VL / EID WASTE MANAGEMENT FOR

LOW & MIDDLE INCOME COUNTRIES

A PRAGMATIC VIEW OF MSF

Joos Van Den Noortgate

Responsible Innovation & Training, Environmental Health
ASLM2018 Conference Seminar: Waste Management Strategies for
HIV Viral Load and Early Infant Diagnosis
December 11, 2018
 CONTENT
• Potential risks of Viral Load waste
• Waste Management Overview:
pragmatic options for VL / EID waste
– Export to countries with correct hazardous waste
facilities:
• Basel convention & International transport rules
• Field example: process
– Elimination options
• Semi-industrial batch incinerators (with loader)
• Co-processing (e.g. cement factories): field examples
 VIRAL LOAD WASTE: POTENTIAL RISKS

Safety Data Sheets

• Acute Toxicity Class 4:
• Harmful if swallowed (H302)
• Harmful if inhaled (H332)
• Aquatic Chronic Toxicity Class 3: LD50 for cyanide:
• Harmful to aquatic life with
• Ingestion: 1.53 mg/kg of body weight,
long lasting effects (H412)
for person of 70 kg => 107.1 mg
• Oral LD50: 475 mg/kg (rat) • Absorption:
• Dermal LD50: >2000 mg/kg 100 mg/kg of body weight
(rabbit) • Inhalation:
by analogy to Guanidine hydrochloride gaseous hydrogen cyanide
100 – 300 ppm
Less risk of exposure with cartridges,
but incorrect final disposal stays dangerous!
WASTE MANAGEMENT OVERVIEW
• Improved stock management
• Reuse: e.g. chlorine
• Neutralization: e.g. certain acids
• Recycling: e.g. X-ray film silver (industrial)
• Co-processing: e.g. cement factory
• High & Medium Temperature Incineration
• Simple Batch Incineration: e.g. rapid tests, sputum
• Inertization: e.g. certain solid pharmaceuticals
• Encapsulation: all hazardous waste, but it’s not a destruction method
• Drain: e.g. certain lab liquids
• Dissolving: e.g. certain drugs
• Dilution: e.g. certain drugs

Most options are WHO compliant!

EXPORT TO COUNTRIES WITH GOOD FACILITIES
• Preferably high temperature incineration
• Basel convention=> authorisations required from:
• Departing country
• Arriving country
• All countries being passed (even by air)
– Can take (very) long
– Potentially (very) expensive
• International transport
– Rules for transport by road, air & sea
• Waste generator stays responsible
for their waste until final disposal!
Donors should take all this in consideration
within their funding!!!
 FIELD EXAMPLE: MOZAMBIQUE
EXPORT TO & DESTRUCTION IN SOUTH AFRICA
• Export of 1100 kg of VL waste via specialized company to
South Africa according to Basel convention rules
• Destruction by high temperature incineration in licensed
specialized hazardous waste plant
– Process
• Identification of best disposal site
• Quotation: packaging, transport, final
disposal and paperwork
• File application for exportation to MITADER
(Ministry of Environment)
• Notification of MITADER to MEA (Ministry of
Environmental Affairs SA)
• Official contract
• Authorization of transboundary movement
• Correct packaging of waste &
loading the special truck (e.g. ADR)
• Passing through customs
• Reception & destruction at the waste plant
– Time frame: about 6 months
– Costs all included: about $6.85/kg
 ELIMINATION PROCEDURES:
MEDIUM & HIGH TEMPERATURE INCINERATION
• Gases > 2 sec. retention time • Double combustion
(in secondary combustion chamber) incineration
• > 850°C (e.g. Viral Load) – Plants difficult to find in LMIC?!
or • Medium temperature:
domestic waste incinerator
> 1100 – 1200 °C (e.g. Cytotoxic drugs) • High temperature:
• Stockholm convention specific medical waste incinerator
– Semi-industrial batch incinerators
• Only for rather small volumes:
max. 1 – 2 % V/V per year
can be hazardous waste
• Rather expensive
(purchase & running)
• Management issues
 ELIMINATION PROCEDURES: CO-PROCESSING
“MEDIUM & HIGH TEMPERATURE INCINERATION”
• Gases > 2 sec. retention time • Cement factory
(in secondary combustion chamber) – > 1400 °C at burner side
• > 850°C (e.g. Viral Load) – > 1050 °C at other side of kiln
or – > 850 °C at pre-calciner
> 1100 – 1200 °C (e.g. Cytotoxic drugs) – Long retention times (> 2 seconds)
– Not everywhere available
• Stockholm convention https://www.cemnet.com/global-cement-report/
– Not willing to do hazardous waste
management
 FIELD EXAMPLE: MALAWI
CO-PROCESSING IN CEMENT FACTORY
• Expired drugs / VL waste eliminated in cement factories
– Stakeholders Ministry of
Health
Médecins Sans
Pharmacy, Frontières
Medicine and
Poison Board
Need for the VL manufacturers to take up more Expired drugs
responsibilities
• Size liquid waste recipient = generated quantity/cycle +
• Provide service to take over the hazardous waste
Viral Load waste Representatives of
• More elaborated SDS
District Hospital &
Cement Factory District Council
as witnesses
during elimination

