waste management in health care sector

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FOREWORD

Way back in 2004, in the capacity of District Surgeon, I, suggested then Medical

Superintendent, DHQ Hospital Jhang that the hospital should buy an incinerator for waste

disposal. To my surprise Late Dr. Ajmal Ahmdani came up with a big no. He said “

Never think of buying an incinerator, it is more a harm than help. You should go for

Autoclave”. A totally unexpected answer I was never ready to accept. “Look at the

person. He seems totally ignorant”. But I did not have enough knowledge to prove my

point. I decided to study the literature to find arguments for proving my point. I searched

books, internet and all available resources. I lost and Dr. Ahmdani won the debate. Now I

had already developed interest in the subject. Literature consistently advocated Autoclave

for the predisposal management of Hospital waste. Then I visited World Wild Life Fund

office in Lahore, where, I was told about presentation of a doctor named Sudheer Joseph

from St. Stephens Hospital, Delhi. I contacted the doctor; planned the trip and visited the

hospital in Nov. 2006. In New Delhi I had the opportunity to visit the central waste

disposal facility managed by the private company Synergy. The facility was catering for

1500 hospitals and was located outside Delhi 3Km away from all the residential areas. A

local NGO with the name of Toxic Links helped me a lot. After that visit I read the

literature again and things became clear in my mind. I realized that very few people in

Pakistan have the idea about waste management. On my return I sought appointment with

Dr. Shagufta ShahJahan, now Director General Environment and discussed the idea of

NO BURNING WASTE with her. She listened to me patiently and finally agreed with

my point. With her help my name was included in WHO collaborated project being run

under Dr. Shakeela Zaman, then Director Health Services Academy Islamabad. In One

and half year after surveys and workshops a national plan was prepared for waste

management in Pakistan. Meanwhile National Programme for Hepititis Control sent a

team to Jhang. This comprised Dr. Rustam and Dr. Mumtaz. I discussed the syringe

disposal programme (Indian model) with them and they liked it very much.

Now the Healthcare waste management became my passion and I founded a society

called “Waste Watch &Works” in Jhang. 15 clinics participated in our syringe disposal

programme.

When you started discussion some hear, out of them few listen and very few act. It is

amazing that Dr. Mazhar ul Khaliq caught the point and started studying about the

subject. He went forward and decided to write a book. Not an easy decision but finally

the product has come in our hands.

At this point of time when Pakistan is seriously considering Healthcare Waste

Management, the problem needs an exhaustive theoretical workup before launching a

comprehensive plan for the country. In order to understand the depth of subject we

should try to take a multidimensional view of current state of affairs in the World with

particular reference to its application in Pakistan.

1. Paradigm Shift: In the last decade there has been global concern about

incineration hazards due to toxic emissions like DIOXIN & FURANS and high

Capitol and recurring costs for minimizing the pollution problems in this system

of Healthcare Waste Management. Therefore developed countries started

adopting alternative methods e.g. Autoclaving, Microwaving and Chemical

Disinfection.

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2. Difference in Circumstances: Third World Countries have limited Resources and

other operational constraints along with peculiar circumstances making it

impossible to replicate the exact models of HCWM of developed nations.

3. Questionable Compliance: New patterns of HCWM e.g. reduction and

segregation of hazardous waste necessitate change in the attitude of the people,

which is a big undertaking in a society of relatively low literacy rate with

longstanding ignorant practices.

Thus,

In PAKISTAN we need to:-

1. Benefit from the research and experiences of developed countries with

customization of methods to fit in our environment.

2. Study HCWM practices in developing countries. In this respect the closest

country with similar environment is India.

In INDIA:-

• The country is updating the system of HCWM.

• They have started alternative techniques like CHEMICAL DISINFECTION

and AUTOCLAVING.

• PVC and other plastics are not incinerated and only body parts are incinerated.

• Central Facilities have been developed in many cities. These cater for many

hospitals and are located outside the cities. These have INCINERATOR,

AUTOCLAVES, SHREDDERS and EFFLUENT TREATMENT PLANTS.

• SEGREGATION with color coding is being adhered to. They are using four

colors for incinerator, autoclave, recyclable and common waste respectively

with separate system for sharps. *Pictures of St. Stephens Hospital Delhi.

• They are considering MERCURY free environment.

• The hospitals are establishing EFFLUENT TREATMENT PLANTS.

This Book is going to fill the gap of reference material locally written on the subject and

will be useful to individuals (doctors & Allied personnel) as well as institutions.

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INTRODUCTION

In a developing country like Pakistan, the need for a proper Hospital Waste Management

System was long over due. With the given limited physical, human and financial

resources we have the target of improving health conditions countrywide. The importance

of reliable database for planning and management of hospital waste cannot be

overemphasized.

It is a matter of pleasure that we have prepared this important national issue by writing a

book on Hospital Waste Management. This book would not only provide informations

about our needs for prevention of ever growing burden of communicable diseases by a

prompt mechanism of hospital waste management but would also enable to reader to

redefine and prioritize our this health problem on rationale estimates. The author of the

book is directly involved in the management of hospital waste at the institute of cardilogy

Multan as chairman of the hospital waste management committee. In this book the reader

will find basic knowledge about hospital waste & its management according to the

international standards with available scarce resources in a country like Pakistan.

It is my pleasure to extend my personal appreciations for Dr. Mazhar-Ul-Khaliq for the

splendid work in accomplishing this highly extensive and invaluable task.

Dr.Mohammad Mohsin Khan

M.B.B.S., MPH.,PhD

Approved PhD Supervisor

Higher Education Commission

Government of Pakistan

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DEDICATED TO MY FATHER

ABDUL KHALIQ &

MY DAUGHTER AYESHA MAZHAR

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1.1 - INTRODUCTION

Dealing with waste is a challenge common to all human societies.

Nature makes no waste: in healthy ecosystems, one species’ waste becomes

food for the next, in an endless cycle. Modern societies interrupt this cycle in

three ways.

First, technology has created a wide range of substances that do

not exist in nature. Human discards are thus increasingly comprised of plastics,

metals, and natural materials laced with hazardous substances (for example,

bleached and inked paper), which, in many cases, are difficult or impossible for

natural ecosystems to break down.

Second, industrial societies use and dispose of much more material

per person than their predecessors, and than their counterparts in the less

industrialized world.

Third, rapid population growth increases the number of people and

the total amount of waste generated. As a result, the global ecosystem is

overwhelmed, both quantitatively and qualitatively, with what we discard.

Ultimately, human societies rely on the natural environment for all their material

needs, including food, clothing, shelter, breathable air, drinkable water, and raw

materials for manufacturing and construction. At the same time, all human

discards go to the environment.

When humans were few and of limited technological capability, we

could afford to ignore the relationship between these two processes. Now that we

dominate the global ecosystem, that is no longer the case. At the same time that

we are confronted with rapid destruction and growing scarcity of natural

resources — deforestation, declining fisheries, contaminated groundwater, and

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so on — we are producing ever-larger quantities of waste that is more hazardous

than ever.

1.2 - WASTE Waste is defined as material which no longer has any value to its

original owner, and which is discarded. Wastes are those materials no longer

required by an individual , institution or industry and thus are regarded as by

products or end products of the production & consumption process respectively.

NATIONAL DEFINITION OF WASTE

According to Pakistan Environmental Protection Act - 1997, "waste"

means any substance or object which has been, is being or is intended to be,

discarded or disposed of, and includes liquid waste, solid waste, waste gases,

suspended waste, industrial waste, agricultural waste, nuclear waste, municipal

waste, hospital waste, used polyethylene bags and residues from the incineration

of all types of waste.

Figure 1 - Open area waste site.

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The main constituents of waste in urban areas are organic waste

(Including kitchen waste and garden trimmings), paper, glass, metals and

plastics. Ash, dust and street sweepings can also form a significant portion of the

waste. Waste is generated by a range of stakeholders including: pedestrians,

households, businesses, markets, industries and healthcare facilities.

Therefore solid waste can also include toxic waste (e.g. chemicals from industry),

biological waste (e.g. dressings from hospitals) and occasionally feaces (e.g.

from nappies). These hazardous wastes require specialized treatment and

disposal, not discussed in this technical brief.

The source of waste often determines its quantities and

characteristics. In developing countries waste generated from various sources

is often combined at collection and disposal, so due care required to ensure the

health and safety of those involved in waste management.

1.3 - TYPES OF WASTE:-

Wastes can be divided into many different types which include

• Solid Wastes

• Liquid Wastes

• Gaseous Wastes

• Hazardous Wastes

• Radioactive Wastes

• Medical Wastes

All the industrial, municipal and Medical wastes consist of the above mentioned

types.

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1.3.1 - SOLID WASTE

Waste materials which contain less than 70% water contents.

Solid waste generation in Pakistan ranges between 0.283 to 0.612 kg/capita/day

and the waste generation growth rate is 2.4% per year.

Source: - (Draft Environmental Assessment Report, Stockholm, November, 1993).

• Pakistan generates 47,920 tons of solid waste per day.

• Urban waste: 19,190 tons

• Rural waste: 28,730 tons

• The industries of chemicals, fertilizers, tanneries, textile units produce

21,173 tons of toxic waste.

• Collection efficiency of solid wastes is about 54% in the urban centers.

TYPES OF SOLID WASTE:-

Solid waste can be classified into different types depending on their

source for example:-

• Municipal Waste

• Industrial Waste

• Hospital Waste

MUNICIPAL WASTE:-

Municipal Solid Waste (MSW) is useless or unwanted material

discarded as a result of human or animal activity. Most commonly it is solids,

semisolids or liquids in containers thrown out of houses, commercial or

industrial premises.

Municipal Solid Waste Management (MSWM) is the generation,

separation, collection, transfer, transportation and disposal of waste in a way

that takes into account public health, economics, conservation, aesthetics, and

the environment, and is responsive to public demands.

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SOURCES OF MSW

Houses: Appliances, newspapers, clothing, disposable tableware, food

packaging, cans, bottles, food scraps, yard trimming.

Commercial buildings: Corrugated boxes, food wastes, office paper, and

disposable tableware.

Institutions: Office paper, cafeteria and restroom waste, classroom wastes,

yard trimmings.

Industries: Corrugated boxes, lunchroom wastes, and office papers, wood

pallets.

Municipal solid waste consists of household waste, construction

and debris, and waste from streets. This garbage is generated mainly from

residential and commercial places. With the change in lifestyle and food habits,

the amount of municipal solid waste has been increasing rapidly.

GARBAGE: THE FOUR BROAD CATEGORIES

Organic waste:

Waste from kitchen, vegetables, flowers, leaves, fruits etc.

Toxic waste:

Used & expired medicines, paints, chemicals, bulbs, spray cans, fertilizer

and pesticide containers, batteries, shoe polish.

The importance placed upon waste and toxicity minimization in the health care

sector is reflected in a 1997 memorandum of understanding between the

American Hospital Association and USEPA (US environmental protection

agency). This agreement includes a commitment to reduce total waste by one-

third by the year 2005 and by 50 percent by 2010; to virtually eliminate mercury-

containing waste by 2005; and to minimize the production of persistent,

bioaccumulative, and toxic (PBT) pollutants.

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Recyclable:

Paper, glass, metals, and plastics, etc.

Soiled Waste: Hospital waste such as cloth soiled with blood and other body fluids.

TABLE 1 - CONTRASTS TYPICAL WASTE CHARACTERISTICS IN LOW &

HIGH INCOME COUNTRIES

Low Income Country High income Country

Generation per household 0.5 Kg 2 Kg

Density 500 Kg cubic meter 100 Kg per cubic meter

Composition

Organic Up to 80% 30%

Paper 5% 40%

Metals Less than 1% 10%

Plastics Less than 1% 2%

Glass Less than 1% 10%

Moisture Contents High Low

INDUSTRIAL WASTE:-

Unwanted materials from an industrial operation; may be liquid,

sludge, solid, or hazardous waste.

FACT SHEET OF INDUSTRIAL CHEMICALS MANAGEMENT IN PAKISTAN

• Our industry imports chemicals worth Rs. 4,500 million and dyes/colors

worth Rs. 5,000 million every year.

• Over 500 types of chemicals are being imported in the country for use in

different processing industries.

• Local production of chemicals is limited to only a few categories viz. Soda

Ash, sulphuric acid, caustic soda, chlorine, fertilizers, pesticides,

paint/varnishes and polishes and creams.

• Import data of 1997-98 indicates that industry imported

• 3,000 tones of formic acid (a carcinogenic chemical),

• 2,052 tons phenols,

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• 4,200 tons isocyanides,

• 31 tons of mercury,

• 22,817 tons inks/dyes,

• 234 tons Arsenic,

• 1,615 tons chromium salt and so on

• Tanneries located in Kasur and Sialkot have been discharging effluent

with chrome concentration

• Ranging between 182-222 mg/liter against the standard of 1 mg/liter and

• Chemical Oxygen Demand 5,002-7320 mg/liter against limit of 150

mg/liter prescribed in the NEQs.

• Biological Oxygen Demand (BOD) of river Ravi has been found as high as

300 mg/liter as compared to acceptable limit of 9 mg/liter

• About 3,600 tons per year of chemical fertilizer is produced in the country.

• 18,000 tons of pesticides are imported every year.

• Another serious issue is that of high content of led in petrol which is

presently 0.35 gms/litre as compared to 0-0.15 gms/litre in other countries

of the region.

• Pakistan Medical Association has found dangerous levels of lead in blood

samples of traffic police, children and adults in Karachi, Islamabad and

Peshawar cities.

• Sulphur in Diesel is also much higher i.e. 1% as compared to 0.05-0.50%

in other countries of the region.

• Sulphur in furnace oil is 3% as compared to 0.5% - 1% in other countries

of the region.

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TABLE 2 – WASTE GENERATION ESTIMATE IN DIFFERENT CITIES OF

PAKISTAN

A B C DE CF E

E F E EAC DE CCA E

EA C DE CCA ED

FEDE

DE E

E AE E E

A E ED

B DEC EE E

ECC

E

E

1.3.2 – LIQUID WASTE:-

Liquid wastes, originating from a community. They may have been

composed of domestic wastewaters or industrial discharges.

1.3.3 - GASEOUS WASTE:-

Waste in form of gas is called gaseous waste.

1.3.4 – HAZARDOUS WASTE:-

Hazardous Waste is a "waste" which because of its quantity,

concentration, or physical, chemical, or infectious characteristics may posses a

substantial or potential hazard to human health or the environment when

improperly treated, stored or disposed of, or otherwise mismanaged; or Cause or

contribute to an increase in mortality, or an increase in irreversible or

incapacitating illness.

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NATIONAL DEFINITION

Pakistan Environmental Protection Act 1997 defines “Hazardous

waste" as waste which is or which contains a hazardous substance, and includes

hospital waste and nuclear waste.

Pakistan Environmental Protection Act 1997 defines " Hazardous

substance" as a substance or mixture of substance, other than a pesticide

which, by reason of its chemical activity is toxic, explosive, flammable, corrosive,

radioactive or other characteristics causes, or is likely to cause, directly or in

combination with other matters, an adverse environmental effect.

1.3.5 – RADIOACTIVE WASTE:-

Liquid, solid ,or gaseous waste resulting from mining of radioactive

ore, production of reactor fuel materials, reactor operation, processing of

irradiated reactor fuels, and related operations, and from use of radioactive

materials in research, industry, and medicine.

Figure 2 - Radioactive waste container with symbol

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These materials contain the unusable radioactive byproducts of the

scientific, military, and industrial applications of nuclear energy. Since its

radioactivity presents a serious health hazard, disposing of such material is a

great problem. Methods of disposal include dumping concrete-encased

containers filled with radioactive waste in the ocean and burying the waste

underground in old salt mines. In 1996 the United States opened a waste

processing plant in Aiken, S.C. at the Savannah River nuclear-weapons complex.

The waste will be converted into cylinders of radioactive glass, which will then be

encased in steel containers that will be stored in an underground concrete vault.

Figure 3 - Packing Of Radioactive waste

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Table 3 - WASTE COMPOSITION IN SELECTED COUNTRIES

AB CD EFA

A A

D C

FACC F C

D C CE C A D A

DE C E

E D

C EC

C F C

C E C C E

C E CC E

D EC

E EC A C ED DE

C E C E

E EC A C ED EC

C E C E

D EC

E E A E

E FE EC

C A EC E

D EC EC

AA E DE

D E E C

E EC

E EC EC C E

C F CE A D

C E A

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HOSPITAL WASTE

2.1 - INTORDUCTION

Hospital waste is generated during the diagnosis, treatment, or

Immunization of human beings or animals. It is also generated in research

activities in these fields or in the testing of biological materials It may include

sharps, soiled waste, disposables, anatomical waste, cultures, discarded

medicines, chemical wastes, etc. These are in the form of disposable syringes,

swabs, bandages, body fluids, human excreta, etc. This waste is highly infectious

and can be a serious threat to human health if not managed in a scientific and

discriminate manner. It has been roughly estimated that of the 4 kg of waste

generated in a hospital at least 1 kg would be infected.

Undestroyed needles and syringes are being circulated back to

recycling, through unscrupulous traders who employ the poor and the destitute,

to collect such waste for repackaging and selling in the market. Reuse of

disposable like syringes, needles, catheters, IV and dialysis sets are causing

spread of infection from healthcare establishments to the general community.

Disposal of hospital waste and veterinary hospital waste in

municipal dumpsite resulting in animals especially cows feeding on the blood

soaked cotton and plastics, and this in turn leading to diseases like bovine

tuberculosis which through milk can infect humans.

The indiscriminate dumping of untreated hospital waste in

municipal bins is increasing the possibility of survival, proliferation and mutation

of pathogenic microbial population in the municipal waste. This leads to

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epidemics and increased incidence and prevalence of communicable diseases in

the community.

Incidence and prevalence of diseases like AIDS, Hepatitis B&C tuberculosis and

other infectious diseases increasing due to inappropriate use, storage, treatment,

transport and disposal of biomedical waste.

Chances of vectors like cats, rats, mosquitoes, flies and stray dogs

getting infected are becoming carriers which also spread diseases in the

community.

Figure 4 - Hospital Waste

Pakistan is also facing this problem. Around 250,000 tones of

medical waste are annually produced from all sorts of health care facilities in the

country. This type of waste has a bad affect on the environment by contaminating

the land, air and water resources. According to a report, 15 tones of waste are

produced daily in Punjab. The rate of generation is 1.8 kilograms per day per

bed. The province houses 250 hospitals with a total capacity of 41,000 beds.

Various studies have shown that the rate of hospital waste

generation in USA is 5.9 to 10.4 Kg/bed/day. The possible reason for this high

rate of hospital waste generation is use of disposable items.

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In the Western Europe this rate varies to 3-6 Kg/bed/day. The daily

production of solid waste in rural hospitals in Sub-Saharan Africa ranges

between 0.3 to 1.5 Kg/bed/day.

A study conducted at District Headquarter Hospital Kusur revealed

that the average waste generation was 2.5 Kg/ Patient / Day.

2.2 – WHAT HOSPITAL WASTE IS?

HOSPITAL WASTE is also known as “Clinical Waste “. Redefining

it scientifically, Hospital Waste is defined as “any solid, fluid or liquid waste,

including its container and any intermediate product, which is generated during

diagnosis, treatment or immunization of human beings or animals, in research or

in the production or testing of biological and the animal wastes from slaughter

houses or any other like establishments.

Figure 5 - Worker colleting the Hospital waste

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2.3 - CLASSIFICATION OF HOSPITAL WASTE

Hospital Wastes are classified into following categories.

1. Infectious Wastes ( Bio-hazardous Waste )

2. Sharps Waste

3. Pharmaceutical Waste

4. Plastics

5. Mercury

6. GLUTARALDEHYDE/ CIDEX

Figure 6 - Healthcare waste characterization

1 - INFECTIOUS WASTE

Infectious wastes are those biomedical wastes which contain

sufficient population of infectious agents that are capable of causing and

spreading infections among people, livestock and vectors. Infectious wastes

include human tissues, anatomical waste, organs, body parts, placenta, animal

waste (tissue / cell cultures), any pathological / surgical waste, microbiology and

biotechnology waste (cultures, stocks, specimens of micro-organism, live or

attenuated vaccines, etc.), cytological, pathological wastes, solid waste (swabs,

bandages, mops, any item contaminated with blood or body fluids), infected

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syringes, needles, other sharps, glass, rubber, metal, plastic disposables and

other such wastes.

Figure 7 - Infectious waste

Figure 8 - Risk Waste

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Figure 9 - Packed infectious waste

2 - SHARP WASTE

Sharps consist of needles, syringes, scalpels, blades, glass etc.,

which have the capability to injure by piercing the skin. As these sharps are used

in patient care, there is every chance that infection can spread through this type

of injury. Nurses can get a sharp injury before and after using a sharp on a

patient. Further, sharps discarded without any special containment or

segregation can injure and transmit disease to those who collect waste (including

municipal sweepers and rag pickers). There have been reports that waste

collected from the hospitals are resold, this creates an additional occupational

and community health hazard.

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Figure 10 - Sharp waste

Sharp Wastes are of two types:-

• Chemical Sharps Waste which are contaminated with chemicals.

• Radioactive Sharps Waste which are contaminated with radio actives.

3 - PHARMACEUTICAL WASTE

Cytotoxic substances, as the word suggests are toxic to cells and

are often anti-neoplastic which inhibit cell growth and multiplication. These drugs

when come in contact with normal cells can damage them and cause severe

disability or even death of those affected. These drugs could be present in the

waste generated from the treatment of cancer patients or from other work related

to testing and control of cancerous cells.

The importance placed upon waste and toxicity minimization in the health care sector is reflected in a 1997 memorandum of understanding between the American Hospital Association and USEPA.

4 - PLASTICS IN HEALTHCARE

Hospitals use plastics because they fear a spread of infection

through the use of reusable medical equipment. Thus, plastic use has grown with

increasing concern for infection control. However, there have been cases where

even with the use of plastics there has been a spread of infection in wards.

Nurses complained of nosocomial infections in wards even though disposable

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equipment was used — they related it to improper waste disposal of disposable

equipment within the wards. PVC is a thermoplastic, with approximately 40

percent of its content being additives. Plasticizers are added to make PVC

flexible and transparent.

• Medical equipment made from PVC:

• Blood bags, breathing tubes

• Feeding tubes, Pressure monitor tubes

• Catheters, Drip chamber

• IV Containers, Parts of a syringe

• IV Components, Lab ware

• Inhalation masks, Dialysis tubes

Figure 11 - Plastic Waste in Hospital Theater

Infected plastics are those biomedical plastics which have been

used for administering patient care or for performing related activities and may

contain blood or body fluids or are suspected to contain infectious agents in

sufficient number which may lead to infections among other humans or animals.

These generally include IV tubes / bottles, tubing, gloves, aprons, blood bags /

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urine bags, disposable drains, disposable plastic containers, endo-tracheal

tubes, microbiology and biotechnology waste and other laboratory waste.

5 - MERCURY: A HEALTH HAZARD Sources of Mercury in hospitals:

1. Thermometers

2. Blood pressure cuffs

3. Feeding tubes

4. Dilators and batteries

5. Dental amalgam

6. Used in laboratory chemicals like Zenkers solution and histological fixatives.

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Figure 12 - Manometers

6 - GLUTARALDEHYDE/ CIDEX

Glutaraldehyde is a colorless, oily liquid, which is also commonly

available as a clear, colorless, aqueous solution. It is a powerful, cold

disinfectant, used widely in the health services for high-level disinfection of

medical instruments and supplies and available with trade names such as: Cidex,

Totacide, korsolex and Asep. Glutaraldehyde is a widely used disinfectant and an

agent (commonly available in 1 percent and 2 percent solutions) in medical and

sterilizing dental settings. It is used in embalming (25% solution), as an

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intermediate and fixative for tissue-fixing in electron microscopy (20 percent, 50

percent and 99 percent solutions) and in X-ray films.

Figure 13 - Cidex

As regards its type and composition, most hospital waste is similar

to household waste and can be disposed of in the same way. In addition to this,

however, hospitals generate certain special types of waste which should not be

handled by domestic refuse collection services, because of the risk of infection,

because they are hazardous in other ways, or for ethical reasons.

Such waste must be collected separately at the places where it is

generated, and disposed of in specially approved plants, e.g., incinerators.

Hence, types of hospital waste may be classified according to the disposal

method.

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2.4 - TYPES OF HOSPITAL WASTE ON THE BASIS OF DISPOSAL

On the basis of disposal method hospital waste can be classified as

follows.

Type A: Waste which does not require any special treatment.

This is the waste produced by the hospital administration, the

cleaning service, the kitchens, stores and workshops. It can be disposed of in the

same way as household waste.

Type B: Waste with which special precautions must be taken to prevent

infection in the hospital.

This is usually taken to include all waste from inpatient and casualty

wards and doctors' practices, e.g. used dressings, disposable linen and

packaging materials. It only constitutes a risk for patients with weakened

defenses while it is still inside the hospital. Once it has been removed from the

wards it can be handled by the local domestic refuse collection service.

Type C: Waste which must be disposed of in a particular way to prevent

infection.

This is waste from isolation wards for patients with infectious

diseases; from dialysis wards and laboratories, in particular those for

microbiological investigations, which contains pathogens of dangerous infectious

diseases, e.g. tuberculosis, hepatitis infectious diarrheas and diseases which

constitutes a real risk of infection when disposing of this waste. It includes

needles and sharp objects coated with blood, or disposable items contaminated

with stool.

Type D: Parts of human bodies: limbs, organs etc.

This waste originates in pathology, surgical, gynecological and

obstetric departments. It has to be disposed of separately, not to prevent

infection but for ethical reasons.

Type E: Other waste materials.

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The improper handling, treatment, storage, transport and disposal

of hospital waste can lead to serious problems like:

The entire waste from a healthcare establishment, which includes noninfectious

as well as infectious waste, if unsegregated and untreated is mixed with the rest

of the waste in a healthcare establishment, will convert the entire non infectious

general waste (75-80%) also into infectious waste.

The indiscriminate disposal of sharps within and outside institutions leading to

occupational hazards like needle stick injuries, cuts, and infections among

hospital employees, municipal workers and rag pickers. Injuries due to the sharp

especially among rag pickers and hospital / municipal workers increase the

incidence of Hepatitis B, C, E and HIV.

Incidents and prevalence of infectious diseases are increasing due to

inappropriate use, storage, treatment, transport and disposal of biomedical

waste. Chance of vectors for spread of diseases in the community is an

important factor.

3.1 - SHARPS Sharps consist of needles, syringes, scalpels, blades, glass etc.,

which have the capability to injure by piercing the skin. As these sharps are used

in patient care, there is every chance that infection can spread through this type

of injury. Nurses can get a sharp injury before and after using a sharp on a

patient. Further, sharps discarded without any special containment or

segregation can injure and transmit disease to those who collect waste (including

ward cleaners, municipal sweepers and rag pickers). There have been reports

that waste collected from the hospitals are resold, this creates an additional

occupational and community health hazard.

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In developing countries a trend to make money easily has

destroyed all our ethical values. It is a common practice that sanitary staff sells

used syringes to junk buyers. These syringes are then repacked just after boiling.

These used repacked syringes are root cause of AIDs & Hepatitis.

WHO estimated that, in 2000, contaminated injections with contaminated

syringes caused:-

• 21 million hepatitis B virus (HBV) infections (32% of all new infections);

• Two million hepatitis C virus (HCV) infections (40% of all new infections);

• At least 260 000 HIV infections (5% of all new infections).

Figure 14 - Disposal of syringes (wrong method as performed without gloves)

3.2 - MEDICAL WASTE INCINERATION

Acid gases include nitrogen oxide, which has been shown to cause

acid rain formation and affect the respiratory and cardiovascular system. As large

amount of plastic are incinerated, hydrochloric acid is produced. This acid attacks

the respiratory system, skin, eyes and lungs with side effects such as coughing,

nausea and vomiting. Heavy metals are released during incineration of medical

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waste. Mercury, when incinerated, vaporizes and spreads easily in the

environment. Lead and cadmium present in the plastics also accumulates in the

ash. Acute and chronic exposure to lead can cause metabolic, neurological and

neuro-psychological disorders. It has been associated with decreased

intelligence and impaired neurobehavioral development in children.

Cadmium has been identified as a carcinogen and is linked to toxic effects on

reproduction, development, liver and nervous system.

Figure 15 - Estimated Hospital waste generation in South Asia

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Figure 16 - Estimated per bed waste generation in south asia

3.3 – EFFECT OF PLASCTICS:

Disposal of PVC via incineration leads to the formation of dioxin

and furans. Dioxin and furans are unwanted by-products of incineration with

carcinogenic and endocrine-disrupting properties. They are toxic at levels as low

as 0.006 pictograms per Kg of body weight.

3.4 - MERCURY HEALTH HAZARD:

When products containing mercury are incinerated, the mercury

becomes airborne and eventually settles in water bodies from, where via

biomagnifications in the food chain and bioaccumulation, it reaches humans. If it

is flushed, it enters water bodies directly, and if it is thrown in bins it could enter

the body of animals via skin or inhalation, or permeate into the ground causing

soil and groundwater poisoning. This metal accumulates in the muscle tissues.

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Three major types of mercury are found in the environment – methyl mercury,

mercury (zero), mercury (two). Out of these, methyl mercury is the most toxic; it

bio accumulates and has the capability to interfere with cell division and cross the

placental barrier. It also binds to DNA and interferes with the copying of

chromosomes and production of proteins. Pregnant women and children are

most vulnerable to the effects of mercury. The Mina Mata disaster in Japan is an

example of mercury-poisoning via biomagnifications and bioaccumulation.

