Eleven Recommendations

These basic recommendations are meant simply as guidelines to stimulate better and more specific planning and action programs at the municipal government level and then at the level of individual health care facilities. They are based on observations made by Hollie Shaner, R.N. and Glenn McRae of CGH Environmental Strategies, Inc. of Burlington, Vermont, USA in their work in the U.S. since 1990, and their experiences in applying that work in other countries including India, Thailand, The Philippines, New Zealand, El Salvador, Costa Rica, Brazil and Caribbean Island nations.

Before any clear improvement can be made in health care waste management, consistent and scientifically based definitions must be established as to what is meant by "health care wastes" in all its components, and what the goals are for how they are managed. If the primary goal of "managing" waste from health care facilities is to prevent the accidental spread of disease, then it must first be acknowledged that there is only a small percentage of the waste stream that is contaminated in a manner that renders it capable of transmitting disease, and that the only documented transmission of disease from health care waste has been from contaminated sharps (syringes, etc.).

In the United States the waste stream from health care facilities is differentiated into at least four major categories:

It is the category of "Potentially Infectious Waste" that a health care waste management scheme usually first addresses. The American Hospital Association (Robert Fenwick, 5/91) indicates that this category of waste should not be any more than 15% of the total hospital waste stream, and a number of U.S. hospitals which have implemented good segregation programs have reduced this portion of their waste stream to less than 8%.

Based on observations at a number of health care facilities in non-US countries we believe that the average hospital waste stream may contain less than 10% of materials that could be considered "potentially infectious waste" if properly segregated. Depending on local conditions and definitions, this could vary between 10-25%.

We support the efforts of the governments and professional associations around the world to create clear definitions and standards in this area, and recommend the following resources as a base line in this effort:

Establishing a clear definition of the type of waste that is seen to be a problem will allow for the development of a sound solution. If we utilize the definition proposed and documented above then the volume of waste that is identified as a problem (potentially infectious) is only 10% of the wastes being generated at hospitals and health care facilities. The solutions to look for must address the 10% first, and not treat all waste generated at hospitals as the same.

The current waste management practice observed at many hospitals is that all wastes, potentially infectious, office, general, food, construction debris, and hazardous chemical materials are all mixed together as they are generated, collected, transported and finally disposed of. As a result of this failure to establish and follow segregation protocols and infrastructure, the waste leaving hospitals, as a whole is both potentially infectious and potentially hazardous (chemical). At greatest risk are the workers who handle the wastes (hospital workers, municipal workers and rag pickers). The risk to the general public is secondary and occurs in three ways:

No matter what final strategy for treatment and disposal of wastes is selected, it is critical that wastes are segregated (preferably at the point of generation) prior to treatment and disposal. This most important step must be taken to safeguard the occupational health of health care workers. Hospitals are currently burning wastes or dumping wastes in municipal bins which are transported to unsecured dumps. The wastes contain mercury and other heavy metals, chemical solvents and preservatives (e.g., formaldehyde) which are know carcinogens, and plastics (e.g., PVC) which when combusted produce dioxins and other pollutants which pose serious human health risks not only to workers but to the general public through food supplies.

Imposing segregation practices within hospitals to separate biological and chemical hazardous wastes (less than 10% of the waste stream) will result in a clean solid waste stream (90%) which can be easily, safely and cost-effectively managed through recycling, composting and landfilling the residues. This resulting waste stream has a high proportion of organic wastes (food) and recyclable wastes (paper, plastic, metal) and actually very little that is truly disposable, especially given the high percentage of reprocessing and reuse of materials which exists in many non-US health care systems. We have observed excellent examples of hospitals in India, Costa Rica and Thailand which have already set up segregation programs providing local examples of what is possible. If proper segregation is achieved through training, clear standards, and tough enforcement, then resources can be turned to the management of the small portion of the waste stream needing special treatment. This is not to minimize the need for resources to be allocated to assisting with segregation. Training, proper containers, signs, and protective gear for workers are all necessary components of this process to assure that segregation takes place and is maintained.

