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MEDICAL & LABORATORY
 WASTE MANAGEMENT

   Dr. Samwel V. Manyele
    Medical Waste Management Research
  Department of Chemical and Process Engineering,
           University of Dar es Salaam
REASONS FOR POOR IPC
• Inadequate knowledge and skills
  among healthcare workers
• Lack of guidelines and standards for
  certain procedures
• Deficiency of equipment and material
• Inadequate supportive supervision
• Lack of renovation and maintenance of
  the infrastructure
             Dr. S.V. Manyele, CPE, UDSM   2
WHY PROMOTE IPC?
• Increased risk from blood born infection like
  HIV, HBV, and HCV
• HIV/AIDS has increased the risk for
  transmission (every person is regarded as
  infected)
• Raised awareness of how risky it is to work in
  healthcare facilities
• Advancement in healthcare provisions –
  scientific information, new technologies in
  providing safe and effective preventive
  services
• These services are provided in congested
  settings         Dr. S.V. Manyele, CPE, UDSM   3
Introduction
• Different medical activities generate
  waste.
• Some of which are hazardous and
  can cause detrimental effects to
  human health and the environment if
  mismanaged.
• Generators must manage
  hazardous/infectious waste safely
  from "cradle to grave," that is, from
  generation, storage, treatment, and
  transportation, to ultimate disposal.
              Dr. S.V. Manyele, CPE, UDSM   4
DEFINITION
1)Solid waste (mixed type)
2)Generated during the diagnosis,
  treatment, or immunization of
  human beings or animals
3)During research research
4)During production or testing of
  biologicals
5) Liquids, semisolids, or contained
  gases
             Dr. S.V. Manyele, CPE, UDSM   5
Waste Generated is Infectious
• Based on induction of disease
  to practitioners
• Presence of pathogens of
  sufficient
 –Virulence, Dose
• Worker exposure via
 –Portal of entry and
  compromised resistance of host
           Dr. S.V. Manyele, CPE, UDSM   6
What properties make medical
      & lab waste hazardous?

• Toxicity –
  chronic, acute           • Can it explode?
• Carcinogenicity          • Will it corrode or
• Teratogenicity             burn skin?
• Mutagenicity             • Is it flammable?

              Dr. S.V. Manyele, CPE, UDSM    7
Prepare for Legal
        Compliance
• This is the key medical & lab
  waste management
  requirement.
• It is related to storage,
  hauling, treatment, and final
  disposal
           Dr. S.V. Manyele, CPE, UDSM   8
Elements of Infectious Waste
       Management
Identification of infectious waste
Segregation
Packaging
Storage
Transport and handling
Treatment techniques
Disposal of treated waste
Contingency planning
Staff training Manyele, CPE, UDSM
           Dr. S.V.                  9
Infectious Waste Treatment
  Change bio-chemical character of waste

1. Monitoring of all treatment processes to
   assure efficient and effective treatment.
2. Use of biological indicators to monitor
   treatment
3. Waste types appropriate for treatment
   technology
4. Most types of medical/lab waste can be
   treated by incineration (changes volume
   and weight of waste but cannot remove
   radioactivity)
               Dr. S.V. Manyele, CPE, UDSM   10
Infectious Waste Treatment
Factors to consider while selecting treatment
                   method

   Sterilization efficacy
   Maintenance & operator skills
   Air emission
   Water emissions
   Treated waste characteristics


               Dr. S.V. Manyele, CPE, UDSM   11
Medical waste Incineration
•Volume & weight reduction
•Effective destruction/sterilization
•Can treat most types of wastes
•Little processing prior to
treatment
•Renders waste unrecognizable
•Best available technology for
destroying organic solid wastes.
•Medical waste = high BTU value.
            Dr. S.V. Manyele, CPE, UDSM   12
Other treatment methods
Do not destroy the waste but does
  destroy the pathogens.

Examples:
• Steam autoclave
• Microwave irradiation
• Chemical Treatment
• Radio frequency irradiation.
            Dr. S.V. Manyele, CPE, UDSM   13
Pathogens in the medical waste

  Reduce risks by eliminating modes of
  transmission between humans and the
  pathogens
  Expose pathogens to temperatures
  encountered in incineration
  Exposure remains in survived fractions
  (ash, smoke) and escape during
  loading.
  Apply testing protocols

               Dr. S.V. Manyele, CPE, UDSM   14
Microbial inactivation
•How do we know the medical or lab
waste treatment system is working
effectively?