Mercury exposure can lead to pneumonitis, bronchitis, muscle tremors, irritability,

personality changes, gingivitis and forms of nerve damage.

HOW ARE PEOPLE EXPOSED TO MERCURY?

Many scientists believe the most common way people are exposed

to any form of mercury is by eating fish containing methyl mercury, a highly toxic

form of mercury. Microscopic organisms convert mercury into methyl mercury,

accumulating up the food chain in fish, fish eating animals, and people.

However, recent research indicates that mercury from amalgam

tooth fillings pose a far greater hazard. Between three and seventeen

micrograms per day are secreted as mercury vapor from slow corrosion,

chewing, brushing and grinding of fillings. Also, while methyl mercury ingested

from fish is generally excreted quickly, mercury vapors from amalgams are

secreted slowly over years.

Lesser sources of exposure include mercury vapors in air, ingestion

via drinking water, vaccines, occupational exposures, home exposures including

fluorescent light bulbs, thermostats, batteries, red tattoo ink, skin lightening

creams, and over-the-counter products such as contact lens fluid and

neosynephrine. The EPA warns that “metallic mercury is often found in school

laboratories as well as in thermometers, barometers, switches, thermostats, and

other devices found.” And, because the effects of mercury toxicity are much more

severe for infants and children, even “lesser” exposure sources such as

thermometers, vaccines and amalgam tooth fillings are extremely hazardous to

them.

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Studies show that today in the United States the average person’s

body contains about 10-15 milligrams of mercury. Inhaled mercury fumes go into

the blood, as mercury is soluble and passes through the lungs. Some mercury is

retained in body tissues, mainly in the kidneys, which store about 50% of body

mercury. The blood, bones, liver, spleen and fat tissues retain mercury; it also

gets into the brain and nerve tissue, causing many of the previously mentioned

nervous system disorders.

HOW DOES MERCURY ENTER THE ENVIRONMENT?

The largest source of mercury in the air (40%) comes from coal-

fired power plants. Industrial boilers are second (10%). Municipal waste

incinerators are third. Medical waste incineration places the health care sector as

the fourth-largest source of mercury air emissions.

WHY IS MERCURY DANGEROUS?

The neurological hazards of mercury were first noticed when

women gave birth to severely impaired infants after being exposure to high levels

of mercury. The EPA notes it is “clear that the developing nervous system of the

fetus may be more vulnerable to methyl mercury than the adult nervous system.”

The toxic effects of mercury include autism, Alzheimer’s, ALS, multiple sclerosis,

Parkinson’s, other neurodevelopment problems, Nephrotoxicity and cancer. A

link between mercury and cardiovascular disease has also been recently

established.

INDUSTRIES WITH HIGH POTENTIAL FOR MERCURY EXPOSURE • Manufacture of barometers and thermometers

• Ink and dyes

• Dentistry

• Dental amalgam fabrication

• Hospitals and medical waste

• Paint

• Neon lights

• Mirror manufacturing

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• Paper

• Insecticides

• Pesticides

• Embalming

• Explosives and fireworks

• Jewelers

• Wood preserving

• Photography

WHAT CAN YOU DO?

The following recommendations are particularly important for

women who are or might become pregnant, nursing mothers, infants and

children.

Only use products that are mercury-free.

Make sure that you properly dispose of any mercury containing items in your

home (thermometers, fluorescent lamps)

Avoid mercury fungicides and fungicide-treated foods by eating only organically

grown grains and produce.

Do not eat shark, swordfish, king mackerel, Chilean sea bass, albacore (white)

tuna or tilefish because they contain high levels of mercury.

Eat no more than 12 ounces (2 average meals) a week of fish and shellfish that

are lower in mercury: shrimp, salmon, Pollock, catfish, sole, wild Alaskan salmon,

some sardines, and California red snapper.

Check local advisories about the safety of fish caught in local lakes, rivers, and

coastal areas.

Women who eat fish should get mercury levels tested before becoming pregnant.

If you have amalgam fillings, talk to your dentist about safe ways to remove and

replace them with alternative materials.

If you work with mercury, report spills or other exposure; wear protective

equipment; and avoid taking mercury home with you (shower and change clothes

at the end of the day at work).

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Contact your legislator and demand adequate labeling and identification of

mercury content of fish products and any other food containing mercury.

Oppose the continued use of coal burning power plants as an energy source.

3.5 - GLUTARALDEHYDE/ CIDEX

Aqueous solution is not flammable. However, after the water

evaporates the remaining material will burn. During a fire, toxic decomposition

products such as carbon monoxide and carbon dioxide can be generated.

3.6 - RADIOACTIVE WASTE

Accidents due to improper disposal of nuclear therapeutic material

from unsafe operation of x-ray apparatus, improper handling of radio isotopic

solutions like spills and left over doses, or inadequate control of radiotherapy

have been reported world over with a large number of persons suffering from the

results of exposure. In Brazil while moving, a radiotherapy institute a left over

sealed radiotherapy source resulted in an exposure to 249 people of whom

several either died or suffered severe health problems (International atomic

Energy Agency, 1988). In a similar incidence four people died from acute

radiation syndrome and 28 suffered serious radiation burns.

(Brazil, 1988)

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The fight against hospital infection demands the cooperation of all

those employed in the hospital: doctors, technicians, nursing and cleaning staff.

This is why one of the most urgent tasks is to convince, train and monitor the

personnel responsible for refuse disposal. Unless they are convinced of the

need, trained and monitored, all efforts to improve the situation will be doomed to

failure.

Hospital waste should always be collected in disposable containers

which satisfy the following requirements: they must be moisture-resistant and

nontransparent; sellable in such a way as to prevent egress of micro-organisms;

safe to transport; and color-coded to distinguish them from household refuse

bags. The waste must be collected in such containers at the point where it is

generated, and removed from the wards daily without being sorted or transferred

to other containers. The containers must be carefully sealed.

Generally, plastic bags are used for Type B and C waste, and

plastic buckets for Type D waste. The material these disposable containers are

made of must be appropriate for the next treatment stage. If the waste is

subsequently incinerated, for example, combustible materials with a low level of

toxicity must be used; if it is heat-disinfected the materials must be steam-

permeable. This requirement also applies, incidentally, to all disposable items

purchased by hospitals.

The waste must be transported to a central incineration plant

outside the hospital in specially designed vehicles which do not compress it. The

interior of the vehicle body must be easy to clean and it must be adequately

ventilated.

A variety of methods, chemical and physical, can be used for

disinfection. To disinfect waste, however, only thermal systems in which the

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waste is steam treated at temperatures above 105°C have so far proved

successful. Disinfection in pressure-resistant installations involves approximately

the same amount of work as incineration, but has the disadvantage that it is not

possible to check visually whether the treatment has been a complete success.

With incineration this is of course possible. For this reason incineration is to be

preferred in countries which have no trained inspection personnel. There are also

devices on the market which shred waste and then disinfect it with liquid

chemicals. These devices are only suitable for small quantities, mostly prone to

breakdowns, and there is no guarantee that the disinfectant fluid will reach all the

waste. They are not suitable for handling all the waste generated by a hospital.

4.1 - SHARPS HANDLING: Make needle reuse impossible:

Auto disable syringes, like Solo Shot device, cannot be used more than once and therefore cannot carry infection from one patient to another.

Take the sharp out of sharps waste:

Needle removers “de-fang” syringes, immediately removing the needles after injection and isolating them in secure containers. The syringe cannot be reused, and there’s no risk of accidental needle sticks.

Keep needles away from vulnerable hands:

Special stick proof containers capture used needles and other medical waste until they can be destroyed. PATH is working to increase access to these “safety boxes,” identifying low-cost options and making them available for all types of injections.

Using a needle cutter/destroyer: 1. Place used needle in the cutter/destroyer. 2. Cut/destroy the needle and the nozzle of syringe in the destroyer/cutter. 3. Separate syringe’s barrel and plunger and put in liquid disinfectant. 4. After every shift empty the contents of needle container/destroyer into liquid disinfectant, remove through pouring out contents through a sieve. 4.2 - MEDICAL WASTE INCINERATION

Due to poor operation and maintenance, these incinerators do not destroy the waste, need a lot of fuel to run, and are often out of order. There is a lot of difference between the theory and practice of incinerator operation. This is true around the world. The problem of medical waste needs a systematic approach, with investments in training of staff, segregation, waste minimization

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and safe technologies, as also centralized facilities. Merely investing in unsafe incinerators cannot solve it.

4.3 - PLASCTICS IN HELTH CARE Do’s and Don’ts: Ensure 1. That the used product is mutilated. 2. That the used product is treated prior to disposal. 3. Segregation Do not 1. Reuse plastic equipment. 2. Mix plastic equipment with other waste. 3. Burn plastic waste.

4.4 - ALTERNATIVES TO MERCURY BASED INSTRUMENTS Digital instruments are available as substitutes to the mercury

containing instruments. Costs: The cost of the blood pressure instruments ranges

from Rs. 2000 to 7000 and the cost of thermometers range from Rs 200 to 300

4.5 - WHY ARE THE ALTERNATIVE TECHNOLOGIES BETTER? These less harmful, non-toxic substitutes pose no environmental or

health hazards and last for a longer duration. The life span of the mercury instruments, on the other hand, is short because of their fragility. Even though the initial investment cost of the alternative technologies is high, the assets associated with them are lifelong.

4.6 - GLUTARALDEHYDE/ CIDEX – PRECAUTIONS & SAFETY Identify All Usage Locations: All departments that use

glutaraldehyde must be identified and included in the safety program. Eliminate as many usage locations as possible and centralize usage to minimize the number of employees involved with the handling of glutaraldehyde

Monitor Exposure Levels: Measurement of glutaraldehyde exposure levels must be conducted in all usage locations.

Training: An in-depth education and training program should be conducted for all employees who work with hazardous chemicals.

Use Personal Protective Equipment: All employees who work with glutaraldehyde must be provided appropriate personal protective equipment. This equipment includes proper eye/face protection, chemical protective gloves, and protective clothing.

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Engineering controls: Rooms in which glutaraldehyde is used

should have an arrangement to exchange fresh air for at least 10 times. For this purpose an active & efficient HVAC System is very important

4.7 - SAFETY MEASURES: A chain is as strong as the weakest link in it, thus, not even one

person in the hospital should be missed while training is given. The entire staff is involved in waste management at some point or the other, including administrators, stores personnel and other, seemingly uninvolved, departments. To ensure that the waste is carried responsibly from cradle to grave, and to see that all the material required for waste management is available to the staff, it is important to involve everyone, including: • Doctors • Administrators • Nurses • Technicians • Ward Boys and ward cleaners

4.8 - INFECTION CONTROL 1. Universal Precautions:

All the healthcare workers being exposed directly or indirectly to

infectious diseases must take Universal Precautions to reduce the chance of spread of infection.

2. Sterilization and cleaning: Ensure that the hospital has adequate procedures for the routine,

cleaning, and disinfection of environmental surfaces, beds, bed rails, bedside equipment, and other frequently touched surfaces, and ensure that these procedures are being followed. Routine microbiology tests for air and water contamination should be carried out in all parts of the hospital. Sterilize and disinfect instruments that enter tissue, or through which blood flows, before and after use. Sterilize devices or items that touch intact mucus membranes. In all the autoclave cycles, spore strips need to be placed to check the efficacy of the machine. Recommended chemical disinfectants should be used for the storage of instruments and fumigation of rooms. All the rooms must have proper ventilation.

3. Managing Body Fluid Spillages: Urine, Vomit , Blood & Feaces :

All spillages of body fluids (urine, blood, vomit or feaces) should be

dealt with immediately. Gloves (ideally disposable) should be worn; spillage should be mopped up with absorbent toilet tissue or paper towels: this should be

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disposed of into the waste bin meant for soiled waste. Pour 10 percent hypochlorite solution and leave it for 15 min. Clean the area with a swab. For spillages outside (e.g. in the playground) wash the area with water. Do not forget to wash the gloves and then wash your hands after you have taken the gloves off. Disposal of blood requires special care and protocol.

4. Patient Placement:

A separate room is important to prevent direct/indirect contact transmission when the patient is with highly transmissible microorganisms, or the patient has poor hygienic habits.

5. Immunization programmes:

Since hospital personnel are at risk of exposure to preventable diseases, maintenance of immunity is an essential. Optimal use of immunizing agents will not only safeguard the health of personnel but also protect patients from becoming infected by personnel. The most efficient use of vaccines with high risk groups is to immunize personnel before they enter high-risk situations.

4.9 - HANDLE MERCURY WITH CARE:

NEVER TOUCH MERCURY WITH BARE HANDS. WEAR ALL PROTECTIVE GEARS. GATHER MERCURY USING STIFF PAPER AND SUCK IT IN THE SYRINGE WITHOUT THE NEEDLE POUR CONTENTS OF THE SYRINGE IN A BOTTLE CONTAINING WATER. PUT SCOTCH TAPE AROUND THE BOTTLE KEEP THE SYRINGE FOR FURTHER USE.

4.10 - RADIOACTIVE WASTE Facilities and procedures described in the rules:

(a) Collection:

It is mandatory to mention the facilities available e.g. polythene lined waste bins for collection of solid wastes, and corrosion resistant cardboards or delay tanks for collection of liquid wastes.

(b) Transfer: it is important to state the type of container employed during

transfer of waste/sources e.g. cardboards, sturdy polythene bags, radio-graphy camera.

(c) Disposal: Identify the disposal methods for solid, liquid and gaseous wastes

briefly such as for:

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i). Solids: Burial pits, municipal dumping site or waste management agency. ii). Liquids: Sanitary sewerage system, soak-pit, waste management agency etc. iii). Gaseous wastes: Incineration facility, fume hood etc.

4.11 - SAFETY CLOTHING: A set of safety clothing and equipment for waste handlers was

identified and provided. It included cap, eye protection goggles, mask, apron,

gloves and boots. Disposable caps and masks were used. Gloves and aprons

selected were of no permeable material to prevent contact with blood & body

fluids. However gloves selected were malleable enough to permit finger

movement.

Handling, segregation, mutilation, disinfection, storage,

transportation and final disposal are vital steps for safe and scientific

management of Hospital waste in any establishment. The key to minimization

and effective management of biomedical waste is segregation (separation) and

identification of the waste. The most appropriate way of identifying the categories

of Hospital waste is by sorting the waste into color coded plastic bags or

containers.

Figure 17 - Worker collecting hospital waste

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The fight against hospital infection demands the cooperation of all

those employed in the hospital: doctors, technicians, nursing and cleaning staff.

This is why one of the most urgent tasks is to convince, train and monitor the

personnel responsible for refuse disposal. Unless they are convinced of the

need, trained and monitored, all efforts to improve the situation will be doomed to

failure.

For an effective waste management system it is necessary to

educate all the employees of the hospital about waste and its effect to our life.

GUIDE LINES

There are Guidelines for Hospital Waste Management In Pakistan

since 1998 prepared by the Environmental Health Unit, of the Ministry of Health,

Government of Pakistan, giving detailed information and covering all aspects of

safe hospital waste management in the country, including the risk associated

with the waste, formation of a waste management team in hospitals, their

responsibilities, plan, collection, segregation, transportation, storage, disposal

methods, containers, and their color coding & waste minimization techniques.

A project was implemented in January, 2000 in the biggest hospital in every

province by the Ministry of Health in Islamabad, in collaboration with WHO.

IMPROPER DISPOSAL

Hospitals and public health care units are supposed to safeguard

the health of the community. However, the waste produced by the medical care

centers if disposed off improperly, can pose an even greater threat than the

original diseases themselves. Pakistan is also facing such problems. There are

no systematic approaches to medical waste disposal. Hospital wastes are

simply mixed with the municipal waste in collecting bins at roadsides and

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disposed off similarly. Some waste is simply buried without any appropriate

measure. The reality is that while all the equipment necessary to ensure the

proper management of hospital waste probably exists, the main problem is that

the staff fails to prepare and implement an effective disposable policy.

In Lahore, like most of the cities in Pakistan, there are no proper measures

taken for the management of hospital waste. The standard practice of hospital

waste disposal is dumping it in the M.C.L. container wherever situated.

Disposable syringes and needles are also not disposed off properly. Some

patients, who routinely use syringes at home, do not know how to dispose them

off properly. They just throw them in a dustbin or other similar places, because

they think that these practices are inexpensive, safe, and easy solution to

dispose off a potentially dangerous waste item.

Figure 18 - Improper waste disposal

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5.1 - WASTE MANAGEMENT PRACTICES IN HCF 1

5.1.1 - LADY HEALTH WORKER (LHW)

In most of the rural area of Pakistan LHW is responsible for the

community health. They provide basic health facilities to community members at

their door step. Their houses are their clinics where they treat the community

members. Their home clinics are also sources of health care waste.

5.1.2 - RURAL DISPESARIES

Rural health dispensaries are major set up for health care facilities

in small villages. Although they provide small & limited services yet they produce

health care waste which is not small and negligible.

5.1.3 - MUNICIPAL DISPENSARIES

Municipal dispensaries are major health services provider in

different areas of cities. These dispensaries provide basic health facilities.

5.1.4 - BASIC HEALTH UNITS (BHU)

The BHU is the basic unit in the HCF hierarchy. It is a composite

structure comprising a consulting space, dispensary, beds for resident patients

(in sub urban locations) and ancillary spaces. Being a free healthcare facility, it

generates a large number of patients per day. The waste generated during these

activities comprises used bandages, gauzes, swabs, bottles, syringes, drip

injections, catheters, tissue papers etc. The BHU normally has plastic buckets for

in-house collection of these materials. The main recyclable material is separated

by the junior staff members for selling to waste buyers. The infectious materials

such as syringes are also sold with the other related items. The non-saleable

waste is disposed in a similar manner as the municipal waste. It may be noted

that the organic waste so disposed is of highly infectious nature, which mixes

with municipal waste and remains exposed for extended periods of time.

1-HCF : Health Care Facilities

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5.1.5 - Consulting Clinics (CCs)

These facilities exist in multiple formats. In certain cases, CCs are

part of the hospital scheme. In such case the waste management of CCs is

linked to the overall collection and disposal system of the hospital. The other and

more common format of consulting clinics is along independent locations. In this

form, an individual doctor or a panel sits in a unit with a waiting space,

examination room, small storage space and supplies room. The wastes

generated during the operation of the Consulting Clinics comprise used syringes,

used medicine bottles, bandages and plasters (in case of orthopedic clinics etc),

paper waste and X-ray films. Much of the material generated from the consulting

clinics is re-cycled and separated by the janitors / junior management staff of the

CCs.

5.1.6 - Laboratories and Diagnostic Establishments

Pathological and radiology labs are two dominant categories of this

facility. The types of waste generated in pathological labs comprise specimen of

excreta / body fluids, bandages, syringes, swabs and linen shreds. In addition, a

significant amount of highly infectious liquid waste is generated which is mixed

with routine sewage without any kind of treatment. The solid waste is divided into

re-salable and non-saleable entities. The saleable articles are separated at

source and sold to waste buyers. The organic waste is disposed with the regular

municipal waste. In case of radiology labs, used X-ray films are the most

attractive item which is burnt to produce small amounts of precious metals that

fetch some revenue. This waste is disposed with the normal municipal waste

stream.

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TABLE 4:- BASIC DATA REGARDING HEALTH FACILITIES VERSUS

POPULATION RATIO IN PAKISTAN

INDICATOR

SITUATION IN PAKISTAN

WHO CRITERIA

Population Per Doctor 1578 200 / Doctor

Population Per Dentist 35557 1000/ Dentist

Population Per Nurse 3822 150 / Nurse

Population Per Hospital Bed 1610 200

Population Per Postgraduate Doctor 11000 800

TABLE 5 - HEALTH CARE DELIVERY SYSTEM IN PAKISTAN

Type / Category Pakistan

Total Hospitals 830

MCH Centers 864

Rural Health centers 542

Basic Health Units 5147

Total Hospital Beds 86921

Total Doctors 90000

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TABLE 6 - HEALTH CARE DELIVERY SYSTEM IN PAKISTAN

Type / Category

Pakistan

Postgraduate Doctors 11160

Dentists 3000

Midwives 21304

Lady Health Visitors 4250

Trained Birth Attendant 57744

Lady Health Workers 65000

5.2 – WASTE COLLECTING STAFF

Usually waste colleting staff consists of Ayas, Ward Boys and Ward

Cleaners who are mainly responsible for the collection of waste from wards and

different departments of the hospital. Waste collecting staff has some interesting

names all over the world. In India they are called “Safai Karamchari”.

In Pakistan we call them “Bhangi”, “Jamedar”, “Chamar” and “Kutana”. It is

necessary to have specially trained staff with their specific uniform and gloves

during handling of waste.

PRIMARY COLLECTION OF HOSPITAL WASTES

Within hospitals, the wastes stored in primary containers and bags

at source are collected by in-house nurses’ aides, cleaners . ‘Sweepers’ (sanitary

staff) employed by the hospitals collect waste from each ward in three shifts. The

waste then transported on trolleys to a central storage area in the hospital

premises or outside the building. One supervisor for each shift is responsible for

hospital cleaning and waste collection.

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It is very important for the health of these workers to vaccinate

them against Typhoid and Tetanus. They should also immunize against Hepatitis

B. Their training & education about waste is also very important. Without proper

training and education they are completely blind to the dangerous effects of

medical waste to human life. In developed countries, a proper system has been

adopted for this purpose. Situation is quite different in developing countries and

especially in Pakistan. During a study conducted in CMH Rawalpindi by Mr.

Naeem Mehmood (2000 – 2001), it was revealed that sanitary workers were not

aware of the infectious and non-infectious waste. It was quite interesting that

30% consider left food and vegetables and 18% consider paper as infectious

waste.

In Pakistan, low literacy rate is the main reason for poor perception

of sanitary workers towards hazards of hospital waste. During this study, it was

revealed that 73% were illiterate, 20% had attended the primary school and

remaining 7% had education up to secondary school level.

Joint Advisory Notice on the Protection against Occupational Exposure to Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV)–Training Program Recommendations

According to the Joint Advisory Notice, “The employer should

establish an initial and periodic training program for all employees who perform

Category I and II tasks. No worker should engage in any Category I or II task

before receiving training pertaining to the Standard Operating Procedures

(SOPS), work practices, and protective equipment required for that task.”

The training program should ensure that all workers:

• Understand the modes of transmission of HBV and HIV.

• Can recognize and differentiate Category I and II tasks.

• Know the types of protective clothing and equipment generally appropriate

for Category I and II tasks, and understand the basis for selection of

clothing and equipment.

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• Are familiar with appropriate actions to take, and persons to contact, if

unplanned Category I tasks are encountered.

• Are familiar with and understand all the requirements for work practices

and protective equipment specified in SOPS covering the tasks they

perform.

• Know where protective clothing and equipment is kept; how to use it

properly; and how to remove, handle, decontaminate, and dispose of

contaminated clothing or equipment.

• Know and understand the limitations of Protective clothing and equipment.

For example, ordinary gloves offer no protection against needle stick

Injuries.

• Employers and workers should be on guard against a sense of security

not warranted by the protective equipment being used.

• Know the corrective actions to take in the event of spills or personal

exposure to fluids or tissues, the appropriate reporting procedures, and

the medical monitoring recommended in cases of suspected potential

exposure.

SOURCE: U.S. Department of Health and Human Services, Centers for Disease Control,

E E C

Polyethylene bags are frequently used for containing bulk wastes

(e. g., contaminated disposable and residual liquids); they may have to be

doubled bagged with polypropylene bags that are heat resistant if steam

sterilization is used. These bags, however, must be opened or of such a nature

as to allow steam to penetrate the waste. Color coded bags are frequently used

to aid in the segregation and identification of infectious wastes. Most often red or

red-orange bags are used for infectious wastes (hence the term ‘‘red bag’ waste).

An ASTM Standard (#D 1709-75) for tensile strength based on a dart drop test

and the mil gauge thickness of the plastic determine its resistance to tearing.

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Color coding is used according to the availability of the polythene

bags. As red, orange, yellow and black polythene bags are easily available in

Pakistan so in most hospitals red or orange bag is used for infectious waste,

yellow or blue bag is used for sharps and black or grey bag is used for non

infectious waste.

Use of the biological hazard symbol on appropriate packaging used

is recommended by the EPA to assist in identifying medical wastes. In addition,

EPA recommends that all of these packages close securely and maintain their

integrity in storage and transportation. In general, compaction or grinding of

infectious wastes is not recommended by EPA before treatment. Even though it

can reduce the volume of waste needing storage, compaction is not encouraged

due to the possibility of packages being violated and the potential for

aerosolization of microorganisms. Commercially available grinding systems that

first involve sterilization before shredding or compaction may alleviate this latter

concern.

Sharps are of concern, not only because of their infectious

potential, but also because of the direct prick/stab type of injury they can cause.

For sharps, puncture-proof containers are currently the preferred handling

package. EPA recommends these types of packages for solid/bulk wastes and

sharps; bottles, flasks, or tanks are recommended for liquids. 4 In the past,

needles were re-capped, chopped, or disposed of by other practices that are no

longer common due to their potential for worker injury and, in the case of

chopping, for aerosolization of microorganisms during the chopping procedure.

New technologies for containing needles and facilitating their safe handling

continue to emerge. For example, one company has announced a process which

uses polymers to sterilize and encapsulate sharps (and other infectious wastes)

into a solid block-like material. A number of companies have also developed

encapsulating systems and other sharp disposal processes (e. g., a shredder

with chemical treatment of needles and other sharps). These processes may

potentially be cost-effective disposal options for doctor offices and other small

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generators of sharps and other infectious wastes, provided landfill operations

would accept the encapsulated wastes.

5.4 – COLOR CODING FOR WASTE PACKING

Color coded bags are frequently used to aid in the segregation and

identification of infectious wastes. Most often red or red-orange bags are used for

infectious wastes (hence the term ‘‘red bag’ waste). An ASTM Standard

(#D 1709-75) for tensile strength based on a dart drop test and the mil gauge

thickness of the plastic determine its resistance to tearing. Use of the biological

hazard symbol on appropriate packaging is recommended by the EPA to assist

in identifying medical wastes.

In some hospitals red polyethylene bags are used for infectious

waste, which includes soiled surgical dressing, cotton swabs , blood , body fluid ,

pus , sputum , culture of infectious agents and other contaminated wastes.

Blue Polyethylene bags are used for all sharps irrespective of

whether infectious or otherwise which includes needles, hypodermic needles,

scalpel and other blades, knives, infusion sets, saws and broken glasses.

Black or Grey Polyethylene bags are used for all non infectious

waste, which includes paper, cigarette packets, cardboard, packing material, left

over food and garbage etc.

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Figure 19 - Color Coded bags

COLOR CODING IN DIFFERENT HOSPITALS OF THE WORLD.

1:- COLOR CODING AT THE CAPITAL MEDICAL CENTER (CMC) MANILA

CMC requires the use of three waste cans lined with three (3) colored plastic

bags for every patient room, emergency room-out patient department, operating

room-recovery room, delivery room-nursery, intensive care unit-coronary care

unit, floor nurses station, x-ray and CT scan areas to separate infectious, non-

infectious and biodegradable wastes.

• Waste cans (8"x10"x12") lined with black plastic bags are for non-

biodegradable and noninfectious wastes such as cans, bottles, tetra brick

containers, styropor, straw, plastic, boxes, wrappers, newspapers.

• Waste cans lined with green plastic bags are biodegradable wastes such

as fruits and vegetables’ peelings, leftover food, flowers, leaves, and

twigs.

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• Waste cans lined with yellow plastic bags are for infectious waste such as

disposable materials used for collection of blood and body fluids like

diapers, sanitary pads, incontinent pads, materials (like tissue paper) with

blood secretions and other exudates, dressings, bandages, used cotton

balls, gauze, IV tubings, used syringes, Foleys catheter/tubings, gloves

and drains.

2;- Color Coding along with disposal method at St.Stephen’s Hospital.

5.5 – WASTE STORAGE IN HOSPITAL

Storage of the waste needs to be in areas which are disinfected

regularly and which are maintained at appropriate temperatures (particularly if

wastes are being stored prior to treatment). EPA recommends that storage time

is minimized, storage areas be clearly identified with the biohazard symbol,

packaging be sufficient to ensure exclusion of rodents and vermin, and access to

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the storage area be limited. The importance of the duration and temperature of

storing infectious wastes is noted, due to their association with increases in rates

of microbial growth and putrefaction. The recommendation by EPA for storage of

infectious waste is limited, however, to suggesting that ‘‘storage times be kept as

short as possible’. EPA does not suggest optimum storage time and temperature

because it finds there is ‘‘no unanimity of opinion’ on these matters. As the EPA

Guide notes, there is State variation in specified storage times and

temperatures. State requirements often stipulate storage times of 7 days or less

for infectious wastes that are unrefrigerated. Sometimes longer periods are

allowed for refrigerated wastes.

A BC D A E B F A A AB

A B A AB E A B B AB E A F

B B E C D AB AB D A D

D EE BA B FA EA AE E B AB

D D B D D F E

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B A B DA A A B D D

F B A AB AB EA AE DAE DAED D A

C BA D F AB B

D E A A B A AB E A B C

AB B AB D F B F EA AE EDAB

D D

EPA recommendations with respect to the transportation of

infectious wastes briefly address the movement of wastes while on-site and in an

even more limited way address the movement of wastes off-site. The

recommendations are largely limited to prudent practices for movement of the

wastes within a facility, such as placement of the wastes in rigid or semi-rigid and

leak-proof containers, and avoidance of mechanical loading devices which might

rupture packaged wastes. Broader issues, such as record keeping and tracking

systems for infectious or medical wastes once they are taken off-site, and the

handling and storage of wastes at transfer stations, have not yet been

addressed. EPA does recommend that hazard symbols “should be in accordance

with municipal, State and Federal regulations”.

