in an underground concrete vault.




Figure 3 - Packing Of Radioactive waste







Page 16 of 224

16


Table 3 - WASTE COMPOSITION IN SELECTED COUNTRIES

Location Organics
Paper and
Cardboard
Plastic and
Rubber
Glass Metals
ArgentIna (uenos AIres) 38.4 24.1 13.8 5.2 2.5
razII 52.5 25.5 2. nla 2.3
Egypt (CaIro) 46 21 4 2 2
FInIand 41 37 5 2 3
Hong Kong 37.0 26.6 16.0 3.4 3.1
IndIa (0eIhI, Iow Income) 65 - 71 4.8 4.1 2. nla
IndIa (0eIhI, hIgh Income)
7 - 84

6.3 - .0

7.1 - 8.65

0.85 - 2.2

nla
IreIand 15.1 58.6 10.6 3.4 1.7
Japan (UtsunomIya,
ruraI)
62 17 12 nla nla
Japan (UtsunomIya,
urban)
55 22 12 nla nla
Jordan 61 23 4 4 3
haIaysIa 32.0 2.5 18.0 4.5 4.3
NepaI (Kathmandu) 67.5 8.8 11.4 1.6 0.
PhIIIppInes (hanIIa) 42 1 17 3 6
Puerto PIco (San Juan) 30.5 16.0 37.8 4.4 6.5
PussIa (VoIgograd) 31.7 37 5.2 3.7 3.8
South AfrIca (Cape Town) 60 15.8 11.4 5.7 3.4
TaIwan 27.76 26.37 23.35 7.31 3.73
ThaIIand (angkok) 2 11 1 10 nla
UnIted KIngdom
(HampshIre)
30.3 32.5 12.8 4.2 5.1
UnIted States 23.0 38.1 10.5 5.5 7.8




Page 17 of 224

17



HOSPITAL WASTE

2.1 - INTORDUCTION
Hospital waste is generated during the diagnosis, treatment, or
Immunization of human beings or animals. It is also generated in research
activities in these fields or in the testing of biological materials It may include
sharps, soiled waste, disposables, anatomical waste, cultures, discarded
medicines, chemical wastes, etc. These are in the form of disposable syringes,
swabs, bandages, body fluids, human excreta, etc. This waste is highly infectious
and can be a serious threat to human health if not managed in a scientific and
discriminate manner. It has been roughly estimated that of the 4 kg of waste
generated in a hospital at least 1 kg would be infected.
Undestroyed needles and syringes are being circulated back to
recycling, through unscrupulous traders who employ the poor and the destitute,
to collect such waste for repackaging and selling in the market. Reuse of
disposable like syringes, needles, catheters, IV and dialysis sets are causing
spread of infection from healthcare establishments to the general community.
Disposal of hospital waste and veterinary hospital waste in
municipal dumpsite resulting in animals especially cows feeding on the blood
soaked cotton and plastics, and this in turn leading to diseases like bovine
tuberculosis which through milk can infect humans.
The indiscriminate dumping of untreated hospital waste in
municipal bins is increasing the possibility of survival, proliferation and mutation
of pathogenic microbial population in the municipal waste. This leads to

Page 18 of 224

18
epidemics and increased incidence and prevalence of communicable diseases in
the community.
Incidence and prevalence of diseases like AIDS, Hepatitis B&C tuberculosis and
other infectious diseases increasing due to inappropriate use, storage, treatment,
transport and disposal of biomedical waste.
Chances of vectors like cats, rats, mosquitoes, flies and stray dogs
getting infected are becoming carriers which also spread diseases in the
community.

Figure 4 - Hospital Waste

Pakistan is also facing this problem. Around 250,000 tones of
medical waste are annually produced from all sorts of health care facilities in the
country. This type of waste has a bad affect on the environment by contaminating
the land, air and water resources. According to a report, 15 tones of waste are
produced daily in Punjab. The rate of generation is 1.8 kilograms per day per
bed. The province houses 250 hospitals with a total capacity of 41,000 beds.
Various studies have shown that the rate of hospital waste
generation in USA is 5.9 to 10.4 Kg/bed/day. The possible reason for this high
rate of hospital waste generation is use of disposable items.

Page 19 of 224

19
In the Western Europe this rate varies to 3-6 Kg/bed/day. The daily
production of solid waste in rural hospitals in Sub-Saharan Africa ranges
between 0.3 to 1.5 Kg/bed/day.
A study conducted at District Headquarter Hospital Kusur revealed
that the average waste generation was 2.5 Kg/ Patient / Day.

2.2 WHAT HOSPITAL WASTE IS?

HOSPITAL WASTE is also known as Clinical Waste . Redefining
it scientifically, Hospital Waste is defined as any solid, fluid or liquid waste,
including its container and any intermediate product, which is generated during
diagnosis, treatment or immunization of human beings or animals, in research or
in the production or testing of biological and the animal wastes from slaughter
houses or any other like establishments.




Figure 5 - Worker colleting the Hospital waste


Page 20 of 224

20

2.3 - CLASSIFICATION OF HOSPITAL WASTE

Hospital Wastes are classified into following categories.
1. Infectious Wastes ( Bio-hazardous Waste )
2. Sharps Waste
3. Pharmaceutical Waste
4. Plastics
5. Mercury
6. GLUTARALDEHYDE/ CIDEX

Figure 6 - Healthcare waste characterization


1 - INFECTIOUS WASTE
Infectious wastes are those biomedical wastes which contain
sufficient population of infectious agents that are capable of causing and
spreading infections among people, livestock and vectors. Infectious wastes
include human tissues, anatomical waste, organs, body parts, placenta, animal
waste (tissue / cell cultures), any pathological / surgical waste, microbiology and
biotechnology waste (cultures, stocks, specimens of micro-organism, live or
attenuated vaccines, etc.), cytological, pathological wastes, solid waste (swabs,
bandages, mops, any item contaminated with blood or body fluids), infected

Page 21 of 224

21
syringes, needles, other sharps, glass, rubber, metal, plastic disposables and
other such wastes.

Figure 7 - Infectious waste

Figure 8 - Risk Waste

Page 22 of 224

22

Figure 9 - Packed infectious waste


2 - SHARP WASTE

Sharps consist of needles, syringes, scalpels, blades, glass etc.,
which have the capability to injure by piercing the skin. As these sharps are used
in patient care, there is every chance that infection can spread through this type
of injury. Nurses can get a sharp injury before and after using a sharp on a
patient. Further, sharps discarded without any special containment or
segregation can injure and transmit disease to those who collect waste (including
municipal sweepers and rag pickers). There have been reports that waste
collected from the hospitals are resold, this creates an additional occupational
and community health hazard.

Page 23 of 224

23


Figure 10 - Sharp waste


Sharp Wastes are of two types:-
Chemical Sharps Waste which are contaminated with chemicals.
Radioactive Sharps Waste which are contaminated with radio actives.
3 - PHARMACEUTICAL WASTE
Cytotoxic substances, as the word suggests are toxic to cells and
are often anti-neoplastic which inhibit cell growth and multiplication. These drugs
when come in contact with normal cells can damage them and cause severe
disability or even death of those affected. These drugs could be present in the
waste generated from the treatment of cancer patients or from other work related
to testing and control of cancerous cells.
The importance placed upon waste and toxicity minimization in the health care
sector is reflected in a 1997 memorandum of understanding between the
American Hospital Association and USEPA.

4 - PLASTICS IN HEALTHCARE
Hospitals use plastics because they fear a spread of infection
through the use of reusable medical equipment. Thus, plastic use has grown with
increasing concern for infection control. However, there have been cases where
even with the use of plastics there has been a spread of infection in wards.
Nurses complained of nosocomial infections in wards even though disposable

Page 24 of 224

24
equipment was used they related it to improper waste disposal of disposable
equipment within the wards. PVC is a thermoplastic, with approximately 40
percent of its content being additives. Plasticizers are added to make PVC
flexible and transparent.
Medical equipment made from PVC:
Blood bags, breathing tubes
Feeding tubes, Pressure monitor tubes
Catheters, Drip chamber
IV Containers, Parts of a syringe
IV Components, Lab ware
Inhalation masks, Dialysis tubes

Figure 11 - Plastic Waste in Hospital Theater


Infected plastics are those biomedical plastics which have been
used for administering patient care or for performing related activities and may
contain blood or body fluids or are suspected to contain infectious agents in
sufficient number which may lead to infections among other humans or animals.
These generally include IV tubes / bottles, tubing, gloves, aprons, blood bags /

Page 25 of 224

25
urine bags, disposable drains, disposable plastic containers, endo-tracheal
tubes, microbiology and biotechnology waste and other laboratory waste.

5 - MERCURY: A HEALTH HAZARD
Sources of Mercury in hospitals:
1. Thermometers
2. Blood pressure cuffs
3. Feeding tubes
4. Dilators and batteries
5. Dental amalgam
6. Used in laboratory chemicals like Zenkers solution and histological fixatives.




Page 26 of 224

26

Figure 12 - Manometers


6 - GLUTARALDEHYDE/ CIDEX

Glutaraldehyde is a colorless, oily liquid, which is also commonly
available as a clear, colorless, aqueous solution. It is a powerful, cold
disinfectant, used widely in the health services for high-level disinfection of
medical instruments and supplies and available with trade names such as: Cidex,
Totacide, korsolex and Asep. Glutaraldehyde is a widely used disinfectant and an
agent (commonly available in 1 percent and 2 percent solutions) in medical and
sterilizing dental settings. It is used in embalming (25% solution), as an

Page 27 of 224

27
intermediate and fixative for tissue-fixing in electron microscopy (20 percent, 50
percent and 99 percent solutions) and in X-ray films.

Figure 13 - Cidex


As regards its type and composition, most hospital waste is similar
to household waste and can be disposed of in the same way. In addition to this,
however, hospitals generate certain special types of waste which should not be
handled by domestic refuse collection services, because of the risk of infection,
because they are hazardous in other ways, or for ethical reasons.
Such waste must be collected separately at the places where it is
generated, and disposed of in specially approved plants, e.g., incinerators.
Hence, types of hospital waste may be classified according to the disposal
method.



Page 28 of 224

28
2.4 - TYPES OF HOSPITAL WASTE ON THE BASIS OF DISPOSAL
On the basis of disposal method hospital waste can be classified as
follows.
Type A: Waste which does not require any special treatment.
This is the waste produced by the hospital administration, the
cleaning service, the kitchens, stores and workshops. It can be disposed of in the
same way as household waste.
Type B: Waste with which special precautions must be taken to prevent
infection in the hospital.
This is usually taken to include all waste from inpatient and casualty
wards and doctors' practices, e.g. used dressings, disposable linen and
packaging materials. It only constitutes a risk for patients with weakened
defenses while it is still inside the hospital. Once it has been removed from the
wards it can be handled by the local domestic refuse collection service.
Type C: Waste which must be disposed of in a particular way to prevent
infection.
This is waste from isolation wards for patients with infectious
diseases; from dialysis wards and laboratories, in particular those for
microbiological investigations, which contains pathogens of dangerous infectious
diseases, e.g. tuberculosis, hepatitis infectious diarrheas and diseases which
constitutes a real risk of infection when disposing of this waste. It includes
needles and sharp objects coated with blood, or disposable items contaminated
with stool.
Type D: Parts of human bodies: limbs, organs etc.
This waste originates in pathology, surgical, gynecological and
obstetric departments. It has to be disposed of separately, not to prevent
infection but for ethical reasons.
Type E: Other waste materials.

Page 29 of 224

29


The improper handling, treatment, storage, transport and disposal
of hospital waste can lead to serious problems like:
The entire waste from a healthcare establishment, which includes noninfectious
as well as infectious waste, if unsegregated and untreated is mixed with the rest
of the waste in a healthcare establishment, will convert the entire non infectious
general waste (75-80%) also into infectious waste.
The indiscriminate disposal of sharps within and outside institutions leading to
occupational hazards like needle stick injuries, cuts, and infections among
hospital employees, municipal workers and rag pickers. Injuries due to the sharp
especially among rag pickers and hospital / municipal workers increase the
incidence of Hepatitis B, C, E and HIV.
Incidents and prevalence of infectious diseases are increasing due to
inappropriate use, storage, treatment, transport and disposal of biomedical
waste. Chance of vectors for spread of diseases in the community is an
important factor.

3.1 - SHARPS
Sharps consist of needles, syringes, scalpels, blades, glass etc.,
which have the capability to injure by piercing the skin. As these sharps are used
in patient care, there is every chance that infection can spread through this type
of injury. Nurses can get a sharp injury before and after using a sharp on a
patient. Further, sharps discarded without any special containment or
segregation can injure and transmit disease to those who collect waste (including
ward cleaners, municipal sweepers and rag pickers). There have been reports
that waste collected from the hospitals are resold, this creates an additional
occupational and community health hazard.

Page 30 of 224

30
In developing countries a trend to make money easily has
destroyed all our ethical values. It is a common practice that sanitary staff sells
used syringes to junk buyers. These syringes are then repacked just after boiling.
These used repacked syringes are root cause of AIDs & Hepatitis.
WHO estimated that, in 2000, contaminated injections with contaminated
syringes caused:-
21 million hepatitis B virus (HBV) infections (32% of all new infections);
Two million hepatitis C virus (HCV) infections (40% of all new infections);
At least 260 000 HIV infections (5% of all new infections).



Figure 14 - Disposal of syringes (wrong method as performed without gloves)

3.2 - MEDICAL WASTE INCINERATION

Acid gases include nitrogen oxide, which has been shown to cause
acid rain formation and affect the respiratory and cardiovascular system. As large
amount of plastic are incinerated, hydrochloric acid is produced. This acid attacks
the respiratory system, skin, eyes and lungs with side effects such as coughing,
nausea and vomiting. Heavy metals are released during incineration of medical

Page 31 of 224

31
waste. Mercury, when incinerated, vaporizes and spreads easily in the
environment. Lead and cadmium present in the plastics also accumulates in the
ash. Acute and chronic exposure to lead can cause metabolic, neurological and
neuro-psychological disorders. It has been associated with decreased
intelligence and impaired neurobehavioral development in children.
Cadmium has been identified as a carcinogen and is linked to toxic effects on
reproduction, development, liver and nervous system.





Figure 15 - Estimated Hospital waste generation in South Asia


Page 32 of 224

32

Figure 16 - Estimated per bed waste generation in south asia



3.3 EFFECT OF PLASCTICS:

Disposal of PVC via incineration leads to the formation of dioxin
and furans. Dioxin and furans are unwanted by-products of incineration with
carcinogenic and endocrine-disrupting properties. They are toxic at levels as low
as 0.006 pictograms per Kg of body weight.

3.4 - MERCURY HEALTH HAZARD:
When products containing mercury are incinerated, the mercury
becomes airborne and eventually settles in water bodies from, where via
biomagnifications in the food chain and bioaccumulation, it reaches humans. If it
is flushed, it enters water bodies directly, and if it is thrown in bins it could enter
the body of animals via skin or inhalation, or permeate into the ground causing
soil and groundwater poisoning. This metal accumulates in the muscle tissues.

Page 33 of 224

33
Three major types of mercury are found in the environment methyl mercury,
mercury (zero), mercury (two). Out of these, methyl mercury is the most toxic; it
bio accumulates and has the capability to interfere with cell division and cross the
placental barrier. It also binds to DNA and interferes with the copying of
chromosomes and production of proteins. Pregnant women and children are
most vulnerable to the effects of mercury. The Mina Mata disaster in Japan is an
example of mercury-poisoning via biomagnifications and bioaccumulation.
Mercury exposure can lead to pneumonitis, bronchitis, muscle tremors, irritability,
personality changes, gingivitis and forms of nerve damage.

HOW ARE PEOPLE EXPOSED TO MERCURY?
Many scientists believe the most common way people are exposed
to any form of mercury is by eating fish containing methyl mercury, a highly toxic
form of mercury. Microscopic organisms convert mercury into methyl mercury,
accumulating up the food chain in fish, fish eating animals, and people.
However, recent research indicates that mercury from amalgam
tooth fillings pose a far greater hazard. Between three and seventeen
micrograms per day are secreted as mercury vapor from slow corrosion,
chewing, brushing and grinding of fillings. Also, while methyl mercury ingested
from fish is generally excreted quickly, mercury vapors from amalgams are
secreted slowly over years.
Lesser sources of exposure include mercury vapors in air, ingestion
via drinking water, vaccines, occupational exposures, home exposures including
fluorescent light bulbs, thermostats, batteries, red tattoo ink, skin lightening
creams, and over-the-counter products such as contact lens fluid and
neosynephrine. The EPA warns that metallic mercury is often found in school
laboratories as well as in thermometers, barometers, switches, thermostats, and
other devices found. And, because the effects of mercury toxicity are much more
severe for infants and children, even lesser exposure sources such as
thermometers, vaccines and amalgam tooth fillings are extremely hazardous to
them.

Page 34 of 224

34
Studies show that today in the United States the average persons
body contains about 10-15 milligrams of mercury. Inhaled mercury fumes go into
the blood, as mercury is soluble and passes through the lungs. Some mercury is
retained in body tissues, mainly in the kidneys, which store about 50% of body
mercury. The blood, bones, liver, spleen and fat tissues retain mercury; it also
gets into the brain and nerve tissue, causing many of the previously mentioned
nervous system disorders.
HOW DOES MERCURY ENTER THE ENVIRONMENT?
The largest source of mercury in the air (40%) comes from coal-
fired power plants. Industrial boilers are second (10%). Municipal waste
incinerators are third. Medical waste incineration places the health care sector as
the fourth-largest source of mercury air emissions.
WHY IS MERCURY DANGEROUS?
The neurological hazards of mercury were first noticed when
women gave birth to severely impaired infants after being exposure to high levels
of mercury. The EPA notes it is clear that the developing nervous system of the
fetus may be more vulnerable to methyl mercury than the adult nervous system.
The toxic effects of mercury include autism, Alzheimers, ALS, multiple sclerosis,
Parkinsons, other neurodevelopment problems, Nephrotoxicity and cancer. A
link between mercury and cardiovascular disease has also been recently
established.
INDUSTRIES WITH HIGH POTENTIAL FOR MERCURY
EXPOSURE

Manufacture of barometers and thermometers
Ink and dyes
Dentistry
Dental amalgam fabrication
Hospitals and medical waste
Paint
Neon lights
Mirror manufacturing

Page 35 of 224

35
Paper
Insecticides
Pesticides
Embalming
Explosives and fireworks
Jewelers
Wood preserving
Photography
WHAT CAN YOU DO?
The following recommendations are particularly important for
women who are or might become pregnant, nursing mothers, infants and
children.

Only use products that are mercury-free.
Make sure that you properly dispose of any mercury containing items in your
home (thermometers, fluorescent lamps)
Avoid mercury fungicides and fungicide-treated foods by eating only organically
grown grains and produce.
Do not eat shark, swordfish, king mackerel, Chilean sea bass, albacore (white)
tuna or tilefish because they contain high levels of mercury.
Eat no more than 12 ounces (2 average meals) a week of fish and shellfish that
are lower in mercury: shrimp, salmon, Pollock, catfish, sole, wild Alaskan salmon,
some sardines, and California red snapper.
Check local advisories about the safety of fish caught in local lakes, rivers, and
coastal areas.
Women who eat fish should get mercury levels tested before becoming pregnant.
If you have amalgam fillings, talk to your dentist about safe ways to remove and
replace them with alternative materials.
If you work with mercury, report spills or other exposure; wear protective
equipment; and avoid taking mercury home with you (shower and change clothes
at the end of the day at work).

Page 36 of 224

36
Contact your legislator and demand adequate labeling and identification of
mercury content of fish products and any other food containing mercury.
Oppose the continued use of coal burning power plants as an energy source.

3.5 - GLUTARALDEHYDE/ CIDEX

Aqueous solution is not flammable. However, after the water
evaporates the remaining material will burn. During a fire, toxic decomposition
products such as carbon monoxide and carbon dioxide can be generated.

3.6 - RADIOACTIVE WASTE

Accidents due to improper disposal of nuclear therapeutic material
from unsafe operation of x-ray apparatus, improper handling of radio isotopic
solutions like spills and left over doses, or inadequate control of radiotherapy
have been reported world over with a large number of persons suffering from the
results of exposure. In Brazil while moving, a radiotherapy institute a left over
sealed radiotherapy source resulted in an exposure to 249 people of whom
several either died or suffered severe health problems (International atomic
Energy Agency, 1988). In a similar incidence four people died from acute
radiation syndrome and 28 suffered serious radiation burns.
(Brazil, 1988)










Page 37 of 224

37


The fight against hospital infection demands the cooperation of all
those employed in the hospital: doctors, technicians, nursing and cleaning staff.
This is why one of the most urgent tasks is to convince, train and monitor the
personnel responsible for refuse disposal. Unless they are convinced of the
need, trained and monitored, all efforts to improve the situation will be doomed to
failure.
Hospital waste should always be collected in disposable containers
which satisfy the following requirements: they must be moisture-resistant and
nontransparent; sellable in such a way as to prevent egress of micro-organisms;
safe to transport; and color-coded to distinguish them from household refuse
bags. The waste must be collected in such containers at the point where it is
generated, and removed from the wards daily without being sorted or transferred
to other containers. The containers must be carefully sealed.
Generally, plastic bags are used for Type B and C waste, and
plastic buckets for Type D waste. The material these disposable containers are
made of must be appropriate for the next treatment stage. If the waste is
subsequently incinerated, for example, combustible materials with a low level of
toxicity must be used; if it is heat-disinfected the materials must be steam-
permeable. This requirement also applies, incidentally, to all disposable items
purchased by hospitals.
The waste must be transported to a central incineration plant
outside the hospital in specially designed vehicles which do not compress it. The
interior of the vehicle body must be easy to clean and it must be adequately
ventilated.
A variety of methods, chemical and physical, can be used for
disinfection. To disinfect waste, however, only thermal systems in which the

Page 38 of 224

38
waste is steam treated at temperatures above 105C have so far proved
successful. Disinfection in pressure-resistant installations involves approximately
the same amount of work as incineration, but has the disadvantage that it is not
possible to check visually whether the treatment has been a complete success.
With incineration this is of course possible. For this reason incineration is to be
preferred in countries which have no trained inspection personnel. There are also
devices on the market which shred waste and then disinfect it with liquid
chemicals. These devices are only suitable for small quantities, mostly prone to
breakdowns, and there is no guarantee that the disinfectant fluid will reach all the
waste. They are not suitable for handling all the waste generated by a hospital.

4.1 - SHARPS HANDLING:

Make needle reuse impossible:
Auto disable syringes, like Solo Shot device, cannot be used more than once and
therefore cannot carry infection from one patient to another.

Take the sharp out of sharps waste:
Needle removers de-fang syringes, immediately removing the needles after
injection and isolating them in secure containers. The syringe cannot be reused,
and theres no risk of accidental needle sticks.

Keep needles away from vulnerable hands:
Special stick proof containers capture used needles and other medical waste
until they can be destroyed. PATH is working to increase access to these safety
boxes, identifying low-cost options and making them available for all types of
injections.
Using a needle cutter/destroyer:
1. Place used needle in the cutter/destroyer.
2. Cut/destroy the needle and the nozzle of syringe in the destroyer/cutter.
3. Separate syringes barrel and plunger and put in liquid disinfectant.
4. After every shift empty the contents of needle container/destroyer into

liquid disinfectant, remove through pouring out contents through a sieve.

4.2 - MEDICAL WASTE INCINERATION
Due to poor operation and maintenance, these incinerators do not
destroy the waste, need a lot of fuel to run, and are often out of order. There is a
lot of difference between the theory and practice of incinerator operation. This is
true around the world. The problem of medical waste needs a systematic
approach, with investments in training of staff, segregation, waste minimization

Page 39 of 224

39
and safe technologies, as also centralized facilities. Merely investing in unsafe
incinerators cannot solve it.

4.3 - PLASCTICS IN HELTH CARE
Dos and Donts:
Ensure
1. That the used product is mutilated.
2. That the used product is treated prior to disposal.
3. Segregation
Do not
1. Reuse plastic equipment.
2. Mix plastic equipment with other waste.
3. Burn plastic waste.

4.4 - ALTERNATIVES TO MERCURY BASED INSTRUMENTS

Digital instruments are available as substitutes to the mercury
containing instruments. Costs: The cost of the blood pressure instruments ranges
from Rs. 2000 to 7000 and the cost of thermometers range from Rs 200 to 300

4.5 - WHY ARE THE ALTERNATIVE TECHNOLOGIES BETTER?
These less harmful, non-toxic substitutes pose no environmental or
health hazards and last for a longer duration. The life span of the mercury
instruments, on the other hand, is short because of their fragility. Even though
the initial investment cost of the alternative technologies is high, the assets
associated with them are lifelong.

4.6 - GLUTARALDEHYDE/ CIDEX PRECAUTIONS & SAFETY

Identify All Usage Locations: All departments that use
glutaraldehyde must be identified and included in the safety program. Eliminate
as many usage locations as possible and centralize usage to minimize the
number of employees involved with the handling of glutaraldehyde

Monitor Exposure Levels: Measurement of glutaraldehyde
exposure levels must be conducted in all usage locations.

Training: An in-depth education and training program should be
conducted for all employees who work with hazardous chemicals.

Use Personal Protective Equipment: All employees who work
with glutaraldehyde must be provided appropriate personal protective equipment.
This equipment includes proper eye/face protection, chemical protective gloves,
and protective clothing.

Page 40 of 224

40

Engineering controls: Rooms in which glutaraldehyde is used
should have an arrangement to exchange fresh air for at least 10 times. For this
purpose an active & efficient HVAC System is very important

4.7 - SAFETY MEASURES:

A chain is as strong as the weakest link in it, thus, not even one
person in the hospital should be missed while training is given. The entire staff is
involved in waste management at some point or the other, including
administrators, stores personnel and other, seemingly uninvolved, departments.
To ensure that the waste is carried responsibly from cradle to grave, and to see
that all the material required for waste management is available to the staff, it is
important to involve everyone, including:
Doctors
Administrators
Nurses
Technicians
Ward Boys and ward cleaners

4.8 - INFECTION CONTROL
1. Universal Precautions:

All the healthcare workers being exposed directly or indirectly to
infectious diseases must take Universal Precautions to reduce the chance of
spread of infection.

2. Sterilization and cleaning:

Ensure that the hospital has adequate procedures for the routine,
cleaning, and disinfection of environmental surfaces, beds, bed rails, bedside
equipment, and other frequently touched surfaces, and ensure that these
procedures are being followed. Routine microbiology tests for air and water
contamination should be carried out in all parts of the hospital. Sterilize and
disinfect instruments that enter tissue, or through which blood flows, before and
after use. Sterilize devices or items
that touch intact mucus membranes. In all the autoclave cycles, spore strips
need to be placed to check the efficacy of the machine. Recommended chemical
disinfectants should be used for the storage of instruments and fumigation of
rooms. All the rooms must have proper ventilation.

3. Managing Body Fluid Spillages: Urine, Vomit , Blood & Feaces :

All spillages of body fluids (urine, blood, vomit or feaces) should be
dealt with immediately. Gloves (ideally disposable) should be worn; spillage
should be mopped up with absorbent toilet tissue or paper towels: this should be

Page 41 of 224

41
disposed of into the waste bin meant for soiled waste. Pour 10 percent
hypochlorite solution and leave it for 15 min. Clean the area with a swab. For
spillages outside (e.g. in the playground) wash the area with water. Do not forget
to wash the gloves and then wash your hands after you have taken the gloves
off. Disposal of blood requires special care and protocol.

4. Patient Placement:

A separate room is important to prevent direct/indirect contact
transmission when the patient is with highly transmissible microorganisms, or the
patient has poor hygienic habits.

5. Immunization programmes:

Since hospital personnel are at risk of exposure to preventable
diseases, maintenance of immunity is an essential. Optimal use of immunizing
agents will not only safeguard the health of personnel but also protect patients
from becoming infected by personnel. The most efficient use of vaccines with
high risk groups is to immunize personnel before they enter high-risk situations.

4.9 - HANDLE MERCURY WITH CARE:

NEVER TOUCH MERCURY WITH BARE HANDS.
WEAR ALL PROTECTIVE GEARS.
GATHER MERCURY USING STIFF PAPER AND SUCK IT IN THE
SYRINGE WITHOUT THE NEEDLE
POUR CONTENTS OF THE SYRINGE IN A BOTTLE CONTAINING
WATER. PUT SCOTCH TAPE AROUND THE BOTTLE KEEP THE
SYRINGE FOR FURTHER USE.

4.10 - RADIOACTIVE WASTE
Facilities and procedures described in the rules:

(a) Collection:
It is mandatory to mention the facilities available e.g. polythene
lined waste bins for collection of solid wastes, and corrosion resistant cardboards
or delay tanks for collection of liquid wastes.

