Department of Health

Manila

Foreword

In these times of heightened environment consciousness, addressing the issue

of proper health care waste disposal is of paramount concern not only for
environmentalists or other members of the health sector but for the whole society as
well, most especially for the agencies involved in the regulation of this very vital
element.

The Clean Air Act (CAA) of 1999 and the Ecological Solid Waste Management
(ESWM) Act of 2000 which both push for reforms in the management of health care
waste highlight the imperative to deal with this issue squarely.

Thus, in order to widely disseminate the proper use of existing technology and
knowledge on this particular concern, this revised Health Care Waste Management
Manual was conceived and produced, in close collaboration with other government
agencies, civil society, the academe and various professional groups.

This Manual provides practical information regarding safe, efficient and

environment-friendly waste management options. It also contains, in detail, safety
procedures attendant to the collection, handling, storage, transport, treatment and
disposal of health care waste.

We hope that this will serve as a useful guide in the planning, implementation,
monitoring and evaluation of the Health Care Waste Management Programs of
hospitals, health centers, laboratories, pharmaceutical firms, blood banks and other
health-related establishments.

With the dissemination and strict adherence to the measures contained herein,
we aim to promote the health and welfare of our people and protect them from the risks
and hazards of exposure to health care waste.

MANUEL M. DAYRIT, M.D., MSc

Secretary of Health
 Acknowledgements

The Department of Health is deeply indebted and express sincere appreciation

to Dr. Desiree M. Narvaez, Engr. Elmer G. Benedictos and Engr. Gerardo S. Mogol of
Environmental and Occupational Health Office for their active roles in bringing this
revised manual from concept to reality. Special acknowledgment is given to
Undersecretary Antonio S. Lopez and Dr. Myrna Cabotaje for their full support and
guidance during the preparation of the manual. Equal recognition is due to the National
Center for Health Facility Development led by Director Criselda Abesamis and Director
Rebecca M. Peñafiel.

Grateful thanks is expressed to the following government agencies, non-

government organizations and professional groups who shared their insights and
experiences during the series of workshops and public consultations whose struggles,
debates and arguments have greatly influenced and contributed to the refinements of
the Revised Health Care Waste Management Manual.

 Asian Development Bank (ADB)

 Bureau of Health Devices and Technology (BHDT)
 Bureau of Health Facilities and Services (BHFS)
 Capitol Medical Center (CMC)
 CHD for Central Mindanao
 CHD for Cordillera
 CHD for Eastern Visayas
 CHD for Northern Luzon
 CHD for Northern Mindanao
 CHD for Metro Manila
 CHD for Southern Mindanao
 Chinese General Hospital (CGH)
 Delos Santos Medical Center (DLMC)
 Department of Science and Technology (DOST)
 Department of Environment and Natural Resources (DENR)
 Dr. Jose Fabella Memorial Hospital (JFMH)
 East Avenue Medical Center (EAMC)
 Health care Without Harm (HCWH)
 Health Policy Development and Planning Bureau (HPDPB)
 Integrated Provincial Health Office of Sulu
 Integrated Waste Management Inc. (IWMI)
 Information Management Service (IMS)
 Jose B. Lingad Memorial and Regional Hospital (JBLMRH)
 Jose R. Reyes Memorial and Medical Center (JRRMMC)
  Las Piñas District Hospital (LPDH)
 League of Municipalities of the Philippines (LMP)
 Lung Center of the Philippines (LCP)
 Metro Manila Development Authority (MMDA)
 National Center for Health Facility Development (NCHFD)
 National Kidney and Transplant Institute (NKTI)
 Paulino J. Garcia Memorial and Medical Center (PJGMMC)
 Philippine Children Medical Center (PCMC)
 Philippine Heart Center (PHC)
 Philippine Medical Association (PMA)
 Philippine Orthopedic Center (POC)
 Philippine Nuclear Research Institute (PNRI)
 Rizal Medical Center (RMC)
 San Lazaro Hospital (SLH)
 South Superhighway Medical Center (SSMC)
 St. Luke’s Medical Center (SLMC)
 Valenzuela General Hospital (VGH)

The DOH also greatly appreciates the assistance of the Development Bank of
the Philippines (DBP) in adding a section in financing health care waste management
projects and in the lay-out and printing of this Manual.
 Acronyms

AIDS Acquired Immune Deficiency Syndrome

BOD Biochemical Oxygen Demand
CHD Center for Health Development
COD Chemical Oxygen Demand
DBP Development Bank of the Philippines
DENR Department of Environment and Natural Resources
DNA Dioxy Ribo-nucleic Acid
DOH Department of Health
ECC Environmental Compliance Certificate
EIA Environmental Impact Assessment
EIS Environmental Impact Statement
EISCP Environmental Infrastructure Support Credit
Program
EMB Environmental Management Bureau
EOHO Environmental and Occupational Health Office
EUFS Environmental User Fee System
FIFO First In, First Out
HCHO Formaldehyde
HDPE High Density Polyethylene
HEPA High Efficiency Particulate Air
HVAC Heating, Ventilation, and Air Conditioning
HWMC Health Care Waste Management Committee
IEC Information, Education and Communication
IEE Initial Environmental Examination
IMS Information Management Service
IRR Implementing Rules and Regulations
IV Intravenous
LGU Local Government Unit
LLDA Laguna Lake Development Authority
NaOCl Sodium Hypochlorite
PD Presidential Decree
PNRI Philippine Nuclear Research
Institute
PPE Personal Protective Equipment
PVC Polyvinyl chloride
RA Republic Act
RPS Radiation Protection Section
TSS Total Suspended Solids
UV Ultraviolet
WHO World Health Organization
WMO Waste Management Officer
 Table of Contents

