Transcript Safe and sustainable healthcare waste treatment – an essential element of healthcare without harm Ruth Stringer International Science and Policy Coordinator Health Care Without Harm.

Safe and sustainable healthcare
waste treatment – an essential
element of healthcare without harm
Ruth Stringer
International Science and Policy Coordinator
Health Care Without Harm
Can you have healthy people on a sick
planet?
The Paradox: Hospitals Create
Environmental Health Problems
• The UK national health service is responsible for 26% of
public sector GHG emissions. Eight percent of US
emissions are from healthcare. Ten percent of Brazil’s
energy is consumed by hospitals.
• The U.S. healthcare sector is the country’s largest
consumer of carcinogenic chemicals.
• Half the world’s population is exposed to the negative
health impacts of medical waste.
• China spends $10 billion a year on health care
construction.
 Making the link between the environment and health
 Evolving the Hippocratic Oath
 Leveraging the purchasing power of health care
 Promoting policy and regulatory frameworks for
sustainability and equity
 Activating health messengers for broader societal
transformation
 Implementing a disease prevention agenda
Hospitals Can Lead by Example and
Promote Public Health by Reducing their
Environmental Footprint
A Global Umbrella Network of
Sustainability in Health Care
The Ten Goals
1. LEADERSHIP: Prioritize Environmental Health
2. CHEMICALS: Substitute Harmful Chemicals with Safer Alternatives
3. WASTE: Reduce, Treat and Safely Dispose of Healthcare Waste
4. ENERGY: Implement Energy Efficiency and Clean Renewable Energy Generation
5. WATER: Reduce Hospital Water Consumption and Supply Potable Water
6. TRANSPORTATION: Improve Transportation Strategies for Patients and Staff
7. FOOD: Purchase and Serve Sustainably Grown, Healthy Food
8. PHARMACEUTICALS: Safely Manage and Dispose of Pharmaceuticals
9. BUILDINGS: Support Green and Healthy Hospital Design and Construction
10. PURCHASING: Buy Safer and More Sustainable Products and Materials
Extent of the problem of medical waste
“Over half of the world’s
population are now at
risk from occupational,
environmental or public
health threats from
improperly treated
medical waste.“
Harhay et al. (2009) Tropical
Medicine and International
Health 14(11): 1414-1417
Dioxins build up in the food chain
A survey of eggs near a
small scale medical
waste incinerator in
India found dioxins at 5
and a half times the EU
limit for food.
IPEN (2005) Contamination of chicken
eggs near the Queen Mary's Hospital,
Lucknow medical waste incinerator in
Uttar Pradesh (India) by dioxins, PCBs
and hexachlorobenzene
http://www.ipen.org/ipepweb1/library/i
pep_pdf_reports/3ind%20lucknow_eggs
report.pdf
Improper healthcare waste management:
a human rights issue
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•
Right of access to
information
On how to handle waste
safely
About generation and
treatment of waste
About pollution
generated by waste
treatment
About the health impacts
of HCWM
The Right to Information
• Clear relationship between knowledge and
good practice
• Nurses better informed than doctors
• Most workers receive little or no waste
management training
• Many completely unaware of the risks
• Need also to improve understanding at at
senior medical and managerial levels
Right to a clean environment
• Dumped medical
waste
• Waste burning and
incineration
• Mercury pollution
• Pharmaceutical
wastes
• Pathogens
Right to a clean environment
Right to a safe working environment
• Medical staff
• Cleaners and hospital
waste treatment staff
• Municipal waste
workers
• Rag pickers
• Waste recyclers
• Workers in centralised
healthcare waste
treatment facilities
Right to a safe working environment
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Little or no training
Poor/no PPE
Poor vaccination
Little or no PEP
Lack of
management
support- quote from
a waste manager
about a worker who
has had an accident:
“This is related only to the fate of that person that has had an
accident. It is not our duty to take action against their fate”
Right to life and health
• Serious lack of research on
the effects of improper
medical waste management
• Very little known about the
impacts of exposure to
chemicals, pharmaceuticals
and radioactive waste
• Infections via various routes
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–
–
–
Needle stick injuries
Inhalation of aerosols
Contaminated surfaces
?Zoonotic transmission
Human Rights Council
Special Rapporteur’s report September 2011
Recommendations include:
• Improved national and international legislation
• Improved access to training, PPE & vaccination
• More funding and technical support from
international community
• Waste minimisation, segregation and proper
handling procedures
• Substitution of incineration with alternatives
wherever practicable
Technological solutions
• Technology alone is not
enough
• Half the donated
equipment in
developing world
hospitals is not in use
because it is
inappropriate or
because it lacks trained
operatives or spare
parts
Lack of resources in the healthcare sector
Per Capita Health Care Expenditures in
Selected Countries Where HCWH
Works
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•
•
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•
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•
•
Nepal
Tanzania
India
Philippines
South Africa
Argentina
Czech Rep
Austria
United States
$24
$ 29
$ 82
$ 174
$ 669
$1,067
$1,302
$2,306
$5,711
Source: UNDP Human Development Index 2006
ADDITIONAL ISSUES:
•
•
Disparities within countries
Public/private mix of health care
services.
