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OverviewofWastesfrom

HealthCareActivities
UNEPIETCOsaka,Japan
19July2012
SusanWilburn,TechnicalOfficer
PublicHealthandEnvironment
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Public health and environment

KeyPoints
Ofthetotalamountofwastegeneratedbyhealthcare
activities,about80%isgeneralwaste.
Theremaining20%isconsideredhazardousmaterialthat
maybeinfectious,toxicorradioactive.
Everyyearanestimated16000millioninjectionsare
administeredworldwide,butnotalloftheneedlesand
syringesareproperlydisposedofafterwards.
Healthcarewastecontainspotentiallyharmful
microorganismswhichcaninfecthospitalpatients,health
careworkersandthegeneralpublic.

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Public health and environment

Whatishealthcarewaste?
Healthcarewasteincludesallthewastegeneratedbyhealth
careestablishments,researchfacilities,andlaboratories.In
addition,itincludesthewasteoriginatingfromminoror
scatteredsourcessuchasthatproducedinthecourseofhealth
careundertakeninthehome(dialysis,insulininjections,etc.).

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Public health and environment

Categoriesofhealthcarewaste
Sharps:Usedorunusedsharps

e.g.hypodermic,intravenousorotherneedles;autodisablesyringes;
syringeswithattachedneedles;infusionsets;scalpels;pipettes;knives;
blades;brokenglass

Infectious:Infectiouswasteismaterialsuspectedtocontainpathogens

(bacteria,viruses,parasitesorfungi)insufficientconcentrationorquantityto
causediseaseinsusceptiblehosts.Thiscategoryincludes:wastecontaminated
withbloodorotherbodyfluids,culturesandstocksofinfectiousagentsfrom
laboratorywork,wastefrominfectedpatientsinisolationwards;dressings,bandages
andothermaterialcontaminatedwithbloodorotherbodyfluids

Pathological:Humantissues,organsorfluids;bodyparts;fetuses;
unusedbloodproducts

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Public health and environment

Categoriesofwaste(cont)
Pharmaceutical:Pharmaceuticalsthatareexpiredornolonger

needed;itemscontaminatedbyorcontainingpharmaceuticals;Cytotoxic
wastecontainingsubstanceswithgenotoxicpropertieswastecontaining
cytostaticdrugs(oftenusedincancertherapy)genotoxicchemicals)

Chemical:Wastecontainingchemicalsubstances

(e.g.laboratoryreagents;filmdeveloper;disinfectantsthatareexpiredorno
longerneeded;solvents;wastewithhighcontentofheavymetals,e.g.
batteries;brokenthermometersandbloodpressuregauges)

Radioactive:Wastecontainingradioactivesubstances

(e.g.unusedliquidsfromradiotherapyorlaboratoryresearch;contaminated
glassware,packages,orabsorbentpaper;urineandexcretafrompatients
treatedortestedwithunsealedradionuclides;sealedsources)

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Public health and environment

Generaldefinitionand
characteristics

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Public health and environment

Health Care Waste


Impropermanagementofhealthcarewastecanhave
bothdirectandindirecthealthconsequencesforhealth
personnel,communitymembersandtheenvironment.
Directconsequenceswhendisposablematerials(especially
syringes)areintentionallyreused
Indirectconsequencesintheformoftoxicemissionsfrom
inadequateburningofmedicalwaste,ortheproductionof
millionsofusedsyringesinaperiodofthreetofourweeks
fromaninsufficientlywellplannedmassimmunization
campaign
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Public health and environment

Health Care Waste Management


Exposed groups and associated risks
Healthcareworkers
UK96to2004,2140reportedoccupationalexposurestobloodborne
viruses.21%oftheinjuriesoccurringduringthedisposalprocess
(Gabriel2009)
Wastehandlers
StudyinMexicocityshowedthatoutof69interviewedwaste
handlers34%(13)reported22needlestickinjuriesbetweenthem
duringthefirst12monthsand96%hadseenneedlesandsyringesin
waste(Thompsonetal,2010).
Scavengersretrievingitemsfromdumpsites
InPakistanonaveragescavengerboyswhoweregoingthrough
medicalwaste,forcollectionandresale,experiencedthreetofive
needlestickinjuriesaday(AltafandMujeed2002)
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Public health and environment

