MEDICAL WASTE MANAGEMENT

IMELDA ASETRE-LUNA, M.D., DPPS, DPIDSP

Pediatrician – Infectious Disease Specialist

St. Luke’s Medical Center

OBJECTIVES

1. To provide an overview of the waste management policies and practices relevant to our setting with emphasis on waste segregation

2. To inform the public on the risks associated with handling of health care wastes

Objectives…

3. To develop awareness on the health, safety and environmental issues relating to health care wastes

Health care waste (HCW)

Includes all waste generated by health care establishments, research facilities, & laboratories

Categories of health care waste

1. General waste2. Infectious waste3. Pathological waste4. Sharps5. Pharmaceutical waste6. Genotoxic waste7. Waste with high content of heavy metal8. Pressurized container9. Radioactive waste

Categories of health care waste

GENERAL WASTE• Comparable to domestic waste• Does not pose special handling problems

or hazards to human health or to the environment

• Mostly from administrative & housekeeping functions of health care establishments, e.g., office paper, food waste

Categories…

General waste…

• 75-90% of HCW

• Non-infectious wastes

• Should be dealt with by the municipal waste disposal system

Categories…

INFECTIOUS WASTE• Contains pathogens (bacteria, viruses,

parasites or fungi) in sufficient concentration to cause disease in susceptible hosts

• 10-15% of hospital waste– Cultures & stocks of infectious agent

from laboratory work

Categories…

Infectious waste…– Waste from surgery & autopsies on

patients with infectious diseases

– Waste from infected patients in isolation wards

– Waste that has been in contact with infected patients undergoing hemodialysis

Categories…

Infectious waste…– Infected animals from laboratories

– Any other instruments or materials that have been contaminated by infected persons or animals

– Pathological waste, sharps

Categories…

PATHOLOGICAL WASTE• Human tissues or fluids (e.g., body parts,

blood or other body fluids, fetuses)

Categories…

SHARPS• Needles, syringes, scalpels, saws,

blades, broken glass, infusion sets, knives, nails, & other items that can cause a cut or punctured wounds

• Considered as highly hazardous HCW

Categories…

PHARMACEUTICAL WASTE• Expired, unused, spilt & contaminated

pharmaceutical products, drugs, vaccines & sera that are no longer required & need to be disposed of appropriately

Categories…

GENOTOXIC WASTE• Cytostatic drugs, vomitus, urine or feces

from patients treated with cytostatic drugs, chemicals & radioactive materials

• Highly hazardous & may have mutagenic, teratogenic or carcinogenic properties

Categories…

CHEMICAL WASTE• Discarded solid, liquid & gaseous

chemicals from diagnostic & experimental work & from cleaning, housekeeping & disinfecting procedures

Categories…

WASTE WITH HIGH CONTENT

OF HEAVY METAL• Batteries, broken thermometers, blood

pressure gauges

• Subcategory of hazardous chemical waste

Categories…

PRESSURIZED CONTAINERS• Gas cylinders, gas cartridges, aerosol

cans

Categories…

RADIOACTIVE WASTE• Waste containing radioactive substances

(e.g., unused liquids from radiotherapy or lab research, contaminated glassware, packages or absorbent paper, urine & excreta from patients treated with unsealed radionucleotides)

Persons at risk

1. Health care personnel

2. Laboratory workers

3. Waste workers

4. Substance abuser

5. General public

Impacts of health care waste

Diseases that can be transmitted through needlestick injury

Infections from:

• Human immunodeficiency virus (HIV)

• Hepatitis B virus (HBV)

• Hepatitis C virus (HCV)

Needlestick injuries

Risk of infection from patients with:

• HBV – 1:3 risk of transmission

• HCV– 1:30

• HIV – 1:300

Hazards

Chemical & pharmaceutical waste: intoxication, burns

Genotoxic waste:

harmful effect on skin or eyes, dizziness, nausea or headache

Radioactive waste:

reddening of skin, cancer induction, genetic consequences

Waste handling, collection, storage and transport

DOH Dept. Circular No. 156-C, 1993

All government hospitals, clinics, laboratories and research offices shall incorporate satisfactory segregation, treatment, collection and disposal system.

All infectious and hazardous hospital wastes shall be treated before storage, collection and disposal.

DOH Dept. Circular No. 156-C…

All hospitals and other related institutions shall inform their staff and personnel about the proper waste segregation (color-coding) and storage, collection and disposal of hospital waste.

