1. I NTRODUCTION TO THE C OMPENDIUM OF T ECHNOLOGIES FOR THE D ESTRUCTION OF H EALTHCARE W ASTE Jorge Emmanuel International Experts Workshop UNEP-DTIE-IETC July 19-20, 2012 Osaka, Japan

2. C OMPONENTS OF THE P ROJECT Compendium of Technologies for the Destruction of Healthcare Waste Excel-based interactive software to assist users in technology selection Training manual

3. P URPOSES OF THE C OMPENDIUM To assist developing countries in assessment and selection of appropriate technologies for the destruction of healthcare waste To promote environmentally sound technologies

4. M AIN P ARTS OF THE C OMPENDIUM Executive Summary 1. Introduction 2. Basic Data on Healthcare Waste 3. Generic Technologies 4. Specific Technologies 5. Technology Assessment Methodology

5. I NTRODUCTION TO H EALTHCARE W ASTE (HCW) Typical Definitions of HCW All the waste generated by healthcare facilities, medical laboratories and biomedical research facilities, as well as waste from minor or scattered sources, such as home health care [WHO Blue Book] Any waste, hazardous or not, generated during the diagnosis, treatment or immunization of humans or animals; or waste generated in research related to the aforementioned activities; or waste generated in the production or testing of biologicals [Bio-medical Waste Rules, India]

6. I NTRODUCTION TO H EALTHCARE W ASTE (HCW) Hazards of healthcare waste in developing countries Waste discarded without treatment in open dumps Waste pickers (scavengers) Waste workers without personal protective equipment Waste burned in antiquated and dysfunctional incinerators Communities exposed to incinerator emissions Workers and waste pickers exposed to incinerator ash

7. Source: ATSDR, 1990; Prüss-Ustün et al., 2005 R ISKS A SSOCIATED W ITH HCW Risk of infection from a deep needle-stick injury involving fresh blood from an infected patient HIV: 1 in 250 Hepatitis C: 1 in 10 to 1 in 30 Hepatitis B: 1 in 3 to 1 in 5 WHO: In 2000, about 16,000 hepatitis C infections, 66,000 hepatitis B infections, and 1,000 HIV infections worldwide among healthcare workers due to occupational exposure to sharps injuries

8. R ISKS A SSOCIATED W ITH HCW Exposure to Blood Splashes 1 to 4 out of every 10,000 workers handling biomedical waste could develop HIV due to blood splashes Source: ATSDR, 1990

9. A IR E MISSIONS F ROM A M EDICAL W ASTE I NCINERATOR

10. M EDICAL W ASTE I NCINERATION (MWI) IS A MAJOR GLOBAL SOURCE OF D IOXINS Europe: 62% of dioxin emissions due to 4 processes, including MWI Belgium: MWI accounts for 14% of dioxin emissions Denmark: MWI is 3rd or 4th largest dioxin source of 16 processes Thailand: MWI - highest dioxin source by far of 7 sources tested Extremely high dioxin levels in MWI ash and wastewater United States: MWIs – third largest source of dioxins: 17% of total dioxins in 1995 Drop in dioxin emissions from MWI in part due to shift to non- incineration methods Canada: MWI - largest dioxin source in Ontario province Drop in dioxin emissions from MWI due to closure of MWIs

11. WHAT ARE DIOXINS? Polychlorinated dibenzo-p-dioxins and dibenzofurans Family of 210 compounds Among the most toxic compounds known to humans > The most toxic is 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD)

12. H OW FAR DO D IOXINS TRAVEL ? Dioxins travels long distances in the air (up to hundreds of kilometers)

13. H OW LONG DO D IOXINS REMAIN IN THE ENVIRONMENT ? Dioxins are very persistent: Environmental half-life t 1/2 on surface soil: 9 to 15 years Environmental half-life t 1/2 in subsurface soil: 25 to 100 years Volatilization half-life t 1/2 in a body of water: more than 50 years CiCi C 1/2 t 1/2 Concentration Time (years)

14. B IOCONCENTRATION OF D IOXINS Bioconcentration factors for 2,3,7,8- TCDD Aquatic plants: 200 to 2,100 in 1-50 days Invertebrates: 700 to 7,100 in 1-32 days Fish (carp): 66,000 in 71 days Fish (fathead minnow): 128,000 in 71 days

