Medical Waste Disposal at
Provincial Hospitals – Western Cape
A new environmentally friendly
medical waste management strategy
CESAR ALEXANDRE
CHIEF ENGINEER
PROVINCIAL ADMINISTRATION WESTERN CAPE - DEPARTMENT OF HEALTH
ABOUT THE SPEAKER
- Mr C S Alexandre has a Masters Degree in Technology and Business Administration, M.Tech.BA.
- He is a lecturer of “Project Management”, for the Masters Degree in Technology & Business Admin., Public Management & Marketing Courses (M.Tech.BA, M.Tech.PM, M.Tech.Marketing), & lecturer & founder of a “Project Management” course plus an “Advanced Project Management” course, for the Centre for Continuing Education & the faculty of Business Informatics with the Cape Technikon.
- He is also a founder & lecturer of Project Management for the Cape Administrative Academy. In December 2002 he was awarded a “Certificate of Excellence” for his outstanding contribution to the promotion of Project Management training within the Provincial Dept. of the Western Cape.
- Mr C Alexandre has previously worked for Mobil Oil Corporation and has more than 30 years experience in Engineering, Operations, and Project Management.
ABSTRACT
Medical waste consists of all waste produced by hospitals, clinics, physicians offices, dentists offices, funeral homes, veterinary clinics and medical and research laboratories.
Although many medical and veterinary institutions practice “universal precaution”, which means that all materials that have come into contact with any type of body fluid are considered to be infected WORLD HEALTH ORGANISATION, Infection Control Guidelines, indicate the most hospital waste is no more infective than residential waste and that hospital waste disposal practices have not caused disease in the community.
One cannot assume that all waste from a health care facility poses a risk. Currently only between 10 and 15% of medical waste is considered infectious.
Most material considered bio hazardous falls primarily into three categories: contaminated laundry, hard and soft wastes (‘sharps’ and bandage materials), and diagnostic specimens.
The word ‘infectious’ and ‘pathological’ imply a degree of hazard and may cause unnecessary alarm, as they are also used to describe material, which is neither human nor animal tissue.
As the SABS proposed code of practice says, in many guidelines, all waste contaminated with blood or body fluids are classified as infectious waste.
This enormously increases the volume of waste requiring expensive handling and disposal.
Identical items of waste are disposed of from homes with no special handling or decontamination.
The identification of every patient who carries a blood borne pathogen such as Hepatitis B or Human Immunodeficiency Virus, is both impractical and inappropriate.
The modern trend in hospital infection control is to build safe practices into all clinical procedures, the precaution taken is dictated by the risk accompanying the procedure, not by the diagnosis.
The purpose of the paper is to analyse the nature of medical waste and its safe Handling, (segregation, packaging, in-house transport, storage), Treatment and Disposal, as well as the new environmentally friendly medical waste processing technology used by the Department of health, Western Cape, which is the first in Africa and one of the most advanced technologies in the world.
Alex/Medical Waste Conference 05/2003
MEDICAL WASTE DISPOSAL AT PROVINCIAL HOSPITALS – WESTERN CAPE
A NEW ENVIRONMENTALLY FRIENDLY
MEDICAL WASTE MANAGEMENT STRATEGY
- INTRODUCTION
Recent media attention has increased the public’s apprehension that medical wastes are not properly controlled. The appearance of AIDS and the prospect of AIDS-contaminated medical waste washing up on public beaches have compounded this fear, so that panic can be created by the mere mention of the words “infectious waste” of “hospital waste”.
Is this fear justified: Certain medical wastes are more dangerous than any of the thousands of hazardous substances disposed of by homes and industries. How are medical wastes defined? Are all medical wastes infectious or hazardous? How are hazardous medical wastes identified, stored, treated, and disposed of? Which medical waste management practices will ensure that waste haulers and handlers will be protected and that the general public will not be exposed to any risk?
The late 1980’s have witnessed a reorientating of official European Community (EC) environmental protection policies, paralleling a deepening sense of public concern over the future prospects for a sustainable economy and environment. Our economy and our environment are fundamentally interrelated with nature imposing physical constraints on human production and consumption activities. Put simply, when materials and energy are “used up” during the making and consuming of goods and services nothing disappears, rather, everything given enough time reappears somewhere in the environment. Unfortunately, the “useful” materials and energy that were initially sucked into the economy are pushed out over time (to the air, water and land) as relatively “useless” wastes of one type or another.
This large and increasing mass of redundant goods, by-products and a variety of residues must be disposed of somehow and at a cost. The environment has a large waste assimilation capacity, but this is not infinite. Too much waste of the wrong sort dumped without appropriate precautions will generate significant and long pollution damage costs, including human health. Defining hazardous waste categories to formulate rational waste management policies is an uncertain and complex exercise. Some sources argue that the toxicity of pollution from MSW landfill sites is indistinguishable from that of hazardous industrial waste sites. Although the proportion of MSW that is hazardous is small, it still represents a substantial problem because of the large volume involved.