Foreword
Acknowledgment
Acronyms
1. INTRODUCTION.....................................................................................................................2
1.1 BACKGROUND.........................................................................................................................2
1.2 COVERAGE...............................................................................................................................2
1.3 OUTCOME....................................................................................................................................................................... 2
2. IMPACTS OF HEALTH CARE WASTE..................................................................................5
2.1 PERSONS AT RISK...................................................................................................................5
2.2 EXPOSURE TO HAZARDOUS HEALTH CARE WASTE.....................................................6
2.3 IMPACTS OF HEALTH CARE WASTE TO PUBLIC HEALTH AND THE ENVIRONMENT 7
3. HEALTH CARE WASTE.......................................................................................................10
WASTE
3.1 DEFINITION.................................................................................................................................................................. 10
3.2 CATEGORIES OF HEALTH CARE WASTE.........................................................................10
3.3 SOURCES AND COMPOSITION OF HEALTH CARE WASTE..........................................12
4. HEALTH CARE WASTE MINIMIZATION.............................................................................16
4.1 WASTE MINIMIZATION.......................................................................................................16
4.2 PRINCIPLES OF WASTE MINIMIZATION..........................................................................16
4.3 IMPLEMENTING WASTE MINIMIZATION STRATEGIES...............................................18
4.4 EXAMPLES OF POLICIES AND PRACTICES THAT ENCOURAGE WASTE MINIMIZATION 18
4.5 BASIC STEPS IN THE DEVELOPMENT OF A WASTE MINIMIZATION PROGRAM....19
5. WASTE HANDLING, COLLECTION, STORAGE, AND TRANSPORT..............................23
5.1 WASTE SEGREGATION AND STORAGE...........................................................................23
5.2 COLOR CODING SCHEME FOR HEALTH CARE WASTE................................................23
5.3 STORAGE...................................................................................................................................................................... 29
5.4 COLLECTION AND TRANSPORT OF HEALTH CARE WASTE.......................................30
6. WASTE TREATMENT AND DISPOSAL SYSTEMS............................................................39
6.1 HEALTH CARE WASTE TREATMENT...............................................................................39
6.2 WASTE DISPOSAL SYSTEMS..............................................................................................44
7. WASTEWATER MANAGEMENT.........................................................................................49
7.1 CHARACTERISTICS OF WASTEWATER FROM HEALTH CARE ESTABLISHMENTS49
7.2 ON-SITE TREATMENT OF WASTEWATER........................................................................................................... 49
7.3 FACTORS TO BE CONSIDERED IN THE ESTABLISHMENT OF WASTEWATER TREATMENT PLANT
....................................................................................................................................................... 51
7.4 SAFETY REQUIREMENTS....................................................................................................51
7.5 SANITARY REQUIREMENTS...............................................................................................52
7.6 REGULATORY REQUIREMENTS........................................................................................52
8. FINANCING OPTIONS FOR HEALTH CARE WASTE MANAGEMENT............................54
8.1 COST AND BENEFITS OF SOURCE REDUCTION, RECYCLING, AND REUSE............54
8.2 COST AND BENEFITS OF HEALTH CARE WASTE TREATMENT OPTIONS................55

i
 Table of Contents
8.3 OTHER FACTORS TO CONSIDER IN SELECTING HEALTH CARE WASTE TREATMENT
TECHNOLOGY.........................................................................................................................64
8.4 CREDIT FINANCING FOR ENVIRONMENTAL INVESTMENTS IN HEALTH CARE WASTE
MANAGEMENT.......................................................................................................................65
8.5 OTHER COST FACTORS IN HEALTH CARE WASTE MANAGEMENT..........................66
9. POLICIES AND LEGISLATIONS..........................................................................................69
9.1 DOH.......................................................................................................................................... 69
9.2 DENR........................................................................................................................................70
9.3 LAGUNA LAKE DEVELOPMENT AUTHORITY (LLDA).................................................................73
10. ADMINISTRATIVE REQUIREMENTS..............................................................................76
10.1 ORGANIZATION AND FUNCTIONS....................................................................................76
10.2 HEALTH CARE WASTE MANAGEMENT COMMITTEE (HCWMC).................................................77
10.3 HEALTH CARE WASTE MANAGEMENT PLAN................................................................81
11. HEALTH AND SAFETY PRACTICES..............................................................................84

12. EMERGENCY RESPONSE..............................................................................................88

12.1 SPILL CONTROL.......................................................................................................................................................... 88
12.2 GENERAL GUIDANCE FOR SPILL CONTROL..................................................................88
12.3 REPORTING ACCIDENTS AND INCIDENTS......................................................................89
13. COMMUNICATION AND TRAINING................................................................................91
13.1 TRAINING OF HEALTH CARE PERSONNEL.....................................................................91
13.2 SUGGESTED TRAINING PACKAGE FOR EACH TARGET GROUP................................92

Glossary of Terms
References
Annexes

ii
 List of Tables

Table 1. Color-coding Scheme for Containers..............................................................................27

Table 2. Approximate Capital Costs of Pyrolysis Systems............................................................57
Table 3. Approximate Capital Costs of Autoclave Systems..........................................................58
Table 4. Approximate Capital Costs of Vacuum/Steam Treatment/Compaction..........................59
Table 5. Approximate Capital Costs of Microwave Systems........................................................60
Table 6. Approximate Capital Costs of Chemical Disinfection Systems.......................................61
Table 7. Side-by-Side Comparison of Different Treatment Methods of.........................................62
 List of Figures

Figure 1 Basic Steps in Health Care Waste Handling..............................................................24

Figure 2. Refuse Receptacle for General Waste with Plastic Bag Cover…..............................26
Figure 3. Refuse Receptacle for Pathological Waste lined with Heavy Gauge Plastic Bag &
Cover….......................................................................................................................26
Figure 4. International Infectious Substance Symbol….............................................................27
Figure 5. For Radioactive Waste and Chemical Waste.............................................................27
Figure 6. Revised Perspective Angle of Wooden Box…............................................................27
Figure 7. Foot Operated Lid Container Refuse Receptacle for Infectious Wards
Lined with Heavy-Guage Plastic Bag with Cover…...................................................29
Figure 8. Refuse Receptacles for Sharp with Heavy Guage Plastic Bag and Cover.................29
Figure 9. Examples of On-Site Collection Vehicles....................................................................31
Figure 10. Typical Route Layout of Hospital Collection System....................................................36
Figure 11. Simple Two-Level Transfer Station…...........................................................................37
Figure 12. Schematic Cross Section of a Secure Landfill…..........................................................46
Figure 13. Burial Pit (Volume = 1x1x1.8)......................................................................................47
Figure 14. Septic/Concrete Vault…...............................................................................................47
Figure 15. Schematic Diagram of Wastewater Treatment…........................................................49
 Annexes

ANNEX 1 HANDLING, STORAGE, COLLECTION AND TRANSPORTATION, TREATMENT AND

DISPOSAL OF SHARPS
ANNEX 2 GUIDELINES FOR DISCARDING DISPOSABLE SYRINGES AND NEEDLES
ANNEX 3 ADMINISTRATIVE ORDER NO. 01 (SERIES OF 1990) – GUIDELINES FOR
THE
RADIOACTIVE WASTES BY PHILIPPINE NUCLEAR RESEARCH INSTITUTE (PNRI)
FROM OFF-SITE WASTE GENERATIONS

ANNEX 4 CONSIGNMENT NOTE

ANNEX 5 SEGREGATION OF HEALTH CARE WASTE ACCORDING TO TYPES OF WASTE AND
SOURCES
ANNEX 6 CHARACTERISTICS OF FORMALDEHYDE (HCHO) AS A CHEMICAL
DISINFECTANT ANNEX 7 CHARACTERISTICS OF SODIUM HYPOCHLORITE (NAOCI) AS A CHEMICAL
DISINFECTANT
 CHAPTER 1
INTRODUCTION
Health Care Waste Management
Manual

1.1 Background

The management of health care waste in the country is driven by concerns about
adverse health and environmental effects, uncertainty regarding regulations, and the
negative perceptions by waste handlers. Although significant progress has been made
on health care waste management, two (2) studies conducted by the Department of
Health (DOH) namely, the Waste Management Practices of DOH-Retained Hospitals in
1995 and the Waste Management Practices of Private and Government Hospitals in
Metro-Manila in 1997, indicated the need to introduce modifications to the existing
health care waste management practices. Some of the most common problems
identified are inadequate waste management, lack of awareness about the health
hazards, insufficient financial and human resources and poor control of waste disposal.