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Figure 20 - Unsafe transportation of solid waste

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Figure 21 –Cost effective Waste Vehicle used in India

The sanitary staff should be trained properly for the handling of the

waste. It is necessary for them to wear their specific uniform, to use special

gloves during handling of waste. It is very important for the health of these

workers to vaccinate them against Typhoid and Tetanus. They should also

immunize against Hepatitis B. A AB E A B C AB

B AB D F B F EA AE EDAB

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Figure 22 – Purpose built vehicle used for transportation of waste safely.

Figure 23 - Workers bringing waste out of the wards in covered trolley.

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D D

A AB AB D A B E B

A AB D A B B F E A A

B F DA C D A A E F

A B E AB D A B F A BE C A A

B D A AB B AEA B

A B D F E A A D

F F B A A D F E B

A D D AB D D F A A D

A AB D EA AE FAB AB D AB D

D D AB A B D F A E A D F

A A AB C A E A E A B D F

A B D A B D F D B E B A B

D F A B E B D A D B C D B D

F A D F D B D D F D A

D A B AB A D A A C A C D B D

F B B AB C A A A D

BA AB E B AB AB B A E

AB B BA C DAED A E B E AE AB EA

C E E A B B E B C A DA D

E BA B D D AB D E AB

AB F A FAB

A B A B E AB D B B D F

B AB DA E D A F D ABAB DA

E B D F D A AB B E D B F F

D D DAB

B E B A B D D B D

B B D B B E

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E A B AB D A AB D A AB D A C D C AB

B D A B E E D F

B B

Table 7 - COMPOSITION AND PER BED WASTE GENERATION IN A

TERTIARY CARE ARMY HOSPITAL IN PAKISTAN

Category Kg / Day % age / day Kg / Bed / Day

Infectious Waste 197.82 9 % 0.309

Sharps 65.94 3 % 0.103


Total Waste 2198 100 % 3.434

Table 8 - ESTIMATES OF MEDICAL WASTE GENERATION IN SOUTH ASIA

Country Waste generation (kg/bed/day)

Total waste generation (tons/year)

Bangladesh 0.8 -1.67 93,075 (255 ton/day) (only in Dhaka)

Bhutan 0.27 73

India 1 -2 330,000

Maldives NA 146

Nepal NA 365

Pakistan 1.06 250,000

Sri Lanka 0.36 6600 (only in Colombo)

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Pre disposal treatment of medical waste is very important.

Treatment prior to final disposal makes infectious waste non infectious. In this

way we reduce the chance of infectious spread. There are several methods for

the treatment of medical waste. Some modern and latest methods are as under:-

Electron Beam Irradiation (EB) OR Ionizing Radiation

Microwave Irradiation (MW) OR Non – Ionizing Radiation

Autoclave

Hydroclave

Chemical Disinfection

6.1 - ELECTRON BEAM IRRADIATION (EB)

This method is also known as “Ionizing Radiation”. This is the latest

technique used for the treatment of biological waste & especially medical waste.

It is a sterilization technique based on the radiation ability to alter physical,

chemical and biological properties of materials. Irradiation with EB was put forth

as a very effective method for material biological decontamination because can

produce ions, electrons, and free radicals at any temperature in the solid, liquid

and gas. EB radiation processes are very effective for sterilization but the

required radiation dose is still high. Low irradiation doses are required for the

process efficiency and a high dose rate must be used to give large production

capacities. The main idea of this work was to combine the advantages of both,

EB irradiation and Micro Wave irradiation, i.e. high EB irradiation efficiency and

high Micro Wave selectivity and volumetric heating for biological waste

processing.

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METHOD & TECHNIQUE

EB disinfection/sterilization processing is based on the radiation

ability to alter biological properties of microorganisms especially due to the water

presence in the living cells. Water is known to be a component of every biological

system and a constituent present in most chemical processes. Due to the

presence of water, EB irradiation can much enhance the microorganism death

rate. The EB processing uses the Coulomb interaction of the accelerated

electrons with atoms or molecules of irradiated matter.

By these interaction ions, thermalized electrons, excited states and

radicals are formed. Thus, the water irradiation by the EB produces radicals such

as e aq, OH*, H*, H2*, H2O2*, OHaq*, H2O* and O2 -*. The free radicals react

with cell membranes, enzymes and nucleic acids to destroy microorganisms. The

fact that the interaction by the radicals is effective to a wide range of

microorganisms is one of the advantages of the ionizing irradiation. The various

products formed during radiolysis of water may, in this way, influence directly or

indirectly the chemical processes and biological effects occurring in the individual

compounds dissolved in water.

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MICROWAVE IRRADIATION (MW)

This method is also known as “Non- Ionizing Radiation”. This is a

technique used for the treatment of biological waste prior to final disposal.

Microwave (MW) treatment is one of the most emerging biological

decontamination technique because in many cases provides distinct advantages

over conventional processes in terms of product properties, process time saving,

increased process yield and environmental compatibility.

The MW processing is a relatively new technology that provides

new approaches to improve the decontamination process compared with

classical methods.

The frequency range of MW is (300 MHz - 300 GHz) . Hence, MW

cannot interact with atoms by generating transitions between principal energy

levels, e.g. between a base state and an excited state. Instead of this,

microwaves couple to transitions within the hyperfine structure of the dynamical

state. Hyperfine splitting of the principal energy levels may be due to the

interaction of magnetic moments of the electron shell and of the nucleus. Most

reports suggest that for various microorganisms, the death rate is enhanced by

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MW heating more than by conventional heating and the more intense the

microwave electric field, the more is the death rate enhancement. Also, due to

the presence of water, which absorbs MW energy very strongly due its

exceptional polarizability, it is possible to pump vibration modes of DNA leading

to unwinding and strand separation.

MW TECHNIQUE

MW is a method to disinfect micro organisms present in biomedical

waste materials. Due to Microwave radiations, biological properties of these

micro organisms are changed.

Due to the presence of water, MW irradiation can much enhance

the microorganism death rate. Most reports suggest that for various

microorganisms, the death rate is enhanced by MW heating more than by

conventional heating and the more intense the microwave electric field, the more

is the death rate enhancement.

6.2 - AUTOCLAVING OF HOSPITAL WASTE

Autoclave was invented by Charles Chamberland in 1879, although

a precursor known as the steam digester was created by Denis Papin in 1679.

Autoclaving, or steam sterilization, is a process to sterilize medical

wastes prior to disposal in a landfill. Since the mid-1970s, steam sterilization has

been a preferred treatment method for microbiological laboratory cultures. Other

wastes (e. g., pathological tissue, chemotherapy waste, and sharps) may not be

adequately treated by some sterilization operations, and thus require

incineration.

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Figure 24 - Steam Autoclave

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Figure 25 - Staff opening the door of Autoclave

AUTOCLAVING PROCESSING RESULTS:-

Typically, for autoclaving, bags of infectious waste are placed in a

chamber (which is sometimes pressurized). Steam is introduced into the

container for roughly 15 to 30 minutes. The 'cooking' process causes plastics to

soften and flatten, paper and other fibrous material to disintegrate into a fibrous

mass, bottles and metal objects to be cleaned, and labels etc. to be removed.

The process reduces the volume of the waste by 60%. Steam temperatures are

usually maintained at 250 ‘F. Some hospital autoclaves, however, are operated

at 270 ‘F.

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This higher temperature sterilizes waste more quickly, allowing

shorter cycle times. After 'cooking', the steam flow is stopped and the pressure

vented via a condenser. When depressurised, the autoclave door is opened, and

by rotating the drum the 'cooked' material can be discharged and separated by a

series of screens and recovery systems.

In early systems, the primary product was cellulose fibres. This

comprises the putrescible, cellulose and lignin elements of the waste stream. The

biodegradability of the waste has not been affected by the autoclave and so must

undergo further treatment to reduce its reactivity prior to landfilling. The fibres

can be fed into anaerobic digesters to reduce the biodegradability of the waste

and to produce biogas. Alternatively the fibre could be used as biofuel.

Newer technology systems wash out hydrolysed hemicellulose

sugars and most of the protein as water-solubles. The remaining materials, after

simple physical separation (trommel screen) has several valuable uses. One

newer system is able to dry the cellulose during processing using heat, and

another newer system is able to dry the cellulose (much more economically)

using pressure and steam kinetics.

After fibre separation, the secondary streams comprise of mixed

plastics, which have normally been softened and deformed which eases

separation, a glass and aggregate stream, which can be exceptionally clean of

both plastic and paper, and separate errous and non ferrous metals. The heat,

steam and rotating action of the autoclave vessel strip off labels and glues from

food cans leaving a very high quality ferrous/non-ferrous stream for recycling.

With the removal of water, fibre, metals, and much of the plastics,

the residual waste stream for disposal may be less than 10% by weight of the

original stream, and is essentially devoid of materials that decompose to produce

methane. Systems in Europe meet and exceed all of the European waste

treatment and recycling requirements.

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The full process of loading, treatment and sorting is normally

completed within 90 minutes in earlier models, and with the advent of newer

technology, the cycle time has been decreased to one hour. In a typical "new"

configuration, 210-ton units operating side by side would treat over 400 tons per

day with time for preventative maintenance.

The size of the vessel varies between vendors. Experience shows

that "small" vessels are not productive enough; while if the vessel is too large,

the pressures in the vessel and the heavy weight of the vessel can cause

equipment failures.

Several studies indicate that the type of container (e.g., plastic

bags, stainless steel containers), the addition of water, and the volume and

density of material have an important influence on the effectiveness of the

autoclaving process.

Each of these factors influences the penetration of steam to the

entire load and, consequently, the extent of pathogen destruction. Autoclaving

parameters (e.g., temperature and residence/cycle time) are determined by these

factors.

Since there is no such thing as a “standard load” for an autoclave,

adjustments need to be made by an operator based on variation in these factors.

Proper operation of autoclaves is key to effective functioning (i.e., in this case,

sufficient pathogen destruction to render wastes non-hazardous).

One method of assuring that pathogen destruction has taken place

is the use of biological indicators, such as Bacillus stearothermophilus.

Elimination of this organism (as measured by spore tests) from a stainless steel

container requires a cycle time of at least 90 minutes of exposure. This is

considerably longer than is currently provided by standard operating procedures.

This conservative approach, however, may provide more pathogen destruction

than is necessary to reduce microbiological contamination to non-infectious

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levels. Chemical disinfection (e. g., with formaldehyde, xylene, and alcohol) is

used to sterilize reusable items. Recently, sodium hypochlorite has been used in

a process to disinfect disposable products. Partial destruction of the material is

achieved, but additional incineration and high capital costs are associated with

the process as well. Several factors have led some hospitals to abandon

autoclaving. For example, problematic operating conditions can lead to

incomplete sterilization.

In addition, landfill and off-site incinerator operators are increasingly

refusing to receive such wastes, questioning whether the waste has actually

been treated. The refusals are partly in response to the fact that most autoclave

“red bags’ do not change color and thus appear no different from non-autoclaved

red bags (even though they often are labeled or in some way identified as

“autoclave”). This also has led to more cumbersome documentation and/or

identification requirements in an effort to avoid refusals.

Modern autoclaves, also referred to as converters, can operate in

the atmospheric pressure range to achieve full sterilization of pathogenic waste.

Super heating conditions and steam generation are achieved by variable

pressure control, which cycles between ambient and negative pressure within the

sterilization vessel. The advantage of this new approach is the elimination of

complexities and dangers associated with operating pressure vessels.

TYPES OF AUTOCLAVES:

There are several different "types" of autoclave; gravity

displacement, positive pressure displacement, and negative pressure (vacuum)

displacement:

• GRAVITY DISPLACEMENT AUTOCLAVE, OR TYPE "N".

The autoclave at your local tattoo or piercing studio (in the US) is

most likely a gravity displacement autoclave, or type "N". This design of

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autoclave generally has a heating element fully or partially submerged in a

pool of water in the bottom of the autoclave chamber, along with a fill hole

that transfers water from a reservoir to the autoclave chamber. As the water

in the pool is heated it begins to evaporate, forming steam. Steam is lighter

then air, as the chamber fills with steam the majority of air in the chamber is

pushed to the bottom of the chamber, and escapes via the fill hole which is

connected to a temperature sensitive diaphragm that closes once it is

sufficiently heated. Once the diaphragm closes pressure builds up inside the

autoclave chamber. The benefit of this type of autoclave is it's simplicity, the

drawback with gravity displacement autoclaves is they are only designed to

function properly with solid unwrapped instruments, however there has been

no indication that a gravity displacement autoclave, properly loaded with

properly processed instruments is unsafe for use in the modification industry.

• A POSITIVE PRESSURE DISPLACEMENT AUTOCLAVE improves on

the design of a gravity displacement autoclave (see above) by creating the

steam in a separate internal unit, sometimes called a "steam generator".

Once the amount of steam needed to displace air in the chamber is

produced a valve opens and a pressurized burst of steam enters the

autoclave chamber, resulting in a higher percentage of air from the

chamber being removed then with a gravity displacement autoclave, this

decreases autoclave cycle times. Currently the most widely distributed

and used if not the only positive pressure displacement autoclave is the

Statim line of autoclaves. The drawbacks to positive pressure

displacement autoclaves are the high initial cost, and the fact they

generally have a smaller chamber.

• NEGATIVE PRESSURE, OR VACUUM DISPLACEMENT

AUTOCLAVES, also known as type "S", have a separate internal "steam

generator", as well as a vacuum pump. After the autoclave chamber is

closed the vacuum pump removes all air form the chamber, and as above,

steam is injected into the chamber. Negative pressure displacement

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autoclaves are able to attain some of the highest sterility assurance level

or SAL. Negative displacement autoclaves generally have a forced filtered

air drying system that allows the autoclave packages to be throughly dries

before contacting any ambient air. The drawback back to negative

pressure displacement autoclaves is the cost, and sometimes the size of

these systems.

• THE LAST "TYPE" OF STEAM AUTOCLAVE IS TYPE "B" for Big, and

the name speaks for itself. These systems are more or less enlarged

negative pressure displacement autoclaves (there are enormous gravity

displacement autoclaves as well, but they are still type "N", and not

usually used in the medical or modification industries). The steam

generator for Type "B" autoclaves is usually a separate stand alone unit,

and the autoclave chamber is sometimes large enough to physically enter.

Due the large scale and astronomical price tag of these autoclaves they

are rarely, if ever used in the modification industry.

COMMERCIAL APPLICATION

Sterecycle is the first company to build a full scale commercial

plant, which has been operational in Yorkshire since June 2008 and is operating

24/7. This plant can process 100,000 tonnes per annum of waste, treating waste

from Rotherham council under a long term contract. Sterecycle builds, owns and

operates waste recycling plants, processing residual waste as a substitute for

landfill.Other companies are looking to build autoclave plants in the UK but all are

at an embrionic stage.

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INCINERATION VS AUTOCLAVING; AND THE IMPORTANCE OF

PROPER OPERATION

1- Temperature

Autoclaves must achieve minimum temperatures and be operated

according to appropriate cycle times to ensure adequate destruction of

pathogens.

Primary and secondary chamber temperatures of 1,400 ‘F and

1,600 ‘F, respectively, must be reached in hospital incinerators to ensure

adequate combustion and minimum air emissions. Normally, these temperatures

would ensure the destruction of pathogens in the waste; however, if an

incinerator is loaded and fired-up cold, pathogens could conceivable escape from

the stack. Data is not readily available to evaluate this point further. At the typical

operating temperature of an autoclave (250 “F), the cycle time of 45 to 90

minutes is necessary to reduce pathogen concentrations in most hospital waste

below infectious levels.

2- Cost

Autoclaves do provide some advantages over incinerators, which

may increase their attractiveness as a disposal option, particularly if incineration

regulations become much more stringent and thereby increase incineration

costs. For example, operation and testing of incinerators is more complex and

difficult than that for autoclaves. Autoclaves are also less costly to purchase &

require less space.

3 – Environmental Releases

In addition, environmental releases from incinerators probably

contain a broader range of constituents (e. g., dioxins, and heavy metals) than

autoclaves.

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4 – Training

The proper operation of incinerators and autoclaves is critical to

their effective functioning. Proper operation is dependent on at least four

conditions:

• Trained operators;

• Adequate equipment (i.e., proper design, construction, controls and

instrumentation);

• Regular maintenance;

• Repair.

For example, trained operators need to be knowledgeable in the

operation of the incinerator and in the proper handling of medical wastes. It is not

clear; however, that workers are consistently receiving adequate training in the

operation of incinerators or autoclaves, and consequently that most units are

operating properly.

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6.3 - HYDRO CLAVE

Hydroclave is a device like Autoclave which sterilizes the waste

utilizing steam, similar to an autoclave, but with much faster and much more

even heat penetration. It hydrolyzes the organic components of the waste such

as pathological material. Removes the water content (dehydrates) of waste.

Breaks up the waste into small pieces of fragmented material and reduces the

waste substantially in weight and volume. Accomplishes the above process

within the totally sealed vessel, which is not opened until sterilization of waste.

THE HYDROCLAVE PROCESS – AND HOW IT WORKS

The Hydroclave is essentially a double-walled (jacketed) cylindrical,

pressurized vessel, horizontally mounted, with one or more side or top loading

doors, and a smaller unloading door at the bottom. The very small Hydroclave

units have a single side door for both loading and unloading. The vessel is fitted

with a motor driven shaft, to which are attached powerful fragmenting/mixing

arms that slowly rotate inside the vessel.

When steam is introduced in the vessel jacket, it transmits heat

rapidly to the fragmented waste, which, in turn, produces steam of its own.

A temperature sensor is located in the bottom inside part of the vessel, which

measures the temperature of the waste as it is agitated and mixed, and this

sensor reports back to the main computerized controller, which automatically

sets treatment parameters ensuring complete waste sterility – even liquid

infectious waste.

After sterilization, the liquid but sterile components of the waste are

steamed out of the vessel, re-condensed and drained to sewer. The remaining

waste is dehydrated, fragmented, and self-unloaded via a reverse rotation of the

mixer/agitator.

There is no correlation between waste characteristics and

treatment efficacy. All the waste is consistently sterilized. Liquid and heavy loads,

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however, will take somewhat longer to reach the temperature and pressure

required to initiate the sterilization cycle, but sterilization automatically occurs.

There is no need for “pre-and post-vacuum”, that is, pull infectious air and liquids

of the vessel, as is the case with autoclaves. Pulling air and liquids out of an

infectious environment increases the risk of live pathogen emission.

The Hydroclave eliminates this risk due to the vigorous dynamic

activity within the Hydroclave, which mixes and heats any entrained air with the

steam and waste material.

DETAILED DESCRIPTION OF THE TREATMENT CYCLE

a) LOADING

The waste can be loaded into the Hydroclave treatment vessel by various

means, depending on your requirements:

In smaller units dropping the waste bags manually into a side or end door.

In medium-sized units by tipping waste containers into top or angled

loading doors. Electric or hydraulic tipping devices are an available option

with the Hydroclave.

In medium to large sized units, for large scale commercial operation, a

combination of conveyors, hoppers and tippers are available to load the

waste into large top loading doors.

The Hydroclave can be fitted with loading doors to suit your

requirements, from small side doors to multiple angled or top doors, which are

sized to accommodate your infectious waste stream – small doors for bagged

biomedical waste, to very large doors for disinfecting large objects such as large

animal carcasses. No special operator skill is required, since over-loading or

loading too tightly is not an issue with this type of process.

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b) HEAT-UP AND FRAGMENTATION

After loading, the vessel doors are closed, and the outer jacket of

the vessel is filled with high temperature steam, which acts as an indirect heating

medium for heating the waste.

The jacket steam condenses into clean, hot condensate, which is

returned back to the steam boiler. This unique feature makes the Hydroclave so

efficient in operation – no steam or hot condensate is lost. During heat-up, the

shaft and mixing arms rotate, causing the waste to be fragmented and

continuously tumbled against the hot vessel walls.

At this point, the waste is broken up into small fragments, and all

material heats up rapidly, being evenly and thoroughly exposed to the hot inner

surfaces. The moisture content of the waste will turn to steam, and the vessel will

start to pressurize.

Initially, no steam will be injected into the waste. If there is not

enough moisture in the waste to pressurize the vessel, a small amount of boiler

steam is added until the desired pressure is reached.

The uniform jacket heat and the location of the temperature sensor

ensures that even liquid waste will be heated up uniformly.

At the end of this period, the correct sterilization temperature and pressure are

reached, and the sterilization period is initiated automatically.

c) STERILIZATION PERIOD

By computer or PLC control, the temperature and pressure are

maintained for the desired time to achieve sterilization. If for any reason the

sterilization parameters drop below desired levels, the sterilization cycle is

stopped, and re-initiated. This ensures sterilization prior to commencement of the

next stage. The mixing/fragmenting arms continue to rotate during the entire

sterilization period, to ensure thorough heat penetration into each waste particle.

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d) DE-PRESSURIZATION AND DE-HYDRATION

After the sterilization period ends, the vessel is de-pressurized via a

steam condenser, which causes initial waste dehydration due to

depressurization.

The steam to the jacket will remain on, agitation continues, and the

waste loses its remaining water content through a combination of heat input from

the jacket and continued agitation.

All waste, no matter how wet initially, even liquid waste, will be dehydrated by

this process.

e) UNLOADING

At the end of the depressurization/dehydration period, jacket steam

is shut off, the discharge door is opened, and the powerful mixing arms are

reversed to a clockwise rotation.

Due to the unique construction of the mixing arms, the opposite rotation causes

the fragmented waste to be pushed out of the vessel discharge door, into a

waste container, or onto a conveyor.

If desired, the waste can be further fine-shredded prior to final

disposal, by a separate shredding system. The dry, sterile, fragmented waste is

well suited for further fine shredding.

The vessel is now ready for another treatment cycle, having retained most of its

heat for the treatment of the next batch.

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TREATMENT PROCESS

How it works…

STAGE ONE - LOADING

The Hydroclave can process:

Bagged waste, in ordinary bags.

Sharps containers.

Liquid containers.

Cardboard containers.

Metal objects.

Pathological waste.

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STAGE TWO – STERILIZING

Powerful rotators mix the waste and break it into small pieces.

Steam fills the double wall (jacket) of the vessel and heats the vessel

interior.

The liquid in the waste turns to steam.

After 20 minutes the waste and liquids are sterile.

STAGE THREE – DEHYDRATION

The vent is opened, the vessel de-pressurizes via a condenser, and sterile

liquid drained into sanitary sewer.

Steam heat and mixing continue until all the liquids are evaporated and

the waste is dry.

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STAGE FOUR – UNLOADING

The unloading door is opened.

The mixer now rotates in the opposite direction, so angled blades on the

mixer can push the waste out the unloading door.

The dry sterile waste can be fine-shredded further or dropped in a waste

disposal bin.

The waste is now ready for safe disposal!

6.4 - CHEMICAL DISINFECTION

Waste which is contaminated through contact with, or having

previously contained, chemotherapeutic agents shall be segregated for storage.

This type of waste must be placed in a secondary container, which shall be

labeled on the lid and the sides with the words “Chemotherapy Waste” or

“CHEMO”. The label must be visible from any lateral direction to ensure

treatment of the Biohazardous waste. Chemotherapeutic waste can be taken

directly to one of the Medical Waste Collection Sites.

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It is very important to dispose off the hospital waste in a proper

way. Due to improper disposal many diseases are spreading very rapidly all over

the world. Here we will discuss the modern & old technologies which are being

used in different countries for HCW disposal.

7.1 – DISPOSAL OF MEDICAL WASTES

There are different methods for the disposal of hospital waste depending upon types of waste i.e. solid, liquid & radioactive waste.

A ) – DISPOSAL OF SOLID HOSPITAL WASTE Methods for disposal of solid hospital waste are :-

• Incineration • Recycling • 3 - R Concept • Land Fill

7.2.1 - INCINERATION METHOD FOR DISPOSAL OF SOLID HOSPITAL WASTE

Incineration

Incineration is a waste treatment and disposal method that involves

the combustion of waste at high temperatures. Incineration of waste materials

converts the waste into heat, gases, particulates and solid residue (ash).

Large Scale Incineration

Incineration can be used to destroy certain hazardous wastes such

as medical wastes where pathogens and toxins must be destroyed by high

temperatures.

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Incinerators that burn municipal wastes are often referred to as

‘MSWI’s: Municipal Solid Waste Incinerators. There are no municipal solid waste

incinerators in New Zealand.

A waste-to-energy plant is an incinerator that burns wastes in high-

efficiency furnace/boilers to produce steam and/or electricity and incorporates

modern air pollution control systems and continuous emissions monitors. This is

often used as a waste disposal method in countries where landfilling is too

difficult or expensive because land is a scarce resource.

Small Scale Incineration

Small scale incinerators include backyard burners or '44-gallon

drum incinerators' that may be used to dispose of garden and household waste.

The amount of household waste burned in backyard fires is only about 1% of the

total amount of household waste land filled in New Zealand.

Bans on outdoor fires of all kinds are common in Canterbury in

summer because of the fire risk. Because of other adverse air quality effects,

outdoor burning is not permitted from 1 May to 31 August in Christchurch Clean

Air Zones 1 and 2.

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Figure 26 - Municipal Solid waste incinerator in USA

Figure 27 - Medical Waste Incinerators in USA

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INCINERATION HAZARDS

• There are arising economic problems because ash is not an ideal fuel.

• The incineration of certain waste product produces some acidic gases.

• Polyvinyl Chloride (PVC), a plastic used in the manufacturing of toys,

rainwear & garden hoses. When it is burnt Hydrogen Chloride Gas is

produced. This gas reacts with water to produce Hydrochloric Acid (HCL)

which is a strongly corrosive liquid.

• What’s threatening is the fact that some of the PVC decomposes before it

burns completely. Decomposition products such as vinyl chloride, or

suspected ones such as, dioxin are known carcinogens. Most of these can

be removed from the exhaust stream if proper air pollution controls are

installed, but these measures are never 100 percent effective and so

expensive.

• Incinerators typically release a wide variety of other toxic metals, including

lead, cadmium, arsenic, chromium, beryllium, nickel and others. Health

effects of these metals include:

• Lead: -nervous system disorders, lung and kidney problems, and

decreased mental abilities in children.

• Cadmium: -kidney disease, lung disorders; high exposures severely

damage the lungs and can cause death

• Arsenic: -arsenic damages many tissues including nerves, stomach,

intestines and skin, causes decreased production of red and white blood

cells and abnormal heart rhythm

• Chromium: -damages nose, lungs and stomach

• Beryllium: -chronic lung problems Incinerators are significant sources of

these forms of air.

® - In 1999, the Philippines became the first country in the world to prohibit all forms of waste

Incineration, including open burning. This environmental milestone was achieved after years of campaigning by environmental and community groups opposing proposals for incinerators, landfills and dumpsites in various parts of the country.

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Figure 28 - Industrial Incinerator

Figure 29 - Medical Waste incinerator

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INCINERATOR BANS AND MORATORIA

1. INTERNATIONAL:

• 1996: the Protocol to the London Convention banned incineration at sea globally.

• 1996: the Bamako Convention banned incineration at sea, on territorial or internal waters in Africa.

• 1992: the OSPAR Convention banned incineration at sea in the north-east Atlantic.

ARGENTINA:

• 2003: the city Council of Granadero Baigorria, Santa Fe province, outlawed medical waste incineration.

• 2002: the Buenos Aires City Council passed a law that bans incineration of medical waste. This includes medical waste generated in the city and sent outside for treatment.

• 2002: the City Council of Villa Constitución, Santa Fé province, banned the construction of incinerators.

• 2002: the City Council of Coronel Bogado, Santa Fé province, banned the construction of incinerators.

• 2002: the City Council of Marcos Juarez, Cordoba province, outlawed the construction of incinerators.

• 2002: the Municipal Council of Casilda, Santa Fe province, banned hazardous waste incineration for 180 days. The resolution was extended for another 180 days in November 2002.

• 2002: the City Council of Capitan Bermudez outlawed all type of waste incineration.

• 2001: the province of San Juan banned crematoria in urban and semi-urban areas.

BRAZIL:

• 1995: the Municipality of Diadema, State of Sao Paulo, approved a law banning incinerators for municipal waste. The city council states that the waste problem should be tackled using reduce, reuse, and recycling policies.

CANADA:

• 2001: the Province of Ontario enacted a hazardous waste plan that includes the phase out of all hospital medical waste incinerators.

CHILE:

• 1976: Resolution 07077 banned incineration in several metropolitan areas of the country.

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CZECH REPUBLIC:

• 1997: Cepi, district Pardubice banned construction of new waste incinerators.

GERMANY:

• 1995: the largest, most populated and most industrialized state in Germany — North Rhine/Westfalia — bans municipal solid waste incinerators.

GREECE:

• 1994: the national government approved legislation declaring it illegal to burn hazardous waste in waste-to-energy plants. In 2001, the Minister for the Environment formally declared a policy of prohibiting municipal waste incineration.

INDIA:

• 1998: the central government banned incineration of chlorinated plastics nationally. The city of Hyderabad in the state of Andhra Pradesh banned on-site hospital waste incineration.

IRELAND:

• 1999: although no formal ban is in place, Ireland closed all of its medical waste incinerators.

JAPAN:

• 1998: the Ministry of Health and Welfare revised the laws to allow disposal of PCBs using chemical methods. Although there is no formal ban on incineration of PCBs, there is an informal proscription on PCB incineration.