Poor infrastructure
• Unreliable power
• Lack of transportation:
– No vehicles or maintenance or fuel
– Long distances
– Bad roads, either part of the time or all year
• No recycling markets to reclaim non-hazardous
wastes/defray costs
• No proper landfills for final disposal of treated
wastes
Bad and illegal practices
Inside the hospital
Outside the hospital
• Reusing syringes etc
• Failing to comply with laws
on segregation and disposal
• Dumping the waste to save
money rather than paying
for treatment
• Selling the waste. As well as
low level staff, management
are alleged to be involved,
taking a cut of the profits
• Waste transporters sell the
waste en route to the
treatment centre
• Untreated waste is recycled
• Waste is washed and
repacked for resale
• Enforcement officers take
bribes to look the other
way.
Lack of priority, management
support
• Donors and governments focus on high profile
issues eg maternal health, HIV and do yet not
give waste the attention it deserves.
• Lack of research- to quantify problems and
identify solutions
• Rarely regarded as important by senior staff
– Management do not provide finance or make sure
rules are enforced
– Doctors notorious for not segregating, often do not
attend training: claim they are “too busy”
Research on disease
• Lots of research on needle stick injuries in
medical staff, but papers rarely distinguish
between injuries giving the injections and
those associated with disposal.
• Over 20% of NSIs are associated with waste
disposal, plus approximately 10 % during trash
collection.
Estimates of disease from NSI
14%
Estimating 20%
associated with waste Estimated 10% during
disposal
trash collection
68,400
2.8%
34,200
1.4%
Hepatitis B 15,000,000
25%
3,000,000
5.0%
1,500,000
2.5%
Hepatitis C
1,000,000
8%
200,000
1.6%
100,000
0.8%
3,000,000
7%
600,000
1.4%
300,000
0.7%
850,000
Not reported
170,000
not
known
85,000
not
known
Disease Total number Percentage
outcomes
of cases
of cases
HIV
Bacterial
infections
Injection
site
abscesses
342,000
Reid 2010
Gabriel 2009, Attaullah et al (2011)
The need for needle cutters
Almost 1/3 of waste handlers’ injuries
are in legs, from carrying bags with
sharps in them
Blenkharn & Odd 2008
Tackling the trade in second hand
medical devices
Waste workers and
ragpickers are rarely
considered, but the
can suffer 3-5 NSI per
day, equivalent to
6000- 9000 times more
injuries than UK waste
handlers.
Need to keep waste handling chain
clean
Risk of nosocomial infection
Reusable containers
Bacteria (%)
Fungi (%)
Single-use containers
Bacteria (%)
Bacillus sp (89.2)
Gram-negative rods (25.0)
Alternaria sp (2.5)
Aspergillus flavus (2.5)
Micrococcus sp (2.5)
Aspergillus fumigatus
(2.5)
Aspergillus glaucus (1.7)
Aspergillus terreus (1.6)
Pseudomonas sp (1.7)
Coagulase-negative
Staphylococci (30.8)
Aspergillus niger (15.0)
Aspergillus sp (14.2)
Cladosporium sp (1.6)
Penicillium sp (1.6)
Staphylococcus aureus ,
including MRSA (1.7)
Aureobasidium pullulans
(2.5)
Alpha-hemolytic Streptococci
(23.3)
Nonhemolytic Streptococci
(1.7)
Cladosporium sp (18.3)
.
Pseudomonas aeruginosa (0.8)
Curvularia sp (0.8)
Fusarium sp (2.5)
Penicillium sp (30.8)
Rhodotorula sp (27.5)
Trichoderma sp (5.0)
Ulcladium sp (0.8)
Verticillium sp (0.8)
Bacillus sp (8.1)
Coagulase-negative
Staphlococci (6.5)
Fungi (%)
Aspergillus flavus (1.6)
Aspergillus fumigatus (1.6)
Aspergillus sp (1.6)
Table shows microorganisms
isolated from incoming infectious
waste containers in the USA
% = percentage of incoming
containers that cultured positive for
that microorganism.
