CHARACTERISTICS OF MEDICAL WASTE IN TAIWAN

HSIEN-WEN KUO , SHU-LUNG SHU, CHIN-CHUNG WU and JIM-SHOUNG LAI

Institute of Environmental Health, China Medical College No. 91, Hsueh-Shin RD., Taichung,
Taiwan, R.O.C.
( author for correspondence, fax: +886 42019901)

(Received 1 October 1997; accepted 9 October 1998)

Abstract. The purpose of this study was threefold: to investigate the types and amounts of medical
waste from various hospitals in Taiwan; to analyze residues from incinerated medical waste for heavy
metal content; and to measure the amount of infectious and general medical waste per bed per day
and determine the ratio of infectious to general medical waste. Information was first obtained on the
amounts of medical waste produced per bed per day and on waste handling and treatment. Next,
residue samples were taken from incinerators and analyzed for heavy metal content. Third, daily
records concerning waste content and weight from one hospital were kept over the period of one
year. Chromium (Cr) and zinc (Zn) concentrations were significantly higher in medical waste than in
general waste. Medical waste fluctuated significantly over the one-year period. Records showed that
wastes containing dialysis material and wood/cotton materials were found to have the highest weight
and wastes containing human organs had the lowest weight. Results of the present study underscore
the need for all hospitals to effectively separate waste for proper treatment and disposal, particularly
waste that produces residues which may be hazardous to the environment. In addition, hospitals also
need to recycle or reuse certain materials in order to reduce waste production.
Keywords: heavy metals, incineration, medical waste, Taiwan

1. Introduction
Medical waste disposal is becoming a major problem in Taiwan due to several
reasons; the large increase in medical waste volume from the growing trend of
using plastics and disposable goods, the continued expansion and construction
of new facilities, and the hazards of handling and disposing of infectious waste.
Taiwans dense population and limited land area makes incineration of medical
waste, as opposed to burial, a necessity. If all of Taiwans 22 hospital incinerators
were fully active, they could treat the 5.21 tonnes (about 60% or 1901.7 tonnes
annually) of infectious waste that is produced daily. However, the incinerators are
currently treating only 3.52 tonnes (about 45% or 1284.8 tonnes annually) of daily
infectious waste output. Previously, most of this infectious waste was produced
by small-scale hospitals and clinics which end was first disinfected by autoclaves
before being combined with general waste and buried in landfills (Chen, 1996;
Lee et al., 1991). Currently, some small-scale hospitals and clinics are required
by the government to send their infectious waste to privately-run incinerators for
treatment.
Water, Air, and Soil Pollution 114: 413421, 1999.
1999 Kluwer Academic Publishers. Printed in the Netherlands.

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H.-W. KUO ET AL.