15. H EALTH E FFECTS A SSOCIATED WITH D IOXIN Classified as a known human carcinogen by IARC in 1997 Cancers linked to dioxins: Chronic lymphocytic leukemia (CLL) Soft-tissue sarcoma Non-Hodgkins lymphoma Respiratory cancer (of lung and bronchus, larynx, and trachea) Prostate cancer

16. H EALTH E FFECTS A SSOCIATED WITH D IOXIN Developmental Effects Birth defects Alteration in reproductive systems Impact on childs learning ability Changes in sex ratio (fewer male births) Effects on the Male Reproductive System Effects on the Female Reproductive System Immune System Impacts

17. D IOXIN T OXICITY LOAELs (animal studies): Increased abortions, severe endometriosis, decreased off-spring survival, etc. (Rhesus monkeys, 3.5-4 years): 0.00064 μg/kg/day WHO tolerable daily intake = 0.001 ng TEQ/kg/day US EPA cancer potency factor (2002) = ( 0.000001 ng TEQ/kg/day) -1 Note: 1 ng = 0.000000001 grams

18. EPIDEMIOLOGICAL STUDIES RELATED TO HEALTH EFFECTS OF INCINERATION STUDY SUBJECTSCONCLUSIONS REGARDING ADVERSE HEALTH EFFECTS REFERENCE Residents living within 10 km of an incinerator, refinery, and waste disposal site Significant increase in laryngeal cancer in men living with closer proximity to the incinerator and other pollution sources P. Michelozzi et al., Occup. Environ. Med., 55, 611-615 (1998) 532 males working at two incinerators from 1962-1992 Significantly higher gastric cancer mortality E. Rapiti et al., Am. J. Ind. Medicine, 31, 659-661 (1997) Residents living around an incinerator and other pollution sources Significant increase in lung cancer related specifically to the incinerator A. Biggeri et al. Environ. Health Perspect., 104, 750- 754 (1996) People living within 7.5 km of 72 incinerators Risks of all cancers and specifically of stomach, colorectal, liver, and lung cancer increased with closer proximity to incinerators P. Elliott et al., Br. J. Cancer, 73, 702-710 (1996)

19. E PIDEMIOLOGICAL S TUDIES RELATED TO HEALTH EFFECTS OF INCINERATION STUDY SUBJECTSCONCLUSIONS REGARDING ADVERSE HEALTH EFFECTS REFERENCE 10 workers at an old incinerator, 11 workers at a new incinerator Significantly higher blood levels of dioxins and furans among workers at the old incinerator A. Schecter et al., Occup. Environ. Medicine, 52, 385-387 (1995) 53 incinerator workersSignificantly higher blood and urine levels of hexachlorobenzene, 2,4/2,5- dichlorophenols, 2,4,5- trichlorophenols, and hydroxypyrene J. Angerer et al., Int. Arch. Occup. Environ. Health, 64, 266-273 (1992) 37 workers at four incinerator facilities Significantly higher prevalence of urinary mutagen/promutagen levels X.F. Ma et al., J. Toxicol. Environ. Health, 37, 483- 494 (1992) 104 workers at seven incinerator facilities Significantly higher prevalence of urinary mutagen and promutagen levels J.M. Scarlett et al., J. Toxicol. Environ. Health, 31, 11-27 (1990)

20. E PIDEMIOLOGICAL S TUDIES RELATED TO HEALTH EFFECTS OF INCINERATION STUDY SUBJECTS CONCLUSIONS REGARDING ADVERSE HEALTH EFFECTS REFERENCE Residents from 7 to 64 years old living within 5 km of an incinerator and the incinerator workers Levels of mercury in hair increased with closer proximity to the incinerator during a 10 year period P. Kurttio et al., Arch. Environ. Health, 48, 243- 245 (1998) 122 workers at an industrial incinerator Higher levels of lead, cadmium, and toluene in the blood, and higher levels of tetrachlorophenols and arsenic in urine among incinerator workers R. Wrbitzky et al., Int. Arch. Occup. Environ. Health, 68, 13-21 (1995) 56 workers at three incinerators Significantly higher levels of lead in the blood R. Malkin et al., Environ. Res., 59, 265-270 (1992)

