1. Health Care Without Harm
Environmentally Responsible Management of Health-Care Waste With a Focus on Immunization Waste
Working Draft, October 2002
Comments and suggestions on the document are welcome. Send comments to:
Health Care Without Harm
1755 S Street NW, Suite 6B
Washington, DC 20009
USA

2. Waste Management Strategies
First Things First
Eliminate unnecessary injections
Product selection and purchasing
Workers as the front-line of defense
Rigorous training
Immunization
Segregation is key
Proper containerization, secure transport & storage
Non-burn treatment technologies
Proper disposal

3. Guidelines Guidelines for Central Planners
Guidelines for Local Managers
Practical Procedures
Treatment and Disposal Options
Guidelines are adapted from valuable existing documents:
Management of wastes from immunization campaign activities (UNICEF)
Safe Management of Wastes from Health Care Activities (WHO)
First, do no harm (SIGN, draft 2002)

4. Toxic Pollutants From Medical Waste Incinerators
Air Emissions
trace metals: As, Cd, Cr, Cu, Hg, Mg, Ni, Pb
acid gases: HCl, SO2, NOx
dioxins & furans, including 2,3,7,8-tetrachlorodibenzo-p-dioxin
other organic compounds: benzene, toluene, xylenes, chlorophenols, vinyl chloride, polycyclic aromatic hydrocarbons, etc.
carbon monoxide
particulate matter
pathogens (under conditions of poor combustion)
Ash Residues: metals, dioxins & furans, other organics
Medical waste incinerators are a major source of
dioxins & mercury in the environment.

5. Health Impacts of Incinerator Emissions
Incinerator emissions have been linked to:
lung, laryngeal, stomach and other cancers
ischemic heart disease
urinary mutagens and promutagens
elevated blood levels of various toxic organic compounds and metals

6. Stockholm Convention on POPs
Stockholm Convention on Persistent Organic Pollutants (POPs Treaty)
Adopted in May 2001
Article 5: countries will take measures to further reduce releases of POPs with the goal of ultimate elimination
Annex C
First in the list of POPs from unintended production: Dioxins and Furans
Source with the potential for comparatively high formation and release of dioxins and furans: Medical Waste Incinerators

7. De Montfort Combustion Efficiencies*
Organic Emissions are 20 to 400 times above the South African limit
India
S. Africa
* Organic Emission Fraction
= 1 - Combustion Efficiency
Field Test: DM1, DM2, DM3, DM4 ; Lab Test: DM5, DM6

8. De Montfort Incinerator Does Not Meet Environmental Standards
Fails to meet combustion temperatures limits
Fails to meet residence time requirements
Exceeds opacity limits
Fails to meet combustion efficiency standards
Exceeds limits on particulate matter
Exceeds some limits on metals
Violates stack height requirements without modification
Has no pollution control, no controls on temperature and air input, no safe ash removal system
Could release significant quantities of dioxins, furans, mercury and other toxic pollutants

9. Summary of Field Investigations
Incinerators (1-2 yrs old) poorly maintained & operated
Broken ash doors and/or chamber doors, heavily corroded, clogged air vents, sharps waste around incinerator, etc.
All waste burned including …
PVC plastics (e.g., IV bags) and mercury thermometers
Non-infectious, recyclable and compostable waste (despite segregation practices or policies)
Large quantities of unburned material in the ash
Ash improperly disposed of in every case
Smoke visible from incinerators; in some cases, smoke coming out of chamber door and air inlets
Incinerators near populated areas

10. Heavy Smoke From Incinerator Operator Using Motorcycle Helmet
Courtesy of P. Madhavan

11. Soot & Molten Plastic (?) Coming Out of Ash Door
Courtesy of Bradley Hersh

12. Undestroyed Needles On the Ground Around Incinerator
Courtesy of Shibu K. Nair

13. Problems of Promoting Incineration
Results in Adverse Health Impacts on Health Workers and Communities
Pollutes the Environment
Weakens Enforcement of Environmental Laws
Threatens Worker Safety
Undermines Good Waste Management Practices
Promotes Dumping of Obsolete Technologies
Hampers Deployment of Cleaner Technologies

14. Low-Cost Options CE Cement Encasing
EI Encapsulation With Immobilizing Materials
BP Waste Burial Pit or Sharps Pit With Concrete Cover
PU Portable Autoclave or Microwave
ND Point-of-Use Needle Destruction Technologies
ND/m Mechanical Needle Destruction
CT Storage, Transport and Centralized Treatment
TG Traditional Grinders
S Shredders or Hammermills
Disposal in Sanitary Landfill
Burial in Restricted Sites

15. Decision Tree 2

16. Cement Encasing

17. Encapsulation With Immobilizing Materials

18. Sharps Waste Burial Pit With Concrete Cover

19. Basic Autoclave (Simple Retort Design)

20. Estimates for Cement Encasing
Trench volume and cement needed for DTP-HepB-Hib vaccination waste
Number of children targeted for vaccination
100
1,000
5,000
10,000
Number of safety boxes 8 75
377
753
Volume of sharps waste (cubic meters)
0.04
0.042
2.12
4.25
Trench volume (cubic meters)
0.08
0.85
8.49
Amount of cement needed (kg) 10 96
478
955
Approximate cost of cement, lime, and sand (US $) $5
$43
$215
$430

21. Comparative Costs for Treating 50,000 Syringes

22. Capital Costs to Treat 1,600 kg/day of Medical Waste in a Region

23. Health Care Without Harm
Environmentally Responsible Management of Health-Care Waste With a Focus on Immunization Waste
Working Draft, October 2002
Comments and suggestions on the document are welcome. Send comments to:
Health Care Without Harm
1755 S Street NW, Suite 6B
Washington, DC 20009
USA