| Global Alliance for Incinerator Alternatives | Basel Action Network |
15 March, 2002
MEMO #1
IFC Environmental, Health and Safety Guidelines
Health Care Facilities (January 2002)
Comments and Recommendations on the Draft
The IFC's approach to developing guidelines for safe management of health care wastes is particularly laudable on three initial points.
• The attempt to provide a succinct overview challenging project personnel to acknowledge the very serious hazards (especially those beyond biohazard/infectious waste), and provide guidance on establishing plans and programs to mitigate those hazards;
• The emphasis on segregation as the essential strategy to minimize the hazardous portion of the waste stream, and the multiple referrals to pollution prevention through product elimination or substitution is also an important contribution to making new health projects safer to workers, patients and the public;
• Coordination of this guidance with already established guidance documents (e.g., WHO)
There are a series of issues, that if addressed will strengthen this document by both creating greater internal consistency and taking advantage of field experience in health care facilities in a number of countries. There is a heavy reliance on the WHO manual Safe Management of Wastes from Healthcare Activities, which is in need of updating according to the authors, and on European and United States specific sources, that are applicable for broad standard setting (e.g., air emissions standards) but are less helpful in terms of specific approaches to management. The following outline reviews a series of points designed to increase the value of the document to guide future projects. It follows the general layout of the document for ease of review and application.
1. Hazardous Health Care Waste Categories
If there is going to be a categorization of wastes then it should be consistent between identification and management. The table on page 1 of the document describing the diverse nature of hazardous wastes to be encountered does not correspond to Table 1 on page 11 later in the document that details management strategies.
The categorization descriptions could be enhanced by further clarification to avoid confusion:
Infectious waste - All waste contains pathogens. To better distinguish this as a particular category set aside for special management the definition would better read: "Waste that potentially contains enough virulent pathogens to transmit disease to humans through direct contact." The examples should be very specific in supporting this. (While more research and documentation is needed there is virtually no scientifically confirmed incident of disease transfer from waste in a hospital other than through contact with sharps). Beyond Laboratory cultures and stocks, liquid blood and blood products and other body fluids, and wastes from patients in isolation with a known infectious disease, other wastes do not have to be routinely managed as potentially infectious. Listing tissues, swabs, general materials and equipment in contact with patients and excreta leads to confusing categorization that has in the field led hospitals to treat all patient contact waste as potentially infectious.
If there is to be a category of "highly infectious waste," it should be stated here as well. In interviewing practitioners in a dozen countries, this category, while widely acknowledged, is rarely utilized in guiding day-to-day management and is reserved largely for emergency situations (e.g., a major outbreak of a highly infectious disease). It is recommended that this categorization be reserved for "emergency response" as opposed to daily use.
Pathological waste - Tissues, blood samples, body parts. It is important to note here, and later, that these wastes need to be separated from the preservative (e.g., formalin/formaldehyde) that they are often found with - the presence of these chemicals makes this a "mixed waste" that without segregation cannot be safely managed either as a biohazardous or a chemically hazardous waste.
Pharmaceutical wastes - A distinction should be made between common drugs and agents, and those that are actually characteristically hazardous (e.g., toxic, ignitable, corrosive, or reactive). A number of commonly used pharmaceuticals are "listed" hazardous substances under the USEPA's RCRA. These require different management strategies for safe handling, storage, treatment and disposal.
Genotoxic waste - While this category is straight from the WHO guide it is not necessarily helpful. There are wastes that are genotoxic that could be classified under both Pharmaceutical and Chemical wastes, as well as radioactive wastes. Genotoxic is a property that represents a subset under these other categorizations, rather than a specific category itself. The management particularly of cytotoxic drugs is of significant concern and needs special treatment as it is often confused with the management practices for infectious waste.
Chemical waste - There is a long list of wastes produced in facility management that also belong on this list from solvents and degreasers used in boiler maintenance, water treatment chemicals, paints and other associated materials used in maintenance of the building, its HVAC system and electrical systems, etc. Hazardous health care wastes need to include all wastes generated in the operation of the facility, not just in patient care.
Heavy metals - There is a longer list that could be included. All mercury containing devices (including whole as well as broken thermometers - the chances are, once broken, the mercury has been released); mercury containing chemicals including cleaning agents, laboratory chemicals such as reagents, etc.; mercury containing thermostats and boiler switches in facilities; batteries, flourescent light tubes and U-bulbs; lead aprons from radiology; silver from film developer and x-rays; etc.
2. Health Care Waste Management Philosophy
Having a basic statement of operating principles is an excellent idea. It gives a foundation against which to measure progress. Some suggested changes include:
a. Under (1) prevention and minimization, a distinction should be made to include both the minimization of the volume of wastes produced and the hazardous nature of those wastes. Integrating this into a systems approach should begin with clear policies in both purchasing of supplies and equipment (e.g., Not purchasing mercury equipment) and an acceptance protocol for "donated" supplies, "free" pharmaceuticals or other samples, and materials that practitioners (e.g., doctors) can bring into the facility.
b. Under (3) treatment by "environmentally sound methods." This needs further definition, as it appears to be contradicted by the recommendations in Table 2, especially that of the use of Pyrolitic Incinerators.
c. While (5), the phase out of PVC products and packaging is a good and sensible goal both from a patient safety and environmental perspectives, it is in fact part of a larger "philosophical" strategy of materials substitution. It would be much stronger to rephrase it as: Phase out the use of hazardous products and materials as suitable replacements are made available. These include mercury-containing equipment and materials made of polyvinyl chloride (PVC). Substitutes for other hazardous chemicals and materials should also be researched.
