Transcript Presentation - UNDP GEF Global Healthcare Waste Project

MODULE 18:
Management of Chemical, Cytotoxic,
Pharmaceutical and Radioactive Wastes
Module Overview
• Describe sources and types of chemical,
cytotoxic, pharmaceutical, and radioactive
wastes in a healthcare setting
• Discuss risks associated with exposure to these
specific wastes
• Describe all aspects of management of these
specific wastes
• Describe treatment and disposal methods
Learning Objectives
• Identify hazardous (non-infectious) wastes in a
healthcare facility
• Identify key steps in collection, handling,
storage, transport, treatment and disposal of
these wastes
Sources & Examples of Hazardous
(Non-Infectious) Wastes
•
Examples of Sources
– Chemicals from diagnostic and experimental work
– Cleaning and disinfecting compounds
– Agents used for chemotherapy
– Drugs that are no longer required
– Waste from nuclear medicine
•
Examples of Wastes
– Formaldehyde (Haemodialysis)
– Photographic fixing and developing solutions (X-ray Department)
– Solvents and fixatives (Pathology or Histology Labs)
– Engine or vacuum pump oils, solvents, degreasers (Facility Engineering)
– Disinfectants, pesticides, rodenticides (Housekeeping)
– Acids, alkalis or reducing agents (Laboratory)
– Mercury (thermometers), cadmium (batteries), lead (Radiology)
– Gases stored under high pressure, in cans or cylinders (Surgical Theater)
– Ethylene oxide gas (Central Sterile Supply)
– Expired drugs, cytotoxic drugs (Pharmacy, Chemotherapy Ward)
Characteristics of Chemical Waste
Discarded solid, liquid and gaseous chemicals that
are:
• Toxic
• Corrosive
• Flammable
• Reactive
- Explosive, water reactive, shock sensitive
• Oxidizing
General Types of Chemical Wastes
Chemical Waste
Examples
Halogenated solvents
chloroform, methylene chloride, perchloroethylene, refrigerants, trichloroethylene
Non-halogenated solvents
acetone, acetonitrile, ethanol, ethyl acetate, formaldehyde, isopropanol, methanol,
toluene, xylenes
Halogenated disinfectants
calcium hypochlorite, chlorine dioxide, iodine solutions, iodophors, sodium
dichloroisocyanurate, sodium hypochlorite (bleach)
Aldehydes
formaldehyde, glutaraldehydes, ortho-pthalaldehyde
Alcohols
ethanol, isopropanol, phenols
Other disinfectants
hydrogen peroxide, peroxyacetic acid, quarternary amines
Metals
arsenic, cadmium, chromium, lead, mercury, silver
Acids
acetic, chromic, hydrochloric, nitric, sulfuric
Bases
ammonium hydroxide, potassium hydroxide, sodium hydroxide
Oxidizers
bleach, hydrogen peroxide, potassium dichromate, potassium permanganate
Reducers
Pharmaceuticals
sodium bisulfate, sodium sulfite
expired drugs, spilled drug, cytotoxic drugs
Miscellaneous
anesthetic gases, asbestos, ethylene oxide, herbicides, paints, pesticides, waste oils
Examples of Chemical Waste Containing
Heavy Metals
• Mercury
–
–
–
–
–
Thermometers, sphygmomanometers
Cantor tubes, esophageal dilators
Mercury switches, fluorescent lamps
Dental amalgam
Some formulations (e.g., Thimerosal)
• Cadmium
– Dry cell batteries
• Lead
– Radiation shielding
Health Impacts of Chemical Exposure
• Effects on the lungs
– Cancer (asbestos, cadmium)
– Asthma (formaldehyde)
– Irritation (glutaraldehyde)
• Effects on the eyes and mucous
membranes
– Irritation (formaldehyde, xylene,
methyl ethyl ketone)
– Conjunctivitis (glutaraldehyde)
– Blurred vision (methyl alcohol)
Health Impacts of Chemical Exposure
• Effects on the skin
– Burns (concentrated acetic acid and
sodium hydroxide)
– Rashes, irritation (methyl ethyl
ketone, other solvents)
• Effects on the nervous system
– Mercury, ethylene oxide, xylene, lead,
chloroform, other chlorinated
solvents, various organochlorine
insecticides