In response, the Environmental and Occupational Health Office (EOHO), DOH in

consultation with other stakeholders initiated the revision of the existing Hospital Waste
Management Manual (EHS-DOH, 1997). The primary purpose of this revision is to
assist facility administrators in evaluating their operations in order to improve the health
care waste management practices. It also aims to promote the use of appropriate
technologies and to communicate with health care personnel as well as to the public
the risks associated with health care waste.

1.2 Coverage

This manual is designed for use by many different classifications of workers within the
health care facilities, local government units (LGU) and private service providers who
are involved in the generation, handling, storage, treatment, and disposal of health care
waste. The major target groups of this manual are individuals responsible for
overseeing the health care waste stream. The unit in-charge of health care waste
management should be the first to become familiar with this manual so that they can
oversee implementation of the program throughout the health care facility.

1.3 Outcome

Hospitals and other health care establishments have the responsibility of ensuring that
there are no adverse health and environmental consequences on their handling,
storage, treatment and disposal of health care waste. Through this manual, health care
establishments will be able to install a more appropriate waste management system
that could provide other benefits such as:

i. Improved regulatory compliance;

ii. Protection of human health by reducing the exposure of employees,

patients, watchers, and entire community to hazardous health care waste in
the work environment;

iii. Enhance community relations by demonstrating a commitment to

environmental protection;

Introduction 2
iv. Economic benefits resulting from pollution prevention products that
reduce and recycle waste;

v. Avoidance of long-term liability. (Health care establishments are the ones

responsible for the proper management and disposal of the waste they
generate.);

vi. Increased employee morale resulting from a healthier and safer work
environment.
 CHAPTER 2
IMPACTS OF HEALTH CARE WASTE
Health Care Waste Management
Manual

A framework for health care waste management should always consider health and
occupational safety. There are many potential hazards associated when dealing or
handling health care waste such as physical, chemical and biological hazards as well
as ergonomic factors. Health care facilities should identify all these specific
environmental and occupational hazards during handling, storing, treating, and
disposing of health care waste. A team consisting of environmental services staff and
workers who will be using the equipment as well as trained industrial hygienist, safety
officer, infection control nurse, occupational health practitioner, facility engineer, and
other professionals can work together to identify such hazards and ways to reduce if not
to eliminate them.

Minimizing these hazards may entail the institution of administrative, engineering and
medical controls including the provision of personal protective equipment.
Administrative control includes proper and regular training, change of job schedules,
rotation of workers. Engineering control includes the substitution of equipment/devices,
change of process to a much safer method, mechanization or computerization, proper
upkeep and regular maintenance of equipment/machine and imposition of warning
devices. Medical control includes a written occupational health and safety program –
physical examination (pre-employment and annual), regular immunization, health
education, regular exercise, healthy diet and continuous medical monitoring and
periodic evaluation of safety measures. Adequate and good designed personal
protective equipment should be provided. These include protection for the head, face,
body, arms, legs and feet.

Exposure to hazardous health care waste can result to disease or injury. The
hazardous nature of health care waste maybe due to one or more of the following
characteristics:

 Contains infectious agents;

 Genotoxic;
 Contains toxic or hazardous chemicals or pharmaceuticals
 Radioactive;
 Contains sharps

2.1 Persons at Risk

All individuals exposed to hazardous health care waste are potentially at risk, including
those within the health care establishments that generate hazardous waste, and those
outside these sources who either handle such waste or are exposed to it as a
consequence of careless management. The main groups of people who are at risk of
exposure to health hazards associated with health care waste are the following:

 Staff of the health care establishments such as physicians, nurses, health

care auxiliaries, and hospital maintenance personnel;

 Patients in the health care establishments or receiving home care;

 Visitors, comforters, and caregivers to health care establishment;

 Personnel and workers providing support services and allied to

health care establishments, such as laundries, waste handling and
transportation;
 Persons transporting hazardous health care waste;

Impacts of Health Care 5

Waste
  Workers and operators of waste treatment and disposal facilities, i.e.
sanitary landfill including scavengers;

 Workers in mortuaries, funeral parlors and autopsy centers; and

 General public.

2.2 Exposure to Hazardous Health Care

Waste

Hazards from Infectious Waste and Sharps

Infectious waste may contain any of a great variety of pathogenic organisms.

Pathogens in infectious waste may enter the human body by a number of routes: (a)
through a puncture, abrasion, or cut in the skin; (b) through the mucous membrane; (c)
by inhalation; and (d) by ingestion.

The presence of concentrated cultures of pathogens and contaminated sharps

(particularly hypodermic needles) in the waste stream represents the most acute
potential hazards to health. Sharps may not only cause cuts and punctures but also
infect the wounds if they are contaminated with pathogens. Because of this double risk
of injury and disease transmission, sharps are considered as a very hazardous class.

The principal concerns are infections that may be transmitted by subcutaneous

introduction of the causative agent, e.g, viral blood infections. Hypodermic needles
constitute an important part of the sharps waste category and are particularly
hazardous because they are often contaminated with patients' blood.

The consequences of improper handling and disposal of medical waste are serious. For
example, the reuse of improperly discarded needles by IV users or accidental needle-
sticks injuries as recyclers sifting through waste dumps could lead to the spread of
hepatitis, AIDS and other blood-borne diseases. Epidemiological studies show that
exposure to pollutants from medical waste incinerators increases the risk of various
types of cancers and heart diseases.

The elements required for infection in the context of medical waste are:

 Some components of medical waste are potential reservoirs of disease-causing

microorganisms (culture dishes, liquid blood, pathological waste, etc.).

 The infective dose depends on the virulence of the microorganisms, the portal of
entry, and the susceptibility of the host.

 Modes of transmission may involve contact (e.g., contaminated needles or blood

splatter), vehicle-borne (e.g., contaminated wastewater), airborne (e.g., aerosolized
pathogens from broken culture dishes or the rupture of yellow bags), and vector-
borne transmission (e.g., rodents in a medical waste storage area).