Taiwans Department of Health classifies infectious medical waste based on

flammability. Flammable items, which are placed in red bags for incineration,
include paper, plastic, cotton, wood, animal cadavers, human organs, and other
materials possibly contaminated by blood. Nonflammable items, which are placed
in yellow bags to be autoclaved, include syringes, needles, scalpels, glass tubes, and
metal cans. Syringes and needles can also be incinerated and their residues buried
in landfills. Unfortunately, infectious waste is not always separated by hospitals.
This lack of waste separation can result in the needless consumption of valuable
energy resources due to the presence of nonflammable items which can overload
the incinerators and shorten their expected life span. The Taiwan government has
privatized the waste treatment industry and set a goal to incinerate 65% of all
infectious waste by the end of 1998.
The U.S. Environmental Protection Agency (1987) estimates that the average
U.S. hospital generates approximately 7 kg bed1 d1 in general waste. Estimates
in Taiwan are about 4 kg bed1 d1 . This number has risen recently mainly due to
the corresponding increase in the use of disposable materials. In 1994, Taiwans
Department of Health listed the number of hospital beds at 103,489, of which
approximately 60% were occupied. One bed averaged 3.4 kg of general waste
per day. The annual general waste output totalled aproximately 77 015 tonnes,
of which 11 559 tonnes (15%) was infectious waste. The average daily output
of general waste was 211.3 tonnes and infectious waste was 31.65 tonnes (Chen,
1996). The main method of waste treatment-incineration decreases volume by 90%
and weight by 80%. Incineration is suitable for treating all types of infectious waste
materials and the Taiwanse government has actively promoted its use. However,
incineration of medical waste is not without its own environmental hazards. When
some plastics and disposable goods are incinerated, carcinogenic chemicals such
as PCBs (polychlorinated biphenyls), PCDFs (polychlorinated dibenzofurans) or
PCDDs (polychlorinated dibenzo p-dioxins) may be produced and contaminate the
air surrounding the incinerator (Thornton et al., 1996; Wagner and Green, 1993).
Another potential threat to the environment comes from disposing of medical waste
containing heavy metals. When needles, syringes, aluminum cans or out-dated instruments of machines are incinerated, the residues are often dumped in landfills.
This harms the environment in numerous ways, foremost by contaminating ground
water. If bottom-ash residues are buried in landfills, it is crucial that contaminants
in these residues not be allowed to exceed permissible levels intended to protect
the environment. If bottom-ash residues do contain high amounts of toxic materials or heavy metals, alternative methods of disposal should then be explored. In
1995, 24.6% or, 5,712 tonnes of general waste treated daily by incineration on
Taiwan. A large portion of the resulting incinerated waste and residues (bottomash), however, was buried in landfills with only a small percentage being used
for ash export or for other industrial purposes such as road construction or metal
reclamation (Liu, 1996). After medical waste has been treated by incinerators, the
residues may contain heavy metals, organic compounds, metal oxides, or other

CHARACTERISTICS OF MEDICAL WASTE IN TAIWAN

415

nonflammable materials. If residues are buried in landfills, it is crucial to know that

the residue compositions do not exceed permissible levels and will not pose a threat
to the environment. If residues contain high amounts of toxic materials or heavy
metals, alternative methods of disposal are needed. In a study of general waste,
Liao (1996) used the Toxicity Characteristic Leaching Procedure (TCLP) to extract heavy metals from bottom ash and found Zn and Pb concentrations exceeded
Taiwans permissible levels. Chang (1996) conducted a similar study and found
that Cu and Pb content in bottom ash were high, but below permissible levels.
Because of the dangers infectious waste causes to its handlers and the environment, a thorough understanding of its amount or composition in medical waste
is necessary for proper treatment and disposal. If hospitals know the approximate
amount of infectious waste per bed day, ratio of infectious waste to general medical
waste, and the composition of infectious waste, they can make appropriate preparations for the disposal of waste materials. Results from several studies (Chen,
1996; Li and Jeng, 1993) in Taiwan showed that the percentage of infectious to
medical waste ranged from 8 to 20%. Amounts of infectious waste ranged from
0.51 to 0.9 kg bed1 day1 . The U.S. Congress (1990) estimates infectious waste
production at 0.6 kg bed1 day1 . Estimates range due to the differences in disease
characteristics and hospital facilities.
The current study includes three main purposes: first, to investigate the kinds
and amounts of medical waste from a hospital over a period of one year; second, to
analyze and measure residues from the incinerated waste of 9 hospitals for heavy
metal content; and thirdly, to investigate the amount of infectious and medical
waste per bed per day and ratio of infectious to general medical waste from 28
hospitals.