(b) Transfer:
it is important to state the type of container employed during
transfer of waste/sources e.g. cardboards, sturdy polythene bags, radio-graphy
camera.

(c) Disposal:
Identify the disposal methods for solid, liquid and gaseous wastes
briefly such as for:


Page 42 of 224

42
i). Solids: Burial pits, municipal dumping site or waste management agency.

ii). Liquids: Sanitary sewerage system, soak-pit, waste management agency
etc.


iii). Gaseous wastes: Incineration facility, fume hood etc.

4.11 - SAFETY CLOTHING:
A set of safety clothing and equipment for waste handlers was
identified and provided. It included cap, eye protection goggles, mask, apron,
gloves and boots. Disposable caps and masks were used. Gloves and aprons
selected were of no permeable material to prevent contact with blood & body
fluids. However gloves selected were malleable enough to permit finger
movement.

Handling, segregation, mutilation, disinfection, storage,
transportation and final disposal are vital steps for safe and scientific
management of Hospital waste in any establishment. The key to minimization
and effective management of biomedical waste is segregation (separation) and
identification of the waste. The most appropriate way of identifying the categories
of Hospital waste is by sorting the waste into color coded plastic bags or
containers.

Figure 17 - Worker collecting hospital waste


Page 43 of 224

43


The fight against hospital infection demands the cooperation of all
those employed in the hospital: doctors, technicians, nursing and cleaning staff.
This is why one of the most urgent tasks is to convince, train and monitor the
personnel responsible for refuse disposal. Unless they are convinced of the
need, trained and monitored, all efforts to improve the situation will be doomed to
failure.
For an effective waste management system it is necessary to
educate all the employees of the hospital about waste and its effect to our life.

GUIDE LINES
There are Guidelines for Hospital Waste Management In Pakistan
since 1998 prepared by the Environmental Health Unit, of the Ministry of Health,
Government of Pakistan, giving detailed information and covering all aspects of
safe hospital waste management in the country, including the risk associated
with the waste, formation of a waste management team in hospitals, their
responsibilities, plan, collection, segregation, transportation, storage, disposal
methods, containers, and their color coding & waste minimization techniques.
A project was implemented in January, 2000 in the biggest hospital in every
province by the Ministry of Health in Islamabad, in collaboration with WHO.
IMPROPER DISPOSAL
Hospitals and public health care units are supposed to safeguard
the health of the community. However, the waste produced by the medical care
centers if disposed off improperly, can pose an even greater threat than the
original diseases themselves. Pakistan is also facing such problems. There are
no systematic approaches to medical waste disposal. Hospital wastes are
simply mixed with the municipal waste in collecting bins at roadsides and

Page 44 of 224

44
disposed off similarly. Some waste is simply buried without any appropriate
measure. The reality is that while all the equipment necessary to ensure the
proper management of hospital waste probably exists, the main problem is that
the staff fails to prepare and implement an effective disposable policy.
In Lahore, like most of the cities in Pakistan, there are no proper measures
taken for the management of hospital waste. The standard practice of hospital
waste disposal is dumping it in the M.C.L. container wherever situated.
Disposable syringes and needles are also not disposed off properly. Some
patients, who routinely use syringes at home, do not know how to dispose them
off properly. They just throw them in a dustbin or other similar places, because
they think that these practices are inexpensive, safe, and easy solution to
dispose off a potentially dangerous waste item.

Figure 18 - Improper waste disposal





Page 45 of 224

45
5.1 - WASTE MANAGEMENT PRACTICES IN HCF
1

5.1.1 - LADY HEALTH WORKER (LHW)
In most of the rural area of Pakistan LHW is responsible for the
community health. They provide basic health facilities to community members at
their door step. Their houses are their clinics where they treat the community
members. Their home clinics are also sources of health care waste.

5.1.2 - RURAL DISPESARIES
Rural health dispensaries are major set up for health care facilities
in small villages. Although they provide small & limited services yet they produce
health care waste which is not small and negligible.

5.1.3 - MUNICIPAL DISPENSARIES
Municipal dispensaries are major health services provider in
different areas of cities. These dispensaries provide basic health facilities.

5.1.4 - BASIC HEALTH UNITS (BHU)
The BHU is the basic unit in the HCF hierarchy. It is a composite
structure comprising a consulting space, dispensary, beds for resident patients
(in sub urban locations) and ancillary spaces. Being a free healthcare facility, it
generates a large number of patients per day. The waste generated during these
activities comprises used bandages, gauzes, swabs, bottles, syringes, drip
injections, catheters, tissue papers etc. The BHU normally has plastic buckets for
in-house collection of these materials. The main recyclable material is separated
by the junior staff members for selling to waste buyers. The infectious materials
such as syringes are also sold with the other related items. The non-saleable
waste is disposed in a similar manner as the municipal waste. It may be noted
that the organic waste so disposed is of highly infectious nature, which mixes
with municipal waste and remains exposed for extended periods of time.


1-HCF : Health Care Facilities

Page 46 of 224

46
5.1.5 - Consulting Clinics (CCs)
These facilities exist in multiple formats. In certain cases, CCs are
part of the hospital scheme. In such case the waste management of CCs is
linked to the overall collection and disposal system of the hospital. The other and
more common format of consulting clinics is along independent locations. In this
form, an individual doctor or a panel sits in a unit with a waiting space,
examination room, small storage space and supplies room. The wastes
generated during the operation of the Consulting Clinics comprise used syringes,
used medicine bottles, bandages and plasters (in case of orthopedic clinics etc),
paper waste and X-ray films. Much of the material generated from the consulting
clinics is re-cycled and separated by the janitors / junior management staff of the
CCs.
5.1.6 - Laboratories and Diagnostic Establishments
Pathological and radiology labs are two dominant categories of this
facility. The types of waste generated in pathological labs comprise specimen of
excreta / body fluids, bandages, syringes, swabs and linen shreds. In addition, a
significant amount of highly infectious liquid waste is generated which is mixed
with routine sewage without any kind of treatment. The solid waste is divided into
re-salable and non-saleable entities. The saleable articles are separated at
source and sold to waste buyers. The organic waste is disposed with the regular
municipal waste. In case of radiology labs, used X-ray films are the most
attractive item which is burnt to produce small amounts of precious metals that
fetch some revenue. This waste is disposed with the normal municipal waste
stream.







Page 47 of 224

47
TABLE 4:- BASIC DATA REGARDING HEALTH FACILITIES VERSUS
POPULATION RATIO IN PAKISTAN


INDICATOR

SITUATION IN PAKISTAN

WHO CRITERIA
Population Per Doctor 1578 200 / Doctor
Population Per Dentist 35557 1000/ Dentist
Population Per Nurse 3822 150 / Nurse
Population Per Hospital Bed 1610 200
Population Per Postgraduate Doctor 11000 800

TABLE 5 - HEALTH CARE DELIVERY SYSTEM IN PAKISTAN

Type / Category Pakistan
Total Hospitals 830
MCH Centers 864
Rural Health centers 542
Basic Health Units 5147
Total Hospital Beds 86921
Total Doctors 90000







Page 48 of 224

48
TABLE 6 - HEALTH CARE DELIVERY SYSTEM IN PAKISTAN


Type / Category

Pakistan
Postgraduate Doctors 11160
Dentists 3000
Midwives 21304
Lady Health Visitors 4250
Trained Birth Attendant 57744
Lady Health Workers 65000

5.2 WASTE COLLECTING STAFF
Usually waste colleting staff consists of Ayas, Ward Boys and Ward
Cleaners who are mainly responsible for the collection of waste from wards and
different departments of the hospital. Waste collecting staff has some interesting
names all over the world. In India they are called Safai Karamchari.
In Pakistan we call them Bhangi, Jamedar, Chamar and Kutana. It is
necessary to have specially trained staff with their specific uniform and gloves
during handling of waste.

PRIMARY COLLECTION OF HOSPITAL WASTES
Within hospitals, the wastes stored in primary containers and bags
at source are collected by in-house nurses aides, cleaners . Sweepers (sanitary
staff) employed by the hospitals collect waste from each ward in three shifts. The
waste then transported on trolleys to a central storage area in the hospital
premises or outside the building. One supervisor for each shift is responsible for
hospital cleaning and waste collection.


Page 49 of 224

49
It is very important for the health of these workers to vaccinate
them against Typhoid and Tetanus. They should also immunize against Hepatitis
B. Their training & education about waste is also very important. Without proper
training and education they are completely blind to the dangerous effects of
medical waste to human life. In developed countries, a proper system has been
adopted for this purpose. Situation is quite different in developing countries and
especially in Pakistan. During a study conducted in CMH Rawalpindi by Mr.
Naeem Mehmood (2000 2001), it was revealed that sanitary workers were not
aware of the infectious and non-infectious waste. It was quite interesting that
30% consider left food and vegetables and 18% consider paper as infectious
waste.
In Pakistan, low literacy rate is the main reason for poor perception
of sanitary workers towards hazards of hospital waste. During this study, it was
revealed that 73% were illiterate, 20% had attended the primary school and
remaining 7% had education up to secondary school level.

Joint Advisory Notice on the Protection against Occupational Exposure to
Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV)Training
Program Recommendations

According to the Joint Advisory Notice, The employer should
establish an initial and periodic training program for all employees who perform
Category I and II tasks. No worker should engage in any Category I or II task
before receiving training pertaining to the Standard Operating Procedures
(SOPS), work practices, and protective equipment required for that task.

The training program should ensure that all workers:

Understand the modes of transmission of HBV and HIV.
Can recognize and differentiate Category I and II tasks.
Know the types of protective clothing and equipment generally appropriate
for Category I and II tasks, and understand the basis for selection of
clothing and equipment.

Page 50 of 224

50
Are familiar with appropriate actions to take, and persons to contact, if
unplanned Category I tasks are encountered.
Are familiar with and understand all the requirements for work practices
and protective equipment specified in SOPS covering the tasks they
perform.
Know where protective clothing and equipment is kept; how to use it
properly; and how to remove, handle, decontaminate, and dispose of
contaminated clothing or equipment.
Know and understand the limitations of Protective clothing and equipment.
For example, ordinary gloves offer no protection against needle stick
Injuries.
Employers and workers should be on guard against a sense of security
not warranted by the protective equipment being used.
Know the corrective actions to take in the event of spills or personal
exposure to fluids or tissues, the appropriate reporting procedures, and
the medical monitoring recommended in cases of suspected potential
exposure.
SOURCE: U.S. Department of Health and Human Services, Centers for Disease Control,

PackagIng

Polyethylene bags are frequently used for containing bulk wastes
(e. g., contaminated disposable and residual liquids); they may have to be
doubled bagged with polypropylene bags that are heat resistant if steam
sterilization is used. These bags, however, must be opened or of such a nature
as to allow steam to penetrate the waste. Color coded bags are frequently used
to aid in the segregation and identification of infectious wastes. Most often red or
red-orange bags are used for infectious wastes (hence the term red bag waste).
An ASTM Standard (#D 1709-75) for tensile strength based on a dart drop test
and the mil gauge thickness of the plastic determine its resistance to tearing.

Page 51 of 224

51
Color coding is used according to the availability of the polythene
bags. As red, orange, yellow and black polythene bags are easily available in
Pakistan so in most hospitals red or orange bag is used for infectious waste,
yellow or blue bag is used for sharps and black or grey bag is used for non
infectious waste.
Use of the biological hazard symbol on appropriate packaging used
is recommended by the EPA to assist in identifying medical wastes. In addition,
EPA recommends that all of these packages close securely and maintain their
integrity in storage and transportation. In general, compaction or grinding of
infectious wastes is not recommended by EPA before treatment. Even though it
can reduce the volume of waste needing storage, compaction is not encouraged
due to the possibility of packages being violated and the potential for
aerosolization of microorganisms. Commercially available grinding systems that
first involve sterilization before shredding or compaction may alleviate this latter
concern.
Sharps are of concern, not only because of their infectious
potential, but also because of the direct prick/stab type of injury they can cause.
For sharps, puncture-proof containers are currently the preferred handling
package. EPA recommends these types of packages for solid/bulk wastes and
sharps; bottles, flasks, or tanks are recommended for liquids. 4 In the past,
needles were re-capped, chopped, or disposed of by other practices that are no
longer common due to their potential for worker injury and, in the case of
chopping, for aerosolization of microorganisms during the chopping procedure.
New technologies for containing needles and facilitating their safe handling
continue to emerge. For example, one company has announced a process which
uses polymers to sterilize and encapsulate sharps (and other infectious wastes)
into a solid block-like material. A number of companies have also developed
encapsulating systems and other sharp disposal processes (e. g., a shredder
with chemical treatment of needles and other sharps). These processes may
potentially be cost-effective disposal options for doctor offices and other small

Page 52 of 224

52
generators of sharps and other infectious wastes, provided landfill operations
would accept the encapsulated wastes.

5.4 COLOR CODING FOR WASTE PACKING
Color coded bags are frequently used to aid in the segregation and
identification of infectious wastes. Most often red or red-orange bags are used for
infectious wastes (hence the term red bag waste). An ASTM Standard
(#D 1709-75) for tensile strength based on a dart drop test and the mil gauge
thickness of the plastic determine its resistance to tearing. Use of the biological
hazard symbol on appropriate packaging is recommended by the EPA to assist
in identifying medical wastes.
In some hospitals red polyethylene bags are used for infectious
waste, which includes soiled surgical dressing, cotton swabs , blood , body fluid ,
pus , sputum , culture of infectious agents and other contaminated wastes.

Blue Polyethylene bags are used for all sharps irrespective of
whether infectious or otherwise which includes needles, hypodermic needles,
scalpel and other blades, knives, infusion sets, saws and broken glasses.
Black or Grey Polyethylene bags are used for all non infectious
waste, which includes paper, cigarette packets, cardboard, packing material, left
over food and garbage etc.


Page 53 of 224

53

Figure 19 - Color Coded bags
COLOR CODING IN DIFFERENT HOSPITALS OF THE WORLD.

1:- COLOR CODING AT THE CAPITAL MEDICAL CENTER (CMC) MANILA
CMC requires the use of three waste cans lined with three (3) colored plastic
bags for every patient room, emergency room-out patient department, operating
room-recovery room, delivery room-nursery, intensive care unit-coronary care
unit, floor nurses station, x-ray and CT scan areas to separate infectious, non-
infectious and biodegradable wastes.

Waste cans (8"x10"x12") lined with black plastic bags are for non-
biodegradable and noninfectious wastes such as cans, bottles, tetra brick
containers, styropor, straw, plastic, boxes, wrappers, newspapers.

Waste cans lined with green plastic bags are biodegradable wastes such
as fruits and vegetables peelings, leftover food, flowers, leaves, and
twigs.


Page 54 of 224

54
Waste cans lined with yellow plastic bags are for infectious waste such as
disposable materials used for collection of blood and body fluids like
diapers, sanitary pads, incontinent pads, materials (like tissue paper) with
blood secretions and other exudates, dressings, bandages, used cotton
balls, gauze, IV tubings, used syringes, Foleys catheter/tubings, gloves
and drains.

2;- Color Coding along with disposal method at St.Stephens Hospital.



5.5 WASTE STORAGE IN HOSPITAL

Storage of the waste needs to be in areas which are disinfected
regularly and which are maintained at appropriate temperatures (particularly if
wastes are being stored prior to treatment). EPA recommends that storage time
is minimized, storage areas be clearly identified with the biohazard symbol,
packaging be sufficient to ensure exclusion of rodents and vermin, and access to

Page 55 of 224

55
the storage area be limited. The importance of the duration and temperature of
storing infectious wastes is noted, due to their association with increases in rates
of microbial growth and putrefaction. The recommendation by EPA for storage of
infectious waste is limited, however, to suggesting that storage times be kept as
short as possible. EPA does not suggest optimum storage time and temperature
because it finds there is no unanimity of opinion on these matters. As the EPA
Guide notes, there is State variation in specified storage times and
temperatures. State requirements often stipulate storage times of 7 days or less
for infectious wastes that are unrefrigerated. Sometimes longer periods are
allowed for refrigerated wastes.



For segregation, the storage site can be divided into two
portions i.e. for infectious wastes and not infectious waste marked by
red and green colors. Moreover, the storage point in hospital should
free from the access of animals and birds. If specific containers are
used for the storage purpose then they should be covered very well.

Page 56 of 224

56
Transportation of this waste is also very important. The waste should
be transported to disposal point in specific vehicles which should fulfill
all safety measures. Moreover, sanitary workers should be trained and
must have all protective equipments. To avoid infections to workers,
loading & unloading should be done by specific machines.





5.6 - TRANSPORTATION OF WASTE FROM HOSPITAL
EPA recommendations with respect to the transportation of
infectious wastes briefly address the movement of wastes while on-site and in an
even more limited way address the movement of wastes off-site. The
recommendations are largely limited to prudent practices for movement of the
wastes within a facility, such as placement of the wastes in rigid or semi-rigid and
leak-proof containers, and avoidance of mechanical loading devices which might
rupture packaged wastes. Broader issues, such as record keeping and tracking
systems for infectious or medical wastes once they are taken off-site, and the
handling and storage of wastes at transfer stations, have not yet been
addressed. EPA does recommend that hazard symbols should be in accordance
with municipal, State and Federal regulations.

Page 57 of 224

57

Figure 20 - Unsafe transportation of solid waste

Page 58 of 224

58

Figure 21 Cost effective Waste Vehicle used in India

The sanitary staff should be trained properly for the handling of the
waste. It is necessary for them to wear their specific uniform, to use special
gloves during handling of waste. It is very important for the health of these
workers to vaccinate them against Typhoid and Tetanus. They should also
immunize against Hepatitis B. To avoid infections to workers, loading &
unloading should be done by specific machines.





Page 59 of 224

59

Figure 22 Purpose built vehicle used for transportation of waste safely.


Figure 23 - Workers bringing waste out of the wards in covered trolley.

Page 60 of 224

60
5.7 - ROLE OF PATIENT IN HOSPITAL WASTE
GENERATION
It is very interesting for a reader that a patient can play a
vital role in hospital waste management because waste primarily
generated by him, 30% to 40% hospital waste is produced by a
patient. By educating the patient about waste importance, it is very
easy to manage hospital waste in an efficient way.
Patient should be educated to mop up spillage with
absorbent toilet tissue or paper towel. He should be educated not to
spit here & there in the ward. He should be guided to dispose the used
tissues or paper towel into the specific bin instead of throwing them
here & there in wards. Patient should be directed to deal with body
fluids (Like Urine, Vomit & Feaces) properly. Clear directions should be
given to the patient to keep the bed sheets neat & clean. Patients
should be advised not to clean their hands, mouth and other parts of
body with bed sheets. Instead they should be taught to use tissue
papers or their napkin to wipe their lips, figures, mouth and other
parts of body. In Menstruating females, it is advised to use the
sanitary towels instead of cotton wrapped in linen or small pieces of
linen as sanitary pad, which is a common practices in our society.
Moreover, due to lack of education and cultural norms, girls hide the
socked sanitary towels and throw them into the commodes instead of
using bedside bins.
Bedridden patients used to defecate in the pane on the bed
and during this process they soil bed sheets. Training for this purpose
can save the bed sheets soilage & in turn reduce the number of bed
sheets for the washing purpose.
In our country usually every patient has more than three
attendants. These attendants are also a major cause of waste

Page 61 of 224

61
production in hospitals. During their stay in hospitals, they eat, drink
and sleep there. It is very necessary to educate them about waste
management.

Table 7 - COMPOSITION AND PER BED WASTE GENERATION IN A
TERTIARY CARE ARMY HOSPITAL IN PAKISTAN

Category Kg / Day % age / day Kg / Bed / Day
Infectious Waste 197.82 9 % 0.309
Sharps 65.94 3 % 0.103
Infectious Waste 1934.24 88 % 3.022
Total Waste 2198 100 % 3.434



Table 8 - ESTIMATES OF MEDICAL WASTE GENERATION IN SOUTH ASIA


Country Waste generation
(kg/bed/day)
Total waste generation (tons/year)
Bangladesh 0.8 -1.67
93,075 (255 ton/day) (only in Dhaka)
Bhutan 0.27 73
India 1 -2 330,000
Maldives NA 146
Nepal NA 365
Pakistan 1.06 250,000
Sri Lanka 0.36
6600 (only in Colombo)


Page 62 of 224

62



Pre disposal treatment of medical waste is very important.
Treatment prior to final disposal makes infectious waste non infectious. In this
way we reduce the chance of infectious spread. There are several methods for
the treatment of medical waste. Some modern and latest methods are as under:-
Electron Beam Irradiation (EB) OR Ionizing Radiation
Microwave Irradiation (MW) OR Non Ionizing Radiation
Autoclave
Hydroclave
Chemical Disinfection

6.1 - ELECTRON BEAM IRRADIATION (EB)
This method is also known as Ionizing Radiation. This is the latest
technique used for the treatment of biological waste & especially medical waste.
It is a sterilization technique based on the radiation ability to alter physical,
chemical and biological properties of materials. Irradiation with EB was put forth
as a very effective method for material biological decontamination because can
produce ions, electrons, and free radicals at any temperature in the solid, liquid
and gas. EB radiation processes are very effective for sterilization but the
required radiation dose is still high. Low irradiation doses are required for the
process efficiency and a high dose rate must be used to give large production
capacities. The main idea of this work was to combine the advantages of both,
EB irradiation and Micro Wave irradiation, i.e. high EB irradiation efficiency and
high Micro Wave selectivity and volumetric heating for biological waste
processing.




Page 63 of 224

63


METHOD & TECHNIQUE
EB disinfection/sterilization processing is based on the radiation
ability to alter biological properties of microorganisms especially due to the water
presence in the living cells. Water is known to be a component of every biological
system and a constituent present in most chemical processes. Due to the
presence of water, EB irradiation can much enhance the microorganism death
rate. The EB processing uses the Coulomb interaction of the accelerated
electrons with atoms or molecules of irradiated matter.
By these interaction ions, thermalized electrons, excited states and
radicals are formed. Thus, the water irradiation by the EB produces radicals such
as e aq, OH*, H*, H2*, H2O2*, OHaq*, H2O* and O2 -*. The free radicals react
with cell membranes, enzymes and nucleic acids to destroy microorganisms. The
fact that the interaction by the radicals is effective to a wide range of
microorganisms is one of the advantages of the ionizing irradiation. The various
products formed during radiolysis of water may, in this way, influence directly or
indirectly the chemical processes and biological effects occurring in the individual
compounds dissolved in water.

Page 64 of 224

64


MICROWAVE IRRADIATION (MW)
This method is also known as Non- Ionizing Radiation. This is a
technique used for the treatment of biological waste prior to final disposal.
Microwave (MW) treatment is one of the most emerging biological
decontamination technique because in many cases provides distinct advantages
over conventional processes in terms of product properties, process time saving,
increased process yield and environmental compatibility.
The MW processing is a relatively new technology that provides
new approaches to improve the decontamination process compared with
classical methods.
The frequency range of MW is (300 MHz - 300 GHz) . Hence, MW
cannot interact with atoms by generating transitions between principal energy
levels, e.g. between a base state and an excited state. Instead of this,
microwaves couple to transitions within the hyperfine structure of the dynamical
state. Hyperfine splitting of the principal energy levels may be due to the
interaction of magnetic moments of the electron shell and of the nucleus. Most
reports suggest that for various microorganisms, the death rate is enhanced by

Page 65 of 224

65
MW heating more than by conventional heating and the more intense the
microwave electric field, the more is the death rate enhancement. Also, due to
the presence of water, which absorbs MW energy very strongly due its
exceptional polarizability, it is possible to pump vibration modes of DNA leading
to unwinding and strand separation.
MW TECHNIQUE
MW is a method to disinfect micro organisms present in biomedical
waste materials. Due to Microwave radiations, biological properties of these
micro organisms are changed.
Due to the presence of water, MW irradiation can much enhance
the microorganism death rate. Most reports suggest that for various
microorganisms, the death rate is enhanced by MW heating more than by
conventional heating and the more intense the microwave electric field, the more
is the death rate enhancement.
6.2 - AUTOCLAVING OF HOSPITAL WASTE
Autoclave was invented by Charles Chamberland in 1879, although
a precursor known as the steam digester was created by Denis Papin in 1679.

Autoclaving, or steam sterilization, is a process to sterilize medical
wastes prior to disposal in a landfill. Since the mid-1970s, steam sterilization has
been a preferred treatment method for microbiological laboratory cultures. Other
wastes (e. g., pathological tissue, chemotherapy waste, and sharps) may not be
adequately treated by some sterilization operations, and thus require
incineration.


Page 66 of 224

66

Figure 24 - Steam Autoclave




Page 67 of 224

67

Figure 25 - Staff opening the door of Autoclave

AUTOCLAVING PROCESSING RESULTS:-
Typically, for autoclaving, bags of infectious waste are placed in a
chamber (which is sometimes pressurized). Steam is introduced into the
container for roughly 15 to 30 minutes. The 'cooking' process causes plastics to
soften and flatten, paper and other fibrous material to disintegrate into a fibrous
mass, bottles and metal objects to be cleaned, and labels etc. to be removed.
The process reduces the volume of the waste by 60%. Steam temperatures are
usually maintained at 250 F. Some hospital autoclaves, however, are operated
at 270 F.

Page 68 of 224

68
This higher temperature sterilizes waste more quickly, allowing
shorter cycle times. After 'cooking', the steam flow is stopped and the pressure
vented via a condenser. When depressurised, the autoclave door is opened, and
by rotating the drum the 'cooked' material can be discharged and separated by a
series of screens and recovery systems.
In early systems, the primary product was cellulose fibres. This
comprises the putrescible, cellulose and lignin elements of the waste stream. The
biodegradability of the waste has not been affected by the autoclave and so must
undergo further treatment to reduce its reactivity prior to landfilling. The fibres
can be fed into anaerobic digesters to reduce the biodegradability of the waste
and to produce biogas. Alternatively the fibre could be used as biofuel.
Newer technology systems wash out hydrolysed hemicellulose
sugars and most of the protein as water-solubles. The remaining materials, after
simple physical separation (trommel screen) has several valuable uses. One
newer system is able to dry the cellulose during processing using heat, and
another newer system is able to dry the cellulose (much more economically)
using pressure and steam kinetics.
After fibre separation, the secondary streams comprise of mixed
plastics, which have normally been softened and deformed which eases
separation, a glass and aggregate stream, which can be exceptionally clean of
both plastic and paper, and separate errous and non ferrous metals. The heat,
steam and rotating action of the autoclave vessel strip off labels and glues from
food cans leaving a very high quality ferrous/non-ferrous stream for recycling.
With the removal of water, fibre, metals, and much of the plastics,
the residual waste stream for disposal may be less than 10% by weight of the
original stream, and is essentially devoid of materials that decompose to produce
methane. Systems in Europe meet and exceed all of the European waste
treatment and recycling requirements.

Page 69 of 224

69
The full process of loading, treatment and sorting is normally
completed within 90 minutes in earlier models, and with the advent of newer
technology, the cycle time has been decreased to one hour. In a typical "new"
configuration, 210-ton units operating side by side would treat over 400 tons per
day with time for preventative maintenance.
The size of the vessel varies between vendors. Experience shows
that "small" vessels are not productive enough; while if the vessel is too large,
the pressures in the vessel and the heavy weight of the vessel can cause
equipment failures.
Several studies indicate that the type of container (e.g., plastic
bags, stainless steel containers), the addition of water, and the volume and
density of material have an important influence on the effectiveness of the
autoclaving process.

Each of these factors influences the penetration of steam to the
entire load and, consequently, the extent of pathogen destruction. Autoclaving
parameters (e.g., temperature and residence/cycle time) are determined by these
factors.
Since there is no such thing as a standard load for an autoclave,
adjustments need to be made by an operator based on variation in these factors.
Proper operation of autoclaves is key to effective functioning (i.e., in this case,
sufficient pathogen destruction to render wastes non-hazardous).

One method of assuring that pathogen destruction has taken place
is the use of biological indicators, such as Bacillus stearothermophilus.
Elimination of this organism (as measured by spore tests) from a stainless steel
container requires a cycle time of at least 90 minutes of exposure. This is
considerably longer than is currently provided by standard operating procedures.
This conservative approach, however, may provide more pathogen destruction
than is necessary to reduce microbiological contamination to non-infectious

Page 70 of 224

70
levels. Chemical disinfection (e. g., with formaldehyde, xylene, and alcohol) is
used to sterilize reusable items. Recently, sodium hypochlorite has been used in
a process to disinfect disposable products. Partial destruction of the material is
achieved, but additional incineration and high capital costs are associated with
the process as well. Several factors have led some hospitals to abandon
autoclaving. For example, problematic operating conditions can lead to
incomplete sterilization.