•Through testing of survivability of
microorganisms.
•A common mathematical model for
thermal death rate of microorganisms
is given by the  following equation:

   N = No x e-kt
             Dr. S.V. Manyele, CPE, UDSM   15
Inactivation levels
Viable     Viable      Reduction        Inactivatio     Time to        %
 cells     cells at      factor           n levels      achieve     reduction
at t = 0    time t                                    inactivatio
                                                         n level

106        105        10               1Log10 1D                    90

106        104        100              2Log10 2D                    99

106        102        10,000           4Log10 4D                    99.99

106        100 =1 1,000,000 6Log10 6D                               99.9999

   Where D = decimal reduction time = 2.303/k
                       Dr. S.V. Manyele, CPE, UDSM                       16
Microbial Inactivation
• Spores are more resistant to heat that
  vegetative cells.
• Microbial inactivation must be designed
  for viable spores.
• Wet (steam) heat is faster in destroying
  spores than dry heat at the same
  temperature.
• Spores may form more heat resistant
  aggregates than single spores.
              Dr. S.V. Manyele, CPE, UDSM   17
Acceptable levels of microbial
         inactivation
Level III:
Vegetative bacteria, fungi, all lipophilic and
hydrophilic viruses, parasites, mycobacteria at a
6log reduction or greater; and inactivation of B.
stearothermophilus spores or B. subtilis spores at a
4log or greater

Level IV:
vegetative bacteria, fungi, lipophilic/hydrophilic
viruses, parasites, mycobacteria, and B.
stearothermophilus spores or B. subtilis spores at a
6log or greater. Dr. S.V. Manyele, CPE, UDSM       18
Table 2. Recommended biological indicators

Vegetative     Staphylococcus aureus (ATCC 6538)
Bacteria       Pseudomonas aeruginosa (ATCC 15442)
Fungi          Candida albicans (ATCC 18804)
               Penicillium chrysogenum (ATCC 24791)
               Aspergillus niger
Viruses        Polio 2, Polio 3
               MS-2 Bacteriophage (ATCC 15597-B1)
Parasites      Cryptosporidium spp. oocysts
               Giardia spp. Cysts
Mycobacteria   Mycobacterium terrae
               Mycobacterium phlei
               Mvcobacterium bovis (BCG) (ATCC 35743)
Bacterial      Bacillus stearothermophilus (ATCC 7953)
Spores
               Bacillus subtilis (ATCC 19659)
                   Dr. S.V. Manyele, CPE, UDSM           19
Procedures for testing Medical
     Waste Incinerators
– Using microorganisms described for
  level III and IV.
– The microorganisms are charged into
  the equipment together with actual
  medical waste load by spraying (or in
  a ampule for incinerator).
– The end of a batch treatment, the
  microorganisms are retrieved under
  aseptic condition and tested for
  survivability.
             Dr. S.V. Manyele, CPE, UDSM   20
Precautions
 The microorganisms selected
represent pathogen surrogates,
 may be pathogenic under certain
conditions.
 Thus, all testing be conducted using
recognized microbial techniques.
  Efficacy testing should be
conducted by qualified laboratory
personnel only.
             Dr. S.V. Manyele, CPE, UDSM   21
Handling Chemical Characteristics
   When hazardous chemicals are mixed
   with infectious waste, the hazardous
   component is given first priority.
   Prefer treatment options which can
   handle both hazardous chemicals and
   infectious waste together.
   Sometimes the infectious nature can
   be addressed first before hazardous
   treatment (to avoiding exposure
   during handling)
             Dr. S.V. Manyele, CPE, UDSM   22
The Chemical Wastes
 Vapors, spills, soaked materials
 Some are precursors of dioxins
 and furans, suspected
 carcinogens (Cl in the waste)
 Toxic metals (Pb, Cd, Cr, Hg) are
 present in medical/lab waste
 Plastics in the waste contributes
 most of the Pb & Cd (thermo-
 and photo-stabilizers)
           Dr. S.V. Manyele, CPE, UDSM   23
Low-level radioactive waste
           (LLW)
 Sources:
   Radiopharmaceuticals; nuclear medicine,
   Radio- immunology procedures
 Medical & research institutions
 produce < 5% of the total volume of
 LLW in USA
 In Tanzania, 90% of these wastes come
 from medical & research institutions.
  Currently, there is no disposal sites for
 LLW in TanzaniaManyele, CPE, UDSM
               Dr. S.V.
                        (TRUE/FALSE?)     24
(LLW)
Usually, radioactive materials used in
diagnosis have a very short half life
(hours to days).
Hospitals do not store LLW with
isotopes of half-lives greater than 8
days given the storage problems.




