MEDICAL

WASTE
MANAGEMENT

TABLE OF CONTENTS
PREFACE 6 1. INTRODUCTION 8

2. DEFINITION AND DESCRIPTION OF “MEDICAL

WASTE” 11 2.1 Description of medical waste 12 2.2 Quantification
of medical waste 14

3. MEDICAL WASTE RISKS AND IMPACT ON HEALTH

AND THE ENVIRONMENT 15 3.1 Persons potentially exposed
16 3.2 Risks associated with hazardous medical waste 17
3.2.1 Risks of trauma and infection 17 3.2.2 Survival of
micro-organisms in the environment 19 3.2.3 Biological risks
associated with exposure to solid
household refuse 21 3.2.4. Chemical risks 21 3.3 Risks
associated with the inappropriate processing
and dumping of hazardous medical waste 24 3.3.1. Incineration
risks 24 3.3.2. Risks related to random disposal or uncontrolled
 dumping 25 3.3.3. Risks related to the discharge of raw sewage
25

4. LEGISLATION 27 4.1 International agreements 28 4.2 National

Legislation 30

5. FUNDAMENTAL PRINCIPLES OF A WASTE MANAGEMENT

PROGRAMME 33 5.1 Assigning responsibilities 34 5.2
Sub-contracting, regional cooperation 37 5.3 Initial assessment 37
5.4 Preparing the waste management plan 38 5.5 Estimating costs
39 5.6 Implementing the waste management plan 40

6. MINIMIZATION, RECYCLING 41

7. SORTING, RECEPTACLES AND HANDLING 45 7.1 Sorting

principles 46 7.2 How to sort waste 47 7.3 Handling of bags 50

8. COLLECTION AND STORAGE 51

9. TRANSPORT 53 9.1 Vehicles and means of conveyance 54 9.2

On-site transport 55 9.3 Off-site transport 56 9.4 Cross-border
transport 5

10. TREATMENT AND DISPOSAL 57 10.1 Choosing treatment

and disposal methods 58 10.2 Incineration 62 10.3 Chemical
disinfection 68 10.4 Autoclaving 69 10.5 Needle extraction or
destruction 71 10.6 Shredders 73 10.7 Encapsulation 74 10.8
Disposal in a sanitary landfill or waste burial pit 75 10.9 Disposal of
liquid wastes in the sewage 77

11. STAFF PROTECTION MEASURES 79 11.1 Personal

protective equipment 81 11.2 Personal hygiene 83 11.3 Vaccination
84 11.4 Measures to be taken in the event of accidental exposure
to blood 84 11.5 Emergency measures in the event of spills or
contamination of surfaces 86 11.6 Emergency measures in the
event that persons
have been contaminated 88

12. TRAINING 89 12.1 Why and how 90 12.2 Content 91

13. FURTHER INFORMATION 93

ANNEX 1 WASTE DATA SHEETS 95 Data sheet no. 1: Sharps

(category 1) 96 Data sheet no. 2: Waste entailing risk of
contamination (category 2.a) 98 Data sheet no. 3: Anatomical waste
(category 2.b) 100 Data sheet no. 4: Infectious waste (category 2.c)
102 Data sheet no. 5: Pharmaceutical waste (category 3.a) 104 Data
sheet no. 6: Cytotoxic waste (category 3.b) 106 Data sheet no. 7:
Mercury waste (category 3.c) 108 Data sheet no. 8: Photographic
development liquids (category 3.d) 110 Data sheet no. 9: Chemical
waste (category 3.d) 112 Data sheet no. 10: Pressurized containers
(category 4) 114 Data sheet no. 11: Radioactive waste (category 5)
116

ANNEX 2 METHOD DATA SHEETS 117 Data sheet 12:

Choosing sharps containers 118 Data sheet 13: Burial pit 120 Data
sheet 14: Burial pit for anatomical waste 122 Data sheet 15 : Sharps
pit 124

ANNEX 3 TOOLS FOR IMPLEMENTING THE WASTE

MANAGEMENT PLAN 127 Annex 3.1 Example of a form for
quantifying waste generation 128 Annex 3.2 Checklist for describing
the current situation 129 Annex 3.3 Example of a waste flow diagram
134 Annex 3.4 Audit checklist 135 Annex 3.5 International transport
of dangerous goods by road 145 Annex 3.6 Example of a poster:
What to do in the event of AEB 150

ANNEX 4 LIST OF SYMBOLS AND PICTOGRAMS 151 LIST

OF TABLES AND FIGURES 156 LIST OF ABBREVIATIONS

158

PREFACE
The world is generating more and more waste and hospi
tals and health centres are no exception. Medical waste can
be infectious, contain toxic chemicals and pose contamina
tion risks to both people and the environment. If patients
are to receive health care and recover in safe surroundings,
waste must be disposed of safely.

Choosing the correct course of action for the different types

of waste and setting priorities are not always straightfor
ward, particularly when there is a limited budget. This
manual provides guidance on what is essential and what
actions are required to ensure the good management of
waste.

Drawing on the most up-to-date professional practice, the

manual provides practical recommendations for use in the
different contexts where the ICRC works. It includestechni
cal sheets ready for use, ideas for training and examples of
job descriptions for hospital staff members. The guidance
in this manual is applicable in resource poor countries as
well asin countries where there is a more developed health
infrastructure.
INTRODUCTION
The management of the waste from health services is
complex and to be successful it must be understood
and addressed by everyone working in health services
from those washing the floors to the senior
administrators. We hope that this manual will convince
readers that the man agement of medical waste is an
essential component of health facilities that must be a
priority shared by ICRC staff and our valued partner
organisations.

Translating best practice for very different

environments into clear and concise guidance for use
by different profes sions is a rare skill. This manual
would not have been pos sible without the expertise of
Sylvie Praplan who has been the main partner and
advisor in this adventure. Thanks are also due to the
expertise of many staff working in the field and in the
Headquarters of the ICRC and in particular to Margrit
Schäfer, in charge of Hospital Administration and
Martin Gauthier, Environmental Engineer, for their
perse verance and guidance throughout the process.
 1. INTRODUCTION
Health-care activities are a means of protecting health,
curing patients and saving lives. But they also generate
waste, 20 percent of which entail risks either of infection, of
trauma or of chemical or radiation exposure.

Although the risks associated with hazardous medical

waste and the ways and means of managing that waste
are relatively well known and described in manuals and
other literature, the treatment and elimination methods
advocated require considerable technical and financial
resources and a legal framework, which are often lacking
in the contextsin which the International Committee of the
Red Cross (ICRC) works. The staff is often unequipped for
coping with this task.

Poor waste management can jeopardize care staff, employ

Hospitals are pollution.
responsible for the waste they produce.
They must ensure In unfavourable contexts, the risks
that the handling, treatment and disposal associated with hazard ous medical
of that waste will waste can be significantly reduced
through simple and appropriate
not have harmful
measures. This manual is intended as a
consequences for
practical and pragmatic tool for the
public health or the environment.
routine manage ment of dangerous
ees who handle medical waste, patients
hospital wastes. It does not under any
and their families, and the neighbouring
circumstancesreplace any existing
population. In addition, the inap propriate
national waste manage ment legislation
treatment or disposal of that waste can
and plans.
lead to environmental contamination or
1. INTRODUCTION
 This manual is designed for the medical, technical or
administrative staff working in medium-sized
hospitals (approximately 100-bed capacity) that
are managed or supported by the ICRC.

The manual includes data sheetsin the Annex. It deals with

wastes that are created in the course of surgical, medical,
laboratory and radiological activities with the exception
of specialties such as oncology, nuclear medicine or pros
thetic/orthotic workshops. It deals mainly with so-called
hazardous or special medical waste except for genotoxic
waste such as cytotoxic substances or radioactive material,
which are wastes that ICRC health care activities generally
do not produce.

2. DEFINITION
AND
DESCRIPTION OF
“MEDICAL
WASTE”
2.1 Description of medical waste
The term “medical waste” covers all wastes produced in
health-care or diagnostic activities.

75 % to 90 % of hospital wastes are similar

to household refuse or municipal waste and
do not entail any particular hazard.

Refuse similar to household waste can be put through the

same collection, recycling and processing procedure as
the community’s municipal waste. The other 10% to 25% is
called hazardous medical waste or special waste. This type
of waste entails health risks.

It can be divided into five categories according to the risks

involved. Table 2.1 gives a description of those various cat
egories and their sub-groups.
2. DEFINITION AND DESCRIPTION OF “MEDICAL WASTE”

Table 2.1 Classification of hazardous medical waste

1. Sharps > Waste entailing risk of injury.

 a. Waste entailing risk of
contamination
b. Anatomical waste

c. Infectious waste

a. Pharmaceutical waste

b. Cytotoxic waste

c. Waste containing heavy

metals d. Chemical waste

Pressurized containers

2. > Waste containing blood, secretions or excreta entailing a risk of

contamination.
> Body parts, tissue entailing a risk of
contamination
> Waste containing large quantities of
material, substances or cultures entailing
the risk of propagating infectious agents
(cultures of infectious agents, waste from
infectious patients placed in isolation
wards).