Of the 10 percent or less portion of the waste stream that is potentially infectious or hazardous, the most immediate threat to human health (patients, workers, public) is the indiscriminate disposal of sharps (needles, syringes, lancets, and other invasive tools). Proper segregation of these materials in rigid, puncture proof containers which are then monitored for safe treatment and disposal is the highest priority for any health care institution. If proper sharps management were instituted in all health care facilities most of the risk of disease transmission from health care waste would be solved. This would include proper equipment and containers distributed everywhere that sharps are generated (needle cutters and needle boxes), a secure accounting and collection system for transporting the contaminated sharps for treatment and final disposal, and proper training of all hospital personnel on handling and management of sharps and personal protection.

Hospitals in the Third World generate significantly less volumes of waste than U.S. hospitals. In part this is a result of a decision to maintain a system that relies on reprocessing and reuse of materials. Establishing clear guidelines for product purchasing that emphasized waste reduction will keep waste management problems in focus. New emphasis needs to be put on waste reduction of hazardous materials. For example, hospital waste management would benefit from a policy of a phase out of mercury-based products and technologies. Digital and electronic technology is available to replace mercury-based diagnostic tools. This is a purchasing and investment decision. Since there is no capacity in most countries to safely manage mercury wastes, this reduction policy will make a serious contribution to cleaning up the hospital waste stream. This is one example of reduction strategies which could be identified and implemented in all countries. Practicing pollution prevention is the most cost effective way of securing public health.

(5) ENSURE WORKER SAFETY THROUGH EDUCATION, TRAINING AND PROPER PERSONAL PROTECTIVE EQUIPMENT

Workers who handle hospital wastes are at greatest risk from exposure to the potentially infectious wastes and chemical hazardous wastes. This process starts with the clinical workers who generate the wastes without proper knowledge of the exposure risks or access to necessary protective gear, and includes the workers who collect and transport the wastes through the hospital, the staff who operates a hospital incinerator or who take the waste to municipal bins, the municipal workers who collect wastes at the municipal bins and transport it to city dumping sites, and the rag pickers, who represent the informal waste management sector, but play an important role in reducing the amount of waste destined for ultimate disposal. Whether rag pickers are considered as part of the formal system or not, they are integrally involved in waste management and their unique role and personal safety and health needs must be considered.

Proper education and training must be offered to all workers from doctors to ward boys, to laborers and rag pickers to ensure an understanding of the risks that wastes pose, how to protect themselves, and how to manage wastes (especially how to properly segregate). Education and training programs must be developed which speak to each population in a way that will best meet the needs and build understanding and change behavior in that population. There is no "one" way to educate all workers.

If the benefits of segregation are to be realized then there must be secure internal and external collection and transportation systems for waste. If waste is segregated at the point of generation only to be mixed together by laborers as they collect it, or if a hospital has segregated its waste and secured it in separate containers for ultimate disposal only to have municipal workers mix it together upon a single collection, then the ultimate value is lost. While worker safety may have been enhanced, the ultimate cost to the environment and the general public is still the same.

In addition the very real concern of hospital administrators and municipal officials to prevent the reuse of medical devices, containers and equipment after disposal should be taken into account in any management scheme. One has only to walk by street vendors selling used latex gloves, or using cidex (a disinfectant regulated as a pesticide in the US) containers to hold water for making tea, to understand the risk that unsecured waste disposal systems have. In addition, the practice of cleaning and reselling, syringes, needles, medicine vials and bottles, is not well documented but appears to have enough informal evidence to indicate that it is a serious concern. Items that could potentially be reused illegitimately must be either rendered unusable after their use (cutting needles, puncturing IV bags, etc.) or secured for legitimate recycling by a vendor or system that can be monitored for compliance.

To ensure continuity and clarity in these management practices, health care institutions should develop clear plans and policies for the proper management and disposal of wastes. They need to be integrated into routine employee training, continuing education, and hospital management evaluation processes for systems and personnel. In the U.S. the Joint Commission for the Accreditation of Health Care Organizations has been developing a set of standards on the "Environment of Care" which includes plans and policies for the proper management of hazardous materials and workers¹ safety, without which a hospital cannot be accredited. The USEPA¹s new MACT rule now requires that hospitals develop waste management plans, a requirement that many states have had on the books for several years. Municipal governments or state governments could require waste management plans from all hospitals as a condition for operating.