2. Materials and Methods

Twenty-eight public hospitals were surveyed and records on general and infectious
waste production were kept for one year. Records focused on the ratio of general medical waste to infectious waste, number of beds, bed occupancy rates and
number of outpatients per day (clinics only). Nine of the twenty-eight hospitals
with incinerators in Taiwan were chosen for collection of residues (bottom-ash).
Samples were collected every day for five days, totaling 45 samples. Each sample
weighed 100 g. These samples were tested based on Taiwan EPAs (1994) Toxicity
Characteristic Leaching Procedure (TCLP) and analyzed for heavy metals using
Inductively Coupled Plasma-Atomic Emission Spectrometry (ICP-AES).
Bottom-ash residues of incinerated medical waste were divided into individual
samples weighing 0.5 g each. Each sample was then put into a 500 mL vessel to
which 96.5 mL of distilled water was added and then stirred vigorously for five
minutes. The pH of each sample was then measured. If the pH value exceeded
5.0, then 10 mL of extraction solution B (5.7 mL acetic acid and 994.3 mL of

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H.-W. KUO ET AL.

distilled water, with a pH value of 2.88) was added. If pH was lower than 5.0, 10
mL of extraction solution A (5.7 mL acetic acid and 64.3 mL 1N NaOH and 430
mL of distilled water, with a pH value of 4.93) was added for analysis. Residue
mixtures were weighed and divided into groups of 100 g then put into a plastic
can and rotated at 50 rpm for 18 hr. The residue solution was then poured into a
high-pressure filter. Solids and liquids were separated and the liquid extract was
analyzed using ICP-AES. Taiwan EPA standard methods (1994) for determining
heavy metals (Zn, Sb, Pb, Cd, Co, Cu, Ni, Mn, Fe, Cr, Be) were followed. Blank
tests were performed on 10 samples to determine detection limits for the 11 heavy
metals. Five different standard solutions were plotted on a calibration curve for
each of the heavy metals. These calibration curves were then used to determine the
concentrations of heavy metals. Duplicate tests were done on samples from each of
the mine hospitals and the relative standard deviation (RSD) was found to be less
than 10%.
One hospital, which was equipped with an incinerator, was selected and its
infectious waste was examined on a daily basis for a period of 59 weeks. This
hospital had a total of 300 beds with an occupancy rate greater than 90% and
an average of 960 outpatients per day. Infectious waste was separated into five
groups: platics, wood/paper/cotton, syringes/needles/scalpels, dialysis materials,
and human organs. Consistency was ensured over the 59-week period as only one
research member was responsible for separating and weighing the hospital waste
materials and for keeping records.

3. Results and Discussion

The number of beds, average number of outpatients per day, and bed occupancy
rates varied significantly due to different sizes and specialties of the hospitals surveyed (Table I). The highest levels of infectious wastes were produced in general
hospitals treating both outpatients and inpatients. Lowest levels of infectious waste
were produced in hospitals specializing in physical regabilitation and chronic care.
General medical waste levels were correlated to the number of beds and bed occupancy rates. The overall average was 0.39 kg for infectious waste and 1.64 kg
for general medical waste per bed per day. If bed occupancy rates were 100%, then
the corrected value would be 0.57 kg bed1 day1 for infectious waste and 2.41
kg bed1 day1 for general medical waste. Chen (1996) found similar results for
amounts of infectious waste which ranged from 0.51 to 0.9 kg bed1 day1 . In
the current study, the ratio of amount of infectious to general waste varied considerably, from 1.7100% due to differences in waste separation procedures and
hospital function. For example, some hospitals with incinerators did not separate
the different forms of waste and treated all waste by incineration. The average ratio
of 23.8% (amount of infectious to general waste) was consistent with other similar
studies performed in Taiwan (Lin, 1996; Liu, 1996, Yang, 1994).