MALTA:

• 2001: all public and private hospitals were to eliminate clinical waste incineration by 2001.

PHILIPPINES:

• 1999: the Clean Air Act was passed which bans all types of waste incineration. The law extends to municipal, medical and hazardous industrial wastes.

SLOVAKIA:

• 2001: banned waste importation for incineration. SPAIN:

• 1995: the regional government of Aragon established autoclaving as the required form of treatment for medical waste, effectively eliminating medical waste incineration.

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2. UNITED STATES:

STATES

• Delaware, 2000: state prohibited new solid waste incinerators within three miles of a residential property, church, school, park, or hospital.

• Iowa, 1993: state enacted a moratorium on commercial medical waste

incinerators. Moratorium still in place. Moratorium does not extend to incinerators operated by a hospital or consortium of hospitals.

• Louisiana, 2000: state revised its statute Title 33, which prohibits

municipalities of more than 500,000 from owning, operating or contracting garbage incinerators in areas zoned for residential or commercial use.

• Maryland, 1997: state prohibited construction of municipal waste

incinerators within one mile of an elementary or secondary school.

• Massachusetts, 1991: state enacted a moratorium on new construction or expansion of solid waste incinerators.

• Rhode Island, 1992: state banned the construction of new municipal solid

waste incinerators. First U.S. state to enact such a ban.

• West Virginia, 1994: state banned the construction of new municipal and commercial waste incinerators. Permits pilot tire incineration projects.

3. COUNTIES

• Alameda County, California, 1990: voter initiative “Waste

Reduction and Recycling Act” passed, banning waste incinerators in the county. A later court ruling limits the ban to the unincorporated areas of the county, however, there are no operating municipal waste incinerators in Alameda county.

• Anne Arundel County, Maryland, 2001: county banned solid

waste and medical waste incinerators.

4. CITIES

• Brisbane, California, 1988: city banned new construction of waste incinerators.

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• Chicago, Illinois, 2000: city banned municipal waste incineration. The ban extends to burning waste in schools and apartment buildings.

• San Diego, California, 1987: ordinance stipulates that waste

incinerators cannot be sited within a certain radius of schools and daycare centers, which results in no eligible land being available for incinerators.

• Ellen burg, New York, 1990: town banned waste incinerators.

• New York City, 1989: Banned all apartment house incinerators by

1993. By 1993, all 2,200 apartment house incinerators that were in operation in 1989 were shut down.

5. MORATORIA:

Several states in the United States, including Arkansas, Wisconsin

and Mississippi, have enacted moratoria on medical or municipal waste incinerators that have since expired or been lifted. The US EPA enacted a nationwide, 18-month freeze on new construction of hazardous waste incinerators in 1993. Two unsuccessful bills were introduced in the US Congress during the 1990s to enact a moratorium on new waste incinerators. Other examples of incinerator moratoria worldwide include:

• 1982: Berkeley, California passes a ballot initiative banning garbage burning plants for five years. The moratorium allowed the city to develop recycling programs which became national models.

• 1985: Sweden implemented a 2-year moratorium on new incinerators.

• 1990: In the Flemish-speaking part of Belgium, public pressure resulted in

a 5-year moratorium on new municipal waste incinerators.

• 1992: Ontario, Canada banned new municipal incinerators. In 1996 a new conservative government overturned the ban.

• 1992: Baltimore, Maryland passed 5-year moratorium on new municipal

incinerators.

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SOME NON INCINERATION TECHNOLOGIES FOR HAZARDOUS WASTE

TREATMENT

Technology Process Description Potential Advantages Current Uses

Base Catalyzed Dechlorination

Wastes reacted with alkali metal hydroxide, hydrogen and catalyst material. Results in salts, water and carbon.

Reportedly high destruction efficiencies. No dioxin formation.

Licensed in the United States, Australia, Mexico, Japan, and Spain. Potential demonstration for PCBs through United Nations project.

Biodegradation

Microorganisms destroy organic compounds in liquid solutions. Requires high oxygen/nitrogen input.

Low temperature, low pressure. No dioxin formation. Contained process.

Chosen for destruction of chemical weapons neutralent in the United States. Potential use on other military explosive wastes. Typically used for commercial wastewater treatment.

Chemical Neutralization

Waste is mixed with water and caustic solution. Typically requires secondary treatment.

Low temperature, low pressure. Contained and controlled process. No dioxin formation.

Chosen for treatment of chemical agents in the United States.

Electrochemical Oxidation (Silver II)

Wastes are exposed to nitric acid and silver nitrate treated in an electrochemical cell.

Low temperature, low pressure. High destruction efficiency. Ability to reuse/recycle process input materials. Contained process. No

dioxin formation.

Under consideration for chemical weapons disposal in the United States. Assessed for treatment of radioactive wastes.

Electrochemical Oxidation (CerOx)

Similar to above, but using cerium rather than silver nitrate.

Same as above; cerium is less hazardous than silver nitrate.

Demonstration unit at the University of Nevada, United States. Under consideration for destruction of chemical agent neutralent waste.

Gas Phase Chemical Reduction

Waste is exposed to hydrogen and high heat, resulting in methane and hydrogen chloride.

Contained, controlled system. Potential for reprocessing byproducts. High destruction efficiency.

Used commercially in Australia and Japan for PCBs and other hazardous waste contaminated materials. Currently under consideration for chemical weapons destruction in the United States. Potential demonstration for PCB destruction through United Nations project.

Solvated Electron Technology

Sodium metal and ammonia used to reduce hazardous wastes to salts and hydrocarbon compounds.

Reported high destruction efficiencies.

Commercially available in the United States for treatment of PCBs.

Supercritical Water Oxidation

Waste is dissolved at high temperature and pressure and treated with oxygen or hydrogen peroxide.

Contained, controlled system. Potential for reprocessing byproducts. High destruction efficiencies.

Under consideration for chemical weapons destruction in the United States. Assessed for use on radioactive wastes in the United States.

Wet Air Oxidation

Liquid waste is oxidized and Hydrolyzed in water at moderate temperature .

Contained, controlled system. No

dioxin formation. Vendor claims 300 systems worldwide, for treatment of hazardous sludge and wastewater.

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7.2.2 - RECYCLING OF MEDICAL WASTE

The definition of recycling is to pass a substance through a system

that enables that substance to be reused. Hospital Waste recycling involves the

collection of hospital waste materials , the separation and clean-up of those

materials. Recycling waste means that fewer new products and consumables

need to be produced, saving raw materials and reducing energy consumption.

SEGREGATION FOR RECYCLING AT HOSPITALS

Varying degrees of segregation of recyclable components of

hospital wastes occur at hospitals. In general, these activities are not organized

by the hospital management and have grown out of opportunities available to the

workers involved in handling the hospital wastes.

The quantities of recyclable materials in waste from minor health

care establishments are small. In general, any segregation for recycling will be

carried out by the workers handling the waste in clinics and health centers, etc.

but the minimal quantities generated limit the opportunities for sale.

SEGREGATION FOR RECYCLING AT MUNICIPAL LANDFILLS

At all landfills, a large number of waste pickers rely on recycling for

their survival. They do not differentiate between general solid waste and

hazardous health care waste and go through all wastes looking for recyclable

materials. Most of the recycling is achieved by urban recyclers, and at the

landfills only relatively small quantities of bone, paper, plastics and glass are

retrieved. Health care wastes in developing countries , are likely to contribute

only a small amount of such recyclable materials at landfills because of the at-

source segregation of the most valuable components.

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THE RECYCLERS

THE INITIAL PLAYERS IN HOSPITAL WASTE RECYCLING

The initial players in hospital waste recycling are the workers

responsible for handling waste in the hospitals. In developing countries , the

nurses’ aides, sweepers and janitors are employed by the hospitals and are

controlled by hospital supervisors with little support or advice from senior

management. Much of their recycling activity is informal and benefits only the

workers involved.

THE SECOND TIER OF HOSPITAL WASTE RECYCLERS

Municipal waste collection workers often serve as the second tier of

hospital waste recyclers. They frequently receive recyclable materials segregated

by the hospital waste handlers and sell them on. In addition, they scavenge the

waste collected at hospitals before dumping it at the landfill site.

THE THIRD TIER OF HOSPITAL WASTE RECYCLERS

Municipal waste collection workers and itinerant junk buyers sell on

the recyclable materials segregated from health care wastes to middle dealers in

the form of junk shops. Middle dealers serve the purpose of storing and,

sometimes, further separating recyclable materials until a sufficient quantity has

accumulated to make it worthwhile selling it on to main dealers.

MAIN DEALERS IN HOSPITAL WASTE RECYCLING

The main dealer purchases all the recyclable products by minor

dealers. The specification of main dealer varies from country to country i.e. the

main recycling dealers in Karachi have decentralized due to ‘pressure on space

and working environment’. The main dealers usually deal in one single waste

item only and have personal contacts with middle dealers.

Vietnam has a long history of recycling waste materials and, in

Hanoi’s case, many villages in the suburbs and in nearby Provinces have

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developed skills which now make them main dealers in the solid waste recycling

system.

One of the main locations for main dealers is close to an industrial

trading estate, making it convenient to access end-users. Bulk quantities of

recyclable materials are collected, prepared and sold on. Even though the

premises of such main dealers have a legal status the operators are not

registered and have to pay protection money to enforcing agencies. The ultimate

industrial receivers of recycled materials tend to be located near the main dealers

and produce end-products for which there is a market. An example of a recycled

end-product is ‘dana’, which are the plastic pellets produced after molten waste

plastic extrusion, cooling and cutting. Waste glass and paper are likewise

converted into useful products in specialist enterprises.

HEALTH AND ENVIRONMENTAL IMPACTS OF HOSPITAL WASTE RECYCLING

Workers segregate paper, cardboard and glass for recycling at any

stage of waste handling. In doing so, they are not careful and recyclable

materials are generally contaminated with blood and infectious fluids leaking from

red bags. Waste pickers at landfill sites are also singled out as being vulnerable

to flies, mosquitoes and air-borne dust. Leachate from landfills is claimed to

pollute surface and ground waters. Work as a recycler in Hanoi is said to be

arduous and to pose risks to health through traffic accidents and contact with

waste.

In health care establishments, particularly in government hospitals

in developing countries, the storage and transport of waste give rise to serious

concern about pollution of wards and storage areas and the potential for spread

of communicable diseases. During transport to disposal sites, health care wastes

are often blown onto streets, creating environmental pollution and health risk.

Burning of waste at dumps causes severe air pollution and exposure of waste

pickers to infectious material and sharps is a serious threat to health.

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Disposal of wastes in waterways create obnoxious odors and look aesthetically

unattractive, as well as having an adverse effect on fisheries.

It is therefore stressed that the health risks to these poorly-paid

workers could be reduced with better and more responsible management.

Workers should be immunized against Tetanus and Hepatitis B and undergo a

medical examination before starting work at a clinic or hospital.

It is very horrible that some black sheep sell the used syringes, drip

bags, blood bags and other plastics material to merchants who sell them on large

scale. After just washing, these syringes, needles, blood bags and tubing are

available in repacking for reuse. These repacked equipments are most

dangerous to health. It is therefore very necessary to make them non reusable by

cutting the plastics bags and completely destroying both syringes & needles.

RECYCLING IN THE U.K

In the UK, the household and commercial sectors have relatively

low recycling rates. This is in comparison to some other wastes, such as

construction and demolition waste and sewage sludge. The Government is

hoping to increase the amount of household waste that we recycle to 33% by

2015. Some of the materials that we can recycle include paper, plastics, metals

(such as aluminum cans) and tyres.

The paper industry generates vast quantities of waste in the form of

paper off-cuttings and damaged paper rolls. This paper can be put back into the

pulping process and recycled. Paper recycling in the UK became popular during

the 1990s. Nearly a million tones of paper from household waste is now recycled

each year. Although paper makes up over one third of all household waste

recycled, this is still no more than about 10% of the total paper consumed. In

contrast, over 50% of paper waste paper produced by the newspaper industry is

currently being recycled. To encourage the public to recycle waste paper, many

council have arranged house to house collection schemes. Separate bins and

containers are provided specifically for paper. They are collected at regular

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intervals and taken to be recycled. Other recycling depots for paper can be found

at municipal centers and supermarkets.

Approximately 6 to 8% of UK household waste comprises of glass

jars and bottles. However, the largest producers of waste glass bottles are hotels

and pubs, as the vast majority of drinks are bottled. A large proportion of glass is

collected in bottle banks and taken to be recycled. There are over 20,000 bottle

banks in the UK, and they are mainly found in car parks and at supermarkets.

There are usually three bottle banks, one for each color of glass: clear, green

and brown. The UK currently recycles about one third of its glass. This is far

behind glass recycling rates in other European countries. Switzerland and the

Netherlands for example have recycling rates as high as 80%.

Plastics make up a large amount of waste, since they are available

in numerous forms. There are two main types of plastic: thermoplastics, which

are the most common; and thermo sets. Thermoplastics melt when heated and

can therefore be remolded. This enables thermoplastics to be recycled relatively

easily. In Western Europe the largest amounts of plastic occur in the form of

packaging. Plastic waste tends to be sorted by hand, either at a materials

recycling facility or the householder can separate it. This may then be taken to a

plastic recycling point or collected by the council. The UK produces

approximately about 4.5 million tones of plastic waste each year. Most of this

waste arises from packaging. The UK has a plastics recycling rate of only 3%. In

Germany the recycling rate for plastic is 70%.

The UK has a recycling rate of approximately 60% for iron and

steel. Most of this waste comes from scrap vehicles, cooker, fridges and other

kitchen appliances. It is estimated that the metal content of household waste is

between 5 and 10%. It is mainly made up of aluminum drinks cans and tin-plated

steel food cans. Aluminum recycling is widely established in the UK. It is an

expensive metal and can therefore produce high incomes for recycling schemes.

Copper, zinc and lead are also recycled in the UK. At present, over a third of

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aluminum drinks cans are recycled. Some other countries have very high

recycling figures for aluminum drinks cans. The USA and Australia for example,

recycle nearly two thirds.

Every year in the UK between 25 and 30 million scrap tyres are

generated. Approximately 21% of these tyres are retreated and reused. The old

tread is ground off the tyre and replaced with a new tread. However, about half of

all used tyres are dumped in landfill sites throughout the country. Other tyres may

be incinerated.

TABLE 9 - MARKET PRICES OF HOSPITAL WASTE RECYCLABLES IN KARACHI

QUANTITY MIDDLE DEALERS MAIN DEALERS

Waste Material in kg/day Prices Total Prices Total

Rs Rs Rs Rs

Swabs/Dressings 1300.5 5 6502.50 7 9103.50

Placenta 120.00 - - - -

Plastic bags and Drips

1175.5 80 94040 100 117550

Urine bags 80.0 80 6400 100 8000 Syringes 630.4 8 5043.2 10 6304

Glassware 411.8 6 2470.80 8 3294.40

Plastic and Polythene

592.6 6 3555.6 8 4740.80

Paper 749.3 10 7493 12 8991.6

TOTAL 5060.10 125505.10 157984.30

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Figure 30 - Waste Recycling rates in USA

Figure 31 - Recycling Rates of selected materials in USA in 2001

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Figure 32 - Recycling Process Of a plastic bottle

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TABLE 10 - Recycling Versus Incineration: An Energy Conservation Analysis

C F AF FA C

FAB CFA F C BF A A AB FA C

B

FAB F FA F AFA

B

D EFA

C C

F C C

AE AB C C

D E E F C C

D C

C C

C C

D B AB C C

A E AB C C

D A A C C

CC

B AB C

D

F

AB

B ABC

D AB C

D B C

AB B A B C

D C

AB C

C C

C C

C C

FA

A C C

D FF C C

F F

B C C

B D AE C C

FAC C C

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7.2.3 - 3-R CONCEPT & THE EUROPEAN WASTE HIERARCHY IN

WASTE MANAGEMENT

Waste policy in the EU widely accepts the waste hierarchy of waste

management to be (in order of priority) as:

• Reduce (Waste prevention)

• Re-use

• Recycling

• Thermal decomposition with energy recovery (i.e. incineration with energy

recovery).

Figure 33 - Waste Hierarchy

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REDUCE

It means to reduce the amount of waste during the production

process. The amount of solid waste produced during production process can be

reduced as:

• We should buy a product without extra packing.

• We should buy long lasting products.

• Old newspapers, bottles and other plastic materials should sale instead of

throwing them here & there.

REUSE

We can reuse many things before we throw them away.

Therefore we could:

• Reuse bags (paper and plastic), containers, paper and other items.

• Sell or donate things you no longer use to people who will use them, e.g.

clothing and shoes.

• Repair shoes, boots, handbags and other items before you consider

‘throwing away’.

• Convert cans and plastic containers into plant pots.

RECYCLE

• To separate a given waste material from other wastes and to process it so

that it can be used again in a form similar to its original use.

• Recycling involves the collection of used and discarded materials

processing these materials and making them into new products.

• It reduces the amount of waste that is thrown into the community dust bins

thereby making the environment cleaner and the air fresher to breathe.

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The EU waste hierarchy in waste management.

In spite of this general consensus, and a growing coherence of this

hierarchy in policy lines of individual EU member states as a consequence of EU-

Directives, the majority of waste in Europe is either land filled or incinerated.

Importantly, these are the methods which also entail the highest and most

serious environmental and health risks.

The waste hierarchy

Within the hierarchy, the Governments do not expect incineration

with energy recovery to be considered before the opportunities for recycling and

composting have been explored

Reduction

Reuse

Recycle

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The proximity principle

Requires waste to be disposed of as close to the place of

production as possible. This avoids passing the environmental costs of waste

management to communities which are not responsible for its generation, and

reduces the environmental costs of transporting waste

The self-sufficiency principle.

The Governments believe that waste should not be exported from

one country to another for disposal. Waste Planning Authorities and the waste

management industry should aim, wherever practicable, for regional self-

sufficiency in managing waste. With regards to the EU Waste hierarchy, not

everything has gone well, however.

A move towards a waste policy aimed at reducing health effects

should put more emphasis on prevention and re-use. Presently, EU waste policy

is not founded upon health data. Fortunately the available data on health effects

from waste management do not conflict, and in important aspects even coincide

with the hierarchy proposed by the EU. For example, waste prevention is

deemed to be the most important (no waste equals no health effects), followed

by re-use and recycling. Despite this, the lack of consideration of the

environment and human health is clearly visible in EU policy.

For instance, regulations put in place for incineration by the EU

together, with national limits on this issue, are based on what is technically

achievable rather than on health and environmental data.

Although emission limits set in the new EU directive have resulted

in the closure and upgrading of some older incinerators in European countries,

the policy itself is already outdated with regard to the OPSPAR agreement to

phase out the releases of all hazardous substances within one generation. The

EU directive is based on the conception that small releases of hazardous

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substances are acceptable. This is the conventional (though misguided)

approach, which proposes that chemicals can be managed at "safe" levels in the

environment. However, it is already known, or is a scientific opinion, that there

are no "safe" levels of many environmental chemical pollutants such as dioxins,

other persistent, bio accumulative and toxic chemicals and endocrine disruptors.

In addition, the abandonment of the principle is increasing in political circles.

Figure 34 - Waste hierarchy

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The Way Forward: Adoption of the Precautionary Principle and Zero

release Strategy

The precautionary principle acknowledges that, if further

environmental degradation is to be minimized and reversed, precaution and

prevention must be the overriding principles of policy. It requires that the burden

of proof should not be laid upon the protectors of the environment to demonstrate

conclusive harm, but rather on the prospective polluter to demonstrate no

likelihood of harm. The precautionary principle is now gaining acceptance

internally as a foundation for strategies to protect the environment and human

health.

Current regulation for incinerators is not based on the precautionary

principle. Instead it attempts to set limits for the discharge of chemicals into the

environment which are designated as "safe". In the current regulatory system the

burden of proof lies with those who need to ‘prove’ that health impacts exist

before being able to attempt to remove the cause of the problem and not with the

polluters themselves. Based on knowledge regarding the toxic effects of many

environmental chemical pollutants, which has accumulated over recent decades,

a more legitimate viewpoint is that "chemicals should be considered as

dangerous until proven otherwise".

We have now reached a situation, and indeed did some time ago,

where health studies on incineration have reported associations between

adverse health effects and residing near to incinerators or being employed at an

incinerator. These studies are warning signs that should not result in government

inactivity, but rather to decisions being taken which implement the precautionary

principle.

There is already sufficient human health and environmental

contamination evidence to justify a phase out of the incineration process based

on the precautionary principle. To wait for further proof from a new generation of

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incinerators from an already harmful and dirty technology would probably be a

blatant disregard for the environment and human health.

The aim of "zero discharge" is to halt environmental releases of all

hazardous substances. Although it is sometimes discussed as being simplistic or

even impossible, it is a goal whereby regulation can be seen as resting places on

the way to achieving it.

Zero discharge necessitates the adoption of clean production

techniques both in industry and agriculture. It is essential that the change to

clean production and material use should be fully supported by fiscal incentives

and enforceable legislation.

The principle of clean production has already been endorsed by the

Governing Council of the UNEP and has received growing recognition at nation

level. The way forward for waste management in line with a zero emissions

strategy and hence towards sustainability, lies in waste prevention, re-use and

recycling. In other words the adoption of the already well-known principle of

"REDUCE, RE-USE AND RECYCLE".

IMPLEMENTATION OF REDUCE, RE-USE AND RECYCLE

We live in a world in which our resources are generally not given

the precious status by industry and agriculture which they deserve. In part, this

has led to the creation, particularly in industrialized countries, of a "disposable

society" in which enormous quantities of waste, including "avoidable waste" are

generated. This situation needs to be urgently changed so that the amount of

waste produced both domestically and by industry is drastically reduced.

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However, far more action is presently required to stimulate the

change needed for much more waste reduction to become a reality. Current

levels of recycling in European countries vary considerably. For instance, the

Netherlands recycles 46% of municipal waste whereas the UK only manages

8%. Intensive re-use and recycling schemes could deal with 80% of municipal

waste. It is recognized that fiscal measures can play a considerable role in

encouraging re-use and recycling schemes whilst discouraging least desirable

practices such as incineration and landfill.

Measures to be taken in the drive towards increased waste

reduction, re-use and recycling, and therefore towards lessening the adverse

health effects from waste management should include:

• The phase out of all forms of industrial incineration by 2020, including

MSW incineration. This is in line with the OSPAR Convention for the

phase out of emissions, losses and discharges of all hazardous

substances by 2020.

• Financial and legal mechanisms to increase re-use of packaging (e.g.

bottles, containers) and products (e.g. computer housings, electronic

components).

• Financial mechanisms (such as the landfill tax) used directly to set up the

necessary infrastructure for effective recycling.

• Stimulating markets for recycled materials by legal requirements for

packaging and products, where appropriate, to contain minimum amounts

of recycled materials.

• Materials that cannot be safely recycled or composted at the end of their

useful life (for example PVC plastic) must be phased out and replaced

with more sustainable materials.

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• In the short term, materials and products that add to the generation of

hazardous substances in incinerators must be prevented from entering the

waste stream at the cost of the producer. Such products would include

electronic equipment, metals and products containing metals, such as

batteries and florescent lighting, and PVC plastics (Vinyl flooring, PVC

electrical cabling, PVC packaging, PVC-u window frames etc) and other

products containing hazardous substances.

TABLE 11 - JOB CREATION: REUSE & RECYCLING VERSUS DISPOSAL IN THE UNITED STATES

EF EFA C DFA CEFA F A

DA F CF

A B

C D EF A F E

EB F B A B

FF A E

F B CF AFAC

EFFB

F BB

B

F B E

B

F C

B E

E E

EFFE

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7.2.4 - LANDFILL METHOD OF SOLID HOSPITAL WASTE DISPOSAL

Landfill is a site for the disposal of waste materials by burial. In the

past there have been problems with old, poorly managed landfills contaminating

waterways and releasing dangerous landfill gases. However, modern municipal

landfills are better managed with greater emphasis on avoiding environmental

effects. Modern municipal landfills still work by burying waste, but in contrast they

are highly engineered, controlled and monitored. They have liners to contain

leachate, a leachate collection and treatment system, a cap to reduce rain

infiltration and a monitoring system to assess the environmental effects.

Components of a Modern Landfill

1. Landfill liners: The first stage is to construct a landfill liner in order to

contain the landfill material and leachate. The most suitable sites will have a

natural clay liner; however the minimum acceptable is 6000mm of compacted

clay with a low permeability coefficient. This acts as a barrier, preventing

leachate from the landfill seeping into nearby aquifers or surface water bodies

where it could cause contamination. In addition to a clay liner, a plastic liner

may also be required for further protection of the surrounding environment.

2. Leachate collection and treatment systems: A series of pipes is

installed above the liner to collect the leachate at the bottom of the landfill.

The leachate is then piped to a leachate storage pond or holding tanks for

further treatment.

3. Landfill gas collection system: Landfill gas is produced from organic

waste disposed of in landfill. A landfill gas collection system is also installed

and consists of a series of perforated pipes laid within the waste connected to

a gas well from which the gas will be extracted. Collecting landfill gas is

important because it is high in methane, a potent greenhouse gas. The gas

may then be used by burn off or flares, or it may be used to generate

electricity.

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4. Monitoring system: This is in order to assess the environmental effects

of the landfill and may include leachate and landfill gas monitoring, an odor

control programme and a vermin control programme.

5. Landfill cap: When a landfill reaches the end of its life, it is closed and capped

with a layer of compacted clay and sometimes plastic sheeting. The capping must be

at least 600mm think and have a finished slope to minimize water infiltration.

Clean fill

A clean fill is another means of landfilling waste. However, unlike

modern municipal landfills, there are little or no containment measures for a

cleanfill.

A clean fill disposal site is usually an active or old quarry site in

which inert material is used to fill in the hollow created by excavation. Inert

material means material that will not cause significant adverse environmental or

health effects i.e. gravels, clays, soils, concrete, bricks, asphalt, chip seal, pavers

and similar construction and demolition wastes. Clean fills should not take

garden waste, timber, metals or other waste that could undergo any significant

physical, chemical or biological reaction to cause leachate or gas.

In June 2006 there were 33 cleanfill sites within Canterbury. 12 of

these are within the Christchurch City area. In Christchurch they can serve the

purpose of protecting groundwater resources by infilling old gravel pits with inert

material.

Cleanfill sites within Christchurch City are governed by their

resource consent conditions from Environmental Canterbury and by the

Christchurch City Council Cleanfill Licensing Bylaw.

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The Christchurch City Council Cleanfill Licensing Bylaw

The Christchurch City Council Cleanfill Licensing Bylaw 2003 came into

effect 1 March 2004 and sets out to encourage resource recovery. The Bylaw regulates

the types of materials that can be disposed of at a cleanfill and promotes materials

recovery, reuse and recycling.

Monofills

A B B C DEBD F DB A BAD D

D A BAA BA B DE C C A AB D AD B

E BC B DB A DEBD DE A F A C D F

F DB BD C DE BAD BD B E A DE D D B DEBD CB DE

A F A F C C

E B A B D BFF C D D

B D A F F A D F CA E B D B F DE C BAD

C A AB D DE B A A DE DE A B C BD B A A FE BA

BAD B C B C C BAD

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Figure 35 - Landfill site in Africa

PROBLEMS OF LANDFILLS

Leachate:

Leachate is the liquid that drains or 'leaches' from a landfill; it varies

widely in composition regarding the age of the landfill and the type of waste that it

contains. It can usually contain both dissolved and suspended material. The

organic material decomposes, producing acids. These acids mix with rainwater,

dissolve heavy metals and other toxics from the waste, and then percolate down

through the landfill. If not stopped by a liner, this Leachate will eventually

contaminate groundwater or surface water supplies. If a liner and collection

system is in place, Leachate treatment becomes an additional problem and

expense. However, even with a liner, all landfills eventually leak.

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Figure 36 - Leachate Pond

Greenhouse gases:

The decomposition of organic material under anaerobic (without

Oxygen) conditions produce large quantities of methane. Methane is a

contributor to the “greenhouse effect,” which is driving global climate change.

Landfill fires:

Methane is also highly flammable, and landfill fires are common

and difficult to put out. The uncontrolled burning of wastes in a landfill is likely to

result in air emissions similar to those from incinerators.

Vermin:

The organic material can attract rodents and other pests. This is

particularly problematic when landfills are located close to areas where people

live or work.

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Odor:

The rotting organics produce a strong, unpleasant odor.

Waste of land:

Landfills consume huge areas of land, often near metropolitan

areas where available land is scarce.

Waste of materials:

Landfills remove resources, both organic and inorganic, from the

economy in much the same way as do incinerators.

In Southern countries, landfills are even worse than in the North, as

they are often no more than unlined open dumps, scavenged by both people and

animals. The precarious living of such resource recoverers has been dramatically

demonstrated by the Payatas landfill disaster in the Philippines, where 200

people were killed in a landfill collapse in 2000.

Figure 37 - Sanitary Landfill - Area Method

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Figure 38 - Sanitary Landfill - Area Method

Figure 39 - Sanitary Landfill - Trench Method

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Figure 40 - Sustainable Landfill

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PVC: THE POISON PLASTIC

PVC is a commonly used plastic found in baby shampoo bottles,

packaging, saran wrap, shower curtains and thousands of other products yet

there is little public awareness of its serious health and environmental impacts.