In addition, landfill and off-site incinerator operators are increasingly
refusing to receive such wastes, questioning whether the waste has actually
been treated. The refusals are partly in response to the fact that most autoclave
red bags do not change color and thus appear no different from non-autoclaved
red bags (even though they often are labeled or in some way identified as
autoclave). This also has led to more cumbersome documentation and/or
identification requirements in an effort to avoid refusals.
Modern autoclaves, also referred to as converters, can operate in
the atmospheric pressure range to achieve full sterilization of pathogenic waste.
Super heating conditions and steam generation are achieved by variable
pressure control, which cycles between ambient and negative pressure within the
sterilization vessel. The advantage of this new approach is the elimination of
complexities and dangers associated with operating pressure vessels.
TYPES OF AUTOCLAVES:
There are several different "types" of autoclave; gravity
displacement, positive pressure displacement, and negative pressure (vacuum)
displacement:
GRAVITY DISPLACEMENT AUTOCLAVE, OR TYPE "N".
The autoclave at your local tattoo or piercing studio (in the US) is
most likely a gravity displacement autoclave, or type "N". This design of

Page 71 of 224

71
autoclave generally has a heating element fully or partially submerged in a
pool of water in the bottom of the autoclave chamber, along with a fill hole
that transfers water from a reservoir to the autoclave chamber. As the water
in the pool is heated it begins to evaporate, forming steam. Steam is lighter
then air, as the chamber fills with steam the majority of air in the chamber is
pushed to the bottom of the chamber, and escapes via the fill hole which is
connected to a temperature sensitive diaphragm that closes once it is
sufficiently heated. Once the diaphragm closes pressure builds up inside the
autoclave chamber. The benefit of this type of autoclave is it's simplicity, the
drawback with gravity displacement autoclaves is they are only designed to
function properly with solid unwrapped instruments, however there has been
no indication that a gravity displacement autoclave, properly loaded with
properly processed instruments is unsafe for use in the modification industry.
A POSITIVE PRESSURE DISPLACEMENT AUTOCLAVE improves on
the design of a gravity displacement autoclave (see above) by creating the
steam in a separate internal unit, sometimes called a "steam generator".
Once the amount of steam needed to displace air in the chamber is
produced a valve opens and a pressurized burst of steam enters the
autoclave chamber, resulting in a higher percentage of air from the
chamber being removed then with a gravity displacement autoclave, this
decreases autoclave cycle times. Currently the most widely distributed
and used if not the only positive pressure displacement autoclave is the
Statim line of autoclaves. The drawbacks to positive pressure
displacement autoclaves are the high initial cost, and the fact they
generally have a smaller chamber.
NEGATIVE PRESSURE, OR VACUUM DISPLACEMENT
AUTOCLAVES, also known as type "S", have a separate internal "steam
generator", as well as a vacuum pump. After the autoclave chamber is
closed the vacuum pump removes all air form the chamber, and as above,
steam is injected into the chamber. Negative pressure displacement

Page 72 of 224

72
autoclaves are able to attain some of the highest sterility assurance level
or SAL. Negative displacement autoclaves generally have a forced filtered
air drying system that allows the autoclave packages to be throughly dries
before contacting any ambient air. The drawback back to negative
pressure displacement autoclaves is the cost, and sometimes the size of
these systems.
THE LAST "TYPE" OF STEAM AUTOCLAVE IS TYPE "B" for Big, and
the name speaks for itself. These systems are more or less enlarged
negative pressure displacement autoclaves (there are enormous gravity
displacement autoclaves as well, but they are still type "N", and not
usually used in the medical or modification industries). The steam
generator for Type "B" autoclaves is usually a separate stand alone unit,
and the autoclave chamber is sometimes large enough to physically enter.
Due the large scale and astronomical price tag of these autoclaves they
are rarely, if ever used in the modification industry.
COMMERCIAL APPLICATION
Sterecycle is the first company to build a full scale commercial
plant, which has been operational in Yorkshire since June 2008 and is operating
24/7. This plant can process 100,000 tonnes per annum of waste, treating waste
from Rotherham council under a long term contract. Sterecycle builds, owns and
operates waste recycling plants, processing residual waste as a substitute for
landfill.Other companies are looking to build autoclave plants in the UK but all are
at an embrionic stage.




Page 73 of 224

73
INCINERATION VS AUTOCLAVING; AND THE IMPORTANCE OF
PROPER OPERATION
1- Temperature

Autoclaves must achieve minimum temperatures and be operated
according to appropriate cycle times to ensure adequate destruction of
pathogens.
Primary and secondary chamber temperatures of 1,400 F and
1,600 F, respectively, must be reached in hospital incinerators to ensure
adequate combustion and minimum air emissions. Normally, these temperatures
would ensure the destruction of pathogens in the waste; however, if an
incinerator is loaded and fired-up cold, pathogens could conceivable escape from
the stack. Data is not readily available to evaluate this point further. At the typical
operating temperature of an autoclave (250 F), the cycle time of 45 to 90
minutes is necessary to reduce pathogen concentrations in most hospital waste
below infectious levels.

2- Cost
Autoclaves do provide some advantages over incinerators, which
may increase their attractiveness as a disposal option, particularly if incineration
regulations become much more stringent and thereby increase incineration
costs. For example, operation and testing of incinerators is more complex and
difficult than that for autoclaves. Autoclaves are also less costly to purchase &
require less space.
3 Environmental Releases

In addition, environmental releases from incinerators probably
contain a broader range of constituents (e. g., dioxins, and heavy metals) than
autoclaves.



Page 74 of 224

74
4 Training
The proper operation of incinerators and autoclaves is critical to
their effective functioning. Proper operation is dependent on at least four
conditions:
Trained operators;
Adequate equipment (i.e., proper design, construction, controls and
instrumentation);
Regular maintenance;
Repair.
For example, trained operators need to be knowledgeable in the
operation of the incinerator and in the proper handling of medical wastes. It is not
clear; however, that workers are consistently receiving adequate training in the
operation of incinerators or autoclaves, and consequently that most units are
operating properly.

























Page 75 of 224

75

6.3 - HYDRO CLAVE
Hydroclave is a device like Autoclave which sterilizes the waste
utilizing steam, similar to an autoclave, but with much faster and much more
even heat penetration. It hydrolyzes the organic components of the waste such
as pathological material. Removes the water content (dehydrates) of waste.
Breaks up the waste into small pieces of fragmented material and reduces the
waste substantially in weight and volume. Accomplishes the above process
within the totally sealed vessel, which is not opened until sterilization of waste.

THE HYDROCLAVE PROCESS AND HOW IT WORKS
The Hydroclave is essentially a double-walled (jacketed) cylindrical,
pressurized vessel, horizontally mounted, with one or more side or top loading
doors, and a smaller unloading door at the bottom. The very small Hydroclave
units have a single side door for both loading and unloading. The vessel is fitted
with a motor driven shaft, to which are attached powerful fragmenting/mixing
arms that slowly rotate inside the vessel.
When steam is introduced in the vessel jacket, it transmits heat
rapidly to the fragmented waste, which, in turn, produces steam of its own.
A temperature sensor is located in the bottom inside part of the vessel, which
measures the temperature of the waste as it is agitated and mixed, and this
sensor reports back to the main computerized controller, which automatically
sets treatment parameters ensuring complete waste sterility even liquid
infectious waste.
After sterilization, the liquid but sterile components of the waste are
steamed out of the vessel, re-condensed and drained to sewer. The remaining
waste is dehydrated, fragmented, and self-unloaded via a reverse rotation of the
mixer/agitator.

There is no correlation between waste characteristics and
treatment efficacy. All the waste is consistently sterilized. Liquid and heavy loads,

Page 76 of 224

76
however, will take somewhat longer to reach the temperature and pressure
required to initiate the sterilization cycle, but sterilization automatically occurs.
There is no need for pre-and post-vacuum, that is, pull infectious air and liquids
of the vessel, as is the case with autoclaves. Pulling air and liquids out of an
infectious environment increases the risk of live pathogen emission.
The Hydroclave eliminates this risk due to the vigorous dynamic
activity within the Hydroclave, which mixes and heats any entrained air with the
steam and waste material.


DETAILED DESCRIPTION OF THE TREATMENT CYCLE
a) LOADING
The waste can be loaded into the Hydroclave treatment vessel by various
means, depending on your requirements:
In smaller units dropping the waste bags manually into a side or end door.
In medium-sized units by tipping waste containers into top or angled
loading doors. Electric or hydraulic tipping devices are an available option
with the Hydroclave.
In medium to large sized units, for large scale commercial operation, a
combination of conveyors, hoppers and tippers are available to load the
waste into large top loading doors.
The Hydroclave can be fitted with loading doors to suit your
requirements, from small side doors to multiple angled or top doors, which are
sized to accommodate your infectious waste stream small doors for bagged
biomedical waste, to very large doors for disinfecting large objects such as large
animal carcasses. No special operator skill is required, since over-loading or
loading too tightly is not an issue with this type of process.





Page 77 of 224

77
b) HEAT-UP AND FRAGMENTATION
After loading, the vessel doors are closed, and the outer jacket of
the vessel is filled with high temperature steam, which acts as an indirect heating
medium for heating the waste.
The jacket steam condenses into clean, hot condensate, which is
returned back to the steam boiler. This unique feature makes the Hydroclave so
efficient in operation no steam or hot condensate is lost. During heat-up, the
shaft and mixing arms rotate, causing the waste to be fragmented and
continuously tumbled against the hot vessel walls.
At this point, the waste is broken up into small fragments, and all
material heats up rapidly, being evenly and thoroughly exposed to the hot inner
surfaces. The moisture content of the waste will turn to steam, and the vessel will
start to pressurize.
Initially, no steam will be injected into the waste. If there is not
enough moisture in the waste to pressurize the vessel, a small amount of boiler
steam is added until the desired pressure is reached.
The uniform jacket heat and the location of the temperature sensor
ensures that even liquid waste will be heated up uniformly.
At the end of this period, the correct sterilization temperature and pressure are
reached, and the sterilization period is initiated automatically.
c) STERILIZATION PERIOD
By computer or PLC control, the temperature and pressure are
maintained for the desired time to achieve sterilization. If for any reason the
sterilization parameters drop below desired levels, the sterilization cycle is
stopped, and re-initiated. This ensures sterilization prior to commencement of the
next stage. The mixing/fragmenting arms continue to rotate during the entire
sterilization period, to ensure thorough heat penetration into each waste particle.





Page 78 of 224

78
d) DE-PRESSURIZATION AND DE-HYDRATION
After the sterilization period ends, the vessel is de-pressurized via a
steam condenser, which causes initial waste dehydration due to
depressurization.
The steam to the jacket will remain on, agitation continues, and the
waste loses its remaining water content through a combination of heat input from
the jacket and continued agitation.
All waste, no matter how wet initially, even liquid waste, will be dehydrated by
this process.
e) UNLOADING
At the end of the depressurization/dehydration period, jacket steam
is shut off, the discharge door is opened, and the powerful mixing arms are
reversed to a clockwise rotation.
Due to the unique construction of the mixing arms, the opposite rotation causes
the fragmented waste to be pushed out of the vessel discharge door, into a
waste container, or onto a conveyor.
If desired, the waste can be further fine-shredded prior to final
disposal, by a separate shredding system. The dry, sterile, fragmented waste is
well suited for further fine shredding.
The vessel is now ready for another treatment cycle, having retained most of its
heat for the treatment of the next batch.











Page 79 of 224

79
TREATMENT PROCESS
How it works

STAGE ONE - LOADING
The Hydroclave can process:

Bagged waste, in ordinary bags.
Sharps containers.
Liquid containers.
Cardboard containers.
Metal objects.
Pathological waste.













Page 80 of 224

80
STAGE TWO STERILIZING


Powerful rotators mix the waste and break it into small pieces.
Steam fills the double wall (jacket) of the vessel and heats the vessel
interior.
The liquid in the waste turns to steam.
After 20 minutes the waste and liquids are sterile.

STAGE THREE DEHYDRATION

The vent is opened, the vessel de-pressurizes via a condenser, and sterile
liquid drained into sanitary sewer.
Steam heat and mixing continue until all the liquids are evaporated and
the waste is dry.



Page 81 of 224

81

STAGE FOUR UNLOADING

The unloading door is opened.
The mixer now rotates in the opposite direction, so angled blades on the
mixer can push the waste out the unloading door.
The dry sterile waste can be fine-shredded further or dropped in a waste
disposal bin.
The waste is now ready for safe disposal!

6.4 - CHEMICAL DISINFECTION
Waste which is contaminated through contact with, or having
previously contained, chemotherapeutic agents shall be segregated for storage.
This type of waste must be placed in a secondary container, which shall be
labeled on the lid and the sides with the words Chemotherapy Waste or
CHEMO. The label must be visible from any lateral direction to ensure
treatment of the Biohazardous waste. Chemotherapeutic waste can be taken
directly to one of the Medical Waste Collection Sites.



Page 82 of 224

82


It is very important to dispose off the hospital waste in a proper
way. Due to improper disposal many diseases are spreading very rapidly all over
the world. Here we will discuss the modern & old technologies which are being
used in different countries for HCW disposal.

7.1 DISPOSAL OF MEDICAL WASTES
There are different methods for the disposal of hospital waste
depending upon types of waste i.e. solid, liquid & radioactive waste.

A ) DISPOSAL OF SOLID HOSPITAL WASTE

Methods for disposal of solid hospital waste are :-

Incineration
Recycling
3 - R Concept
Land Fill

7.2.1 - INCINERATION METHOD FOR DISPOSAL OF SOLID
HOSPITAL WASTE


Incineration
Incineration is a waste treatment and disposal method that involves
the combustion of waste at high temperatures. Incineration of waste materials
converts the waste into heat, gases, particulates and solid residue (ash).
Large Scale Incineration
Incineration can be used to destroy certain hazardous wastes such
as medical wastes where pathogens and toxins must be destroyed by high
temperatures.

Page 83 of 224

83
Incinerators that burn municipal wastes are often referred to as
MSWIs: Municipal Solid Waste Incinerators. There are no municipal solid waste
incinerators in New Zealand.
A waste-to-energy plant is an incinerator that burns wastes in high-
efficiency furnace/boilers to produce steam and/or electricity and incorporates
modern air pollution control systems and continuous emissions monitors. This is
often used as a waste disposal method in countries where landfilling is too
difficult or expensive because land is a scarce resource.
Small Scale Incineration
Small scale incinerators include backyard burners or '44-gallon
drum incinerators' that may be used to dispose of garden and household waste.
The amount of household waste burned in backyard fires is only about 1% of the
total amount of household waste land filled in New Zealand.
Bans on outdoor fires of all kinds are common in Canterbury in
summer because of the fire risk. Because of other adverse air quality effects,
outdoor burning is not permitted from 1 May to 31 August in Christchurch Clean
Air Zones 1 and 2.

Page 84 of 224

84

Figure 26 - Municipal Solid waste incinerator in USA

Figure 27 - Medical Waste Incinerators in USA






Page 85 of 224

85
INCINERATION HAZARDS


There are arising economic problems because ash is not an ideal fuel.
The incineration of certain waste product produces some acidic gases.
Polyvinyl Chloride (PVC), a plastic used in the manufacturing of toys,
rainwear & garden hoses. When it is burnt Hydrogen Chloride Gas is
produced. This gas reacts with water to produce Hydrochloric Acid (HCL)
which is a strongly corrosive liquid.
Whats threatening is the fact that some of the PVC decomposes before it
burns completely. Decomposition products such as vinyl chloride, or
suspected ones such as, dioxin are known carcinogens. Most of these can
be removed from the exhaust stream if proper air pollution controls are
installed, but these measures are never 100 percent effective and so
expensive.
Incinerators typically release a wide variety of other toxic metals, including
lead, cadmium, arsenic, chromium, beryllium, nickel and others. Health
effects of these metals include:
Lead: -nervous system disorders, lung and kidney problems, and
decreased mental abilities in children.
Cadmium: -kidney disease, lung disorders; high exposures severely
damage the lungs and can cause death
Arsenic: -arsenic damages many tissues including nerves, stomach,
intestines and skin, causes decreased production of red and white blood
cells and abnormal heart rhythm
Chromium: -damages nose, lungs and stomach
Beryllium: -chronic lung problems Incinerators are significant sources of
these forms of air.

- In 1999, the Philippines became the first country in the world to prohibit all forms of waste
Incineration, including open burning. This environmental milestone was achieved after years of
campaigning by environmental and community groups opposing proposals for incinerators,
landfills and dumpsites in various parts of the country.


Page 86 of 224

86

Figure 28 - Industrial Incinerator


Figure 29 - Medical Waste incinerator


Page 87 of 224

87



Page 88 of 224

88
INCINERATOR BANS AND MORATORIA

1. INTERNATIONAL:

1996: the Protocol to the London Convention banned incineration at
sea globally.
1996: the Bamako Convention banned incineration at sea, on
territorial or internal waters in Africa.
1992: the OSPAR Convention banned incineration at sea in the
north-east Atlantic.

ARGENTINA:

2003: the city Council of Granadero Baigorria, Santa Fe province,
outlawed medical waste incineration.
2002: the Buenos Aires City Council passed a law that bans incineration
of medical waste. This includes medical waste generated in the city and
sent outside for treatment.
2002: the City Council of Villa Constitucin, Santa F province, banned
the construction of incinerators.
2002: the City Council of Coronel Bogado, Santa F province, banned the
construction of incinerators.
2002: the City Council of Marcos Juarez, Cordoba province, outlawed the
construction of incinerators.
2002: the Municipal Council of Casilda, Santa Fe province, banned
hazardous waste incineration for 180 days. The resolution was extended
for another 180 days in November 2002.
2002: the City Council of Capitan Bermudez outlawed all type of waste
incineration.
2001: the province of San Juan banned crematoria in urban and semi-
urban areas.

BRAZIL:
1995: the Municipality of Diadema, State of Sao Paulo, approved a law
banning incinerators for municipal waste. The city council states that the
waste problem should be tackled using reduce, reuse, and recycling
policies.

CANADA:
2001: the Province of Ontario enacted a hazardous waste plan that
includes the phase out of all hospital medical waste incinerators.

CHILE:
1976: Resolution 07077 banned incineration in several metropolitan areas
of the country.

Page 89 of 224

89

CZECH REPUBLIC:
1997: Cepi, district Pardubice banned construction of new waste
incinerators.

GERMANY:
1995: the largest, most populated and most industrialized state in
Germany North Rhine/Westfalia bans municipal solid waste
incinerators.

GREECE:
1994: the national government approved legislation declaring it illegal to
burn hazardous waste in waste-to-energy plants. In 2001, the Minister for
the Environment formally declared a policy of prohibiting municipal waste
incineration.

INDIA:
1998: the central government banned incineration of chlorinated plastics
nationally. The city of Hyderabad in the state of Andhra Pradesh banned
on-site hospital waste incineration.

IRELAND:
1999: although no formal ban is in place, Ireland closed all of its medical
waste incinerators.

JAPAN:
1998: the Ministry of Health and Welfare revised the laws to allow disposal
of PCBs using chemical methods. Although there is no formal ban on
incineration of PCBs, there is an informal proscription on PCB incineration.

MALTA:
2001: all public and private hospitals were to eliminate clinical waste
incineration by 2001.

PHILIPPINES:
1999: the Clean Air Act was passed which bans all types of waste
incineration. The law extends to municipal, medical and hazardous
industrial wastes.

SLOVAKIA:
2001: banned waste importation for incineration.

SPAIN:
1995: the regional government of Aragon established autoclaving as the
required form of treatment for medical waste, effectively eliminating
medical waste incineration.

Page 90 of 224

90

2. UNITED STATES:

STATES

Delaware, 2000: state prohibited new solid waste incinerators within three
miles of a residential property, church, school, park, or hospital.

Iowa, 1993: state enacted a moratorium on commercial medical waste
incinerators. Moratorium still in place. Moratorium does not extend to
incinerators operated by a hospital or consortium of hospitals.

Louisiana, 2000: state revised its statute Title 33, which prohibits
municipalities of more than 500,000 from owning, operating or contracting
garbage incinerators in areas zoned for residential or commercial use.

Maryland, 1997: state prohibited construction of municipal waste
incinerators within one mile of an elementary or secondary school.

Massachusetts, 1991: state enacted a moratorium on new construction
or expansion of solid waste incinerators.

Rhode Island, 1992: state banned the construction of new municipal solid
waste incinerators. First U.S. state to enact such a ban.

West Virginia, 1994: state banned the construction of new municipal and
commercial waste incinerators. Permits pilot tire incineration projects.

3. COUNTIES

Alameda County, California, 1990: voter initiative Waste
Reduction and Recycling Act passed, banning waste incinerators
in the county. A later court ruling limits the ban to the
unincorporated areas of the county, however, there are no
operating municipal waste incinerators in Alameda county.

Anne Arundel County, Maryland, 2001: county banned solid
waste and medical waste incinerators.

4. CITIES

Brisbane, California, 1988: city banned new construction of waste
incinerators.


Page 91 of 224

91
Chicago, Illinois, 2000: city banned municipal waste incineration.
The ban extends to burning waste in schools and apartment
buildings.

San Diego, California, 1987: ordinance stipulates that waste
incinerators cannot be sited within a certain radius of schools and
daycare centers, which results in no eligible land being available for
incinerators.

Ellen burg, New York, 1990: town banned waste incinerators.

New York City, 1989: Banned all apartment house incinerators by
1993. By 1993, all 2,200 apartment house incinerators that were in
operation in 1989 were shut down.

5. MORATORIA:

Several states in the United States, including Arkansas, Wisconsin
and Mississippi, have enacted moratoria on medical or municipal waste
incinerators that have since expired or been lifted. The US EPA enacted a
nationwide, 18-month freeze on new construction of hazardous waste
incinerators in 1993. Two unsuccessful bills were introduced in the US Congress
during the 1990s to enact a moratorium on new waste incinerators.

Other examples of incinerator moratoria worldwide include:

1982: Berkeley, California passes a ballot initiative banning garbage
burning plants for five years. The moratorium allowed the city to develop
recycling programs which became national models.

1985: Sweden implemented a 2-year moratorium on new incinerators.

1990: In the Flemish-speaking part of Belgium, public pressure resulted in
a 5-year moratorium on new municipal waste incinerators.

1992: Ontario, Canada banned new municipal incinerators. In 1996 a new
conservative government overturned the ban.

1992: Baltimore, Maryland passed 5-year moratorium on new municipal
incinerators.






Page 92 of 224

92
SOME NON INCINERATION TECHNOLOGIES FOR HAZARDOUS WASTE
TREATMENT
Technology Process Description Potential Advantages Current Uses

Base Catalyzed
Dechlorination

Wastes reacted with alkali metal
hydroxide, hydrogen and catalyst
material. Results in salts, water
and carbon.

Reportedly high destruction
efficiencies. No dioxin formation.


Licensed in the United States,
Australia, Mexico, Japan, and
Spain. Potential demonstration for
PCBs through United Nations
project.
Biodegradation

Microorganisms destroy organic
compounds in liquid solutions.
Requires high oxygen/nitrogen
input.
Low temperature, low pressure. No
dioxin formation. Contained
process.


Chosen for destruction of
chemical
weapons neutralent in the United
States. Potential use on other
military explosive wastes.
Typically used for commercial
wastewater treatment.
Chemical
Neutralization

Waste is mixed with water
and caustic solution. Typically
requires secondary treatment.
Low temperature, low pressure.
Contained and controlled process.
No dioxin formation.
Chosen for treatment of chemical
agents in the United States.

Electrochemical
Oxidation
(Silver II)

Wastes are exposed to
nitric acid and silver nitrate
treated in an electrochemical cell.

Low temperature, low pressure.
High destruction efficiency. Ability to
reuse/recycle process input
materials. Contained process. No
dioxin formation.
Under consideration for chemical
weapons disposal in the United
States. Assessed for treatment of
radioactive wastes.

Electrochemical
Oxidation
(CerOx)

Similar to above, but using cerium
rather than silver nitrate.


Same as above; cerium is less
hazardous than silver nitrate.

Demonstration unit at the
University of Nevada, United
States. Under consideration for
destruction of chemical agent
neutralent waste.
Gas Phase
Chemical
Reduction

Waste is exposed to hydrogen
and high heat, resulting in
methane and hydrogen chloride.

Contained, controlled system.
Potential for reprocessing
byproducts. High destruction
efficiency.

Used commercially in Australia
and
Japan for PCBs and other
hazardous waste contaminated
materials. Currently under
consideration for chemical
weapons destruction in the United
States. Potential demonstration
for PCB destruction through
United Nations project.
Solvated
Electron
Technology
Sodium metal and ammonia used
to reduce hazardous wastes to
salts and hydrocarbon
compounds.
Reported high destruction
efficiencies.

Commercially available in the
United States for treatment of
PCBs.
Supercritical
Water Oxidation

Waste is dissolved at high
temperature and pressure and
treated with oxygen or hydrogen
peroxide.

Contained, controlled system.
Potential for reprocessing
byproducts. High destruction
efficiencies.
Under consideration for chemical
weapons destruction in the United
States. Assessed for use on
radioactive wastes in the United
States.
Wet Air
Oxidation

Liquid waste is oxidized and
Hydrolyzed in water at
moderate temperature .
Contained, controlled system. No
dioxin formation.
Vendor claims 300 systems
worldwide, for treatment of
hazardous sludge and
wastewater.



Page 93 of 224

93
7.2.2 - RECYCLING OF MEDICAL WASTE
The definition of recycling is to pass a substance through a system
that enables that substance to be reused. Hospital Waste recycling involves the
collection of hospital waste materials , the separation and clean-up of those
materials. Recycling waste means that fewer new products and consumables
need to be produced, saving raw materials and reducing energy consumption.
SEGREGATION FOR RECYCLING AT HOSPITALS

Varying degrees of segregation of recyclable components of
hospital wastes occur at hospitals. In general, these activities are not organized
by the hospital management and have grown out of opportunities available to the
workers involved in handling the hospital wastes.
The quantities of recyclable materials in waste from minor health
care establishments are small. In general, any segregation for recycling will be
carried out by the workers handling the waste in clinics and health centers, etc.
but the minimal quantities generated limit the opportunities for sale.

SEGREGATION FOR RECYCLING AT MUNICIPAL LANDFILLS

At all landfills, a large number of waste pickers rely on recycling for
their survival. They do not differentiate between general solid waste and
hazardous health care waste and go through all wastes looking for recyclable
materials. Most of the recycling is achieved by urban recyclers, and at the
landfills only relatively small quantities of bone, paper, plastics and glass are
retrieved. Health care wastes in developing countries , are likely to contribute
only a small amount of such recyclable materials at landfills because of the at-
source segregation of the most valuable components.




Page 94 of 224

94
THE RECYCLERS
THE INITIAL PLAYERS IN HOSPITAL WASTE RECYCLING
The initial players in hospital waste recycling are the workers
responsible for handling waste in the hospitals. In developing countries , the
nurses aides, sweepers and janitors are employed by the hospitals and are
controlled by hospital supervisors with little support or advice from senior
management. Much of their recycling activity is informal and benefits only the
workers involved.

THE SECOND TIER OF HOSPITAL WASTE RECYCLERS
Municipal waste collection workers often serve as the second tier of
hospital waste recyclers. They frequently receive recyclable materials segregated
by the hospital waste handlers and sell them on. In addition, they scavenge the
waste collected at hospitals before dumping it at the landfill site.

THE THIRD TIER OF HOSPITAL WASTE RECYCLERS
Municipal waste collection workers and itinerant junk buyers sell on
the recyclable materials segregated from health care wastes to middle dealers in
the form of junk shops. Middle dealers serve the purpose of storing and,
sometimes, further separating recyclable materials until a sufficient quantity has
accumulated to make it worthwhile selling it on to main dealers.

MAIN DEALERS IN HOSPITAL WASTE RECYCLING
The main dealer purchases all the recyclable products by minor
dealers. The specification of main dealer varies from country to country i.e. the
main recycling dealers in Karachi have decentralized due to pressure on space
and working environment. The main dealers usually deal in one single waste
item only and have personal contacts with middle dealers.
Vietnam has a long history of recycling waste materials and, in
Hanois case, many villages in the suburbs and in nearby Provinces have

Page 95 of 224

95
developed skills which now make them main dealers in the solid waste recycling
system.
One of the main locations for main dealers is close to an industrial
trading estate, making it convenient to access end-users. Bulk quantities of
recyclable materials are collected, prepared and sold on. Even though the
premises of such main dealers have a legal status the operators are not
registered and have to pay protection money to enforcing agencies. The ultimate
industrial receivers of recycled materials tend to be located near the main dealers
and produce end-products for which there is a market. An example of a recycled
end-product is dana, which are the plastic pellets produced after molten waste
plastic extrusion, cooling and cutting. Waste glass and paper are likewise
converted into useful products in specialist enterprises.