The science of the reprocessing of equipment and materials for reuse in health care facilities is well established in many countries outside of the U.S.A. and Europe, and should be supported. Professional health care associations should be urged to firmly support judicious reuse of materials, and should begin to set standards for reprocessing. Maintenance of this effort within hospitals will provide quality products and thwart efforts to increase reliance on disposables. Disposables are costly, increase waste generation, and do not necessarily provide for decreases in infection rates in hospitals. A reprocessing industry must however be supported with investment in proper equipment and training so that it is carried on in a safe and efficient manner.

(9) INVEST IN ENVIRONMENTALLY SOUND & COST EFFECTIVE HEALTH CARE WASTE TREATMENT AND DISPOSAL TECHNOLOGIES

The rush to incinerate health care waste in countries around the world as an ultimate solution to a problem without definition is doing a great injustice to the community, the public health of its people, and the environment. Of the eleven recommendations that we are making, it is no accident in giving attention to treatment technologies as ninth. Without proper attention being paid to one through eight on this list, whatever decisions being made for treatment and disposal will be insufficient, if not counter productive. The mass incineration of health care waste, given current practices of waste disposal will not reduce risk to workers (this is where the greatest risk of disease transmission or chemical exposure exists). It will actually create a greater threat to the general public as mercury and other heavy metals are spewed out into the general air of cities whose air quality is already compromised, or when dioxins and furans are created from the combustion of plastics such as PVC which is growing in use in medical packaging. Additionally the ash generated from incineration of health care waste is also tainted with heavy metals and other toxic residues. Lesser risks are associated with the treatment of unsegregated wastes through other treatment technologies such as autoclaving, hydroclaving, microwaving and chemical disinfection, which affect workers more than the general public, and contaminate water sources rather than air if improperly operated.

Choices of treatment technologies should be made in line with a clear knowledge of the waste stream to be managed and the goal to be achieved through treatment. If the technology is to be environmentally sound, the waste stream should be able to be treated (disinfected) without creating other hazardous by-products. Incineration may be an "overkill" technology. Its goal is sterilization, not disinfection. One has to ask the question as to whether sterilization is necessary, or if the goal is simply disinfection. Is achieving sterilization worth the cost of transferring the risk from a potentially "infectious" material to a clearly hazardous chemical one?

If the overall goal of waste management is to prevent disease transmission from waste products, then the emphasis should be placed on the "management" aspect of the process and not on the "technological fix" which time and again has proven to be an expensive diversion rather than an effective solution. Technology should fit the situation and work in the management system to achieve the final goal as part of the overall system, not as a replacement for the system. Technology choices will be made to meet local needs and conditions and cannot be uniformly applied throughout a state or country. National standards for operating acceptable treatment technologies should be set, and there is no reason for any country to have standards any less stringent than those being modeled in the U.S. or Europe.

(10) DEVELOP AN INFRASTRUCTURE FOR THE SAFE DISPOSAL AND RECYCLING FOR HAZARDOUS MATERIALS

There was little or no observable capacity for the management, treatment, recycling or final disposal of hazardous wastes in most countries (e.g. chemicals, mercury, batteries). Hospitals seeking to segregate hazardous wastes are left with little or no option for safe disposal. The development of an industry which is capable of managing hazardous waste (chemicals) is essential. On-site reprocessing technology is available for hospitals for materials such as xylene or formalin, and recovery technology for silver from developing solution. These technologies may be cost prohibitive at this time. Pollution prevention and the choice of nonhazardous or less hazardous material is the only real option left to hospitals, which should be followed regardless of the existence of a hazardous waste industry.

As a result of a lack of waste segregation practices in most hospitals, many of these hazardous materials are flushed down a waste water drain that flows directly to an open sewer or river, are mixed into general solid waste for disposal in municipal bins or are mixed into wastes which are incinerated as potentially infectious waste. In either case they represent a serious health hazard to workers and the public. At this time even if they were segregated the lack of real alternatives to properly dispose of them would mean that they would be stockpiled, potentially creating yet another threat. (NOTE: See attached appendix for an overview of hazardous wastes generated in a health care facility waste stream).