3. > Spilled/unused medicines, expired drugs and used medication receptacles.

> Expired or leftover cytotoxic drugs,
equipment contaminated with cytotoxic
substances.
> Batteries, mercury waste (broken
thermometers or manometers, fluorescent
or compact fluorescent light tubes).
 > Waste containing chemical substances:
leftover laboratory solvents, disinfectants,
photographic developers and fixers.

4. > Gas cylinders, aerosol cans.

5. Radioactive waste > Waste containing radioactive substances: radionuclides

used in laboratories or
nuclear medicine, urine or excreta of
patients treated.

The various categories of waste are set out in detail in the

data sheetsin Annex 1 (sheets 1 to 11). Cytotoxic and radio
active wastes are dealt with briefly in that annex.

2.2 Quantification of medical waste

The quantity of waste produced in a hospital depends on
the level of national income and the type of facility con
cerned. A university hospital in a high-income country can
produce up to 10 kg of waste per bed per day, all categories
combined.

An ICRC hospital with 100 beds will produce an

average of 1.5 to 3 kg of waste per patient per
day depending
on the context (all categories combined and
including household refuse).

An estimate of the quantities of waste produced must be

drawn up in each facility (see chapter 5.3 and Annex 3.1).

3. MEDICAL
WASTE
RISKS AND
IMPACT
ON HEALTH
AND THE
ENVIRONMENT
3.1 Persons potentially exposed
All persons who are in contact with hazardous medical
waste are potentially exposed to the various risks it entails:
persons inside the establishment generating the waste,
those who handle it, and persons outside the facility
who may be in contact with hazardous wastes or their
by-products, if there is no medical waste management or
if that management is inadequate.

The following groups of persons are potentially exposed:

> Inside the hospital: care staff (doctors, nursing staff,
auxiliaries), stretcher-bearers, scientific, technical
and logistic personnel (cleaners, laundry staff,
waste managers, carriers, maintenance personnel,
pharmacists, laboratory technicians, patients, families
and visitors).
> Outside the hospital: off-site transport personnel,
personnel employed in processing or disposal
infrastructures, the general population (including
adults or children who salvage objects found around
the hospital or in open dumps).
3. MEDICAL WASTE RISKS AND IMPACT ON HEALTH AND THE ENVIRONMENT
3.2 Risks associated with hazardous medical
waste
The health risks associated with hazardous medical waste
can be divided into five categories:
> risk of trauma
(waste category 1);

> risk of infection

(waste categories 1 and 2);

> chemical risk

(waste categories 3 and 4);

> risk of fire or explosion

(waste categories 3 and 4);

> risk of radioactivity

(waste category 5, which is not dealt with in this manual).

The risk of environmental pollution and contamination

must be added to these categories.

3.2.1 RISKS OF TRAUMA AND INFECTION

Health-care wastes are a source of potentially dangerous
micro-organisms that can infect hospital patients, person
nel and the general public. There are many different expo
sure routes: through injury (cut, prick), through contact
with the skin or mucous membranes, through inhalation
or through ingestion.

Table 3.1 gives examples of infections that can be caused

by hazardous medical waste.

Table 3.1 Examples of infections that can be caused

by hazardous medical waste1

Type of infection Infective agent Transmission agent

Gastrointestinal Ente Mycobacteri

infections (Sa um
Vi tuberculosi
ch s,
Respiratory
Sh Streptococc
infections
 us an Hepatitis A virus
pn
SAR Ne Hepatitis B and C virus
me
Acu
Res Hum
mea Imm
ViruFaeces, vomit
Her
Lass
St
and
Inhaled secretions,
Ba saliva

Eye infections Eye secretions Skin infections Pus

Anthrax Skin secretions Meningitis Cerebro-spinal fluid

AIDS Blood, sexual secretions, other body fluids

Blood and secretions
Haemorrhagic fever

Viral hepatitis A Faeces

Blood and other biological fluids
Viral hepatitis B and C
Avian influenza H5N1 virus Blood, faeces

Some accidental exposure to blood (AEB) or to other body

fluids are examples of accidental exposure to hazardous
medical waste.

note1

1 Source: A. Prüss, E. Giroult, and P. Rushbrook, Safe management of wastes from

health-care activities, WHO, 1999.
3. MEDICAL WASTE RISKS AND IMPACT ON HEALTH AND THE ENVIRONMENT

As regards viral infections such as AIDS and hepatitis B

and C, it is nursing staff who are most at risk of
infection through contaminated needles. Sharps and
 pathogenic cultures are regarded as the most
hazardous medical waste.

In 2000, the World Health Organisation (WHO) estimated

that at world level accidents caused by sharps accounted
for 66,000 cases of infection with the hepatitis B virus,
16,000 cases of infection with hepatitis C virus and 200
to 5,000 cases of HIV infection amongst the personnel of
health-care facilities.

Some wastes, such as anatomical wastes, do not

necessarily entail a health risk or risk for the
environment but must be treated as special
wastes for ethical or
cultural reasons.
A further potential risk is that of the propagation of micro
organisms outside health-care facilities which are present
in those facilities and which can sometimes be resistant − a
phenomenon that has not yet been sufficiently studied.

3.2.2 SURVIVAL OF MICRO-ORGANISMS

IN THE ENVIRONMENT
Pathogenic micro-organisms have a limited capacity ofsur
vival in the environment. Survival depends on each micro
organism and on environmental conditions (temperature,
humidity, solar radiation, availability of organic substrate,
presence of disinfectants, etc.). Bacteria are less resistant
than viruses. Very little is known as yet about the survival
of prions and the agents of degenerative neurological dis
eases (such as Creutzfeldt-Jakob’s disease, Kuru, and so on),
which seem to be more resistant than viruses.

Table 3.2 gives a summary of what is known about the sur

vival of various pathogens.

Table 3.2: Examples of the survival time of certain pathogens2

 micro-organism
Pathogenic Observed survival time

Hepatitis B virus > Several weeks on a surface in dry air > 1

week on a surface at 25°C
> Several weeks in dried blood
> 10 hours at 60°C
> Survives 70% ethanol.
> 1 week in a drop of blood in a
Infectious dose of hypodermic needle
hepatitis B and C viruses

Hepatitis C > 7 days in blood at 4°C.

HIV > 3 − 7 days in ambient air

> Inactivated at 56°C
> 15 minutes in 70% ethanol
> 21 days in 2 μl of blood at ambient temperature
> Drying the virus reduces its concentration by 90-99%
within the next few hours.

The concentration of micro-organisms in medical waste, with the exception of

laboratory cultures of pathogens and the excreta of infected patients, is
generally no higher than in household refuse. However, medical waste contain
a wider variety of micro-organisms.

On the other hand, the survival time of the micro-organisms present in medical
waste is short (probably because the wastes contain disinfectants).

The role played by carrierssuch asrats and insects must also

be taken into account in the evaluation of micro-organism
survival time in the environment. They are passive carriers
of pathogens, and measures must be taken to control their
proliferation.

2 WHO 2010, Public Health Agency of Canada 2001, Thomson et al. 2003.
3. MEDICAL WASTE RISKS AND IMPACT ON HEALTH AND THE ENVIRONMENT

3.2.3 BIOLOGICAL RISKS ASSOCIATED WITH EXPOSURE

 TO SOLID HOUSEHOLD REFUSE
Since exposure conditions are often the same for employ
ees dealing with household refuse and those dealing with
medical waste, the impact on the health of the former can
be used as an indicator for the latter.

Various studies conducted in high-income countries have

shown the following results:
Compared to the general population, in the case of per
sons employed in the processing of household waste
> the risk of infection is 6 times higher;
> the risk of contracting an allergic pulmonary disease is
2.6 times higher;
> the risk of contracting chronic bronchitis is 2.5 times
higher;
> and the risk of contracting hepatitis is 1.2 times higher.

Pulmonary diseases and bronchitis are caused by exposure

to the bio-aerosols contained in the air at the sites where
the refuse is dumped, stored or processed.3

3.2.4. CHEMICAL RISKS

Many chemical and pharmaceutical products are used in
health-care facilities. Most of them entail a health risk due
to their properties (toxic, carcinogenic, mutagenic, repro
toxic, irritant, corrosive, sensitizing, explosive, flammable,
etc.). There are various exposure routes for contact with
these substances: inhalation of gas, vapour or droplets,
contact with the skin or mucous membranes, or ingestion.
Some substances (such as chlorine and acids) are incom
patible and can generate toxic gases when mixed.

3 These bio-aerosols contain gram-positive and gram-negative bacteria, aerobic

Actinomycetes and sewage fungi.

The identification of potential hazards caused by

certain substances or chemical preparations can be
easily done through labelling: symbols, warning
statements or hazard statements. More detailed
information is set out
in the material safety data sheet (MSDS).

Some examples of the European and international hazard

symbols are shown in Annex 4. Figures 3.1 and 3.2 give
examples of European and international labelling (Globally
Harmonized System - GHS).

Cleaning products and, in particular, disinfectants are

examples of dangerous chemicals which are used in large
quantities in hospitals. Most are irritant or even corrosive,
and some disinfectants (such asformaldehyde) can be sen
sitizing and toxic.