Hospitals use plastics because they fear a spread of infection through the use of

reusable medical equipment. Thus, plastic use has grown with increasing

concern for infection control. However, there have been cases where even with

the use of plastics there has been a spread of infection in wards. Nurses

complained of nosocomial infections in wards even though disposable equipment

was used — they related it to improper waste disposal of disposable equipment

within the wards. PVC is a thermoplastic, with approximately 40 percent of its

content being additives. Plasticizers are added to make PVC flexible and

transparent.

• Medical equipment made from PVC:

• Blood bags, breathing tubes

• Feeding tubes, Pressure monitor tubes

• Catheters, Drip chamber

• IV Containers, Parts of a syringe

• IV Components, Lab ware

• Inhalation masks, Dialysis tubes

In the U.S., an estimated 300 billion pounds of longer-lasting PVC

products, such as construction materials that last 30 to 40 years, will soon reach

the end of their useful life and require replacement and disposal. As much as 7

billion pounds of PVC are discarded every year in the U.S. PVC disposal is the

largest source of dioxin-forming chlorine and phthalates in solid waste, as well as

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a major source of lead, cadmium and organ tins-which pose serious health

threats. Short-lived products account for more than 70% of PVC disposed in

America's solid waste with 2 billion pounds discarded every year, including

"blister packs" and other packaging, plastic bottles and plastic wrap. PVC was

promoted in industries as a replacement of metals. Therefore its use increased in

all types of industries very rapidly. But side effects are so dangerous that we

should avoid its use.

Figure 41 - Trends in U.S PVC Consumption

8.1 - SUMMARY OF KEY FINDINGS OF THE FIVE EU STUDIES PVC WASTES ON THE INCREASE:

The amounts of PVC wastes are projected to increase more than

80% over the next 20 years, from 4.1 to 7.2 millions tones/year. Almost 90% of

these wastes are post consumer wastes.

CONSUMPTION OF PVC IN EUROPE

The consumption of final PVC products according to application

sectors in Europe and in some Member States is shown below:

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Europe Austria Germany Denmark France

Building 53 % 81 % 60 % 69 % 50 %

Packaging 16 % 2 % 11 % 8 % 30 %

Electronics/cable 9 % 8 % 8 % 8 %

Transport/cars 3 % 4 % 4 % 6 %

Furniture 3 % 2 % 3 %

Others 16 % 3 % 14 % 23 % 6 %

TABLE 12 - Source: Europe, Austria, Germany (AgPU, 1997), Denmark (Moeller et al., 1996), France (PVC working Group, 1999)

8.2 - INCINERATION – MAKING THINGS WORSE:

Incineration of 1 kg of PVC in the EU creates on average 0.8-1.4 kg

of hazardous wastes (in incinerators with non-wet flue gas treatment) and 0.4-0.9

kg of residues in liquid effluent (in incinerators with wet flue gas treatment).

Hazardous waste from PVC incineration will also be more likely to contaminate

the environment, as PVC increases the amount of Leachate and leach able salts

in this waste significantly. Incineration of PVC creates additional costs between

20-335 Euro/tonne. PVC is responsible for 38 to 66% of the chlorine content in

Municipal solid waste. The formation of dioxins due to PVC has been beyond the

scope of the study. Diverting PVC from incineration always leads to

environmental improvements. Nevertheless, PVC incineration is estimated to

increase more than fivefold over the next 20 years in a business-as-usual

scenario, from currently 0.5 million tones/year to 2.6-2.9 million tonnes/year.

DON'T BURN IT: THE HAZARDS OF BURNING PVC WASTE

• More than 100 municipal waste incinerators in the U.S. burn 500 to 600

million pounds of PVC each year, forming highly toxic dioxins and

releasing toxic additives to the air and in ash disposed of on land.

• Open burning of solid waste, which contains PVC, is a major source of

dioxin air emissions. Backyard burning of PVC household trash is

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unrestricted in Michigan and Pennsylvania, partially restricted in 30 states

and banned in 18 states.

• The incineration of medical waste is being steadily replaced by cleaner

non-burn technologies.

• When burned, PVC plastic forms dioxins, a highly toxic group of chemicals

that build up in the food chain, can cause cancer and harms the immune

and reproductive systems.

• PVC is the leading contributor of chlorine to four combustion sources

municipal solid waste incinerators, backyard burn barrels, medical waste

incinerators and secondary copper smelters that account for an estimated

80% of dioxin air emissions (USEPA).

TOP TEN STATES INCINERATING PVC

STATE AMOUNT OF

PVC INCINERATED

(TONS)

NUMBER OF INCINERATORS

PERCENT INCINERATED(AFTER

RECYCLING)

FLORIDA 45,364 13 37.1%

NEW YORK 37,517 10 24.4%

MASSACHUSETTS 28,145 7 54.6%

VIRGINIA 18,806 5 27.9%

PENNSYLVANIA 17,746 6 22.6%

CONNECTICUT 16,257 6 55.4%

MINNESOTA 14,432 15 46.1%

MARYLAND 12,486 3 22.6%

MAINE 5,448 4 66.2%

HAWAII 3,454 1 32.7%

NEW HAMPSHIRE 1,675 2 22.2%

REMAINING STATES *

49,075 32 VARIES

TOTAL 250,405 104 10.5%

TABLE 13 – TOP TEN STATES INCINERATING PVC

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PVC PRODUCTS + WASTE INCINERATORS OR OPEN BURNING = DIOXIN EMISSIONS

Dioxin formation is the Achilles heel of PVC. Burning PVC plastic,

which contains 57% chlorine when pure, forms dioxins, a highly toxic group of

chemicals that build up in the food chain. PVC is the major contributor of chlorine

to four combustion sources—municipal solid waste incinerators, backyard burn

barrels, medical waste incinerators and secondary copper smelters—that

account for a significant portion of dioxin air emissions. In the most recent

USEPA Inventory of Sources of Dioxin in the United States, these four sources

accounted for more than 80% of dioxin emissions to air based on data collected

in 1995. Since then, the closure of many incinerators and tighter regulations have

reduced dioxin air emissions from waste incineration, while increasing the

proportion of dioxin disposed of in landfills with incinerator ash. The PVC content

in the waste steam fed to incinerators has been linked to elevated levels of

dioxins in stack air emissions and incinerator ash.

Incineration and open burning of PVC-laden waste seriously

impacts public health and the environment. More than 100 municipal waste

incinerators in the U.S. burn 500 to 600 million pounds of PVC each year,

forming highly toxic dioxins that are released to the air and disposed of on land

as ash. The biggest PVC-burning states include Massachusetts, Connecticut,

Maine—which all burn more than half of their waste— Florida, New York,

Virginia, Pennsylvania, Maryland, Minnesota, Michigan, New Jersey, Indiana and

Washington.

The incineration of medical waste, which has the highest PVC

content of any waste stream, is finally being replaced across the U.S. by cleaner

non burn technologies after years of community activism and leadership by

environmentally-minded hospitals.

Backyard burning of PVC-containing household trash is not regulated at the

federal level and is poorly regulated by the states. There are no restrictions on

backyard burning in Michigan and Pennsylvania. It is partially restricted in 30

states, and banned in 18 states.

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8.3 - RECYCLING – NOT SOLVING THE PROBLEM:

Recycling was found not to be qualified to contribute significantly to

the management of PVC waste in the next decades, reaching at most 18% of

total waste in 2020. Assuming that the maximum potential of PVC recycling is

achieved, incineration of PVC waste would still increase more than fourfold to

2.2-2.5 million tones in 2020. Current recycling rates are at less than 3%. Most

current recycling (2%) is down cycling - the recycling of PVC into low quality

recycled that do not replace virgin PVC – and therefore has no environmental

benefits. Almost all PVC wastes contain hazardous additives.

Recycling these wastes leads to a spreading of these hazardous

substances into new products. High-quality recycling of PVC wastes without

spreading lead, cadmium or PCBs into the recycled is estimated to reach a

maximum of 5% by 2020. Chemical recycling was found to be not economically

viable.

PVC PRODUCTS + RECYCLING = CONTAMINATION OF THE ENTIRE PLASTICS RECYCLING PROCESS

Unfortunately, PVC recycling is not the answer. The amount of PVC

products that are recycled is negligible, with estimates ranging from only 0.1% to

3%. PVC is very difficult to recycle because of the many different formulations

used to make PVC products. Its composition varies because of the many

additives used to make PVC products. When these different formulations of PVC

are mixed together, they cannot readily be separated which is necessary to

recycle the PVC into its original formulation. It’s also virtually impossible to create

a formulation that can be used for a specific application. PVC can never be truly

recycled into the same quality material—it usually ends up being made into lower

quality products with less stringent requirements such as park benches or speed

bumps. When PVC products are mixed in with the recycling of non-chlorinated

plastics, such as in the “all-bottle” recycling programs favored by the plastics

industry, they contaminate the entire recycling process. Although other types of

non-chlorine plastics make up more than 95% of all plastic bottles, introducing

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only one PVC bottle into the recycling process can contaminate 100,000 bottles,

rendering the entire stock unusable for making new bottles or products of similar

quality. PVC also increases the toxic impacts of other discarded products such

as computers, automobiles and corrugated cardboard during the recycling

process.

8.4 - PVC PRODUCTS + LANDFILL DISPOSAL =GROUNDWATER CONTAMINATION

Land disposal of PVC is also problematic. Dumping PVC in landfills

poses significant long-term environmental threats due to leaching of toxic

additives into groundwater, dioxin-forming landfill fires, and the release of toxic

emissions in landfill gases. Land disposal is the final fate of between 2 billion and

4 billion pounds of PVC that are discarded every year at some 1,800 municipal

waste landfills in the U.S.

Most PVC in construction and demolition debris ends up in landfills,

many of which are unlined and cannot capture any contaminants that leak out.

An average of 8,400 landfill fires is reported every year in the U.S., contributing

further to PVC waste combustion.

LAND FILLING - THE TICKING TIME BOMB:

Land filling of PVC results in the release of hazardous softeners.

Releases of hazardous stabilisers cannot be excluded. Stabilisers are ingredients

that are generally added to the PVC polymer in order to prevent thermal

degradation and hydrogen chloride evolution during processing and to give the

finished article optimum properties (heat and UV stability). Approximately 1-8 %

may be added to PVC formulation depending on other components and the final

application.

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The most important group of stabilisers are (based on Moeller et al, 1996)

• Metal salts (i.e. calcium and zinc stearates, basic lead sulphate and lead

phosphate)

• Organo metals (i.e. mono- and diorganotin, tin thioglycolate)

• Organo phosphites (i.e. tri alkyl-phosphites)

• Epoxy compounds (i.e. epoxidised Soya bean oil, sunflower oil and

linseed oil)

• Antioxidants, polyols (i.e. BHT, pentaerythritol)

These releases will occur for a very long period of time - longer

than the guarantee of the technical barrier of the landfill. PVC waste will

furthermore contribute to the formation of dioxins and furans in landfill fires.

Ettala et al (1996) have investigated landfill fires in Finland. On

average, there are 633 sanitary landfills in operation in Finland. In the period of

1987-92 between 360 and 380 landfill fires occurred annually. One-quarter were

deep fires at a depth of more than 2m and a maximum depth of 8m. Deep fires

are difficult to extinguish and last longer than surface fires.

The most severe deep fires lasted for 2 months. Only four fires

occurred in waste older than 2 years. In 400 sanitary landfills in Sweden, 200-

250 fires have been reported. According to international experts11, landfill fires

are common in Iceland because of arson. Other replies considered that landfill

fires are very uncommon but reliable statistics were lacking. Disposal of ash,

deliberate fire starting and insufficient covering or compacting were reported to

be the most common causes for landfill fires. Possible air flow through drainage

pipes has been one reason for landfill fires in the U.K.

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ESTIMATED AMOUNTS OF PVC DISCARDED IN LANDFILLS ACCORDING TO STATES THAT LANDFILL THE MOST MUNICIPAL SOLID WASTE (MSW)

STATE NUMBER OF LANDFILLS

AMOUNT OF PVC LANDFILLED (TONS)

California 161 328,260

Texas 175 176,896

New York 26 116,088

Ohio 44 100,509

Illinois 51 98,896

Michigan 52 96,241

Florida 100 76,817

Georgia 60 69,177

Pennsylvania 49 60,844

New Jersey 60 56,166

North Carolina 41 54,842

Indiana 35 52,986

Washington 21 49,128

Virginia 67 48,636

Maryland 20 42,722

Remaining States * 805 610,553

Total 1,767 2,038,761

TABLE 14 – TOP STATES USING LANDFILL METHOD

By comparing the above data of incineration & land filling, the writer

is of the opinion that land filling of PVC is a lesser evil as compared to the

incineration. As incineration of PVC results in pollution of world’s atmosphere

while land filling of PVC results in pollution of a specific piece of land.

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THE BEHAVIOR OF PVC UNDER SIMULATED LANDFILL CONDITIONS

1. METHODOLOGICAL APPROACH

All investigations into the impact of landfill conditions on different

materials or substances have to take two major factors into consideration: time

and scale. To evaluate the behavior of PVC in landfills suitable methods had to

be developed to overcome these factors. Investigations in earlier studies showed

that the final state of organic substances in a staunch free landfill is always the

same: an aerobic stabilised humic-like substance, nearly water insoluble. The

same result can be reached by aerobic degradation within a much shorter time

span. To achieve comparability between tests and the real behavior of PVC in

landfill, PVC samples from a landfill were analyzed. At the second stage,

examinations were carried out at container size under aerobic thermophilic

conditions at a biological waste treatment plant. In laboratory scale the samples

were exposed to aerobic thermophilic conditions, to anaerobic thermophilic

conditions and to alternating aerobic-anaerobic conditions.

CONCLUSION

On the basis of performed analysis it is to conclude that PVC-

additives during staying for more than 20 years in a landfill will neither

degrade completely nor release completely from PVC products.

2. INVESTGATION OF BEHAVIOR OF PVC IN A BIOLOGICAL WASTE

TREATMENT PLANT IN TECHNICAL SCALE

Due to operation control of the plant the heat production which

causes high temperature during aerobic degradation processes was restricted.

Therefore the temperatures were generally lower than in lysimeter investigations.

The intensive degradation phase in the waste treatment plant usually takes about

12 days dependent on the amount of waste to be treated. This phase is carried

out in containers which will be emptied after that time. Therefore the PVC

samples could not be stored in the waste continuously. The intervals of

temperature of about 20°C in figure below show the times the PVC was stored

while waiting for the next run of waste treatment.

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The PVC-materials changed during the incubation in the biological waste

treatment plant. Both, optically and mechanically they showed differences to the

raw materials. Analysis of the materials was carried out similarly to investigations

during the lysimeter tests. Changes in materials were examined by electron

scanning microscopy, tensibility tests, and analysis of molecular weight

distribution and analysis of the contents of additives. Investigations on the

behavior of PVC products in the biological waste treatment plant showed clearly

recognizable effects on the PVC.

Figure 42 - Course of temperature and carbon dioxide production in lysimeter (aerobic, without

added PVC)

The results show a clear loss of plasticiser during the lysimeter

studies under aerobic thermophilic conditions within the short time of

examinations. Measured losses from the materials taken from the lysimeters 4

and 6 are within the tolerance of the determination method. The trend towards a

decreasing content of plasticiser is probable. A clear loss of plasticiser has

occurred to the car interior material in the aerobic biological treatment plant

supporting the results from lysimeter 2. The theory to explain the differences

between the losses of plasticiser between the used car interior and the

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packaging foil with the dependence on the thickness of the material are

strengthened by the results from lysimeter 6 and the biological treatment plant. In

these investigations too the percentage of loss of plasticiser is higher from the

thin material.

The content of the plasticiser DIDP in both flooring materials shows

no decrease following the aerobic treatment in lysimeter 2. On the one hand it

could be explained with the fact that DIDP will leach much slower than DEHP or

it would not leach out.

Any loss of stabiliser leads to emissions in Leachate. The stabiliser

content was investigated by analysis of the heavy metal contents before and

after storing the PVC-materials in the lysimeters. In this investigation only the

samples containing stabilisers based on heavy metals were tested. These are

PVC II, PVC VI, PVC V, PVC VI and PVC VII. In spite of its content of Ba/Zn-

stabiliser PVC III was not investigated because PVC II contains the same

elements. The results are summarized in table below.

Material Examined condition Contents of heavy metals in % by weight

Pb Ba Zn Cd

PVC II Raw material - 0,01 0,02 -

Lysimeter 2; aerobic Lysimeter 6; Anaerobic --

0,09 0,03 0,02 0,01 --

PVC IV Raw material 2,8 - - -

Lysimeter 2; Aerobic Lysimeter 6; Anaerobic

1,2 1,8 -- -- --

PVC V Raw material - 0,18 - 0,33

Lysimeter 2; Aerobic Lysimeter 6; Anaerobic biol. waste treatment plant

---

0,13 0,16 0,16

---

0,33 0,33 0,31

PVC VI Raw material - <0,01 0,01 -

Lysimeter 2; Aerobic Lysimeter 6; Anaerobic Biol. Waste Treatment Plant

--- 0,15 0,04 0,16

0,04 0,05 0,05

---

PVC VII Raw Material - 0,14 - 0,39

Lysimeter 2; Aerobic - 0,13 - 0,38

TABLE 15 – PVC EXAMINATION RESULTS

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3. BEHAVIOR OF GASEOUS EMISSION FROM LADNFILL

To examine gaseous emissions from PVC the condensate from

lysimeter gas and the gas, enriched on charcoal, from the lysimeters were

analyzed to identify differences in composition and possible detrimental

substances in gas from waste not contaminated with PVC and waste enriched

with PVC. Only aerobic and aerobic-anaerobic lysimeters were included in the

investigation because of the constant gas flow through the waste. This flow was

caused by aeration of the lysimeters. Gas flow from anaerobic lysimeters can not

be assumed as constant and no analysis was undertaken. The result indicates

that volatile substances are released in case of the presence of PVC in

degrading waste.

4. BEHAVIOR OF EMISSION FROM LADNFILL SIMULATION TO

LEACHATE

To examine emissions from PVC, the Leachate from the lysimeters

was analyzed to investigate differences in composition and pollution of Leachate

from waste not contaminated with PVC and waste enriched with PVC. The

samples were taken from the lysimeters half-way through and at the end of the

studies.

The results show no certain differences between the lysimeters

containing PVC and the lysimeters without PVC. There are normal differences

between the three conditions aerobic, aerobic-anaerobic and anaerobic, but

there is no connection to the PVC materials.

To evaluate emissions of heavy metals caused by the PVC

stabilisers, the Leachate from the lysimeters was analyzed by atom absorption

spectroscopy. The results are shown in table below.

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Lysimeters Cadmium

[mg/l] Lead [mg/l] Zinc [mg/l]

after 45

days

after 90

days

after 45

days

after 90

days

after 45

days

After 90

days

• Aerobic without PVC 0.08 0.08 0.77 0.50 17.1 5.18

• Aerobic with PVC 0.04 0.04 0.25 0.27 1.38 1.32

• Aerobic-Anaerobic without PVC

0.03 0.03 0.33 0.66 33.0 20.8

• Aerobic-Anaerobic with PVC

0.01 0.05 0.37 0.50 1.30 3.48

• Anaerobic without PVC 0.02 0.02 0.23 0.12 0.21 0.16

• Anaerobic with PVC 0.05 0.02 0.40 0.12 0.23 0.18 TABLE 16 - Results from the analysis of heavy metals in the Leachate of the lysimeters

CONCLUSIONS:

The aerobic thermophilic condition is considered to accelerate landfill

degradation processes and to provoke a state of degradation, which is

similar to the state of degradation in the final aerobic landfill phase.

Landfills are very heterogeneous in terms of waste composition and

physico-chemical characteristics not only between landfills but also

within a single landfill. PVC products are subjected to different

degradation processes in landfills which are determined by the

parameters temperature, moisture, presence of oxygen, activity of micro-

organisms and the interactions between parameters at different stages

of the ageing development of landfills.

Changes in the PVC products are reported from aerobic as well as from

anaerobic conditions. In real landfills aerobic conditions prevails in the

initial stage, which is rather short. Losses of Phthalates from PVC

materials under soil-buried (aerobic) conditions are reported to amount

to 30-35% of the total content.

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During the anaerobic phases of the landfill, degradation of PVC products

appears to be slower than under aerobic thermophilic conditions but the

release of phthalates in particular, will probably continue and an attack

on the PVC polymer, at least caused by high temperatures which may

occur in large landfill sites, cannot be excluded.

The analysis of materials being disposed of in a landfill more than 20

years ago still showed considerable amounts of plasticisers and

stabilisers. A release of phthalates under methanogenic conditions is

reported in the literature in a range of 4 to 40 %.

Heavy metals are more likely to be released under acidogenic conditions

while phthalates are particularly released during aerobic and

methanogenic stages of landfill development.

With regard to the release of phthalates again different processes are to

be distinguished, i.e. physical, hydrolytic and biological effects occur

concurrently. The fate of released additives is in case of phthalates

depending on hydrolytic and biological effects, on the retention capacity

of the waste matrix, on adsorption to particulate matter and co-transport.

In case of heavy metals, particularly acidity, the retention capacity of the

waste matrix and hydraulic effects determine emissions.

The degradation of phthalates from PVC under methanogenic conditions

is observed to be higher than under acidogenic conditions. Results from

studies on the degradability of phthalates under landfill conditions show

that degradation of PAEs occur, however, the rate of degradation does

appear to be influenced by the length of their side chain. Both, PAEs and

phthalic monoesters can be detected in landfill Leachate, which indicates

that these substances are not completely degraded.

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There is no evidence that the release of additives will come to a

standstill. Thus, it is expected that this process will last for a very long

time which cannot be estimated at a probably steady decreasing level.

Nowadays the technical guarantee for landfill bottom liners and pipes for

Leachate collection is restricted to 80 years. Emissions resulting from

the presence of PVC in landfills are likely to last longer than the

guarantee of the technical barrier.

Emissions to environmental media such as air, soil and groundwater is

to be expected particularly from landfills without active environmental

protection measures (old landfills). Furthermore, as there is evidence

that phthalates, DEHP mainly, are not fully eliminated through current

Leachate treatment, even from landfill sites equipped with Leachate

collection system and treatment of Leachate either on-site or off-site,

emissions to aquatic ecosystems cannot be excluded.

8.5 - SAFER ALTERNATIVES ARE AVAILABLE TO REPLACE PVC

Safer alternatives to PVC are widely available and effective for

almost all major uses in building materials, medical products, packaging, office

supplies, toys and consumer goods. PVC is the most environmentally harmful

plastic. Many other plastic resins can substitute more safely for PVC when

natural materials are not available.

PVC alternatives are affordable and already competitive in the

market place. In many cases, the alternatives are only slightly more costly than

PVC, and in some cases the costs of the alternative materials are comparable to

PVC when measured over the useful life of the product.

Phasing out PVC in favor of safer alternatives is economically

achievable. A PVC phase-out will likely require the same total employment as

PVC production. The current jobs associated with U.S. PVC production (an

estimated 9,000 in VCM and PVC resin production, and 126,000 in PVC

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fabrication) would simply be translated into production of the same products from

safer plastic resins.

8.6 - HOW CAN WE GET RID OF PVC?

To end the myriad of problems created by PVC disposal, we

recommend the following policies and activities.

Policymakers at the local, state and federal level should enact and

implement laws that steadily reduce the impacts of PVC disposal and lead

to a complete phase-out of PVC use and waste incineration within ten

years (see box below).

A new materials policy for PVC that embraces aggressive source

reduction of PVC should be adopted to steadily reduce the use of PVC

over time.

Federal and state waste management priorities should be changed to

make incineration of PVC waste the least preferable option. In the interim,

any PVC waste generated should be diverted away from incineration to

hazardous waste landfills.

Consumers should take personal action to buy PVC free alternatives and

to remove PVC from their trash for management as household hazardous

waste.

Communities should continue to organize against PVC-related dioxin

sources such as waste incinerators while working to promote safer

alternatives.

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8.7 - A PVC- FREE POLICY ACTION AGENDA

Accomplish Within Three Years

1. Ban all open waste burning.

2. Educate the public about PVC hazards.

3. Ban the incineration of PVC waste.

4. Collect PVC products separately from other waste.

5. In the interim, divert PVC away from incineration to hazardous waste landfills.

Accomplish Within Five Years 6. Establish our Right-to-Know about PVC.

7. Label all PVC products with warnings.

8. Give preference to PVC-free purchasing.

9. Ban PVC use in bottles and disposable packaging.

10. Ban sale of PVC with lead or cadmium.

Accomplish Within Seven Years 11. Phase out other disposable PVC uses.

12. Phase out other high hazard PVC uses.

13. If safer alternatives are not yet available, extend the PVC phase-out

deadlines for specific purposes.

14. Fund efforts to reduce the amount of PVC generated through fees on the

PVC content of products.

Accomplish Within Ten Years 15. Phase out remaining durable PVC uses.

16. Decommission municipal waste incinerators in favor of zero waste.

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8.8 - GREENPEACE ADVOCATES THE FOLLOWING MEASURES

The studies show multiple significant environmental and/or

economic problems for each of the PVC waste disposal options. They show that

neither incineration nor landfill is safe, and that recycling cannot solve the

problem. It is irresponsible to keep manufacturing such a material. Its

manufacture and use needs to be phased out as soon as possible, starting with

short-lived applications such as packaging. Existing wastes need to be fully

separated from the general waste stream and safely stored separately until an

environmentally safe destruction technology has been established. The costs

should be borne by the producer.

Greenpeace advocates that the following measures be taken against PVC:

1. SHORT-TERM ACTION:

• Phase out of short-lived PVC uses such as packaging and toys,

• Phase out of PVC medical devices, for which alternatives are

available,

• Phase out of the use of hazardous stabilizers and softeners,

• Ban on incineration and land filling of PVC wastes,

• Ban on recycling of PVC containing hazardous additives, and

• Producer responsibility for the separation of PVC from the general

waste stream and temporary storage until a waste solution has

been found and implemented by the producer,

2. Mid-Term Action

• Develop and implement programme on phase out of entire PVC

production.

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9.1 - ENVIRONMENTAL LEGISLATION IN PAKISTAN

At independence, Pakistan inherited a number of laws from the

colonial period that were converted to environmental provisions. The constitution

of 1973 mentions environmental objectives in the preamble, but no specific law

was drafted at that time.

9.1.1-PEPO – PAKISTAN ENVIRONMENTAL PROTECTION ORDINANCE

The first piece of legislation to consider environment as a whole

was the Environment Protection Ordinance of 1983, which sanctioned

establishment of Pakistan Environmental Protection Council chaired by the Prime

Minister, Pakistan Environmental Protection Agency and provincial

Environmental Protection Agencies. Since then many institutional, policy and

regulatory developments have taken place at the Federal and Provincial levels.

These, inter-alia, include creation of the Ministry of Environment, promulgation of

Pakistan Environmental Protection Ordinance-1983. This highlighted the need to

have a framework of environmental law in Pakistan to address emerging national

issues. PEPO established the Pakistan Environmental Protection Council

(PEPC) and the Pakistan Environmental Protection Agency, as well as

introducing the concept of Environmental Impact Assessments. It is unfortunate

that PEPO has remained largely unimplemented.

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9.1.2 - PAKISTAN ENVIRONMENTAL PROTECTION COUNCIL (PEPC)

BACKGROUND IN SUMMARY:

Pakistan Environmental Protection Council (PEPC) was set

up in 1984: Pakistan Environmental Protection Council (PEPC) is an apex

organization at the National level for formulation and implementation of the

national environmental policy and programmes. It was set up in 1984 under

section 3 of the Pakistan Environmental Protection Ordinance. During the first ten

years of its existence only one meeting of the PEPC had been held under the

Caretaker Prime Minister of Pakistan whom decided to establish the National

Environmental Quality Standards.

THE STANDARDS WERE RELATED TO:

• Municipal and liquid industrial effluent

• Industrial gaseous emissions and

• Motor vehicle exhaust and noise. These standards were notified in the

Gazette of Pakistan on 29 August 1993

A CHANGE IN MANAGEMENT REVITALIZED PEPC:

Later on in July 1994, there was a change in the Chairperson of

PEPC. The new Chairperson re-vitalized the PEPC and it emerged as a fully

functioning institution. As against, only one meeting of the PEPC in 10 years

(between 1984 to 1993), seven meetings of the PEPC were held in the span of

20 months from 1994 to 1996.

SIGNIFICANT PHYSICAL IMPROVEMENTS WERE MADE IN FORESTATION:

During his tenure from 1994 to 1996, he accorded the highest priority to tree

plantation as the key component of environment. He launched a massive

forestation campaign throughout the country with a view to double the forest

cover in ten years. About 90 million saplings were planted in 1995 and 280

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million in 1996, in addition to plantation of 218 million saplings, as part of the

regular programmes of the Forestry Departments of the Provincial Governments.

9.1.3 - NATIONAL ENVIRONMENTAL QUALITY STANDARS

PEPC met in 1993 for the first time and approved National

Environmental Quality Standards (NEQS) which later formulated the limits on

major pollutants in municipal and industrial liquid effluents, industrial gaseous

emissions, motor vehicle exhaust and noise.

9.1.4 - PEPA – PAKISTAN ENVIRONMENTAL PROTECTION ACT – 1997

The draft Environmental Protection Act, which lapsed in 1996 after failing

to be approved in the National Assembly has recently been redrafted and

unanimously passed by the Assembly. The Pakistan Environmental Protection

Act 1997 was passed by the National Assembly of Pakistan on September 3,

1997, and by the Senate of Pakistan on November 7, 1997. The Act received the

assent of the President of Pakistan on December 3, 1997.

