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)

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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?