Childrenwhomaycomeintocontactwithcontaminatedwaste
DozenofchildreninSadrCity,largestsuburbofBaghdad,havebeen
admittedtohospitalswithsymptomsofinfectiousdiseasesduetocontact
withwaste(IntegratedRegionalInformationNetworks,2007).
Communitieslivingnearlandfillandwastesitesorneartreatmentfacilities
Lowincomehouseholdsaremorelikelytoliveclosetowastesites
resultinginmoredirectcontactwithhealthcarewaste(AppletonandAli,
2000)
Localpopulationsaffectedbytheutilizationofproductsrecycledfrom
healthcarewasteandthereuseofuntreatedmedicalequipment
InIndiamorethan30%oftheinjectionsadministeredeachyearwere
carriedoutusingreusedorinadequatelysterilizedmedicalequipmentand
thatnationally,10%ofhealthcarefacilitiessoldusedsyringestowaste
pickers(IndiaCLEN2004).
pickers(IndiaCLEN2004).
Communitiesimpactedbypollutionfrompoorlyoperatedincinerators
Researchsuggeststhatpopulationlivingwithin3kmofoldincinerators
sawanincreaseof3.5%intheriskofcontractingcancer(Portaetal,2009)
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Public health and environment

ProcessofHCWastemanagement

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Wasteclassification
Wastesegregation
Wasteminimization
Containerization
Colorcoding
Labelingandsignage

Public health and environment

Handling
Transport
Storage
Treatment
Finaldisposalof
waste.

Wastemanagementhierarchy
Most preferable
Prevent
Reduce
Reuse
Recycle
Recover
Treat
Dispose
Least preferable
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Public health and environment

Wastesegregationiskey
Carefulsegregationandseparate
collectionofhospitalwasteisthekey
tosafe,soundmanagementofhealth
carewaste.
Segregationcansubstantiallyreduce
thequantityofhealthcarewastethat
requiresspecializedtreatment.
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Public health and environment

Segregationofhealthcarewaste
(continued)
Inanyareathatproduces
hazardouswastehospitalwards,
treatmentrooms,operating
theatres,laboratories,etc.

binsplusseparate
sharpscontainerwillbeneeded.

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Public health and environment

Segregationofhealthcarewaste

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Public health and environment

Sharpswaste
Sharpsareitemsthatcancause
cutsorpuncturewounds,
including:

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needles,

hypodermicneedles,

scalpelandotherblades,

knives,

infusionsets,

saws,

brokenglass,

andpipettes

Public health and environment

Sharpwastemanagement
SharpsHandlingRecommendations
Donotrecapneedles
Neverpassusedsharpsfromone
persontoanother
Locateneedledestroyerand
containernearthepointof
generationtohavegoodvisibility
Sharpsshouldbedisposedofin
punctureresistantsharps
containers

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Public health and environment

Highlyhazardoushealthcarewaste
Highly hazardous healthcare wastes, which should be given special
attention, includes
highly infectious non-sharp waste such as laboratory supplies,
highly infectious physiological fluids, pathological and anatomical
waste, stools from cholera patients,
and sputum and blood of patients with highly infectious diseases such
as TB and HIV/AIDS.
They also include large quantities of expired or unwanted
pharmaceuticals and hazardous chemicals,
as well as all radioactive or genotoxic wastes.

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Public health and environment

Subcategoriesofhazardouswaste:Infectious
wasteandhighlyinfectiouswaste
Infectiouswasteincludes:
culturesandstocksofinfectiousagentsfrom
laboratorywork;
wastefromsurgeryandautopsiesonpatients
withinfectiousdiseases;
wastefrominfectedpatientsinisolationwards;
wastethathasbeenincontactwithinfected
patientsundergoinghaemodialysis;
infectedanimalsfromlaboratories;
anyotherinstrumentsormaterialsthathave
beenincontactwithinfectedpersonsoranimals.