The approach taken for the protection of the environment in

Pakistan is laid down in the Environmental Conservation Strategy of 1992 and its

review in 2000. For specific rules and regulations, “The Environmental Protection

Act” was enacted in 1997 and it provides the backbone and framework for

environmental legislation in Pakistan. This act establishes the Pakistan

Environmental Protection Council, the highest decision making body in

environmental issues, the Pakistan Environmental protection Agency (Pak EPA)

and Environmental Tribunals.

The Pakistan Environmental Protection Council (PEPC) shall,

among other duties, co-ordinate and approve comprehensive national

environmental polices and approve National Environmental Quality Standards.

The act further defines the functions of institutions, providing a broad mandate to

for enacting rules, procedures and technical standards in different areas of

environmental protection. The Act requires Pak EPA to co-ordinate

environmental policies and programmes nationally and internationally, initiate

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legislation, establish surveys, manage monitoring and auditing schemes,

promote research as well as education and awareness in the field of the

environment.

The Environmental Protection Act does further require the

provincial authorities to establish Provincial Environmental Protection Agencies

for carrying out functions delegated to the provinces. The Government of

Pakistan has recently elaborated its further action in-line with the finding of the

review of the National Conservation Strategy in the form of the National

Environmental Action Plan, NEAP (as approved by PEPC in 2001).

The Government of Pakistan has, with assistance from UNDP,

embarked on a major programme in support of the NEAP. The NEAP-support

Programme has subprogrammes in the areas of policy Co ordination and

Environmental Governance, and Pollution Control. POPs Enabling Activity

Project of Pak-EPA has been launched in collaboration with UNDP and GEF.

UNITAR is providing technical assistance and international coordination for the

project.

Pakistan ratified the Basel Convention on Trans boundary

Movements of Hazardous Waste and their Disposal in 1994 and is a signatory to

the Rotter dam Convention (1997) for the Prior informed Consent (PIC)

procedure for Banned or Restricted Chemicals in International Trade. Pakistan

has also signed Stockholm Convention in 2001 and ratification of the SC is

currently under consideration. Pakistan has developed a National Profile for

chemicals, published in October 2000, with the assistance of UNITAR.

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9.1.5 - NATIONAL ENVIRONMENTAL POLICY 2005

The National Environmental Policy (2005-15) has, therefore, been

prepared to provide an overarching framework for achieving the goals of

sustainable development through protection, conservation and restoration of

Pakistan's environment.

POLICY VISION

The National Environmental Policy aims to improve the quality of

life of people of Pakistan through conservation, protection and improvement of

the country's environment and effective cooperation among government

agencies, civil society, private sector and other stakeholders.

OBJECTIVES

The objectives of the Policy are to:

• Secure a clean and healthy environment for the people of Pakistan.

• Attain sustainable economic and social development with due regard to

protecting the resource base and the environment of the country.

• Ensure effective management of the country's environment through active

participation of all stakeholders.

Guide lines / Principles

• The following guiding principles shall be applied to achieve the objectives

of the Policy:

• Principle of sustainable development.

• Principle of equitable access to environmental resources.

• Creation of demand for a better environment.

• Respect and care for the environment.

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• Integration of environment into planning and implementation of policies,

programs and projects.

• Changing personal attitudes and behaviors.

• Precautionary principle.

• Polluter pays principle.

• Substitution principle.

• Improving efficiency with which environmental resources are used.

• Cradle to grave management.

• Best available technology.

• Decentralization and empowerment.

• Extensive participation of communities, stakeholders and the public.

• Accountability and transparency.

• Increased coordination and cooperation among federal and provincial

governments, NGOs, private sector and academia.

• Increased regional and international cooperation.

Pollution and Waste Management

Pollution caused by liquid and solid waste in the country shall be

prevented and reduced. For this purpose, the government shall:

• Strictly enforce the National Environmental Quality Standards.

• Introduce self monitoring and reporting system nationwide.

• Introduce discharge licensing system for industry.

• Make installation of wastewater treatment plants an integral part of all

sewerage schemes.

• Develop and implement the National Sanitation Policy.

• Implement the Master Plan for Treatment of Urban Waste Water.

• Develop and implement a strategy for establishment of combined

treatment plants in industrial clusters.

• Establish cleaner production centers and promote cleaner production

techniques and practices.

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• Promote ISO 14000 certification.

• Encourage reduction, recycling and reuse of municipal and industrial solid

and liquid wastes.

• Establish standards for receiving water bodies.

• Launch phased programs for clean up and gradual up-gradation of quality

of water bodies.

• Develop and enforce regulations to reduce the risk of contamination from

underground storage tanks.

• Finalize the National Oil Spill Contingency Plan.

• Implement projects for mitigation of pollution caused by oil spill from the

Tasman Spirit.

• Establish a Marine Pollution Control Commission. Frame Pakistan Oil

Pollution Act.

• Develop arid enforce rules and regulations for proper management of

municipal solid waste and industrial, hazardous and hospital waste.

• Regulate production / import of hazardous substances and wastes.

• Develop and implement strategies for integrated management of

municipal, industrial, hazardous and hospital waste at national, regional

and local levels.

• Strengthen capacity of institutions involved in waste management.

• Encourage involvement of the private sector in waste management.

• Establish facilities for recovery of raw material and energy from waste.

Create market for recovered and recycled materials.

• Promote research and development focusing on low-waste technologies

and technologies for waste recovery and reuse.

• Develop environmental risk assessment guidelines for existing industries

as well as new development interventions.

• Develop national emergency response and accidents preventions plans to

prevent, and mitigate the effects of, accidents involving pollution of

environment.

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National Environmental Policy is the most comprehensive policy

ever formulated in Pakistan. This policy not only differentiates between industrial,

chemical & healthcare waste but also provides guidelines to solve the problems.

It is a serious effort to solve the waste problem according to the

international standards. Solid Waste Management (SWM), in all major cities of

Pakistan has been started very successfully in accordance to this policy. In near

future, Pakistan will be able to manage the different types of waste in an efficient

way.

9.1.6 – HOSPITAL WASTE MANAGEMENT RULES 2005

Hospital waste management rules were implemented in 2005.

RESPONSIBILITY FOR WASTE MANAGEMENT

Every hospital shall be responsible for the proper management of

the waste generated, collected, and received by it till its final disposal in

accordance with the provisions of the Act and the rules 16 to 22.

WASTE MANAGEMENT TEAM

The Medical Superintendent of the hospital shall constitute a Waste

Management Team comprising the following members, by whatever designation

called -

(a) The Medical Superintendent, who shall be the Chairman;

(b) The Heads of all hospital departments;

(c) The Infection Control Officer;

(d) The Chief Pharmacist;

(e) The Radiology Officer;

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(f) The Senior Matron;

(g) The Head of Administration;

(h) The Hospital Engineer;

(I) Senior Nursing Officer; and

(i) Such other staff members as the Medical Supervisor may designate.

(2) - In hospital where the posts mentioned in sub-rule (1) do not exist, the

Medical Superintendent shall either himself perform, or designate another staff

member to perform, the duties and responsibilities of the holder of such posts, as

described in Rules 8 to 14.

(3) - Members of the Waste Management Team shall be informed in writing by

the Medical Superintendent of their appointment and their duties and

responsibilities, as described in Rules 8 to 14

(4) - One of the members of the Waste Management Team shall be designated

by the Medical Superintendent as the Waste Management Officer.

5. DUTIES AND RESPONSIBILITIES OF THE WASTE MANAGEMENT TEAM

The Waste Management Team shall be responsible for the better

administration, preparation, careful planning, monitoring, periodic review,

coordinate and control disposal operations, revision or updating if necessary, and

implementation of the Waste Management Plan.

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6. DUTIES AND RESPONSIBILITIES OF THE MEDICAL SUPERINTENDENT

The Medical Superintendent shall –

(a) Constitute the Waste Management Team;

(b) Designate the Waste Management Officer;

(c) Supervise implementation, monitoring and review of the Waste

Management Plan, and ensure that it is kept up-to-date;

(d) Arrange for a waste audit of the hospital by an external agency as

may be designated for the purposes by the provincial Government,

involving analysis of the existing waste stream and assessment of

existing waste management practices;

(e) Allocate sufficient financial and manpower resources to ensure

efficient and effective implementation of the Waste Management

Plan; and

(f) Ensure adequate training and refresher courses for the concerned

hospital staff members and attend them himself as well.

7. DUTIES AND RESPONSIBILITIES OF THE HEADS OF DEPARTMENTS

Heads of departments shall be responsible for the proper

management of waste generated in their respective departments, and in

particular shall-

(a) Ensure that all doctors, nurses, clinical and non-clinical staff in their

respective departments are aware of, and where required properly

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trained in, waste management procedures as prescribed under the

Waste Management Plan;

(b) Arrange proper supervision of the sanitary staff and sweepers to

ensure that they comply with waste management procedures at all

times as prescribed under the Waste Management Plan; and

(c) Lliaise with the Waste Management Officer for effective monitoring

and reporting of mistakes and errors in implementation of the Waste

Management Plan.

7. DUTIES AND RESPONSIBILITIES OF THE INFECTION CONTROL

OFFICER.

The Infection Control Officer shall be responsible for -

(a) Achieving reduction in infection rates; (b) Giving advice regarding the control of infection and the standards of

the waste disposal system; (c) Identifying training requirements for each category of staff;

(d) Organizing, with others, training and refresher courses on safe waste

management procedures; and

(e) Organizing infection control plan 9. DUTIES AND RESPONSIBILITIES OF THE CHIEF PHARMACIST The Chief Pharmacist shall be responsible for the sound management of pharmaceutical stores and in particular shall -

(a) Give advice regarding formulation of appropriate procedures for

management of pharmaceutical waste, and coordinate

implementation of these procedures; and

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(b) Ensure that the concerned hospital staff members receive adequate

training in pharmaceutical waste management procedures.

(c) Ensure that the Pharmaceutical waste is being disposed of in

accordance with the Waste Management Plan

10. DUTIES AND RESPONSIBILITIES OF THE RADIOLOGY OFFICER

The Radiology Officer shall be responsible for the sound management of

radioactive waste, and in particular shall -

(a) Give advice regarding formulation of appropriate procedures for

management of radioactive waste and coordinate implementation of

these procedures; and

(b) Ensure that the concerned hospital staff members receive adequate

training in radioactive waste management procedures..

(c) Ensure that the radioactive waste is being dispose of in accordance

with the Waste Management Plan

11. DUTIES AND RESPONSIBILITIES OF THE SENIOR MATRON AND HEAD

OF ADMINISTRATION

The Senior Matron and Head of Administration shall be responsible

for ensuring training of nursing staff, medical assistants and sanitary staff and

sweepers in waste management procedures, and basic personal hygiene.

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12. DUTIES AND RESPONSIBILITIES OF THE HOSPITAL ENGINEER

The Hospital Engineer shall be responsible for installation,

maintenance and safe operation of waste storage facilities and waste handling

equipment and, where installed, the hospital incinerator, and shall ensure that the

concerned hospital staff members are properly trained for these purposes.

13. DUTIES AND RESPONSIBILITIES OF THE WASTE MANAGEMENT

OFFICER

The Waste Management Officer shall, in addition to his normal duties and

responsibilities, be responsible for the day-to-day implementation and monitoring

of the Waste Management Plan and in particular, shall –

(a) for waste collection –

(i) Ensure internal collection of waste bags and waste containers

and their transport to the central storage facility of the hospital

on a daily basis;

(ii) Liaise with the Stores and Supplies Department to ensure that

an adequate supply of waste bags, containers, protective

clothing and collection trolleys are available at all times;

(iii) Esure that sanitary staff and sweepers immediately replace

used bags and containers with the new bag and containers of

the same type on the required time or when it is full, and, where

a waste bag is removed from container, that the container is

properly cleaned before a new bag is fitted there in; and

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(iv) Directly supervise the hospital sweepers assigned to collect

and transport the waste on the specified time and when they

are full.

(b) for waste storage –

(i) Ensure correct use of the central storage facility and that it is

kept secured from unauthorized access; and

(ii) Prevent unsupervised dumping of waste bags and waste

containers on the hospital premises, even for short periods of

time.

(c) for waste disposal –

(i) Co-ordinate and monitor all waste disposal operations, and for

this purpose meet regularly with the concerned representative

of the local council;

(ii) Ensure that the correct methods of transportation of waste are

used on-site to the central storage facility or incinerator if

installed, and off-site by the local council; and

(iii) Ensure that the waste is not stored on the hospital premises for

longer than 24 hours, by coordinating with the incinerator

operators and with the local council.

(d) for staff training and information –

(i) Liaise with the Heads of departments, Head of Administration

and Senior Matron to ensure that all doctors, clinical staff,

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nursing staff, and medical assistants are fully aware of their

duties and responsibilities under the Waste Management Plan;

(ii) Ensure that sanitary staff and sweepers are not involved in

waste segregation and that they only handle waste bags and

containers, in the correct manner.

(e) for incident management and control –

(i) Ensure that emergency procedures are available and in place

at all times and that all staff members are aware of the action to

be taken by them;

(ii) Investigate, record and review all incidents reported regarding

hospital waste management; and

(iii) Record the quantities of waste generated by each department

on a weekly basis.

14. WASTE MANAGEMENT PLAN

(1) The Waste Management Plan shall be drafted by the Waste Management

Officer for approval by the Waste Management Team, and shall be based on

internationally recognized environment management standards such as the ISO

14000 series.

(2) The Waste Management Plan shall include -

(a) A plan of the hospital showing the waste disposal points for every

ward and department, indicating whether each point is for risk waste

or non-risk waste, and showing the sites of the central storage facility

for risk waste and the central storage facility for non-risk waste;

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(b) Details of the types, numbers and estimated costs of containers,

plastic bags and trolleys required annually;

(c) Time-tables including frequency of waste collection from each ward

and department;

(d) Duties and responsibilities for each of the different categories of

hospital staff members who will generate hospital waste and be

involved in the management of the waste;

(e) An estimate of the number of staff members required for waste

collection;

(f) Procedures for the management of wastes requiring special

treatment such as autoclaving before final disposal;

(g) Contingency plans for storage or disposal of risk waste in the event

of breakdown of incinerator, or of maintenance or collection

arrangements;

(h) Training courses and programmes; and

(i) Emergency procedures.

(3) The representatives of the local council responsible for the collection and

disposal of waste from the hospital shall be consulted in drafting and finalization

of the Waste Management Plan.

(4) The Waste Management Plan shall be regularly monitored, reviewed, and

revised and updated by the Waste Management Team as and when necessary.

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15. WASTE SEGREGATION

(1) - Risk waste shall be separated from non-risk waste at the source, i.e. at the

ward bedside, operation theatre, laboratory, or any other room in the hospital

where the waste is generated, by the doctor, nurse, or other person generating

the waste.

(2) - All disposal medical equipment and supplies including syringes, needles,

plastic bottles, drips and infusion bags shall be cut or broken and rendered non-

reusable at the point of use by the person using the same, or in case any such

used equipment or supplies is found or comes to the possession of any person,

by such person.

(3) - All risk waste other than sharps, large quantities of pharmaceuticals, or

chemicals, waste with a high content of mercury or cadmium such as broken

thermometers or used batteries, or radioactive waste shall be placed in a suitable

container made of metal or tough plastic, with a pedal type or swing lid, lined with

a strong yellow plastic bag. The bags shall be removed when it is not more than

three quarters full and sealed, preferably with self-locking plastic sealing tags and

not by stapling. Each bag shall be labeled, indicating date, point of

production/ward/hospital, quantity and description of waste, and prominently

displaying the biohazard symbol. The bag removed should be immediately

replaced with a new one of the same type.

(4) - Sharps including the cut or broken syringes and needles shall be placed in

metal or high-density plastic containers resistant to penetration and leakage,

designed so that items can be dropped in using one hand, and no item can be

removed. The containers shall be colored yellow and marked "DANGER!

CONTAMINATED SHARPS”. The sharps container shall be closed when three

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quarters full. If the sharp container is to be incinerated, it shall be placed in the

yellow plastic bag with the other risk waste.

(5) - Large quantities of pharmaceutical waste shall be returned to the suppliers.

Small quantities shall be placed in a yellow plastic bag, preferably after being

crushed, where this can be done safely.

(6) - Large quantities of chemical waste, and waste with a high content of

mercury or cadmium shall not be incinerated, but shall be placed in chemical

resistant containers and sent to specialized treatment facilities.

(7) - Radioactive waste which has to be stored to allow decay to background

level shall be placed in a plastic bag, in a large yellow container or drum. The

container or drum shall be labeled, showing the radio nuclide’s activity on a given

date, and the period of storage required, and marked 'RADIOACTIVE WASTE',

with the radiation symbol. Non-infectious radioactive waste which has decayed to

background level shall be placed in black plastic bags. Infectious radioactive

waste which has decayed to background level shall be placed in yellow plastic

bags. High level and relatively long half-life radionuclide shall be packaged and

stored in accordance with instructions of the original supplier under supervision

of the Radiology Officer, and sent back to the supplier for disposal.

(8) - Non-risk waste shall be placed in a suitable container lined with a black

plastic bag. Adequate numbers of non-risk waste containers shall be placed in all

areas of the hospital and notices affixed to encourage visitors to use them.

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16. WASTE COLLECTION

(1) - Waste shall be collected in accordance with the schedules specified in the

Waste Management Plan.

(2) - Sanitary staff and sweepers shall, when handling waste, wear protective

clothing at all times including face masks, industrial aprons, leg protectors,

industrial boots and disposable or heavy duty gloves, as required.

(3) - Sanitary staff and sweepers shall ensure that –

(a) Waste is collected at least daily if not full, but more often if

necessary;

(b) All bags are labeled before removal, indicating the point of

production, ward and hospital, and contents; and

(c) Bags and containers which are removed are immediately replaced

with new ones of the same type and color;

(d) Where a waste bag is removed from a container, the container is

properly cleaned before a new bag is fitted therein and in case of

severe infection the container should also be discarded.

17. WASTE TRANSPORTATION

(1) - For on-site transportation, the waste collection trolley shall be free of sharp

edges, easy to load and unload and to clean, and preferably a stable three or

four wheeled design with high sides. The trolley shall not be used for any other

purpose. The trolley shall be cleaned regularly, and especially before any

maintenance work is performed on it.

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(2) - The sealed plastic bags shall be carefully loaded by hand onto the trolley, to

minimize the risks of punctures or tears.

(3) - Yellow-bagged risk waste and black-bagged non-risk waste shall be

collected on separate trolleys which shall be painted or marked in the

corresponding colors.

(4) - The collection route shall be the most direct one from the final collection

point to the central storage facility designated in the Waste Management Plan.

The collected waste shall not be left even temporarily anywhere other than at the

designated central storage facility.

(5) - Transportation off-site shall, unless otherwise agreed, be the responsibility

of the local council, which shall ensure that -

(i) All yellow-bagged waste is collected at least once daily;

(ii) All staff members handling yellow-bagged waste wear protective

clothing;

(iii) Yellow-bagged waste is transported separately from all other

waste;

(iv) Vehicles or skips used for the carriage of yellow- bagged waste are

not used for any other purpose, are free of sharp edges, easy to

load and unload by hand, easy to clean/disinfect, and fully

enclosed, preferably with hinged and lockable shutters or lids, to

prevent any spillage in the hospital premises or on the highway

during transportation;

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(v) All concerned staff members are properly trained in the handling,

loading and unloading, transportation and disposal of yellow

bagged waste, and are fully aware of emergency procedures for

dealing with accidents and spillages;

(vi) All vehicles carry adequate supply of plastic bags, protective

clothing, cleaning tools and disinfectants to clean and disinfect any

spillage;

(vii) The transportation of waste is properly documented, and all

vehicles carry a consignment note from the point of collection to the

incinerator or landfill or other final disposal facility; and

(viii) All vehicles are cleaned and disinfected after use.

18. WASTE STORAGE

(1) - A separate central storage facility shall be provided for yellow-bagged

waste, with a sign prominently displaying the biohazard symbol and clearly

mentioning that the facility stores risk waste.

(2) - The designated central storage facility shall -

(a) Be located within the hospital premises close to the incinerator, if

installed, but away from food storage or food preparation areas;

(b) Be large enough to contain all the risk waste produced by the

hospital, with spare capacity to cater for collection or incinerator

breakdowns;

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(c) Be easy to clean and disinfect, with an impermeable hard-standing

base, plentiful water supply and good drainage, lighting and

ventilation;

(d) Have adequate cleaning equipment, protective clothing and waste

bags and containers located nearby; and

(e) Be easily accessible to collection vehicles and authorized staff, but

totally enclosed and secure from unauthorized access, and

especially inaccessible to animals, insects and birds.

(3) - No materials other than yellow-bagged waste shall be stored in the central

storage facility.

(4) - No waste shall be stored at the central storage facility for more than 24

hours. Provided that if in an emergency infectious waste is required to be stored

for more than 24 hours, it shall be refrigerated at a temperature of 30C to 80C.

(5) - Containers with radioactive waste shall be stored in a specifically marked

area in a lead-shielded storage room.

(6) - Containers with chemical waste which are to be specialized treatment

facilities shall also be stored in a separate room or area.

(7) - The central storage facility shall be thoroughly cleaned in accordance with

procedures stipulated in the Waste Management Plan.

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19. WASTE DISPOSAL

(1) - Depending upon the type and nature of the waste material and the

organisms in the waste, risk waste should be inactivated or rendered safe before

final disposal by a suitable thermal, chemical, irradiation incineration, filtration or

other treatment method, or by a combination of such methods, involving proper

validation and monitoring procedures. Effluent from the waste treatment methods

shall also be periodically tested to verify that it conforms to the NEQS before it is

discharged into the sewerage system.

(2) - Yellow-bagged waste shall be disposed of by burning in an incinerator or by

burial in a land-fill, or by any other method of disposal approved by the Federal

Agency or Provincial Agency concerned:

(3) - Sharps containers which have not been placed in yellow bags for incinerator

shall be disposed of by encapsulation or other method of disposal approved by

the Federal Agency or provincial Agency concerned.

(4) - The method of disposal, whether by burning in an incinerator or by burial in

a landfill or otherwise, shall be operated by a hospital only after approval of its

EIA in accordance with the provisions of section 12:

Provided that hospitals, local councils or other persons already using an

incinerator or land-fill on the date of enforcement of these rules shall submit an

EIA in respect thereof to the Federal Agency or Provincial Agency concerned

within two months from the said date, and may continue to use the incinerator or

land-fill pending decision on the EIA.

(5) - All risk waste delivered to an incinerator shall be burned within 24 hours.

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(6) - Ash and residues from incineration and other methods shall be placed in

robust, noncombustible containers and sent to the local council's designated risk

waste landfill site.

(7) - Landfills shall be located at sites with minimal risk of pollution of

groundwater and rivers. Access to the site shall be restricted to authorized

personnel only. Risk waste shall be buried in a separate area of the landfill under

a layer of earth or non-risk waste of at least 1 meter depth which shall then be

compacted. The landfill shall be regularly monitored by the local council to check

groundwater contamination and air pollution. The local council shall also ensure

that the landfill operators are properly trained, especially in safe disposal

procedures, use of protective equipment and hygiene and emergency response

procedures.

(8) - Daily collection of risk waste from hospitals shall be taken by the vehicles of

the local council immediately to the designated landfill site or incinerator by the

most direct route, in accordance with prior scheduling of collection times and

journey times.

(9) - Radioactive waste which has decayed to background level shall either be

buried in the landfill site or incinerated: Provided that an incineration facility for

radioactive waste shall require, in addition to approval of its EIA by the Federal

Agency or Provincial Agency concerned, registration with, and issue of license

by, the Directorate of Nuclear Safety and Radiation Protection in accordance with

the provisions of the Pakistan Nuclear Safety and Radiation Protection

Ordinance IV of 1984, and Pakistan Nuclear Safety and Radiation Protection

Regulations, 1990.

(10) - All liquid infectious waste shall be discharged into the sewerage system

only after being properly treated and disinfected: Provided that liquid radioactive

waste shall be discharged into the sewerage system only after it has decayed to

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background level and after it has been ensured that the radioactive materials are

soluble and dispersible in water, failing which it shall be filtered:

Provided further that radioactive waste containing Tritium and Carbon-14

isotopes shall be stored separately and shipped to the disposal site of the

Pakistan Atomic Energy Commission at KANUPP, Karachi or PINSTECH,

Islamabad.

(11) - In the case of gaseous radioactive waste, portable filter assembles shall be

used to extract iodine and xenon. The used filters shall be treated as solid

radioactive waste.

20. ACCIDENTS AND SPILLAGES

(1) - In case of accidents or spillages, the following action shall be taken -

(a) The emergency procedures mentioned in the Waste Management

Plan shall be implemented immediately;

(b) The contaminated area shall be immediately evacuated, if required;

(c) The contaminated area shall be cleared and, if necessary,

disinfected;

(d) Exposure of staff shall be limited to the extent possible during the

clean-up operation, and appropriate immunization carried out, as

may be required; and

(e) Any emergency equipment used shall be immediately replaced in the

same location from which it was taken.

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(2) - All hospital staff members shall be properly trained and prepared for

emergency response, including procedures for treatment of injuries, cleanup of

the contaminated area and prompt reporting of all incidents of accidents,

spillages and near-misses.

(3) - The Waste Management Officer shall immediately investigate, record and

review all such incidents to establish causes and where necessary shall amend

the Waste Management Plan to prevent recurrence.

21. WASTE MINIMIZATION AND REUSE

(1) - To minimize hospital waste, each hospital shall introduce -N

(a) Purchasing and stock controls, involving careful management of the

ordering process to avoid over-stocking, particularly with regard to

date-limited pharmaceutical and other products, and to accord

preference to products involving low amounts of packaging;

(b) Waste recycling programmes, involving return of un-used or waste

chemicals in quantity to the supplier for reprocessing, return of

pressurized gas cylinders to suppliers for refilling and reuse, sale of

materials such as mercury, cadmium, nickel and lead-acid to

specialized recyclers, and transportation of high level radioactive

waste to the original supplier; and

(c) Waste reduction practices in all hospital departments.

(2) - To encourage reuse, each hospital shall separately collect, wash and

sterilize, either thermally or chemically in accordance with approved procedures,

surgical equipment and other items which are designed for reuse and are

resistant to the sterilization process.

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22. INSPECTION

(1) - A Health officer may inspect any hospital, incinerator or landfill located

within the area of his jurisdiction to check that the provisions of these rules are

being compiled with.

(2) - If a Health officer discovers any contravention of any provision of these

rules, he shall report the contravention to a District complaint scrutiny committee

constituted by the [provincial Government comprising two Medical Superintended

of hospitals owned by the provincial Government, one of which shall be the

Chairman of the committee, and one Medical Superintended of a private sector

hospital:

Provided that Hospitals whose Medical Superintendents on the District complaint

scrutiny committee shall not be located in the said District.

(3) - The District Complaint Scrutiny Committee shall review details of the

contravention reported by the Health officer and after giving the duly authorized

representative of the hospital or incinerator or landfill an opportunity of being

heard, either recommend that action be initiated against the person responsible

through the district Health Officer or local council or the Federal Agency or the

Provincial Agency concerned.

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23. PROVINCIAL HOSPITAL WASTE MANAGEMENT ADVISORY

COMMITTEE

(1) - The provincial Government shall be notification in the official Gazette,

constitute a Hospital Waste Management Advisory Committee comprising-

(a) The Secretary, Provincial Health Department, Chairman

(b) Representative of Ministry of Health, Member

(c) Secretary, Provincial Environment Department, Member

(d) Secretary, Provincial Local Government Department, Member

(e) President, Pakistan Medical Association or his representative,

Member

(f) Vice Chancellor of a Medical University in the Province, Member

(g) Medical Superintendents of 2 hospitals in the public sector and 2

hospitals in the private sector Member

(h) Representative of 2 non-governmental organizations, Member

(i) Director General, Provincial Environmental Protection Agency,

Secretary

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(2) - The Hospital Waste Management Advisory Committee shall:

(a) Periodically review the implementation of these rules and

recommend amendment there to;

(b) Recommended adoption of such policy measures, plans and

projects as it may consider necessary for the effective management

of hospital waste in the province.

24. PHASED IMPLEMENTATION

The Federal Government may by notification in the official Gazette -

(1) - Exempt any class of hospitals from all or any of the provisions of these

rules; or

(2) - Direct that the provisions of some or all of the rules shall apply to certain

class of hospitals only after a stipulated time period.

25. APPLICABILITY OF THE HAZARDOUS SUBSTANCES AND WASTE

MANAGEMENT RULES, 2003.

(1) - Each hospital generating risk waste shall apply to the Federal Agency for

grant of license under section 14, in accordance with the provisions of the

Hazardous Substances and Waste Management Rules, 2003.

(2) - The provisions of these rules shall, to the extent of any inconsistency qua

hospital waste, prevail over the Hazardous Substances Rules, 2000.

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26. ANNUAL REPORT

Every hospital shall submit an annual report to the Provincial

Agency to include information about the categories and quantities of waste

handled during the proceeding year. The Provincial Agency shall send this

Federal EPA who will publish this to the annual National Environment Report

under Section 6(d) of the Act.

27. MAINTENANCE OF REGISTER

Every Provincial Agency shall maintain a Register of the record

related to the generation, collection, disposal, transportation of the hospital waste

which is open for inspection to the public.