Improper disposal of all wastes, municipal solid waste, hazardous wastes, industrial wastes, human wastes, etc. poses a major health hazard. The development of sanitary landfills, sewage treatment plants and other waste management facilities providing for the ultimate safe disposal of those wastes which cannot be otherwise recycled, composted or reused is necessary to securing public health in the country. Studies of the municipal waste stream in many countries such as Haiti or India conclude that approximately 50% of the wastes generated are organic and could be composted. Another large segment includes easily recyclable materials, leaving a relatively small portion requiring actual disposal. Just as in the discussion of health care waste management, proper segregation and pollution prevention, combined with a clear definition of the problem and the goal will provide the best, most environmentally safe and cost-effective solution to waste disposal. Also again, proposals for large mass burn incinerators for the general mixed waste stream, not only do not address the real problem but are burdened with numerous "side effects" which render their real value as a negative.

Health care facilities need to be able to tie into a municipal system of proper waste management to ensure that they are meeting their mission of providing for the public health. Until such an infrastructure exists there are numerous decisions and actions that any hospital can make (listed above) to begin the process of improving their waste management practices and ensuring public health and worker safety today.

Specific waste streams that any hospital or health care facility must examine in its assessment and planning process include:

Hazardous Material	Point of Generation	Point of Use/Disposal	Common Disposal
Chemotherapy and antineoplastic chemicals	Prepared in central clinic or pharmacy	Patient Care areas Pharmacy Special Clinics	Incineration as RMW Disposal as HW
Formaldehyde	Pathology Autopsy Dialysis Nursing Units	Pathology Autopsy Dialysis Nursing Units	Diluted and flushed down sanitary sewer
Photographic Chemicals	Radiology Satellite Clinics offering radiology services	Radiology Clinics offering radiology services	Developer and Fixer is often flushed down sanitary sewer X-ray film is disposed of as solid waste
Solvents	Pathology Histology Engineering Laboratories	Pathology Histology Engineering Laboratories	Evaporation Discharged to Sanitary sewer
Mercury	Throughout all clinical areas in thermometers, blood pressure cuffs, cantor tubes, etc. Labs	Clinical areas Labs	Broken thermometers are often disposed in sharps containers or in general waste Often incinerated
Anesthetic Gases	Operating Theater	Operating Theater	Waste gases are often direct vented by vacuum lines to the outside
Ethylene Oxide	Central Sterile Re-processing Respiratory Therapy	Central Sterile Re-processing Respiratory Therapy	Vent exhaust gas to the outside
Radio nuclides	Radiation Oncology	Radiation Oncology	Storage in secure area - disposal by national atomic energy com.
Disinfecting Cleaning Solutions	Hospital-wide Environmental Services, Facilities Management, Operating Theater	Diagnostic Areas Operating Theater Facilities Management	Dilution, disposal in sewer
Maintenance: Waste Oil, Cleaning solvents, Leftover Paints, Spent flourescent lamps, Degreasers, Paint Thinner, Gasoline	Maintenance / Engineering	Maintenance / Engineering	Solid Waste Sewer

These are some key resources for understanding and addressing the management of health care wastes in nations with fewer resources and less infrastructure than might be found in the United States or Europe. CGH staff contributed to some of these publications, but does not formally endorse any of them. The management of wastes in other nations requires a careful analysis of the existing infrastructure, an assessment of resources (including knowledge resources) available, and the commitment and cooperation of private, public and NGO sectors to provide management systems which protect public and worker health and install environmentally sound approaches.

Safe management of wastes from health care activities. Edited by A. Prüüss, E. Giroult, P. Rushbrook. Geneva, World Health Organization, August 1999. 228 p.

This comprehensive handbook recommends safe, efficient and sustainable methods for the handling, treatment and disposal of wastes from health care activities. It addresses not only a variety of technical options that have been applied in this field, but also organizational and policy issues that should be considered to achieve levels of health care waste management that ensure the protection of public health. Although it particularly emphasizes the needs of developing countries and proposes approaches for gradual improvement, it provides a catalogue of options for diverse degrees of sophistication in health care waste management. It is targeted at an audience of public health professionals, regulators and hospital managers and administrators.