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Public health and environment

Infectiouswastemanagement
Infectiouswasteshouldgointo
yellowleakproofplasticbagsor
containers.
Bagsandcontainersfor
infectiouswasteshouldbe
markedwiththeinternational
infectioussubstancesymbol

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Public health and environment

Subcategoriesofhazardouswaste:
Chemicalwasteandpharmaceutical
waste
Chemicalwasteconsistsof
discardedsolid,liquid,and
gaseouschemicals,for
examplefromdiagnosticand
experimentalworkandfrom
cleaning,housekeeping,and
disinfectingprocedures.

Pharmaceuticalwasteincludes
expired,unused,spilt,and
contaminatedpharmaceutical
products,drugs,vaccines,and
serathatarenolongerrequired
andneedtobedisposedof
appropriately.
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Public health and environment

Chemicalandpharmaceuticalwaste
management
Smallamountsofchemicalor
pharmaceuticalwastemaybe
collectedtogetherwithinfectious
waste.
Largequantitiesofchemical
wasteshouldbepackedin
chemicalresistantcontainers.

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Public health and environment

Theidentityofthechemicals
shouldbeclearlymarkedonthe
containers:hazardouschemical
wastesofdifferenttypesshould
neverbemixed.

Radioactivewaste
Thewasteproducedbyhealthcareandresearchactivities
involvingradionuclides,andrelatedactivitiessuchas
equipmentmaintenance,storage,etc.,canbeclassifiedas
follows:
sealedsources;
spentradionuclidegenerators;
lowlevelsolidwaste,e.g.absorbentpaper,swabs,glassware,syringes,vials;
residuesfromshipmentsofradioactivematerialandunwantedsolutionsofradionuclides
intendedfordiagnosticortherapeuticuse;
liquidimmisciblewithwater,suchasliquidscintillationcountingresiduesusedin
radioimmunoassay,andcontaminatedpumpoil;
wastefromspillsandfromdecontaminationofradioactivespills;
excretafrompatientstreatedortestedwithunsealedradionuclides;
lowlevelliquidwaste,e.g.fromwashingapparatus;
gasesandexhaustsfromstoresandfumecupboards.

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Public health and environment

Generalhealthcarewaste
General healthcare
waste, similar or
identical to domestic
waste, including
materials such as
packaging or unwanted
paper. 7590% of waste
generated by healthcare
facilities falls into this
category.

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Public health and environment

Generalwastemanagement
This waste is generally
harmless and needs no
special handling; and
General health-care waste
should join the stream of
domestic refuse for disposal.
Bags and containers for
general healthcare waste are
black.

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Public health and environment

Wasterecycling
Only15%ofthehospitalwastestreamisclassified
regulatedorpotentiallyinfectious,andmustbe
handledassuch.
Themajorityofhospitalwasteissimilartothatfoundin
anofficebuildingorhotelmostlypaper,cardboard,
metalandfoodwaste.
Muchofthiswastecanbedivertedfromlandfillsandcan
reducewastedisposalcoststhroughwasterecycling.

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Public health and environment

Examplesof
Reuse,Recycle
ofWaste,Water
ThailandGREEN&
CLEANHospitals

Biogasfromfoodwasteusedfor
hospitalcooking
RecyclingplasticIVbottles

IndiaBhopal
SambhavnaTrustClinic

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Harvestsrainwaterforhospitaluse
Solarwaterheatersandpassive
ventilationreduceenergyuse
Tropicalgardens,irrigatedby
recycledwater,providefreshfruits
andvegetablesforstaffandpatients
Public health and environment

Greeninghealthsector:cobenefitsfor
patients,healthworkersandclimate
mitigation
Chemicalhazards:

"Riskingtheirhealthwhile
Captureandreuse
caringforothers:
ofwasteanesthetic Reproductivehealth
gases:reproductive hazardsofgermkillers"

hazardsandpotent NIOSH,HarvardSchoolofPublic
HealthandBrigham&Women's
Hospitalsurveyedof7,000women
GHGases*
nursesandfoundnumerouspotential
*Estimatedtohaveaglobal
occupationalchemicalexposuresthat
warmingpotentialof500
3700XCO2