Waste segregation

• Process of separating different types of wastes at the point of generation & keeping them isolated from each other

Waste segregation…

• To promote recycling, reuse of resources and to reduce the volume of waste for collection and disposal

• Responsibility of the waste producer

• Should take place as close as possible to where the waste is generated

Color coding scheme for containers

Black

Green

Yellow

Yellow with black band

Orange

Red

- non-infectious dry waste

- non-infectious wet waste

- infectious & pathological waste

- chemical/heavy metal wastes

- radioactive waste

- sharps/pressurized containers

Waste disposal practices

Residuals of General HCW should join the stream of domestic refuse or municipal solid waste for proper waste management.

Waste disposal practices

Sharps should be collected at source of use in puncture-proof containers (metal or high-density plastic) with fitted

covers.

Containers should be rigid,

impermeable, & puncture-proof.

Container made of dense cardboard may be a substitute.

Waste disposal…

Bags & containers for infectious waste should be marked with the international infectious substance symbol.

Waste disposal…

Cytotoxic waste mostly produced in major hospitals or research facilities should be collected in strong, leak-proof containers labeled “cytotoxic waste.”

Microbiological laboratory waste should be sterilized by autoclaving.

Waste disposal…

Large quantities of obsolete or expired pharmaceuticals stored in hospital wards should be returned to the pharmacy for disposal.

Small amounts of chemical or pharma-ceutical waste may be collected together with infectious waste.

Waste disposal…

Waste with high content of heavy metals (e.g., cadmium or mercury) should be collected separately.

Large quantities of chemical waste should be packed in chemical-resistant container and sent to specialized treatment facilities.

Waste disposal…

Aerosol containers may be collected with general HCW once they are completely empty.

Aerosol containers should not be burnt or incinerated.

Waste disposal…

Appropriate containers or bag holder should be placed in all locations where particular categories of waste may be generated.

Waste disposal…

Staff should never attempt to correct errors of segregation by removing items from a bag after disposal or by placing one bag inside another bag of different color.

If general & hazardous wastes are accidentally mixed, it should be classified as hazardous HCW.

Segregation of HCW according to types of waste and sources

RED(Sharps & Pressurized containers)

• needles & syringes• scalpel blades• glass vials – tuberculin / insulin• stylet• capillary tubes• ampules• test tubes• blood evacuation tubes

• pipette slides / cover slips• aluminum cover• blood lancets• empty aerosol cans• rusty pins, nails, clips & screws• broken glasses

• gauze, cotton bandage, cotton applicators soaked with blood/body fluids from dressing of infected wounds and post operative cases, procedures such as Pap’s smear, immunization

• foreign bodies removed from any body parts• placenta, umbilical cord• used gloves• used foley catheters• used tubing – IV, nebulizer

YELLOW(Infectious & Pathological wastes)

YELLOW(Infectious & Pathological wastes)

• used diapers, sanitary napkin• used suction tubes• used NGT• used test strips• used urine bags• used drains – penrose• used cord clamp• used plaster

• empty colostomy bag• used swabs• heplock & ET tubes• used tongue guard• used oxygen tubing• used gladwrap• used mask / face mask• used thoracic tube

• used hemovac• used sensor / electrodes• used bandages• used rubber sheet• used rubber tubing• used CVP tubes• used t-tubes• used central lines

• used oxygen catheter• amputated limbs, toes, fingers, organs, extracted tooth• tissues from minor / major operation• specimen containers of blood & body fluids• used culture media, tissue culture plate

YELLOW(Infectious & Pathological wastes)

• used test strips• used beads / plates• used kit from laboratory analyzer• used reaction pads, foils• used plastic wares / disposables• used Hemoline Diphasique

• used T & B cell separator• used tissue typing / x-matching trays for discards• used filter• used blood products bags & tubing

YELLOW(Infectious & Pathological wastes)

YELLOW WITH BLACK BAND(Chemical & Pharmaceutical wastes)

• empty bottles of acids – HCl, H2SO4, HNO3, etc.• empty bottles of betadine, iodine, KMNO3

• empty bottles of laboratory reagents (Formaline, Toluene, Xylene)

• empty bottles / cans of Kerosene, Acetone, Alcohol, Anesthetic, Lacquer• empty bottles of disinfectants• busted Fluorescent bulb• defective thermometer

YELLOW WITH BLACK BAND(Chemical & Pharmaceutical wastes)