 Portals of entry include breaks in the skin and mucous membranes (e.g., needle-
stick injuries or blood splashes into the mucous membranes), the respiratory tract
(inhalation of pathogenic aerosols), etc.
 Potential susceptible host include health care workers, waste handlers, patients and
visitors in the health care facility, landfill operators, scavengers, and the public, in
general.

Hazards from Chemical and Pharmaceutical Waste

Although chemical and pharmaceutical products may be found in small quantities in

health care waste, these substances are hazardous. They may cause intoxication,
either by acute or by chronic exposure, and injuries, including burns. Intoxication can
result from absorption of a chemical or pharmaceutical substance through the skin or
the mucous membranes, or from inhalation or ingestion. Injuries to the skin, the eyes,
or the mucous membranes of the airways can be caused by contact with flammable,
corrosive, or reactive chemicals (e.g. formaldehyde and other volatile substances). The
most common injuries are burns. Disinfectants such as chlorine and sodium
hypochloride are particularly important members of this group; they are used in large
quantities and are often corrosive. It should be noted that reactive chemicals might form
highly toxic secondary compounds.

Hazards from Genotoxic Waste

Inhalation of dust or aerosols, absorption through the skin, ingestion of food

accidentally contaminated with cytotoxic drugs, chemicals, or waste and ingestion are
the main pathways of exposure to genotoxic substances. The severity of the hazards
also depends on the mode of exposure (inhalation, dermal contact, etc.). Exposure to
genotoxic substances may also occur during the preparation of treatment with particular
drugs or chemicals or through contact with bodily fluids and secretions of patients
undergoing chemotheraphy.

Many cytotoxic drugs are extremely irritating and have harmful local effects after direct
contact with skin or eyes. They may also cause dizziness, nausea, headache, or
dermatitis. Special care in handling genotoxic waste is therefore essential; any
discharge of such waste into the environment could have disastrous ecological
consequences.

Hazards from Radioactive Waste

Health effects caused by exposure to radioactive substances or materials contaminated

with radioactivity can range from reddening of the skin and nausea to more serious
problems such as cancer induction and genetic consequences to succeeding
generations of the exposed individual. The handling of high activity sources, e.g. certain
sealed and unsealed radiation sources used in cancer therapy poses higher health
risks such that adequate protection measures have to be established to minimize these
risks. The health hazards from low activity contaminated wastes may arise from
external and internal exposures from undetected contaminated working environment
and improper handling and storage of radioactive wastes and spent/unused radiation
sources. Both the workers and other staff personnel are at risk to this health hazard.

2.3 Impacts of Health Care Waste to Public

Health and the Environment

Apart from the risk to the patients and health care personnel, consideration must be
given to the impact of health care waste to the general public and the environment. In
particular, attention should be paid to the possible pollution of the air, water and soil
including the aesthetic aspects. Minimizing the risk to public health and the environment
will require actions to deal with health care waste within the health care establishment
such as proper waste segregation and minimization so that it does not enter the waste
stream requiring disposal.

While the hospital personnel are at greater risk of infection through injuries from
contaminated sharps, other hospital workers and waste management operators outside
of the health care establishment are also at risk. Certain infection, however, spread
through media or caused by more resilient agents, may pose a significant risk to the
public. For example, the uncontrolled discharges of sewage from field hospitals treating
cholera patients are a potential source of cholera epidemic. Feces and urine from
patients in isolation wards should be disinfected before disposal in the sewer. However,
the use of strong disinfectants should be minimized when there are alternatives.

Chemicals used in health care establishments are a potential source of water pollution
via the sewer system. Chemical waste survey is a prerequisite to the development of an
effective waste management program. Any hazardous chemical waste generated
should be dealt with by a proper chemical waste management system. Substituting
chemicals with lesser environmental and health impacts than those presently in use is a
sound practice.

In addition, the public is very sensitive about the visual impact of anatomical waste, that
is, recognizable body parts, including fetuses. The present culture in the country do not
accept the disposal of anatomical waste inappropriately, such as on a landfill.
 CHAPTER 3

HEALTH CARE WASTE

 Health Care Waste Management
Manual
3. HHeea lthh care
WWaste

3.1 Definition

"Health care waste" includes all the waste that is generated or produced as a result of
any of the following activities:

 Diagnosis, treatment, or immunization of human beings or animals;

 Research pertaining to the above activities;

 Production or testing of biologicals; and

 Waste originating from minor or scattered sources.

3.2 Categories of Health Care Waste

1) General Waste - Comparable to domestic waste, this type of waste does not pose
special handling problem or hazard to human health or to the environment. It comes
mostly from the administrative and housekeeping functions of health care
establishments and may also include waste generated during maintenance of health
care premises. General waste should be dealt with by the municipal waste disposal
system.

2) Infectious Waste – This type of waste is suspected to contain pathogens (bacteria,

viruses, parasites, or fungi) in sufficient concentration or quantity to cause disease
in susceptible hosts. This includes:

 Cultures and stocks of infectious agents from laboratory work;

 Waste from surgery and autopsies on patients with infectious diseases (e.g.
tissues, materials or equipment that have been in contact with blood or other
body fluids);

 Waste from infected patients in isolation wards (e.g. excreta, dressings from
infected or surgical wounds, clothes heavily soiled with human blood or other
body fluids);

 Waste that has been in contact with infected patients undergoing haemodialysis
(e.g. dialysis equipment such as tubing and filters, disposable towels, gowns,
aprons, gloves, and laboratory coats);

 Infected animals from laboratories; and

 Any other instruments or materials that have been in contact with infected
persons or animals.

3) Pathological Waste - Pathological waste consists of tissues, organs, body parts,

human fetus and animal carcasses, blood and body fluids. Within this category,
recognizable human or animal body parts are also called anatomical waste. This
category should be considered as a subcategory of infectious waste, even though it
may also include healthy body parts.

Health Care 10
Waste
4) Sharps - Include needles, syringes, scalpels, saws, blades, broken glass, infusion
sets, knives, nails and any other items that can cause a cut or puncture wounds.
Whether or not they are infected, such items are usually considered as highly
hazardous health care waste.

5) Pharmaceutical waste - Includes expired, unused, spilt, and contaminated

pharmaceutical products, drugs, vaccines, and sera that are no longer required and
need to be disposed of appropriately. This category also includes discarded items
used in handling of pharmaceuticals such as bottles or boxes with residues, gloves,
masks, connecting tubing and drug vials.

6) Genotoxic Waste - Genotoxic waste may include certain cytostatic drugs, vomit,
urine, or feces from patients treated with cytostatic drugs, chemicals, and
radioactive materials. This type of waste is highly hazardous and may have
mutagenic, teratogenic, or carcinogenic properties.

