Non-Burn Technologies

Non-Burn and Alternative Treatment Technologies for Health Care Waste in Lower Income Countries

Treatment options: Making choices

Prior to beginning any decision making process about waste treatment, it is vital to understand the status of waste management and ensure that all feasible efforts to optimize waste segregation have been undertaken. Waste treatment is a costly venture, and minimizing the volume of wastes requiring special treatment will provide years of cost savings and benefit the project. No one treatment technology is sufficient to address all the problems or needs. Rather than looking for one "solution" a health care project needs to plan from the start to look to an array of technologies and approaches to manage the multiple waste streams of health care. Improper use of a treatment technology can actually produce a result in terms of environmental or public health harm that is worse than the condition is was employed to correct.

This is a basic approach in medicine. Multiple pathways are proposed for treatment of disease - treat the whole person, not just the diseased part.

If the questioning begins with: "What technology will be select to treat and dispose of medical waste?," then the series of important questions which need to be asked first to make a logical, safe and cost effective decision become irrelevant. The foundational questions and processes for assessing health care wastes, and understanding how it is or is not integrated into the municipal waste stream has been addressed in other appendices. Once the decision comes down to choosing treatment technologies, it should be based on a sound understanding of what, and how much needs to be treated.

There is a great deal of information on technologies now available. In terms of treatment technologies for biomedical wastes we know more than we ever did about incineration as a technique for treating (it is often erroneously listed as a disposal technology) medical waste and this new knowledge has raised many questions about the viability of this technology for this purpose. In The Philippines it lead to a total ban on the use of incineration for any waste treatment. In the U.S. it has meant a steady decline in the number of incinerators in use, and a significant rise in the use of non-burn technologies. In a 1997 survey of the U.S. industry, the Environmental Industries Association identified more than

1500 non-burn technologies installed to treat medical waste in the US
400 non-burn technologies supplied by the same companies for use overseas

These non-burn technologies include steam sterilization, micro and macro-wave heat technologies, and chemical disinfection. More than 45 different treatment technologies for disinfecting or sterilizing potentially infectious wastes have been permitted in the United States. A lesser number has been utilized overseas. In 1998 a brief survey of what technologies were in use in lower-income countries was conducted.

NOTE: Though specific companies and technologies are cited in the following examples, CGH does not endorse any specific technology. It is up to local regulatory agencies to review data on technology performance and for individual institutions or central facilities to review cost (capital and operational), performance and maintenance records of any preferred technology.

India

From recent work in India three installations using two examples of non-burn technologies were identified:

Sanjay Gandhi MangolPuri, New Delhi

System: Dedicated Waste Autoclave (Tuttnatuer 66190EP - Israel)

Installed: September 1997

Provisioner: Omron Medical, New Delhi

Escorts Heart Hospital, New Delhi

System: Dedicated Waste Autoclave and Shredder, 360 Kg./hr. (Tuttnatuer 5590EP - Israel)

Installed: April 1999

Provisioner: Omron Medical, New Delhi

Tata Memorial Hospital, Mumbai

System: Hydroclave (advanced autoclave using indirect steam sterilization technology and a rotary flow), (Hydroclave H-25 - Canada)

Installation: June 1999

Provisioner: Consolidated Waste Management India (P) Ltd., Mumbai

For direct information: cwmwaste@bom7.vsnl.net.in

NOTE: Tata Consultancy services, Pune, have also recommended the Hydroclave for some 203 hospitals to treat their waste in West Bengal. TCS is working under contract to the "Health and Family Welfare Department (HFWD) Govt. of West Bengal".

Web Page: http://www.hydroclave.com.

RESOURCE: In India, Dr. Rohini Kelkar, M.D., the head of microbiology and infection control at Tata Memorial Hospital ( a premier cancer research hospital) in Mumbai, has been involved in investigating non-burn alternatives. She was responsible for shutting down her hospitals incinerator because of public health concerns, instituting a rigid segregation program at the facility, evaluating using a regional incinerator (rejected) and then selecting a new technology for on-site treatment of wastes. She is an active member of the Hospital Infection Society of India, and has been a featured speaker at a number of national and regional conferences on approaches to medical waste management. Tata Memorial Hospital, Dr. Ernest Borges Rd., Parel, Bombay 400012 (ph. 414 6750)

Examples of specific companies:

I. San-I-Pak, a U.S. based manufacturer of autoclave systems with more than 500 installations in the United States, has also reported installations in Chile, Columbia, and Taiwan with a longer operating history than the systems in India. The systems they have installed in Chile, Columbia, and Taiwan are all used to treat medical waste. Additional information on their technology can be found at www.sanipak.com