HEALTH AND ENVIRONMENTAL IMPACTS OF HOSPITAL WASTE
RECYCLING

Workers segregate paper, cardboard and glass for recycling at any
stage of waste handling. In doing so, they are not careful and recyclable
materials are generally contaminated with blood and infectious fluids leaking from
red bags. Waste pickers at landfill sites are also singled out as being vulnerable
to flies, mosquitoes and air-borne dust. Leachate from landfills is claimed to
pollute surface and ground waters. Work as a recycler in Hanoi is said to be
arduous and to pose risks to health through traffic accidents and contact with
waste.
In health care establishments, particularly in government hospitals
in developing countries, the storage and transport of waste give rise to serious
concern about pollution of wards and storage areas and the potential for spread
of communicable diseases. During transport to disposal sites, health care wastes
are often blown onto streets, creating environmental pollution and health risk.
Burning of waste at dumps causes severe air pollution and exposure of waste
pickers to infectious material and sharps is a serious threat to health.

Page 96 of 224

96
Disposal of wastes in waterways create obnoxious odors and look aesthetically
unattractive, as well as having an adverse effect on fisheries.
It is therefore stressed that the health risks to these poorly-paid
workers could be reduced with better and more responsible management.
Workers should be immunized against Tetanus and Hepatitis B and undergo a
medical examination before starting work at a clinic or hospital.
It is very horrible that some black sheep sell the used syringes, drip
bags, blood bags and other plastics material to merchants who sell them on large
scale. After just washing, these syringes, needles, blood bags and tubing are
available in repacking for reuse. These repacked equipments are most
dangerous to health. It is therefore very necessary to make them non reusable by
cutting the plastics bags and completely destroying both syringes & needles.
RECYCLING IN THE U.K
In the UK, the household and commercial sectors have relatively
low recycling rates. This is in comparison to some other wastes, such as
construction and demolition waste and sewage sludge. The Government is
hoping to increase the amount of household waste that we recycle to 33% by
2015. Some of the materials that we can recycle include paper, plastics, metals
(such as aluminum cans) and tyres.
The paper industry generates vast quantities of waste in the form of
paper off-cuttings and damaged paper rolls. This paper can be put back into the
pulping process and recycled. Paper recycling in the UK became popular during
the 1990s. Nearly a million tones of paper from household waste is now recycled
each year. Although paper makes up over one third of all household waste
recycled, this is still no more than about 10% of the total paper consumed. In
contrast, over 50% of paper waste paper produced by the newspaper industry is
currently being recycled. To encourage the public to recycle waste paper, many
council have arranged house to house collection schemes. Separate bins and
containers are provided specifically for paper. They are collected at regular

Page 97 of 224

97
intervals and taken to be recycled. Other recycling depots for paper can be found
at municipal centers and supermarkets.
Approximately 6 to 8% of UK household waste comprises of glass
jars and bottles. However, the largest producers of waste glass bottles are hotels
and pubs, as the vast majority of drinks are bottled. A large proportion of glass is
collected in bottle banks and taken to be recycled. There are over 20,000 bottle
banks in the UK, and they are mainly found in car parks and at supermarkets.
There are usually three bottle banks, one for each color of glass: clear, green
and brown. The UK currently recycles about one third of its glass. This is far
behind glass recycling rates in other European countries. Switzerland and the
Netherlands for example have recycling rates as high as 80%.
Plastics make up a large amount of waste, since they are available
in numerous forms. There are two main types of plastic: thermoplastics, which
are the most common; and thermo sets. Thermoplastics melt when heated and
can therefore be remolded. This enables thermoplastics to be recycled relatively
easily. In Western Europe the largest amounts of plastic occur in the form of
packaging. Plastic waste tends to be sorted by hand, either at a materials
recycling facility or the householder can separate it. This may then be taken to a
plastic recycling point or collected by the council. The UK produces
approximately about 4.5 million tones of plastic waste each year. Most of this
waste arises from packaging. The UK has a plastics recycling rate of only 3%. In
Germany the recycling rate for plastic is 70%.
The UK has a recycling rate of approximately 60% for iron and
steel. Most of this waste comes from scrap vehicles, cooker, fridges and other
kitchen appliances. It is estimated that the metal content of household waste is
between 5 and 10%. It is mainly made up of aluminum drinks cans and tin-plated
steel food cans. Aluminum recycling is widely established in the UK. It is an
expensive metal and can therefore produce high incomes for recycling schemes.
Copper, zinc and lead are also recycled in the UK. At present, over a third of

Page 98 of 224

98
aluminum drinks cans are recycled. Some other countries have very high
recycling figures for aluminum drinks cans. The USA and Australia for example,
recycle nearly two thirds.
Every year in the UK between 25 and 30 million scrap tyres are
generated. Approximately 21% of these tyres are retreated and reused. The old
tread is ground off the tyre and replaced with a new tread. However, about half of
all used tyres are dumped in landfill sites throughout the country. Other tyres may
be incinerated.






TABLE 9 - MARKET PRICES OF HOSPITAL WASTE RECYCLABLES IN
KARACHI


QUANTITY MIDDLE DEALERS MAIN DEALERS
Waste Material in kg/day


Prices Total Prices Total

Rs Rs Rs Rs
Swabs/Dressings 1300.5 5 6502.50 7 9103.50
Placenta 120.00 - - - -
Plastic bags and
Drips
1175.5 80 94040 100 117550
Urine bags 80.0 80 6400 100 8000
Syringes 630.4 8 5043.2 10 6304
Glassware 411.8 6 2470.80 8 3294.40
Plastic and
Polythene
592.6 6 3555.6 8 4740.80
Paper 749.3 10 7493 12 8991.6
TOTAL 5060.10

125505.10

157984.30


Page 99 of 224

99

Figure 30 - Waste Recycling rates in USA


Figure 31 - Recycling Rates of selected materials in USA in 2001


Page 100 of 224

100


Figure 32 - Recycling Process Of a plastic bottle






Page 101 of 224

101
TABLE 10 - Recycling Versus Incineration: An Energy Conservation Analysis


Waste Stream Materials
Energy Conserved by Substituting
Secondary for Virgin Materials
(MJ/Mg)
Energy Generated from
MSW Incineration
(MJ/Mg)
Paper

Newspaper 22,398 8,444
Corrugated Cardboard 22,887 7,388
Office (Ledger & Computer Printout) 35,242 8,233
Other Recyclable Paper 21,213 7,600
Plastic

PET 85,888 210,004
HDPE 74,316 21,004
Other Containers 62,918 16,782
Film/Packaging 75,479 14,566
Other Rigid 68,878 16,782
Glass
Containers 3,212 106
Other 582 106
Metal


Aluminum Beverage
Containers
256,830 739

Other Aluminum 281,231 317
Other Non-Ferrous 116,288 317

Tin and Bi-Metal Cans 22,097 739
Other Ferrous 17,857 317
Organics

Food Waste 4,215 2,744
Yard Waste 3,556 3,166
Wood Waste 6,422 7,072
Rubber

Tires 32,531
14,777
Other Rubber 25,672
11,505
Textile

Cotton 42,101
7,283
Synthetic 58,292
7,283
Others 10,962 10,713



Page 102 of 224

102
7.2.3 - 3-R CONCEPT & THE EUROPEAN WASTE HIERARCHY IN
WASTE MANAGEMENT

Waste policy in the EU widely accepts the waste hierarchy of waste
management to be (in order of priority) as:

Reduce (Waste prevention)
Re-use
Recycling
Thermal decomposition with energy recovery (i.e. incineration with energy
recovery).




Figure 33 - Waste Hierarchy






Page 103 of 224

103
REDUCE
It means to reduce the amount of waste during the production
process. The amount of solid waste produced during production process can be
reduced as:

We should buy a product without extra packing.
We should buy long lasting products.
Old newspapers, bottles and other plastic materials should sale instead of
throwing them here & there.

REUSE
We can reuse many things before we throw them away.
Therefore we could:

Reuse bags (paper and plastic), containers, paper and other items.
Sell or donate things you no longer use to people who will use them, e.g.
clothing and shoes.
Repair shoes, boots, handbags and other items before you consider
throwing away.
Convert cans and plastic containers into plant pots.
RECYCLE

To separate a given waste material from other wastes and to process it so
that it can be used again in a form similar to its original use.
Recycling involves the collection of used and discarded materials
processing these materials and making them into new products.
It reduces the amount of waste that is thrown into the community dust bins
thereby making the environment cleaner and the air fresher to breathe.




Page 104 of 224

104


























The EU waste hierarchy in waste management.


In spite of this general consensus, and a growing coherence of this
hierarchy in policy lines of individual EU member states as a consequence of EU-
Directives, the majority of waste in Europe is either land filled or incinerated.
Importantly, these are the methods which also entail the highest and most
serious environmental and health risks.

The waste hierarchy
Within the hierarchy, the Governments do not expect incineration
with energy recovery to be considered before the opportunities for recycling and
composting have been explored





Reduction



Reuse


Recycle

Page 105 of 224

105
The proximity principle
Requires waste to be disposed of as close to the place of
production as possible. This avoids passing the environmental costs of waste
management to communities which are not responsible for its generation, and
reduces the environmental costs of transporting waste

The self-sufficiency principle.
The Governments believe that waste should not be exported from
one country to another for disposal. Waste Planning Authorities and the waste
management industry should aim, wherever practicable, for regional self-
sufficiency in managing waste. With regards to the EU Waste hierarchy, not
everything has gone well, however.

A move towards a waste policy aimed at reducing health effects
should put more emphasis on prevention and re-use. Presently, EU waste policy
is not founded upon health data. Fortunately the available data on health effects
from waste management do not conflict, and in important aspects even coincide
with the hierarchy proposed by the EU. For example, waste prevention is
deemed to be the most important (no waste equals no health effects), followed
by re-use and recycling. Despite this, the lack of consideration of the
environment and human health is clearly visible in EU policy.

For instance, regulations put in place for incineration by the EU
together, with national limits on this issue, are based on what is technically
achievable rather than on health and environmental data.

Although emission limits set in the new EU directive have resulted
in the closure and upgrading of some older incinerators in European countries,
the policy itself is already outdated with regard to the OPSPAR agreement to
phase out the releases of all hazardous substances within one generation. The
EU directive is based on the conception that small releases of hazardous

Page 106 of 224

106
substances are acceptable. This is the conventional (though misguided)
approach, which proposes that chemicals can be managed at "safe" levels in the
environment. However, it is already known, or is a scientific opinion, that there
are no "safe" levels of many environmental chemical pollutants such as dioxins,
other persistent, bio accumulative and toxic chemicals and endocrine disruptors.
In addition, the abandonment of the principle is increasing in political circles.


Figure 34 - Waste hierarchy




Page 107 of 224

107
The Way Forward: Adoption of the Precautionary Principle and Zero
release Strategy

The precautionary principle acknowledges that, if further
environmental degradation is to be minimized and reversed, precaution and
prevention must be the overriding principles of policy. It requires that the burden
of proof should not be laid upon the protectors of the environment to demonstrate
conclusive harm, but rather on the prospective polluter to demonstrate no
likelihood of harm. The precautionary principle is now gaining acceptance
internally as a foundation for strategies to protect the environment and human
health.
Current regulation for incinerators is not based on the precautionary
principle. Instead it attempts to set limits for the discharge of chemicals into the
environment which are designated as "safe". In the current regulatory system the
burden of proof lies with those who need to prove that health impacts exist
before being able to attempt to remove the cause of the problem and not with the
polluters themselves. Based on knowledge regarding the toxic effects of many
environmental chemical pollutants, which has accumulated over recent decades,
a more legitimate viewpoint is that "chemicals should be considered as
dangerous until proven otherwise".

We have now reached a situation, and indeed did some time ago,
where health studies on incineration have reported associations between
adverse health effects and residing near to incinerators or being employed at an
incinerator. These studies are warning signs that should not result in government
inactivity, but rather to decisions being taken which implement the precautionary
principle.

There is already sufficient human health and environmental
contamination evidence to justify a phase out of the incineration process based
on the precautionary principle. To wait for further proof from a new generation of

Page 108 of 224

108
incinerators from an already harmful and dirty technology would probably be a
blatant disregard for the environment and human health.

The aim of "zero discharge" is to halt environmental releases of all
hazardous substances. Although it is sometimes discussed as being simplistic or
even impossible, it is a goal whereby regulation can be seen as resting places on
the way to achieving it.


Zero discharge necessitates the adoption of clean production
techniques both in industry and agriculture. It is essential that the change to
clean production and material use should be fully supported by fiscal incentives
and enforceable legislation.

The principle of clean production has already been endorsed by the
Governing Council of the UNEP and has received growing recognition at nation
level. The way forward for waste management in line with a zero emissions
strategy and hence towards sustainability, lies in waste prevention, re-use and
recycling. In other words the adoption of the already well-known principle of
"REDUCE, RE-USE AND RECYCLE".

IMPLEMENTATION OF REDUCE, RE-USE AND RECYCLE

We live in a world in which our resources are generally not given
the precious status by industry and agriculture which they deserve. In part, this
has led to the creation, particularly in industrialized countries, of a "disposable
society" in which enormous quantities of waste, including "avoidable waste" are
generated. This situation needs to be urgently changed so that the amount of
waste produced both domestically and by industry is drastically reduced.


Page 109 of 224

109
However, far more action is presently required to stimulate the
change needed for much more waste reduction to become a reality. Current
levels of recycling in European countries vary considerably. For instance, the
Netherlands recycles 46% of municipal waste whereas the UK only manages
8%. Intensive re-use and recycling schemes could deal with 80% of municipal
waste. It is recognized that fiscal measures can play a considerable role in
encouraging re-use and recycling schemes whilst discouraging least desirable
practices such as incineration and landfill.

Measures to be taken in the drive towards increased waste
reduction, re-use and recycling, and therefore towards lessening the adverse
health effects from waste management should include:

The phase out of all forms of industrial incineration by 2020, including
MSW incineration. This is in line with the OSPAR Convention for the
phase out of emissions, losses and discharges of all hazardous
substances by 2020.

Financial and legal mechanisms to increase re-use of packaging (e.g.
bottles, containers) and products (e.g. computer housings, electronic
components).

Financial mechanisms (such as the landfill tax) used directly to set up the
necessary infrastructure for effective recycling.
Stimulating markets for recycled materials by legal requirements for
packaging and products, where appropriate, to contain minimum amounts
of recycled materials.

Materials that cannot be safely recycled or composted at the end of their
useful life (for example PVC plastic) must be phased out and replaced
with more sustainable materials.

Page 110 of 224

110
In the short term, materials and products that add to the generation of
hazardous substances in incinerators must be prevented from entering the
waste stream at the cost of the producer. Such products would include
electronic equipment, metals and products containing metals, such as
batteries and florescent lighting, and PVC plastics (Vinyl flooring, PVC
electrical cabling, PVC packaging, PVC-u window frames etc) and other
products containing hazardous substances.

TABLE 11 - JOB CREATION: REUSE & RECYCLING VERSUS DISPOSAL IN
THE UNITED STATES

Type of Operation Jobs Per 10,000 Tons
per Year
Product Reuse
Computer Reuse 296
Textile Reclamation

85
Misc. Durables Reuse 62
Wooden Pallet Repair 28
Recycling-Based Manufacturers 25
Paper Mills 18
Glass Product
Manufacturers
26
Plastic Product
Manufacturers
93
Conventional MRFs101 10
Composting 4
Incineration 1
Landfilling 1










Page 111 of 224

111
7.2.4 - LANDFILL METHOD OF SOLID HOSPITAL WASTE
DISPOSAL

Landfill is a site for the disposal of waste materials by burial. In the
past there have been problems with old, poorly managed landfills contaminating
waterways and releasing dangerous landfill gases. However, modern municipal
landfills are better managed with greater emphasis on avoiding environmental
effects. Modern municipal landfills still work by burying waste, but in contrast they
are highly engineered, controlled and monitored. They have liners to contain
leachate, a leachate collection and treatment system, a cap to reduce rain
infiltration and a monitoring system to assess the environmental effects.
Components of a Modern Landfill
1. Landfill liners: The first stage is to construct a landfill liner in order to
contain the landfill material and leachate. The most suitable sites will have a
natural clay liner; however the minimum acceptable is 6000mm of compacted
clay with a low permeability coefficient. This acts as a barrier, preventing
leachate from the landfill seeping into nearby aquifers or surface water bodies
where it could cause contamination. In addition to a clay liner, a plastic liner
may also be required for further protection of the surrounding environment.
2. Leachate collection and treatment systems: A series of pipes is
installed above the liner to collect the leachate at the bottom of the landfill.
The leachate is then piped to a leachate storage pond or holding tanks for
further treatment.
3. Landfill gas collection system: Landfill gas is produced from organic
waste disposed of in landfill. A landfill gas collection system is also installed
and consists of a series of perforated pipes laid within the waste connected to
a gas well from which the gas will be extracted. Collecting landfill gas is
important because it is high in methane, a potent greenhouse gas. The gas
may then be used by burn off or flares, or it may be used to generate
electricity.

Page 112 of 224

112
4. Monitoring system: This is in order to assess the environmental effects
of the landfill and may include leachate and landfill gas monitoring, an odor
control programme and a vermin control programme.
5. Landfill cap: When a landfill reaches the end of its life, it is closed and capped
with a layer of compacted clay and sometimes plastic sheeting. The capping must be
at least 600mm think and have a finished slope to minimize water infiltration.
Clean fill
A clean fill is another means of landfilling waste. However, unlike
modern municipal landfills, there are little or no containment measures for a
cleanfill.
A clean fill disposal site is usually an active or old quarry site in
which inert material is used to fill in the hollow created by excavation. Inert
material means material that will not cause significant adverse environmental or
health effects i.e. gravels, clays, soils, concrete, bricks, asphalt, chip seal, pavers
and similar construction and demolition wastes. Clean fills should not take
garden waste, timber, metals or other waste that could undergo any significant
physical, chemical or biological reaction to cause leachate or gas.
In June 2006 there were 33 cleanfill sites within Canterbury. 12 of
these are within the Christchurch City area. In Christchurch they can serve the
purpose of protecting groundwater resources by infilling old gravel pits with inert
material.
Cleanfill sites within Christchurch City are governed by their
resource consent conditions from Environmental Canterbury and by the
Christchurch City Council Cleanfill Licensing Bylaw.



Page 113 of 224

113
The Christchurch City Council Cleanfill Licensing Bylaw
The Christchurch City Council Cleanfill Licensing Bylaw 2003 came into
effect 1 March 2004 and sets out to encourage resource recovery. The Bylaw regulates
the types of materials that can be disposed of at a cleanfill and promotes materials
recovery, reuse and recycling.
Monofills
A 'monofill' is a landfill that contains only one waste type (e.g.
tyres, glass) as a method of disposal or long-term storage.
The advantage of monofill is that the resources do not become
contaminated by other waste material. There is the potential that one day the
resources could be mined.
There are no monofills in Canterbury according to Environment
Canterbury resource consent records. They are not a common method of waste
disposal, but there are some monofills in the North !sland for materials such as
plasterboard and wood waste.

Page 114 of 224

114

Figure 35 - Landfill site in Africa

PROBLEMS OF LANDFILLS
Leachate:
Leachate is the liquid that drains or 'leaches' from a landfill; it varies
widely in composition regarding the age of the landfill and the type of waste that it
contains. It can usually contain both dissolved and suspended material. The
organic material decomposes, producing acids. These acids mix with rainwater,
dissolve heavy metals and other toxics from the waste, and then percolate down
through the landfill. If not stopped by a liner, this Leachate will eventually
contaminate groundwater or surface water supplies. If a liner and collection
system is in place, Leachate treatment becomes an additional problem and
expense. However, even with a liner, all landfills eventually leak.

Page 115 of 224

115

Figure 36 - Leachate Pond

Greenhouse gases:
The decomposition of organic material under anaerobic (without
Oxygen) conditions produce large quantities of methane. Methane is a
contributor to the greenhouse effect, which is driving global climate change.
Landfill fires:
Methane is also highly flammable, and landfill fires are common
and difficult to put out. The uncontrolled burning of wastes in a landfill is likely to
result in air emissions similar to those from incinerators.
Vermin:
The organic material can attract rodents and other pests. This is
particularly problematic when landfills are located close to areas where people
live or work.



Page 116 of 224

116
Odor:
The rotting organics produce a strong, unpleasant odor.

Waste of land:
Landfills consume huge areas of land, often near metropolitan
areas where available land is scarce.

Waste of materials:
Landfills remove resources, both organic and inorganic, from the
economy in much the same way as do incinerators.

In Southern countries, landfills are even worse than in the North, as
they are often no more than unlined open dumps, scavenged by both people and
animals. The precarious living of such resource recoverers has been dramatically
demonstrated by the Payatas landfill disaster in the Philippines, where 200
people were killed in a landfill collapse in 2000.

Figure 37 - Sanitary Landfill - Area Method



Page 117 of 224

117



Figure 38 - Sanitary Landfill - Area Method


Figure 39 - Sanitary Landfill - Trench Method


Page 118 of 224

118

Figure 40 - Sustainable Landfill


Page 119 of 224

119



PVC: THE POISON PLASTIC
PVC is a commonly used plastic found in baby shampoo bottles,
packaging, saran wrap, shower curtains and thousands of other products yet
there is little public awareness of its serious health and environmental impacts.
Hospitals use plastics because they fear a spread of infection through the use of
reusable medical equipment. Thus, plastic use has grown with increasing
concern for infection control. However, there have been cases where even with
the use of plastics there has been a spread of infection in wards. Nurses
complained of nosocomial infections in wards even though disposable equipment
was used they related it to improper waste disposal of disposable equipment
within the wards. PVC is a thermoplastic, with approximately 40 percent of its
content being additives. Plasticizers are added to make PVC flexible and
transparent.
Medical equipment made from PVC:
Blood bags, breathing tubes
Feeding tubes, Pressure monitor tubes
Catheters, Drip chamber
IV Containers, Parts of a syringe
IV Components, Lab ware
Inhalation masks, Dialysis tubes
In the U.S., an estimated 300 billion pounds of longer-lasting PVC
products, such as construction materials that last 30 to 40 years, will soon reach
the end of their useful life and require replacement and disposal. As much as 7
billion pounds of PVC are discarded every year in the U.S. PVC disposal is the
largest source of dioxin-forming chlorine and phthalates in solid waste, as well as

Page 120 of 224

120
a major source of lead, cadmium and organ tins-which pose serious health
threats. Short-lived products account for more than 70% of PVC disposed in
America's solid waste with 2 billion pounds discarded every year, including
"blister packs" and other packaging, plastic bottles and plastic wrap. PVC was
promoted in industries as a replacement of metals. Therefore its use increased in
all types of industries very rapidly. But side effects are so dangerous that we
should avoid its use.

Figure 41 - Trends in U.S PVC Consumption

8.1 - SUMMARY OF KEY FINDINGS OF THE FIVE EU STUDIES

PVC WASTES ON THE INCREASE:
The amounts of PVC wastes are projected to increase more than
80% over the next 20 years, from 4.1 to 7.2 millions tones/year. Almost 90% of
these wastes are post consumer wastes.

CONSUMPTION OF PVC IN EUROPE
The consumption of final PVC products according to application
sectors in Europe and in some Member States is shown below:

Page 121 of 224

121
Europe Austria Germany Denmark France
Building 53 % 81 % 60 % 69 % 50 %
Packaging 16 % 2 % 11 % 8 % 30 %
Electronics/cable 9 % 8 % 8 %

8 %
Transport/cars 3 % 4 % 4 %

6 %
Furniture 3 % 2 % 3 %


Others 16 % 3 % 14 % 23 % 6 %

TABLE 12 - Source: Europe, Austria, Germany (AgPU, 1997), Denmark (Moeller et al., 1996), France (PVC working
Group, 1999)

8.2 - INCINERATION MAKING THINGS WORSE:

Incineration of 1 kg of PVC in the EU creates on average 0.8-1.4 kg
of hazardous wastes (in incinerators with non-wet flue gas treatment) and 0.4-0.9
kg of residues in liquid effluent (in incinerators with wet flue gas treatment).
Hazardous waste from PVC incineration will also be more likely to contaminate
the environment, as PVC increases the amount of Leachate and leach able salts
in this waste significantly. Incineration of PVC creates additional costs between
20-335 Euro/tonne. PVC is responsible for 38 to 66% of the chlorine content in
Municipal solid waste. The formation of dioxins due to PVC has been beyond the
scope of the study. Diverting PVC from incineration always leads to
environmental improvements. Nevertheless, PVC incineration is estimated to
increase more than fivefold over the next 20 years in a business-as-usual
scenario, from currently 0.5 million tones/year to 2.6-2.9 million tonnes/year.
DON'T BURN IT: THE HAZARDS OF BURNING PVC WASTE
More than 100 municipal waste incinerators in the U.S. burn 500 to 600
million pounds of PVC each year, forming highly toxic dioxins and
releasing toxic additives to the air and in ash disposed of on land.
Open burning of solid waste, which contains PVC, is a major source of
dioxin air emissions. Backyard burning of PVC household trash is

Page 122 of 224

122
unrestricted in Michigan and Pennsylvania, partially restricted in 30 states
and banned in 18 states.
The incineration of medical waste is being steadily replaced by cleaner
non-burn technologies.
When burned, PVC plastic forms dioxins, a highly toxic group of chemicals
that build up in the food chain, can cause cancer and harms the immune
and reproductive systems.
PVC is the leading contributor of chlorine to four combustion sources
municipal solid waste incinerators, backyard burn barrels, medical waste
incinerators and secondary copper smelters that account for an estimated
80% of dioxin air emissions (USEPA).

TOP TEN STATES INCINERATING PVC
STATE
AMOUNT OF
PVC
INCINERATED
(TONS)
NUMBER OF
INCINERATORS
PERCENT
INCINERATED(AFTER
RECYCLING)
FLORIDA 45,364 13 37.1%
NEW YORK 37,517 10 24.4%
MASSACHUSETTS 28,145 7 54.6%
VIRGINIA 18,806 5 27.9%
PENNSYLVANIA 17,746 6 22.6%
CONNECTICUT 16,257 6 55.4%
MINNESOTA 14,432 15 46.1%
MARYLAND 12,486 3 22.6%
MAINE 5,448 4 66.2%
HAWAII 3,454 1 32.7%
NEW HAMPSHIRE 1,675 2 22.2%
REMAINING
STATES *
49,075 32 VARIES
TOTAL 250,405 104
10.5%
TABLE 13 TOP TEN STATES INCINERATING PVC


Page 123 of 224

123

PVC PRODUCTS + WASTE INCINERATORS OR OPEN BURNING = DIOXIN
EMISSIONS

Dioxin formation is the Achilles heel of PVC. Burning PVC plastic,
which contains 57% chlorine when pure, forms dioxins, a highly toxic group of
chemicals that build up in the food chain. PVC is the major contributor of chlorine
to four combustion sourcesmunicipal solid waste incinerators, backyard burn
barrels, medical waste incinerators and secondary copper smeltersthat
account for a significant portion of dioxin air emissions. In the most recent
USEPA Inventory of Sources of Dioxin in the United States, these four sources
accounted for more than 80% of dioxin emissions to air based on data collected
in 1995. Since then, the closure of many incinerators and tighter regulations have
reduced dioxin air emissions from waste incineration, while increasing the
proportion of dioxin disposed of in landfills with incinerator ash. The PVC content
in the waste steam fed to incinerators has been linked to elevated levels of
dioxins in stack air emissions and incinerator ash.
Incineration and open burning of PVC-laden waste seriously
impacts public health and the environment. More than 100 municipal waste
incinerators in the U.S. burn 500 to 600 million pounds of PVC each year,
forming highly toxic dioxins that are released to the air and disposed of on land
as ash. The biggest PVC-burning states include Massachusetts, Connecticut,
Mainewhich all burn more than half of their waste Florida, New York,
Virginia, Pennsylvania, Maryland, Minnesota, Michigan, New Jersey, Indiana and
Washington.
The incineration of medical waste, which has the highest PVC
content of any waste stream, is finally being replaced across the U.S. by cleaner
non burn technologies after years of community activism and leadership by
environmentally-minded hospitals.
Backyard burning of PVC-containing household trash is not regulated at the
federal level and is poorly regulated by the states. There are no restrictions on
backyard burning in Michigan and Pennsylvania. It is partially restricted in 30
states, and banned in 18 states.

