emerging technologies on health care waste management
DESCRIPTION
Dr. Jorge Emmanuel, environmental scientist, and medical waste consultant for the United Nations Development Programme, presented emerging technologies on disposal of health care wastes. Presented at the Philippine Department of Environment and Natural Resources (DENR) forum celebrating the First Philippine Zero Waste Month last January 26, 2015 in Quezon City, Philippines.TRANSCRIPT
Medical Waste Technologies: Ecological Solid Waste Management Act Summit
RA 9003 Anniversary DENR, Quezon City, Philippines 26 January 2015 Jorge Emmanuel, PhD, PE, REP, CESCO
As APPLIED SCIENTISTS, we seek answers to questions about the natural world …
As ENGINEERS, we are trained to solve problems …
But are we really asking the right questions
But are we solving the
right problems ... or are we solving the problems the right way
Example: PM’s DAP-BL, RJR’s REST, BAT’s ROOT, and related technologies
Question: How to manipulate the addictive drug nicotine in cigarettes to enhance the impact on smokers?
Answer: Freebase nicotine
Results: An estimated 100 million deaths in the 20th
century; more than 5 million deaths a year today
Example: DDT, BHC and dieldrin treatment
Question (1950s): How to control malaria in Borneo? Answer: DDT, BHC and dieldrin indoor spraying Results: malaria-causing mosquitos dropped
35.6% 1.6% but …
chalcid wasps died roof caterpillars increased 50%
thatched roofs collapsed
village cats died population of rats rose
outbreak of bubonic plague
house geckos died
Persistent, bio-accumulative, toxic to marine animals & birds (eggshell thinning) Possible cancer and developmental effects on humans Mosquito resistance
Are the questions we seek to answer the right questions? ◦ How is development defined? ◦Who benefits?
Oath from the Order of the Engineer: As an Engineer, I pledge to practice integrity and … to uphold devotion to the standards and the dignity of my profession, conscious always that my skill carries with it the obligation to serve humanity by making the best use of Earth’s precious wealth … my skill and knowledge shall be given without reservation for the public good.
Are we solving problems the right way? ◦ Is the solution a technology or much more than
just a technology? ◦ Have stakeholders affected by the problem
participated in seeking a solution? ◦ Have people most affected by a potential solution
been consulted? ◦ Have the consequences of a potential solution
been examined from a life-cycle perspective? Have health, environmental, social and cultural impacts
been taken into account? ◦ What criteria are used to select the best option? ◦ How do we weigh risks versus benefits?
Precautionary Principle Embodied in international law (UN
Framework Convention on Climate Change, Stockholm Convention on Persistent Organic Pollutants, Rio Declaration, etc.)
Requires that precautionary measures
be taken when an activity threatens serious harm to human health and the environment, when the balance of scientific evidence suggests a relationship between the activity and harmful effects
“Dioxins”
Short term for polychlorinated dibenzo-p-dioxins and dibenzofurans
Family of 210 compounds Among the most toxic compounds known
to humans > The most toxic is
2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD)
Persistence of Dioxins in the Environment
◦ Environmental half-life on surface soil: 9 to 15 years ◦ Environmental half-life in subsurface soil:
25 to 100 years ◦ Volatilization half-life in a body of water:
more than 50 years
Health Effects Related to Dioxin
Classified as a known human carcinogen by IARC in 1997
Cancers linked to dioxins: ◦ Chronic lymphocytic leukemia (CLL) ◦ Soft-tissue sarcoma ◦Non-Hodgkin’s lymphoma ◦ Respiratory cancer (of lung and bronchus,
larynx, and trachea) ◦ Prostate cancer
Health Effects Related to Dioxin
Developmental Effects ◦ Birth defects ◦ Alteration in reproductive systems ◦ Impact on child’s learning ability and attention ◦ Changes in sex ratio (fewer male births)
Immune System Impacts ◦ Suppression of the immune system ◦ Increased susceptibility to disease
Male and Female Reproductive Effects
Medical Waste Incineration (MWI) is a major global source of Dioxins
◦ Europe: 62% of dioxin emissions due to 4 processes, including MWI ◦ Belgium: MWI accounts for 14% of dioxin emissions ◦ Denmark: MWI is 3rd or 4th largest dioxin source of 16 process
groups ◦ Thailand:
MWI - highest dioxin source by far of 7 sources tested Extremely high dioxin levels in MWI ash and wastewater
◦ United States: MWIs – third largest source of dioxins: 17% of total dioxins in 1995 Drop in dioxin emissions from MWI in part due to shift to non-