CHARACTERISTICS OF MEDICAL WASTE IN TAIWAN

417

TABLE I
Production of infectious and general medical waste form 28 hospitals in Taiwan
Hospital

# of beds

# of
inpatients

Rate of
occupancy
(%)

Infectious waste
General waste
(I)
(G)
(kg bed1 day1 ) (kg bed1 day1 )

Ratio of
I/G
(%)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

330
401
112
600
429
132
298
301
60
326
305
212
516
129
300
382
200
210
30
96
102
970
472
1850
600
200
240
100

644
993
230
1800
200
246
480
960
560
1500
900
526
712
289
500
900
430
600
108
200
150
n/a
129
5
125
389
10
n/a

56.7
74.8
55.0
75.6
95.0
72.1
55.8
92.0
34.9
96.0
60.0
63.9
63.9
65.0
93.6
97.0
58.5
80.0
51.1
90.0
80.0
59.0
97.2
97.0
90.0
72.0
90.0
n/a

0.30
0.50
0.04
0.50
0.78
0.33
0.21
0.25
0.67
0.26
1.97
0.08
0.19
n/a
0.44
0.32
0.11
n/a
0.67
0.34
0.11
n/a
0.01
0.01
0.03
0.00
n/a
0.33

1.81
2.12
0.07
3.33
3.50
2.48
1.00
1.99
2.50
2.15
1.97
4.72
0.68
3.49
1.67
3.14
n/a
0.95
3.89
0.83
0.00
n/a
0.21
0.16
0.03
3.50
4.17
1.50

16.6
23.6
57.1
15.0
22.3
13.3
21.0
12.6
26.8
21.1
100
1.7
27.9
n/a
26.3
10.2
n/a
n/a
17.2
41.0
n/a
n/a
4.8
6.2
100
n/a
n/a
22.0

309

490

68

0.39
0.57a

1.64
2.41a

23.8

Average

a corrected by rate of occupancy.

n/a: not available.

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H.-W. KUO ET AL.

TABLE II
Comparison of heavy metals in incineration residue from nine hospitals
Hospital

Zn

Sb

Pb

Cd

Co

Ni

Mn

Fe

Cr

Be

Cu

14
19
16
10
9
24
8
13
21

209.59
73.1
71.58
289.78
272.22
15.46
96.86
4.65
0.15

1.64
1.58
1.92
1.67
1.63
2.01
1.81
1.86
1.74

23.17
3.59
13.39
7.36
102.98
1.95
3.04
2.27
1.83

0.34
0.85
0.25
0.37
0.36
0.3
0.33
0.29
0.25

0.67
0.55
0.25
0.82
0.5
0.5
0.9
0.59
0.47

7.31
3.25
7.49
6.85
2.96
1.69
17.62
3.73
1.27

9.17
7.74
6.66
9.42
3.5
4.26
7.13
2.8
0.47

6.03
40
3.21
17.9
8.9
4.0
8.49
0.31
0.25

1.1
0.93
0.89
1.13
0.95
1.38
1.83
2.51
0.94

0.01
0.01
0.01
0.01
0.01
0.01
0.01
0.01
0.01

1.1
0.9
0.4
2.4
1.2
0.2
0.5
0.2
0.2

All values represent the mean (in ppm) from 5 consecutive days of measurement.

The mean of heavy metal concentrations found in bottom-ash residues taken

from 5 consecutive days of measurement from the 9 hospitals with incinerators are
displayed in Table II (19 of the hospitals investigated did not have an incinerator).
Of the 11 types of heavy metals found, Zn had the highest concentration ranging
from 0.15 to 289.78 ppm, followed by Pb (1.83102.98 ppm), Ni (1.2717.62
ppm), and Fe (0.2539.96 ppm). Other heavy metals varied less in concentration.
Hospitals 10 and 9 produced residues containing the highest concentrations of Zn,
Pb, and Fe and Hospitals 13 and 21 produced the lowest overall concentrations
of heavy metals. Based on Taiwans standards for permissible heavy metal levels
in residue (Zn = 25 ppm; Pb = 5 ppm; Cd = 1.0 ppm; Cr = 5.0 ppm; Cu = 15.0
ppm), tests on the 45 samples showed Zn was in excess in 31 samples (68.9%),
followed by Pb in 12 samples (26.7%), and Cd in two samples (4.4%). Cr and Cu
were not found in excess of permissible levels in any of the 45 samples. Compared
to general waste, the highest concentrations found in infectious waste were Cr, Zn,
and Cd and the lowest were Pb and Cu. Particularly high concentrations of Cr were
found in infectious waste due its content in needles and syringes. Its high content of
Cr makes it necessary to properly treat bottom ash in order to avoid contamination
of ground water.
Because most hospitals in Taiwan do not grind or melt down needles or syringes, high concentrations of Cr, Fe, Ni are found in bottom-ash residues. Although Cr did not exceed permissible levels in the present study, it was found in
concentrations 17 times higher than those found in general waste. Harmful effects
on the environment may result, if such residues containing high concentrations of
Cr are not properly treated. For instance, the soluble Cr(VI) is considered to be a
human lung carcinogen and its proper treatment is of vital importance. The authors
suggest hospitals separate syringes and needles to be ground or melted down and