Ryan,SM,NielsenCJ.Globalwarmingpotentialof
inhaledanaesthetics:applicationtoclinicaluse.
InternationalAnesthesiaResearchSociety,July2010,
111(1).
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doubledortripledmiscarriagerisk.
LawsonCetal.AmJObstetGynecol.2011Dec30

...Examplesofmercuryelimination
NewDelhi,India:thecityspublichealth
systemissubstitutingmercuryinits
hospitals.Todate12hospitalsarein
theprocessofsubstitution.(Poster
fromcampaignonright)
SaoPaulo,Brazil:morethan100private
hospitalsand34publichospitalshave
gonemercuryfree
MexicoCity,Mexico:Thehealth
secretariatannouncedinSeptember
2009thatitssystemof28hospitalsand
morethan200healthclinicswouldjoin
theWHOHCWHInitiativeandphase
outmercurybasedmedicaldevices.

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Public health and environment

Global Policy and Driving forces


SIXTYTHIRDWORLDHEALTHASSEMBLY(WHA63.25)
Agendaitem11.18Improvementofhealththroughsafeand
environmentallysoundwastemanagement
TheLibrevilleDeclarationonHealthandEnvironmentinAfrica:
FrameworkforHealthCareWasteManagement(Douala2010)
GlobalAllianceforVaccinesandImmunization
72countriesreceivingsupportforhealthcarewaste
WHOSafeManagementofWastesfromHealthcareactivities
SecondeditionSeptember2012

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Public health and environment

SpecialRapporteuronhazardouswaste,
Theimproper
managementand
disposalofmedical
wastehasan
adverseimpacton
theenjoymentof
humanrightsin
manycountries.
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Public health and environment

ReferstotheStockholm
ConventiononPOPs
Sourcewiththepotential
forcomparativelyhigh
formationofdioxins&
furans:MedicalWaste
Incinerators
40,000timeshigherthan
emissionlimitssetforth.

Sept2011A/HRC/18/31

Despite major driving forces - HCWM


remains weak
Lack of existing policies developed and implemented at country level
Resources are mobilized but remains limited and not in phase with
the magnitude of the public health problem
Difficulty to find ways or platform to influence decision, e.g.: how
long needle removers will remain as a Yes or No decision while it is
introduced in some countries without safety guaranties
Mass campaigns are to be prepared long in advance to ensure that
the strategy on site will be able to safely handle huge amounts of
waste

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Public health and environment

Affordable technologies for waste treatment are


not developed in and for low income countries and
are mostly geared towards industrialized countries
Low cost technologies are often not
environmentally friendly and safe
In low income countries the trade-off is between
direct health risks / indirect health risks related to
poor strategy or environmental pollution

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Public health and environment

Supply Chain
Lookforsolutionstoreducewastetocontributetoimproving
someofthehealthcarewastemanagementproblemcountries
face
Ultimately,thewastemanagementproblemmustbeaddressedat
alllevels,fromupstreamtechnologydevelopmenttodownstream
wasteminimizationandmanagement,toensurethathealthcare
canbedeliveredwithoutsideeffectsonhealthcareworkers,
communities,ortheenvironment
Improvementsmadebycountriesbyadoptingpurchasepolicies
thatconsiderthewastestream
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Public health and environment

Healthwastemanagement
Some25%ofhealthwasteishazardousdevelopingcountriesaremost
atriskduetopoorwastemanagementpractices.

Energybenefitsofenergywastesystemsareclearbutmayinvolveahealth
penalty(e.g.emissionsofdioxins,pollutants)
Environmentalbenefitsofmechanical/thermaltreatment(e.g.
microwaving/autoclaving)arealsoclearenergyaspectsneedsmore
exploration.