3. Air Emissions
See Memo #2
4. Wastewater Management
See Memo #2
5. Community involvement and awareness
This is an excellent addition that is most often missing from other guidelines. However, community consultation and right-to-know should be obligatory upon health care institutions, not just "good practice." It should always be understood that no matter what methods are undertaken for the management and treatment of health care wastes that they will have to at some point intersect with the municipal waste streams - solid and water, and that operation of health care facilities has a significant impact on the overall ecological footprint of any community.
6. Resources
The Sustainable Hospitals website at the University of Massachusetts Lowell is the best collection of alternative materials for minimizing use of hazardous substances, including mercury and PVC, in hospitals. www.sustainablehospitals.org
In addition the new Danish web site on PVC alternative products should also be listed.
7. Comprehensive Hazardous Health Care Waste Management Plan (Appendix A)
The requirement for a waste management plan at facilities is excellent. It should however not just include Hazardous Health Care Waste, but all wastes, as it is difficult to plan for one sub-section of the waste stream from a hospital.
There should be a section of the plan dedicated to general waste minimization, reuse, and recycling. Another distinct section should be dedicated to purchasing policies that reinforce the waste management goals.
A. Occupational Safety and Health
In addition to "events" there should also be a requirement for monitoring of worker health in situations where workers are routinely exposed to hazardous substances (e.g., waste treatment technology workers; workers utilizing hazardous chemical disinfectants).
A reporting protocol should be established to record all needlestick injuries, exposure to blood and body fluids, and exposure to chemicals or radioactive materials.
B. Training
Training for spill containment and clean-up should include both blood and body fluid spills, and protocols for various chemical spills (i.e., the procedure for addressing a mercury spill is very different than a blood spill, although in most clinical setting observed workers treated them the same. In addition the protocol for clean-up of a mercury spill is very different from a spill of a solvent or a cytotoxic drug.)
C. Waste Storage
While there are some similarities for storage areas for different types of hazardous wastes, there are many more differences. This section should be broken up into at least three sections: (1) infectious waste storage; (2) chemical waste storage; (3) radioactive waste storage. For example a well drained area that is easily cleaned is appropriate for infectious waste storage, but not effective for chemical waste storage where spill and leaks need to be contained. Also, Personal Protective gear (PPE) for workers handling infectious waste may not be appropriate for workers handling chemical wastes.
D. Waste Transport
All wastes should be transported independently. Internal carts and external vehicles should be dedicated to one waste stream (e.g., general waste, infectious waste)
8. Table 1: Waste containerization and marking
This entire table needs to be re-worked to correspond with the categories identified on Page 1. The universal symbols for various types of wastes should be identified in the document and required as part of the labeling.
a. The categories of "Highly Infectious Waste" should be a sub-category of "Infectious Waste."
b. In terms of treatment and identification, lab cultures and stocks may want to be distinguished.
c. The color coding can be listed, but whatever is chosen it should be part of a consistent national standard. This should not encourage varying color coding between hospitals.
d. For purposes of identification for later treatment, pathological wastes should be separately containerized and labelled.
e. Chemical and pharmaceutical wastes - these need to be separately identified. Rigid leak proof containers (NOT bags) should be used.
f. Mercury needs to be specially collected and sealed as it volatilizes at room temperature.
g. General health care waste. We advocate for clear bags where ever possible. Clear bags for general waste build confidence that the facility is doing a good job of segregation. Clear bags can be easily inspected by workers to identify any errors in disposal. While there may be some aesthetic concerns, the safety issues far outweigh these. While bags are preferable, accommodation and alternatives should be presented to facilities where the cost of bags may be prohibitive over the long term. Separating wet from dry solid wastes, increasing recycling, etc., can reduce the need for bags.
9. Table 2: Hazardous Health care waste treatment options
This table corresponds to the WHO table that was published in 1999. There are indications that it is becoming out of date and needs to be re-evaluated.
A simple table to provide a snapshot of treatment options for the many different waste streams is actually counterproductive. To lump all chemical into one waste stream, or all pharmaceuticals, and make generalizations about them can lead to a series of bad management practices.
A. Referencing Cytotoxic wastes (15) as needing to reach a minimum of 800 degrees C. is not a useful guide, since destruction for each of these drugs requires different temperatures, many of them higher than 800 degrees. It also insinuates that they could be treated in a biomedical waste incinerator, mixing different waste streams. A pyrolitic incinerator designed for biohazard waste is an inappropriate treatment technology for cytotoxic wastes. This is one of the waste streams that the project will have to determine if there is external treatment capacity that can handle it.
B. There are similar problems in the reference to pharmaceutical wastes. Including them as part of an waste stream (even in small quantities) that can be adequately treated in an incinerator without giving the specifications of that incinerator is also not wise. As there are different categories of pharmaceuticals, some more hazardous than others, differentiation needs to be made prior to determining treatment and disposal options.
C. At a minimum, the incinerator operation should be restricted by having a plan to eliminate all PVC plastics from its feedstock; certify that it is not being used for chemical waste disposal, including the formaldehyde used to preserve pathological samples that may be incinerated.