CHARACTERISTICS OF MEDICAL WASTE IN TAIWAN

419

Figure 1. Amount of infectious waste produced over 59 weeks in a Taiwan hospital.

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H.-W. KUO ET AL.

then desinfected by autoclave and lastly buried in landfills. The highest variations
of heavy metal concentrations found in the current study were likely due to differences in the physical and chemical composition of hospital waste materials and
incinerator operational conditions such as temperature, supply of air, and retention
time.
Li and Jeng (1993) compared the physical and chemical composition of water
from the three hospitals in Taiwan. They showed flammable materials ranged from
82.9499.01% and metal (nonflammable) ranged from 0.409.9%. They based the
reasons for their findings on the fact that different hospitals produce different forms
of waste. Wong et al. (1994) studied two large hospitals in Florida. Their results
showed that the nursing home care unit produced the heaviest amount of flammable
waste (25.67% of total waste) and the cardiac intensive care unit produced the
lowest (6.91% of total waste). Cotton was heaviest among flammable materials
consisting of 34.38% of the total weight and metals was highest at 2.23%. Wong
et al. (1994) also found that plastics were being used at significant rates (32.64%
of general medical waste) in the ICUs and dialysis units. In their study in Taiwan,
Li and Jeng (1993) found plastics constituted 18 to 50% of all general waste which
resulted in correspondingly high levels of Pb and Cd found in bottom-ash. Plastics
also emit hydrogen chloride which is damaging to incinerators and hazardous to
the environment (Crow, 1985). Previous studies (Thornton et al., 1996; Kolenda
et al., 1994) focused on the treatment of general medical waste and found that
botom-ash residues contain PCBs (polychlorinated biphenyls), PCDFs (polychlorinated dibenzofurans), PCDDs (polychlorinated dibenzo p-dioxins), glass, porcelain, chlorinated organic compounds and other nonflammable materials.
Total amount of infectious waste and the five groups (plastics, wood/cotton/paper,
syringes/needles, dialysis materials, human organs) measured from one hospital
on a weekly basis for 59 weeks is shown in Figure 1. Total amount of infectious waste varied substantially over this period, ranging from approximately 400
to 1000 kg per week. An overall comparison of average weekly production for
the five groups showed dialysis materials was heaviest (169.6 kg), followed by
wood/paper/cotton (142.98 kg), syringes/needles (107.47 kg), plastics (99.16 kg),
and human organs (48.49 kg). The total amount of infectious waste was mainly
affected by the production of wood/paper/cotton and dialysis materials. The waste
group with the lowest variation in weight was human organs. Due to the significant
increase in number of kidney abnormality cases (mainly, continuous ambulance
peritoneal daily or CAPD) in Taiwan, plastic wastes from dialysis materials has
also grown and their treatment poses a threat to incinerators and the environment.
When incinerated the plastics produce energy which damages the incinerator over
time and releases toxic substances (i.e. PCBs, PCDFs, and PCDDs) into the air. In
an effort to reduce the burden on its incinerator, the hospital studied implemented
recycling and waste minimization programs. The effectiveness of such programs
requires future investigation.

CHARACTERISTICS OF MEDICAL WASTE IN TAIWAN

421

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