Historically, most wastes of all categories have been disposed of via landfill sites. Only a small percentage of waste is incinerated and an even smaller amount is incinerated at facilities with an energy recovery capability. There is a legacy of abandoned and operational landfills containing a variety of wastes whose exact composition is often unknown. Standards of operation, maintenance and monitoring have been and continue to be variable; many sites probably pose significant environmental risks. The financial costs of landfill disposal continue to be relatively low, representing an under-pricing of the waste assimilating capacity service of the environment. The full economic price for landfill (encompassing all relevant costs such as, for example, pre-treatment and proper pollution containment measures) is much higher.
2.THE PURPOSE OF THE PAPER
The purpose of the paper is to analyse the nature of medical waste and its safe Handling, (segregation, packaging, in-house transport, storage), Treatment and Disposal, as well as the new environmentally friendly medical waste processing technology used by the Department of Health, Western Cape, which is the first in Africa and one of the most advanced technologies in the world.
3.NATURE OF MEDICAL WASTE
Medical waste consists of all waste produced by hospitals, clinics, physicians offices, dentists offices, funeral homes, veterinary clinics and medical and research laboratories.
Although many medical and veterinary institutions practice “universal precaution”, which means that all materials that have come into contact with any type of body fluid are considered to be infected WORLD HEALTH ORGANISATION, Infection Control Guidelines, indicate the most hospital waste is no more infective than residential waste and that hospital waste disposal practices have not caused disease in the community.
One cannot assume that all waste from a health care facility poses a risk. Currently only between 10 and 15% of medical waste is considered infectious.
Most material considered bio hazardous falls primarily into three categories: contaminated laundry, hard and soft wastes (‘sharps’ and bandage materials), and diagnostic specimens.
The word ‘infectious’ and ‘pathological’ imply a degree of hazard and may cause unnecessary alarm, as they are also used to describe material, which is neither human nor animal tissue.
As the SABS proposed code of practice says, in many guidelines, all waste contaminated with blood or body fluids are classified as infectious waste.
This enormously increases the volume of waste requiring expensive handling and disposal.
Identical items of waste are disposed of from homes with no special handling or decontamination.
The identification of every patient who carries a blood borne pathogen such as Hepatitis B or Human Immunodeficiency Virus is both impractical and inappropriate.
The modern trend in hospital infection control is to build safe practices into all clinical procedures, the precaution taken is dictated by the risk accompanying the procedure, not by the diagnosis.
The simple presence of viable organisms does not constitute a hazard; a mechanism by which these organisms can infect a host must coexist.
Since Hepatitis B and HIV are usually transmitted by inoculation the concern with blood alone, for example, is misplaced.
The emphasis should more appropriately be applied to the category of clinical sharps.
Infections acquired by waste handlers are rare but almost always associated with trauma.
High priority should be toward the precaution of these injuries.
The incidence of both the wounds and accompanying infections can be reduced dramatically by adherence to safe procedures.
Absolute elimination of all risks is impossible. A realistic goal is a reasonable degree of safety at all times without compromising efficiency.
The safe and effective management of medical waste depends on appropriate segregation, packaging, in-house transport, and storage procedures, and finally treatment and disposal.
Of course such appropriateness can only be achieved by all healthcare facilities having a documented policy and procedures and the staff is properly trained.
4.EXAMPLES OF HEALTH CARE RISK WASTE
The Health Care Waste (HCW) is divided into Health Care General Waste (GCGW) and Health Care Risk Waste (HCRW) (Medical Waste).
The purpose of HCRW management is the elimination or minimisation of the negative impact of medical waste on humans, animals and environment.
*The Health Care General Waste (HCGW) is the non-hazardous component of the HCWM. It is generated during the administrative and housekeeping functions of health care facilities and includes a number of recyclable materials.
Health Care Waste (HCW)Health Care Risk Waste (HCRW) / Health Care General Waste (HCGW) *
Infectious waste:All kinds of waste that is likely to contain pathogenic microorganisms.
Pathological waste:Includes parts that are sectioned from a body (Human Anatomical Waste).
Sharps:Includes sharp and pricking objects that may cause injury as well as infection.
Chemical & pharmaceutical waste:Includes all kinds of discarded chemicals, including pharmaceuticals.
Radioactive waste:This includes solid, liquid and gaseous waste contaminated with radionuclides.
Cytotoxic waste:Waste containing substances with genotoxic (affecting genes) properties including drugs often used in cancer.
5.TREATMENT AND DISPOSAL
Disposal in a landfill site is a common method, and is appropriate for many varieties of medical waste. (Infectious non-anatomical waste) (WHO, World Health Organisation)
If some infectious material is present in the waste transported to the landfill, the concentration of pathogens is reduced by soil filtration. An organism passing further into the soil bed is denied the nutrients, oxygen and other conditions necessary for survival. Certain techniques may reduce exposure to infectious wastes. The most effective of these procedures are the segregation of infectious loads from other loads, the visual inspection of infectious waste and the avoidance of the direct handling of open bags, the immediate burial of infectious waste so that it is not directly compacted on the landfill surface, and the proper personnel protective equipment by use of employees who work on the face of the landfill.
The only special requirement for the disposal of infectious wastes in a landfill is that the wastes be rendered unrecognisable for aesthetic reasons.