Acetone
eyes, rinse label.
immediately
with plenty Risk
of water and
Highly seek medical statements
flammable Irritant
advice.
Precautionary
S46 If
swallowed, statements
seek medical
S9 Keep advice (R-statements)
container in a immediately
R11 Highly
well-ventilated and show this
flammable. (P-statements)
place.
R36 Irritating to
the eyes. S16 Keep away
from sources of
R66 Repeated
exposure may ignition – No
cause skin smoking.
dryness or

cracking.
R67 Vapours
may cause
drowsiness and
dizziness.

S26 In case of
contact with container or
Name, address and telephone number
of the firm responsible in Switzerland.
 Figure 3.1: Example of the labelling of chemicals
(European system applicable until 2015)
3. MEDICAL WASTE RISKS AND IMPACT ON HEALTH AND THE ENVIRONMENT

Acetone

H225 Highly flammable well-ventilated

liquid and vapour. P403/
H319 Causes serious eye place. Keep container
irritation. tightly
H335 May cause closed.
drowsiness or dizziness.
EUHD55 Repeated Hazard statements
exposure may cause skin
dryness or (H-statements)
cracking.

P210 Keep away from

heat/sparks/ open
flames/hot surfaces – Precautionary
No smoking.
statements
P361 Avoid breathing
(P-statements)
vapours. 333Store in a
P305/ 351/ 338 Remove contact
If in eyes: Rinse lenses if present
carefully with and easy to do –
water for several continue rinsing.
minutes.

Name, address and telephone number

of the firm responsible in Switzerland.

Figure 3.2: Example of the labelling of chemicals

according to the new (international) system (GHS)

Mercury is a heavy metal in liquid form at room

tempera ture and pressure. It is very dense (1 litre of
mercury weighs 13.5 kg!). It evaporates readily and
can remain for up to a year in the atmosphere. It
accumulates in sediments, where it is converted into
methylmercury, a more toxic organic derivative.
Mercury is found mainly in thermom eters,
manometers, dental alloys, certain types of battery,
electronic components and fluorescent or compact
fluores cent light tubes. Health-care facilities are one of
the main sources of mercury in the atmosphere due to
the incinera tion of medical waste. These facilities are
also responsible for the mercurial pollution of surface
water.

Mercury is highly toxic. There is no threshold under

which it does not produce any undesirable effect.
Mercury can cause fatal poisoning when inhaled.4 It is
also harmful in the event of transcutaneous
absorption and has dangerous effects on pregnancy.

Silver is another toxic element that is found in hospitals

(photographic developers). It is bactericidal. Bacteria which
develop resistance to silver are also thought to be resistant
to antibiotics.54

The trading and use of expired medicines also entail a pub

lic health risk whenever thistype of waste is not controlled.
This manual does not cover the risk associated with cyto
toxic drugs (see information outlined in Annex 1 – data
sheet no. 6).

3.3 Risksassociated with the inappropriate

processing and dumping of hazardous
medical waste
3.3.1. INCINERATION RISKS
In some cases, particularly when wastes are incinerated at
low temperature (lessthan 800°C) or when plastics contain
ing polyvinyl chloride (PVC) are incinerated, hydrochloric
acid (which causes acid rain), dioxins, furans and various
other toxic air-borne pollutants are formed. They are found
in emissions but also in residual and other air-borne ash
and in the effluent gases released through incinerator
chimneys. Exposure to dioxins, furans and other coplanar
polychlorinated biphenyls can have effectsthat are harmful
to public health.65

4 The disease caused by exposure to mercury is called mercurialism.

5 Anon 2007, Chopra 2007, Senjen & Illuminato 2009.
6 Long-term exposure to low doses of dioxins and furans can result in immune
system disorders in humans as well as abnormal development of the
nervous system, endocrine disruption and reproductive damage. Short-term
 exposure to high doses can cause skin lesions and impaired liver function. The
International Agency for Research on Cancer (IARC) classes dioxins as known
human carcinogens.
3. MEDICAL WASTE RISKS AND IMPACT ON HEALTH AND THE ENVIRONMENT

These substances are persistent, that is to say, the mol

ecules do not break down in the environment and they
accumulate in the food chain. The bulk of human exposure
to dioxins, furans and coplanar polychlorinated biphenyls
takes place through food intake.

Even in high-temperature incinerators (over 800°C) there

are cooler pockets at the beginning or the end of the
incineration process where dioxins and furans can form.
Optimization of the process can reduce the formation of
these substances if it is ensured, for example, that incinera
tion takes place only at temperatures above 800°C and if
the formation of combustion gas is prevented at tempera
tures of 200 - 400°C (see good incineration practices in
Chapter 10.2).

And lastly, the incineration of metals or of materials with a

high metal content (especially lead, mercury and cadmium)
can result in metals being released into the environment.

3.3.2. RISKS RELATED TO RANDOM DISPOSAL

OR UNCONTROLLED DUMPING
In addition to the above-mentioned risks, burial and ran
dom dumping on uncontrolled sites can have a direct
impact on the environment in terms of soil and water
pollution.

3.3.3. RISKS RELATED TO THE DISCHARGE

OF RAW SEWAGE
Poor management of wastewater and sewage sludge can
result in the contamination of water and soil with patho
gens or toxic chemicals.

Pouring chemical and pharmaceutical wastes down the

drain can impair the functioning of biological sewage treat
ment plants orseptic tanks. These can end up polluting the
ecosystem and water sources.septiques. Antibiotics and
their metabolites are excreted in the urine and faeces of
 patients under treatment and end up in sewage. Hospital
sewage contains 2 to 10 times more antibiotic-resistant
bacteria than domestic wastewater, a phenomenon which
contributes to the emergence and propagation of patho
gens such as MRSA (methicillin-resistant Staphylococcus
aureus ).

4. LEGISLATION
4.1 International agreements
Several international agreements have been concluded
which lay down fundamental principles concerning public
health, environmental protection and the safe manage
ment of hazardous wastes. These principles and conven
tions are set out below and must be taken into account in
the planning of hazardous medical waste management.

Basel Convention on the Control of Transboundary

Movements of Hazardous Wastes and Their Disposal (UNEP,
1992)
The main objectives of the Basel Convention are to minimize the
generation of hazardous wastes, treat those wastes as close as possible
to where they were generated and reduce transboundary movements
of hazardous wastes.
It stipulates that the only case where the cross-border movement of
hazardous waste is legitimate is the export of waste from a
country which does not have the expertise or the infrastructure
forsafe disposal to a country which does.

Bamako Convention (1991)

Thistreaty banning the importation of any hazardous wastesinto Africa
has been signed by 12 nations.
 Stockholm Convention on Persistent Organic Pollutants
(UNEP, 2004)
This convention aims to reduce the production and use of persistent
organic pollutants and to eliminate uncontrolled emissions of
substances such as dioxins and furans.

Polluter pays principle

Any producer of waste is legally and financially liable for disposing of
that waste in a manner that is safe for people and the environment
(even if some of the processes are sub-contracted).
4. LEGISLATION

Precautionary principle

When the risk is uncertain it must be regarded as significant and

protective measures must be taken accordingly.

Proximity principle
Hazardous wastes must be treated and disposed of as close as
possible to where they are produced.

Agenda 21 (plan of action for the 21st century adopted

by 173 heads of State at the Earth Summit held in Rio
in 1992 To minimize the generation of waste, to re-use and
recycle, treat and dispose of waste products by safe and
environmentally sound methods, placing all residue in sanitary
landfills.

WHO and UNEP initiatives concerning mercury

and Decision VIII/33 of the Conference of the
Parties to the Basel Convention on mercury
wastes
Measuresshould be taken assoon as possible to identify
populations at risk of exposure to mercury and to reduce
anthropogenic wastes. The WHO is ready to guide countries in
implementing a long-term strategy to ban appliances containing
mercury.
The ISWA76(International Solid Waste Association) is
an international network of waste treatment and
manage ment experts. Its purpose is to exchange
information with a view to promoting modern waste
management strate gies and environmentally sound
disposal technologies. The ISWA is currently active in
over 20 countries with some 1200
members throughout the world.

4.2 National Legislation

National legislation constitutes a basis which must be
drawn on to improve waste treatment practices in a coun
try. Many countries are currently drawing up national
medical waste management plans. The Global Alliance for
Vaccines and Immunization (GAVI) has been financing a
project in collaboration with the WHO in this context since
2006, the aim being to help 72 countries adopt a policy,
strategy and plan for managing the wastes generated in
health-care activities.

The following countries are concerned:

Africa
Angola, Benin, Burkina Faso, Burundi, Cameroon, Chad,
Comoros, Congo, Central African Republic, Côte d’Ivoire,
Eritrea, Ethiopia, Gambia, Ghana, Guinea, Guinea Bissau,
Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali,
Mauritania, Mozambique, Niger, Nigeria, Uganda, Rwanda,
Senegal, Sierra Leone, Somalia, Sudan, Tanzania, Togo,
Zambia, Zimbabwe.

South America
 Bolivia, Cuba, Guyana, Haiti, Honduras, Nicaragua.

Middle East:
Afghanistan, Djibouti, Pakistan, Yemen.