Harmful cytostatic drugs can be categorized as follows:

 Alkylating agents: cause alkylation of DNA nucleotides, which leads

to cross-linking and miscoding of the genetic stock;

 Anti-metabolites: inhibit the biosynthesis of nucleic acids in the cell;

mitotic inhibitors: prevent cell replication

Cytotoxic wastes are generated from several sources and include the following:

 Contaminated materials from drug preparation and administration, such as

syringes, needles, gauges, vials, packaging; outdated drugs, excess (left over)
solutions, and drugs returned from the wards;

 Urine, feces, and vomit from patients which may contain potentially
hazardous amounts of the administered cytotoxic drugs or of their
metabolites and which should be considered genotoxic for at least 48
hours and sometimes up to 1 week after drug administration.

7) Chemical Waste - Chemical waste consists of discarded solid, liquid, and gaseous
chemicals, for example from diagnostic and experimental work and from cleaning,
housekeeping, and disinfecting procedures. Chemical waste from health care may
be hazardous or non-hazardous.

Chemical waste is considered hazardous if it has at least one of the following

properties:

 Toxic
 Corrosive (e.g. acids of pH <2 and bases of pH >12)
 Flammable
 Reactive (explosive, water-reactive, shock-sensitive)
 Genotoxic (e.g. cytostatic drugs)

Non-hazardous chemical waste consists of chemicals with none of the above

properties, such as sugars, amino acids, and certain organic and inorganic salts.
8) Waste with high content of heavy metals - Wastes with a high heavy-metal content
represent a subcategory of hazardous chemical waste, and are usually highly toxic.
Mercury wastes are typically generated by spillage from broken clinical equipment
(thermometers, blood pressure gauges, etc.). Whenever possible, spilled drops of
mercury should be recovered. Residues from dentistry have high mercury content.
Cadmium waste comes mainly from discarded batteries. Certain "reinforced wood
panels" containing lead is still being used in radiation proofing of X-ray and
diagnostic departments. A number of drugs contain arsenic but these are treated
here as pharmaceutical waste.

9) Pressurized Containers - Many types of gas are used in health care and are often
stored in pressurized cylinders, cartridges, and aerosol cans. Many of these, once
empty or of no further use (although they may still contain residues), are reusable,
but certain types notably aerosol cans, must be disposed of. Whether inert or
potentially harmful; gases in pressurized containers should always be handled with
care; containers may explode if incinerated or accidentally punctured.

10) Radioactive Waste – Includes disused sealed radiation sources, liquid and gaseous
materials contaminated with radioactivity, excreta of patients who underwent radio-
nuclide diagnostic and therapeutic applications, paper cups, straws, needles and
syringes, test tubes, and tap water washings of such paraphernalia. It is produced
as a result of procedures such as in vitro analysis of body tissues and fluids, in vivo
organ imaging, tumor localization and treatment, and various clinical studies
involving the use of radioisotopes. Radioactive health care wastes generally contain
radionuclides with short half-lives, which lose their activity in a shorter time.
However, certain radionuclides e.g. C-14 contaminated wastes have much longer
half-life, more than a thousand years, which need to be specially managed in a
centralized treatment facility for radioactive wastes. The same is required for the
management of disused sealed radiation sources used for cancer treatment.

3.3 Sources and Composition of Health Care

Waste

Sources

Sources of health care waste include health care facilities, institutions, business
establishments and other similar health care services with activities or work processes
that generate / produce health care waste. Activities or processes that produce health
care waste, which include, but not limited to, a provider of health care services. Below
are examples of facilities that generate health care waste:

1) Hospitals

2) Clinics

 Medical  Dental
 Veterinary  Maternity and Lying-in
 Health care centers and dispensaries  Dialysis centers
 Alternative medicine  Physician Offices
3) Laboratories and Research Centers

 Medical and biomedical laboratories  Biotechnology laboratories

 Medical research centers and institutions  Animal research and testing
 Blood banks and blood collection services  Nuclear medicine laboratories

4) Drug Manufacturers

5) Institutions

 Medical  Nursing
 Nursing homes  Drug rehabilitation centers
 Dental  Veterinary
 Paramedics

6) Mortuary and Autopsy Centers

7) Ambulances and Emergency Care

8) Home Treatment (e.g. Dialysis, Insulin injection, etc.)

9) Cosmetic Ear Piercing and Tattoo Parlors

Composition

The type of source often characterizes the composition of wastes. For example, the
different units within the health care establishment would generate waste with the
following characteristics:

 Medical wards – mostly general waste; a limited amount of infectious waste such as
blood-soaked dressings, bandages, and sticking plaster; contaminated gloves,
contaminated packaging and disposable medical items; used or unused hypodermic
needles and intravenous sets; and certain body fluids.

 Operating theatres and surgical wards – general waste (including packaging);

pathological and anatomical waste, including tissues, organs, products of
conception and body parts, other potentially infectious wastes (blood soaked gauze
and materials, contaminated gloves, tubing, body fluid containers, and sharps).

 Other health care units - mostly general waste with small percentage of infectious
waste (mostly sharps).

 Laboratories - general waste (including packaging and containers), pathological

(including some anatomical) wastes, tissue samples, microbiological cultures and
stocks, blood and body fluids, contaminated gloves, tubing and containers, sharps,
possibly some radioactive materials, a large number of chemicals. Many tissue
samples will come packed in formalin or will be put in containers with formalin. They
will no longer be infectious, but the tissue sample and the formalin must be
separated creating a chemical and a pathological waste for proper disposal.

 Pharmaceutical and chemical stores - mainly general waste, product packaging,

small quantities of pharmaceutical and chemical wastes (if stocks are properly
 managed to prevent large quantities from expiring), possibly cytotoxic drugs, if
chemotherapy treatment are prepared in the pharmacy.

 Support units - general waste only.

Health care waste from other sources generally has the following composition:

 Health care provided by nurses – general waste, a limited amount of infectious and
some sharps

 Physician's offices – general waste, a limited amount of infectious and some sharps

 Dental clinics and dentist's offices - general waste, a limited amount of infectious,
sharps and waste with high heavy metal content

 Home health care (e.g. dialysis, insulin injections) - general waste, a limited
amount of infectious waste, and sharps.
 CHAPTER 4
HEALTH CARE WASTE MINIMIZATION
Health Care Waste Management
Manual

4.1 Waste Minimization

The waste management hierarchy consists of source reduction, recycling, treatment

and residuals disposal. In addressing waste management, waste minimization basically
utilizes the first two elements that could help reduce the bulk of health care wastes for
disposal. Waste minimization is beneficial not just to the waste-receiving environment
but to the waste producers also. The cost for both the purchases of goods and for
waste treatment and disposal are reduced and the liabilities associated with the
disposal of health care waste is lessened. The extent to which a hazardous waste
minimization program is implemented depends upon the health care establishment's
particular operations and procedures.