OpenhealthwasteincinerationpitHaiti

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Public health and environment

Hydroclave:forhealthwastesteamsterilizationand
griding/volumereductionGuyana

Tools to support Water, Sanitation, Hygiene and health


care waste interventions in settings
WORLD HEALTH ORGANIZATION

Safe health-care
waste management

POLICY PAPER
1 - Unsafe health-care waste management leads to death and disability
Health-care activities lead to the production of waste that may lead to adverse health effects. Most of this waste
is not more dangerous than regular household waste. However, some types of health-care waste represent a
higher risk to health. These include infectious waste (15% to 25% of total health-care waste) among which are
sharps waste (1%), body part waste (1%), chemical or pharmaceutical waste (3%), and radioactive and
cytotoxic waste or broken thermometers (less than 1%).
Sharps waste, although produced in small quantities, is highly infectious. Poorly managed, they expose healthcare workers, waste handlers and the community to infections. Contaminated needles and syringes represent a
particular threat and may be scavenged from waste areas and dump sites and be reused. WHO has estimated
that, in 2000, 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);

260 000 HIV infections (5% of all new infections).


Epidemiological studies indicate that a person who experiences one needle-stick injury from a needle used on
an infected source patient has risks of 30%, 1.8%, and 0.3% respectively to become infected with HBV, HCV
and HIV. In 2002, the results of a WHO assessment conducted in 22 developing countries showed that the
proportion of health-care facilities that do not use proper waste disposal methods ranges from 18% to 64%.

2 - Health-care waste management may also represent a risk to health


Health-care waste management options may themselves lead to risks to health and no perfect readily
achievable solution to manage health-care waste exists. Health-care waste, whether generated at smaller rural
clinics or larger facilities, can be managed where adequate well-operated infrastructures exist. However, the
volumes of waste generated within large facilities and targeted public efforts (e.g., immunization campaigns) are
more challenging, particularly in developing countries where resources may be limited. In these difficult
situations for which waste disposal options are limited, small-scale incinerators have been used and are still
used as an interim solution in less developed and transitional countries. However, small-scale incinerators often
operate at temperatures below 800 degrees Celsius. This may lead to the production of dioxins, furans or other
toxic pollutants as emissions and/or in bottom/fly ash. Transport to centralised disposal facilities may also
produce hazards to health-care handlers, if not safely managed.

3 Balancing risks to make sound policy decisions in health-care waste management


In addition to risks to health from infectious agents, long-term low-level exposure of humans to dioxins and
furans may lead to impairment of the immune system, and impaired development of t he nervous system, the
endocrine system and the reproductive functions. Short-term high level exposure may result in skin lesions and
altered liver function.
The International Agency for Research on Cancer (IARC) classifies dioxins as a known human carcinogen.
However, most of the evidence documenting the toxicity of dioxins and furans is based upon studies of
populations that have been exposed to high concentrations of dioxins either occupationally or through industrial
accidents. There is little evidence to determine whether chronic low-level exposure to dioxins and furans causes
cancer in humans. Overall, it is not possible to estimate the global burden of diseases from exposure to dioxins
and furans because of large areas of uncertainty.
In the last 10 years, the enforcement of stricter emission standards for dioxins and furans by many countries
*
significantly reduced the release of these substances into the environment .
*

Standards: 0.1 ng TEQ/m (Toxicity Equivalence) in Europe to 0.1 ng to 5 ng TEQ/m in Japan according to
incinerator capacity.

RapidAssessment
Toole.Monitoring
Tool
Mercury in
Health Care
WORLD HEALTH ORGANIZATION

POLICY PAPER
1 - Background
Mercury is a naturally occurring heavy metal. At ambient temperature and pressure, mercury is a silvery-white
liquid that readily vaporizes and may stay in the atmosphere for up to a year. When released to the air, mercury
is transported and deposited globally. Mercury ultimately accumulates in lake bottom sediments, where it is
transformed into its more toxic organic form, methyl mercury, which accumulates in fish tissue.