Health Impacts of Chemical Exposure
• Effects on the liver and kidneys
– Lead, cadmium, chloroform,
tetrachloroethylene and other
chlorinated solvents
• Effects on the reproductive system
– Various pesticides, lead, ethylene oxide
• Cancers
– Ethylene oxide, benzene, various
pesticides, some chlorinated solvents,
many cytotoxic agents
Segregation of Chemical Waste
• Chemical Waste
– Separate from infectious waste, radioactive
waste, and general non-risk waste
– Segregate based on compatibility
• Toxic, Corrosive, Flammable, Reactive
Containers and Color Coding for
Chemical Waste
• WHO recommendation
Waste
Color and Markings
Container Type
Chemical and
pharmaceutical waste
Brown
Plastic bag or container
Labeling of Chemical Waste
o Waste container label should have:
–
Name, address, telephone of the generator
–
Point of generation (if applicable)
–
Start date of accumulation of waste
–
Estimated quantity
–
Description of contents
–
Waste classification
–
Hazard symbols
–
Precautionary statement
–
Emergency contact information
International Chemical Waste Symbols
– Toxic
– Explosive
– Corrosive
– Oxidizer
– Flammable
Handling of Chemical Waste
• Proper personal protective
equipment (PPE) should be used
when handling hazardous chemicals
• Type of PPE required is specific for
each chemical
Handling of Chemical Waste
• Appropriate transferring methods
must be used
•
Bonding, grounding, and explosion
proof devices for flammable waste
• Spill kit accessible
•
Different spill kits for different hazards
•
All materials in the kit are hazardous
after use
• Secondary containment
On-Site Transport of Chemical Waste
• Use wheeled trolleys, containers, or carts
designated for chemical waste transport with
the following specifications
• Easy to load and unload
• No sharp edges that could damage waste
bags or containers during loading and
unloading
• Easy to clean
• Leak proof
Storage of Chemical Waste
• Use a separate and enclosed area, room, or
building
• Provide good ventilation
• Have easy access to safety shower and
eyewash station
• Equip with a liquid or chemical proof sump
(secondary containment in case of leaks)
Storage of Chemical Waste
• No mixing of chemical waste (according to
manufacturers’ specifications)
• Incompatible wastes should be stored
separately, e.g. acids and bases
• Temperature should be controlled or kept
within the acceptable range based on
manufacturers’ requirements
Sample Sketch of a Chemical Waste
Storage Area
Storage of Chemical Waste
o Storage rooms and facilities should be labeled
on the exterior with a sign:
- NO ENTRY: Hazardous waste
o Other symbols if needed:
– No Smoking
– No Eating or Drinking
Off-Site Transport
• Transport vehicles should meet basic
requirements
– E.g., well maintained, bulkhead to separate driver from
vehicle load, system to secure load, proper placards
and markings including hazard symbol and emergency
contacts, spill kit, easy to decontaminate, etc.
• Driver should be trained on:
– Laws, risks, safe handling methods, labeling,
documentation and emergency procedures
• Consignment or manifest system
Treatment of Chemical Waste
•
Chemical and Physical Treatment
– Neutralization
– Detoxification
– Chemical reduction or oxidation
– Electrolytic oxidation
– Hydrogenation, hydrolysis
• Biological Treatment
– Biodegradation
• Thermal Treatment
– High-temperature
incineration with
air pollution control
Treatment of Chemical Waste in LowIncome Countries
• Encapsulation
• Inertization with cement
• Burial of encapsulated or
inertized waste in
engineered, controlled and
secure landfills
• Return of chemicals to
manufacturers
Chemical Wastes Containing Heavy Metals
•
•
•
Chemical Wastes containing toxic metals, in general