Page 124 of 224

124
8.3 - RECYCLING NOT SOLVING THE PROBLEM:

Recycling was found not to be qualified to contribute significantly to
the management of PVC waste in the next decades, reaching at most 18% of
total waste in 2020. Assuming that the maximum potential of PVC recycling is
achieved, incineration of PVC waste would still increase more than fourfold to
2.2-2.5 million tones in 2020. Current recycling rates are at less than 3%. Most
current recycling (2%) is down cycling - the recycling of PVC into low quality
recycled that do not replace virgin PVC and therefore has no environmental
benefits. Almost all PVC wastes contain hazardous additives.
Recycling these wastes leads to a spreading of these hazardous
substances into new products. High-quality recycling of PVC wastes without
spreading lead, cadmium or PCBs into the recycled is estimated to reach a
maximum of 5% by 2020. Chemical recycling was found to be not economically
viable.
PVC PRODUCTS + RECYCLING = CONTAMINATION OF THE ENTIRE
PLASTICS RECYCLING PROCESS

Unfortunately, PVC recycling is not the answer. The amount of PVC
products that are recycled is negligible, with estimates ranging from only 0.1% to
3%. PVC is very difficult to recycle because of the many different formulations
used to make PVC products. Its composition varies because of the many
additives used to make PVC products. When these different formulations of PVC
are mixed together, they cannot readily be separated which is necessary to
recycle the PVC into its original formulation. Its also virtually impossible to create
a formulation that can be used for a specific application. PVC can never be truly
recycled into the same quality materialit usually ends up being made into lower
quality products with less stringent requirements such as park benches or speed
bumps. When PVC products are mixed in with the recycling of non-chlorinated
plastics, such as in the all-bottle recycling programs favored by the plastics
industry, they contaminate the entire recycling process. Although other types of
non-chlorine plastics make up more than 95% of all plastic bottles, introducing

Page 125 of 224

125
only one PVC bottle into the recycling process can contaminate 100,000 bottles,
rendering the entire stock unusable for making new bottles or products of similar
quality. PVC also increases the toxic impacts of other discarded products such
as computers, automobiles and corrugated cardboard during the recycling
process.


8.4 - PVC PRODUCTS + LANDFILL DISPOSAL =GROUNDWATER
CONTAMINATION

Land disposal of PVC is also problematic. Dumping PVC in landfills
poses significant long-term environmental threats due to leaching of toxic
additives into groundwater, dioxin-forming landfill fires, and the release of toxic
emissions in landfill gases. Land disposal is the final fate of between 2 billion and
4 billion pounds of PVC that are discarded every year at some 1,800 municipal
waste landfills in the U.S.
Most PVC in construction and demolition debris ends up in landfills,
many of which are unlined and cannot capture any contaminants that leak out.
An average of 8,400 landfill fires is reported every year in the U.S., contributing
further to PVC waste combustion.

LAND FILLING - THE TICKING TIME BOMB:

Land filling of PVC results in the release of hazardous softeners.
Releases of hazardous stabilisers cannot be excluded. Stabilisers are ingredients
that are generally added to the PVC polymer in order to prevent thermal
degradation and hydrogen chloride evolution during processing and to give the
finished article optimum properties (heat and UV stability). Approximately 1-8 %
may be added to PVC formulation depending on other components and the final
application.






Page 126 of 224

126
The most important group of stabilisers are (based on Moeller et al, 1996)

Metal salts (i.e. calcium and zinc stearates, basic lead sulphate and lead
phosphate)
Organo metals (i.e. mono- and diorganotin, tin thioglycolate)
Organo phosphites (i.e. tri alkyl-phosphites)
Epoxy compounds (i.e. epoxidised Soya bean oil, sunflower oil and
linseed oil)
Antioxidants, polyols (i.e. BHT, pentaerythritol)
These releases will occur for a very long period of time - longer
than the guarantee of the technical barrier of the landfill. PVC waste will
furthermore contribute to the formation of dioxins and furans in landfill fires.
Ettala et al (1996) have investigated landfill fires in Finland. On
average, there are 633 sanitary landfills in operation in Finland. In the period of
1987-92 between 360 and 380 landfill fires occurred annually. One-quarter were
deep fires at a depth of more than 2m and a maximum depth of 8m. Deep fires
are difficult to extinguish and last longer than surface fires.
The most severe deep fires lasted for 2 months. Only four fires
occurred in waste older than 2 years. In 400 sanitary landfills in Sweden, 200-
250 fires have been reported. According to international experts11, landfill fires
are common in Iceland because of arson. Other replies considered that landfill
fires are very uncommon but reliable statistics were lacking. Disposal of ash,
deliberate fire starting and insufficient covering or compacting were reported to
be the most common causes for landfill fires. Possible air flow through drainage
pipes has been one reason for landfill fires in the U.K.








Page 127 of 224

127


ESTIMATED AMOUNTS OF PVC DISCARDED IN LANDFILLS
ACCORDING TO STATES THAT LANDFILL THE MOST MUNICIPAL
SOLID WASTE (MSW)
STATE
NUMBER OF
LANDFILLS
AMOUNT OF PVC
LANDFILLED (TONS)
California 161 328,260
Texas 175 176,896
New York 26 116,088
Ohio 44 100,509
Illinois 51 98,896
Michigan 52 96,241
Florida 100 76,817
Georgia 60 69,177
Pennsylvania 49 60,844
New Jersey 60 56,166
North Carolina 41 54,842
Indiana 35 52,986
Washington 21 49,128
Virginia 67 48,636
Maryland 20 42,722
Remaining States * 805 610,553
Total 1,767
2,038,761
TABLE 14 TOP STATES USING LANDFILL METHOD

By comparing the above data of incineration & land filling, the writer
is of the opinion that land filling of PVC is a lesser evil as compared to the
incineration. As incineration of PVC results in pollution of worlds atmosphere
while land filling of PVC results in pollution of a specific piece of land.






Page 128 of 224

128
THE BEHAVIOR OF PVC UNDER SIMULATED LANDFILL CONDITIONS

1. METHODOLOGICAL APPROACH
All investigations into the impact of landfill conditions on different
materials or substances have to take two major factors into consideration: time
and scale. To evaluate the behavior of PVC in landfills suitable methods had to
be developed to overcome these factors. Investigations in earlier studies showed
that the final state of organic substances in a staunch free landfill is always the
same: an aerobic stabilised humic-like substance, nearly water insoluble. The
same result can be reached by aerobic degradation within a much shorter time
span. To achieve comparability between tests and the real behavior of PVC in
landfill, PVC samples from a landfill were analyzed. At the second stage,
examinations were carried out at container size under aerobic thermophilic
conditions at a biological waste treatment plant. In laboratory scale the samples
were exposed to aerobic thermophilic conditions, to anaerobic thermophilic
conditions and to alternating aerobic-anaerobic conditions.
CONCLUSION
On the basis of performed analysis it is to conclude that PVC-
additives during staying for more than 20 years in a landfill will neither
degrade completely nor release completely from PVC products.

2. INVESTGATION OF BEHAVIOR OF PVC IN A BIOLOGICAL WASTE
TREATMENT PLANT IN TECHNICAL SCALE
Due to operation control of the plant the heat production which
causes high temperature during aerobic degradation processes was restricted.
Therefore the temperatures were generally lower than in lysimeter investigations.
The intensive degradation phase in the waste treatment plant usually takes about
12 days dependent on the amount of waste to be treated. This phase is carried
out in containers which will be emptied after that time. Therefore the PVC
samples could not be stored in the waste continuously. The intervals of
temperature of about 20C in figure below show the times the PVC was stored
while waiting for the next run of waste treatment.

Page 129 of 224

129
The PVC-materials changed during the incubation in the biological waste
treatment plant. Both, optically and mechanically they showed differences to the
raw materials. Analysis of the materials was carried out similarly to investigations
during the lysimeter tests. Changes in materials were examined by electron
scanning microscopy, tensibility tests, and analysis of molecular weight
distribution and analysis of the contents of additives. Investigations on the
behavior of PVC products in the biological waste treatment plant showed clearly
recognizable effects on the PVC.

Figure 42 - Course of temperature and carbon dioxide production in lysimeter (aerobic, without
added PVC)
The results show a clear loss of plasticiser during the lysimeter
studies under aerobic thermophilic conditions within the short time of
examinations. Measured losses from the materials taken from the lysimeters 4
and 6 are within the tolerance of the determination method. The trend towards a
decreasing content of plasticiser is probable. A clear loss of plasticiser has
occurred to the car interior material in the aerobic biological treatment plant
supporting the results from lysimeter 2. The theory to explain the differences
between the losses of plasticiser between the used car interior and the

Page 130 of 224

130
packaging foil with the dependence on the thickness of the material are
strengthened by the results from lysimeter 6 and the biological treatment plant. In
these investigations too the percentage of loss of plasticiser is higher from the
thin material.
The content of the plasticiser DIDP in both flooring materials shows
no decrease following the aerobic treatment in lysimeter 2. On the one hand it
could be explained with the fact that DIDP will leach much slower than DEHP or
it would not leach out.
Any loss of stabiliser leads to emissions in Leachate. The stabiliser
content was investigated by analysis of the heavy metal contents before and
after storing the PVC-materials in the lysimeters. In this investigation only the
samples containing stabilisers based on heavy metals were tested. These are
PVC II, PVC VI, PVC V, PVC VI and PVC VII. In spite of its content of Ba/Zn-
stabiliser PVC III was not investigated because PVC II contains the same
elements. The results are summarized in table below.

Material Examined condition Contents of heavy metals in % by weight

Pb Ba Zn Cd
PVC II Raw material - 0,01 0,02 -

Lysimeter 2; aerobic Lysimeter 6;
Anaerobic
--
0,09 0,03 0,02 0,01
--
PVC IV Raw material 2,8 - - -

Lysimeter 2; Aerobic Lysimeter 6;
Anaerobic
1,2 1,8
-- -- --
PVC V Raw material - 0,18 - 0,33

Lysimeter 2; Aerobic Lysimeter 6;
Anaerobic biol. waste treatment plant
---
0,13 0,16
0,16
---
0,33
0,33
0,31
PVC VI Raw material - <0,01 0,01 -

Lysimeter 2; Aerobic Lysimeter 6;
Anaerobic Biol. Waste Treatment Plant
--- 0,15 0,04
0,16
0,04 0,05
0,05
---
PVC VII Raw Material - 0,14 - 0,39
Lysimeter 2; Aerobic - 0,13 - 0,38
TABLE 15 PVC EXAMINATION RESULTS



Page 131 of 224

131
3. BEHAVIOR OF GASEOUS EMISSION FROM LADNFILL
To examine gaseous emissions from PVC the condensate from
lysimeter gas and the gas, enriched on charcoal, from the lysimeters were
analyzed to identify differences in composition and possible detrimental
substances in gas from waste not contaminated with PVC and waste enriched
with PVC. Only aerobic and aerobic-anaerobic lysimeters were included in the
investigation because of the constant gas flow through the waste. This flow was
caused by aeration of the lysimeters. Gas flow from anaerobic lysimeters can not
be assumed as constant and no analysis was undertaken. The result indicates
that volatile substances are released in case of the presence of PVC in
degrading waste.

4. BEHAVIOR OF EMISSION FROM LADNFILL SIMULATION TO
LEACHATE
To examine emissions from PVC, the Leachate from the lysimeters
was analyzed to investigate differences in composition and pollution of Leachate
from waste not contaminated with PVC and waste enriched with PVC. The
samples were taken from the lysimeters half-way through and at the end of the
studies.
The results show no certain differences between the lysimeters
containing PVC and the lysimeters without PVC. There are normal differences
between the three conditions aerobic, aerobic-anaerobic and anaerobic, but
there is no connection to the PVC materials.
To evaluate emissions of heavy metals caused by the PVC
stabilisers, the Leachate from the lysimeters was analyzed by atom absorption
spectroscopy. The results are shown in table below.






Page 132 of 224

132

Lysimeters
Cadmium
[mg/l]
Lead [mg/l] Zinc [mg/l]
after
45
days
after
90
days
after
45
days
after
90
days
after
45
days
After
90
days
Aerobic without PVC 0.08 0.08 0.77 0.50 17.1 5.18
Aerobic with PVC 0.04 0.04 0.25 0.27 1.38 1.32
Aerobic-Anaerobic
without PVC
0.03 0.03 0.33 0.66 33.0 20.8
Aerobic-Anaerobic
with PVC
0.01 0.05 0.37 0.50 1.30 3.48
Anaerobic without PVC 0.02 0.02 0.23 0.12 0.21 0.16
Anaerobic with PVC 0.05 0.02 0.40 0.12 0.23 0.18

TABLE 16 - Results from the analysis of heavy metals in the Leachate of the
lysimeters

CONCLUSIONS:
The aerobic thermophilic condition is considered to accelerate landfill
degradation processes and to provoke a state of degradation, which is
similar to the state of degradation in the final aerobic landfill phase.

Landfills are very heterogeneous in terms of waste composition and
physico-chemical characteristics not only between landfills but also
within a single landfill. PVC products are subjected to different
degradation processes in landfills which are determined by the
parameters temperature, moisture, presence of oxygen, activity of micro-
organisms and the interactions between parameters at different stages
of the ageing development of landfills.

Changes in the PVC products are reported from aerobic as well as from
anaerobic conditions. In real landfills aerobic conditions prevails in the
initial stage, which is rather short. Losses of Phthalates from PVC
materials under soil-buried (aerobic) conditions are reported to amount
to 30-35% of the total content.


Page 133 of 224

133
During the anaerobic phases of the landfill, degradation of PVC products
appears to be slower than under aerobic thermophilic conditions but the
release of phthalates in particular, will probably continue and an attack
on the PVC polymer, at least caused by high temperatures which may
occur in large landfill sites, cannot be excluded.

The analysis of materials being disposed of in a landfill more than 20
years ago still showed considerable amounts of plasticisers and
stabilisers. A release of phthalates under methanogenic conditions is
reported in the literature in a range of 4 to 40 %.

Heavy metals are more likely to be released under acidogenic conditions
while phthalates are particularly released during aerobic and
methanogenic stages of landfill development.

With regard to the release of phthalates again different processes are to
be distinguished, i.e. physical, hydrolytic and biological effects occur
concurrently. The fate of released additives is in case of phthalates
depending on hydrolytic and biological effects, on the retention capacity
of the waste matrix, on adsorption to particulate matter and co-transport.
In case of heavy metals, particularly acidity, the retention capacity of the
waste matrix and hydraulic effects determine emissions.

The degradation of phthalates from PVC under methanogenic conditions
is observed to be higher than under acidogenic conditions. Results from
studies on the degradability of phthalates under landfill conditions show
that degradation of PAEs occur, however, the rate of degradation does
appear to be influenced by the length of their side chain. Both, PAEs and
phthalic monoesters can be detected in landfill Leachate, which indicates
that these substances are not completely degraded.


Page 134 of 224

134
There is no evidence that the release of additives will come to a
standstill. Thus, it is expected that this process will last for a very long
time which cannot be estimated at a probably steady decreasing level.
Nowadays the technical guarantee for landfill bottom liners and pipes for
Leachate collection is restricted to 80 years. Emissions resulting from
the presence of PVC in landfills are likely to last longer than the
guarantee of the technical barrier.

Emissions to environmental media such as air, soil and groundwater is
to be expected particularly from landfills without active environmental
protection measures (old landfills). Furthermore, as there is evidence
that phthalates, DEHP mainly, are not fully eliminated through current
Leachate treatment, even from landfill sites equipped with Leachate
collection system and treatment of Leachate either on-site or off-site,
emissions to aquatic ecosystems cannot be excluded.

8.5 - SAFER ALTERNATIVES ARE AVAILABLE TO REPLACE PVC

Safer alternatives to PVC are widely available and effective for
almost all major uses in building materials, medical products, packaging, office
supplies, toys and consumer goods. PVC is the most environmentally harmful
plastic. Many other plastic resins can substitute more safely for PVC when
natural materials are not available.
PVC alternatives are affordable and already competitive in the
market place. In many cases, the alternatives are only slightly more costly than
PVC, and in some cases the costs of the alternative materials are comparable to
PVC when measured over the useful life of the product.
Phasing out PVC in favor of safer alternatives is economically
achievable. A PVC phase-out will likely require the same total employment as
PVC production. The current jobs associated with U.S. PVC production (an
estimated 9,000 in VCM and PVC resin production, and 126,000 in PVC

Page 135 of 224

135
fabrication) would simply be translated into production of the same products from
safer plastic resins.

8.6 - HOW CAN WE GET RID OF PVC?

To end the myriad of problems created by PVC disposal, we
recommend the following policies and activities.
Policymakers at the local, state and federal level should enact and
implement laws that steadily reduce the impacts of PVC disposal and lead
to a complete phase-out of PVC use and waste incineration within ten
years (see box below).

A new materials policy for PVC that embraces aggressive source
reduction of PVC should be adopted to steadily reduce the use of PVC
over time.

Federal and state waste management priorities should be changed to
make incineration of PVC waste the least preferable option. In the interim,
any PVC waste generated should be diverted away from incineration to
hazardous waste landfills.

Consumers should take personal action to buy PVC free alternatives and
to remove PVC from their trash for management as household hazardous
waste.

Communities should continue to organize against PVC-related dioxin
sources such as waste incinerators while working to promote safer
alternatives.





Page 136 of 224

136
8.7 - A PVC- FREE POLICY ACTION AGENDA

Accomplish Within Three Years
1. Ban all open waste burning.
2. Educate the public about PVC hazards.
3. Ban the incineration of PVC waste.
4. Collect PVC products separately from other waste.
5. In the interim, divert PVC away from incineration to hazardous waste landfills.

Accomplish Within Five Years

6. Establish our Right-to-Know about PVC.
7. Label all PVC products with warnings.
8. Give preference to PVC-free purchasing.
9. Ban PVC use in bottles and disposable packaging.
10. Ban sale of PVC with lead or cadmium.

Accomplish Within Seven Years

11. Phase out other disposable PVC uses.
12. Phase out other high hazard PVC uses.
13. If safer alternatives are not yet available, extend the PVC phase-out
deadlines for specific purposes.
14. Fund efforts to reduce the amount of PVC generated through fees on the
PVC content of products.

Accomplish Within Ten Years

15. Phase out remaining durable PVC uses.
16. Decommission municipal waste incinerators in favor of zero waste.







Page 137 of 224

137
8.8 - GREENPEACE ADVOCATES THE FOLLOWING MEASURES

The studies show multiple significant environmental and/or
economic problems for each of the PVC waste disposal options. They show that
neither incineration nor landfill is safe, and that recycling cannot solve the
problem. It is irresponsible to keep manufacturing such a material. Its
manufacture and use needs to be phased out as soon as possible, starting with
short-lived applications such as packaging. Existing wastes need to be fully
separated from the general waste stream and safely stored separately until an
environmentally safe destruction technology has been established. The costs
should be borne by the producer.
Greenpeace advocates that the following measures be taken against PVC:

1. SHORT-TERM ACTION:
Phase out of short-lived PVC uses such as packaging and toys,
Phase out of PVC medical devices, for which alternatives are
available,
Phase out of the use of hazardous stabilizers and softeners,
Ban on incineration and land filling of PVC wastes,
Ban on recycling of PVC containing hazardous additives, and
Producer responsibility for the separation of PVC from the general
waste stream and temporary storage until a waste solution has
been found and implemented by the producer,
2. Mid-Term Action
Develop and implement programme on phase out of entire PVC
production.






Page 138 of 224

138



9.1 - ENVIRONMENTAL LEGISLATION IN PAKISTAN
At independence, Pakistan inherited a number of laws from the
colonial period that were converted to environmental provisions. The constitution
of 1973 mentions environmental objectives in the preamble, but no specific law
was drafted at that time.

9.1.1-PEPO PAKISTAN ENVIRONMENTAL PROTECTION ORDINANCE
The first piece of legislation to consider environment as a whole
was the Environment Protection Ordinance of 1983, which sanctioned
establishment of Pakistan Environmental Protection Council chaired by the Prime
Minister, Pakistan Environmental Protection Agency and provincial
Environmental Protection Agencies. Since then many institutional, policy and
regulatory developments have taken place at the Federal and Provincial levels.
These, inter-alia, include creation of the Ministry of Environment, promulgation of
Pakistan Environmental Protection Ordinance-1983. This highlighted the need to
have a framework of environmental law in Pakistan to address emerging national
issues. PEPO established the Pakistan Environmental Protection Council
(PEPC) and the Pakistan Environmental Protection Agency, as well as
introducing the concept of Environmental Impact Assessments. It is unfortunate
that PEPO has remained largely unimplemented.





Page 139 of 224

139
9.1.2 - PAKISTAN ENVIRONMENTAL PROTECTION COUNCIL (PEPC)
BACKGROUND IN SUMMARY:
Pakistan Environmental Protection Council (PEPC) was set
up in 1984: Pakistan Environmental Protection Council (PEPC) is an apex
organization at the National level for formulation and implementation of the
national environmental policy and programmes. It was set up in 1984 under
section 3 of the Pakistan Environmental Protection Ordinance. During the first ten
years of its existence only one meeting of the PEPC had been held under the
Caretaker Prime Minister of Pakistan whom decided to establish the National
Environmental Quality Standards.
THE STANDARDS WERE RELATED TO:
Municipal and liquid industrial effluent
Industrial gaseous emissions and
Motor vehicle exhaust and noise. These standards were notified in the
Gazette of Pakistan on 29 August 1993
A CHANGE IN MANAGEMENT REVITALIZED PEPC:
Later on in July 1994, there was a change in the Chairperson of
PEPC. The new Chairperson re-vitalized the PEPC and it emerged as a fully
functioning institution. As against, only one meeting of the PEPC in 10 years
(between 1984 to 1993), seven meetings of the PEPC were held in the span of
20 months from 1994 to 1996.
SIGNIFICANT PHYSICAL IMPROVEMENTS WERE MADE IN FORESTATION:
During his tenure from 1994 to 1996, he accorded the highest priority to tree
plantation as the key component of environment. He launched a massive
forestation campaign throughout the country with a view to double the forest
cover in ten years. About 90 million saplings were planted in 1995 and 280

Page 140 of 224

140
million in 1996, in addition to plantation of 218 million saplings, as part of the
regular programmes of the Forestry Departments of the Provincial Governments.
9.1.3 - NATIONAL ENVIRONMENTAL QUALITY STANDARS
PEPC met in 1993 for the first time and approved National
Environmental Quality Standards (NEQS) which later formulated the limits on
major pollutants in municipal and industrial liquid effluents, industrial gaseous
emissions, motor vehicle exhaust and noise.

9.1.4 - PEPA PAKISTAN ENVIRONMENTAL PROTECTION ACT 1997
The draft Environmental Protection Act, which lapsed in 1996 after failing
to be approved in the National Assembly has recently been redrafted and
unanimously passed by the Assembly. The Pakistan Environmental Protection
Act 1997 was passed by the National Assembly of Pakistan on September 3,
1997, and by the Senate of Pakistan on November 7, 1997. The Act received the
assent of the President of Pakistan on December 3, 1997.
The approach taken for the protection of the environment in
Pakistan is laid down in the Environmental Conservation Strategy of 1992 and its
review in 2000. For specific rules and regulations, The Environmental Protection
Act was enacted in 1997 and it provides the backbone and framework for
environmental legislation in Pakistan. This act establishes the Pakistan
Environmental Protection Council, the highest decision making body in
environmental issues, the Pakistan Environmental protection Agency (Pak EPA)
and Environmental Tribunals.
The Pakistan Environmental Protection Council (PEPC) shall,
among other duties, co-ordinate and approve comprehensive national
environmental polices and approve National Environmental Quality Standards.
The act further defines the functions of institutions, providing a broad mandate to
for enacting rules, procedures and technical standards in different areas of
environmental protection. The Act requires Pak EPA to co-ordinate
environmental policies and programmes nationally and internationally, initiate

Page 141 of 224

141
legislation, establish surveys, manage monitoring and auditing schemes,
promote research as well as education and awareness in the field of the
environment.
The Environmental Protection Act does further require the
provincial authorities to establish Provincial Environmental Protection Agencies
for carrying out functions delegated to the provinces. The Government of
Pakistan has recently elaborated its further action in-line with the finding of the
review of the National Conservation Strategy in the form of the National
Environmental Action Plan, NEAP (as approved by PEPC in 2001).
The Government of Pakistan has, with assistance from UNDP,
embarked on a major programme in support of the NEAP. The NEAP-support
Programme has subprogrammes in the areas of policy Co ordination and
Environmental Governance, and Pollution Control. POPs Enabling Activity
Project of Pak-EPA has been launched in collaboration with UNDP and GEF.
UNITAR is providing technical assistance and international coordination for the
project.
Pakistan ratified the Basel Convention on Trans boundary
Movements of Hazardous Waste and their Disposal in 1994 and is a signatory to
the Rotter dam Convention (1997) for the Prior informed Consent (PIC)
procedure for Banned or Restricted Chemicals in International Trade. Pakistan
has also signed Stockholm Convention in 2001 and ratification of the SC is
currently under consideration. Pakistan has developed a National Profile for
chemicals, published in October 2000, with the assistance of UNITAR.








Page 142 of 224

142

9.1.5 - NATIONAL ENVIRONMENTAL POLICY 2005
The National Environmental Policy (2005-15) has, therefore, been
prepared to provide an overarching framework for achieving the goals of
sustainable development through protection, conservation and restoration of
Pakistan's environment.

POLICY VISION
The National Environmental Policy aims to improve the quality of
life of people of Pakistan through conservation, protection and improvement of
the country's environment and effective cooperation among government
agencies, civil society, private sector and other stakeholders.

OBJECTIVES
The objectives of the Policy are to:
Secure a clean and healthy environment for the people of Pakistan.
Attain sustainable economic and social development with due regard to
protecting the resource base and the environment of the country.
Ensure effective management of the country's environment through active
participation of all stakeholders.

Guide lines / Principles

The following guiding principles shall be applied to achieve the objectives
of the Policy:
Principle of sustainable development.
Principle of equitable access to environmental resources.
Creation of demand for a better environment.
Respect and care for the environment.

Page 143 of 224

143
Integration of environment into planning and implementation of policies,
programs and projects.
Changing personal attitudes and behaviors.
Precautionary principle.
Polluter pays principle.
Substitution principle.
Improving efficiency with which environmental resources are used.
Cradle to grave management.
Best available technology.
Decentralization and empowerment.
Extensive participation of communities, stakeholders and the public.
Accountability and transparency.
Increased coordination and cooperation among federal and provincial
governments, NGOs, private sector and academia.
Increased regional and international cooperation.

Pollution and Waste Management
Pollution caused by liquid and solid waste in the country shall be
prevented and reduced. For this purpose, the government shall:
Strictly enforce the National Environmental Quality Standards.
Introduce self monitoring and reporting system nationwide.
Introduce discharge licensing system for industry.
Make installation of wastewater treatment plants an integral part of all
sewerage schemes.
Develop and implement the National Sanitation Policy.
Implement the Master Plan for Treatment of Urban Waste Water.
Develop and implement a strategy for establishment of combined
treatment plants in industrial clusters.
Establish cleaner production centers and promote cleaner production
techniques and practices.

Page 144 of 224

144
Promote ISO 14000 certification.
Encourage reduction, recycling and reuse of municipal and industrial solid
and liquid wastes.
Establish standards for receiving water bodies.
Launch phased programs for clean up and gradual up-gradation of quality
of water bodies.
Develop and enforce regulations to reduce the risk of contamination from
underground storage tanks.
Finalize the National Oil Spill Contingency Plan.
Implement projects for mitigation of pollution caused by oil spill from the
Tasman Spirit.
Establish a Marine Pollution Control Commission. Frame Pakistan Oil
Pollution Act.
Develop arid enforce rules and regulations for proper management of
municipal solid waste and industrial, hazardous and hospital waste.
Regulate production / import of hazardous substances and wastes.
Develop and implement strategies for integrated management of
municipal, industrial, hazardous and hospital waste at national, regional
and local levels.
Strengthen capacity of institutions involved in waste management.
Encourage involvement of the private sector in waste management.
Establish facilities for recovery of raw material and energy from waste.
Create market for recovered and recycled materials.
Promote research and development focusing on low-waste technologies
and technologies for waste recovery and reuse.
Develop environmental risk assessment guidelines for existing industries
as well as new development interventions.
Develop national emergency response and accidents preventions plans to
prevent, and mitigate the effects of, accidents involving pollution of
environment.

Page 145 of 224

145
National Environmental Policy is the most comprehensive policy
ever formulated in Pakistan. This policy not only differentiates between industrial,
chemical & healthcare waste but also provides guidelines to solve the problems.
It is a serious effort to solve the waste problem according to the
international standards. Solid Waste Management (SWM), in all major cities of
Pakistan has been started very successfully in accordance to this policy. In near
future, Pakistan will be able to manage the different types of waste in an efficient
way.