Chile

Customer: Procesan SA in Santiago

Contact: Francisco Izquierdo

Installed: August 1996

Capacity: 100 pounds/hour

Colombia

Customer: Chagnon International Ltee in Cali

Contact: Daniel Chagnon

Installed: May 1993

Capacity: 100 pounds/hour

II. Sanitec is a private U.S. based firm manufacturing and operating medical waste treatment technologies world-wide. Theirs is a patented microwave technology which processes the waste in stages after maceration. They have operated their own plant with this technology since 1990 in New Jersey. Installations:

Brazil

Facility: Ambiental Technologia

Tratmento de Residuos E.

Sevicos Ltda of Brazil Sao Bernardo

Contact: Roberto Faccini (ph: 551155066688)

Unit: (2) HG-A-250

Capacity: 550-900 lbs per hour

Installed: June 1997, Dec. 1997

Saudi Arabia

Facility: SEPCO

Hail Street, ANUQBA/CTRE

North Tower, 5th Fl., Off. #8

Jeddah, KSA 21533

Contact: Mr. Abdul Lateef, Engineer (p: 966 26513013)

Unit: (1) HG-A-250

Capacity: 550-900 pounds per hour

Installed: August 1998

Korea

Facility: Korea Environmental Development Co., Ltd.

5-626 Sunggok-Dong, Ansan-Si

Kyungki-Do

Contact: Yeong-Oh, Choi, President (p: 82 345 498 6644)

Unit: (1) HG-A-250

Capacity: 550-900 pounds per hour

Installed: February 1997

Several Units have been installed in Japan and England and one slated to be installed in Panama in 1999.

More information on their technology and installations can be found at: www.sanitec-inc.com

Other non-burn technologies:

While there are reports of other non-burn technologies in use, specifics on these installations were not available. The two other non-burn methods in place and in common usage, not requiring technology include, deep burial (secure burial in a designated site that is protected from disturbance) and chemical disinfection (spreading of a disinfectant - e.g. chlorine by hand on wastes, or soaking of waste material in a hypochlorite solution prior to disposal by burial.) The WHO Guide on Safe Management of Health Care Wastes provide specifications for some of these as well as more detailed information on the full range of technologies.

Understand the waste first, then pick treatment and disposal technologies

The technologies that are widely available and are starting to be put in place in health care setting in the "developing world" are what one would define as soft technologies. Similar to what we learned in the 1970's in energy management, it made more sense to invest in training, behavior change, and low-cost infrastructure to save energy, rather than to just continue building new power plants. We needed to learn to manage energy just as we now need to manage wastes. Some of these soft technology approaches which have been successfully implemented in a number of hospitals with outcomes such as increased worker safety, a vast reduction in the volume of waste needing special treatment, a lessening of public health risks, and lower costs for waste disposal.

Segregation. This involves an investment in training, signage and containers and results in waste being sorted into appropriate secure containers which determine treatment and disposal. When properly instituted, a hospital can safely dispose of up to 90% of its waste as municipal solid waste. In particular, if safe and effective segregation of sharps occurs most of the hazards inherent in potentially infectious wastes generated in health care can be managed.
Reduction. This involves an analysis of what materials are purchased for use at a facility and identifying what packaging or specific items can be eliminated. In other cases it involves a careful analysis of disposable products which could be replaced by reusable ones.
Substitution. Particularly hazardous materials, needing special management and creating a specific risk to workers and the community can be substituted by less hazardous materials (e.g. mercury based diagnostic technologies, with non-mercury technologies).
Personal Protective. Most workers in hospitals in "developing countries" do not Gear and Immunizations a clear understanding of the principles of disease transmission or the basic steps they can take to protect themselves. To protect workers, health care facilities need to invest in training and education for workers, the purchase of personal protective gear and clothing for clinical and non-clinical staff who are likely to come into contact with potentially infectious or hazardous materials, and to make sure workers receive at least basic immunizations against tetanus or hepatitis.
Secure Collection. Once waste has been generated and collected it needs to get and Transportation from that point of generation to treatment and final disposal. To do this requires an investment in secure and easily moveable transport containers, protective gear and training for workers, and larger storage containers. The key is keeping the wastes secure and isolated from point of generation to point of disposal so that contact with workers and the public is minimized.

