.png)
Our Enviropedia is an educational tool to keep you well-informed on the different aspects of disinfection, infectious waste handling and other healthcare and environment-related resources.
ENVIROPEDIA
Healthcare Waste Treatment and Disposal Methods
Effective healthcare waste treatment and disposal methods reduce the risk of health and environmental contamination. The WHO has outlined measures to minimize and reuse waste items where it is deemed safe. Unusable healthcare waste materials should be treated and disposed of responsibly to minimize environmental and health risks.
The following factors are to be considered when selecting treatment methods for healthcare waste: Capability of the healthcare facility to handle the quantity of waste Local availability of treatment options and technology Treatment efficiency Volume and mass reduction Available space for equipment Operation and maintenance requirements Skills needed for operating the technology Cost considerations
Chemical Treatment and Shredding Technology
The majority of hazardous healthcare waste falls under the potentially infectious category. Disinfection is pivotal when it concerns waste management technologies. Chemical processes often involve shredding, grinding, or mixing to increase the exposure of the waste to the chemical agent including disinfectants such as peracetic acid.
Disinfection minimizes the potential for disease transmission by reducing or removing disease-causing pathogens. Shredding reduces the bulk volume of healthcare waste by at least half and increases the surface area in preparation for further treatment or disposal. Shredders also easily reduce the toughest medical-grade materials ranging from fabrics to glass, plastics, stainless-steel instruments, and more. Shredding should be done in a closed system to avoid air contamination via pathogens. The advantages of implementing on-site shredding: • To increase the surface area of contact between waste and disinfectant, eliminating voids in the waste load • To render any anatomical parts unrecognizable to avoid adverse visual impact on disposal • To reduce the volume of waste
PVC Recycling in Australian Hospitals
In Australia, an average of 15 tons of PVC healthcare waste are reprocessed per month currently. Since late 2016, the PVC Recycling in Hospitals Program continues to expand to other states, where the materials collected are reprocessed in Australia and New Zealand. They are mainly used to make new hoses for fire extinguishers, gardens and industry; and play as well as safety mats for children and workplaces.
According to The Vinyl Council of Australia, it is estimated that PVC medical products account for 5 to 10 percent of the 260,000 tons of waste produced by Australian hospitals per annum. A minimum of 2,500 tons of recyclable materials including 50 million used IV bags, as well as face masks and tubing, are available for collection and reprocessing. An initiative begun by an Anaethetist, the PVC Recycling in Hospitals Program targets to annually collect and recycle about 2,000 tons of IV bags, face masks and oxygen tubing into useful new products. The program was developed as a pilot project by the Vinyl Council in collaboration with Western Health, Victoria. The program has successfully expanded its services to about 100 hospitals, mostly in Victoria, New Zealand and Tasmania.
Impact of Healthcare Waste on the Environment
.jpeg)
Coronavirus has made healthcare waste more visible than ever, but the environmental footprint of healthcare goes much further – and reducing it could save lives. The healthcare sector is reported to contribute a total of 4.4% of global carbon emissions (2019) – a staggering amount from a single source. 70% of this is believed to come from healthcare waste.
It's incredibly difficult to treat healthcare waste efficiently without suitable technology. The most common waste treatment method involves transporting waste to external treatment facilities followed by landfill – a procedure that is neither optimal for the health of the public nor for the environment. Landfills are an ineffective solution and a finite resource upon which the healthcare industry cannot rely on upon as an effective solution to the problem of global waste. Post-treatment remnants of healthcare waste are slow to decompose and accumulate significantly over time, posing both environmental and public health risks. The carbon-intensive resource cycle of healthcare around the world means greenhouse gasses (GHG) are constantly being released into the atmosphere. If healthcare were a country, it would be the fifth-largest emitter of greenhouse gases on the planet, according to the non-profit organisation Health Care Without Harm. That’s a carbon footprint the same as the emissions of 514 coal-fired power plants, equivalent to 4.4% of global net emissions. More than half of that was a result of energy use: electricity, gas, steam, air conditioning and operational emissions. The most developed nations emit the most healthcare-based carbon emissions. In the USA the ratio of medical to total carbon emissions has been reported to be close to 10%, while in the UK it sits at 6.3%. China also has a similarly high ratio. “Fossil fuel combustion is a major contributor to air pollution-related deaths, which kill more than four million people around the world every year. More than tuberculosis, more than malaria, and more than Aids combined,” says Gary Cohen, president and co-founder of Health Care Without Harm. One of the problems is those on the frontline often see providing necessary healthcare and being environmentally friendly as an either/or choice. “It’s difficult to think about sustainability when we have to weigh that up against the safety of a patient,” says Ko.