WHOcoreprinciples

Mercury is highly toxic, especially when metabolized into methyl mercury. It may be fatal if inhaled and harmful if
absorbed through the skin. Around 80% of the inhaled mercury vapour is absorbed in the blood through the
lungs. It may cause harmful effects to the nervous, digestive, respiratory, immune systems and to the kidneys,
besides causing lung damage. Adverse health effects from mercury exposure can be: tremors, impaired vision
and hearing, paralysis, insomnia, emotional instability, developmental deficits during fetal development, and
attention deficit and developmental delays during childhood. Recent studies suggest that mercury may have no
threshold below which some adverse effects do not occur.

forachievingsafeand
sustainable
management
ofhealthcarewaste
35 | Public health and environment

http://www.healthcarewaste.org

2 - Contribution from the health-care sector and Regulation


Health-care facilities are one of the main sources of mercury release into the atmosphere because of emissions
from the incineration of medical waste. The Environment Minister of the Canadian province of Ontario declared
on December 2002 that emissions from incinerators were the fourth-largest source of mercury.
In the United States, according to US Environmental Protection Agency (EPA) in a 1997 report, medical waste
incinerators may have been responsible for as much as 10% of all mercury air releases.
Health-care facilities are also responsible for mercury pollution taking place in water bodies from the release of
untreated wastewater. According to a 1999 report, health-care facilities may also have been responsible for as
much as 5% of all mercury releases in wastewater. Environment Canada estimates that more than one-third of
the mercury load in sewage systems is due to dental practice.
Dental amalgam is the most commonly used dental filling material. It is a mixture of mercury and a metal alloy.
The normal composition is 45-55% mercury; approximately 30% silver and other metals such as copper, tin and
zinc. In 1991, the World Health Organization confirmed that mercury contained in dental amalgam is the
greatest source of mercury vapour in non-industrialized settings, exposing the concerned population to mercury
levels significantly exceeding those set for food and for air.
(Source:http://www.who.int/ipcs/publications/cicad/en/cicad50.pdf)
According to a report submitted to the OSPAR Commission, in the United Kingdom, annually 7.41 tonnes of
mercury from dental amalgam are discharged to the sewer, atmosphere or land, with another 11.5 tonnes sent
for recycling or disposed with the clinical waste stream. Together, mercury contained in dental amalgam and in
laboratory and medical devices, account for about 53% of the total mercury emissions.
Waste incineration and crematoria are also listed as major sources of mercury emissions. Many countries, such
as Armenia, Cameroon, Ghana, Honduras, Pakistan, and Peru, recognize the contributions from hospital
thermometers, dental amalgams, hospital waste and/or medical waste incinerators but lack quantitative data.
Despite the lack of data, there is good reason to believe that mercury releases from the health sector in general
are substantial.
Some countries have restricted the use of mercury thermometers or have banned them without prescription. A
variety of associations have adopted resolutions encouraging physicians and hospitals to reduce and eliminate
their use of mercury containing equipment.

3 Occupational health hazard


The most common potential mode of occupational exposure to mercury is via inhalation of metallic liquid
mercury vapours. If not cleaned up properly, spills of even small amounts of elemental mercury, such as from
breakage of thermometers, can contaminate indoor air above recommended limits and lead to serious health
consequences. Since mercury vapour is odourless and colourless, people can breathe mercury vapour and not
know it. For liquid metallic mercury, inhalation is the route of exposure that poses the greatest health risk.

"WaterandSanitationisoneoftheprimarydriversofpublic
health.IoftenrefertoitasHealth101,whichmeansthatoncewe
cansecureaccesstocleanwaterandtoadequatesanitationfacilities
forallpeople,irrespectiveofthedifferenceintheirlivingconditions,
ahugebattleagainstallkindsofdiseaseswillbewon."
DrLEEJongwook,DirectorGeneral,WorldHealthOrganization.

YvesCHARTIER
http://www.who.int/water_sanitation_health

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http://www.healthcarewaste.org
Public
health and environment

For More Information


WHO Health in the
Green Economy
www.who.int/hia/green
_economy
www.who.int/water_sanit
ation_health
http://www.healthcarewa
ste.org
Health care waste
www.gefmedwaste.org
Mercury-free health care
www.mercuryfreehealthc
are.org
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Public health and environment