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Statement
by GAIA, HCWH and BAN
on IFC
Environmental, Health and Safety Guidelines for Health Care
Facilities
Comments
and Recommendations on
the Draft Health Care Waste Management Guidance
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 waste
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
<click here>
4.
Wastewater Management <click
here>
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. http://cold.aaa.dk/pvc/
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.
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