Incineration of Healthcare Waste
Treatment and disposal of healthcare waste may pose health risks indirectly through the release of pathogens and toxic pollutants into the environment. Untreated healthcare wastes in landfills can contaminate drinking, surface, and ground waters if those landfills are not properly constructed.
Chemical disinfectants in healthcare waste treatment can result in the release of chemical substances into the environment if those substances are not handled, stored and disposed of in an environmentally sound manner.
Healthcare waste incineration continues to be widely practised, but inadequate incineration or the incineration of unsuitable materials results in the release of pollutants into the air, generating ash residue. Incinerated materials containing or treated with chlorine can generate dioxins and furans, which are human carcinogens and have been associated with a range of adverse health effects. Incineration of heavy metals or materials with high metal content (in particular lead, mercury and cadmium) can lead to the spread of toxic metals in the environment. Modern incinerators which operate at 850-1100 °C and fitted with special gas-cleaning equipment are designed to comply with the international emission standards for dioxins and furans. Alternative healthcare waste treatments such as autoclaving, microwaving and steam treatment integrated with internal mixing, which minimize the formation and release of chemicals or hazardous emissions, should be considered in settings where there are sufficient resources to operate and maintain such systems and dispose of the treated waste.
Types of Healthcare Waste
According to WHO, about 85% of waste generated by healthcare activities is general, non-hazardous waste comparable to domestic waste. The remaining 15% is considered hazardous material that may be infectious, chemical or radioactive.
Healthcare waste and by-products cover a diverse range of materials as shown below:
-
Infectious waste: waste contaminated with blood and other bodily fluids (e.g. from discarded diagnostic samples), cultures and stocks of infectious agents from laboratory work (e.g. waste from autopsies and infected animals from laboratories), or waste from patients with infections (e.g. swabs, bandages and disposable medical devices);
-
Pathological waste: human tissues, organs or fluids, body parts and contaminated animal carcasses;
-
Sharps waste: syringes, needles, disposable scalpels and blades, etc.;
-
Chemical waste: for example solvents and reagents used for laboratory preparations, disinfectants, sterilants and heavy metals contained in medical devices (e.g. mercury in broken thermometers) and batteries;
-
Pharmaceutical waste: expired, unused and contaminated drugs and vaccines;
-
Cytotoxic waste: waste containing substances with genotoxic properties (i.e. highly hazardous substances that are, mutagenic, teratogenic or carcinogenic), such as cytotoxic drugs used in cancer treatment and their metabolites;
-
Radioactive waste: such as products contaminated by radionuclides including radioactive diagnostic material or radiotherapeutic materials; and
-
Non-hazardous or general waste: waste that does not pose any particular biological, chemical, radioactive or physical hazard.
The major sources of healthcare waste are:
Four Ways to Manage Healthcare Waste Sustainably
The WHO estimates that annually, 16 billion injections are administered worldwide without proper disposal, while an average of 0.5kg of hazardous waste per hospital bed per day is generated in high-income countries like the US. For the record, Phnom Penh in Cambodia produced 342.54kg of healthcare waste from 3,114 hospital beds, according to a 2003 Cambodia Environmental Association survey, and Japan creates 285,000 tonnes of infectious waste and 945,000 tonnes of non-infectious also in 2003. The non-separation of healthcare waste into hazardous and non-hazardous waste streams further complicates the issue.