The sanitary sewer system is a safe and acceptable method of disposal for untreated bulk blood, suctioned fluids excretions, secretions, and other infectious wastes that can be ground and flushed into the sewer. Grinding and sewering of wastes constitutes immediate removal of the infectious waste, eliminating storage, transport and handling costs. This method is not advised, however, because vapours can be produced and sewer lines may become clogged. The sewer system is designed to attenuate sewage and is, therefore, effective in attenuating infectious agents found in blood and other body fluids. This disposal practice is allowed because sewage is normally an infectious material. When wastes are treated in this manner, the waste should be poured carefully to eliminate spills and the formation of vapours. The municipal sewerage treatment system should have secondary treatment available, and the practice should meet with the approval of all applicable local sewerage bylaws.
Incineration has traditionally been the principal method used by healthcare facilities to dispose of anatomical and infectious non-anatomical wastes.
Over the last decade, the industry has seen a number of new medical waste processing technologies enter the market.
Everything from micro waving to vacuum pyrolysis to steam treatment to plasma arching.
The reason for the plethor of new technologies is a result of an ever-increasing trend by countries to phase out the use of incineration.
While incineration had been the standard of medical waste processing technology, countries are becoming increasingly aware of the detrimental effects of incineration to stakeholders and the environment. (Green peace recently released a report, “Incineration and Health”, that links incineration to cancer.)
The issue with incinerators is emissions. Burning waste does not make it disappear. Depending on the type of waste, up to 100 chemicals can be emitted into the atmosphere.
One of the common emissions from incinerators is dioxins, the toxic component of “Agent Orange”, which was used during the Vietnam War.
Dioxins are carcinogenic, depress the immune system, and disrupt the reproductive and hormonal systems.
Because of its effects on human health and the environment, dioxin is one of the 12 persistent organic pollutants “Pops” that have been prioritised for immediate action under the global Pops convention, to which South Africa is a signatories.
The Stockholm convention names incinerators as contributors to the formation of new Pops. Medical and chemical waste incinerators are one of the largest causes of dioxin emissions.
In addition, South Africa, intends to be on the forefront in meeting the objectives set in Rio, in the Kyoto Protocol and more recently in the United Nations Conference on Sustainable Development, in Durban, South Africa.
The mission of any medical waste treatment technology should be three fold:
- Render the material non-infectious and the processed waste 100% recyclable.
- Render the material unrecognisable/un-reusable.
- Be environmentally friendly.
Preventing circumstances in the industry, dictates that the problem of medical waste is dealt with as a matter of collection, incineration and post incineration disposal.
However, it should address the entire spectrum from point of generation to final disposal, all within an infectious control paradigm.
This means that the system should provide maximum security against nosocomial risks and provide maximum safety to the health care worker, from clinician to janitor, and comprehensive in-training is provided to ensure correct use of the system, guarantees safety for the communities and ensures zero negative environmental interfaces, i.e. be environmentally friendly.
6.WASTE MANAGEMENT SYSTEMS VS ENVIRONMENTAL HEALTH RISKS
An effective system will have to integrate waste minimisation, recycling, processing, transport and final disposal activities.
Waste recycling is not a magic panacea for the waste generation/disposal conundrum. Speculation about complete recycling communities and societies is both scientifically and economically illiterate. Recycling is not an end in itself, it should not be carried out if there is no net environmental gain – when more fuel and material usage and more pollution occur through re-use than would have occurred if new products ware made with virgin resources.
Present management systems are still largely based on a “dispose, dilute and disperse” approach.
All the indications are that a fundamental philosophical switch is required towards a “recycle, concentrate and contain” approach. Landfill disposal will remain an important component of the new strategy. However, the landfill of the future will be a more costly and amore “engineered” set of operations (in order, for example, to contain pollution on-site and recover methane gas) than it has been in the past. The long-term objective of the overall system should not therefore be simply the maximisation of waste recycling. What is required, and will be costly and difficult to achieve, is a reliable, relatively low environmental risk, socially acceptable, mixed bout integrated waste treatment, recovery and disposal system. To coil a phrase, identifying the “best practicable environment option” for elements of the system, and more ambitiously the system itself, is the ultimate long-term challenge for sustainable economy and society.
Given the nature of our economic system & its technological bias, it is the case that we cannot expect to accept the material benefits of this system and enjoy zero-environmental risk founded in zero exposure to pollution. Some sort of risk-benefit balancing process is required, in which “acceptable” trade-offs between risk levels and the costs of reducing exposures are struck.
Environmental health risks, natural or of human origin, are an ever-present feature of human life. As economies have industrialised, the nature of these risks has changed from past concerns over infectious diseases, through more recent chemical and radiation exposures in the workplace, to current worries over “environmental” (non-occupational) toxic exposures. This shift in public health focus has inevitably meant a shift in concern away from acute illness arising promptly after relatively high doses of toxic exposure, towards concern for delayed (perhaps years later) health effects resulting from low dose exposure. Risk assessment (typical of hazardous waste facilities) with respect to this latter situation can be quite an ambiguous process and will not produce the precise answers that society seems to demand.