ENVIRONMENTALLY

RESPONSIBLE HEALTH CARE

WASTE MANAGEMENT PRACTICES
Present Philippine Environmental
Situation

• Aerial view of Metro Manila with

tree less environment and constant
burning of wastes.
Effects to Environment
Most Hospital Waste Is
Simply “Trash

Hazardous
Reg. Med.
<5%
Waste
10-15% Waste

Includes 2%
pathological
waste

85%
Hospital Waste (Trash)

Hospital Waste(Trash) Regulated Medical Waste Hazardous Waste

Hospital Waste Like Household Trash
Is Largely Recyclable
45%
10%

10%
3%
15% 7%
10%

Food Waste Metals

Wood Glass
Other Plastics
Paper and Paperboard
 Categories of Wastes
 1.) General Waste is 85% of healthcare waste. It is
comparable to domestic waste, this type of waste does not
pose special handling problem or hazard to human health
or to the environment. It comes mostly from
administrative and housekeeping functions of healthcare
establishments and may also include waste generated
during maintenance of healthcare premises.
 
2.) Infectious, Hazardous and Regulated Wastes is only 15%
of total healthcare wastes that need special treatment and
management. This fifteen percent needs to be treated
before disposal.
2.1 Infectious wastes: They are generally categorized
as:
a) anything that the infectious patient used.
•   Cultures and stocks of infectious agents from
laboratory work;
• Waste from surgery and autopsies on patients with
infectious diseases (e.g. tissues, materials or
equipment that have been in contact with blood or
other body fluids);
• Waste from infected patients in isolation wards (e.g.
excreta, dressings from infected or surgical wounds,
clothes heavily soiled with human blood other body
fluids);
• Waste that has been in contact with infected patients undergoing
hemodialysis (e.g. dialysis equipment such as tubing and filters,
disposable towels, gowns, aprons, gloves and laboratory coats);
Infected animals from laboratories;
• Any other instruments or materials that have been in contact with
infected persons or animals.
 
b) Pathological Waste. 2% of total waste is pathological waste
consisting of tissues, organs, body parts, human fetus and animal
carcasses, blood and body fluids.
2.2 Hazardous and Regulated Wastes
a) Sharps- include needles, syringes, scalpels, saw, blades, broken glass,
infusion sets, knives, nails and any other items that can cause a cuts or
are
puncture wounds. Whether or not they are infected, such items
usually considered as highly hazardous
healthcare waste.
b) Pharmaceutical wastes. These include expired, unused, spilt, and
contaminated pharmaceutical products, drugs, vaccines, and sera that
are not longer required and needed to be disposed of appropriately.
This category also includes discarded items used in handling of
pharmaceuticals such as bottles or boxes with residues, gloves, and
masks, connecting tubing and drug vials.
c) Genotoxic Waste. Genotoxic waste may
include certain cytostatic drugs, vomit,
urine, or feces from patients treated with
cytostatic drugs, chemicals, and
radioactive materials. This type of waste
is highly hazardous and may have
mutagenic, teratogenic, or carcinogenic
properties.
d) Chemical Waste- Chemical waste
consists of discarded solid, liquid, and
gaseous chemicals. Chemical waste from
healthcare may be hazardous or non–
hazardous. Non-hazardous chemical
waste consists of chemicals with none of
the above properties, such as sugars,
amino acids, and certain organic and
inorganic salts.
e) Waste with High Content of Heavy Metals. Wastes with a high heavy metal
content represent a subcategory of hazardous chemical waste, and are
usually highly toxic. Mercury present in thermometers etc., Cadmium
wastes comes mainly from discarded batteries, Certain” enforced wood
panels” containing lead still is being used in radiation proofing of X-ray and
diagnostic departments.
f) Pressurized Containers. Many types of gas are
used in health care and are often stored in
pressurized cylinders, cartridges, and aerosol cans.
Many of these, once empty or of no further use
(although they may still contain residues), re
reusable, but certain types-notably aerosol cans-
must be disposed of. Whether inert or potentially
harmful; gases in pressurized containers should
always be handled with care; containers may
explode if incinerates or accidentally punctured.
g) Radioactive Waste. Includes disused sealed radiation sources, liquid
and gaseous materials contaminated with radioactivity, excreta of
patients who underwent radio nuclide diagnostic and therapeutic
applications, paper cups, straws, needles and syringes, test tubes, and
tap water washings of such paraphernalia.
 
Human Health Effects of Dioxin

Cancer Immune System

• Known human carcinogen • Change in immune system
parameters / modulation
Neonatal Abnormalities
• Change in sex ratio
• Altered level of thyroid Endocrine System Effects
hormone • Low levels of testosterone
Skin Disorders • Increase glucose intolerance or
• Porphyria cutanea tarda diabetes
• Chloracne • Decreased estrogen & estrogen-
receptor levels after fetal
Neurological Disorders exposure
• Peripheral (animal)
• Central
Toxins found in breast milk
http://www.metrowestdailynews.com/arts_lifestyle/health/breastmilk05212003.htm

By Michelle Hillman / News Staff Writer

Wednesday, May 21, 2003

BOSTON -- A master's degree in environmental sciences, a vegetarian diet and careful selection of
household cleaners weren't enough to ensure Amanda Elkin’s breast milk was free from toxins.