Europe
Armenia, Azerbaijan, Kyrgyzstan, Georgia, Moldavia,
Uzbekistan, Tajikistan, Ukraine.

Asia
Bangladesh, Bhutan, Cambodia, Democratic People’s
Republic of Korea, India, Indonesia, Laos, Mongolia,
Myanmar, Nepal, Solomon Islands, Sri Lanka, Timor-Leste,
Viet Nam.
4. LEGISLATION

The ICRC will have to investigate these various measures.

Other national legislative provisions will have to be taken
into account in the medical waste management context:
> general legislation on waste;
> legislation on public health and environmental
protection;
> legislation on air and water quality;
> legislation on the prevention and control of infections;
> legislation on radiation protection;
> legislation on the transport of hazardous substances;
> occupational safety and health legislations and
regulations.

5.
FUNDAMENTAL
PRINCIPLES
OF A WASTE
MANAGEME
NT
PROGRAMM
E
5.1 Assigning responsibilities

The proper management of medical waste depends on good

organization, sufficient funding and the active participation of
informed and trained personnel. Those are the preconditions for
the consistent
application of measures throughout the waste chain (from where it is
generated to where it is eventually disposed of).

Only too often, waste management is relegated to the rank of a

menial task, whereas it ought to be valued and all actors in a
hospital made to
realize their share of responsibility.

A “waste management” working group must thus be set up

by the hospital manager. That team must include the fol
lowing members: the hospital project manager, the water
and habitat engineer, the local waste manager, and mem
bers of the hospital staff,such asthe hospital administrator,
the head nurse, the head of radiology, the chief pharmacist
and the head of laboratory.
 Duties of the hospital project manager
The hospital project manager has the overall responsibility
of ensuring that the hospital wastes are managed in com
pliance with national legislation and international conven
tions. He is also responsible for:
> setting up a working group in charge of drafting the
waste management plan;
> appointing the local waste manager, who will
supervise and coordinate the waste management plan
on a daily basis;
> assigning duties; drawing up job descriptions;
> allocating financial and human resources;
> implementing the waste disposal plan;
> conducting audits and continuously updating and
improving the waste management system.
5. FUNDAMENTAL PRINCIPLES OF A WASTE MANAGEMENT PROGRAMME

Duties of the water and habitat engineer

The water and habitat engineer isresponsible for:
> carrying out an initial assessment of the waste situation;
> proposing a waste management plan to the working
group (including the choice of treatment/disposal
methods) that isin line with any existing national waste
management plan;
> planning the construction and maintenance of waste
storage and disposal facilities;
> assessing the environmental impact of waste
management (monitoring contamination, conducting
hydrogeological assessments, etc.);
> regularly analysing risksfor the personnel;
> supervising the local waste manager;
> training.

Duties of the local waste manager

The local waste manager is the person in charge of admin
istering the waste management plan on a daily basis. He87is
the guarantor of the long-term sustainability of the system
and must thus be in direct contact with all the members of
the working group and all hospital employees. His duties
include:
> monitoring the collection,storage and transport of
wastes on a daily basis;
> monitoring the stocks of receptacles and containers,
bags and personal protective equipment as well asthe
maintenance of the means of transport used; forwarding
ordersto the hospital administrator;
> supervising the personsin charge of collecting and
transporting wastes;
> monitoring the measuresto be taken in the event of an
accident (posting notices, informing the staff);
> monitoring protective measures;
> investigating incidents/accidentsinvolving wastes;

8 For the sake of simplicity and easier reading, the masculine form is used
throughout. It is to be understood as including women exercising the various
professions.

> drawing up reports (quantities of waste produced,

incidents);
> ensuring the maintenance of storage and treatment
facilities.

Duties of the hospital administrator

The hospital administrator is responsible for:
> ensuring that stocks of consumables (bags, receptacles
and containers, personal protective equipment, etc.)
are permanently available;
> examining and evaluating costs;
> drawing up contracts with third parties (carriers,
sub-contractors);
> giving advice on purchasing policies with a view
to minimize/substitute certain items (mercury-free
equipment, PVC-free equipment, etc.);
> monitoring proper implementation of protective
measures;
> supervising in the absence of the water and habitat
engineer.

Duties of the head nurse

The head nurse is responsible for:
> training care staff in waste management (paying
 special attention to new staff members);
> monitoring sorting, collection, storage and transport
procedures in the various wards;
> monitoring protective measures;
> supervising the hospital hygiene and taking measures
to control infection.

Duties of the chief pharmacist

The chief pharmacist is responsible for:
> maintaining medicine stocks and minimizing expired
stock;

Each person’s responsibilities and duties

must be assigned in writing.
5. FUNDAMENTAL PRINCIPLES OF A WASTE MANAGEMENT PROGRAMME

> managing waste containing mercury.

> In the absence of the pharmacist, the hospital
administrator takes over these responsibilities.

Duties of the head of laboratory

The head of laboratory is responsible for:
> maintaining the stock of chemicals and minimizing
chemical wastes;
> managing chemical wastes.

5.2 Sub-contracting, regional cooperation

In certain circumstances the ICRC may have to choose a
transport/treatment/disposal solution outside the hospital,
either by requesting the services of a private company or by
organizing cooperation amongst the health-care facilities
in the region.

The hospital remains responsible under all

circumstances for the wastes it produces and for
their impact on persons or the environment.
The facility will thus have to call in companies qualified to
handle special wastes and ensure that the treatment/dis
posal procedures followed by them are compatible with
national legislation and international agreements.
5.3 Initial assessment

The first stage when drawing up a waste

management plan is to carry out an initial
assessment of needs and resources, that is,
of describing the initial situation.

A checklist (Annex 3.2) can be used to describe the ini

tial situation and resources. This stage involves making
an inventory, and consists of gathering information on
national waste policy and legislation, local waste manage
ment practices and the staff involved.

It will be up to the water and habitat engineer (or, in his/her

absence, the hospital administrator) to draw up this inven
tory together with the members of the waste management
group and the heads of department and also consulting
the national authorities, where possible.

Form 3.1 (Annex 3) can be used to evaluate the quantity

of waste produced by the hospital. The categories used
must match those registered in the national directives
(policies, legislations and regulations). Where there are no
such directives, the waste categories set out in the present
manual (Table 2.1) must be referred to. The purpose of
this stage of the procedure is to determine the quantity of
waste produced per category and per department.

5.4 Preparing the waste management plan98

A draft waste management plan will then have to be drawn
up using the data that has been collected. It must contain
the following chapters:

Table 5.1: Tools for drafting the waste management plan

Stages Tools
Inventory Quantification of waste, Annex 3.1 Checklist for describing the current
situation, Annex 3.2
Minimization/recycling and purchasing policy Chapter 6
Sorting, collection, storage and transport Chapters 7, 8 and 9
Identification and evaluation ofChapter 10
treatment/ disposal options - Example: Annex 3.3
Diagram of waste flows
Protective measures Chapter 11 Training Chapter 12
Estimating costs Section 5.5
publication: CEHA, Basic steps in the
Implementation strategy Audit and preparation of health care
follow-up waste management plans for
Section 5.6 health care establishments, 2002,
www.emro.who.int/ceha
Audit checklist, Annex 3.4

9 Further information can be found in the following

5. FUNDAMENTAL PRINCIPLES OF A WASTE MANAGEMENT PROGRAMME

A diagram of waste flows should summarize the sorting

procedures and treatment chains for the various types of
waste. An example of the system used in Lokichokio (Kenya
– 2001) is included in Annex 3.3.

5.5 Estimating costs

Medical waste management costs vary widely depending
on the context, the amount of waste generated and the
treatment methods chosen. A WHO estimate dating from
2003 shows that in a small health-care facility the cost per
kg of waste incinerated in a SICIM-type single-chamber
incinerator can range from $0,08/kg to $1,36/kg.

The following factors must be taken into account in the cost

estimate:109
> Investment costs:
– cost of the land;
– cost of building/purchasing infrastructures (such as
an incinerator, a storeroom, or a waste burial pit);
– vehicles;
– on-site means of transport (such as wheelbarrows);
– bag stands or containers;
– personal protective equipment (clothes, boots).

> Operating costs

– fuel or electricity or water;
– spare parts, maintenance of treatment facilities;
– staff salaries;
 – sharps containers and bags;
– vehicle maintenance;
– personal protective equipment (gloves, masks);
– training.

10 Tools for estimating costs: Health-care waste management. Costing

Analysis Tool (CAT). Expanded Costing Analysis Tools (ECAT). http://www.
healthcarewaste.org

5.6 Implementing the waste management

plan
The hospital project manager isresponsible for implement
ing the waste management plan. He can delegate certain
tasks to the water and habitat engineer or the hospital
administrator. The implementation of the plan includesthe
following steps:
> approval and signing of the waste management plan;
> allocation of resources;
> assignation of tasks;
> organization of training;
> regular audits and monitoring, on-going improvement
of the waste management plan.

A sample checklist for audits is included in Annex 3.4.