From Neely et al. 2003
Developing appropriate technologies
Key Features of the New Technologies
– Low-cost, modular, ergonomically designed autoclaves with multiple
energy options (electricity, bottled gas, other fuels)
– Autoclavable metal waste containers that are leak-proof,
colour-coded, designed for rapid steam penetration, and
durable to last for many years
– Container stands with foot pedals to lift the container lids thus
reducing cross-contamination
– Mechanical sharps destroyer or autoclavable sharps container for use
with an autoclave-shredder
– Compactor to reduce waste volume with an integrated baler to
inhibit scavenging at landfills
– No generation of dioxins, furans, toxic metals, acid gases, etc.
– Potential for recovery and re-melting of sterilized waste materials
– Designed to be affordable and cost-competitive with incinerators
with little pollution control of the same capacity
– More information at www.gefmedwaste.org
Implementing appropriate systems
Health Care Without Harm works in collaboration with
Health Care Foundation Nepal (HECAF)
Everybody is involved
• Full management
support – director,
head of nursing and
housekeeping
• All staff orientated
at the start of the
process- including
security who
prevent staff selling
waste unofficially
Model ward, participatory approach
• Changes are
implemented in a
model ward first
• Nurses consulted on
the changes in their
ward
• Only when
everything is
working well do the
team move on to
the next wards
Trolley designed by HECAF and nurses,
made by maintenance
Bir hospital- comprehensive system
Validation of gravity autoclave
New old technologies- biodigestion
• Established for food and sewage, can also
cope with anatomical/tissue waste
• Biogas renewable fuel
• Slurry directed to sewer- no further handling
• Testing to come for pathogens, esp TB
• Negotiating with first maternity hospital
• Thermophilic digestion for higher resource
areas
Bir Hospital 2011
New technologies- biodigestion
• Established for food
• Designs for large and
small facilities
• Biogas renewable fuel
• Slurry can go to sewer
• Testing to come for
pathogens, esp TB
• Negotiating with first
maternity hospital
• Vermiculture – worm
composting for soft waste
Recycling garden built on
top of biodigester at Bir- the
house in the background is
for safe mercury storage
New technologies- biodigestion
• Bir Hospital biodigester and recycling garden
• Constructed 2011, capacity 25 cubic metres for a 460 bed
hospital
• In first year, has treated over 25 tonnes of food waste
• Capacity of 150kg/day with retention time over 100 days
• Average 75kg waste a day, plus small amounts of
pathological waste from the operating theatres
• Has generated 1375 m3 of biogas
• Average since Jan 2012: 7.25 m3/day
• Construction cost: USD6000
• Projected value of gas projected to be USD1000 per year
• Payback on construction is approximately 6 years.
Vermiculture
• Vermiculture – worm composting
• Mathur et al. (2006) found it removed
pathogens from soft waste
• So far recommending only for autoclaved
waste
• Significant potential for soft waste, sanitary
pads, diapers.
• Tests planned
Pharmaceutical waste
Solutions in use
• Overused:
– Flushing
– Uncontrolled landfill
– Incineration, co-incineration,
burning etc
• Underused
• Encapsulation
• Denaturing with bleach, peroxide,
permanganate
Solutions in waiting
• GEF technology reactor
• Alkaline hydrolysis
– Tissue digesters in production
and use
– Method originally intended
for hazardous waste
– Funding and legislative
barriers to use for drugs
• ?? Thermophilic anaerobic
digestion??
Reagents to denature
cytostatics
• Sodium
hyprochlorite
• Hydrogen peroxide
• Fenton reagents
• Low cost, low tech,
suitable for rinsing
used giving sets etc
Biomass autoclave
• Based on high efficiency
cook stove, uses wood
or biomass briquettes
• Key tech for small
facilities, where
electricity is unreliable
• 60 litre model, 100 litre
coming soon
• Validation under way
• Field tests in rural Nepal
under UNDP SGP grant
Low cost small scale technologies
Placenta pit (MSF design)
Biogas generator made from
water tanks
How to bridge the implementation gap
• Technology provision will fail without proper
implementation support
• Need to make use of the international
framework that exists through the Basel and
Stockholm Conventions
Thank you! More info at www.hcwh.org