21. STUDY SUBJECTSCONCLUSIONS REGARDING ADVERSE HEALTH EFFECTS REFERENCE Mothers living close to incinerators and crematoriums in Cumbria, north west England, from 1956 to 1993 Increased risk of lethal congenital anomaly, in particular, spina bifida and heart defects around incinerators, and increased risk of stillbirths and anacephalus around crematoriums T. Drummer, H. Dickinson and L. Parker, Journal of Epidemiological and Community Health, 57, 456-461 (2003) E PIDEMIOLOGICAL S TUDIES RELATED TO HEALTH EFFECTS OF INCINERATION

22. H EALTH R ISK A SSESSMENT S TUDY Assessment of Small-Scale Incinerators for Health Care Waste by S. Batterman, 21 January 2004 Study commissioned by WHO Screening level health risk assessment Exposure to dioxin and dioxin-like compounds through inhalation and ingestion http://uqconnect.net/signfiles/Files/WHOIncinerationReportFeb2004.pdf

23. H EALTH R ISK A SSESSMENT S TUDY Three classes of small-scale incinerators Best practice Engineered design Properly operated and maintained Sufficient temperatures and residence time Has an afterburner and other pollution control Expected practice Improperly designed Improperly operated or maintained Worst-case No afterburner

24. H EALTH R ISK A SSESSMENT S TUDY Three usage scenarios Low use 1 hour per month (12 kg waste per week) Medium use 2 hours per week (24 kg waste per week) High use 2 hours per day (24 kg waste per day)

25. Compared to WHO ADI Compared to EPA Cancer Risk Worst Case: High Use unacceptable Worst Case: Medium unacceptable Worst Case: Low Useunacceptable Expected: High Useunacceptable Expected: Medium Use unacceptable Expected: Low Use Acceptableunacceptable Best Practice: High Use Acceptableunacceptable Best Practice: MediumAcceptable Best Practice: Low UseAcceptable S UMMARY OF R ESULTS Low use = 1 hr/month Medium use = 2 hr/week High use = 2 hrs/day

26. Permissible limit in cows milk (Netherlands): 0.006 picograms/kg milk Source: Costner, 2000

27. S TOCKHOLM C ONVENTION ON P ERSISTENT O RGANIC P OLLUTANTS (POP S ) International effort to eliminate dioxins, furans, and other highly toxic and persistent chemicals Adopted in May 2001 151 Signatories

28. S TOCKHOLM C ONVENTION ON POP S Article 5: Countries have to take measures to further reduce releases of POPs from unintended production with the goal of their continuing minimization and, where feasible, ultimate elimination. Annex C Source with the potential for comparatively high formation and release of dioxins & furans: Medical Waste Incinerators

29. S TOCKHOLM C ONVENTION ON POP S Annex C, Part IV (Definitions): On best available techniques: [P]riority consideration should be given to alternative processes, techniques or practices that have similar usefulness but which avoid the formation and release of … [dioxins and furans].

30. C ONTEXT FOR THE C OMPENDIUM To promote environmentally sound technologies To promote the WHO Policy Paper on safe healthcare waste management (2004): Prevent the health risks associated with exposure to health-care waste for both health workers and the public by promoting environmentally sound management policies for healthcare waste; Support global efforts to reduce the amount of noxious emissions released into the atmosphere to reduce disease and defer the onset of global change; Support the Stockholm Convention on Persistent Organic Pollutants (POPs); Promote non-incineration technologies for the final disposal of healthcare waste to prevent the disease burden from: (a) unsafe healthcare waste management; and (b) exposure to dioxins and furans;

31. W E INVITE YOUR COMMENTS AND SUGGESTIONS TO MAKE THE C OMPENDIUM AS USEFUL AS POSSIBLE.

32. Q UESTIONS FOR P ARTICIPANTS Are the HCW characteristics, e.g., material constituents, representative based on your knowledge/experience? Are the average HCW generation rates consistent with your knowledge/experience? Are the comparisons of technical, environmental, occupational health, social and cultural aspects of the generic technologies consistent with your knowledge/experience? Are the capital and operating cost comparisons consistent with your knowledge/experience? Have any major specific technologies been left out? Are the technical descriptions of specific technologies accurate? Are the sample scenarios used to demonstrate the application of the SAT methodology realistic?