6.
MINIMIZATION,
RECYCLING
 The reduction of waste generation must be encouraged by
the following practices:

> Reducing the amount of waste at source

– Choosing products that generate less waste: less
wrapping material, for example.
– Choosing suppliers who take back empty containers
for refilling (cleaning products); returning gas
cylinders to the supplier for refilling.
– Preventing wastage: in the course of care, for
example, or of cleaning activities.
– Choosing equipment that can be reused such as
tableware that can be washed rather than disposable
tableware.

It is prohibited to re-use needles or syringes.

The plastic part of syringes is recycled in some
regions, but this practice is not recommended
in ICRC contexts.

> Purchasing policy geared to minimizing risks

– Purchase of PVC-free equipment (choosing PET, PE or
PP) - see Health Care Without Harm site.1110
– Purchase of mercury-free equipment: mercury-free
thermometers (ICRC standards), mercury-free blood
pressure gauges).
– If possible, purchase of new safe injection and blood
sampling systems (where the needle is withdrawn
automatically).
– Opting for the least toxic products (cleaning
products, for example).

11 http://www.noharm.org
6. MINIMIZATION, RECYCLING
> Product recycling
– Recycling of batteries, paper, glass, metals and plastic.
– Composting of plant waste (kitchen and garden
wastes).
– Recycling of the silver used in photographic
processing.
– Recovering energy for water heating for example.

> Stock management

– Centralized purchasing.
– Chemical and pharmaceutical stock management
aiming to avoid a build-up of expired or unused
items: “first-in – first out” stock management, expiry
date monitoring.
– Choice of suppliers according to how promptly they
deliver small quantities and whether unused goods
can be returned.

> Sorting at source

– Segregating waste is the best way to reduce the
volume of hazardous wastes requiring special
treatment.

7.
SORTING,
RECEPTACL
ES AND
HANDLING
7.1 Sorting principles
Sorting consists of clearly identifying the various types of
waste and how they can be collected separately. There are
two important principles that must be followed:

Waste sorting must always be the responsibility of the

entity that produces them. It must be done as close
as possible to the site where the wastes are
produced.
For example, the nursing staff must dispose of sharps in
needle containers located as close as possible to the place
where the needles are used so asto avoid any manipulation
of used needles. Ideally, the nursing staff will take the nee
dle container to the patient’s bedside. Do not put the caps
back on syringe needles or remove them from the syringe
by hand! It is much too dangerous to do so.

Maintain sorting throughout the chain (in storage areas

and during transport).

There is no point in sorting wastes that undergo

the same treatment process, with the exception of
sharps, which must at all times be separated at
source from
other wastes.

Sorting is a significant stage in waste management, which

concerns all members ofstaff. Training, regular information
and frequent checking are essential if the sustainability of
the system that has been established is to be guaranteed.

Do not correct mistakes: if non-hazardous material has been placed in a

container for wastes entailing the risk of contamination, that waste must now
be considered hazardous (precautionary principle).
7. SORTING, RECEPTACLES AND HANDLING

7.2 How to sort waste

The simplest way to identify the different types of waste
and to encourage people to sort them is to collect the vari
ous types of waste in separate containers or plastic bags
that are colour-coded and/or marked with a symbol. The
international recommendations are as follows:

Table 7.1 Coding recommendations (WHO – UNEP/SBC 2005)

Type of waste Colour coding - symbol Type of container

Black

Yellow and

Yellow and

Yellow marked “highly

infectious” and

0. Household refuse Plastic bag 1. Sharps Sharps container

2a. Waste entailing a risk of 2b. Anatomical waste

contamination Plastic bag or container

2c. Infectious waste Plastic bag or container which can be

autoclaved
suitable symbol (see
3. Chemical and E.g.:
Annex 4, chapter 4:
pharmaceutical waste Plastic bag, container
Brown, marked with a Labelling of chemicals).
 Setting up a 3-container sorting system (for sharps, potentially infectious waste
and household refuse) is effective as a first step which is easy to do and
provides a means of drastically reducing the major risks.

In an emergency, during victim triage it is strongly recom

mended that all wastes generated by this activity be con
sidered wastes entailing a risk of contamination and should
be stored in appropriate containers (containers equipped
with yellow bags).

Household refuse, in black bags, must be put through the

same treatment chain as municipal waste. But before this
is done, recyclable waste and compostable materials must
first be separated at source.

The criteria for choosing sharps containers are set out in

detail in data sheet no. 12 (Annex 2). Photo 7.3 shows the
sharps containers used by the ICRC.

The bags must be placed either in rigid containers or on

castor-fitted stands (see photos 7.1 and 7.2). In certain cir
cumstances, if no plastic bags are available, the containers
must first be emptied, then washed and disinfected (with a
5% active chlorine solution).
Photo 7.1: (household refuse) castors
Container equipped with Photo 7.2: Photo 7.3:
a black plastic bag Plastic bag stand on Sharps container (ICRC)
7. SORTING, RECEPTACLES AND HANDLING
collected in yellow plastic bags for cultural
or religious reasons. It must be treated in
accordance with local customs (often
There must be an adequate stock of bags buried).
and containers wherever waste is
produced. Thisisthe responsibility of the Chemical and pharmaceutical wastes
local waste manager and the hospital must be sorted and treated separately.
administrator. The sub-categories include mercury
wastes, light bulbs, batteries,
The following are the criteria for choosing photographic developers, laboratory
plastic bags: appropriate size for the chemicals, pesticides and medicines.
container and the quantity of waste
How to recognize PVC: it sinks in water
produced, sufficiently thick (70 μm – ISO
(is
7765 2004) and of suitable quality
denser than water) and it produces a
(tear-resistant), non-halogenated plastic
green flame when burnt.
(no PVC).
PE and PP float.

Anatomical waste cannot always be

7.3 Handling of bags

Bags and containers must be closed whenever they are

two-thirds full. This is the responsibility of the nursing
staff! Never pile bags or empty them; grasp them from
the top (never hold them against the body) and wear
 gloves (see photo 7.4).

Photo 7.4:
Handling a bag of wastes

8.
COLLECTION
AND
STORAGE
Waste must be collected regularly - at least once a day. It must
never be allowed to accumulate where it is produced. A daily
collection programme and collection round must be planned.
Each type of waste must be collected and stored separately.

Infectious wastes (categories 1 and 2) must never be stored in

placesthat are open to the public.

The personnel in charge of collecting and transporting wastes

 must be informed to collect only those yellowbags and sharps
containers which the care staff have closed. They must wear
gloves.

The bagsthat have been collected must be replaced immedi

ately with new bags.

A specific area must be designated for storing medical waste

and must meetthe following criteria12:11
> it must be closed, and access must be restricted to
authorized persons only;
The wastes can be stored for a week in aeasy accessfor on-site and off-site
refrigerated area (3° to 8° C). Where means of transport;
there is no such refrigerated area, the > it must be well aired and well lit;
storage time for infectious medical > it must be compartmented (so thatthe
waste must not exceed the following varioustypes of waste can be sorted);
limits: > in temperate > it must be nearthe incinerator, if
climates: 72 hours in winter and 48 hoursincineration isthe treatment method
in summer; used;
> in hot climates: 48 hours in the cool > there must be wash basins nearby;
season and 24 hours in the hot season. > the entrance must be marked with a
> it must be separate from any food sign (“No unauthorized access”, “Toxic”,
store; or “Risk of infection” – see Annex 4,
> it must be covered and sheltered from Sections 1 and 2).
the sun; > the flooring must be
waterproof with good drainage; > it must 12 See Table 7.1, Safe management of
be easy to clean; wastes from health-care
activities, WHO, 1999. Op. cit.
> it must be protected from rodents,
birds and other animals; > there must be

9. TRANSPORT
9.1 Vehicles and means of conveyance

As far as possible, the means used for transporting

waste must be reserved for that purpose, and
different means must be used for each type of waste
 (e.g. one wheelbarrow for household refuse and
another one for Type 1 or Type 2 medical waste).
This is not always possible in the contexts where the
ICRC works.

These means of conveyance must meet the following

requirements:
> they must be easy to load and unload;
> they must not have any sharp corners or edges that
might tear the bags or damage the containers;
> they must be easy to clean; (with a 5% active chlorine
solution);
> they must be clearly marked.

Furthermore, off-site means of transport must meet the fol

lowing requirements:
> they must be closed in order to avoid any spilling on
the road;
> they must be equipped with a safe loading system (to
prevent any spilling inside or outside the vehicle);
> they must be marked according to the legislation in
force if the load exceeds 333 kg (see Annex 3.5).

The vehicles and means of conveyance must be cleaned

daily.
9. TRANSPORT

9.2 On-site transport

Different means of conveyance may be used inside the
facility – wheelbarrows, containers on wheels, carts (see
photos 9.1 and 9.2).
Photo 9.1: Photo 9.2:
An example of an An example of an
on-site means of on-site means of
conveyance conveyance
(Lokichokio, 2001) (container on wheels)

Inside the facility, wastes must be transported during

slacker periods. The itinerary must be planned so as to
avoid any exposure of staff, patients or the general
public. It must run through asfew clean zones
(sterilization rooms), sensitive areas (operating
theatres, intensive care units) or public areas as
possible.

9.3 Off-site transport

The entity producing the waste is responsible for

packaging and labelling the waste to be transported
outside the hospital.