The repercussions of mismanaging healthcare wastes include long-term health and environmental impacts such as radiation burns, sharps-inflicted injuries, toxic exposure to pharmaceutical products—especially antibiotics and cytotoxic drugs. Mercury and dioxin leaks could eventually seep into the ground and pollute our water, agricultural land, and even the air through the incineration of healthcare waste in waste-to-energy facilities. Ironically, the very industry that helps in healing and caring for people is also the same one that might be contributing to higher incidents of cancer and respiratory symptoms as well as possible congenital abnormalities and hormonal defects. The recently launched Sustainability in Action: Best Practices of Global Green and Healthy Hospitals Asia Members and other Countries recommends 4 ways for hospitals and healthcare centres to sustainably manage healthcare waste: 1.Plan. Every sound management scheme (whether of waste items or not) starts with a solid plan. At this stage, hospitals will lay out their waste management strategy, as well as the roles and responsibilities of each member. Typically, this includes the creation of a waste management committee and the designation of a waste management officer who oversees the day-to-day handling and monitoring of waste. It is equally important for the hospital to know how much and what types of waste it generates, and to what degree it fluctuates. 2.Minimize. The worst way to deal with waste items is to dispose of them. That is, the most effective waste management solution is to not produce waste in the first place. This is an impossible standard, and in cases where waste is unavoidable hospitals should consider waste minimization through the reuse of materials as long as patient safety is not compromised. To this end, hospitals should also be smarter with their procurement, opting instead for greener alternatives, such as non-mercury thermometers and recyclable plastic containers. 3.Segregate. Proper handling and segregation of waste is vital in keeping the hospital environment clean and restful. The immediate responsibility of proper healthcare waste segregation is on the person who produces the waste. At each point of waste generation, separate, properly labelled and color-coded containers appropriate for the specified type of waste. 4.Dispose. Before disposal, waste items should undergo a variety of treatment processes, to simultaneously minimize potential public health threats and reduce the damage to the environment. While the choice of treatment depends largely on the waste characteristics, the immediate environment of the disposal facility, and its impact on public and planetary health, the most common ones include mechanical treatment, such as shredding and grinding; chemical treatment, which involves the use of disinfectants; and steam sterilization such as using autoclaves to destroy pathogens. As global healthcare advances, it is not just about modern technologies and top-of-the-line medications, but also the realization of truly sustainable and safe healthcare systems that understand the link between the sector’s landmark operations and the negative impacts it can create on the environment and people’s health. Government commitment and support is needed for universal, long-term improvement, although immediate action can be taken locally.
Uses of Plastic in Healthcare Devices
Plastics have received much backlash for its effect on the environment. Yet plastic, when utilized correctly with well thought-out efforts to recycle or reuse them, can be a big advantage in healthcare. The plastic grade used in healthcare is thermoplastics, which vary in quality and purposes. Thermoset plastics used for medical device manufacturing do exist but have limited use.
Why is plastic used for medical equipment?
1. One-time use stops the spread of infections
2. Practical choice for manufacturing
3. Lightweight and ergonomic
4. Economical
5. Compatibility
6. Recyclability
Color Coded Healthcare Waste Bins
In the world of medical and surgical practices, there are many systems in place that ensure safety and actively prevent potential outbreaks and contaminations. These systems are often overlooked by those who aren’t directly related to the field, but they do more to stop the spread of disease than the actual medical and surgical procedures. Within these is the healthcare waste removal system of color-coded waste bags.
The following outline the features of plastic clinical waste bin bags used in Australia:
1
Color code: yellow
2
Wording: ‘Clinical waste’ displayed on at least 2 sides
3
Clinical waste symbol: Black biological hazard icon
4
Once used, these bags require incineration for complete disposal in a suitably permitted or licensed facility
Guide on Healthcare Waste Management by WHO
WHO developed the first global and comprehensive guidance document, ‘Safe Management of Wastes from Healthcare Activities’, now in its second edition and more recently a short guide that summarizes the key elements.