Should not be burned or disposed in dumpsites

Some heavy metals, like silver in x-ray processing, can be recovered

Return to supplier for reprocessing or disposal if possible

If no options currently exist, store the waste safely in a medium-term storage site

Refer to the Secretariat of the Basel Convention’s guidelines on the
environmentally sound management or reclamation of metals including mercury
and lead
Mercury

Develop safe clean-up, handling and storage procedures

Sequester mercury waste safely in a long-term storage facility

Reduce unnecessary use of mercury equipment

Replace mercury-containing products with mercury-free alternatives

Develop plans to become a mercury-free facility
Cadmium and Lead

Send to facilities that specialize in recovery of heavy metals

Return to suppliers if possible

Send to a treatment, storage and disposal facility for hazardous industrial waste
Chemical Waste Management
• Integrate chemical waste management into the HCWM
plan, program and organization
• Identify chemical waste sources and hazards
• Control hazards by using less hazardous materials,
modifying equipment to reduce exposures, implementing
safe practices, PPE and administrative controls
• Train workers on the proper use of PPE
• Provide workers with information such as material safety
data sheets (MSDS) and international chemical safety
cards (ICSC)
• Comply with the country’s chemical waste regulations
• Develop strategies for waste minimization
Workers’ Right to Know
• Principle 10 of the Rio Declaration on Environment and
Development
– “Each individual shall have appropriate access to information …
on hazardous materials and activities ….”
• Principle 10 is embodied in many national and regional
laws on “Workers’ Right To Know” about the hazards of
chemicals they are working with
• Facilities can provide chemical hazard information by
making available or International Chemical Safety Cards
or Safety Data Sheets (SDSs), which are also called
Material Safety Data Sheets (MSDSs)
Safety Data Sheets
• Sections of a safety data
sheet
1.
Identification
2.
Hazard identification
3.
First-aid measures
4.
Fire-fighting measures
5.
Accidental release measures
6.
Handling and storage
7.
Exposure controls/personal
protection
8.
Exposure controls/personal
protection
9.
Physical and chemical
properties
10. Stability and reactivity
11. Toxicological information
12. Ecological information
13. Disposal considerations
14. Transport considerations
15. Regulatory information
16. Other information, including
date
Example of an ICSC
ICSCs can be found at: http://www.ilo.org/dyn/icsc/showcard.home
Example of a Safety Data Sheet
MSDSs can be found on the Internet or obtained from manufacturers.
Chemical Waste Minimization
• Source Reduction (most desirable method of
waste minimization)
– Segregate hazardous chemical waste
– Evaluate possible substitutions using less
hazardous or non-hazardous materials
– Use steam cleaning or non-toxic cleaners
– Control the inventory of chemicals
– Minimize unnecessary dilution of wastes
– Develop plans for a mercury phase-out
Chemical Waste Minimization
• Recycling
– Select vendors that are willing to reprocess or
recycle their products
– Use a silver recovery unit for photographic
waste
– Use a distillation column to recover solvents
– Purchase compressed gas cylinders from
manufacturers who accept return of empty or
partially used cylinders
Chemotherapeutic Waste
•
Chemotherapeutic waste – waste generated from the
use of chemical agents for treatment, especially cancer
therapy
•
Cytotoxic agents – substances capable of killing or
stopping the growth of cells
•
Cytostatic agents – capable of suppressing growth and
multiplication of cells
•
Antineoplastic agents – inhibiting the development of
abnormal tissue growth
•
Genotoxic agents – capable of inducing genetic mutation
•
Teratogenic agents – capable of causing defects in an
embryo or fetus
Examples of Cytotoxic Waste
•
Examples of sources
–
–
•
Contaminated materials from drug preparation including vials
and syringes
Contaminated materials from drug administration including
gloves, gauze, needles
Examples of specific agents
–
–
–
–
–
Alkylating agents (e.g., mechlorethamine, chlorambucil,
cyclophosphamide, ifosfamide, melphalan, streptozocin,
carmustine, busulfan, dacarbazine, thiotepa cisplatin)
Antimetabolites (e.g., 5-fluorouracil, methotrexate)
Anti-tumor antibiotics (daunorubicin, doxorubicin, bleomycin)
Topoisomerase inhibitors (etoposide, teniposide)
Mitotic inhibitors (paclitaxel, vinblastine, vincristine)
Segregation of Cytotoxic Waste
• Cytotoxic/Genotoxic Waste
– Should be stored separately from other waste in
designated secure location
– Collect in strong containers
– Containers should be leak-proof
– Clearly label containers “cytotoxic wastes”
– Do not dispose in dumpsites or discharged into
sewerage systems
Treatment and Disposal of
Chemotherapeutic Waste

Chemical degradation
–
Convert chemo waste into non-toxic residues by alkaline
hydrolysis, chemical oxidation with potassium permanganate or
sulfuric acid, denitrosation with hydrobromic acid, or other effective
methods for the particular type of cytotoxic waste