Packaging and labelling must be in conformity with

national legislation on the transport of dangerous sub
stances and with the Basel Convention in the case of
cross-border transport. If there is no national legislation
on the subject, the [United Nations] Recommendations
on the Transport of Dangerous Goods13 or the European
12

Agreement on the International Carriage of Dangerous

Goods by Road (ADR)14 should be referred to.
13

If a vehicle is carrying less than 333 kg of medical waste

 entailing the risk of contamination (UN 3291), it is not
required to be marked. Otherwise it must bear sign plates.

See Annex 3.5 for further information.

9.4 Cross-border transport

The Basel Convention lays down stringent regulations
Where the transport of these wastes is Protection Act – 1997.
sub-contracted to an external firm, the
ICRC must ensure that the carrier is According to the Basel Convention, the
authorized to handle hazardous code for clinical wastes from medical
substances and that it complies with the care provided in hospitals, medical
legislation in force. The organization centres and clinics is Y1. The code for
must furthermore ensure that the wastes unwanted/unused drugs is Y3. And the
will be treated appropriately and safely code for wastes generated in the pro
at their destination. duction, preparation and use of
on the export of wastes. Enquiries must photographic products and materials is
be made in each individual country as to Y16.
the provisions in effect. In the case of
Pakistan, for example, which is a 13 Recommendations on the Transport of Dangerous
Goods, sixteenth revised edition, 2009,
signatory of the Basel Convention but http://www.unece.org/trans/danger/publi/unrec/
rev16/16files_e.html
has not ratified its amendments, the 14
requirements are laid down in the http://www.unece.org/trans/danger/publi/adr/adr2009/09C
ontentsE.html
Pakistan Environmental

10.
TREATMENT
AND DISPOSAL
10.1 Choosing treatment and disposal
methods
 The choice of treatment and disposal techniques depends on a
number of parameters: the quantity and type of wastes produced,
whether or not there is a waste treatment site near the hospital, the
cultural acceptance of treatment methods, the availability of
reliable means of transport, whether there is enough space
around the
hospital, the availability of financial, material and human resources,
the availability of a regular supply of electricity, whether or not
there is national legislation on the subject, the climate,
groundwater level, etc.

The method must be selected with a view to minimizing negative

impacts on health and the environment. There is no universal
solution for waste treatment. The option chosen can only be a
compromise that depends on local circumstances.

Where there is no appropriate treatment infrastructure in the

vicinity, it is the responsibility of the hospital to treat or pre-treat
its wastes
on-site. This also has the advantage of avoiding the complications
involved in the transport of hazardous substances (see previous
chapter).
10. TREATMENT AND DISPOSAL

The following treatment or disposal techniques may be

used for hazardous medical waste, depending on the cir
cumstances and the type of waste concerned:
> disinfection:
– chemical: addition of disinfectants (chlorine dioxide,
sodium hypochlorite, peracetic acid, ozone, alkaline
hydrolysis);
– thermal
t low temperatures (100° to 180°C): vapour
(autoclave, micro-waves) or hot air (convection,
combustion, infrared heat);
t high temperatures (200° to over 1000°C):
incineration (combustion, pyrolysis and/or
gasification);
– by irradiation: UV rays, electron beams;
– biological: enzymes;
 > mechanical processes: shredding (a process which
does not decontaminate the waste);
> encapsulation (or solidification) of sharps;
> burial: sanitary landfills, trenches, pits.

The techniques most likely to be used in ICRC operations

are described in the present chapter along with their
advantages and disadvantages.1514

The appropriate treatment and disposal techniques for the

various types of waste are set out in Table 10.1 (and in the
data sheets in Annex 1).

15 See the following publication for further details on techniques other than
incineration (suppliers, prices, technologies): Health Care Without Harm, Non
Incineration Medical Waste Treatment Technologies.
http://www.noharm.org/
lib/downloads/waste/Non-Incineration_Technologies.pdf

quantities
3d.
Chemic
yes no no no no no no
al waste
yes no
small

3a. Medicinal waste

Table 10.1 Suitability of treatment techniques by type of

waste Type of waste / Technique 1. Sharps 2a. Waste entailing

risk of contamination 2b. Anatomical waste 2c. Infectious waste

ye no no yes sm sm
s all all
no n
o qua qua

ntiti ntiti

es es
 yes yes

ye yes yes ye y after

s s deconta
with
e n n
s o minatio o
preca
n
utions
yes

ye yes yes yes

s
with
no n n n
preca o o o
utions

ye yes yes ye y yes

s s
with
e n n
preca s o o
utions

ye yes yes ye y yes yes yes

s s
with
e
preca s
utions

no
after decontamination

yes

no

with precautions

yes

small quantities,

encapsulation
 using

yes
r
900-120 dual-ch >800°C to disinfec Encaps pit pit
0°C amber 300°-40 tion ulation
Single-c Off/site
Rotary Pyrolyti incinera 0°C Chemic Autocla
hamber On-site sanitary
kiln c or tor al ve Needle
incinera burial landfills
10. TREATMENT AND DISPOSAL

Figure 10.1 is an example of a diagram intended to support

decision-making on the treatment methods to be used in
the absence of appropriate regional infrastructures.

Figure 10.1 Example of a diagram intended as a guide for deciding on

the treatment/disposal methods to be used in the absence
of appropriate regional infrastructures

Reduction of waste production

Sorting

Infectious or
Sharps

On-site treatment

Is it a densely
populated area
No No (people living
Is there plenty of space
available on-site?
potentially within a radius of
contaminated waste less than 50 m)?
Household refuse

Local
waste-treatment
facility
 Yes

No
conditions
Is it possible to Are the incineration acceptable?
train staff and
invest resources Yes
in incineration Yes Yes
or alternative Small incinerator
methods?
No
waste burial pit
Ash
On-site

10.2 Incineration
Controlled incineration at high temperatures (over 1000°C)
is one of the few technologies with which all types of
health-care waste can be treated properly and it has the
advantage ofsignificantly reducing the volume and weight
of the wastes treated.

However, modern large-scale processing plants such as

high-temperature incinerators are not a solution for hospi
tals; they are designed for centralized networks. Enquiries
should be made as to whether there is an infrastructure
of this nature in the region. Another possibility is to use
a household refuse incineration plant. This type of plant
generally operates at over 850°C. But medical waste must
be fed directly into the kiln hopper, thus bypassing the
bunker. Cement works incinerators or the blast furnaces
used in the metal industry can also provide an accept
able local solution, although not normally recommended
for the incineration of medical waste (because the waste
loading system is not secured and the emissions are not
treated).

There are simple incinerator models for treating small

quantities of medical waste. Some are available on the mar
ket, and others have to be built with local materials on the
spot according to relatively simple plans. These incinerators
consist essentially of one or two combustion chambers (the
primary and secondary chambers) and a discharge chim
ney. The combustion and air-borne emission control system
is simple; indeed, in some cases there is none.
10. TREATMENT AND DISPOSAL
 Links for the technical specifications for small incinerators:
> Publication prepared with the assistance of the WHO,
Africa Region, Managing Health Care Waste Disposal
(WDU): http://www.healthcarewaste.org/documents/
WDU_guidelines2_en.pdf
> See http://www.mw-incinerator.info/en/101_welcome.
html, for further information on the construction of De
Montfort incinerators.

There are two De Montfort models – to be constructed with

local materials – that can be considered for ICRC hospitals:
the De Montfort 8a (12 kg/h, for hospitals with lessthan 300
beds) or the De Montfort 7 (for emergencies). These small
incinerators are composed of two combustion chambers.
They cost Sfr 1,000 and can be built in three or four days.
The manufacturer indicates a temperature of 800°C in the
secondary chamber. The principle of the De Montfort incin
erators is illustrated in Figure 10.2.

Figure 10.2: The principle of De Montfort incinerators (Pr. D.J. Picken)

1 Loading door
2 Primary combustion
chamber
8 6 Gas transfer tunnel
7 Secondary
combustion
3
chamber
8 Chimney

5
1

6
3 Air inlet
4 Fire grate
5 Ash door
2
 4

Incinerators can also be imported and assembled on the

spot without the use of local materials. These facilities are
generally more reliable, provided that there is a reliable
source of electricity. They guarantee combustion tempera
tures of over 800°C and even over 1000°C. However, they
are also more expensive and require more maintenance.