The guide addresses aspects such as regulatory framework, planning issues, waste minimization and recycling, handling, storage and transportation, treatment and disposal options, and training. The document is aimed at managers of hospitals and other healthcare facilities, policy makers, public health professionals and managers involved in waste management. In addition, as part of monitoring Sustainable Development Goal 6 on safely managed water and sanitation, the WHO/UNICEF Joint Monitoring Programme will regularly report on safe management of healthcare waste as part of wider monitoring efforts on water and sanitation in healthcare facilities. In collaboration with other partners, WHO also developed a series of training modules on good practices in healthcare waste management covering all aspects of waste management activities from identification and classification of wastes to considerations guiding their safe disposal using both non-incineration or incineration strategies. WHO guidance documents on healthcare waste are also available including: • a monitoring tool; • a cost assessment tool; • a rapid assessment tool; • a policy paper; • guidance to develop national plans; • management of waste from injection activities; • management of waste at primary health care centres; • management of waste from mass immunization activities; and • management of waste in emergencies. In addition, WHO and UNICEF together with partners in 2015 launched a global initiative to ensure that all healthcare facilities have adequate water, sanitation and hygiene services. This includes addressing healthcare waste.
Updating Reprocessing Guidelines by GI Societies
In early 2021, the gastroenterological multi-society task force, headed by the American Society for Gastrointestinal Endoscopy, published the updated guidelines on the effective infection prevention in the endoscopy unit. Ultimately, the updated guidelines state, successful reprocessing requires a “team-based multidisciplinary approach” that includes adequate competency assessments for reprocessing staff and a diverse endoscopy unit leadership team. Other recommendations from the document are summarized below. Spaulding Classification Change: Not Recommended Under the Spaulding classification, flexible endoscopes are considered “semi-critical” devices because they meet mucous membranes or non-intact skin and do not penetrate sterile tissue. Despite some push to update the classification to critical – particularly with duodenoscopes and echoendoscopes that may contact sterile tissue – the guidance is that all endoscopes remain classified as semi-critical. Semi-critical devices require a minimum of high-level disinfection prior to reuse. Double High-Level Disinfection: Not Recommended Recent research has suggested double HLD may be one way to reduce endoscope-associated infection. A study published in July 2021 found that at high-volume ERCP facilities, double HLD and liquid chemical sterilization offered the same infection prevention benefits. However, the newly updated guidelines state that in a non-outbreak setting, one cycle of high-level disinfection – preferably in an automated endoscope reprocessor (AER) – is enough to ensure adequate reprocessing. Tracking Patient Information: Recommended Careful records are crucial in the event of an outbreak, that connects contaminated endoscopes back to the patients they were used on. The following information is recommended to be recorded during each reprocessing cycle should an infection outbreak occur: •Patient’s name •Medical record number •Date and type of procedure •Scope serial number •AER serial number •Name of reprocessing technician Microbiologic Surveillance: Recommended Previously, there has been no standard for microbiologic surveillance testing post-reprocessing in the U.S. The new guidelines recommend endoscopy units adopt such procedures to ensure adequate reprocessing and patient safety. Detecting even common GI tract pathogens on reprocessed endoscopes can indicate that dangerous microbes may be present on the scopes. Regular Performance Evaluations: Recommended Endoscopy units should comply with manufacturer instructions for use for regular scope maintenance and repair. A maintenance log should be used to track when scopes are in and out of service for the unit, according to the multi-society group recommendations. Normal wear and tear on flexible endoscopes can lead to inadequate reprocessing. Studies show that cracks or scratches on endoscope channels harbor dangerous bacteria or biofilm and potentially cause patient infection. The U.S. Food and Drug Administration (FDA) began stepping up studies of endoscope-associated infections five years ago after some high-profile infections resulting from contaminated duodenoscopes. Duodenoscopes have an elevator mechanism that is particularly difficult to clean and disinfect. The FDA has recommended device manufacturers develop duodenoscopes with disposable components or fully disposable scopes as one way to address infection risk to patients. Single-use duodenoscopes are made for one-time use and no reprocessing and repairs are needed.