– May 2018, 2000 kg of hazardous waste eliminated in Shayona cement factory

– Costs all included: $1.52/kg
– Comparison with Semi-industrial incinerator in Lilongwe: $1.91/kg
– Negotiations ongoing with Mangochi cement factory
 MEDICAL RELATED HAZARDOUS WASTE:
MORE THAN VIRAL LOAD
• Laboratory waste
– Reagents / substances
– Diagnostic test kits, products & equipment
• Pharmaceutical waste
– Specifically cytotoxic & cytostatic waste
• X-ray related waste
– Developing liquid for the X-ray film
– Fixer liquid for the X-ray film
– Expired X-ray film
• Specific hazardous waste
– Radioactive waste
– Small batteries of medical equipment: heavy metals
– Old and broken equipment: e.g. containing mercury
– Material related to the ambulance:
e.g. engine oil, car battery
• Inappropriate / expired insecticides & old LN
• Bio-hazardous waste
– Samples of potentially infected persons
– Lab cultures
– Specific body fluids: e.g. TB sputum
– VIRAL LOAD WASTE IS NOT BIO-HAZARDOUS WASTE!
 CONCLUSIONS
• All Hazardous Waste needs to be disposed of safely,
whatever the context
• All relevant conventions need to be respected, but
potentially slightly adapted to be appropriate for LMIC
• Appropriate and safe Hazardous Waste Management
solutions exist for LMIC
• Although that the waste generator stays responsible for
their waste, efforts of authorities & manufacturers are
required to improve waste management in LMIC
 ACKNOWLEDGEMENT
• Maria Haraldsson, MSF
• Luca Fontana, MSF
• Bertrand Rose, former MSF
• Quentin Pulinckx, MSF
• Fortunat Kolela, MSF
• Labana Steven , MSF
• MSF Mozambique mission
• MSF Malawi mission

THANK YOU!
joos.van.den.noortgate@brussels.msf.org
 COMMON CHALLENGES & BARRIERS IN LMIC
• Low awareness about the risks of VL / EID waste & how to manage it
– Diagnostic / Treatment technologies, supported by institutions,
agencies, donors are moving faster than their waste management
• Donation of lab supplies with limited disposal instructions and without
waste disposal funding
• Political request to donors to install incinerators, whilst other solutions
might be more appropriate
• Limited availability of hazardous waste experts (with pragmatic view of the
reality of LMIC)
– Often no national policy or guidelines existing cc hazardous waste
(e.g. expired drugs, medical equipment & lab waste like VL / EID)
– No integrated waste management for hazardous waste,
even general medical waste is badly managed
– In practice VL cartridges are often burnt in simple waste reducers,
and liquid VL waste is drained into sinks or at best stored for later
treatment
 COMMON CHALLENGES & BARRIERS IN LMIC
• No clear instructions for Low & Middle Income Countries
– Low awareness on how to use existing opportunities (e.g. cement kiln)
– Limited private waste management providers involved in medical waste

• Respecting Conventions: might be difficult to respect to the letter for LMIC

– Basel: Transboundary Movements of Hazardous Waste & Disposal
– Stockholm: Persistent Organic Pollutants – POP’s: procurement & incineration
– European Agreement : Carriage of Dangerous Goods by Road (ADR)
 HAZARDOUS WASTE ELIMINATION:
MORE THAN JUST DISPOSAL
• Isolating the hazardous waste using correct Personal Protective Equipment (PPE)
(correct storage, incompatibilities of different products)
• Making a list of all the hazardous products that have to be eliminated
(including physical, health & environmental hazards)
• Choosing the most appropriate elimination procedure per product
– Authorized institute / company for the elimination of the hazardous waste
– Export to a country with correct elimination facilities (Basel convention)
– Self-management (has to be at least WHO compliant; 1999 guide)
• Preparing the elimination procedures
– Obtaining all required licenses: transport (transboundary), elimination
– Potential packaging (strict regulation: categories I to III, Limited Quantity)
– Potentially preparing the facilities / site for Self-management
• (Potentially) transporting the hazardous waste (strict regulation: e.g. ADR)
• Implementing the elimination procedures (e.g. Stockholm convention)
• Keeping records of all relevant documents
 FIELD EXAMPLE: MOZAMBIQUE
CO-PROCESSING IN CEMENT FACTORY
• Expired drugs / potentially VL in cement factory nearby Maputo
– Process

– Destruction of MISAU drugs has taken place in 2017

– Cement factory closed ‘temporarily’ due to maintenance & overproduction
– Ministry of Environment has taken up the dossier but doesn’t seem to advance
– Cement factory owner would have changed & not sure if there is still the
willingness to do hazardous waste elimination
– Foreseen costs all included: about $0.840/kg