If waste minimization is to be undertaken by the health care facility, it is important to

develop a good baseline data of the amount of waste generated prior to implementation
of the waste minimization program. Health care waste generation data from the various
units of the health care facility should be properly recorded on a chart with the amount
of waste displayed in descending order. This method can be used easily to determine
the highest waste generating areas in which the minimization strategies should be
initiated. This information should be displayed and communicated throughout the
facility.

The waste minimization strategy should be formally approved in writing by the top
management within the health care facility as a demonstration of their support and
commitment to the program.

4.2 Principles of Waste Minimization

 Identify baseline waste generation rates, current hazardous waste management

strategies, and current waste management costs.
 Health care establishment operators/owners must be committed to waste
minimization for it to be successful and sustainable in the long run.
 Waste minimization programs should include a written policy with specific goals,
objectives, and timeliness.
 Train employees in hazardous waste handling and site specific waste minimization
methods.
 Be aware of and keep updated on the hazardous materials regulations.

Health care waste minimization is centered on the elimination or reduction of the health
care waste stream. There are several measures that can be instituted to achieve waste
minimization including the following:

1) Reduction at source

Some reduction involves measures that either completely eliminate use of a material or
generate less waste. Examples are: improving housekeeping practices to eliminate use
of chemical air fresheners (which only serve to masks odors and release toxic
compounds such as formaldehyde, petroleum distillates, p-dichlorobenzene, etc.);
replacing mercury thermometers with digital electronic thermometers; working with
suppliers to reduce packing of the products; and substituting a non-toxic biodegradable
cleaner for a hazardous chemical cleaner.

Health Care Waste 16

Minimization
2) Re-use

Reuse is not only finding another use for a product but, more importantly, reusing
product over and over again for a given function as intended. Promoting re-use entails
the selection of reusable rather than disposable products whenever possible. Reuse will
also entail setting reliable standards for disinfection and sterilization of equipment and
materials for use.

3) Recycling

Recycling is collecting waste and processing it into something new. Many items in the
hospital can be recycled. Items such as organics, plastic, paper, glass and metal can
be recycled easily.

4) Segregation of Waste

Segregation is an important step to waste management. There are several reasons to

undertake waste segregation:

 Segregation minimizes the amount of waste that needs to be managed as bio-

hazardous or hazardous waste (since mixing non-infectious waste with infectious or
hazardous waste renders the combined amount as infectious or hazardous
respectively);

 Segregation facilitates waste minimization by generating a solid waste stream which

can be easily, safely, and cost-effectively managed through recycling or
composting;

 Segregation reduces the amount of toxic substances release to the environment

through disposal of general waste (e.g., by removing mercury from general waste).

 Segregation makes it easier to conduct assessments of the quantity and

composition of different waste streams thereby allowing health care facilities to
obtain baseline data, identify options, determine waste management costs, and
assess the effectiveness of waste minimization strategies.

5) Composting

Composting is another important strategy to minimize waste such as food discards,

kitchen waste, cardboard, and yard waste. Some hospitals in other countries have also
successfully composted placenta waste. Sufficient land space for on-site composting
far enough from patient care and public access area would be needed. Food scraps
can provide most of the nitrogen while bulking agents commonly found in hospitals
such as cardboard and wooden chips could provide carbon. Composting techniques
range from simple un-aerated static piles to aerated windrows to vermi-composting.
The resulting rich compost can be sold or donated to local farmers and gardeners or
used for plants around the health care facility grounds.
4.3 Implementing Waste Minimization
Strategies

Implementing workable health care waste minimization practices should be

incorporated into the on-going operations of the health care facility through policy
directives to staff. The implementation should consider the following:

 Applying health care waste minimization strategies to specific areas of the facility
 Tracking the waste minimization efforts and comparing the results with the
waste data gathered during the assessment phase of the program
 Documenting results and studying the system for continuous improvement
 Evaluating the waste minimization process to document success, determine
training efficiency and needs
 Instituting policy directives incorporating improved health care waste
minimization processes
 Planning new health care waste minimization pilot projects for further waste
reduction

4.4 Examples of Policies and Practices That

Encourage Waste Minimization

Reduction of Waste at source

 Purchase/select supplies and materials that are less wasteful and less hazardous
 Use less hazardous method in cleaning (e.g. steam disinfection instead of
chemical disinfection)

Management and control measures at hospital level

 Centralized purchasing of hazardous chemicals

 Monitoring of chemical flows within the health facility from receipt as raw
materials to disposal as hazardous waste

Stock management of chemical and pharmaceutical products

 Systematize use of product “first in, first out (FIFO)”

 Frequent ordering of relatively small quantities rather than large
amounts at one time (applicable in particular to unstable
products/unpredictable consumption rate)
 Use all the contents of each container
 Checking of the expiry date of all products at the time of delivery and based
on its optimum consumption rate
Recycling and Reuse

Waste contaminated with radioactivity such as plastic and paper cups, disposable
gloves, syringes and needles may not be recycled and reused unless the radioactivity
levels are below the clearance levels established by the Philippine Nuclear Research
Institute (PNRI) for specific radionuclides.

Health care facilities generate large amount of waste and end up throwing away
valuable resources into landfills. Keeping recyclables out of the landfill, and returning
them as resources to be processed again, hospitals decrease the burden placed on the
environment. Safe reuse and recycling process is an important practice in health care
facilities to prevent excess waste whenever possible.

Medical and other equipment used in health care establishments may be reused
provided that it is designed for the purpose and will withstand the sterilization process.
Reusable items may include certain sharps, such as scalpels, glass bottles and
containers. After use, these should be collected separately from non-reusable items,
carefully washed and sterilized by the DOH-approved method such as autoclaving.
Plastic syringes and catheters should not be thermally or chemically sterilized nor
reused but should be properly discarded.

Certain types of container may be reused provided that they are carefully washed and
disinfected. Pressurized gas containers, however, should generally be sent to
specialized centers to be refilled. Containers that once held detergents or other liquid
may be reused as containers for sharps waste (if purpose-made containers are not
affordable) provided that they are puncture proof and correctly and clearly marked on
all sides. Recycling of papers, metals, glass and plastics can result in savings for the
health care facility either through reduced disposal costs or through payments made by
the recycling company.

In determining the economic viability of recycling, it is important to take account of the

cost of alternative disposal methods and not just the cost of the recycling process and
the value of the reclaimed material.

4.5 Basic Steps in the Development of a

Waste Minimization Program

There are five basic stages in the development of a waste minimization program:
planning and organization, assessment, feasibility analysis, implementation, and
periodic inspection.