High-temperature incineration with air pollution control

Options for low-income countries:

UNDP GEF technology developed in Argentina
www.gefmedwaste.org

Safely package and return to original supplier

Encapsulation as a last resort

Do not disposed in dumpsites nor discharged into sewer systems
Chemotherapeutic Waste Minimization
• Segregate chemotherapy wastes through worker
training and separate waste containers
• Use degradable chemo agents instead of
environmentally persistent agents
• Purchase drug volumes based on need
• Return expired agents to manufacturer
• Develop spill containment and clean-up
procedures that minimize waste clean-up
volume
Characteristics of Radioactive Wastes
• Waste contaminated with radionuclides
• Produced as a result of:
 in-vitro analysis of body tissue and fluid
 in-vivo organ imaging and tumor localization
 investigative and therapeutic practices
• Can be sealed (encapsulated in pins, seeds or needles) or
unsealed (liquids administered directly)
• Some have relatively short half-lives causing them to lose
activity quickly (e.g., technitium-99m – 6 hours; iodine-123 – 13
hours; phosphorus-32 – 14 days)
• Others have long half-lives (carbon-14 – 5730 years)
Sources of Radioactive Wastes in Healthcare
•
Sealed sources
•
Spent radionuclide generators
•
Low-level solid waste, e.g. absorbent paper, swabs, glassware, syringes,
vials
•
Residues from shipments of radioactive material and unwanted solutions of
radionuclides intended for diagnostic or therapeutic use
•
Liquid immiscible with water, such as liquid scintillation-counting
•
Residues used in radioimmunoassay, and contaminated pump oil
•
Waste from spills and decontamination of radioactive spills
•
Excreta from patients treated or tested with unsealed radionuclides
•
Low-level liquid waste, e.g. from washing apparatus
•
Gases and exhausts from stores and fume cupboards
Health Risks of Radioactive Waste
• Health impacts determined by type and extent of
exposure to ionizing radiation
– Chromosomal damage
– Headaches, dizziness, vomiting
– Tissue destruction, hemorrhage, hair loss,
diarrhea, death at high doses
• An extreme case from Brazil (1988)
– Sealed radioactive source was removed from a
radiotherapy institute and broken open – 249
people exposed, several died or suffered severe
health problems
Containers for Radioactive Wastes
• Low-level radioactive infectious waste (swabs,
syringes) may be collected in bags or
containers
• There is no recommended color code for
radioactive waste containers
• Containers should have the radioactive symbol
Segregation of Radioactive Waste
•
Separate radioactive wastes based on
•
Half-life
–
Short-lived (<60 days) versus long-lived (>60 days)
•
Activity and radionuclide content
•
Physical and chemical form
•
–
Liquid: aqueous and organic
–
Non-homogeneous (e.g. contain sludge or suspended solids)
–
Solid: combustible/non-combustible and compactable/noncompactable
Sealed versus non-sealed sources
–
•
Spent sealed sources
Waste content
–
Waste containing hazardous (e.g. pathogenic, infectious,
toxic) material
Labeling of Radioactive Waste
Radioactive wastes
•
“Radioactive waste” marking and symbol
•
Identification number
•
Radionuclide
•
Activity and date of measurement
•
Period of storage required
•
Origin of the waste (room, lab, etc.)
•
Potential/actual hazards
•
Surface dose rate and date of measurement
•
Quantity (weight or volume)
•
Responsible person
Storage of Radioactive Waste
•
Secure cabinet, dedicated area, room or small building
•
Waste segregated according to the time needed for storage
•
Extremely short half lives (<5 days), short half lives (5 to 30 days), longer half lives
(30 to 60 days)
•
Restricted access for safety
•
Radiation shielding depending on radiological hazard
•
Radiation monitoring and surveillance
•
Fire protection
•
Periodic inspections for leakage
•
Recordkeeping, inventory log
Disposal of Radioactive Waste
•
Return to supplier
•
“Decay in Storage” or storage for decay
•

Store the waste for at least 10 times the half-life of
the longest lived radionuclide in the waste

Conduct a radiation survey to confirm that
radioactivity is below the clearance level