Elkin, 32, volunteered to have her breast milk tested at a laboratory in Germany to look for toxins
as part of a demonstration by the Alliance for a Healthy Tomorrow.

The Alliance is a coalition of scientists and health, environmental and labor groups. "Despite these
efforts all of my life, they still found all of these toxins in my body," said Elkin, a Natick
resident and mother.

Researchers found pesticides, dioxins or byproducts of trash incinerators, and brominated flame-
retardants used in curtains, hard plastics and other fabrics in Elkin's breast milk.

Elkin said she wants to know what effects these toxins will have on her child.
More Children Are Getting Cancer

Among Boys: Among Girls:

• Bone Cancer up 40% • Bone Cancer up 33%

• Brain Cancer up 24% • Brain Cancer up 19%

• Leukemia up 10% • Leukemia up 21%

• Total Cancer up 13% • Total Cancer up 10%

Comparison of cancer rates from 1975-1979 to the rates in 1987-1991

Source: Devesa, 1995

 MOST WIDELY KNOWN INCINERATOR
POLLUTANTS OF CONCERN

• DIOXINS • CHROMIUM

• PARTICULATE MATTER • LEAD

• ARSENIC
• MERCURY

• ACIDIC GASES

Source: National Research Council, 2000. Waste Incineration and Public

Health, Washington, DC: National Academy Press
Mercury

. Mercuryis found in many healthcare facilities.

Dental profession especially as amalgams.
 
Mercury
• Mercury can be found throughout many hospitals, In-
patient and laboratory : thermometers, blood pressure
devices (sphygmomanometers), dilation and feeding
tubes, batteries, and fluorescent lamps. Because of the
significant use of these items in many hospitals,
medical waste may account for 20% of the mercury in
the solid waste stream.
Mercury’s Effects to Humans

• Mercury is a potent neurotoxin, which means it

attacks the body’s central nervous system. Neurotoxin
risks to developing fetuses and young children are the
primary reasons for fish consumption advisories,
which aim to discourage pregnant women, women of
childbearing age, a young children from eating much
fish. Studies hone on Emory who are methyl mercury-
contaminated fish or grain showed that even then the
mothers showed few effects of exposure, their infants
demonstrated nervous system damage.
 
• Mercury not only attacks the node’s centric nervous
system but it can also harm the brain, kidneys, and
ungues. It can cross the blood-brain barrier as week as
the placenta. Methyl mercury from contaminated fish
readily crosses the placenta and enters the brain of
the developing fetus. The critical effects from prenatal
exposure to methyl mercury are mental retardation,
Seizures, Cerebral Palsy, Disturbance of vision, hearing
and sensation, Abnormal gait, abnormal speech,
Disturbances of swallowing and sucking and abnormal
reflexes.
Health Care Products Containing
Mercury and Their Alternatives
• Alternatives
• Product
• Hg batteries
• Esophageal devices, Cantor &
Miller-Abbott tubes
• Hg thermometers
• Hg-based blood pressure
• monitoring devices
• Lamps & lighting devices
• Hg switches
• Hg dental amalgams
• Lithium, zinc air, alkaline
• Products w/ tungsten tubing
Anderson AN-20
• Digital, expansion or aneroid
• Electronic vacuum gauge,
expansion or aneroid
• Non-Hg based-sodium vapor
glow lights, optical
• Non-Hg switches
• Gold, ceramic, porcelain
Framework
• Waste Minimization
• Waste Segregation
• Occupational Safety
and Health
• Environmental
Protection
 Nine Steps to Environmentally Responsible Health
Care
Step 1. Establish a GREEN TEAM. Convene task force of
administrators housekeepers, and others responsible
for waste handling. Authorize them to:
a. Identify the percentage and content of your
facility’s waste stream that is currently being treated
and recycled.
b. conduct a waste audit with either in-house staff or
an outside consultant to identify wasteful practices
and design a waste management strategy that
incorporate waste reduction, reuse and recycling
measures.
Step 2. Put someone in charge. Assign
or hire a staff for the fulltime
responsibility of developing and
implementing a new and more
environmentally thorough waste
management program.
Step 3. Train staff about the environmental consequences of medical
waste incineration and of not following DOH guidelines provided by the
health care waste management manual. Everyone in the facility/ system
should be made aware of the problems and costs of unnecessary red-
bagging and the availability of less expensive and more protective waste
disposal alternatives.
Step 4. Don’t throw out what you can recycle.
Implement or expand your recycling program.
Cardboard, glass, office paper, drink cans,
newspapers, magazines, have nationwide
markets. Implement a purchasing program
that favors products made of recycled paper
that has not been bleached with chlorine.
Communicate with suppliers about the need
for totally recyclable or reusable packaging
materials.
Step 5. Don’t throw out what you can
reuse. Create a plan to assess, on
an ongoing basis, the availability of
reusable products.
Step 6. Do not use any burn
technology/method of waste disposal. The
small percentage of infectious waste can be
made harmless and unidentifiable with the
use of environment friendly technology.
Step 7. Begin a program to eliminate the use
of mercury-containing products within the
institution.
Step 8. Create a plan to reduce the use of
chlorinated plastics, such as polyvinyl
chloride (PVC) which may be present in
ventilators, IV bags, oxygen therapy and etc.
Step 9. Assign materials management staff
to research and communicate with suppliers
concerning substitution of materials...
Key points to Medical Waste Management
• Medical waste management needs to address systems first and
foremost, then technology.
• Use of PVC (polyvinyl chloride) and mercury containing
material, and incineration are the main areas where health
care waste treatment effects the environment and these areas
need to be addressed in any health care management system.
• Sharps management is critical since 90% of infections
transmitted from medical waste are from port of entry created
through sharps.
• Segregation, procurement and cradle to cradle approach are all
very critical.
 Principles of Waste Minimization.
 