Planning and Organization

The initial stage entails getting top management to be committed to waste minimization
(as reflected in a formal policy statement), setting overall goals, finding “champions”
who can provide the initiative and energy to sustain the program, and creating a task
force to get crucial personnel from key departments involved.
Assessment

The assessment phase begins with establishing a baseline of how much is being
produced and by whom. This involves gathering data regarding waste streams,
processes and operations, types of practices, information on input materials and
economic information. A waste audit is a valuable tool for the assessment phase,
providing data on the sources of waste, compositions, generation rates and waste flow
within the facility. Waste analysis involves preparation, data collection, analysis, and
recommendations. Preparation entails defining goals, planning, enlisting the
cooperation of key personnel and department heads, and a preliminary “walk through
survey” of the facility. Data can be collected in-house using self-audit forms and
questionnaires. Another approach is to employ an outside consultant. Data collected for
a few days provides a snapshot of the waste flow. Collecting data for two or more
weeks requires greater staff effort but it may reveal important variations.

From the data, one establishes the flow of waste and generation rates of every unit of
the facility. Data on waste composition can be used to evaluate segregation practices.
A waste analysis can uncover inefficiencies, reveal the true costs of waste
management, and show the levels of compliance to policies. It is useful to prioritize
waste streams based on quantity, toxicity, environmental impact, potential liability, cost
and other factors. An assessment team of selected staff should review the data and
come up with waste minimization options, which may involve determining recycling
equipment, changing purchasing policies, improving inventory management, product
substitutions, or changing procedures or processes.

Feasibility Analysis

In the feasibility analysis phase, a technical and economic evaluation of possible waste
minimization options is conducted. Among the criteria for technical evaluation are
worker safety, maintaining quality of service, compatibility with existing operating
procedures and schedules, minimal disruption, and space availability. The economic
evaluation could use standard measures of comparative analysis such as payback
period and return on investment.

Implementation

The final phase is implementation. This entails obtaining top management approval,
launching educational and communication programs, installing new equipment or
initiating new procedures and evaluating performance. A pilot project or demonstration
may be necessary to evaluate an option before final installation. Measures to assess
the effectiveness of waste minimization include comparing recorded quantities of waste
based on the number of patients per day or comparing the cost of waste disposal
before and after implementation.

Educational and communication programs are key factors. These programs must be
designed to reach out to the entire staff, tap existing channels of education, provide
education on a continuing basis especially for new staff, and respond to feedback from
employees. Documenting, publicizing, and celebrating successes as well as rewarding
individuals and departments, provide incentives for greater staff support and
participation in waste minimization.
Periodic Inspection

Regular monitoring and evaluation could uncover problems, identify areas that need
improvement, and reveal new issues that may arise in managing waste. Regular
inspection provides an opportunity to educate staff further and reinforce good practices.
 CHAPTER 5
WASTE HANDLING, COLLECTION,
STORAGE, AND TRANSPORT
Health Care Waste Management
Manual

5.1 Waste Segregation and Storage

The effective management of health care waste considers the basic elements of waste
minimization, segregation and proper identification of the waste. In the past, there were
no incentives to separate, recycle, or reduce waste. Appropriate handling, treatment
and disposal of waste by type reduce costs and do much to protect public health.
Segregation at source should always be the responsibility of the waste producer.
Segregation should take place as close as possible to where the waste is generated
and should be maintained in storage areas and during transport.

Segregation is the process of separating different types of waste at the point of

generation and keeping them isolated from each other. Appropriate resource recovery
and recycling technique can be applied to each separate waste stream. Moreover the
amount of hazardous waste that needs to be treated will be minimized or reduced
subsequently prolonging the operational life of the disposal facility and may gain benefit
in terms of conservation of resources.

Hazardous waste should be placed in clearly marked containers that are appropriately
labeled for the type and weight of the waste. Except for sharps and fluids, hazardous
wastes are generally put in plastic bags, plastic lined cardboard boxes, or leaked
proofed containers that meet specific performance standards.

To improve segregation efficiency and minimize incorrect use of containers, proper

placement and labeling of containers must be carefully determined. General waste
containers placed beside infectious waste containers could result in better segregation.
Too many hazardous waste containers tend to inflate waste volume but too few
containers may lead to non-compliance. Minimizing or eliminating the number of
hazardous waste containers in patient care areas (except for sharp containers, which
should be readily accessible,) may further reduce waste. Facility management should
develop a segregation plan that includes staff training.

5.2 Color Coding Scheme for Health Care

Waste

The most appropriate way of identifying the categories of health care waste is by
sorting the waste into color-coded plastic bags or containers. Recommended color-
coding scheme for health care waste is shown in Table 1.

Waste Handling, Collection, Storage, and 23

Transport
Figure 1 Basic Steps in Health Care Waste Handling
 Table 1. Color-coding Scheme for Containers

Color of container/bag Type of waste

Black Non-infectious dry waste

Green Non-infectious wet waste (kitchen, dietary etc.)
Yellow Infectious and Pathological waste
Yellow with black band Chemical waste including those w/ heavy metals
Orange Radioactive waste
Red Sharps and pressurized containers

Apart from the color-coding system for health care waste, the following practice should
also be observed:

a. Residuals of the general health care

waste should join the stream of
domestic refuse or municipal solid waste Figure 2. Refuse Receptacle for General
for proper waste management. Waste with Plastic Bag Cover

b. Sharps should all be collected together,

regardless of whether or not they are
contaminated. Containers should be
puncture proof (usually made of metal or
high-density plastic) and fitted with
covers. It should be rigid and BOX TYPE
impermeable to contain not only the
sharps but also any residual liquids from 4 GALLON CAPACITY OIL CAN

syringes. To discourage abuse,

containers should be tamper proof
(difficult to open or break) and needles
and syringes should be rendered
unusable. Where plastic or metal containers are unavailable or too costly, containers
made of dense cardboard are recommended.

c. Bags and containers for infectious waste should be marked

with the international infectious substance symbol.

d. Highly infectious and other hazardous waste should, whenever

possible, be treated immediately by any method recommended
in this manual. It therefore needs to be package in bags that
are compatible with the proposed treatment process.

e. Cytotoxic waste, most of which is produce in major hospital or

research facilities, should be collected in strong, leak proof
containers clearly labeled “Cytotoxic wastes”.

f. Radioactive wastes should be segregated according to its Figure 3. Refuse

physical form: solid & liquid and according to its half-life or Receptacle for
potency: short-live and lived in especially marked containers as Pathological
Waste lined with
Heavy Gauge
Plastic Bag and
Cover
 prescribed by the pertinent regulation of the Philippine Nuclear Research Institute
(PNRI) specific to such authorized practice.