9.1.6 HOSPITAL WASTE MANAGEMENT RULES 2005
Hospital waste management rules were implemented in 2005.

RESPONSIBILITY FOR WASTE MANAGEMENT
Every hospital shall be responsible for the proper management of
the waste generated, collected, and received by it till its final disposal in
accordance with the provisions of the Act and the rules 16 to 22.

WASTE MANAGEMENT TEAM
The Medical Superintendent of the hospital shall constitute a Waste
Management Team comprising the following members, by whatever designation
called -

(a) The Medical Superintendent, who shall be the Chairman;

(b) The Heads of all hospital departments;

(c) The Infection Control Officer;

(d) The Chief Pharmacist;

(e) The Radiology Officer;

Page 146 of 224

146

(f) The Senior Matron;

(g) The Head of Administration;

(h) The Hospital Engineer;

(I) Senior Nursing Officer; and

(i) Such other staff members as the Medical Supervisor may designate.

(2) - In hospital where the posts mentioned in sub-rule (1) do not exist, the
Medical Superintendent shall either himself perform, or designate another staff
member to perform, the duties and responsibilities of the holder of such posts, as
described in Rules 8 to 14.

(3) - Members of the Waste Management Team shall be informed in writing by
the Medical Superintendent of their appointment and their duties and
responsibilities, as described in Rules 8 to 14

(4) - One of the members of the Waste Management Team shall be designated
by the Medical Superintendent as the Waste Management Officer.

5. DUTIES AND RESPONSIBILITIES OF THE WASTE MANAGEMENT TEAM

The Waste Management Team shall be responsible for the better
administration, preparation, careful planning, monitoring, periodic review,
coordinate and control disposal operations, revision or updating if necessary, and
implementation of the Waste Management Plan.



Page 147 of 224

147
6. DUTIES AND RESPONSIBILITIES OF THE MEDICAL SUPERINTENDENT

The Medical Superintendent shall

(a) Constitute the Waste Management Team;

(b) Designate the Waste Management Officer;

(c) Supervise implementation, monitoring and review of the Waste
Management Plan, and ensure that it is kept up-to-date;

(d) Arrange for a waste audit of the hospital by an external agency as
may be designated for the purposes by the provincial Government,
involving analysis of the existing waste stream and assessment of
existing waste management practices;

(e) Allocate sufficient financial and manpower resources to ensure
efficient and effective implementation of the Waste Management
Plan; and

(f) Ensure adequate training and refresher courses for the concerned
hospital staff members and attend them himself as well.

7. DUTIES AND RESPONSIBILITIES OF THE HEADS OF DEPARTMENTS

Heads of departments shall be responsible for the proper
management of waste generated in their respective departments, and in
particular shall-

(a) Ensure that all doctors, nurses, clinical and non-clinical staff in their
respective departments are aware of, and where required properly

Page 148 of 224

148
trained in, waste management procedures as prescribed under the
Waste Management Plan;

(b) Arrange proper supervision of the sanitary staff and sweepers to
ensure that they comply with waste management procedures at all
times as prescribed under the Waste Management Plan; and

(c) Lliaise with the Waste Management Officer for effective monitoring
and reporting of mistakes and errors in implementation of the Waste
Management Plan.

7. DUTIES AND RESPONSIBILITIES OF THE INFECTION CONTROL
OFFICER.
The Infection Control Officer shall be responsible for -

(a) Achieving reduction in infection rates;

(b) Giving advice regarding the control of infection and the standards of
the waste disposal system;

(c) Identifying training requirements for each category of staff;

(d) Organizing, with others, training and refresher courses on safe waste
management procedures; and

(e) Organizing infection control plan

9. DUTIES AND RESPONSIBILITIES OF THE CHIEF PHARMACIST

The Chief Pharmacist shall be responsible for the sound management of
pharmaceutical stores and in particular shall -

(a) Give advice regarding formulation of appropriate procedures for
management of pharmaceutical waste, and coordinate
implementation of these procedures; and


Page 149 of 224

149
(b) Ensure that the concerned hospital staff members receive adequate
training in pharmaceutical waste management procedures.

(c) Ensure that the Pharmaceutical waste is being disposed of in
accordance with the Waste Management Plan

10. DUTIES AND RESPONSIBILITIES OF THE RADIOLOGY OFFICER

The Radiology Officer shall be responsible for the sound management of
radioactive waste, and in particular shall -

(a) Give advice regarding formulation of appropriate procedures for
management of radioactive waste and coordinate implementation of
these procedures; and

(b) Ensure that the concerned hospital staff members receive adequate
training in radioactive waste management procedures..

(c) Ensure that the radioactive waste is being dispose of in accordance
with the Waste Management Plan
11. DUTIES AND RESPONSIBILITIES OF THE SENIOR MATRON AND HEAD
OF ADMINISTRATION

The Senior Matron and Head of Administration shall be responsible
for ensuring training of nursing staff, medical assistants and sanitary staff and
sweepers in waste management procedures, and basic personal hygiene.






Page 150 of 224

150
12. DUTIES AND RESPONSIBILITIES OF THE HOSPITAL ENGINEER
The Hospital Engineer shall be responsible for installation,
maintenance and safe operation of waste storage facilities and waste handling
equipment and, where installed, the hospital incinerator, and shall ensure that the
concerned hospital staff members are properly trained for these purposes.

13. DUTIES AND RESPONSIBILITIES OF THE WASTE MANAGEMENT
OFFICER

The Waste Management Officer shall, in addition to his normal duties and
responsibilities, be responsible for the day-to-day implementation and monitoring
of the Waste Management Plan and in particular, shall

(a) for waste collection

(i) Ensure internal collection of waste bags and waste containers
and their transport to the central storage facility of the hospital
on a daily basis;

(ii) Liaise with the Stores and Supplies Department to ensure that
an adequate supply of waste bags, containers, protective
clothing and collection trolleys are available at all times;

(iii) Esure that sanitary staff and sweepers immediately replace
used bags and containers with the new bag and containers of
the same type on the required time or when it is full, and, where
a waste bag is removed from container, that the container is
properly cleaned before a new bag is fitted there in; and


Page 151 of 224

151
(iv) Directly supervise the hospital sweepers assigned to collect
and transport the waste on the specified time and when they
are full.

(b) for waste storage

(i) Ensure correct use of the central storage facility and that it is
kept secured from unauthorized access; and

(ii) Prevent unsupervised dumping of waste bags and waste
containers on the hospital premises, even for short periods of
time.

(c) for waste disposal

(i) Co-ordinate and monitor all waste disposal operations, and for
this purpose meet regularly with the concerned representative
of the local council;

(ii) Ensure that the correct methods of transportation of waste are
used on-site to the central storage facility or incinerator if
installed, and off-site by the local council; and

(iii) Ensure that the waste is not stored on the hospital premises for
longer than 24 hours, by coordinating with the incinerator
operators and with the local council.

(d) for staff training and information

(i) Liaise with the Heads of departments, Head of Administration
and Senior Matron to ensure that all doctors, clinical staff,

Page 152 of 224

152
nursing staff, and medical assistants are fully aware of their
duties and responsibilities under the Waste Management Plan;

(ii) Ensure that sanitary staff and sweepers are not involved in
waste segregation and that they only handle waste bags and
containers, in the correct manner.

(e) for incident management and control

(i) Ensure that emergency procedures are available and in place
at all times and that all staff members are aware of the action to
be taken by them;

(ii) Investigate, record and review all incidents reported regarding
hospital waste management; and

(iii) Record the quantities of waste generated by each department
on a weekly basis.
14. WASTE MANAGEMENT PLAN

(1) The Waste Management Plan shall be drafted by the Waste Management
Officer for approval by the Waste Management Team, and shall be based on
internationally recognized environment management standards such as the ISO
14000 series.

(2) The Waste Management Plan shall include -

(a) A plan of the hospital showing the waste disposal points for every
ward and department, indicating whether each point is for risk waste
or non-risk waste, and showing the sites of the central storage facility
for risk waste and the central storage facility for non-risk waste;

Page 153 of 224

153

(b) Details of the types, numbers and estimated costs of containers,
plastic bags and trolleys required annually;

(c) Time-tables including frequency of waste collection from each ward
and department;

(d) Duties and responsibilities for each of the different categories of
hospital staff members who will generate hospital waste and be
involved in the management of the waste;

(e) An estimate of the number of staff members required for waste
collection;

(f) Procedures for the management of wastes requiring special
treatment such as autoclaving before final disposal;

(g) Contingency plans for storage or disposal of risk waste in the event
of breakdown of incinerator, or of maintenance or collection
arrangements;

(h) Training courses and programmes; and

(i) Emergency procedures.

(3) The representatives of the local council responsible for the collection and
disposal of waste from the hospital shall be consulted in drafting and finalization
of the Waste Management Plan.

(4) The Waste Management Plan shall be regularly monitored, reviewed, and
revised and updated by the Waste Management Team as and when necessary.

Page 154 of 224

154

15. WASTE SEGREGATION

(1) - Risk waste shall be separated from non-risk waste at the source, i.e. at the
ward bedside, operation theatre, laboratory, or any other room in the hospital
where the waste is generated, by the doctor, nurse, or other person generating
the waste.

(2) - All disposal medical equipment and supplies including syringes, needles,
plastic bottles, drips and infusion bags shall be cut or broken and rendered non-
reusable at the point of use by the person using the same, or in case any such
used equipment or supplies is found or comes to the possession of any person,
by such person.

(3) - All risk waste other than sharps, large quantities of pharmaceuticals, or
chemicals, waste with a high content of mercury or cadmium such as broken
thermometers or used batteries, or radioactive waste shall be placed in a suitable
container made of metal or tough plastic, with a pedal type or swing lid, lined with
a strong yellow plastic bag. The bags shall be removed when it is not more than
three quarters full and sealed, preferably with self-locking plastic sealing tags and
not by stapling. Each bag shall be labeled, indicating date, point of
production/ward/hospital, quantity and description of waste, and prominently
displaying the biohazard symbol. The bag removed should be immediately
replaced with a new one of the same type.

(4) - Sharps including the cut or broken syringes and needles shall be placed in
metal or high-density plastic containers resistant to penetration and leakage,
designed so that items can be dropped in using one hand, and no item can be
removed. The containers shall be colored yellow and marked "DANGER!
CONTAMINATED SHARPS. The sharps container shall be closed when three

Page 155 of 224

155
quarters full. If the sharp container is to be incinerated, it shall be placed in the
yellow plastic bag with the other risk waste.

(5) - Large quantities of pharmaceutical waste shall be returned to the suppliers.
Small quantities shall be placed in a yellow plastic bag, preferably after being
crushed, where this can be done safely.

(6) - Large quantities of chemical waste, and waste with a high content of
mercury or cadmium shall not be incinerated, but shall be placed in chemical
resistant containers and sent to specialized treatment facilities.

(7) - Radioactive waste which has to be stored to allow decay to background
level shall be placed in a plastic bag, in a large yellow container or drum. The
container or drum shall be labeled, showing the radio nuclides activity on a given
date, and the period of storage required, and marked 'RADIOACTIVE WASTE',
with the radiation symbol. Non-infectious radioactive waste which has decayed to
background level shall be placed in black plastic bags. Infectious radioactive
waste which has decayed to background level shall be placed in yellow plastic
bags. High level and relatively long half-life radionuclide shall be packaged and
stored in accordance with instructions of the original supplier under supervision
of the Radiology Officer, and sent back to the supplier for disposal.

(8) - Non-risk waste shall be placed in a suitable container lined with a black
plastic bag. Adequate numbers of non-risk waste containers shall be placed in all
areas of the hospital and notices affixed to encourage visitors to use them.







Page 156 of 224

156
16. WASTE COLLECTION

(1) - Waste shall be collected in accordance with the schedules specified in the
Waste Management Plan.

(2) - Sanitary staff and sweepers shall, when handling waste, wear protective
clothing at all times including face masks, industrial aprons, leg protectors,
industrial boots and disposable or heavy duty gloves, as required.

(3) - Sanitary staff and sweepers shall ensure that

(a) Waste is collected at least daily if not full, but more often if
necessary;

(b) All bags are labeled before removal, indicating the point of
production, ward and hospital, and contents; and

(c) Bags and containers which are removed are immediately replaced
with new ones of the same type and color;

(d) Where a waste bag is removed from a container, the container is
properly cleaned before a new bag is fitted therein and in case of
severe infection the container should also be discarded.

17. WASTE TRANSPORTATION

(1) - For on-site transportation, the waste collection trolley shall be free of sharp
edges, easy to load and unload and to clean, and preferably a stable three or
four wheeled design with high sides. The trolley shall not be used for any other
purpose. The trolley shall be cleaned regularly, and especially before any
maintenance work is performed on it.

Page 157 of 224

157

(2) - The sealed plastic bags shall be carefully loaded by hand onto the trolley, to
minimize the risks of punctures or tears.

(3) - Yellow-bagged risk waste and black-bagged non-risk waste shall be
collected on separate trolleys which shall be painted or marked in the
corresponding colors.

(4) - The collection route shall be the most direct one from the final collection
point to the central storage facility designated in the Waste Management Plan.
The collected waste shall not be left even temporarily anywhere other than at the
designated central storage facility.

(5) - Transportation off-site shall, unless otherwise agreed, be the responsibility
of the local council, which shall ensure that -

(i) All yellow-bagged waste is collected at least once daily;

(ii) All staff members handling yellow-bagged waste wear protective
clothing;

(iii) Yellow-bagged waste is transported separately from all other
waste;

(iv) Vehicles or skips used for the carriage of yellow- bagged waste are
not used for any other purpose, are free of sharp edges, easy to
load and unload by hand, easy to clean/disinfect, and fully
enclosed, preferably with hinged and lockable shutters or lids, to
prevent any spillage in the hospital premises or on the highway
during transportation;


Page 158 of 224

158
(v) All concerned staff members are properly trained in the handling,
loading and unloading, transportation and disposal of yellow
bagged waste, and are fully aware of emergency procedures for
dealing with accidents and spillages;

(vi) All vehicles carry adequate supply of plastic bags, protective
clothing, cleaning tools and disinfectants to clean and disinfect any
spillage;

(vii) The transportation of waste is properly documented, and all
vehicles carry a consignment note from the point of collection to the
incinerator or landfill or other final disposal facility; and

(viii) All vehicles are cleaned and disinfected after use.

18. WASTE STORAGE

(1) - A separate central storage facility shall be provided for yellow-bagged
waste, with a sign prominently displaying the biohazard symbol and clearly
mentioning that the facility stores risk waste.

(2) - The designated central storage facility shall -

(a) Be located within the hospital premises close to the incinerator, if
installed, but away from food storage or food preparation areas;

(b) Be large enough to contain all the risk waste produced by the
hospital, with spare capacity to cater for collection or incinerator
breakdowns;


Page 159 of 224

159
(c) Be easy to clean and disinfect, with an impermeable hard-standing
base, plentiful water supply and good drainage, lighting and
ventilation;

(d) Have adequate cleaning equipment, protective clothing and waste
bags and containers located nearby; and

(e) Be easily accessible to collection vehicles and authorized staff, but
totally enclosed and secure from unauthorized access, and
especially inaccessible to animals, insects and birds.

(3) - No materials other than yellow-bagged waste shall be stored in the central
storage facility.

(4) - No waste shall be stored at the central storage facility for more than 24
hours. Provided that if in an emergency infectious waste is required to be stored
for more than 24 hours, it shall be refrigerated at a temperature of 30C to 80C.

(5) - Containers with radioactive waste shall be stored in a specifically marked
area in a lead-shielded storage room.

(6) - Containers with chemical waste which are to be specialized treatment
facilities shall also be stored in a separate room or area.

(7) - The central storage facility shall be thoroughly cleaned in accordance with
procedures stipulated in the Waste Management Plan.






Page 160 of 224

160
19. WASTE DISPOSAL

(1) - Depending upon the type and nature of the waste material and the
organisms in the waste, risk waste should be inactivated or rendered safe before
final disposal by a suitable thermal, chemical, irradiation incineration, filtration or
other treatment method, or by a combination of such methods, involving proper
validation and monitoring procedures. Effluent from the waste treatment methods
shall also be periodically tested to verify that it conforms to the NEQS before it is
discharged into the sewerage system.

(2) - Yellow-bagged waste shall be disposed of by burning in an incinerator or by
burial in a land-fill, or by any other method of disposal approved by the Federal
Agency or Provincial Agency concerned:

(3) - Sharps containers which have not been placed in yellow bags for incinerator
shall be disposed of by encapsulation or other method of disposal approved by
the Federal Agency or provincial Agency concerned.

(4) - The method of disposal, whether by burning in an incinerator or by burial in
a landfill or otherwise, shall be operated by a hospital only after approval of its
EIA in accordance with the provisions of section 12:

Provided that hospitals, local councils or other persons already using an
incinerator or land-fill on the date of enforcement of these rules shall submit an
EIA in respect thereof to the Federal Agency or Provincial Agency concerned
within two months from the said date, and may continue to use the incinerator or
land-fill pending decision on the EIA.

(5) - All risk waste delivered to an incinerator shall be burned within 24 hours.


Page 161 of 224

161
(6) - Ash and residues from incineration and other methods shall be placed in
robust, noncombustible containers and sent to the local council's designated risk
waste landfill site.

(7) - Landfills shall be located at sites with minimal risk of pollution of
groundwater and rivers. Access to the site shall be restricted to authorized
personnel only. Risk waste shall be buried in a separate area of the landfill under
a layer of earth or non-risk waste of at least 1 meter depth which shall then be
compacted. The landfill shall be regularly monitored by the local council to check
groundwater contamination and air pollution. The local council shall also ensure
that the landfill operators are properly trained, especially in safe disposal
procedures, use of protective equipment and hygiene and emergency response
procedures.

(8) - Daily collection of risk waste from hospitals shall be taken by the vehicles of
the local council immediately to the designated landfill site or incinerator by the
most direct route, in accordance with prior scheduling of collection times and
journey times.

(9) - Radioactive waste which has decayed to background level shall either be
buried in the landfill site or incinerated: Provided that an incineration facility for
radioactive waste shall require, in addition to approval of its EIA by the Federal
Agency or Provincial Agency concerned, registration with, and issue of license
by, the Directorate of Nuclear Safety and Radiation Protection in accordance with
the provisions of the Pakistan Nuclear Safety and Radiation Protection
Ordinance IV of 1984, and Pakistan Nuclear Safety and Radiation Protection
Regulations, 1990.

(10) - All liquid infectious waste shall be discharged into the sewerage system
only after being properly treated and disinfected: Provided that liquid radioactive
waste shall be discharged into the sewerage system only after it has decayed to

Page 162 of 224

162
background level and after it has been ensured that the radioactive materials are
soluble and dispersible in water, failing which it shall be filtered:

Provided further that radioactive waste containing Tritium and Carbon-14
isotopes shall be stored separately and shipped to the disposal site of the
Pakistan Atomic Energy Commission at KANUPP, Karachi or PINSTECH,
Islamabad.

(11) - In the case of gaseous radioactive waste, portable filter assembles shall be
used to extract iodine and xenon. The used filters shall be treated as solid
radioactive waste.

20. ACCIDENTS AND SPILLAGES

(1) - In case of accidents or spillages, the following action shall be taken -

(a) The emergency procedures mentioned in the Waste Management
Plan shall be implemented immediately;

(b) The contaminated area shall be immediately evacuated, if required;

(c) The contaminated area shall be cleared and, if necessary,
disinfected;

(d) Exposure of staff shall be limited to the extent possible during the
clean-up operation, and appropriate immunization carried out, as
may be required; and

(e) Any emergency equipment used shall be immediately replaced in the
same location from which it was taken.


Page 163 of 224

163
(2) - All hospital staff members shall be properly trained and prepared for
emergency response, including procedures for treatment of injuries, cleanup of
the contaminated area and prompt reporting of all incidents of accidents,
spillages and near-misses.

(3) - The Waste Management Officer shall immediately investigate, record and
review all such incidents to establish causes and where necessary shall amend
the Waste Management Plan to prevent recurrence.

21. WASTE MINIMIZATION AND REUSE

(1) - To minimize hospital waste, each hospital shall introduce -N

(a) Purchasing and stock controls, involving careful management of the
ordering process to avoid over-stocking, particularly with regard to
date-limited pharmaceutical and other products, and to accord
preference to products involving low amounts of packaging;

(b) Waste recycling programmes, involving return of un-used or waste
chemicals in quantity to the supplier for reprocessing, return of
pressurized gas cylinders to suppliers for refilling and reuse, sale of
materials such as mercury, cadmium, nickel and lead-acid to
specialized recyclers, and transportation of high level radioactive
waste to the original supplier; and

(c) Waste reduction practices in all hospital departments.

(2) - To encourage reuse, each hospital shall separately collect, wash and
sterilize, either thermally or chemically in accordance with approved procedures,
surgical equipment and other items which are designed for reuse and are
resistant to the sterilization process.

Page 164 of 224

164

22. INSPECTION

(1) - A Health officer may inspect any hospital, incinerator or landfill located
within the area of his jurisdiction to check that the provisions of these rules are
being compiled with.

(2) - If a Health officer discovers any contravention of any provision of these
rules, he shall report the contravention to a District complaint scrutiny committee
constituted by the [provincial Government comprising two Medical Superintended
of hospitals owned by the provincial Government, one of which shall be the
Chairman of the committee, and one Medical Superintended of a private sector
hospital:

Provided that Hospitals whose Medical Superintendents on the District complaint
scrutiny committee shall not be located in the said District.

(3) - The District Complaint Scrutiny Committee shall review details of the
contravention reported by the Health officer and after giving the duly authorized
representative of the hospital or incinerator or landfill an opportunity of being
heard, either recommend that action be initiated against the person responsible
through the district Health Officer or local council or the Federal Agency or the
Provincial Agency concerned.









Page 165 of 224

165
23. PROVINCIAL HOSPITAL WASTE MANAGEMENT ADVISORY
COMMITTEE


(1) - The provincial Government shall be notification in the official Gazette,
constitute a Hospital Waste Management Advisory Committee comprising-

(a) The Secretary, Provincial Health Department, Chairman

(b) Representative of Ministry of Health, Member

(c) Secretary, Provincial Environment Department, Member

(d) Secretary, Provincial Local Government Department, Member

(e) President, Pakistan Medical Association or his representative,
Member

(f) Vice Chancellor of a Medical University in the Province, Member

(g) Medical Superintendents of 2 hospitals in the public sector and 2
hospitals in the private sector Member

(h) Representative of 2 non-governmental organizations, Member

(i) Director General, Provincial Environmental Protection Agency,
Secretary





Page 166 of 224

166
(2) - The Hospital Waste Management Advisory Committee shall:

(a) Periodically review the implementation of these rules and
recommend amendment there to;

(b) Recommended adoption of such policy measures, plans and
projects as it may consider necessary for the effective management
of hospital waste in the province.

24. PHASED IMPLEMENTATION

The Federal Government may by notification in the official Gazette -

(1) - Exempt any class of hospitals from all or any of the provisions of these
rules; or

(2) - Direct that the provisions of some or all of the rules shall apply to certain
class of hospitals only after a stipulated time period.

25. APPLICABILITY OF THE HAZARDOUS SUBSTANCES AND WASTE
MANAGEMENT RULES, 2003.

(1) - Each hospital generating risk waste shall apply to the Federal Agency for
grant of license under section 14, in accordance with the provisions of the
Hazardous Substances and Waste Management Rules, 2003.

(2) - The provisions of these rules shall, to the extent of any inconsistency qua
hospital waste, prevail over the Hazardous Substances Rules, 2000.




Page 167 of 224

167
26. ANNUAL REPORT

Every hospital shall submit an annual report to the Provincial
Agency to include information about the categories and quantities of waste
handled during the proceeding year. The Provincial Agency shall send this
Federal EPA who will publish this to the annual National Environment Report
under Section 6(d) of the Act.

27. MAINTENANCE OF REGISTER

Every Provincial Agency shall maintain a Register of the record
related to the generation, collection, disposal, transportation of the hospital waste
which is open for inspection to the public.

STATE OF HEALTHCARE WASTE LEGISLATIONS,
POLICIES, GUIDELINES IN SOUTH ASIA

COUNTRY LEGISLATION
Bangladesh No specific legislation covered in Bangladeshs Environmental
protection Act 1995
Bhutan Guidelines for Infection Control (Ministry of Health) Addressed
Environmental Code of Practice for Hazardous Waste Management,
2001 Policy
India Biomedical waste Regulations (1998) (Amended: March, 2000 and
June, 2000)
Maldives No separated rules in Environmental Protection and Preservation Act
1993
Nepal No polices and legislation dealing with hazardous waste
Pakistan Hospital waste management rules, August 2005
Sri Lanka No proper legal framework in National Environmental Act (Draft of
national policy, 2001 exist)
TABLE 17 COPARASION OF HEALTHCARE LEGISLATION IN SOUTH ASIA

Page 168 of 224

168

Figure 43 - Healthcare Legislation in South Asia


9.2 - INTERNATIONAL LAWS
The growing consensus against incineration has also been
reflected in the body of international environmental law, which has increasingly
restricted its use and acceptability. In a few cases, conventions have addressed
the question of incineration head-on. More often, however, international
lawmakers have preferred to articulate a number of general principles that
mitigate against the use of incineration and its variants (such as pyrolysis). When
incorporated into national law and policy-making, these principles clearly push
nations away from the use of incineration, although they still fall short of outright
bans. Communities and advocates for sustainable discards systems can use the
following language from treaties and conventions as leverage, especially those
treaties and conventions that a country has signed or ratified.
The Precautionary Principle was devised to solve the problem that
scientific uncertainty poses for policy-making. Many countries will not restrict an
activity or substance until it has been proven harmful to human health or the

Page 169 of 224

169
environment. On its face, this seems a reasonable approach. However, given the
thousands of synthetic chemicals to which humans are exposed, the complexities
(largely unexplored) of interactions between these chemicals, and the limited
research budgets of most countries, it is simply not feasible to test every
conceivable combination of chemicals for their effects on humans. Even if that
were feasible, it would still be impossible to conclusively establish causal links
between a particular facilitys releases and the illness or death of any individual
or group of individuals. In any case, by the time such a causal link is established,
it is too late: the population has already been exposed and suffered the
consequences.
This has sarcastically been referred to as the count the dead
bodies technique of chemicals testing. At any given time, therefore, many
substances are in the gray area of scientific uncertainty: their harmful effects
are not conclusively proven, but sufficient evidence of harm exists to suspect that
they are not safe. The Precautionary Principle, as stated in the 1998 Wingspread
Statement, is: When an activity raises threats of harm to human health or the
environment, precautionary measures should be taken even if some cause and
effect relationships are not fully established scientifically. In this context, the
proponent of an activity, rather than the public, should bear the burden of proof.
The process of applying the Precautionary Principle must be open, informed and
democratic and must include potentially affected parties. It must also involve an
examination of the full range of alternatives, including no action.

9.2.1 - INTERNATIONAL CONVENTIONS
Several important documents in international law reference the
Precautionary Principle, although each uses a somewhat different formulation,
and some refer to it without any definition. It is clearly spelled out as principle 15
of the Rio Declaration on Environment and Development, adopted at the Earth
Summit in Rio de Janeiro, Brazil, in 1992: In order to protect the environment,
the precautionary approach shall be widely applied by States according to their
capabilities. Where there are threats of serious or irreversible damage, lack of full

Page 170 of 224

170
scientific certainty shall not be used as a reason for postponing cost-effective
measures to prevent environmental degradation.
9.2.2 - LONDON CONVENTION 1972
CONVENTION ON THE PREVENTION OF MARINE POLLUTION BY DUMPING OF WASTES
AND OTHER MATTER 1972 AND 1996 PROTOCOL
The "Convention on the Prevention of Marine Pollution by Dumping
of Wastes and Other Matter 1972", the "London Convention" for short, is one of
the first global conventions to protect the marine environment from human
activities and has been in force since 1975. Its objective is to promote the
effective control of all sources of marine pollution and to take all practicable steps
to prevent pollution of the sea by dumping of wastes and other matter. Currently,
85 States are Parties to this Convention.
In 1996, the "London Protocol" was agreed to further modernize the
Convention and, eventually, replace it. Under the Protocol all dumping is
prohibited, except for possibly acceptable wastes on the so-called "reverse list".
The Protocol entered into force on 24 March 2006 and there are currently 37
Parties to the Protocol.
9.2.3 - CONVENTION ON LONG-RANGE TRANS BOUNDARY AIR
POLLUTION
The 1979 Geneva Convention on Long-range Tran boundary Air Pollution
The Convention on Long-range Trans boundary Air Pollution
entered into force in 1983. It has been extended by eight specific protocols. The
Convention is one of the central means for protecting our environment. It has,
over the years, served as a bridge between different political systems and as a
factor of stability in years of political change. It has substantially contributed to
the development of international environmental law and has created the essential
framework for controlling and reducing the damage to human health and the
environment caused by trans boundary air pollution. It is a successful example of
what can be achieved through intergovernmental cooperation.