STATE OF HEALTHCARE WASTE LEGISLATIONS,

POLICIES, GUIDELINES IN SOUTH ASIA

COUNTRY LEGISLATION

Bangladesh No specific legislation covered in Bangladesh’s Environmental protection Act 1995

Bhutan Guidelines for Infection Control (Ministry of Health) Addressed Environmental Code of Practice for Hazardous Waste Management, 2001 Policy

India Biomedical waste Regulations (1998) (Amended: March, 2000 and June, 2000)

Maldives No separated rules in Environmental Protection and Preservation Act 1993

Nepal No polices and legislation dealing with hazardous waste

Pakistan Hospital waste management rules, August 2005

Sri Lanka No proper legal framework in National Environmental Act (Draft of national policy, 2001 exist)

TABLE 17 – COPARASION OF HEALTHCARE LEGISLATION IN SOUTH ASIA

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Figure 43 - Healthcare Legislation in South Asia

9.2 - INTERNATIONAL LAWS

The growing consensus against incineration has also been

reflected in the body of international environmental law, which has increasingly

restricted its use and acceptability. In a few cases, conventions have addressed

the question of incineration head-on. More often, however, international

lawmakers have preferred to articulate a number of general principles that

mitigate against the use of incineration and its variants (such as pyrolysis). When

incorporated into national law and policy-making, these principles clearly push

nations away from the use of incineration, although they still fall short of outright

bans. Communities and advocates for sustainable discards systems can use the

following language from treaties and conventions as leverage, especially those

treaties and conventions that a country has signed or ratified.

The Precautionary Principle was devised to solve the problem that

scientific uncertainty poses for policy-making. Many countries will not restrict an

activity or substance until it has been proven harmful to human health or the

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environment. On its face, this seems a reasonable approach. However, given the

thousands of synthetic chemicals to which humans are exposed, the complexities

(largely unexplored) of interactions between these chemicals, and the limited

research budgets of most countries, it is simply not feasible to test every

conceivable combination of chemicals for their effects on humans. Even if that

were feasible, it would still be impossible to conclusively establish causal links

between a particular facility’s releases and the illness or death of any individual

or group of individuals. In any case, by the time such a causal link is established,

it is too late: the population has already been exposed and suffered the

consequences.

This has sarcastically been referred to as the “count the dead

bodies technique” of chemicals testing. At any given time, therefore, many

substances are in the “gray area” of scientific uncertainty: their harmful effects

are not conclusively proven, but sufficient evidence of harm exists to suspect that

they are not safe. The Precautionary Principle, as stated in the 1998 Wingspread

Statement, is: “When an activity raises threats of harm to human health or the

environment, precautionary measures should be taken even if some cause and

effect relationships are not fully established scientifically. In this context, the

proponent of an activity, rather than the public, should bear the burden of proof.

The process of applying the Precautionary Principle must be open, informed and

democratic and must include potentially affected parties. It must also involve an

examination of the full range of alternatives, including no action.”

9.2.1 - INTERNATIONAL CONVENTIONS

Several important documents in international law reference the

Precautionary Principle, although each uses a somewhat different formulation,

and some refer to it without any definition. It is clearly spelled out as principle 15

of the Rio Declaration on Environment and Development, adopted at the Earth

Summit in Rio de Janeiro, Brazil, in 1992: “In order to protect the environment,

the precautionary approach shall be widely applied by States according to their

capabilities. Where there are threats of serious or irreversible damage, lack of full

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scientific certainty shall not be used as a reason for postponing cost-effective

measures to prevent environmental degradation.”

9.2.2 - LONDON CONVENTION 1972

CONVENTION ON THE PREVENTION OF MARINE POLLUTION BY DUMPING OF WASTES AND OTHER MATTER 1972 AND 1996 PROTOCOL

The "Convention on the Prevention of Marine Pollution by Dumping

of Wastes and Other Matter 1972", the "London Convention" for short, is one of

the first global conventions to protect the marine environment from human

activities and has been in force since 1975. Its objective is to promote the

effective control of all sources of marine pollution and to take all practicable steps

to prevent pollution of the sea by dumping of wastes and other matter. Currently,

85 States are Parties to this Convention.

In 1996, the "London Protocol" was agreed to further modernize the

Convention and, eventually, replace it. Under the Protocol all dumping is

prohibited, except for possibly acceptable wastes on the so-called "reverse list".

The Protocol entered into force on 24 March 2006 and there are currently 37

Parties to the Protocol.

9.2.3 - CONVENTION ON LONG-RANGE TRANS BOUNDARY AIR POLLUTION The 1979 Geneva Convention on Long-range Tran boundary Air Pollution

The Convention on Long-range Trans boundary Air Pollution

entered into force in 1983. It has been extended by eight specific protocols. The

Convention is one of the central means for protecting our environment. It has,

over the years, served as a bridge between different political systems and as a

factor of stability in years of political change. It has substantially contributed to

the development of international environmental law and has created the essential

framework for controlling and reducing the damage to human health and the

environment caused by trans boundary air pollution. It is a successful example of

what can be achieved through intergovernmental cooperation.

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The history of the Convention can be traced back to the 1960s,

when scientists demonstrated the interrelationship between Sulphur emissions in

continental Europe and the acidification of Scandinavian lakes. The 1972 United

Nations Conference on the Human Environment in Stockholm signaled the start

for active international cooperation to combat acidification. Between 1972 and

1977 several studies confirmed the hypothesis that air pollutants could travel

several thousands of kilometers before deposition and damage occurred. This

also implied that cooperation at the international level was necessary to solve

problems such as acidification.

In response to these acute problems, a High-level Meeting within

the Framework of the ECE on the Protection of the Environment was held at

ministerial level in November 1979 in Geneva. It resulted in the signature of the

Convention on Long-range Trans boundary Air Pollution by 34 Governments and

the European Community (EC). The Convention was the first international legally

binding instrument to deal with problems of air pollution on a broad regional

basis. Besides laying down the general principles of international cooperation for

air pollution abatement, The Convention sets up an institutional framework

bringing together research and policy.

9.2.4 - OSPAR Convention

The Oslo and Paris Commissions is the mechanism by which

fifteen Governments of the western coasts and catchments of Europe, together

with the European Community, cooperate to protect the marine environment of

the North-East Atlantic. It started in 1972 with the Oslo Convention against

dumping. It was broadened to cover land-based sources and the offshore

industry by the Paris Convention of 1974. These two conventions were unified,

up-dated and extended by the 1992 OSPAR Convention. The new annex on

biodiversity and ecosystems was adopted in 1998 to cover non-polluting human

activities that can adversely affect the sea.

The fifteen Governments are:-

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1. Belgium

2. Denmark

3. Finland

4. France

5. Germany

6. Iceland

7. Ireland

8. Luxembourg

9. The Netherlands

10. Norway

11. Portugal

12. Spain

13. Sweden

14. Switzerl

15. United Kingdom

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9.2.5 - BASEL CONVENTION

The Basel Convention on the Control of Transboundary Movements

of Hazardous Wastes and Their Disposal, usually known simply as the Basel

Convention, is an international treaty that was designed to reduce the

movements of hazardous waste between nations, and specifically to prevent

transfer of hazardous waste from developed to less developed countries (LDCs).

It does not, however, address the movement of radioactive waste. The

Convention is also intended to minimize the amount and toxicity of wastes

generated, to ensure their environmentally sound management as closely as

possible to the source of generation, and to assist LDCs in environmentally

sound management of the hazardous and other wastes they generate.

The Convention was opened for signature on 22 March 1989, and

entered into force on 5 May 1992. 172 parties to the Convention, Afghanistan,

Haiti, and the United States have signed the Convention but have not yet ratified

it.

History

With the tightening of environmental laws in developed nations in

the 1970s, disposal costs for hazardous waste rose dramatically. At the same

time, globalization of shipping made transboundary movement of waste more

accessible, and many LDCs were desperate for foreign currency. Consequently,

the trade in hazardous waste, particularly to LDCs, grew rapidly.

One of the incidents which led to the creation of the Basel

Convention was the Khian Sea waste disposal incident, in which a ship carrying

incinerator ash from the city of Philadelphia in the United States after having

dumped half of its load on a beach in Haiti, was forced away where it sailed for

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many months, changing its name several times. Unable to unload the cargo in

any port, the crew was believed to have dumped much of it at sea.

Another is the 1988 Koko case in which 5 ships transported 8,000 barrels of hazardous waste from Italy to the small town of Koko in Nigeria in

9.2.6 - THE BAMAKO CONVENTION

The Bamako Convention (in full: Bamako Convention on the ban on

the Import into Africa and the Control of Transboundary Movement and

Management of Hazardous Wastes within Africa) is a treaty of African nations

prohibiting the import of any hazardous (including radioactive) waste. The

Convention was negotiated by twelve nations of the Organization of African Unity

at Bamako, Mali in January, 1991, and came into force in 1998.

Impetus for the Bamako Convention arose from the failure of the

Basel Convention to prohibit trade of hazardous waste to less developed

countries (LDCs), and from the realization that many developed nations were

exporting toxic wastes to Africa. This impression was strengthened by several

prominent cases. One important case, which occurred in 1987, concerned the

importation into Nigeria of 18,000 barrels of hazardous waste from the Italian

companies Ecomar and Jelly Wax, which had agreed to pay local farmer Sunday

Nana $100 per month for storage. The barrels, found in storage in the port of

Lagos, contained toxic waste including polychlorinated biphenyls, and their

eventual shipment back to Italy led to protests closing three Italian ports.

The Bamako Convention uses a format and language similar to that

of the Basel Convention, but is much stronger in prohibiting all imports of

hazardous waste. Additionally, it does not make exceptions on certain hazardous

wastes (like those for radioactive materials) made by the Basel Convention.

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The Bamako Convention similarly obligates its members to

implement the precautionary approach “without waiting for scientific proof” of the

harms in question.

It is the Bamako Convention, however, which most clearly lays out

the prevention principle and its implications for industry, saying: “Each party

shall...ensure that the generation of hazardous wastes within the area under its

jurisdiction is reduced to a minimum taking into account social, technological and

economic aspects.” It then goes on to specifically require the implementation of

clean production: “Each Party shall strive to adopt and implement the preventive,

precautionary approach to pollution problems...through the application of clean

production methods, rather than the pursuit of a permissible emissions approach

based on assimilative capacity assumptions.”

It then goes on to define clean production methods as applicable to

the entire life cycle of the product, including: “raw material selection, extraction

and processing; product conceptualization, design, manufacture and

assemblage; materials transport during all phases; industrial and household

usage; reintroduction of the product into industrial systems or nature when it no

longer serves a useful function. Clean production shall not include ‘end-of-pipe’

pollution controls such as filters and scrubbers, or chemical, physical or biological

treatment. Measures which reduce the volume of waste by incineration or

concentration, mask the hazard by dilution, or transfer pollutants from one

environmental medium to another, are also excluded.”

The Bamako Convention’s detailed wording clearly indicates the

contradiction between prevention and incineration. On the one hand, incineration,

as a waste treatment technology, is an indication of a failure to implement clean

production and waste minimization. On the other hand, as a technology that

produces hazardous byproducts, incineration itself runs counter to the prevention

principle.

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9.2.7 - THE ROTTERDAM CONVENTION

The Rotterdam Convention on the Prior Informed Consent

Procedure for Certain Hazardous Chemicals and Pesticides in International

Trade, more commonly known simply as the Rotterdam Convention, is a

multilateral treaty to promote shared responsibilities in relation to importation of

hazardous chemicals. The convention promotes open exchange of information

and calls on exporters of hazardous chemicals to use proper labeling, include

directions on safe handling, and inform purchasers of any known restrictions or

bans. Parties can decide whether to allow or ban the importation of chemicals

listed in the treaty, and exporting countries are obliged make sure that producers

within their jurisdiction comply.

Substances covered under the Convention are :-

• 2,4,5-T and its salts and esters

• Aldrin

• Asbestos - Actinolite, Anthophyllite, Amosite, Crocidolite, and Tremolite

only

• Benomyl (certain formulations)

• Binapacryl

• Captafol

• Carbofuran (certain formulations)

• Chlordane

• Chlordimeform

• Chlorobenzilate

• DDT

• Dieldrin

• Dinitro-ortho-cresol (DNOC) and its salts

• Dinoseb and its salts and esters

• 1,2-dibromoethane (EDB)

• Ethylene dichloride

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• Ethylene oxide

• Fluoroacetamide

• Hexachlorocyclohexane (mixed isomers)

• Heptachlor

• Hexachlorobenzene

• Lindane

• Mercury compounds including inorganic and organometallic mercury

compounds

• Methamidophos (certain formulations)

• Methyl parathion (certain formulations)

• Monocrotophos

• Parathion

• Pentachlorophenol and its salts and esters

• Phosphamidon (certain formulations)

• Polybrominated biphenyls (PBB)

• Polychlorinated biphenyls (PCB)

• Polychlorinated terphenyls (PCT)

• Tetraethyl lead

• Tetramethyl lead

• Thiram (certain formulations)

• Toxaphene

• Tris (2,3-dibromopropyl) phosphate (TRIS)

Substances proposed for addition to the Convention

• Alachlor

• Aldicarb

• Chrysotile Asbestos

• Endosulfan

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9.2.8 - THE STOCKHOLM CONVENTION AND INCINERATION

Stockholm Convention on Persistent Organic Pollutants is an

international environmental treaty that aims to eliminate or restrict the production

and use of persistent organic pollutants (POPs).

History

In 1995, the Governing Council of the United Nations Environment

Programme (UNEP) called for global action to be taken on POPs, which it

defined as "chemical substances that persist in the environment, bio-accumulate

through the food web, and pose a risk of causing adverse effects to human

health and the environment".

Following this, the Intergovernmental Forum on Chemical Safety

(IFCS) and the International Programme on Chemical Safety (IPCS) prepared an

assessment of the 12 worst offenders, known as the dirty dozen.

The negotiations for the Convention were completed on 23 May 2001 in

Stockholm. The convention entered into force on 17 May 2004 with ratification by

an initial 128 parties and 151 signatories. Co-signatories agree to outlaw nine of

the dirty dozen chemicals, limit the use of DDT to malaria control, and curtail

inadvertent production of dioxins and furans.

Parties to the convention have agreed to a process by which

persistent toxic compounds can be reviewed and added to the convention, if they

meet certain criteria for persistence and transboundary threat. The first set of

new chemicals to be added to the Convention were agreed at a conference in

Geneva on 8 May 2009.

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KEY POINTS OF THE CONVENTION

The treaty includes provisions to expand this list to include other

chemicals, using the Precautionary Principle to judge their fitness for inclusion in

the list. Although the Stockholm Convention does not ban incineration or even

the construction of new incinerators, it does place serious obstacles in the path of

any incineration project. The Convention specifically states in Annex C that

“waste incinerators, including co-incinerators of municipal, hazardous or medical

waste or of sewage sludge; cement kilns firing hazardous waste” are among the

technologies that have the “potential for comparatively high formation and

release of such unintentional POPs.” In fact, incinerators are significant sources

of four of the 12 listed pollutants: dioxins, furans, PCBs, and hexachlorobenzene.

As such, incinerators as a class are clearly subject to the restrictions of the

Stockholm Convention.

• MEASURES TO REDUCE UNINTENTIONAL POPs

The Convention requires parties to take “measures to reduce the

total releases derived from anthropogenic sources” of the unintentional POPs.

Within this context, it becomes very difficult to justify any new or additional

sources of POPs, such as a new incinerator or increased quantities of waste sent

to an existing incinerator.

• CONTROL OF HAZARDS

In fact, the Convention goes further; it is the strongest legal

expression to date of the preference for source prevention over mere control of

environmental hazards. For most of the intentionally produced POPs, the

Convention requires elimination. For the unintentionally produced, or byproduct,

pollutants, the treaty’s Article 5 establishes a goal of their “continuing

minimization and, where feasible, ultimate elimination.”

The Stockholm Convention makes a significant departure from past

policy regarding incineration’s environmental impacts because it does not apply

to air emissions alone for determining dioxins minimization rates. Rather, the

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Stockholm Convention looks at total releases, which include solid and liquid

residues, including residues from air pollution control devices (fly ashes).

Most past justification of incinerators was based on the argument

that dioxin emissions to the atmosphere could be captured and therefore

controlled. However, the Stockholm Convention considers such solid and liquid

releases to be part of what must be continually minimized and, where feasible,

eliminated.

• SUBSTITUTION CONTROL

Indeed, Article 5 also contains a particularly relevant substitution

principle, which states that Parties to the treaty shall “Promote the development

and, where it deems appropriate, require the use of substitute or modified

materials, products and processes to prevent the formation and release of

[unintentional POPs].” It is important to note the use of the term “formation” and

to realize that this obligation makes it apparent that where there are alternative

methods of waste management, any process that produces dioxins should be

avoided.

• STRONG DIRECTIONS ON MANAGEMENT OF POPs

The Stockholm Convention also contains strong direction on the

management and treatment of existing stockpiles of POPs wastes (which are

often treated in hazardous waste incinerators). Article 6 calls for Parties to take

measures so that POPs wastes are “disposed of in such a way that the persistent

organic pollutant content is destroyed or irreversibly transformed so that they do

not exhibit the characteristics of persistent organic pollutants.” Although this text

is followed with some caveats, such as excepting low levels of POPs content,

which must await further interpretation, the use of the words “destroyed or

irreversibly transformed so that they do not exhibit the characteristics of POPs,”

is meant again to be inclusive of all formation and outputs (not just air

emissions). This goes far beyond what has previously been envisaged for any

chemical waste in international law.

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151 nations signed the treaty in May 2001 in Stockholm. Although

The Convention will not come into force until 50 nations have ratified it, and then

only in the ratifying countries, it is not toothless in the interim. Under international

law, signing a treaty is a statement of commitment to comply with the treaty; and

governments that do sign are enjoined from taking actions that are clearly

prejudicial to the goals of the treaty, even though they may not yet have ratified it.

As such, the Stockholm Convention is already a barrier against the construction

of any new incinerator in signatory nations.

MEMBER COUNTRIES OF STOCKHOLM CONVENTION

Albania Cape Verde Eritrea

Jordan

Moldova

Algeria

Central African Rep.

Estonia

Kazakhstan Monaco

Angola

Chad

Ethiopia

Kenya

Mongolia

Angola

Chile

European Commission

Kiribati

Morocco

Argentina

China

Fiji

Kuwait

Mozambique

Armenia

Colombia

Finland

Kyrgyzstan

Myanmar

Australia

Comoros

France

Laos

Namibia

Austria

Congo, P. R.

Gabon

Latvia

Nauru

Azerbaijan

Cook Islands

Gambia

Lebanon

Nepal

Bahamas

Costa Rica

Georgia

Lesotho

Netherlands

Bahrain Cote d'Ivoire

Germany

Liberia

New Zealand

Bangladesh

Croatia

Ghana

Libya

Nicaragua

Barbados

Cuba

Greece

Liechtenstein

Niger

Belarus

Cyprus

Guatemala

Lithuania

Nigeria

Belgium

Czech Republic

Guinea

Luxembourg

Niue

Benin Dem. P. Rep. of Korea

Guinea-Bissau

Macedonia

Norway

Bolivia

Dem. Rep. of Congo

Guyana

Madagascar

Oman

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Botswana

Denmark

Honduras

Maldives

Pakistan

Brazil

Djibouti

Hungary

Mali

Panama

Bulgaria

Dominica

Iceland

Marshall Islands

Papua New Guinea

Burkina Faso

Dominican Republic

India

Mauritania

Paraguay

Burundi

Ecuador

Iran

Mauritius

Peru

Cambodia

Egypt

Jamaica

Mexico

Philippines

Canada

El Salvador

Japan

Micronesia

Poland

Portugal

Samoa

Solomon Islands

Syria

Uganda

Qatar

Sao Tome & Principe

South Africa

Tajikistan

Ukraine

Rep. of Korea

Senegal

Spain

Tajikistan

U.A.E

Romania

Seychelles

Sri Lanka

Thailand

United Kingdom

Rwanda

Sierra Leone

Sudan

Togo

Uruguay

Saint Kitts and Nevis

Singapore

Swaziland

Trinidad and Tobago

Vanuatu

Saint Lucia

Slovak Republic

Sweden

Tunisia

Venezuela

Saint Vincent & the Grenadines

Slovenia

Switzerland

Tuvalu

Viet Nam

Yemen

Zambia

TABLE 18 – MEMBERS COUNTRIES OF STOCKHOLM CONVENTION

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PRECAUIONARY PRINCIPLES:-

The Precautionary Principle bears on incineration in two different

ways. First, combustion is an extremely complex process, and it is still not known

precisely what substances are produced and released through the incineration of

wastes. This is particularly true when the waste in question is highly variegated,

as in the case of municipal or health care waste. Without knowing the pollutants

produced, their quantities, environmental fate, or health effects, it is impossible to

assure the safety of such a process (even if the known dangers could somehow

be eliminated). Thus, precaution argues for avoiding the activity, i.e., incineration.

Second, many of the substances which have been identified in air emissions and

incinerator ash have varied and subtle effects on the human body, which are still

being investigated. Some, such as lead and PCBs, may also interact with each

other or other pollutants present in the environment to create synergistic effects.

Given the uncertainty surrounding these health effects, precaution again argues

for avoiding their production and release.

A second principle found in international law, although more rarely

mentioned by name, is prevention. This is simply the common-sense notion that

it is better to prevent harm than to allow damage to occur and then attempt to

mitigate it or clean it up. International law clearly indicates that the minimization

of environmental damage is to be prioritized over end-of-pipe techniques. Thus,

Agenda 21, the framework document adopted at the Earth Summit in 1992,

states that a target of hazardous waste policy must be “preventing or minimizing

the generation of hazardous wastes as part of an overall integrated cleaner

production approach.”

The third principle, cited in documents too numerous to mention, is the

importance of limiting transboundary environmental effects.

States should effectively cooperate to discourage or prevent the

relocation and transfer to other States of any activities and substances that

cause severe environmental degradation or are found to be harmful to human

health.” This is an abiding concern of international law, for the obvious reason

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that national laws are insufficient to address environmental harms whose root

causes lie in another country. Given the tendency towards long-range transport

exhibited by many incinerator pollutants, it is impossible to confine incinerator

emissions to the national territory or airspace of any country.

Thus, incineration clearly contradicts the principle of minimizing

trans boundary environmental effects.

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In this chapter we will discuss waste management structure in

detail in order to understand the hospital waste management in a hospital.

The scope of this chapter is to provide our readers a complete

detail about the waste management in a hospital. We are thankful to the following

respected individuals for their active participation for the case studies of the

hospitals.

• Dr. Akhlaq Ahmed Ansari Medical Superintendent, Ch. Pervaiz Elahi Institute of Cardiology, Multan

• Dr. Waseem Abbas Zaidi Additional Medical Superintendent Ch. Pervaiz Elahi Institute of Cardiology, Multan

• Dr. Syed Raza Mohi-UD-Din Medical Superintendent Civil Hospital, Multan

• Col. Iqbal Ahmed Khan Professor of Community Medicine Army Medical College, Rawalpindi

• Eng. Rehan Ahmed Environmental and Sanitary Engineering Consultant, Karachi

• Mr. Abdul Rehman Chief Ward Master Ch. Pervaiz Elahi Institute of Cardiology, Multan

• Shafiq-Ur-Rehman Composer of the book Ch. Pervaiz Elahi Institute of Cardiology, Multan

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DA B F A B E A A D A DA

D D DE A AB A E

D A AB AB A DA D A E B A F

B F E AB D D A C B F B C

F AE D D EA A C B BA A

D D A A E BE B A B AB AB C

A A C A A A B C A B C C

F AB A A B B F EE BE A

DA F D DAE E A

E AE B A AB A

D BA A D EA BE C D

AB B E D

A C

• AE

• AE DA BE

• B E F AE

•

• D AE

FE A F C

• D F

• A

• A B D

• B

AB CD EB C F E C C DC

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D

D A B E E E E AB F

D A ED F D E E AB A D D B

F B AB E

A E

D AB E A DAED ABE A AEAB C E B F C F C F A B D E B AB

C A

D A E A D D AB E A

D A DAED ABE B C E C F C BA C AB A B

B F B

A C A

B B AB E A DAED ABE C EA

E C B F E

BA A B AB

E E A B B D D E D A B C D A B B C

B B D AE A E AB D

B B E AB A D E E A D

F A B E E EA

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A B F B EB B B



Sharps 65.94 3 % 0.103


Total Waste 2198 100 % 3.434

This hospital also uses incinerator for hospital waste disposal.

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CIVIL HOSPITAL, KARACHI

It is one of the largest public sector health care facilities in the city.

Presently, the hospital is composed of 1800 beds in 40 departments in medical,

surgical, intensive care and other domains. Being a teaching hospital in

association with Dow University of Health Sciences, it is a key facility that

extends healthcare services mainly to lower middle and poor sections of Karachi

and also patients pouring in from other parts of country.

WASTE MANAGEMENT SYSTEM

The prevailing waste management system is run by a team of sanitary workers,

supervisors and management officers. There are about 350 sanitary workers /

sweepers who are working on the government’s payroll. In the waste

management work, the operating staff also participates and assists the sweepers

in collection and disposal of waste. They include male nursing staff ward

supervisors and ward incharges under the overall management control of

Additional Medical Superintendent (Waste Management).

Basic flow of the waste management system is as:

The staff functions in three shifts of eight hours each. They are

assigned different duties such as sweeping, collection of ward waste,

transportation of waste at different stages and special duties in the operation

Wards Incharges

Additional Medical Superintendent

Waste Management

Wards Cleaners

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theaters, intensive care unit wards and special wards. The hospital management

has developed a large dumping site for the hospital waste.

The waste has been classified into three categories including

infectious waste, non-infectious waste and ordinary solid waste. Three types of

bags are provided to each ward with color codes. The red bags are kept for

infectious waste, yellow bags for non-infectious materials including shapes of all

kinds and blue bags for ordinary solid waste. The incinerator staff visits different

wards during morning and evening shifts to collect the waste material. Ordinary

solid waste is disposed to the local collection / storage point of the hospital from

where the municipal refuse van collects it to dump it at the urban dumping site.

WASTE ITEMS

As reported and surveyed during the study, the commonly found

waste items included syringes, drips, canola chambers, surgical tapes / dressing

material, orthopedic dressing rejects, needles / butterfly equipment, injection

disposals, X ray, rejected chemical plasters, cadmium batteries, cotton sanitary

pads, placentas, blood bags, urine bags, colostomy bags, plastic tubing, stomach

tubing, disposable gloves, bottles of plastic and glass and other similar articles.

The other units that generate waste comprise hospital kitchen and laundry. In the

kitchen, both organic and inorganic waste is generated which is disposed in the

usual municipal waste stream of the hospital. The laundry makes use of

detergents and washing chemicals. Its packing material is the main waste item

which is also disposed in the municipal stream.

One of the items separated for recycling comprise X ray films.

There are about 1000 films that are rejected on a daily basis from different units

of radiology. The hospital also deals with police / medical – legal cases where a

large number of X ray films are produced for record keeping. In a clandestine

manner, the hospital staff collects these films and privately sells them to junk

dealers.

The Burns Unit of this hospital is another unique facility. It is the

only such facility of its kind available in the entire city. Due to the special nature

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of care / treatment, a sizable proportion of bandages / gauzes and cotton refuse

is produced in this ward, much of which is sent for incineration.

WASTE DISPOSAL

A sizable part of liquid waste generated during operations and other

functions of the hospital is disposed in the normal drainage / sewerage channels.

With the exception of ward waste that is transported to incinerator, the remaining

waste is stored in this dumping point from where a CDGK refuse van collects and

disposes this material to the municipal landfill site.

It is a major cause of the spread of infections. At times, the ward

sweepers also dispose the regular ward waste to the dumping site, which creates

a very hazardous situation. The overall process of collecting, segregation,

transportation & incineration can be described as:

Collection of waste in

bins

Segregation of

recyclables

Remaining waste is

transferred to wards /

floor drum

Transference of

needles to Hospital’s

dumping point

Transference to

Hospital’s incineration

point

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Agha Khan University Hospital, Karachi

Hospital waste management system is very well maintained in Aga

Khan University Hospital. Unlike other hospitals in Pakistan, this hospital has a

unique “Liquid Waste Disposal System”. We have not noticed such a brilliant and

efficient liquid waste disposal system.

Segregation of infectious and non-infectious waste is done from its

point of generation in the form of red (infectious waste) and green (non infectious

general waste) bags. These bags are taken to the incinerator and disposed off by

the process of burning. In case of failure or non-working conditions of the

incinerator, AKUH has the system of walk in freezers, which can store the waste

for 2-3 days after that it is discarded properly.

For the liquid infectious waste, Agha Khan University Hospital has

neutralization tank system, which is made underground and filled with limestone,

a strong disinfectant. Sewerage lines from pathological laboratory and research

labs drive into this tank and from here after disinfection, this liquid drains into

main sewerage lines. This is a PVC lined tank about 4 feet in diameter and 8 foot

in depth. Lime stones are replaced and tank is cleaned after every 4-6 months.

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A brief flow diagram as following can describe the Aga Khan University Hospital

infectious waste management system.

Infectious waste

Solid Waste

Incineration

Non Infectious Ashes

Dumping

Liquid Waste

Neutralization Tank

Main Sewerage Line

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CH.PERVAIZ ELAHI INSTITUTE OF CARDIOLOGY MULTAN

C.P.E.I.C Multan is a cardiac hospital situated in the centre of

Multan. This hospital provides best treatment facilities to the poor & needy

patients of South Punjab.

This hospital is equipped with the latest world class technologies.

A detailed fact sheet about the hospital is as under:-

01 Name & Address of Hospital CPE Institute of Cardiology

Abdali Road , Multan

02 Name of Chief Executive /

owner

Dr. Prof. Syed Ali Raza Gardazi

03 Year of establishment of

hospital

2005 – 06

04 No. of wards 06

05 No. of beds 201

06 Total area :

• Covered area

• Uncovered area

Total Area = 60 Kanals & 11 Marlas

• Main = 230038 Sft

• Doctor’s Hostel = 39715 Sft.