Disinfect mixed radioactive infectious waste before
discarding with regular waste
Long-term storage at an authorized radioactive waste
disposal facility
Radioactive Waste Minimization
• Develop a radioactive waste management plan
• Substitute long-lived radionuclides with short-lived
radionuclides
• Substitute stable isotopes for radionuclides where
possible
• Limit the quantity of radioactive items purchased
• Improve procedures to avoid contamination and to
minimize the volume of waste generated
Sources of Pharmaceutical Waste
•
•
•
•
•
•
•
•
Expired pharmaceuticals
Discontinued drugs
IV preparations
Partially used vials and syringes
Compounding of drugs
Breakage and spills of pharmaceuticals
Unused single-dose repackaged drugs
Patients’ personal medications
Characteristics of Pharmaceutical
Waste
• Pharmaceuticals can be
– Acutely hazardous (e.g., arsenic trioxide,
epinephrine, nitroglycerin, warfarin >0.3%)
– Toxic (e.g., barium, chloral hydrate, chloroform,
chlorambucil, cyclophosphamide, mitomycin C,
streptozotocin, lindane, phenol, thimerosal)
– Flammable or ignitable (e.g., isopropanol,
paregoric, collodion-based preparations)
– Corrosive (e.g., acetic acid used for
compounding)
Environmental Impact of
Pharmaceutical Waste
• Pharmaceuticals are present in most hospital
wastewater
• More than 100 different types of pharmaceuticals or
their metabolites are found in water bodies in Europe
and the U.S.
• Some pharmaceuticals can seep into the groundwater
• Environmental concentrations could affect fish and
other wildlife
• Antibiotics found in streams worldwide raise concerns
of the possible rise of antibiotic-resistant organisms
Segregation of Pharmaceutical Waste
• Pharmaceutical Waste
– Should be segregated from other infectious
and radioactive wastes
– National and local regulations must be
followed
Treatment and Disposal of
Pharmaceutical Waste
•
•
•
•
•
Chemical Treatment
Chemical Absorption
Denaturing (e.g., alkaline hydrolysis)
High Temperature Incineration
Recovery of active pharmaceutical ingredients
through solvent extraction, separation, distillation,
filtration, etc.
Disposal of Pharmaceutical Waste in LowIncome Countries
•
Reverse distribution (return to supplier)
•
Safe burial on hospital premises
•
Encapsulation or inertization
•

Solid, liquid, or semi-liquid waste can be encapsulated in metal drums

Solids ground up; mixed with cement, lime and water; made into pellets or blocks
Landfill disposal

•
Landfilling large quantities of pharmaceuticals is not recommended, unless waste is
encapsulated and disposed in a sanitary landfill where there is no risk of leaching
into the groundwater
Discharge to a sewer

Only for relatively mild liquid or semi-liquids (vitamins, cough syrups, eye drops,
saline solution, glucose, electrolytes, etc.)

Discharge into a large flow of water and into municipal sanitary sewers

Antibiotics and cytotoxic drugs should not be discharged in a sewer
Pharmaceutical Waste Minimization
• Good inventory control
– Increase inventory turnover
– Apply inventory control strategies (e.g., ABC
classification, First In First Out, Just-In-Time
management, etc.)
• Avoiding unnecessary prescriptions, especially
antibiotics
• Reformulation of drugs
Discussion
• What are some sources of chemical, cytotoxic, and pharmaceutical
wastes in your facility? What are some examples of these
healthcare wastes that may occur both inside and outside of your
facility? What are some major hazards and risks that are posed by
these wastes?
• What are some sources of radioactive wastes in your facility? Give
some examples, as well as their hazards and risks.
• How does your facility segregate chemical and pharmaceutical
wastes? What about specific wastes that have cytotoxic and/or
genotoxic properties? What handling and safety procedures are
followed by those who deal directly with the wastes?
Discussion
• How does your facility store chemical, cytotoxic, pharmaceutical,
and radioactive wastes? What treatment and disposal methods
does it use or has it used in the past for each category of waste?
• What are country/region-specific policies and guidelines for
chemical and radioactive waste management? What about
international guidelines specifically meant for radioactive wastes? Is
your facility able to follow these guidelines?
• How does your facility regulate mercury? Are there plans to use
alternative sources in place of mercury and to eventually phase out
its use in most medical equipment?