Treatment Technologies in "Middle and Lower Income Countries"

The five "soft" technology approaches listed above are in place at a variety of institutions of varying sizes in lower income countries. No matter what "hard" treatment technology choice is selected, without attention to these five areas, risk to workers and the public is still substantial.

For the past 100 years a simple technology for sterilizing instruments and materials to be used in patient treatment, and for disinfecting lab instruments and wastes after use, has been familiar to health care professionals. That technology is the autoclave, a devise which uses steam and pressure to disinfect materials. It is a simple straight-forward technology, and many hospitals in the lower and middle income countries have experience in operations and maintenance in their laboratory or central sterile supply departments. This experience, combined with the ease of operation and maintenance, low cost, and modular nature makes it a good choice for waste treatment. Recommendations for using autoclaving for treatment of wastes however must include separate technologies for that purpose, and not combined usage with the autoclave responsible for sterilizing instruments.

RESOURCES

The 1992 study sponsored by Minnesota Healthcare Partners (St. Paul, MN, USA 612-641-0719) Study of Non-Burn Technologies for the Treatment of Infectious and Pathological Waste still provides an excellent overview of the various treatment technologies.

The Washington, DC based Medical Waste Institute, in an industry sponsored association which provides current information on issues and options in the medical waste industry. 4301 Connecticut Avenue, Suite #300, NW; Washington DC 20008 ph. 202-244-4700

Treatment of chemical wastes

While the focus has been on the treatment of wastes that represent a biological hazard, treatment technologies in health care facilities are also required for addressing chemical waste issues. An array of chemical materials which pose significant threats have been identified in other sections. For chemicals that can be "treated on-site" there are a variety of approaches and technologies that can be utilized. In the discussion of Mercury the most basic approach was suggested - that of eliminating use of the material all together to avoid having to address the waste issue. For other materials that may prove more difficult. Therefore the approaches that remain include dilution, neutralization or recycling. Incineration of chemical wastes, while conducted in Europe, The United States and Japan, is done only in certified hazardous waste incinerators. The use of other incinerators (and there are many concerns about hazardous waste incinerators) will create a greater problem than doing nothing.

Each chemical used in the health care facility should have a treatment and disposal plan. This might require an array of approaches or technologies. Many chemical wastes end up in the sewer or water discharge of the health care facility. As a result significant waster pollution can result. Some examples of approaches to chemical waste treatment include:

Glutaraldehye is a cold sterilant commonly used to sterilize surgical instruments. It is actually a strong pesticide which can contaminate water supplies or significantly disrupt the working of a sewage treatment plant. The manufacturer supplies a neutralizing agent which will render it safe to dispose of to the sewer.
Xylene is a solvent used extensively in labs and commonly is disposed of to the sewer or burned in incinerators. In both cases it represents a significant health hazard. In common use now are xylene stills which recycle the xylene safely, and provide a form more pure that most that is purchased new. Hospitals and labs using xylene stills have found that they seldom need to purchase new xylene, and that their test results are not compromised. Xylene is recycled on-site and no longer is considered a waste. Formalin, a preservative and disinfectant is also in wide use.
Formalin exposure can cause a number of serious health problems. As with xylene, formalin can be recovered, filtered and reused over and over again. In the case of both of these substances the investment in recycling technology is quickly paid back by the lowered cost of purchasing new materials. If there are fees associated with hazardous waste disposal the pay back is even faster.
Silver is a by-product of photo finishing, and a significant pollutant to waste water coming out of radiology where x-rays are developed. Simple devices are now available to reclaim that silver from the waste water before it enters the sewer. The recovered silver has enough value to repay the investment.

A more detailed list of chemicals and possible pollution prevention options is detailed in the USEPA publication on Pollution Prevention for Selected Hospital Waste Streams

Contingency planning for waste management in times of emergency or system break-down.

All technologies and all management systems are subject to breakdown. Each facility should have a plan for emergency or temporary management of all wastes in the event that the primary treatment or disposal option is no long available. Technologies go down for repair, or parts wear out and new ones must be ordered. Many areas of the world are also subject to natural disasters or adverse conditions which create breakdowns in fuel supplies (electricity or fuel oil) or transportation networks. Hurricanes, earthquakes, civil unrest are common features in many countries, and health care institutions should have plans for how to handle such disruptions.

Even with out natural or man-made disasters, there is a need for redundancy in technology, storage capacity (spill containment) and management systems. Conditions change. Landfills close, truckers go on strike, incinerators breakdown, or resistance to a chosen technology emerges in the community. A clearly spelled out contingency plan for each waste stream should be developed.

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