incineration methods: 2470 g TEQ/yr in 1987 to 477 g TEQ/yr in 1995
◦ Canada: MWI - largest dioxin source in Ontario province Drop in dioxin emissions from MWI due to closure of MWIs: 130 g
TEQ/yr in 1990 to 25 g TEQ/yr in 1999
Epidemiological Studies related to health effects of incineration
STUDY SUBJECTS
CONCLUSIONS REGARDING ADVERSE HEALTH EFFECTS
REFERENCE
Residents living within 10 km of an incinerator, refinery, and waste disposal site
Significant increase in laryngeal cancer in men living with closer proximity to the incinerator and other pollution sources
P. Michelozzi et al., Occup. Environ. Med., 55, 611-615 (1998)
532 males working at two incinerators from 1962-1992
Significantly higher gastric cancer mortality
E. Rapiti et al., Am. J. Ind. Medicine, 31, 659-661 (1997)
Residents living around an incinerator and other pollution sources
Significant increase in lung cancer related specifically to the incinerator
A. Biggeri et al. Environ. Health Perspect., 104, 750-754 (1996)
People living within 7.5 km of 72 incinerators
Risks of all cancers and specifically of stomach, colorectal, liver, and lung cancer increased with closer proximity to incinerators
P. Elliott et al., Br. J. Cancer, 73, 702-710 (1996)
STUDY SUBJECTS
CONCLUSIONS REGARDING ADVERSE HEALTH EFFECTS
REFERENCE
122 workers at an industrial incinerator
Higher levels of lead, cadmium, and toluene in the blood, and higher levels of tetrachlorophenols and arsenic in urine
R. Wrbitzky et al., Int. Arch. Occup. Environ. Health, 68, 13-21 (1995) 176 incinerator workers
employed for more than a year from 1920-1985
Excessive deaths from ischemic heart disease and lung cancer among workers employed for at least 1 year; significant increase in deaths from ischemic heart disease among workers employed for more than 30 years or followed up for more than 40 years
P. Gustavsson, Am. J. Ind. Medicine, 15, 129-137 (1989)
Mothers living close to incinerators and crematoria in Cumbria, England, from 1956 to 1993
Increased risk of lethal congenital anomaly, in particular, spina bifida and heart defects around incinerators, and increased risk of stillbirths and anacephalus around crematoria
T. Drummer, H. Dickinson and L. Parker, Journal of Epidemiological and Community Health, 57, 456-461 (2003)
Epidemiological Studies related to health effects of incineration
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Some Trends: Medical Waste Incineration (MWI)
Germany Portugal
Ireland
United States Canada
Non-Incineration Treatment Options Treatment technologies ◦ Autoclaves- various sizes ◦ Autoclaves with shredders ◦ Hybrid autoclaves ◦ Continuous steam treatment systems ◦ Batch microwave units ◦ Continuous microwave units ◦ Frictional heating units
Medical Waste Management is not a Technology but a System Waste Classification Waste Segregation Waste Minimization Containerization Color Coding Labeling, Signage Handling Transport Storage Treatment Final Disposal Contingency Plans Wastewater Treatment
Policies, Roles and Responsibilities
Written Procedures Plans & Roadmap Training ◦ Periodic, multi-level training ◦ Certification
Organization ◦ HCWM committee, HCWM
coordinator System of Monitoring,
Evaluation & Improvement ◦ Champions, Incentives
Allocating Human & Financial Resources
Kyrgyzstan Project (2005-2013) One of the poorest of the former Soviet
countries PROBLEM before the project: ◦ No national regulations on medical waste ◦ Little or no segregation of waste ◦ Some hospitals treated infectious waste with
hypochlorite ◦ Many needle-stick injuries and occupational
health issues ◦ Most waste was either dumped untreated
along with regular waste or burned in open pits
Approach National assessment (2004) Developed a model with stakeholder
participation – included reusable containers, waste minimization, and recycling (2005-2006)
Tested and refined the model at selected hospitals (2006)
Worked on national regulations Expanded model nationwide –training, local
organization, technology deployment, monitoring (2007-2013)
Medical Waste Management Model
Autoclave-based Technology
Results (as of end of 2013)
All hospitals in the country (> 25 beds), all primary health centers, and many private clinics use the model (67% of hospital beds)
Hospitals found an average 33% cost savings compared to previous system of hypochlorite treatment
Needle-stick injuries and cuts and occupational exposures were reduced
Hospitals generated revenue from sale of recycled plastic and metal
Advantages of re-designing healthcare waste management around a steam-based technology
The color-coded container can now be reusable Get rid of the single-use color-coded plastic bags and boxes.