If infectious medical waste is treated in small single-cham

ber or dual-chamber incinerators on site, fractions of waste
such as drugs, chemicals, halogenated materials or wastes
with high heavy metal content (such as batteries, broken
thermometers, etc.) must not be treated in thistype of facil
ity. The following best practices must be borne in mind with
a view to minimizing pollutant emissions:1615
> reduction of waste generated and sorting of wastes at
the source.
> good incinerator design to ensure optimal combustion
conditions: extension of the chimney (if the height
of the chimney is doubled from 3 to 6 metres, the
concentrations of pollutants in the air are 5 to 13 times
lower).1716
> installation of incinerators far from inhabited or
cultivated areas;
> best operating practices: appropriate startup and
cooling, care to obtain a sufficiently high temperature
before feeding the wastes in, adherence to the correct
quantity of waste and fuel, regular removal of ash;

16 Secretariat ofthe Basel Convention, Technical Guidelines on the Environmentally

Sound Management of Biomedical and Health-Care Waste (Y1, Y3), 2003: http://
www.basel.int/pub/techguid/biomed-e.pdf
Secretariat of the Stockholm Convention, UNEP: Guidelines on best available
techniques and provisional guidance on best environmental practices,
2007
http://chm.pops.int/Portals/0/Repository/batbep_guideline08/UNEP-POPS
BATBEP-GUIDE-08-18.English.PDF
17 S. Batterman, Findings on an Assessment of Smale-scale Incinerators for
Health-care Waste, WHO, 2004; http://www.who.int/water_sanitation_health/
medicalwaste/en/smincineratorstoc.pdf
10. TREATMENT AND DISPOSAL

– the incinerator should be lit with paper, wood

or fuel oil; after 30 minutes, small quantities of
waste should be loaded at regular intervals (5-10
minutes); wet waste must be mixed with drier waste;
sharps containers must be loaded one by one; the
incinerator must run for long periods (at least 2
hours); heavy-duty gloves, a body protection, and
goggles must always be worn as well as a respirator
whenever ash is being removed;
> no incineration of PVC plastics or other wastes
containing chlorine;
> regular planned maintenance: replacement of faulty
parts, inspection, inventory of spare parts;
> regular training for operators, operating manual;
> emission control: emissions must not exceed the
national limit values and they must comply with
the BAT/BEP18 recommendations set forth in the
17

Stockholm Convention.

And lastly, the burning of hazardous medical waste (uncon

trolled incineration in barrels or at dumps) must be avoided
at all times because of the risk for staff, which is due not
only to the emission of toxic gases but also to the fact that
infectious wastes are not fully burnt. In an emergency, how
ever, incineration in a barrel can be a temporary solution
until a better solution is found. In this case, care must be
taken to use a barrel with sufficient air intake below the
combustion flame and to protect the top with fine wire
mesh (to contain the ash). It should be noted that Annex C
of the Stockholm Convention rejects techniques of uncon
trolled incineration in barrels, at dumping sites or in single
chamber incinerators. These techniques must be regarded
as provisional arrangements.
 18 Best Available Technique / Best Environmental Practice

Drawbacks

High construction costs (Sfr 25,000 to

100,000 − Sfr 350,000 in the case of
>

rotary kilns).
Relatively high operating and maintenance >
costs; the more sophisticated the emission
control system, the higher the costs.
ff, Requires electricity, highly skilled sta >
and fuel.
Produces ash that contains leached metals,
dioxins and furans.
>

Relatively high investment costs >

(Sfr 15,000)
Needs fuel. >
Requires skilled staff and permanent monitoring. >
Emission of toxic flue gas (including >
dioxins and furans).
Sharps are not destroyed. >
Unsuitable for chemical and >

pharmaceutical wastes.
Produces ash that contains leached >
metals, dioxins and furans.

Table 10.2 Advantages and drawbacks of incineration

Incineration Advantages

Waste volume and All types of organic

weight are significantly waste (liquid and soli
Large quantities are

of waste can be Micro-organisms are complete

treated. destroyed.

The waste is completely Waste volume and weight

destroyed. are significantly

The waste is not Large quantities of waste can b

recognizable. treated.

Suitable for all types reduced (>95%).

of waste. destroyed.
>
Toxic emissions >
>
are reduced.
>
reduced.
>
>
>
>
>
>

High-temperature incinerato r
 )
(>1000°C incinerato refuse
Rotary r (800°- incinerati
)
kiln t
Dual-cha 900°C Ho on plan
(>1200°C) mber usehold

Needs fuel. >

Relatively effective disinfection. >

Single-chamber
Wastes are only partially burnt – risk of >

Waste volume and weight are significantly >

incinerator (300°-400°C)

incomplete sterilization. reduced.

Significant levels of emission of atmospheric >

Simple and cheap (Sfr 1000). >
pollutants.
Soot needs to be removed periodically. >
Ineffective for destroying heat-resistant >
chemicals or pharmaceuticals.

Sharps are not destroyed. >

Produces ash that contains leached metals, >
dioxins and furans.
10. TREATMENT AND DISPOSAL

10.3 Chemical disinfection

Chemical disinfection, which is commonly used in health
facilities to kill micro-organisms on medical equipment,
has been extended to the treatment of health-care wastes.
Chemicals are added to the wastes to kill or inhibit patho
gens. However, the chemicals that are used themselves
entail a health risk for the people who handle them and a
risk of environmental pollution.

This type of treatment is suitable mainly for treating liquid

infectious wastes such as blood, urine, faeces or hospital
sewage. Typically, a 1% bleach (sodium hypochlorite) solu
tion or a diluted active chlorine solution (0.5%) is used.
In the case of liquids with high protein content, such as
blood, a non-diluted solution of bleach is required as well
as a contact time of more than 12 hours. Pay caution that
when bleach is mixed with urine, toxic gases are formed
(combination of chlorine and ammonia). Furthermore, liq
uid waste that has been disinfected with chlorine must not
be discharged into a septic tank.

The other disinfectants used are as follows: lime, ozone,

ammonium salts and peracetic acid. Formaldehyde, glut
 araldehyde and ethylene oxide must no longer be used
because of their toxicity (carcinogenic or sensitizing prop
erties). All strong disinfectants irritate the skin, eyes and
respiratory system. They must be handled with caution – in
particular, personal protective equipment must be used –
and they must be stored correctly.

Solid medical waste can be chemically disinfected, but

they must first be shredded. This practice poses a number
of safety problems, and the wastes are only disinfected on
the surface. Thermal disinfection must be preferred over
chemical disinfection for reasons of effectiveness and for
ecological reasons.
10. TREATMENT AND DISPOSAL

Table 10.3:Advantages and drawbacks of chemical disinfection

Advantages Drawbacks

> Simple. available. 10.4 Autoclaving

> Relatively cheap.
> Disinfectants are widely

> The chemicals used are

themselves dangerous substances,
which must be handled with
 caution. The final disposal method must be the
> For proper disinfection, the prescribed same as for untreated medical waste. >
contact time and concentrations must The process generates dangerous
be complied with. effluents, which need to be treated. >
> The waste volume is not reduced. > Mixing chlorine/hypochlorite with
The wastes have to be shredded /mixed organic matter or ammonia creates
before being treated with chemicals. > toxic substances.

Autoclaving is a thermal process at low temperatures

where waste is subjected to pressurized saturated
steam for a sufficient length of time to be disinfected
(60 minutes at 121°C and 1 bar). Where prions (which
cause Creutzfeldt Jakob’s disease) are present, a
cycle of 60 minutes at 134°C is recommended, since
they are exceptionally resistant.19 Efficiency tests
18

(biological or thermal) must in any case be carried out

regularly.

Autoclaving is environmentally safe but in most cases

it requires electricity, which is why in some regions it is
not always suitable for treating wastes.

19 Recommended by the Robert Koch Institute (Germany)

Small autoclaves are frequently used for sterilizing medi

cal equipment, but the models used for treating health
care wastes can involve relatively complex and expensive
plants (with internal mixing,shredding and drying systems)
requiring meticulous design, proper sorting and a high
level of operating support and maintenance. Furthermore,
the effluents must be disposed of carefully and properly
monitored. And lastly, large autoclaves may require a boiler
that generatesseveral types of emissions, which have to be
monitored.

Once wastes have been processed in an autoclave, they are

no longer infectious materials: they can be landfilled with
 municipal refuse. Autoclaving is often used for pre-treating
highly infectious waste before it is transported outside the
hospital.
10. TREATMENT AND DISPOSAL

Table 10.4:Advantages and drawbacks of steam

disinfection Advantages Drawbacks

> Autoclaved waste becomes is needed with emission control.

safe household refuse. > Unsuitable for chemical or
> Health facilities are familiar pharmaceutical wastes.
with this processing method. > The appearance of the waste
> Ecologically sound technology. > does not change.
Facilitates the recycling of plastics. > Shredding is essential in order to
> Low operating costs. avoid re-use.
> Moderate to high installation costs (Sfr > The weight of the waste does not
500 to 100,000). change. > Unpleasant odours.
> Requires electricity. > Presence of chemicals which can
> Produces contaminated effluents, generate toxic fumes.
which need to undergo special > Slow and time-consuming.
treatment. > In some cases a boiler

10.5 Needle extraction or destruction Forsafety

reasons, the ICRC does not recommend that nee dles
be extracted or destroyed, although this practice is
followed in certain circumstances, mainly for two
reasons: when the needles are removed from used
syringes they cannot be re-used, and, secondly, the
volume of sharps is reduced.

Some appliances run on electricity (destroying the

needles by melting) and cannot be used widely in
ICRC contexts, particularly in remote areas.
Furthermore, these appliances require regular
maintenance and have to be handled with care.

Needles can also be removed from syringes

immediately after the injection by means of small
manually operated
 devices. The needles are then discarded into the sharps pit.
Plastic syringes must be disinfected before being disposed
of in the household refuse chain or in plastics recycling.