            Dr. S.V. Manyele, CPE, UDSM   25
Conclusions
• Review and approval of waste treatment
      technologies is needed in Tanzania.
  Guidelines with strict review and approval
  policy is needed.
• Occupational health and safety is in jeopardy,
  due to mismanagement of these wastes.
• Knowledge dissemination is the key towards
  minimization of the problems.
• It is expensive to generate waste of any kind!
  So, minimize or don’t generate.
• Full cost accounting is need for proper
  medical and laboratory waste management
                Dr. S.V. Manyele, CPE, UDSM   26

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Ab ipc on medical &lab waste (2)

  • 1. MEDICAL & LABORATORY WASTE MANAGEMENT Dr. Samwel V. Manyele Medical Waste Management Research Department of Chemical and Process Engineering, University of Dar es Salaam
  • 2. REASONS FOR POOR IPC • Inadequate knowledge and skills among healthcare workers • Lack of guidelines and standards for certain procedures • Deficiency of equipment and material • Inadequate supportive supervision • Lack of renovation and maintenance of the infrastructure Dr. S.V. Manyele, CPE, UDSM 2
  • 3. WHY PROMOTE IPC? • Increased risk from blood born infection like HIV, HBV, and HCV • HIV/AIDS has increased the risk for transmission (every person is regarded as infected) • Raised awareness of how risky it is to work in healthcare facilities • Advancement in healthcare provisions – scientific information, new technologies in providing safe and effective preventive services • These services are provided in congested settings Dr. S.V. Manyele, CPE, UDSM 3
  • 4. Introduction • Different medical activities generate waste. • Some of which are hazardous and can cause detrimental effects to human health and the environment if mismanaged. • Generators must manage hazardous/infectious waste safely from "cradle to grave," that is, from generation, storage, treatment, and transportation, to ultimate disposal. Dr. S.V. Manyele, CPE, UDSM 4
  • 5. DEFINITION 1)Solid waste (mixed type) 2)Generated during the diagnosis, treatment, or immunization of human beings or animals 3)During research research 4)During production or testing of biologicals 5) Liquids, semisolids, or contained gases Dr. S.V. Manyele, CPE, UDSM 5
  • 6. Waste Generated is Infectious • Based on induction of disease to practitioners • Presence of pathogens of sufficient –Virulence, Dose • Worker exposure via –Portal of entry and compromised resistance of host Dr. S.V. Manyele, CPE, UDSM 6
  • 7. What properties make medical & lab waste hazardous? • Toxicity – chronic, acute • Can it explode? • Carcinogenicity • Will it corrode or • Teratogenicity burn skin? • Mutagenicity • Is it flammable? Dr. S.V. Manyele, CPE, UDSM 7
  • 8. Prepare for Legal Compliance • This is the key medical & lab waste management requirement. • It is related to storage, hauling, treatment, and final disposal Dr. S.V. Manyele, CPE, UDSM 8
  • 9. Elements of Infectious Waste Management Identification of infectious waste Segregation Packaging Storage Transport and handling Treatment techniques Disposal of treated waste Contingency planning Staff training Manyele, CPE, UDSM Dr. S.V. 9
  • 10. Infectious Waste Treatment Change bio-chemical character of waste 1. Monitoring of all treatment processes to assure efficient and effective treatment. 2. Use of biological indicators to monitor treatment 3. Waste types appropriate for treatment technology 4. Most types of medical/lab waste can be treated by incineration (changes volume and weight of waste but cannot remove radioactivity) Dr. S.V. Manyele, CPE, UDSM 10
  • 11. Infectious Waste Treatment Factors to consider while selecting treatment method Sterilization efficacy Maintenance & operator skills Air emission Water emissions Treated waste characteristics Dr. S.V. Manyele, CPE, UDSM 11
  • 12. Medical waste Incineration •Volume & weight reduction •Effective destruction/sterilization •Can treat most types of wastes •Little processing prior to treatment •Renders waste unrecognizable •Best available technology for destroying organic solid wastes. •Medical waste = high BTU value. Dr. S.V. Manyele, CPE, UDSM 12
  • 13. Other treatment methods Do not destroy the waste but does destroy the pathogens. Examples: • Steam autoclave • Microwave irradiation • Chemical Treatment • Radio frequency irradiation. Dr. S.V. Manyele, CPE, UDSM 13
  • 14. Pathogens in the medical waste Reduce risks by eliminating modes of transmission between humans and the pathogens Expose pathogens to temperatures encountered in incineration Exposure remains in survived fractions (ash, smoke) and escape during loading. Apply testing protocols Dr. S.V. Manyele, CPE, UDSM 14