Previously infectious materials can be recycled if they are properly segregated, sterilized and crushed/shredded.
Expand recycling and waste minimization to recyclable and compostable non-infectious non-hazardous materials.
Promote segregation to maximize the advantages of steam-based technologies.
Shift from a “waste management” framework to a “resource management” framework.
Ebola Waste Project (2014)
Problem: What to do with highly infectious waste at Ebola Treatment Centers?
Context in October 2014: 13,600 cases of Ebola of which 4900 had died, mostly in Liberia, Guinea, and Sierra Leone
Up to 90% case fatality rate No known cure
Initial Solution: Incineration ◦ Heavy black smoke and high levels of HCl ◦ Waste worker exposed to PM10 above
permissible exposure limits ◦ Ebola patients in wards some as near as 4
meters exposed to high levels of PM10, CO, HCl and other toxic pollutants ◦ Strong opposition by nearby communities ◦ No technical support provided
Initial Solution: Incineration Problems ◦ PPE has a seam coating that melts at 98°C ◦ PPE has flash ignition point of 343°C ◦ PPE material has a heat release capacity of about
1560 J/g-K self-sustaining combustion ◦ PPE has a heating value of 46.3 MJ/kg (same as gasoline)
Another Solution: Autoclaving Ebola is destroyed by autoclaving in seconds
Technology built by Africans for Africa No smoke, no dioxins nor HCl, no toxic air pollutants Safe for workers with PPE Special barrel trolley protects workers from Ebola exposure Uses mechanical controls instead of computer controls –
easier to fix Rides through power outages that are common in Africa Uses steam ejectors instead of vacuum pumps – less
maintenance problems, waste volume reduced by 40-60% Installs in one day Cheaper than an incinerator Exceeded international standards by an order of magnitude
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Place waste inside stainless steel barrel and close the lid
When barrel is full, take to autoclave
Slide barrel into autoclave Close sliding door
Start heating, multi-vacuum and sterilization cycles
When finished, open door and remove sterilized barrel
Unlock & rotate barrel to dump treated waste at the bottom
Barrel and trolley are ready to pick up more waste
www.medi-clave.co.za
Another Solution: Improve healthcare waste management nationwide
Incorporate healthcare waste management (HCWM) into the infection control and prevention (ICP) strategy and policy at all levels
Conduct national-level training programs on HCWM and ICP
Build capacity in each country including training of local experts on HCWM and autoclaving
At each hospital where autoclaves are installed: ◦ Develop HCWM plans and procedures at the facility level ◦ Create ICP committees and HCWM subcommittees ◦ Develop local training programs
Monitoring and evaluation plan
Questions to Ask ◦ Who benefits from the technology? Does the technology enhance public health and the
environment? Does the technology improve the physical, mental, social,
and cultural well-being of the people?
◦ Have stakeholders been consulted about or participated in finding a solution? ◦ Has the potential solution been examined from a
life-cycle perspective taking into consideration environmental health and socio-cultural impacts? ◦ Has the precautionary principle been applied?