Further information on needle extractors can be obtained

from the Program for Appropriate Technology in Health
(PATH)20 or on the WHO website.2120
19

Table 10.5 Advantages

and drawbacks of needle extractors
and destroyers

Advantages Drawbacks

Needle extractor
> Destroys the needles
completely.
> Plastic from syringes can
be recycled after being
disinfected and shredded.
> Risk of splashing body
fluids. > Some models run
on electricity. > The
needles and syringes
remain contaminated.
Needle destroyer > Risk of breakdown of
> Prevents rdestroyer. > The needles
syringes are prone to come out of
> Relativelythe receptacle.
(Sfr 2 > The safety of the > A sterile part of the
availableprocess has not been needle remains attached to
manufactestablished. the syringe.
> The volum
reduced.
> Plastic fro> Cost (Sfr 100 to Sfr 600).
be recyclThere should be one in
disinfecteeach room or ward.
> Easy to us> Requires electricity.
 20
http://www.path.org/publications/browse.php?k=10
21 http://www.healthcarewaste.org
10. TREATMENT AND DISPOSAL

10.6 Shredders
Shredders cut the waste into small pieces. This
technique requires competent staff for operating and
maintaining the device, since some of these rotary
devices are indus trial models. They are often built into
closed chemical or thermal disinfection systems.
However, grain mills can be converted into simple
shredders, but due to the risk forstaff while the
shredder isrunning only disinfected waste should be
treated in these devices. Shredding, which in certain
cir cumstances provides a means of recycling plastics
and nee dles,should be considered whenever needles
and syringes are available in large quantities, this
involves a centralized system for collecting and
transporting wastesfrom the vari ous facilities.

Table 10.6 Advantages and drawbacks of shredders

Advantages Drawbacks

> Makes the waste The shredder can be damaged by

unrecognizable. > Prevents the large pieces of metal.
re-use of needles and syringes. > The waste is not disinfected.
> Reduces volume. > The staff are exposed to air-borne
> Facilitates the recycling of plastics. > pathogens when untreated waste
Enhances the effectiveness of chemical is shredded.
or thermal treatment in closed and > Requires skilled staff and
integrated systems. permanent monitoring.
> Requires electricity.
> Some facilities are very expensive. >
 10.7 Encapsulation
Encapsulation (or solidification) consists of containing a
small number of hazardous items or materials in a mass of
inert material. The purpose of the treatment is to prevent
humans and the environment from any risk of contact.

Encapsulation involves filling containers with waste, add

ing an immobilizing material, and sealing the containers.
The process uses either cubic boxes made of high-density
polyethylene or metallic drums, which are three-quarters
filled with sharps, chemical or pharmaceutical residues, or
incinerator ash. The containers or boxes are then filled up
with a medium such as plastic foam, bituminoussand, lime,
cement mortar, or clay. Once the medium has dried, the
containers are sealed and disposed of in a sanitary landfill
or waste burial pit.

The following proportions are recommended, for exam

ple: 65% pharmaceutical waste, 15% lime, 15% cement,
5% water.

The main advantage of the process is that it is very

effective in reducing the risk of scavengers gaining
access to the hazardous waste. Encapsulation of sharps
is generally not considered to be a long-term solution.
Encapsulation of sharps or unwanted vaccines could,
however, be envisaged in temporary settings, such as
camps or vaccination campaigns.

Table 10.7 Advantages and drawbacks of encapsulation

Advantages Drawbacks
are small.
> Simple, inexpensive and safe.
> The weight and volume of the waste
> A solution that can be
is increased.
envisaged for sharps and
pharmaceutical wastes.
> The risks for scavengers are reduced.
> To be regarded as a
temporary solution. 10.8 Disposal in a sanitary
> The quantities of waste treated landfill or waste burial pit
 10. TREATMENT AND DISPOSAL

The disposal of untreated health-care waste in an

uncon trolled dump is not recommended and must
only be used as a last resort.

It can be disposed of in a sanitary landfill, subject to

cer tain precautions: it is important that health-care
waste be covered rapidly. One technique is to dig a
trench down to the level where old municipal refuse
(over three months old) has been buried and to
immediately bury health-care waste that is discarded
at this level under a 2-metre layer of fresh municipal
refuse.

The following are the essential factors that must be

taken into consideration in the design and use of a
sanitary landfill:2221
> access must be restricted and controlled;
> competent staff must be available;
> the discarding areas must be planned;
> the bottom of the landfill must be waterproofed; >
the water table must be more than 2 metres below the
bottom of the landfill;
> there must be no drinking water sources or wells in
the vicinity of the site;
> chemicals must not be disposed of on these sites;
> the waste must be covered daily and vectors
(insects, rodents, etc.) must be controlled;
> the landfill must be equipped with a final cover
to prevent rainwater infiltration;
> leachates must be collected and treated.

Whenever a municipal landfill is being used, the water

and habitat engineer must inspect the site before
hazardous medical waste are discarded there.

22 Further information on the design of sanitary landfills can be found in

Solid Waste Landfills in Middle- and Lower- Income Countries: A
Technical Guide to Planning, Design, and Operation. Rushbrook, Philip
and Pugh, Michael. 1999. World Bank Technical
Paper No. 426. The World Bank, Washington, D.C. pp. 248.
 A purpose-built burial pit could also be used, preferably on
the hospital site. Ideally, the pit should be lined with low
permeability material such as clay to prevent the pollution
of shallow groundwater and should be fenced in so as to
preventscavenger access. Health-care wastes must be bur
ied immediately under a layer of soil after each unloading
operation. It is suggested that lime be spread on the waste
for added health protection (in the event of an epidemic,
for example) or to eliminate odour. The pitshould be sealed
once it has been filled.

Examples of burial pits or wells for anatomical waste or

sharps are presented in Annex 2 (data sheets 13, 14 and 15).

Table 10.8 Advantages and drawbacks of disposal by burial

Advantages Drawbacks

Sanitary
> Simple anthe hospital.
landfill,
trench inexpens> Control is facilitated.
method operating> The health-care wastes
> Can be care not treated and remain
out usinghazardous.
existin> The landfill must be
municipasecure, fenced in, and
managem guarded.
system. > > Scavengers and animals
Scavengersneed to be controlled.
access the > A high degree of
health-carecoordination is needed
the landfill ibetween collectors and
Separate pit on hospital managed. landfill operators. > Makes
site health workers less aware
of the need to sort the
various types of waste. >
> Simple and relatively Transport to the landfill can
inexpensive to build be a lengthy and costly
and manage. operation.
> Dangerous > Risk of water pollution.
substances are not
> The health-care waste is
transported outside not treated and remains
hazardous. > Vectors (insects, controlled.
> Risk of water pollution. rodents, etc.) need to be > Space is needed around
> Problem of odour. the hospital.
10. TREATMENT AND DISPOSAL

10.9 Disposal of liquid wastes in the sewage

In general, the sewage system should not be used to
dispose of chemicals. It is strictly prohibited to dilute
wastewater discharges so that the concentration falls
below the exemption thresholds in force in the particular
country. Scientific or legislative data on exemption
thresholds are rare. The exemption thresholds in effect in
Switzerland are set out in Table 10.9.

Table 10.9 Permissible

limits in force in Switzerland
(Decree on water protection, Switzerland)

Chemicals Permissible limits Practical disposal

pH between 6.5 et 9

50 mg/l

20 mg/l

Acids – alkalis Exceptions are allowed if the chemicals are mixed with a
sufficient quantity of other sewer
effluents.

Silver If less than 1000 litres are produced per year.

Total hydrocarbons Organic solvents

Volatile halogenated hydrocarbons

Volatile halogenated solvents as a rule, not be poured down the drain,
Tolerance allowed for products since they contain substances that are
which biodegrade easily and which toxic or even carcinogenic (silver,
are disposed of in small quantities, hydroquinone, for maldehyde). If it is not
provided there is no noteworthy possible to have them recycled by an
effect on health or the environment. approved firm,small quantities may, as an
exception, be discharged within the
0,1 mg/l Chlorine No tolerance.
limitsset out above. Fixers and devel
opers must be mixed and stored for one
day (neutralization

Photographic developing liquids should,

process) and then diluted (1:2) and emptied slowly

into the sink.

Non-hazardous pharmaceutical wastes (syrups,

vitamins, eye drops, etc.) may be poured down the
drain, unless otherwise stated by national
legislation.

Liquid biological waste (small quantities of blood,

rinsing liquids from operating theatres, etc.) may be
poured down the drain without being pre-treated,
unless the patient is suffering from an infectious
disease. In all other cases it must first be inactivated –
preferably by autoclave, but otherwise by means of a
chemical disinfectant (undiluted bleach or chlorine
dioxide, contact time of more than 12 hours).

Where a septic tank is used, the quantity of

disinfectant or biocide (bleach, silver, etc.) should be
reduced, since these substances can actually disrupt
the biological digestion of the wastes.

Expired units of blood must not be emptied down the

drain. They must be incinerated at high temperature
(over 1000°C) or autoclaved. Where there are no such
facilities, they must be disposed of in a waste burial
pit.
At all times, any national regulations that are more
strin gent than the general recommendations set out
above must be complied with.