Teacher's guide : management of wastes from health care activities. By A. Prüüss and W.K. Townsend. Geneva, World Health Organization, 1998. 227 p.

The teacher's guide accompanies the forthcoming WHO publication on management of wastes from health care activities. It provides teaching materials (ready-to-copy texts for overhead transparencies, lecture notes, handouts, exercises and course evaluation forms) and recommendations for a three-day training course. It is designed mainly for managers of health care establishments, public health professionals and policy makers. A selection of photographs to support training in health care waste management is available on line.

Guidelines for safe disposal of unwanted pharmaceuticals in and after emergencies. Geneva, World Health Organization, April 1999. WHO/EDM/PAR/99.2

Practical guidance is provided on the disposal of drugs in difficult situations in or after emergencies, in relation to armed conflicts, natural disasters or others. In such situations, it may happen that large quantities of unwanted drugs accumulate due to difficulties, mismanagement of stocks and inappropriate donations. The guidance provided consists in relatively simple and low-cost measures and is addressed to local authorities, health care personnel or other professionals confronted to this type of problem.

Guidebook for Hospital Waste Reduction Planning and Program Implementation. By Glenn McRae and Hollie Shaner. Chicago, American Hospital Association, 1996.

A comprehensive guide to management of hospital waste streams minimizing environmental impact and increasing worker safety. Focus on U.S. hospitals but information can be easily adapted to other situations.

Hospital Waste Management in Four Major Cities. By M.B. Pescod and C.B. Saw. The Netherlands, Urban Waste Expertise Programme, 1998.

Concise overview of different approaches to managing health care wastes in four different cities with guidance for improving situations.

"Infectious Waste Mismatch between Science and Policy," in The New England Journal of Medicine, Vol 325, No.8, 578-581. 1991. By William Rutala and David Weber.

An overview of the scientific understanding of infectious or biohazardous waste, the risks it presents to the public, and how policy solutions for its management often do not solve the problems or in fact can increase the risk.

Managing Hospital Waste: A guide for health care facilities. By Megha Kela, Samir Nazareth and Ravi Agarwal. New Delhi, Shristi, 1998.

An excellent example of a very down-to-earth guide written for local use in a collaborative between an NGO and health care professionals.

Manual Para Personal Medico y de Enfermeria & Manual para Tecnicos e Inspectores de Saneamiento Gestion Y Manejo de Desechos Solidos Hospitalarios. Programa Regional de Desechos Solidos Hospitalarios, Convenio ALA 91/33, entre la Union Europea y los Gobiernos Centroamericanos. 1998

These manuals were developed through a European Union project in Central America to increase safety in the management of health care wastes. The Costa Rican Ministry of Health is currently distributing copies of the manuals and other educational materials as part of their effort to control risks in the management of health care wastes. The manuals are also available on CD Rom.

Solid Waste Landfills in Middle- and Lower- Income Countries: A Technical Guide to Planning, Design and Operation. By Philip Rushbrook and Michael Pugh. Washington, D.C., The World Bank, 1999.

While not specifically dealing with health care wastes (though there are references to it under "difficult wastes") this volume provides an excellent and understandable introduction to landfill design and management. While the first choice for disposal of hazardous or biohazardous health care wastes should not be directly to landfills, in some cases there is no other option. In addition, whatever treatment technology is chosen to manage biohazardous health care wastes, the residuals from that process will end up in a landfill. An understanding of how final disposition of wastes can be handled is essential to developing a full plan for management of health care wastes.

Solid Waste Management in Latin America: The Role of Micro- and Small Enterprises and Cooperatives. By Jorge Arroyo Moreno, Francisco Rivas Rios, and Inge Lardinois. The Netherlands, WASTE Urban Waste Series 5, 1997.

An important review of the role of scavengers and ragpickers in solid waste management, and options for building safer waste management systems which do not marginalize these workers or negate their livelihood.