Page 171 of 224

171
The history of the Convention can be traced back to the 1960s,
when scientists demonstrated the interrelationship between Sulphur emissions in
continental Europe and the acidification of Scandinavian lakes. The 1972 United
Nations Conference on the Human Environment in Stockholm signaled the start
for active international cooperation to combat acidification. Between 1972 and
1977 several studies confirmed the hypothesis that air pollutants could travel
several thousands of kilometers before deposition and damage occurred. This
also implied that cooperation at the international level was necessary to solve
problems such as acidification.
In response to these acute problems, a High-level Meeting within
the Framework of the ECE on the Protection of the Environment was held at
ministerial level in November 1979 in Geneva. It resulted in the signature of the
Convention on Long-range Trans boundary Air Pollution by 34 Governments and
the European Community (EC). The Convention was the first international legally
binding instrument to deal with problems of air pollution on a broad regional
basis. Besides laying down the general principles of international cooperation for
air pollution abatement, The Convention sets up an institutional framework
bringing together research and policy.
9.2.4 - OSPAR Convention
The Oslo and Paris Commissions is the mechanism by which
fifteen Governments of the western coasts and catchments of Europe, together
with the European Community, cooperate to protect the marine environment of
the North-East Atlantic. It started in 1972 with the Oslo Convention against
dumping. It was broadened to cover land-based sources and the offshore
industry by the Paris Convention of 1974. These two conventions were unified,
up-dated and extended by the 1992 OSPAR Convention. The new annex on
biodiversity and ecosystems was adopted in 1998 to cover non-polluting human
activities that can adversely affect the sea.
The fifteen Governments are:-

Page 172 of 224

172
1. Belgium
2. Denmark
3. Finland
4. France
5. Germany
6. Iceland
7. Ireland
8. Luxembourg
9. The Netherlands
10. Norway
11. Portugal
12. Spain
13. Sweden
14. Switzerl
15. United Kingdom


















Page 173 of 224

173
9.2.5 - BASEL CONVENTION
The Basel Convention on the Control of Transboundary Movements
of Hazardous Wastes and Their Disposal, usually known simply as the Basel
Convention, is an international treaty that was designed to reduce the
movements of hazardous waste between nations, and specifically to prevent
transfer of hazardous waste from developed to less developed countries (LDCs).
It does not, however, address the movement of radioactive waste. The
Convention is also intended to minimize the amount and toxicity of wastes
generated, to ensure their environmentally sound management as closely as
possible to the source of generation, and to assist LDCs in environmentally
sound management of the hazardous and other wastes they generate.
The Convention was opened for signature on 22 March 1989, and
entered into force on 5 May 1992. 172 parties to the Convention, Afghanistan,
Haiti, and the United States have signed the Convention but have not yet ratified
it.
History
With the tightening of environmental laws in developed nations in
the 1970s, disposal costs for hazardous waste rose dramatically. At the same
time, globalization of shipping made transboundary movement of waste more
accessible, and many LDCs were desperate for foreign currency. Consequently,
the trade in hazardous waste, particularly to LDCs, grew rapidly.
One of the incidents which led to the creation of the Basel
Convention was the Khian Sea waste disposal incident, in which a ship carrying
incinerator ash from the city of Philadelphia in the United States after having
dumped half of its load on a beach in Haiti, was forced away where it sailed for

Page 174 of 224

174
many months, changing its name several times. Unable to unload the cargo in
any port, the crew was believed to have dumped much of it at sea.
Another is the 1988 Koko case in which 5 ships transported 8,000 barrels of
hazardous waste from Italy to the small town of Koko in Nigeria in

9.2.6 - THE BAMAKO CONVENTION
The Bamako Convention (in full: Bamako Convention on the ban on
the Import into Africa and the Control of Transboundary Movement and
Management of Hazardous Wastes within Africa) is a treaty of African nations
prohibiting the import of any hazardous (including radioactive) waste. The
Convention was negotiated by twelve nations of the Organization of African Unity
at Bamako, Mali in January, 1991, and came into force in 1998.
Impetus for the Bamako Convention arose from the failure of the
Basel Convention to prohibit trade of hazardous waste to less developed
countries (LDCs), and from the realization that many developed nations were
exporting toxic wastes to Africa. This impression was strengthened by several
prominent cases. One important case, which occurred in 1987, concerned the
importation into Nigeria of 18,000 barrels of hazardous waste from the Italian
companies Ecomar and Jelly Wax, which had agreed to pay local farmer Sunday
Nana $100 per month for storage. The barrels, found in storage in the port of
Lagos, contained toxic waste including polychlorinated biphenyls, and their
eventual shipment back to Italy led to protests closing three Italian ports.
The Bamako Convention uses a format and language similar to that
of the Basel Convention, but is much stronger in prohibiting all imports of
hazardous waste. Additionally, it does not make exceptions on certain hazardous
wastes (like those for radioactive materials) made by the Basel Convention.



Page 175 of 224

175
The Bamako Convention similarly obligates its members to
implement the precautionary approach without waiting for scientific proof of the
harms in question.
It is the Bamako Convention, however, which most clearly lays out
the prevention principle and its implications for industry, saying: Each party
shall...ensure that the generation of hazardous wastes within the area under its
jurisdiction is reduced to a minimum taking into account social, technological and
economic aspects. It then goes on to specifically require the implementation of
clean production: Each Party shall strive to adopt and implement the preventive,
precautionary approach to pollution problems...through the application of clean
production methods, rather than the pursuit of a permissible emissions approach
based on assimilative capacity assumptions.
It then goes on to define clean production methods as applicable to
the entire life cycle of the product, including: raw material selection, extraction
and processing; product conceptualization, design, manufacture and
assemblage; materials transport during all phases; industrial and household
usage; reintroduction of the product into industrial systems or nature when it no
longer serves a useful function. Clean production shall not include end-of-pipe
pollution controls such as filters and scrubbers, or chemical, physical or biological
treatment. Measures which reduce the volume of waste by incineration or
concentration, mask the hazard by dilution, or transfer pollutants from one
environmental medium to another, are also excluded.
The Bamako Conventions detailed wording clearly indicates the
contradiction between prevention and incineration. On the one hand, incineration,
as a waste treatment technology, is an indication of a failure to implement clean
production and waste minimization. On the other hand, as a technology that
produces hazardous byproducts, incineration itself runs counter to the prevention
principle.




Page 176 of 224

176
9.2.7 - THE ROTTERDAM CONVENTION
The Rotterdam Convention on the Prior Informed Consent
Procedure for Certain Hazardous Chemicals and Pesticides in International
Trade, more commonly known simply as the Rotterdam Convention, is a
multilateral treaty to promote shared responsibilities in relation to importation of
hazardous chemicals. The convention promotes open exchange of information
and calls on exporters of hazardous chemicals to use proper labeling, include
directions on safe handling, and inform purchasers of any known restrictions or
bans. Parties can decide whether to allow or ban the importation of chemicals
listed in the treaty, and exporting countries are obliged make sure that producers
within their jurisdiction comply.
Substances covered under the Convention are :-
2,4,5-T and its salts and esters
Aldrin
Asbestos - Actinolite, Anthophyllite, Amosite, Crocidolite, and Tremolite
only
Benomyl (certain formulations)
Binapacryl
Captafol
Carbofuran (certain formulations)
Chlordane
Chlordimeform
Chlorobenzilate
DDT
Dieldrin
Dinitro-ortho-cresol (DNOC) and its salts
Dinoseb and its salts and esters
1,2-dibromoethane (EDB)
Ethylene dichloride

Page 177 of 224

177
Ethylene oxide
Fluoroacetamide
Hexachlorocyclohexane (mixed isomers)
Heptachlor
Hexachlorobenzene
Lindane
Mercury compounds including inorganic and organometallic mercury
compounds
Methamidophos (certain formulations)
Methyl parathion (certain formulations)
Monocrotophos
Parathion
Pentachlorophenol and its salts and esters
Phosphamidon (certain formulations)
Polybrominated biphenyls (PBB)
Polychlorinated biphenyls (PCB)
Polychlorinated terphenyls (PCT)
Tetraethyl lead
Tetramethyl lead
Thiram (certain formulations)
Toxaphene
Tris (2,3-dibromopropyl) phosphate (TRIS)
Substances proposed for addition to the Convention
Alachlor
Aldicarb
Chrysotile Asbestos
Endosulfan



Page 178 of 224

178
9.2.8 - THE STOCKHOLM CONVENTION AND INCINERATION
Stockholm Convention on Persistent Organic Pollutants is an
international environmental treaty that aims to eliminate or restrict the production
and use of persistent organic pollutants (POPs).
History
In 1995, the Governing Council of the United Nations Environment
Programme (UNEP) called for global action to be taken on POPs, which it
defined as "chemical substances that persist in the environment, bio-accumulate
through the food web, and pose a risk of causing adverse effects to human
health and the environment".
Following this, the Intergovernmental Forum on Chemical Safety
(IFCS) and the International Programme on Chemical Safety (IPCS) prepared an
assessment of the 12 worst offenders, known as the dirty dozen.
The negotiations for the Convention were completed on 23 May 2001 in
Stockholm. The convention entered into force on 17 May 2004 with ratification by
an initial 128 parties and 151 signatories. Co-signatories agree to outlaw nine of
the dirty dozen chemicals, limit the use of DDT to malaria control, and curtail
inadvertent production of dioxins and furans.
Parties to the convention have agreed to a process by which
persistent toxic compounds can be reviewed and added to the convention, if they
meet certain criteria for persistence and transboundary threat. The first set of
new chemicals to be added to the Convention were agreed at a conference in
Geneva on 8 May 2009.





Page 179 of 224

179
KEY POINTS OF THE CONVENTION
The treaty includes provisions to expand this list to include other
chemicals, using the Precautionary Principle to judge their fitness for inclusion in
the list. Although the Stockholm Convention does not ban incineration or even
the construction of new incinerators, it does place serious obstacles in the path of
any incineration project. The Convention specifically states in Annex C that
waste incinerators, including co-incinerators of municipal, hazardous or medical
waste or of sewage sludge; cement kilns firing hazardous waste are among the
technologies that have the potential for comparatively high formation and
release of such unintentional POPs. In fact, incinerators are significant sources
of four of the 12 listed pollutants: dioxins, furans, PCBs, and hexachlorobenzene.
As such, incinerators as a class are clearly subject to the restrictions of the
Stockholm Convention.

MEASURES TO REDUCE UNINTENTIONAL POPs
The Convention requires parties to take measures to reduce the
total releases derived from anthropogenic sources of the unintentional POPs.
Within this context, it becomes very difficult to justify any new or additional
sources of POPs, such as a new incinerator or increased quantities of waste sent
to an existing incinerator.
CONTROL OF HAZARDS
In fact, the Convention goes further; it is the strongest legal
expression to date of the preference for source prevention over mere control of
environmental hazards. For most of the intentionally produced POPs, the
Convention requires elimination. For the unintentionally produced, or byproduct,
pollutants, the treatys Article 5 establishes a goal of their continuing
minimization and, where feasible, ultimate elimination.
The Stockholm Convention makes a significant departure from past
policy regarding incinerations environmental impacts because it does not apply
to air emissions alone for determining dioxins minimization rates. Rather, the

Page 180 of 224

180
Stockholm Convention looks at total releases, which include solid and liquid
residues, including residues from air pollution control devices (fly ashes).
Most past justification of incinerators was based on the argument
that dioxin emissions to the atmosphere could be captured and therefore
controlled. However, the Stockholm Convention considers such solid and liquid
releases to be part of what must be continually minimized and, where feasible,
eliminated.
SUBSTITUTION CONTROL
Indeed, Article 5 also contains a particularly relevant substitution
principle, which states that Parties to the treaty shall Promote the development
and, where it deems appropriate, require the use of substitute or modified
materials, products and processes to prevent the formation and release of
[unintentional POPs]. It is important to note the use of the term formation and
to realize that this obligation makes it apparent that where there are alternative
methods of waste management, any process that produces dioxins should be
avoided.

STRONG DIRECTIONS ON MANAGEMENT OF POPs
The Stockholm Convention also contains strong direction on the
management and treatment of existing stockpiles of POPs wastes (which are
often treated in hazardous waste incinerators). Article 6 calls for Parties to take
measures so that POPs wastes are disposed of in such a way that the persistent
organic pollutant content is destroyed or irreversibly transformed so that they do
not exhibit the characteristics of persistent organic pollutants. Although this text
is followed with some caveats, such as excepting low levels of POPs content,
which must await further interpretation, the use of the words destroyed or
irreversibly transformed so that they do not exhibit the characteristics of POPs,
is meant again to be inclusive of all formation and outputs (not just air
emissions). This goes far beyond what has previously been envisaged for any
chemical waste in international law.


Page 181 of 224

181
151 nations signed the treaty in May 2001 in Stockholm. Although
The Convention will not come into force until 50 nations have ratified it, and then
only in the ratifying countries, it is not toothless in the interim. Under international
law, signing a treaty is a statement of commitment to comply with the treaty; and
governments that do sign are enjoined from taking actions that are clearly
prejudicial to the goals of the treaty, even though they may not yet have ratified it.
As such, the Stockholm Convention is already a barrier against the construction
of any new incinerator in signatory nations.

MEMBER COUNTRIES OF STOCKHOLM CONVENTION

Albania Cape Verde Eritrea

Jordan

Moldova

Algeria

Central African Rep.

Estonia

Kazakhstan Monaco

Angola

Chad

Ethiopia

Kenya

Mongolia

Angola

Chile

European Commission

Kiribati

Morocco

Argentina

China

Fiji

Kuwait

Mozambique

Armenia

Colombia

Finland

Kyrgyzstan

Myanmar

Australia

Comoros

France

Laos

Namibia

Austria

Congo, P. R.

Gabon

Latvia

Nauru

Azerbaijan

Cook Islands

Gambia

Lebanon

Nepal

Bahamas

Costa Rica

Georgia

Lesotho

Netherlands

Bahrain Cote d'Ivoire

Germany


Liberia

New Zealand

Bangladesh

Croatia

Ghana

Libya

Nicaragua

Barbados

Cuba

Greece

Liechtenstein

Niger

Belarus

Cyprus

Guatemala

Lithuania

Nigeria

Belgium

Czech Republic

Guinea

Luxembourg

Niue

Benin Dem. P. Rep. of Korea


Guinea-Bissau

Macedonia

Norway

Bolivia

Dem. Rep. of Congo

Guyana

Madagascar

Oman


Page 182 of 224

182
Botswana

Denmark

Honduras

Maldives

Pakistan

Brazil

Djibouti

Hungary

Mali

Panama

Bulgaria

Dominica

Iceland

Marshall Islands

Papua New
Guinea

Burkina Faso

Dominican Republic

India

Mauritania

Paraguay

Burundi

Ecuador

Iran

Mauritius

Peru

Cambodia

Egypt

Jamaica

Mexico

Philippines

Canada

El Salvador

Japan

Micronesia

Poland

Portugal

Samoa

Solomon Islands

Syria

Uganda

Qatar

Sao Tome &
Principe

South Africa

Tajikistan

Ukraine

Rep. of Korea

Senegal

Spain

Tajikistan

U.A.E
Romania

Seychelles

Sri Lanka

Thailand

United
Kingdom

Rwanda

Sierra Leone

Sudan

Togo

Uruguay

Saint Kitts and
Nevis

Singapore

Swaziland

Trinidad and
Tobago

Vanuatu

Saint Lucia

Slovak Republic

Sweden

Tunisia

Venezuela

Saint Vincent
& the
Grenadines


Slovenia

Switzerland

Tuvalu

Viet Nam

Yemen

Zambia


TABLE 18 MEMBERS COUNTRIES OF STOCKHOLM CONVENTION







Page 183 of 224

183
PRECAUIONARY PRINCIPLES:-
The Precautionary Principle bears on incineration in two different
ways. First, combustion is an extremely complex process, and it is still not known
precisely what substances are produced and released through the incineration of
wastes. This is particularly true when the waste in question is highly variegated,
as in the case of municipal or health care waste. Without knowing the pollutants
produced, their quantities, environmental fate, or health effects, it is impossible to
assure the safety of such a process (even if the known dangers could somehow
be eliminated). Thus, precaution argues for avoiding the activity, i.e., incineration.
Second, many of the substances which have been identified in air emissions and
incinerator ash have varied and subtle effects on the human body, which are still
being investigated. Some, such as lead and PCBs, may also interact with each
other or other pollutants present in the environment to create synergistic effects.
Given the uncertainty surrounding these health effects, precaution again argues
for avoiding their production and release.

A second principle found in international law, although more rarely
mentioned by name, is prevention. This is simply the common-sense notion that
it is better to prevent harm than to allow damage to occur and then attempt to
mitigate it or clean it up. International law clearly indicates that the minimization
of environmental damage is to be prioritized over end-of-pipe techniques. Thus,
Agenda 21, the framework document adopted at the Earth Summit in 1992,
states that a target of hazardous waste policy must be preventing or minimizing
the generation of hazardous wastes as part of an overall integrated cleaner
production approach.
The third principle, cited in documents too numerous to mention, is the
importance of limiting transboundary environmental effects.
States should effectively cooperate to discourage or prevent the
relocation and transfer to other States of any activities and substances that
cause severe environmental degradation or are found to be harmful to human
health. This is an abiding concern of international law, for the obvious reason

Page 184 of 224

184
that national laws are insufficient to address environmental harms whose root
causes lie in another country. Given the tendency towards long-range transport
exhibited by many incinerator pollutants, it is impossible to confine incinerator
emissions to the national territory or airspace of any country.
Thus, incineration clearly contradicts the principle of minimizing
trans boundary environmental effects.




Page 185 of 224

185



In this chapter we will discuss waste management structure in
detail in order to understand the hospital waste management in a hospital.
The scope of this chapter is to provide our readers a complete
detail about the waste management in a hospital. We are thankful to the following
respected individuals for their active participation for the case studies of the
hospitals.

Dr. Akhlaq Ahmed Ansari
Medical Superintendent,
Ch. Pervaiz Elahi Institute of Cardiology, Multan

Dr. Waseem Abbas Zaidi
Additional Medical Superintendent
Ch. Pervaiz Elahi Institute of Cardiology, Multan

Dr. Syed Raza Mohi-UD-Din
Medical Superintendent
Civil Hospital, Multan

Col. Iqbal Ahmed Khan
Professor of Community Medicine
Army Medical College, Rawalpindi

Eng. Rehan Ahmed
Environmental and Sanitary Engineering Consultant, Karachi

Mr. Abdul Rehman
Chief Ward Master
Ch. Pervaiz Elahi Institute of Cardiology, Multan


Shafiq-Ur-Rehman
Composer of the book
Ch. Pervaiz Elahi Institute of Cardiology, Multan





Page 186 of 224

186




























Page 187 of 224

187
This was an observational descriptive study. The aim of this study was
to assess the healthcare waste disposal system in a tertiary care army
hospital in Rawalpindi. This hospital consists of 640 beds. Total
numbers of doctors in the hospital are 106, number of nurses 136,
public health specialist 01, and sanitary workers 86. As for daily work
load of the hospital is concerned 1589 patients are examined in OPD, 5
-6 deliveries, 71 daily admissions, 24 major operations, X-Rays 281,
lab investigations 626 and bed occupancy is 82 %.
This study was approved by the ethical committee of
Armed Forces Post Graduate Medical Institute Rawalpindi as well as
The University of Health Sciences, Lahore.

Following wards / departments were selected for the study:

Wards

Surgical
Medical / Child Oncology
Gynecology / Obstetrics
E.N.T.
Orthopedics

Departments

Pathology Laboratory
Radiology
Operation Theatre
Trauma Centre

Five beds each of the above mentioned wards were observed for seven
days.




Page 188 of 224

188
PROTOCOL FOR COLLECTING WASTE:

Three different colored receptacles were placed lying by
the side of each bed. These receptacles were lined with a polythene
bag and used as per following protocol.

Red container

For all the infectious waste which includes soiled surgical
dressing, cotton swabs, blood, body fluids and other contaminated
waste.

BLUE CONTAINER

For all sharps irrespective of whether infectious or
otherwise which include needles, scalpel, blades, knives, infusion sets
and broken glasses.
GREY CONTAINER

For all non-infectious waste which includes paper, cigarette
packets, left food and garbage etc.

Sanitary assistants & sweepers were trained for waste
collection and for the whole process. The patients, their attendants,
nurses and the paramedical staff were also directed regarding the
waste management process in detail. The collected was weighed
before its removal on a scale of 10 kg capacity.











Page 189 of 224

189
RESULTS

Results of this study were as under:

Category Kg / Day % age / day Kg / Bed / Day
Infectious Waste 197.82 9 % 0.309
Sharps 65.94 3 % 0.103
Infectious Waste 1934.24 88 % 3.022
Total Waste 2198 100 % 3.434


This hospital also uses incinerator for hospital waste disposal.






























Page 190 of 224

190


































Page 191 of 224

191
CIVIL HOSPITAL, KARACHI

It is one of the largest public sector health care facilities in the city.
Presently, the hospital is composed of 1800 beds in 40 departments in medical,
surgical, intensive care and other domains. Being a teaching hospital in
association with Dow University of Health Sciences, it is a key facility that
extends healthcare services mainly to lower middle and poor sections of Karachi
and also patients pouring in from other parts of country.

WASTE MANAGEMENT SYSTEM
The prevailing waste management system is run by a team of sanitary workers,
supervisors and management officers. There are about 350 sanitary workers /
sweepers who are working on the governments payroll. In the waste
management work, the operating staff also participates and assists the sweepers
in collection and disposal of waste. They include male nursing staff ward
supervisors and ward incharges under the overall management control of
Additional Medical Superintendent (Waste Management).
Basic flow of the waste management system is as:










The staff functions in three shifts of eight hours each. They are
assigned different duties such as sweeping, collection of ward waste,
transportation of waste at different stages and special duties in the operation
Wards Incharges

Additional Medical Superintendent
Waste Management
Wards Cleaners


Page 192 of 224

192
theaters, intensive care unit wards and special wards. The hospital management
has developed a large dumping site for the hospital waste.
The waste has been classified into three categories including
infectious waste, non-infectious waste and ordinary solid waste. Three types of
bags are provided to each ward with color codes. The red bags are kept for
infectious waste, yellow bags for non-infectious materials including shapes of all
kinds and blue bags for ordinary solid waste. The incinerator staff visits different
wards during morning and evening shifts to collect the waste material. Ordinary
solid waste is disposed to the local collection / storage point of the hospital from
where the municipal refuse van collects it to dump it at the urban dumping site.

WASTE ITEMS
As reported and surveyed during the study, the commonly found
waste items included syringes, drips, canola chambers, surgical tapes / dressing
material, orthopedic dressing rejects, needles / butterfly equipment, injection
disposals, X ray, rejected chemical plasters, cadmium batteries, cotton sanitary
pads, placentas, blood bags, urine bags, colostomy bags, plastic tubing, stomach
tubing, disposable gloves, bottles of plastic and glass and other similar articles.
The other units that generate waste comprise hospital kitchen and laundry. In the
kitchen, both organic and inorganic waste is generated which is disposed in the
usual municipal waste stream of the hospital. The laundry makes use of
detergents and washing chemicals. Its packing material is the main waste item
which is also disposed in the municipal stream.
One of the items separated for recycling comprise X ray films.
There are about 1000 films that are rejected on a daily basis from different units
of radiology. The hospital also deals with police / medical legal cases where a
large number of X ray films are produced for record keeping. In a clandestine
manner, the hospital staff collects these films and privately sells them to junk
dealers.
The Burns Unit of this hospital is another unique facility. It is the
only such facility of its kind available in the entire city. Due to the special nature

Page 193 of 224

193
of care / treatment, a sizable proportion of bandages / gauzes and cotton refuse
is produced in this ward, much of which is sent for incineration.

WASTE DISPOSAL
A sizable part of liquid waste generated during operations and other
functions of the hospital is disposed in the normal drainage / sewerage channels.
With the exception of ward waste that is transported to incinerator, the remaining
waste is stored in this dumping point from where a CDGK refuse van collects and
disposes this material to the municipal landfill site.
It is a major cause of the spread of infections. At times, the ward
sweepers also dispose the regular ward waste to the dumping site, which creates
a very hazardous situation. The overall process of collecting, segregation,
transportation & incineration can be described as:


























Collection of waste in
bins
Segregation of
recyclables
Remaining waste is
transferred to wards /
floor drum
Transference of
needles to Hospitals
dumping point
Transference to
Hospitals incineration
point

Page 194 of 224

194


































Page 195 of 224

195
Agha Khan University Hospital, Karachi

Hospital waste management system is very well maintained in Aga
Khan University Hospital. Unlike other hospitals in Pakistan, this hospital has a
unique Liquid Waste Disposal System. We have not noticed such a brilliant and
efficient liquid waste disposal system.
Segregation of infectious and non-infectious waste is done from its
point of generation in the form of red (infectious waste) and green (non infectious
general waste) bags. These bags are taken to the incinerator and disposed off by
the process of burning. In case of failure or non-working conditions of the
incinerator, AKUH has the system of walk in freezers, which can store the waste
for 2-3 days after that it is discarded properly.
For the liquid infectious waste, Agha Khan University Hospital has
neutralization tank system, which is made underground and filled with limestone,
a strong disinfectant. Sewerage lines from pathological laboratory and research
labs drive into this tank and from here after disinfection, this liquid drains into
main sewerage lines. This is a PVC lined tank about 4 feet in diameter and 8 foot
in depth. Lime stones are replaced and tank is cleaned after every 4-6 months.




















Page 196 of 224

196
A brief flow diagram as following can describe the Aga Khan University Hospital
infectious waste management system.









































Infectious waste
Solid Waste
Incineration
Non Infectious
Ashes
Dumping
Liquid Waste
Neutralization
Tank
Main Sewerage
Line

Page 197 of 224

197


































Page 198 of 224

198
CH.PERVAIZ ELAHI INSTITUTE OF CARDIOLOGY MULTAN

C.P.E.I.C Multan is a cardiac hospital situated in the centre of
Multan. This hospital provides best treatment facilities to the poor & needy
patients of South Punjab.
This hospital is equipped with the latest world class technologies.
A detailed fact sheet about the hospital is as under:-

01 Name & Address of Hospital CPE Institute of Cardiology
Abdali Road , Multan
02 Name of Chief Executive /
owner
Dr. Prof. Syed Ali Raza Gardazi
03 Year of establishment of
hospital
2005 06
04 No. of wards 06
05 No. of beds 201
06 Total area :
Covered area
Uncovered area
Total Area = 60 Kanals & 11 Marlas
Main = 230038 Sft
Doctors Hostel = 39715 Sft.
Nursing Hostel = 32445 Sft.
07 No. of Doctors 70
08 Total no. of staff 382
09 Total hospital waste generated
per day. ( In Kg)
Municipal Waste = 80 Kg
Biological Waste = 10 Kg
10 Has Hospital Waste
Management Team been
notified?
Yes
11 Are Hospital Waste
Management Rules 2005 are
being implemented within the
hospital?
Yes

Page 199 of 224

199
WASTE MANAGEMENT IN HOSPITAL:
CPE Institute of Cardiology has an active, efficient and well defined
waste management system except its disposal. The hospital uses the state of the
art technology for collection of waste. This hospital is planning to use Autoclave
technology for disinfecting the hospital waste.
WASTE MANAGEMENT TEAM:

According to the Hospital Waste Management Rules, 2005, the
hospital has a specific waste management team. The detail about the members
of this team are as:

1. Dr.Mazhar-UL-Khaliq DMS (G) Chairman
2. Mst. Rizwana H/N Committee Secretary

Committee Members:
1. Dr. Faiyaz Hashmi Pathology Department
2. Dr. Khalid Khanzada X-Ray Department
3. Dr. Jawad Microbiologist
4. Tasleem Kausar Nursing Superintendent
5. Mr. Sohail Pharmacist
6. Abdul Rehman Chief Ward Master

Figure 44 - Waste Management Team of C.P.E.I.C. Multan

Page 200 of 224

200

HIRERACHAL CHART OF HOSPITAL WASTE MANGEMENT IN
C.P.E.I.C MULTAN















Sanitary
Inspector
Ward Masters
Deputy Medical
Superintendent
Nurses
Head Nurses
Medical Superintendent
Additional Medical
Superintendent
Nursing Superintendent /
Deputy Nursing Superintendent
Waste
Collectors
Ayas

Page 201 of 224

201

TYPES OF WASTE GENERATED IN HOSPITAL:
The hospital generates waste materials of five basic types:
Clinical
Sharps
Glass
Domestic
Radioactive

COLOR CODING
According to Hospital Waste Management Rules 2005 color
coding system is used actively in the hospital for safe packing & disposal of the
hospital waste.