• empty cans of glue, epoxy & floor wax• expired & adulterated drugs & medicines

• used batteries

BLACK(Non-infectious dry wastes)

• paper & paper products

– used papers– newspapers– tetra packs, paper

cups– boxes / cartons

• bottles– glass & plastic

• packaging materials– styropore– aluminum– plastic candy / food

wrapper

GREEN(Non-infectious wet wastes)

• kitchen leftover food• used cooking oil• fish entrails, scale & fins• fruits & vegetable peelings

• rotten fruits & vegetables• non-infectious leftover foods

ORANGE(Radioactive / Nuclear wastes)

• Iodine 125 (I-125)• Iodine 131 (I-131)• H3 – Thymidine• Cesium 137• Chromium 51• Technetium 99m• Iridium• used x-ray films, developers & fixers

• contaminated things– gloves– tissue papers– cotton swabs– aluminum foil– gauze– test tubes– pipette tips– repetitive syringes

Collection and transport ofhealth care waste

Collection & transport of HCW

• Waste should be collected daily (or as frequently as required) & transported to the designated central storage site.

• No bags should be removed unless they are labeled with their point of production & contents.

• Bags or containers should be replaced immediately with new ones of the same type.

Collection & transport…

• A supply of fresh collection bags or containers should be readily available at all locations where waste is produced.

• Collection practice for active solid radioactive waste shall consist of distributing orange color-coded suitable containers with the radiation symbol.

Health care waste treatment technology

(Non-incinerator treatment technology)

Purpose

To change the biological & chemical characteristic of the waste to minimize its potential to cause harm

Clean Air Act of 1999

• Prohibits the incineration of medical wastes

• It promotes the use of state of the art, environmentally sound & safe non-burn technologies for handling, treatment, thermal destruction, utilization & disposal of sorted unrecycled biomedical & hazardous waste.

Waste treatment technologies

A. Thermal process

B. Chemical disinfection

C. Biologic process

D. Radiation technology

A. Thermal process

1. Pyrolysis – thermal decomposition of substance & materials in the absence of supplied molecular O2 in the destruction chamber in which the said material is converted into gaseous, liquid or solid form

A. Thermal process…

• Pyrolysis is suitable for bulk chemotherapy waste, many hazardous substances, spent solvents & chemicals, expired pharmaceuticals, low-level radioactive waste.

A. Thermal process…

2. Wet & dry thermal treatment – based on exposure of shredded infectious waste to high temperature, high pressure steam, and similar to the autoclave sterilization process

a. Autoclave

b. Microwave

AUTOCLAVE

• Uses steam sterilization to render waste harmless & is an efficient wet thermal disinfection process

• Cultures & stocks, sharps, materials contaminated with blood, isolation & surgery waste, laboratory waste, soft waste (gauze, bandages, drapes, gowns, beddings)

Autoclave…

• Volatile & semi-volatile organic compounds, chemotherapeutic waste, mercury, other hazardous chemical waste & radiological waste SHOULD NOT be treated in an autoclave.

Shredding

• Mechanical process done after autoclaving

• To increase the contact of reducing agent with the waste,

to decrease the volume of the treated waste, and

to render the waste unrecognizable

B. Chemical disinfection

• Chemicals like aldehydes, chlorine, phenolic compounds are added to waste to kill or inactivate pathogens present in HCW.

• Most suitable in treating blood, urine, stool, & sewage

Waste disposal system

1. Sanitary landfill – an engineered method to keep the waste isolated from the environment

2. Safe burial on hospital premises

3. Septic or concrete vault – especially suitable for the disposal of used sharps & syringes

Basic steps in health care waste handling

Advantages of goodhealth care waste management

1. Help control nosocomial disease, complementing the protection effect of proper handwashing

2. Reduce community exposure to multi-drug resistant bacteria

3. Dramatically reduce HIV/AIDS sepsis and hepatitis transmission from dirty needles & other improperly cleaned/ disposed medical items

Advantages of good HCW management…

4. Control zoonoses (disease passed to humans through insects, birds, rats & other animals)

5. Cut cycles of infection

6. Easily and cost-effectively address health care worker safety issues, including reducing the risk of needlestick injuries

Advantages of good HCW management…

7. Prevent illegal repackaging & resale of contaminated needles

8. Avoid negative long-term health effects, e.g., cancer from the environmental release of toxic substances such as dioxin, mercury & others

Thank you.