• Nursing Hostel = 32445 Sft.

07 No. of Doctors 70

08 Total no. of staff 382

09 Total hospital waste generated

per day. ( In Kg)

• Municipal Waste = 80 Kg

• Biological Waste = 10 Kg

10 Has Hospital Waste

Management Team been

notified?

Yes

11 Are Hospital Waste

Management Rules 2005 are

being implemented within the

hospital?

Yes

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WASTE MANAGEMENT IN HOSPITAL: CPE Institute of Cardiology has an active, efficient and well defined

waste management system except its disposal. The hospital uses the state of the

art technology for collection of waste. This hospital is planning to use “Autoclave”

technology for disinfecting the hospital waste.

WASTE MANAGEMENT TEAM:

According to the “Hospital Waste Management Rules, 2005, the hospital has a specific waste management team. The detail about the members of this team are as:

1. Dr.Mazhar-UL-Khaliq DMS (G) Chairman

2. Mst. Rizwana H/N Committee Secretary

• Committee Members:

1. Dr. Faiyaz Hashmi Pathology Department

2. Dr. Khalid Khanzada X-Ray Department

3. Dr. Jawad Microbiologist

4. Tasleem Kausar Nursing Superintendent

5. Mr. Sohail Pharmacist

6. Abdul Rehman Chief Ward Master

Figure 44 - Waste Management Team of C.P.E.I.C. Multan

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HIRERACHAL CHART OF HOSPITAL WASTE MANGEMENT IN

C.P.E.I.C MULTAN

Sanitary

Inspector

Ward Masters

Deputy Medical

Superintendent

Nurses

Head Nurses

Medical Superintendent

Additional Medical

Superintendent

Nursing Superintendent /

Deputy Nursing Superintendent

Waste

Collectors Ayas

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TYPES OF WASTE GENERATED IN HOSPITAL:

The hospital generates waste materials of five basic types:

• Clinical

• Sharps

• Glass

• Domestic

• Radioactive

COLOR CODING

According to “Hospital Waste Management Rules 2005” color

coding system is used actively in the hospital for safe packing & disposal of the

hospital waste.

• Clinical Yellow Bags

• Sharps Yellow Sharps Bins

• Glass Clear Plastic Bags

• Domestic Black Bags

• Radioactive According to type

COLORED CODED BAGS FOR NON WASTE

• Infected Linen Red Alginate Bag

• Dirty Linen White Cotton Bag

• CSSD Clear Plastic

• Theatre Linen Green

• Patient’s Property Grey

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HOSPITAL WASTE GENERATION IN C.P.E.I.C MULTAN PER DAY

Following record is according to the 60 % bed occupancy.


Municipal Waste 176.23 Kg 93.47 % 1.76 Kg

Biological Waste 12.30 Kg 6.52 % 0.12 Kg

Total 188.53 Kg 99.99 % 1.88 Kg

S.No. Wards Category Kg/Bed/Day % age

01 Adult Cardiology Ward Mun.Waste 1.8 Kg 92.30 %

Plastic 0.125 Kg 6.41 %

Sharps 0.025 Kg 1.28 %

Total 1.95 Kg 99.99 %

02 C.C.U - 1 Municipal Waste 1.70 Kg 83.33

Plastic 0.3 Kg 14.70

Sharps 0.041 Kg 1.96

Total 2.041 99.99

WASTE DISPOSAL

• Dry non-infectious waste such as paper, plastics and other non-infectious

ordinary wastes are placed in separate black plastic bags and are

collected daily by the waste collecting staff for disposal.

• Excess blood, serum and plasma specimens from different sections of the

laboratory are collected in a glass container or flask (9"x5" dia.) and

sterilized by autoclaving (pressure cooker) for thirty minutes at 121

degrees centigrade. Unused and expired blood bags are packed together

and sent for incineration.

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• Pipettes, test tubes, and other glassware used in testing infectious

specimen (hepatitis, AIDS, typhoid fever, etc.) are soaked in 0.5% sodium

hypochlorite for at least 30 minutes before disposal.

• Sharps like disposable syringes are collected in bags and incinerated at

Christian Women Hospital Multan Cantt.

• Needles and sharps are collected immediately after use in yellow boxes

(8" x 4" dia.) for incineration.

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THE CIVIL HOSPITAL MULTAN

The Civil Hospital is situated in the heart of Multan. This hospital is

providing the health services to the poor & needy peoples very efficiently under

the energetic & devotional management of Dr.Syed Raza Mohi-Ud-Din.

This hospital has total 22 beds. The OPD deals an average of 700

patients in a day. The average stay of a patient lasts for 1.42 days.

TYPES OF WASTE GENERATED IN HOSPITAL:

The hospital generates waste materials of five basic types:

• Clinical

• Sharps

• Glass

• Domestic

• Radioactive

S.No. Category Kg / Month % age

01 Biological Waste 5 1.72

02 Glass Ware 12 4.18

03 Sharps 20 6.96

04 Other Disposable 10 3.48

05 Municipal Waste 240 83.62

Total Waste 287 99.96

The Civil Hospital uses “Dumping” method for disposal of hospital waste.

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THE CAPITAL MEDICAL CENTER (CMC) MANILA

CMC acquires the use of three waste cans lined with three (3)

colored plastic bags for every patient room, emergency room-out patient

department, operating room-recovery room, delivery room-nursery, intensive

care unit-coronary care unit, floor nurses station, x-ray and CT scan areas to

separate infectious, non-infectious and biodegradable wastes.

• Waste cans (8"x10"x12") lined with black plastic bags are for non-

biodegradable and noninfectious wastes such as cans, bottles, tetra brick

containers, styropor, straw, plastic, boxes, wrappers, newspapers.

• Waste cans lined with green plastic bags are biodegradable wastes such

as fruits and vegetables’ peelings, leftover food, flowers, leaves, and

twigs.

• Waste cans lined with yellow plastic bags are for infectious waste such as

disposable materials used for collection of blood and body fluids like

diapers, sanitary pads, incontinent pads, materials (like tissue paper) with

blood secretions and other exudates, dressings, bandages, used cotton

balls, gauze, IV tubings, used syringes, Foleys catheter/tubings, gloves

and drains.

In the Department of Pathology, there are three types of wastes that are

segregated namely,

• Dry non-infectious waste, blood, serum and plasma and urine and feces.

• Dry non-infectious waste such as paper, plastics and other non-infectious

ordinary wastes are placed in separate black plastic bags and are

collected daily by the housekeeping personnel for disposal.

• Excess blood, serum and plasma specimens from different sections of the

laboratory are collected in a glass container or flask (9"x5" dia.) and

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sterilized by autoclaving (pressure cooker) for thirty minutes at 121

degrees centigrade. Unused and expired blood bags are packed together

and disposed by incineration.

• Pipettes, test tubes, and other glassware used in testing infectious

specimen (hepatitis, AIDS, typhoid fever, etc.) are soaked in 0.5% sodium

hypochlorite for at least 30 minutes before disposal.

• Sharps like disposable syringes are collected in bags and bought down for

incineration.

• Needles and sharps are collected immediately after use in cans or

puncture free containers (8" x 4" dia. Hard plastic) for incineration.

• Pathological waste such as tissues, organs, fetuses and body parts are

disinfected and/or preserved in covered plastic or bottle containers with

10% formalin. These are disposed by incineration.

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REFERENCES:- 1. Asahi Shimbun, “Hundreds of Dirty Incinerators at End of Road,” May 29,

2002. 2. Associated Press (AP), “Japan Is the Land of Rising Garbage Heaps,”

December 9, 2000b. 3. Bailey, Jeff, “Up in Smoke: Fading Garbage Crisis Leaves Incinerators

Competing for Trash,” Wall Street Journal, Page A1, August 11, 1993. 4. Biggeri. A., Barbone, F., Lagazio, C., Bovenzi, M., and Stanta, G., “Air

Pollution and Lung Cancer in Trieste, Italy: Spatial Analysis of Risk as a Function of Distance from Sources,” Environmental Health Perspectives, vol. 104, no. 7, pp. 750-754, 1996.

5. Biocycle magazine, “The State of Garbage” annual survey, 1996. 6. Biocycle magazine, “The State of Garbage” annual survey, 1997. 7. Biocycle magazine, “The State of Garbage” annual survey, 2000. 8. Birnbaum, Linda, “Re-evaluation of Dioxin,” Presentation to the 102nd

Meeting of the Great Lakes Water Quality Connett, Paul, and Sheehan, Bill, A Citizen’s Agenda for Zero Waste, G&G Video and Grassroots Recycling Network, October 2001.

9. Crowe, Elizabeth, and Schade, Mike, Learning Not to Burn: a Primer for

Citizens on Alternatives to Burning Hazardous Waste, June 2002. 10. Denison, Richard, “Environmental Life-Cycle Comparisons of Recycling,

Land filling, and Incineration: A Review of Recent Studies Annual Review of Energy and the Environment, vol. 21, pp. 191–237, 1996.

11. Elliot, P., Shaddick, G., Kleinschmidt, I., Jolley, D., Walls, P., Beresford,

J., and Grundy, C., “Cancer Incidence Near Municipal Solid Waste Incinerators in Great Britain,” British Journal of Cancer, vol. 73, pp. 702-710, 1996.

12. Elston, Suzanne, “Zero Waste Turns Garbage Into Savings,” Environmental

News Network, January 2, 2000. 13. Ghosh, A.K., “Comparative Statement of Technological Evaluation of Waste

Autoclave and Waste Microwave,” West Bengal Health Systems Development Project, Department of Health & Family Welfare, Government of West Bengal, India, 2002.

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14. Hegberg, Bruce A., Hallenbeck, William H., Brenniman, Gary R., “Municipal Solid Waste Incineration With Energy Recovery: Technologies, Facilities, and Vendors for Less Than 550 Tons Per Day,” University of Illinois Center for Solid Waste Management and Research, Office of Technology Transfer, School of Public Health, 1990.

15. Hencke, David, “Britain Steps Out of Line on Incinerators,” Guardian, Friday, May 19, 2000. Available at: http:// www.guardian.co.uk/Archive/Article/0,4273,4019735,00.html.

16. ILSR, “Job Creation: Reuse and Recycling versus Disposal” (Chart),

Washington, DC, 1997. www.ilsr.org/recycling 17. ILSR, Manila: Wasting and Recycling in Metropolitan Manila, Philippines,

October 2000b. 18. Morris, Jeffrey, and Canzoneri, Diana, Recycling Versus Incineration: An

Energy Conservation Analysis, Sound Resource Management Group (SRMG) Seattle, Washington, September, 1992. (This report has been summarized in the Sound Resource Management’s publication, The Monthly UnEconomist, vol. 2, no. 2-4, February, March and April 2000.)

19. Motavelli, Jim, “Zero Waste,” E Magazine, March-April 2001. 20. Platt, Brenda, “Aiming for Zero Waste: Ten Steps to Get Started,” ILSR,

Washington, DC, 2002. 21. R. W. Beck Inc., “U.S. Recycling Economic Information Study,” National

Recycling Coalition, July 2001. 22. Stanners, D., and Bourdeau P., eds., Europe’s Environment, The Dobris

Assessment, Copenhagen: European Environment Agency, 1995. 23. Trenholm, A., and Thurnau, R., “Total Mass Emissions from a Hazardous

Waste Incinerator,” in Land Disposal, Remedial Action, Incineration, and Treatment of Hazardous Waste, Proceedings of the Thirteenth Annual Research Symposium, U.S.EPA Hazardous Waste Engineering Laboratory, Cincinnati, EPA/600/9- 87/015, July 1987.

24. USEPA, Dioxin: Summary of the Dioxin Reassessment Science, 2000a. 25. USEPA, “Municipal Solid Waste Basic Facts,” June 20, 2001. Available at:

http://www.epa.gov/epaoswer/non-hw/muncpl/ facts.htm, accessed May 2002.

26. Zero Waste New Zealand Trust, “Zero Waste Communities: Progress to

Date,” May 2002

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27. Environmental Urban Affairs Division, Govt. of Pakistan. Environmental

Project of Pakistan. 28. Environmental and Urban Affairs Division, Govt. of Pakistan (1995)

Environmental Protection Act. 29. Government of Pakistan (1983) Pakistan Environmental Protection

Ordinance. 30. Daily Dawn, Karachi (1997). 31. NTCS (1992) Protection of Work Recycling and Reuse in Developing

Countries. 32. Population Census Organization (1981) District Census Report of Karachi. 33. Ministry of Housing and Works (1980) Housing Survey of Karachi. 34. USEPA (1972) Sind Waste Handling and Disposal in Multistorey Buildings

and Hospitals. 35. SCOPE (1993) Basic Report on Hospital Waste Management in Metropolis of

Karachi. 36. Ahmed, Rehan (1993) Hospital Waste Management in Pakistan, Turkish

National Committee on Solid Waste and International Solid Waste and Cleansing Association, Denmark.

37. MANILA, PHILIPPINES Capitol Medical Center (1994) Policies on Hospital

Waste Management 38. Center for Advance Philippine Studies (1992) A Study on Urban

Environment-Related Activities for Non-Government Organizations and Community-Based Organizations, Philippines: Asia-Pacific 2000-UNDP, December.

39. Center for Advance Philippine Studies (1992) Waren Project: Recycling

Activities in Metro Manila, Philippines: Waste Consultants, Netherlands 40. C.Visvanathan, Asian Institute of Technology , Thailand.

http://www.faculty.ait.ac.th/visu/

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RESOURCE ORGANIZATIONS:

1. Global Anti-Incinerator Alliance/ Global Alliance for Incinerator Alternatives GAIA Secretariat Unit 320, Eagle Court Condominium 26 Matalino Street, Barangay Central 1100 Quezon City, The Philippines Telephone: +632 929 0376 Fax: +632 436 4733 [email protected] http://www.no-burn.org

2. Alliance for Safe Alternatives

PO Box 6806 Falls Church, VA 22040 , USA Telephone: + 1 703 237 2249 ext.19 http://www.safealternatives.org

3. Basel Action Network Secretariat

c/o Asia Pacific Environmental Exchange 1305 Fourth Ave., Suite 606 Seattle, Washington 98101, USA Telephone: +1 206 652 5555 Fax: +1 206 652 5750 [email protected] http://www.ban.org

4. Communities Against Toxics

PO Box 29 Ellesmere Port Cheshire, CH66 3TX, UK Telephone/Fax: + 44 151 3395473 [email protected]

5. Chemical Weapons Working Group Kentucky Environmental

Foundation P.O. Box 467 Berea, KY 40403, USA Telephone: +1 859 986 7565 Fax: +1 859 986 2695 [email protected] http://www.cwwg.org

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6. Clean Production Action 2307 Avenue Belgrave Montreal, Qc H4A 2L9, Canada Tel: +1 514 484 8647 [email protected] http://www.cleanproduction.org

7. Coalicion Ciudadana Anti-Incineracion dela Argentina

Sucre 1207 PB “B” B(1708) IUU-Moron, Argentina [email protected] http://www.noalaincineracion.org

8. CNIID ( Centre National d'information Indépendante sur

les Déchets) 51 rue du Fbg St-Antoine 75011 Paris, France Telephone: +33 01 5578 2860 Fax: +33 01 5578 2861 [email protected] http://www.cniid.org

9. Earth life Africa

Johannesburg Branch PO Box 11383 2000 Telephone: +27 11 4036056 Fax: +27 11 3394584 [email protected] http://www.earthlife.org.za

10. Friends of the Earth-International

PO Box 19199, 1000 GD Amsterdam, The Netherlands Telephone: +31 20 622 1369. Fax: +31 20 639 218 http://www.foei.org

11. Grass Roots Recycling Network

P.O. Box 49283 Athens, GA 30604 9283, USA Telephone: +1 706 613 7121 Fax: +1 706 613 7123 [email protected] http://www.grrn.org

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12. Greenpeace International Keizersgracht 176, 1016 DW, Amsterdam, the Netherlands Telephone: + 31 20 523 6222 Fax: + 31 20 523 6200 http://www.greenpeace.org

13. GroundWork

P.O. Box 2375 Pietermaritzburg, 3200, South Africa Telephone: +27 33 342 5662 Fax: +27 33 342 5665 [email protected] http://www.groundwork.org.za

14. Health Care Without Harm

1755 S Street, NW Suite 6B Washington DC 20009, USA Telephone: +1 202 234 0091 Fax: +1 202 234 9121 [email protected] http://www.noharm.org

15. Institute for Local Self-Reliance

2425 18th Street, NW Washington, DC 20009-2096, USA Telephone: +1 202 232 4108 Fax: +1 202 332 0463 [email protected] http://www.ilsr.org

16. International POPs Elimination Network

c/o Center for International Environmental Law 1367 Connecticut Ave., NW, Suite 300 Washington, DC 20036, USA Telephone: +1 202 785 8700 Fax: +1 202 785 8701 http://www.ipen.org

17. Lowell Center for Sustainable Production

Kitson Hall, Room 200 One University Avenue Lowell, MA 01854, USA Telephone: +1 978 934 2980 Fax: +1 978 452 5711 http://www.uml.edu/centers/LCSP

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18. National Cleaner Production Centers Programme United Nations Industrial Development Organization PO Box 300, A 1400 Vienna, Austria Telephone: +43 1 26026 5079 Fax: +43 1 21346 6819 [email protected] http://www.unido.org/doc/331390.htmls

19. National Institutes of Health

Information on alternatives to mercury-bearing medical products http://www.nih.gov/od/ors/ds/nomercury/alternatives.htm

20. Pesticide Action Network Latin America

Alianza por una Mejor Calidad de Vida/Red de Acción en Plaguicidas Avenida Providencia N° 365, Dpto. N° 41 Providencia, Santiago de Chile. Telephone: +562 3416742 Fax: +562 3416742 [email protected] http://www.rap-al.org

21. Pesticide Action Network Africa

BP: 15938 Dakar-Fann Dakar, Senegal Phone +221 825 49 14 Fax + 21 825 14 43 [email protected] http://www.pan-africa.sn

22. Pesticide Action Network Asia and the Pacific

P.O. Box 1170 10850 Penang, Malaysia Phone +60 4 656 0381 Fax +60 4 657 7445 [email protected] http://www.panap.net

23. Pesticide Action Network Europe

Eurolink Centre 49, Effra Road UK - London SW2 1BZ Telephone: +44 207 274 8895 Fax: +44 207 274 9084 [email protected] http://www.pan-europe.net

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24. Pesticide Action Network North America 49 Powell St., Suite 500 San Francisco, CA 94102, USA Telephone +1 415 981 1771 Fax +1 415 981 1991 [email protected] http://www.panna.org

25. Silicon Valley Toxics Coalition

760 N. First Street San Jose, CA 95112, USA Telephone: +1 408 287 6707 Fax: +1 408 287 6771 [email protected] http://www.svtc.org

26. H-2 Jungpura Extension

New Delhi-14, India Telephone: +91 11 432 1747, 8006, 0711 [email protected] http://www.toxicslink.org/medical

27. Sustainable Hospitals Project

Kitson 200 One University Avenue Lowell, MA 01854, USA Telephone: +1 978 934 3386 [email protected] http://www.sustainablehospitals.org

28. Toxics Use Reduction Institute

University of Massachusetts Lowell One University Ave. Lowell, MA 01854, USA Tel: +1 978 934 3346 Fax: +1 978 934 3050 [email protected] http://www.turi.org

29. Waste Prevention Association “3R”

P.O.Box 54 30-961 Krakow 5, Poland [email protected] http://www.otzo.most.org.pl

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30. World Alliance for Breastfeeding Action PO Box 1200, 10850 Penang, Malaysia Telephone: + 604 658 4816 Fax: +604 657 2655 [email protected] http://waba.org.my or http://waba.org.br

31. World Wildlife Fund International

Avenue du Mont-Blanc 1196 Gland, Switzerland Phone: +41 22 364 91 11 Fax: +41 22 364 53 58 http://www.wwf.org

32. Zero Waste Alliance International

PO Box 33239 Takapuna, Auckland, New Zealand Telephone: + 649 9178340 [email protected]

33. Zero Waste New Zealand Trust

PO Box 33 1695 Takapuna , Auckland New Zealand Telephone: +64 9 486 0734 Fax: +64 9 489 3232 [email protected] http://www.zerowaste.co.nz

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GLOSSARY

1. ACWA (Assembled Chemical Weapons Assessment): A program of the U.S. government to demonstrate the viability of non-incineration methods for treatment of chemical weapons stockpiles.

2. AFSSA (Agence Française de Sécurité Sanitaire des Aliments):

The agency for food safety in the French Ministry of Health.

3. Basel Convention: An international treaty which, as amended (with the Basel Ban) prohibits the export of hazardous waste from OECD (wealthy) countries to non-OECD countries.

4. Bamako Convention: An international treaty which regulates hazardous waste within Africa, including a ban on importing hazardous waste from outside the continent and provisions for minimization of hazardous waste generation.

5. Bioaccumulation:

The process in which a pollutant builds up in the body over an individual’s lifetime.

6. Biomagnifications:

The process by which a pollutant becomes increasingly concentrated as it moves up the food chain.

7. Body burden:

The load of a given pollutant that an individual carries in his/her body.

8. Bottom ash (also, clinker): The residue from an incinerator that falls through the grate mechanism at the bottom of the furnace.

9. Clean Production:

An approach to designing products and manufacturing processes that takes a life cycle view of all material flows, from extraction of the raw material to product manufacture and the ultimate fate of the product at the end of its life. It aims to eliminate toxic wastes and inputs and promote the judicious use of renewable energy and materials.

10. Clinker: see bottom ash.

11. Destruction and removal efficiency (DRE):

A measure of the efficacy of a treatment technology for preventing the release to air of a given pollutant. DRE is the percentage of the pollutant in

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the waste stream that is not released to the air through the stack. Releases to other media are considered “removal.” Cf. destruction efficiency.

12. Destruction efficiency (DE):

Another measure of the efficacy of treatment technologies. DE is the percentage of pollutant that is destroyed by treatment, i.e., not released in gaseous, liquid or solid form. Cf. destruction and removal efficiency.

13. Dioxins:

As used in this report, polychlorinated dibenzo dioxins (PCDD), polychlorinated dibenzo furans (PCDF) and coplanar polychlorinated biphenyls (PCBs). These are all aromatic chemical compounds formed during the incineration process. Dioxins belong to the class of chemicals known as persistent organic pollutants (POPs).

14. Discards:

Materials of no immediate use to their present owner, to be differentiated from waste, which are materials of no possible use to anyone.

15. Diversion rate:

The percentage of discards that are reused, recycled, composted or otherwise prevented from being wasted.

16. Emissions:

Releases of byproducts from a process (e.g. incineration) to the air.

17. End-of-pipe: Interventions to reduce the environmental impact of an activity that are not integrated into the design but added at the end of the process, often as an afterthought.

18. Energy recovery:

Euphemism usually used for waste to energy or energy-from-waste incineration.

19. Energy-from-waste (EFW):

Incineration with an attached steam turbine to generate electricity. This term occasionally refers to non-incineration technologies.

20. Extended producer responsibility (EPR):

A policy approach that makes firms responsible for their products and packaging in the post-consumer phase, providing an incentive to design products for end-of-life recycling.

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21. Flow control: Legal measures adopted by certain jurisdictions to ensure that all municipal discards from that jurisdiction go to a particular waste treatment facility rather than finding the cheapest option available on the market.

22. Fly ash:

The ash recovered from an incinerator’s air pollution control equipment.

23. Hazardous waste: Wastes which are corrosive, ignitable, reactive or toxic.

24. Health care waste:

All waste generated by health care facilities, such as hospitals, doctors’ offices and clinics; also includes veterinary facilities, funeral homes and laboratories that prepare medicines or deal with human tissue.

25. Life cycle assessment:

A process to evaluate the environmental burdens associated with a product, process, or activity by identifying energy and materials used and wastes released to the environment, and to evaluate and implement opportunities to affect environmental improvements.

26. Lipophilic:

Chemicals which have an affinity for and tend to combine with lipids (fatty substances).

27. Medical waste:

An ambiguous term, sometimes used to refer to all health care waste and sometimes only to that portion which is potentially infectious.

28. Microgram:

1 x 10-6 gram, or one one-millionth of a gram. MNCs (multinational corporations)

29. Municipal discards:

As MSW, below, but disaggregated so that each fraction can be dealt with appropriately (recycling, composting, etc.).

30. Municipal solid waste (MSW):

The mixed waste stream produced by residential and commercial establishments.(But generally not industry)

31. Nanogram:

1 x 10-9 gram, or one one-billionth of a gram.

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32. Neutralent: The liquid waste stream resulting from neutralization of chemicals weapons agent.

33. NGO (non-governmental organization):

Usually refers to non-profit organizations working for the public interest.

34. PBTs (Persistent, Bioaccumulative Toxics): A class of chemicals whose members are persistent in the environment; bioaccumulate in living creatures; and are toxic to life.

35. PCBs (Polychlorinated Biphenyls):

A class of chemicals composed of two benzene rings linked by a single carbon-carbon bond, with one or more chlorine atoms in place of hydrogen. Often, coplanar PCBs (those with the two benzene rings in the same plane) are included in the set of dioxin-like compounds for their similar structure, origin, and effects.

36. PCDD (Polychlorinated Dibenzo Dioxin):

A class of chemicals, referred to as dioxins, composed of two benzene rings linked by two oxygen molecules, with one or more chlorine atoms in place of hydrogen.

37. PCDF (Polychlorinated Dibenzo Furan):

A class of chemicals, referred to as furans, composed of two benzene rings, linked with a carbon-carbon bond and through a single oxygen molecule, with one or more chlorine atoms in place of hydrogen. Furans are considered dioxin-like compounds for their similar structure, origin, and effects.

38. Picogram:

1 x 10-12 gram, or one one-trillionth of a gram.

39. Pg/kg/day: Picograms per kilogram of body weight per day. A measurement of the rate of intake of a pollutant (usually dioxins) relative to a person’s body weight.

40. POPs (Persistent Organic Pollutants):

Synthetic chemicals which display the following properties: they are organic (composed of hydrocarbons); persist long times in the environment; are capable of long-distance transport; and are toxic to humans. Subject to regulation under the Stockholm Convention.

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41. Precautionary Principle: The principle that, in cases of scientific uncertainty regarding the safety of an activity, the burden of proof should rest with the proponent of the activity rather than with the persons to be affected; and that action should be taken to prevent harm whenever there is credible evidence that harm is occurring or is likely to occur, even when the exact nature and magnitude of the harm is not proven.

42. Preventive Principle:

The principle that prevention of harm is always preferable to amelioration or compensation after the fact.

43. Process wastes:

Byproducts of production processes such as manufacturing.

44. PVC (Polyvinyl Chloride): A common form of plastic often referred to as vinyl, with chlorine as a major component.

45. Pyrolysis:

A form of incineration in which waste is treated in a depleted-oxygen environment, producing a gas, which is burned, and other byproducts, including slag. Legally classified as a form of incineration in the European Union and United States.

46. Quench:

A pollution control device in an incinerator which sprays water into the exhaust gases shortly after they leave the furnace chamber. The object is to quickly reduce the gases’ temperature to less than 200°C, the minimum temperature for dioxin formation.

47. Releases:

All byproducts from a process (e.g. incineration) including emissions (to air), effluent (to water bodies) and solids (to land).

48. Slag:

A fused, solid byproduct of pyrolysis or incineration.

49. Stockholm Convention: The Stockholm Convention on Persistent Organic Pollutants. An international treaty which bans or regulates production and emissions of a class of synthetic chemicals.

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50. TDI (Tolerable daily intake): The maximum amount of a chemical which can theoretically be safely ingested. WHO and various governments set TDIs for some chemicals of concern.

51. TEF (Toxic Equivalency Factor):

A value that is empirically assigned to each congener (type) of dioxins and furans to represent their toxic potency relative to 2,3,7,8-TCDD (which has a TEF of 1).

52. TEQ (Toxic Equivalency):

A calculated figure used to estimate the overall toxicity of multiple congeners (types) of dioxin-like chemicals at once. There are two primary TEQ systems,I-TEQ (International) and WHO, which yield slightly different results. The TEQ for a given sample is calculated by multiplying the quantity (mass) of each congener in the sample by that congener’s TEF, then adding the results together.

53. TNCs (transnational corporations):

Companies with operations in multiple countries. Also MNCs.

54. UN: The United Nations.

55. UNDP (United Nations Development Program): An agency of the United Nations whose primary mission is to reduce poverty worldwide.

56. UNEP (United Nations Environment Programme):

An agency of the United Nations whose mission is to encourage sustainable development through sound environmental practices everywhere.

57. UNIDO (United Nations Industrial Development Organization):

An agency of the United Nations dedicated to helping Southern countries’ industrial bases develop.

58. USEPA (United States Environmental Protection Agency):

An agency of the United States government.

59. Vitrification: A rarely-used process of melting ash and allowing it to cool into glass-like balls. The intention is to destroy some organic compounds and make pollutants in the ash less available to the environment.

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60. Waste-to-Energy (WTE): see energy-from-waste.

61. WHO (World Health Organization): An agency of the United Nations working to improve human health.

62. Zero Waste:

A philosophy and a design principle that includes recycling but goes further by taking a “whole system” approach to the entire flow of resources and waste through human society. Zero Waste maximizes recycling, minimizes waste and ensures that products are made to be reused, repaired or recycled back into nature or the marketplace.

waste management in health care sector

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