Statement by GAIA, HCWH and BAN
on IFC Environmental, Health and Safety Guidelines for Health Care Facilities

• Letter to IFC
• Detailed Assessment of draft Health Care Waste Management Guidance Document
• Comments on the Air Emission Limits for Incinerators, Health Care Facility Wastewater Management, and Air Emissions Limits sections
• Read Draft IFC Guidelines
  

Comments on the Air Emission Limits for Incinerators, Health Care Facility Wastewater Management, and Air Emissions Limits sections

1. Air Emissions Limits for Incinerators:

A medical waste incinerator releases into the air a wide variety of pollutants including highly toxic dioxins and furans, metals (such as lead, mercury, and cadmium), particulate matter, acid gases such as hydrogen chloride, sulfur dioxide, and nitrogen oxides, carbon monoxide, as well as organic compounds such as hexachlorobenzene, trichloroethylene, tetrachloroethylene, etc. These emissions have serious adverse consequences on worker safety, public health and the environment. Dioxins, for example, have been linked to cancer,
immune system disorders, diabetes, birth defects, and other health effects. Mercury is associated with nervous system disorders
particularly affecting developing fetuses and small children. Medical waste incinerators are a leading source of dioxins and
mercury in the environment. Studies in the last decade have shown a link between incinerator emissions and adverse health impacts on
incinerator workers and residents living downwind of incinerators, as summarized in Table I.

Table I. Epidemiological Studies on Adverse Health Effects Associated with Incineration

Moreover, incinerator ash remaining at the bottom of an incinerator contains leachable heavy metals as well as dioxins and furans. Air pollution control devices such as baghouse filters and scrubber merely transfer dioxins, furans, and other pollutants to other environmental media. Due to the environmental problems associated with incineration and the cost of air pollution control devices, the number of hospital incinerators in the United States has dropped dramatically in the last decade: from about 6,200 in 1988 to 767 in 2002, with only three new hospital incinerators constructed since 1996 in operation.

In light of the environmental and health impacts of incinerators, the IFC consider promoting non-incineration treatment technologies instead of incinerators, in keeping with the IFC's stated principle of treating waste "by environmentally sound methods" (Read Draft IFC Guidelines, page 2 ). Alternative technologies, such as autoclaves, advanced autoclaves, and microwaves, have been in operation for decades, have a significantly lower environmental impact, and generally have lower capital and operating costs compared to incinerators. Information on alternative technologies can be found in HCWH's resource book Non-Incineration Medical Waste Treatment Technologies.

Nevertheless, should the IFC decide to support incineration, more stringent air emission limits be used. According to the IFC guidelines (page 3), the incinerator limits were adapted from the 1999 WHO report ("Safe Management of Wastes From Health Care Activities"). The WHO report did not set any standards but recommended that if no national standards are available to "refer to standards in force in Europe or USA for instance." However, Table 8.2 in the WHO report for the US Environmental Protection Agency (EPA) standards has four erroneous figures for the EPA limits - using less stringent values for particulate matter, dioxins/furans, hydrogen chloride, and cadmium for new incinerators with burn design capacities greater than 200 lbs/hr. For example, the dioxins/furans limits are mistakenly shown as 125 ng/dscm instead of 25 ng/dscm for new medium to large incinerators. WHO also published the wrong units for the European Union limits on dioxins (mg/m3 instead of ng/m3).

Table II below compares the IFC guidelines with the corrected EPA emission limits for incinerators with burn capacities greater than 200 lbs/hr, as well as the EU emission limits, and emission limits proposed by the Natural Resources Defense Council (NRDC).

Table II. Comparison of Air Emission Limits for Incinerators

* US EPA limits for new incinerators with burning capacities greater than 200 lbs/hr
** EU limits as reported in the WHO report for daily averages (dioxin units corrected; all unit under standard conditions); hourly average limits not shown

Table II shows that, except for carbon monoxide, the IFC emission standards are as a general rule significantly weaker than the US EPA, EU, and NRDC limits. Moreover, the IFC emission limits do not include such critical pollutants as lead, SO2, total organic carbon, and chlorine compounds. Two requirements that the EPA also has (which the WHO report did not mention) are a 5% visible emission limit for fugitive emissions during ash handling, and a 10% stack opacity limit. Since the serious health effects of these pollutants are well known and the US EPA limits were based NOT on health impacts but on costs and available control technologies, the IFC promulgate much more stringent limits and to include other key pollutants in order to protect public and occupational health. In particular, the most stringent limits are needed for dioxins/furans, mercury, particulate matter, hydrogen chloride, lead, and cadmium.