  • 15. Microbial inactivation •How do we know the medical or lab waste treatment system is working effectively? •Through testing of survivability of microorganisms. •A common mathematical model for thermal death rate of microorganisms is given by the following equation: N = No x e-kt Dr. S.V. Manyele, CPE, UDSM 15
  • 16. Inactivation levels Viable Viable Reduction Inactivatio Time to % cells cells at factor n levels achieve reduction at t = 0 time t inactivatio n level 106 105 10 1Log10 1D 90 106 104 100 2Log10 2D 99 106 102 10,000 4Log10 4D 99.99 106 100 =1 1,000,000 6Log10 6D 99.9999 Where D = decimal reduction time = 2.303/k Dr. S.V. Manyele, CPE, UDSM 16
  • 17. Microbial Inactivation • Spores are more resistant to heat that vegetative cells. • Microbial inactivation must be designed for viable spores. • Wet (steam) heat is faster in destroying spores than dry heat at the same temperature. • Spores may form more heat resistant aggregates than single spores. Dr. S.V. Manyele, CPE, UDSM 17
  • 18. Acceptable levels of microbial inactivation Level III: Vegetative bacteria, fungi, all lipophilic and hydrophilic viruses, parasites, mycobacteria at a 6log reduction or greater; and inactivation of B. stearothermophilus spores or B. subtilis spores at a 4log or greater Level IV: vegetative bacteria, fungi, lipophilic/hydrophilic viruses, parasites, mycobacteria, and B. stearothermophilus spores or B. subtilis spores at a 6log or greater. Dr. S.V. Manyele, CPE, UDSM 18
  • 19. Table 2. Recommended biological indicators Vegetative Staphylococcus aureus (ATCC 6538) Bacteria Pseudomonas aeruginosa (ATCC 15442) Fungi Candida albicans (ATCC 18804) Penicillium chrysogenum (ATCC 24791) Aspergillus niger Viruses Polio 2, Polio 3 MS-2 Bacteriophage (ATCC 15597-B1) Parasites Cryptosporidium spp. oocysts Giardia spp. Cysts Mycobacteria Mycobacterium terrae Mycobacterium phlei Mvcobacterium bovis (BCG) (ATCC 35743) Bacterial Bacillus stearothermophilus (ATCC 7953) Spores Bacillus subtilis (ATCC 19659) Dr. S.V. Manyele, CPE, UDSM 19
  • 20. Procedures for testing Medical Waste Incinerators – Using microorganisms described for level III and IV. – The microorganisms are charged into the equipment together with actual medical waste load by spraying (or in a ampule for incinerator). – The end of a batch treatment, the microorganisms are retrieved under aseptic condition and tested for survivability. Dr. S.V. Manyele, CPE, UDSM 20
  • 21. Precautions The microorganisms selected represent pathogen surrogates, may be pathogenic under certain conditions. Thus, all testing be conducted using recognized microbial techniques. Efficacy testing should be conducted by qualified laboratory personnel only. Dr. S.V. Manyele, CPE, UDSM 21
  • 22. Handling Chemical Characteristics When hazardous chemicals are mixed with infectious waste, the hazardous component is given first priority. Prefer treatment options which can handle both hazardous chemicals and infectious waste together. Sometimes the infectious nature can be addressed first before hazardous treatment (to avoiding exposure during handling) Dr. S.V. Manyele, CPE, UDSM 22
  • 23. The Chemical Wastes Vapors, spills, soaked materials Some are precursors of dioxins and furans, suspected carcinogens (Cl in the waste) Toxic metals (Pb, Cd, Cr, Hg) are present in medical/lab waste Plastics in the waste contributes most of the Pb & Cd (thermo- and photo-stabilizers) Dr. S.V. Manyele, CPE, UDSM 23
  • 24. Low-level radioactive waste (LLW) Sources: Radiopharmaceuticals; nuclear medicine, Radio- immunology procedures Medical & research institutions produce < 5% of the total volume of LLW in USA In Tanzania, 90% of these wastes come from medical & research institutions. Currently, there is no disposal sites for LLW in TanzaniaManyele, CPE, UDSM Dr. S.V. (TRUE/FALSE?) 24
  • 25. (LLW) Usually, radioactive materials used in diagnosis have a very short half life (hours to days). Hospitals do not store LLW with isotopes of half-lives greater than 8 days given the storage problems. Dr. S.V. Manyele, CPE, UDSM 25
  • 26. Conclusions • Review and approval of waste treatment technologies is needed in Tanzania. Guidelines with strict review and approval policy is needed. • Occupational health and safety is in jeopardy, due to mismanagement of these wastes. • Knowledge dissemination is the key towards minimization of the problems. • It is expensive to generate waste of any kind! So, minimize or don’t generate. • Full cost accounting is need for proper medical and laboratory waste management Dr. S.V. Manyele, CPE, UDSM 26