Clinical Yellow Bags
Sharps Yellow Sharps Bins
Glass Clear Plastic Bags
Domestic Black Bags
Radioactive According to type
COLORED CODED BAGS FOR NON WASTE
Infected Linen Red Alginate Bag
Dirty Linen White Cotton Bag
CSSD Clear Plastic
Theatre Linen Green
Patients Property Grey







Page 202 of 224

202
HOSPITAL WASTE GENERATION IN C.P.E.I.C MULTAN PER DAY
Following record is according to the 60 % bed occupancy.

Category Kg / Day % age / day Kg / Bed / Day
Municipal Waste 176.23 Kg 93.47 % 1.76 Kg
Biological Waste 12.30 Kg 6.52 % 0.12 Kg
Total 188.53 Kg 99.99 % 1.88 Kg


S.No. Wards Category Kg/Bed/Day % age
01 Adult Cardiology Ward Mun.Waste 1.8 Kg 92.30 %
Plastic 0.125 Kg 6.41 %
Sharps 0.025 Kg 1.28 %
Total 1.95 Kg 99.99 %
02 C.C.U - 1 Municipal Waste 1.70 Kg 83.33
Plastic 0.3 Kg 14.70
Sharps 0.041 Kg 1.96
Total 2.041 99.99


WASTE DISPOSAL

Dry non-infectious waste such as paper, plastics and other non-infectious
ordinary wastes are placed in separate black plastic bags and are
collected daily by the waste collecting staff for disposal.
Excess blood, serum and plasma specimens from different sections of the
laboratory are collected in a glass container or flask (9"x5" dia.) and
sterilized by autoclaving (pressure cooker) for thirty minutes at 121
degrees centigrade. Unused and expired blood bags are packed together
and sent for incineration.

Page 203 of 224

203
Pipettes, test tubes, and other glassware used in testing infectious
specimen (hepatitis, AIDS, typhoid fever, etc.) are soaked in 0.5% sodium
hypochlorite for at least 30 minutes before disposal.
Sharps like disposable syringes are collected in bags and incinerated at
Christian Women Hospital Multan Cantt.
Needles and sharps are collected immediately after use in yellow boxes
(8" x 4" dia.) for incineration.




















Page 204 of 224

204




















Page 205 of 224

205
THE CIVIL HOSPITAL MULTAN
The Civil Hospital is situated in the heart of Multan. This hospital is
providing the health services to the poor & needy peoples very efficiently under
the energetic & devotional management of Dr.Syed Raza Mohi-Ud-Din.
This hospital has total 22 beds. The OPD deals an average of 700
patients in a day. The average stay of a patient lasts for 1.42 days.

TYPES OF WASTE GENERATED IN HOSPITAL:
The hospital generates waste materials of five basic types:
Clinical
Sharps
Glass
Domestic
Radioactive

S.No. Category Kg / Month % age
01 Biological Waste 5 1.72
02 Glass Ware 12 4.18
03 Sharps 20 6.96
04 Other Disposable 10 3.48
05 Municipal Waste 240 83.62

Total Waste 287 99.96

The Civil Hospital uses Dumping method for disposal of hospital waste.






Page 206 of 224

206


















Page 207 of 224

207
THE CAPITAL MEDICAL CENTER (CMC) MANILA

CMC acquires the use of three waste cans lined with three (3)
colored plastic bags for every patient room, emergency room-out patient
department, operating room-recovery room, delivery room-nursery, intensive
care unit-coronary care unit, floor nurses station, x-ray and CT scan areas to
separate infectious, non-infectious and biodegradable wastes.

Waste cans (8"x10"x12") lined with black plastic bags are for non-
biodegradable and noninfectious wastes such as cans, bottles, tetra brick
containers, styropor, straw, plastic, boxes, wrappers, newspapers.

Waste cans lined with green plastic bags are biodegradable wastes such
as fruits and vegetables peelings, leftover food, flowers, leaves, and
twigs.

Waste cans lined with yellow plastic bags are for infectious waste such as
disposable materials used for collection of blood and body fluids like
diapers, sanitary pads, incontinent pads, materials (like tissue paper) with
blood secretions and other exudates, dressings, bandages, used cotton
balls, gauze, IV tubings, used syringes, Foleys catheter/tubings, gloves
and drains.

In the Department of Pathology, there are three types of wastes that are
segregated namely,
Dry non-infectious waste, blood, serum and plasma and urine and feces.
Dry non-infectious waste such as paper, plastics and other non-infectious
ordinary wastes are placed in separate black plastic bags and are
collected daily by the housekeeping personnel for disposal.
Excess blood, serum and plasma specimens from different sections of the
laboratory are collected in a glass container or flask (9"x5" dia.) and

Page 208 of 224

208
sterilized by autoclaving (pressure cooker) for thirty minutes at 121
degrees centigrade. Unused and expired blood bags are packed together
and disposed by incineration.
Pipettes, test tubes, and other glassware used in testing infectious
specimen (hepatitis, AIDS, typhoid fever, etc.) are soaked in 0.5% sodium
hypochlorite for at least 30 minutes before disposal.
Sharps like disposable syringes are collected in bags and bought down for
incineration.
Needles and sharps are collected immediately after use in cans or
puncture free containers (8" x 4" dia. Hard plastic) for incineration.
Pathological waste such as tissues, organs, fetuses and body parts are
disinfected and/or preserved in covered plastic or bottle containers with
10% formalin. These are disposed by incineration.



















Page 209 of 224

209
REFERENCES:-

1. Asahi Shimbun, Hundreds of Dirty Incinerators at End of Road, May 29,
2002.

2. Associated Press (AP), Japan Is the Land of Rising Garbage Heaps,
December 9, 2000b.

3. Bailey, Jeff, Up in Smoke: Fading Garbage Crisis Leaves Incinerators
Competing for Trash, Wall Street Journal, Page A1, August 11, 1993.

4. Biggeri. A., Barbone, F., Lagazio, C., Bovenzi, M., and Stanta, G., Air
Pollution and Lung Cancer in Trieste, Italy: Spatial Analysis of Risk as a
Function of Distance from Sources, Environmental Health Perspectives, vol.
104, no. 7, pp. 750-754, 1996.

5. Biocycle magazine, The State of Garbage annual survey, 1996.

6. Biocycle magazine, The State of Garbage annual survey, 1997.

7. Biocycle magazine, The State of Garbage annual survey, 2000.

8. Birnbaum, Linda, Re-evaluation of Dioxin, Presentation to the 102nd
Meeting of the Great Lakes Water Quality Connett, Paul, and Sheehan, Bill, A
Citizens Agenda for Zero Waste, G&G Video and Grassroots Recycling
Network, October 2001.

9. Crowe, Elizabeth, and Schade, Mike, Learning Not to Burn: a Primer for
Citizens on Alternatives to Burning Hazardous Waste, June 2002.

10. Denison, Richard, Environmental Life-Cycle Comparisons of Recycling,
Land filling, and Incineration: A Review of Recent Studies Annual Review of
Energy and the Environment, vol. 21, pp. 191237, 1996.

11. Elliot, P., Shaddick, G., Kleinschmidt, I., Jolley, D., Walls, P., Beresford,
J., and Grundy, C., Cancer Incidence Near Municipal Solid Waste
Incinerators in Great Britain, British Journal of Cancer, vol. 73, pp. 702-710,
1996.

12. Elston, Suzanne, Zero Waste Turns Garbage Into Savings, Environmental
News Network, January 2, 2000.

13. Ghosh, A.K., Comparative Statement of Technological Evaluation of Waste
Autoclave and Waste Microwave, West Bengal Health Systems
Development Project, Department of Health & Family Welfare, Government of
West Bengal, India, 2002.

Page 210 of 224

210
14. Hegberg, Bruce A., Hallenbeck, William H., Brenniman, Gary R.,
Municipal Solid Waste Incineration With Energy Recovery: Technologies,
Facilities, and Vendors for Less Than 550 Tons Per Day, University of Illinois
Center for Solid Waste Management and Research, Office of Technology
Transfer, School of Public Health, 1990.
15. Hencke, David, Britain Steps Out of Line on Incinerators, Guardian, Friday,
May 19, 2000. Available at: http://
www.guardian.co.uk/Archive/Article/0,4273,4019735,00.html.

16. ILSR, Job Creation: Reuse and Recycling versus Disposal (Chart),
Washington, DC, 1997. www.ilsr.org/recycling

17. ILSR, Manila: Wasting and Recycling in Metropolitan Manila, Philippines,
October 2000b.

18. Morris, Jeffrey, and Canzoneri, Diana, Recycling Versus Incineration: An
Energy Conservation Analysis, Sound Resource Management Group (SRMG)
Seattle, Washington, September, 1992. (This report has been summarized in
the Sound Resource Managements publication, The Monthly UnEconomist,
vol. 2, no. 2-4, February, March and April 2000.)

19. Motavelli, Jim, Zero Waste, E Magazine, March-April 2001.

20. Platt, Brenda, Aiming for Zero Waste: Ten Steps to Get Started, ILSR,
Washington, DC, 2002.

21. R. W. Beck Inc., U.S. Recycling Economic Information Study, National
Recycling Coalition, July 2001.

22. Stanners, D., and Bourdeau P., eds., Europes Environment, The Dobris
Assessment, Copenhagen: European Environment Agency, 1995.

23. Trenholm, A., and Thurnau, R., Total Mass Emissions from a Hazardous
Waste Incinerator, in Land Disposal, Remedial Action, Incineration, and
Treatment of Hazardous Waste, Proceedings of the Thirteenth Annual
Research Symposium, U.S.EPA Hazardous Waste Engineering Laboratory,
Cincinnati, EPA/600/9- 87/015, July 1987.

24. USEPA, Dioxin: Summary of the Dioxin Reassessment Science, 2000a.

25. USEPA, Municipal Solid Waste Basic Facts, June 20, 2001. Available at:
http://www.epa.gov/epaoswer/non-hw/muncpl/ facts.htm, accessed May
2002.

26. Zero Waste New Zealand Trust, Zero Waste Communities: Progress to
Date, May 2002

Page 211 of 224

211

27. Environmental Urban Affairs Division, Govt. of Pakistan. Environmental
Project of Pakistan.

28. Environmental and Urban Affairs Division, Govt. of Pakistan (1995)
Environmental Protection Act.

29. Government of Pakistan (1983) Pakistan Environmental Protection
Ordinance.

30. Daily Dawn, Karachi (1997).

31. NTCS (1992) Protection of Work Recycling and Reuse in Developing
Countries.

32. Population Census Organization (1981) District Census Report of Karachi.

33. Ministry of Housing and Works (1980) Housing Survey of Karachi.

34. USEPA (1972) Sind Waste Handling and Disposal in Multistorey Buildings
and Hospitals.

35. SCOPE (1993) Basic Report on Hospital Waste Management in Metropolis of
Karachi.

36. Ahmed, Rehan (1993) Hospital Waste Management in Pakistan, Turkish
National Committee on Solid Waste and International Solid Waste and
Cleansing Association, Denmark.

37. MANILA, PHILIPPINES Capitol Medical Center (1994) Policies on Hospital
Waste Management

38. Center for Advance Philippine Studies (1992) A Study on Urban
Environment-Related Activities for Non-Government Organizations and
Community-Based Organizations, Philippines: Asia-Pacific 2000-UNDP,
December.

39. Center for Advance Philippine Studies (1992) Waren Project: Recycling
Activities in Metro Manila, Philippines: Waste Consultants, Netherlands


40. C.Visvanathan, Asian Institute of Technology , Thailand.
http://www.faculty.ait.ac.th/visu/




Page 212 of 224

212
RESOURCE ORGANIZATIONS:

1. Global Anti-Incinerator Alliance/ Global Alliance for Incinerator
Alternatives
GAIA Secretariat
Unit 320, Eagle Court Condominium
26 Matalino Street, Barangay Central
1100 Quezon City,
The Philippines
Telephone: +632 929 0376
Fax: +632 436 4733
info@no-burn.org
http://www.no-burn.org

2. Alliance for Safe Alternatives
PO Box 6806
Falls Church, VA 22040 , USA
Telephone: + 1 703 237 2249 ext.19
http://www.safealternatives.org

3. Basel Action Network Secretariat
c/o Asia Pacific Environmental Exchange
1305 Fourth Ave., Suite 606
Seattle, Washington 98101, USA
Telephone: +1 206 652 5555
Fax: +1 206 652 5750
info@ban.org
http://www.ban.org

4. Communities Against Toxics
PO Box 29
Ellesmere Port
Cheshire, CH66 3TX, UK
Telephone/Fax: + 44 151 3395473
Ralph@tcpublications.freeserve.co.uk

5. Chemical Weapons Working Group Kentucky Environmental
Foundation
P.O. Box 467
Berea, KY 40403, USA
Telephone: +1 859 986 7565
Fax: +1 859 986 2695
kefcwwg@cwwg.org
http://www.cwwg.org



Page 213 of 224

213
6. Clean Production Action
2307 Avenue Belgrave
Montreal, Qc H4A 2L9, Canada
Tel: +1 514 484 8647
Bev@cleanproduction.org
http://www.cleanproduction.org

7. Coalicion Ciudadana Anti-Incineracion dela Argentina
Sucre 1207 PB B
B(1708) IUU-Moron, Argentina
vodriozo@ar.greenpeace.org
http://www.noalaincineracion.org

8. CNIID ( Centre National d'information Indpendante sur
les Dchets)
51 rue du Fbg St-Antoine
75011 Paris, France
Telephone: +33 01 5578 2860
Fax: +33 01 5578 2861
info@cniid.org
http://www.cniid.org

9. Earth life Africa
Johannesburg Branch
PO Box 11383 2000
Telephone: +27 11 4036056
Fax: +27 11 3394584
muna@iafrica.com
http://www.earthlife.org.za

10. Friends of the Earth-International
PO Box 19199,
1000 GD Amsterdam,
The Netherlands
Telephone: +31 20 622 1369.
Fax: +31 20 639 218
http://www.foei.org

11. Grass Roots Recycling Network
P.O. Box 49283
Athens, GA 30604 9283, USA
Telephone: +1 706 613 7121
Fax: +1 706 613 7123
zerowaste@grrn.org
http://www.grrn.org


Page 214 of 224

214
12. Greenpeace International
Keizersgracht 176,
1016 DW, Amsterdam, the Netherlands
Telephone: + 31 20 523 6222
Fax: + 31 20 523 6200
http://www.greenpeace.org

13. GroundWork
P.O. Box 2375
Pietermaritzburg, 3200, South Africa
Telephone: +27 33 342 5662
Fax: +27 33 342 5665
groundwork@sn.apc.org
http://www.groundwork.org.za

14. Health Care Without Harm
1755 S Street, NW Suite 6B
Washington DC 20009, USA
Telephone: +1 202 234 0091
Fax: +1 202 234 9121
info@hcwh.org
http://www.noharm.org

15. Institute for Local Self-Reliance
2425 18th Street, NW
Washington, DC 20009-2096, USA
Telephone: +1 202 232 4108
Fax: +1 202 332 0463
ilsr@ilsr.org
http://www.ilsr.org

16. International POPs Elimination Network
c/o Center for International Environmental Law
1367 Connecticut Ave., NW, Suite 300
Washington, DC 20036, USA
Telephone: +1 202 785 8700
Fax: +1 202 785 8701
http://www.ipen.org

17. Lowell Center for Sustainable Production
Kitson Hall, Room 200
One University Avenue
Lowell, MA 01854, USA
Telephone: +1 978 934 2980
Fax: +1 978 452 5711
http://www.uml.edu/centers/LCSP

Page 215 of 224

215
18. National Cleaner Production Centers Programme
United Nations Industrial Development Organization
PO Box 300, A 1400 Vienna, Austria
Telephone: +43 1 26026 5079
Fax: +43 1 21346 6819
ncpc@unido.org
http://www.unido.org/doc/331390.htmls

19. National Institutes of Health
Information on alternatives to mercury-bearing medical products
http://www.nih.gov/od/ors/ds/nomercury/alternatives.htm

20. Pesticide Action Network Latin America
Alianza por una Mejor Calidad de Vida/Red de Accin en Plaguicidas
Avenida Providencia N365, Dpto. N41
Providencia, Santiago de Chile.
Telephone: +562 3416742
Fax: +562 3416742
rapal@rapal.cl
http://www.rap-al.org

21. Pesticide Action Network Africa
BP: 15938 Dakar-Fann
Dakar, Senegal
Phone +221 825 49 14
Fax + 21 825 14 43
panafrica@pan-africa.sn
http://www.pan-africa.sn

22. Pesticide Action Network Asia and the Pacific
P.O. Box 1170
10850 Penang, Malaysia
Phone +60 4 656 0381
Fax +60 4 657 7445
panap@panap.net
http://www.panap.net

23. Pesticide Action Network Europe
Eurolink Centre
49, Effra Road
UK - London SW2 1BZ
Telephone: +44 207 274 8895
Fax: +44 207 274 9084
coordinator@pan-europe.net
http://www.pan-europe.net


Page 216 of 224

216
24. Pesticide Action Network North America
49 Powell St., Suite 500
San Francisco, CA 94102, USA
Telephone +1 415 981 1771
Fax +1 415 981 1991
panna@panna.org
http://www.panna.org

25. Silicon Valley Toxics Coalition
760 N. First Street San Jose, CA 95112, USA
Telephone: +1 408 287 6707
Fax: +1 408 287 6771
svtc@svtc.org
http://www.svtc.org

26. H-2 Jungpura Extension
New Delhi-14, India
Telephone: +91 11 432 1747, 8006, 0711
srishtidel@vsnl.net
http://www.toxicslink.org/medical

27. Sustainable Hospitals Project
Kitson 200
One University Avenue
Lowell, MA 01854, USA
Telephone: +1 978 934 3386
shp@uml.edu
http://www.sustainablehospitals.org

28. Toxics Use Reduction Institute
University of Massachusetts Lowell
One University Ave.
Lowell, MA 01854, USA
Tel: +1 978 934 3346
Fax: +1 978 934 3050
librarian@turi.org
http://www.turi.org

29. Waste Prevention Association 3R
P.O.Box 54
30-961 Krakow 5, Poland
pawel@otzo.most.org.pl
http://www.otzo.most.org.pl




Page 217 of 224

217
30. World Alliance for Breastfeeding Action
PO Box 1200, 10850 Penang, Malaysia
Telephone: + 604 658 4816
Fax: +604 657 2655
secr@waba.po.my
http://waba.org.my or http://waba.org.br

31. World Wildlife Fund International
Avenue du Mont-Blanc
1196 Gland, Switzerland
Phone: +41 22 364 91 11
Fax: +41 22 364 53 58
http://www.wwf.org

32. Zero Waste Alliance International
PO Box 33239
Takapuna, Auckland, New Zealand
Telephone: + 649 9178340
jdickinson@zwia.org

33. Zero Waste New Zealand Trust
PO Box 33 1695
Takapuna , Auckland
New Zealand
Telephone: +64 9 486 0734
Fax: +64 9 489 3232
mailbox@zerowaste.co.nz
http://www.zerowaste.co.nz



















Page 218 of 224

218
GLOSSARY

1. ACWA (Assembled Chemical Weapons Assessment):
A program of the U.S. government to demonstrate the viability of non-
incineration methods for treatment of chemical weapons stockpiles.

2. AFSSA (Agence Franaise de Scurit Sanitaire des Aliments):
The agency for food safety in the French Ministry of Health.

3. Basel Convention:
An international treaty which, as amended (with the Basel Ban) prohibits
the export of hazardous waste from OECD (wealthy) countries to non-
OECD countries.

4. Bamako Convention:
An international treaty which regulates hazardous waste within Africa,
including a ban on importing hazardous waste from outside the continent
and provisions for minimization of hazardous waste generation.

5. Bioaccumulation:
The process in which a pollutant builds up in the body over an individuals
lifetime.

6. Biomagnifications:
The process by which a pollutant becomes increasingly concentrated as it
moves up the food chain.

7. Body burden:
The load of a given pollutant that an individual carries in his/her body.

8. Bottom ash (also, clinker):
The residue from an incinerator that falls through the grate mechanism at
the bottom of the furnace.

9. Clean Production:
An approach to designing products and manufacturing processes that
takes a life cycle view of all material flows, from extraction of the raw
material to product manufacture and the ultimate fate of the product at the
end of its life. It aims to eliminate toxic wastes and inputs and promote the
judicious use of renewable energy and materials.

10. Clinker: see bottom ash.

11. Destruction and removal efficiency (DRE):
A measure of the efficacy of a treatment technology for preventing the
release to air of a given pollutant. DRE is the percentage of the pollutant in

Page 219 of 224

219
the waste stream that is not released to the air through the stack.
Releases to other media are considered removal. Cf. destruction
efficiency.

12. Destruction efficiency (DE):
Another measure of the efficacy of treatment technologies. DE is the
percentage of pollutant that is destroyed by treatment, i.e., not released in
gaseous, liquid or solid form. Cf. destruction and removal efficiency.

13. Dioxins:
As used in this report, polychlorinated dibenzo dioxins (PCDD),
polychlorinated dibenzo furans (PCDF) and coplanar polychlorinated
biphenyls (PCBs).
These are all aromatic chemical compounds formed during the
incineration process. Dioxins belong to the class of chemicals known as
persistent organic pollutants (POPs).

14. Discards:
Materials of no immediate use to their present owner, to be differentiated
from waste, which are materials of no possible use to anyone.

15. Diversion rate:
The percentage of discards that are reused, recycled, composted or
otherwise prevented from being wasted.

16. Emissions:
Releases of byproducts from a process (e.g. incineration) to the air.

17. End-of-pipe:
Interventions to reduce the environmental impact of an activity that are not
integrated into the design but added at the end of the process, often as an
afterthought.

18. Energy recovery:
Euphemism usually used for waste to energy or energy-from-waste
incineration.

19. Energy-from-waste (EFW):
Incineration with an attached steam turbine to generate electricity. This
term occasionally refers to non-incineration technologies.

20. Extended producer responsibility (EPR):
A policy approach that makes firms responsible for their products and
packaging in the post-consumer phase, providing an incentive to design
products for end-of-life recycling.


Page 220 of 224

220
21. Flow control:
Legal measures adopted by certain jurisdictions to ensure that all
municipal discards from that jurisdiction go to a particular waste treatment
facility rather than finding the cheapest option available on the market.

22. Fly ash:
The ash recovered from an incinerators air pollution control equipment.

23. Hazardous waste:
Wastes which are corrosive, ignitable, reactive or toxic.

24. Health care waste:
All waste generated by health care facilities, such as hospitals, doctors
offices and clinics; also includes veterinary facilities, funeral homes and
laboratories that prepare medicines or deal with human tissue.

25. Life cycle assessment:
A process to evaluate the environmental burdens associated with a
product, process, or activity by identifying energy and materials used and
wastes released to the environment, and to evaluate and implement
opportunities to affect environmental improvements.

26. Lipophilic:
Chemicals which have an affinity for and tend to combine with lipids (fatty
substances).

27. Medical waste:
An ambiguous term, sometimes used to refer to all health care waste and
sometimes only to that portion which is potentially infectious.

28. Microgram:
1 x 10-6 gram, or one one-millionth of a gram. MNCs (multinational
corporations)

29. Municipal discards:
As MSW, below, but disaggregated so that each fraction can be dealt with
appropriately (recycling, composting, etc.).

30. Municipal solid waste (MSW):
The mixed waste stream produced by residential and commercial
establishments.(But generally not industry)

31. Nanogram:
1 x 10-9 gram, or one one-billionth of a gram.



Page 221 of 224

221
32. Neutralent:
The liquid waste stream resulting from neutralization of chemicals
weapons agent.

33. NGO (non-governmental organization):
Usually refers to non-profit organizations working for the public interest.

34. PBTs (Persistent, Bioaccumulative Toxics):
A class of chemicals whose members are persistent in the environment;
bioaccumulate in living creatures; and are toxic to life.

35. PCBs (Polychlorinated Biphenyls):
A class of chemicals composed of two benzene rings linked by a single
carbon-carbon bond, with one or more chlorine atoms in place of
hydrogen. Often, coplanar PCBs (those with the two benzene rings in the
same plane) are included in the set of dioxin-like compounds for their
similar structure, origin, and effects.

36. PCDD (Polychlorinated Dibenzo Dioxin):
A class of chemicals, referred to as dioxins, composed of two benzene
rings linked by two oxygen molecules, with one or more chlorine atoms in
place of hydrogen.

37. PCDF (Polychlorinated Dibenzo Furan):
A class of chemicals, referred to as furans, composed of two benzene
rings, linked with a carbon-carbon bond and through a single oxygen
molecule, with one or more chlorine atoms in place of hydrogen. Furans
are considered dioxin-like compounds for their similar structure, origin,
and effects.

38. Picogram:
1 x 10-12 gram, or one one-trillionth of a gram.

39. Pg/kg/day:
Picograms per kilogram of body weight per day. A measurement of the
rate of intake of a pollutant (usually dioxins) relative to a persons body
weight.

40. POPs (Persistent Organic Pollutants):
Synthetic chemicals which display the following properties: they are
organic (composed of hydrocarbons); persist long times in the
environment; are capable of long-distance transport; and are toxic to
humans. Subject to regulation under the Stockholm Convention.




Page 222 of 224

222
41. Precautionary Principle:
The principle that, in cases of scientific uncertainty regarding the safety of
an activity, the burden of proof should rest with the proponent of the
activity rather than with the persons to be affected; and that action should
be taken to prevent harm whenever there is credible evidence that harm is
occurring or is likely to occur, even when the exact nature and magnitude
of the harm is not proven.

42. Preventive Principle:
The principle that prevention of harm is always preferable to amelioration
or compensation after the fact.

43. Process wastes:
Byproducts of production processes such as manufacturing.

44. PVC (Polyvinyl Chloride):
A common form of plastic often referred to as vinyl, with chlorine as a
major component.

45. Pyrolysis:
A form of incineration in which waste is treated in a depleted-oxygen
environment, producing a gas, which is burned, and other byproducts,
including slag. Legally classified as a form of incineration in the European
Union and United States.

46. Quench:
A pollution control device in an incinerator which sprays water into the
exhaust gases shortly after they leave the furnace chamber. The object is
to quickly reduce the gases temperature to less than 200C, the minimum
temperature for dioxin formation.

47. Releases:
All byproducts from a process (e.g. incineration) including emissions (to
air), effluent (to water bodies) and solids (to land).

48. Slag:
A fused, solid byproduct of pyrolysis or incineration.

49. Stockholm Convention:
The Stockholm Convention on Persistent Organic Pollutants. An
international treaty which bans or regulates production and emissions of a
class of synthetic chemicals.





Page 223 of 224

223
50. TDI (Tolerable daily intake):
The maximum amount of a chemical which can theoretically be safely
ingested. WHO and various governments set TDIs for some chemicals of
concern.

51. TEF (Toxic Equivalency Factor):
A value that is empirically assigned to each congener (type) of dioxins and
furans to represent their toxic potency relative to 2,3,7,8-TCDD (which has
a TEF of 1).

52. TEQ (Toxic Equivalency):
A calculated figure used to estimate the overall toxicity of multiple
congeners (types) of dioxin-like chemicals at once. There are two primary
TEQ systems,I-TEQ (International) and WHO, which yield slightly different
results. The TEQ for a given sample is calculated by multiplying the
quantity (mass) of each congener in the sample by that congeners TEF,
then adding the results together.

53. TNCs (transnational corporations):
Companies with operations in multiple countries. Also MNCs.

54. UN: The United Nations.

55. UNDP (United Nations Development Program):
An agency of the United Nations whose primary mission is to reduce
poverty worldwide.

56. UNEP (United Nations Environment Programme):
An agency of the United Nations whose mission is to encourage
sustainable development through sound environmental practices
everywhere.

57. UNIDO (United Nations Industrial Development Organization):
An agency of the United Nations dedicated to helping Southern countries
industrial bases develop.

58. USEPA (United States Environmental Protection Agency):
An agency of the United States government.

59. Vitrification:
A rarely-used process of melting ash and allowing it to cool into glass-like
balls. The intention is to destroy some organic compounds and make
pollutants in the ash less available to the environment.




Page 224 of 224

224
60. Waste-to-Energy (WTE): see energy-from-waste.

61. WHO (World Health Organization):
An agency of the United Nations working to improve human health.

62. Zero Waste:
A philosophy and a design principle that includes recycling but goes
further by taking a whole system approach to the entire flow of resources
and waste through human society. Zero Waste maximizes recycling,
minimizes waste and ensures that products are made to be reused,
repaired or recycled back into nature or the marketplace.