A serious shortcoming of the IFC guidelines is the lack of information on how stack emissions should be measured. EPA requires a minimum of three test runs under "representative operating conditions", a minimum sampling time of 1 hour per test except for total dioxins/furans which require a longer sampling time, and annual tests for at least three years (after which the frequency of testing depends on what stack test results have been). We recommend that IFC require that tests be conducted at the maximum design burn capacity of the incinerator, using a standardized composition of surrogate medical waste, and a minimum sampling time of 8 hours for dioxins/furans. The challenge load of surrogate waste could be constituted as follows: 45% paper and cloth, 35% PVC plastics, 5% metals, 5% glass, 5% fluids, 5% animal waste, to simulate the typical composition of infectious waste and test the ability of the incinerator and pollution control devices. Moreover, the manufacturers should demonstrate a minimum 2-second residence time in their incinerators, and that all tests should be conducted and reported annually.

In addition to the tests, the IFC should also require operator training; annual equipment inspections; and continuous monitoring/documentation to show compliance at all times. The parameters that require continuous monitoring are: charging (feed) rate, secondary chamber temperature, flue gas temperature, operating parameters of all air pollution control devices, as well as continuous emission monitoring of carbon monoxide, particulate matter, HCl, and mercury.

2. Health Care Facility Waste Water Management

With regards to the conditions listed on page 3, mercury should also be kept out of the sewer discharge and should be reduced and, if possible, eliminated from the facility entirely. Health care facilities have a negative impact on the environment due to their releases of mercury through the wastewater.

Table III presents a comparison of the IFC effluent limits with those of the European Union, Saudi Arabia, and US EPA's water quality criteria concentrations. The EPA's water quality criteria are recommended values reflecting the latest EPA thinking on environmental and health effects that provide a basis for controlling discharges of pollutants into the water.

Table III. Comparison of Effluent Limits

Note: Except for pH, all units are in mg/L
#EU 1991 Council Directive concerning urban wastewater treatment (91/271/EEC)
* CMC is the criteria maximum concentration which EPA defines as an estimate of the highest concentration of a material in surface water to which an aquatic community can be exposed briefly without an unacceptable effect; metal concentrations are expressed in terms of dissolved metal in the water column; 1999
** CCC is the criterion continuous concentration which EPA defines as an estimate of the highest concentration of a material in surface water to which an aquatic community can be exposed indefinitely without resulting in an unacceptable effect; metal concentrations are expressed in terms of dissolved metal in the water column; 1999

The limits shown for conventional pollutants are typical of those used in many countries. However, because of the known health and environmental effects of heavy metals, the IFC should use the most stringent effluent limits for cadmium, lead, and mercury found in the EPA's water quality criteria. As much as possible, other effluent limits should also be lowered, such as BOD5, COD, residual chlorine, and phenols.

3. Air Emission Limits

The air emission limits for boilers, furnaces, and electrical generating equipment (heat output equivalent greater than 10 MMBtu/hr) are similar to those found in many countries. However, the IFC's NOx limits for oil-fired and gas-fired units are higher than those provided in guidelines of the Canadian Council of Ministers of the Environment (CCME), as shown in Table IV. We recommend more stringent NOx limits as those found in the CCME guidelines.

Table IV. Comparison of NOx limits (units with equivalent heat outputs > 10 MMBtu/hr)

4. Summary of Recommendations

A. Promote non-incineration treatment technologies instead of incinerators, in keeping with the principle of treating waste "by environmentally sound methods"

B. For incinerator emission:

a. Promulgate much more stringent air emission limits (for dioxins/furans, mercury, hydrogen chloride, particulate matter, and cadmium), and include other key emission limits (for lead, sulfur dioxide, chlorine compounds, total organic carbon, other metals) in order to protect health and the environment;

b. Require that tests be conducted at the maximum design burn capacity of the incinerator, using a standardized composition of surrogate medical waste (45% paper and cloth, 35% PVC plastics, 5% metals, 5% glass, 5% fluids, 5% animal waste), a minimum sampling time of 8 hours for dioxins/furans, and that tests be conducted and reported annually;

c. Require manufacturers to demonstrate a minimum 2-second residence time in the incinerators;

d. Require operator training; annual equipment inspections; continuous monitoring of key operational parameters (feed rate, secondary chamber temperature, flue gas temperature, parameters of air pollution control devices), as well as continuous emission monitoring of carbon monoxide, particulate matter, HCl, and mercury.

C. Promulgate the most stringent effluent limits for mercury, lead, and cadmium found in EPA's water quality criteria and lower effluent limits for conventional pollutants.

D. Promulgate more stringent NOx limits for oil-fired and gas-fired units such as those found in the CCME guidelines.