Train employees in
 Identify baseline waste hazardous waste handling
generation rates, current and site specific waste
hazardous waste minimization for it to be
successful and sustainable in
management strategies, the long run.
and current waste
management costs. goals, objectives, and
timeliness.
  minimization methods.
  Be aware of and keep updated
on the hazardous materials
regulations 
Waste Reduction/Minimization

• Procurement and Segregation: Waste minimization

strategies must begin with the initial process of
procurement of hospital supplies. Minimizing
packaging, and buying products that are durable
rather than disposable will lead to reduction of
disposal costs. Use more mercury and PVC free
materials to avoid severe pollution problems.
Recycling and Reuse

• Medical and other equipment used in healthcare establishment may

be reused provided that it is designed for the purpose and will
withstand the sterilization process. ( sharps-scalpels, glass bottles,
and containers, etc.)
• Keep recyclables out of landfill. ..
Segregation Scheme
 Practice proper segregation of wastes (see DOH HCWM page 18)
Require everyone in the institution to strictly follow color
coding segregation

Black: Non Infectious dry waste

• Green: non Infectious wet waste (kitchen dietary etc.)
• Yellow: Infectious and Pathological wastes (this should be
labeled properly for everyone’s guidance.
Yellow with Black Band: Chemical waste including those
w/heavy metals.
• Orange: Radioactive waste
• Red: Sharps and pressurized containers
 Indigenous Way of Managing Biodegradable
COMPOSTING
• Treated Body parts may be buried in a cemetery ground ( being done by some
hospitals)
• Used diapers, sanitary napkins, tissue papers, cotton from non infected patients may
be composted.
• 2 types of composting:
-Underground composting- Dig 4 sq.m. wide x 5m deep and drop all
diapers, cottons, tissues inside the hole and cover it with 1 foot thick soil.
- Aboveground composting – use drums or sacks. Lasagna style (soil+
biodegradable +soil)
composting diapers etc.( compost soil for ornamental plants only)
Food Wastes and plant trimmings can be composted using the above method.
Compost may be used for vegetable and fruit bearing plants provided no paper or
chlorinated materials were included when composting. They serve as soil enhancers.
Occupational Safety and Health

• All health workers should undergo proper training.

Immunization of workers should be done at the first day of
work.
• All health workers should be provided with personal
protective equipment (from head to toe)
• Establishment of an effective occupational health program
that includes immunization, post exposure prophylactic
treatment, and continuous medical surveillance
• Information Education and Communication activities.
• All workers should be provided with adequate protective
equipment.
“Add-on” safety feature

Attached to blood tube holder

 Autoclave Example

Autoclave With Safety Interlocks on the Door

Process:
Steam treatment
Shredding Range of capacities:
Compaction 200 - 750 lbs/hr

Source: Sierra Industries, Santa Ana, California, USA

 Advanced Autoclave: Vacuum / steam
treatment / shredding / compaction
Process:
Waste feed
Pre-vacuum
Steam at 140 C
Steam condensation
Shredding (optional)
High level compaction

Three-position articulating chambers (modular)

Range of capacities: 45 to 1,000 kg/hr
Over 500 units in a dozen countries

Source: San-I-Pak, Tracy, California

 Example: Large Microwave System
Process:
Waste automatically
fed into hopper and
sealed
Internal shredder
Steam added
Waste heated by six
microwave
generators up to 100
C while mixed in
rotating screw
Holding tank for
longer exposure time
Second shredder for
Range of capacities: 100 kg/cycle to 250 kg/hr sharps
75 units in 7 countries

Source: Sanitec, West Caldwell, New Jersey, USA

Example: Small Microwave

• Small-scale system
• Waste heated to 121 – 134 C
using microwave generators
for 30 minutes
• Optional post-treatment
shredder
• Range: 60 – 70 liters/cycle

Source: Sintion, Graz, Austria