g. Small amounts of chemical or pharmaceutical waste may

be collected together with infectious waste.

h. Large quantities of obsolete or expired pharmaceuticals

stored in hospital wards or departments should be
returned to the pharmacy for disposal. Other
pharmaceutical waste generated at this level, such as
expired drugs or packaging containing drug residues
should not be returned because of the risk of
contaminating the pharmacy. It should be deposited in
the specified container at the point of generation.

i. Large quantities of chemical waste should be packed in Figure 4. International

chemical resistant containers and sent to specialized Infectious Substance
treatment facilities (if available). The identity of the Symbol
chemicals should be clearly marked on the containers.
Hazardous chemical waste of different types
should never be mixed.

j. Waste with a high content of heavy metals (e.g.

cadmium or mercury) should be collected
separately. These wastes can be sent to waste
treatment facility available in the area.

k. Aerosol containers may be collected with general

DANGER

health care waste once they are completely

empty. Aerosol containers should not be burnt or
incinerated.

l. Appropriate containers or bag holder should

be placed in all locations where particular
Figure 5. For Radioactive Waste and
categories of waste may be generated.
Chemical Waste

m. Staff should never attempt to correct

errors of segregation by removing items
from a bag or container after disposal or
by placing one bag inside another bag of
a different color. If general and hazardous
waste are accidentally mixed, the mixture
should be classified as hazardous health
care waste.

n. Cultural and religious constraints in

certain parts of the country make it
unacceptable for anatomical waste to be
collected in the usual yellow bags; such OFF LIMITS TO
UNAUTHORIZED PERSONS

waste should be disposed of in Figure 6. Perspective Angle of the Wooden Box

accordance with the local custom, which
commonly specifies burial.
5.3 Storage

All health care waste should be collected and stored in waste storage area until
transported to a designated off-site treatment facility. This area shall be marked with
warning sign: "CAUTION: BIOHAZARDOUS WASTE STORAGE AREA -
UNAUTHORIZED PERSONS KEEP OUT."

Storage areas for health care waste should be located within the establishment or
research facility. However, these areas should be located away from patient rooms,
laboratories, hospital function/operation rooms or any public access areas. The waste
in bags or containers should be stored in a separate area, room or building of a size
appropriate to the quantities of waste produced and the frequency of collection. In
cases where the health care facility lacks the space, daily collection and disposal
should be enforced.

Cytotoxic waste should be stored separately from other waste in a designated secured
location. Radioactive waste should be stored separately in containers that prevent
dispersion, and if necessary behind lead shielding. Waste that is to be stored during
radioactive decay should be labeled with the type of radionuclide, the date, and details
of required storage conditions. Storage facility for radioactive waste must bear the sign
“Radioactive Waste” placed conspicuously. Methods of treatment and disposal of
radioactive waste shall conform to the requirements and guidelines of the PNRI.

During “storage for decay”, radioactive waste should be separated according to the
length of time needed for storage, for example, short-term storage (half-lives less than
30 days) and long-term storage (half-lives from 30 to 65 days). Low level radioactive
waste should be stored for a minimum of ten times the half-life of the longest-lived
radionuclides in the container and until radioactivity decays to background levels as
confirmed by a radiation survey.

Requirements for Storage Facilities

1. The storage area should have an impermeable, hard-standing floor with good
drainage; it should be easy to clean and disinfect.

2. There should be water supply for cleaning purposes.

3. The storage area should allow easy access for staff in charge of handling the
waste.

4. It should be possible to lock the storage area to prevent access by unauthorized

persons.

5. Easy access for waste collection vehicle is essential.

6. There should be protection from sun, rain, strong winds, floods, etc.

7. The storage area should be inaccessible to animals, insects and birds.

8. There should be good lighting and adequate ventilation.

 9. The storage area should not be situated in the proximity of fresh food stores or
food preparation areas.

10. A supply of cleaning equipment, protective clothing, and waste bags or

containers should be located conveniently close to the storage area.

11. Floors, walls, and ceilings of the storage area must be kept clean in accordance
to established procedures, which at a minimum should include daily cleaning of
floors.

12. Biodegradable general and hazardous waste should not be stored longer than 2
days to minimize microbial growth, putrefaction, and odors. If the waste must be
stored longer than 2 days, application of treatment like chemical disinfection or
refrigeration at 4oC or lower is recommended.

5.4 Collection and Transport of Health Care

Waste

The proper collection and transportation is an important component in health care

waste management. Its implementation requires the direct involvement of the health
care facility’s maintenance services, housekeeping services, motor pool service
personnel and cooperation of all the health care personnel.

Health care waste collection practices should be designed to achieve an efficient

movement of waste from points of generation to storage or treatment while minimizing
the risk to personnel.

Suggested collection frequency on room to room basis is once every shift or as often as
necessary. Time of collection regardless of category should be at the start of every
shift.

Figure 7. Foot Operated Lid Container

Figure 8. Refuse Receptacles for
Refuse Receptacle for Infectious Wards
Sharps with Heavy Gauge Plastic
Lined with Heavy-Gauge Plastic Bag
Bag and Cover (Plastic Container)
with Cover

On-site Collection

Waste should not be allowed to accumulate at the point of production. A program for
their collection and transportation should be established as part of the health care waste
management plan. Nursing and other clinical staff should ensure that waste bags are
tightly closed or sealed when they are about three-quarters full. Light-gauge bags can
be closed by tying the neck, but heavier gauge bags probably require plastic sealing tag
of the self-locking type. Bags should not be closed by stapling. Sealed sharp containers
should not be placed in a labeled, yellow infectious health care waste bag.

The following are recommendations that should be followed by health care

personnel directly involved in waste handling and collection:

 Waste should be collected daily (or as frequently as required) and transported to

the designated central storage site or waste transfer station.

 No bags should be removed unless they are labeled with their point of
production (hospital ward or department) and contents.

 The bags or containers should be replaced immediately with new ones of the
same type.

 A supply of fresh collection bags or containers should be readily available at all

locations where waste is produced.

 Collection practice for active solid radioactive waste shall consist of distributing
orange color-coded suitable containers with the radiation symbol colored
magenta or black. The collection of active solid radioactive waste from
designated storage area can only be made when the activity (delay-to-decay)
decays to a safe level and upon the strict supervision and guidance of the
radiological health and safety officer.

 Handling, collection, transport and disposal of these materials shall be based on

the guidelines issued by PNRI.

On-site Transport

Transportation of waste within the establishment could utilize wheeled trolleys,

containers, or carts that are dedicated solely for the purpose. On-site transportation
vehicle should meet the following specifications:

 Easy to load and unload

 No sharp edges that could damage waste bags or containers during loading and
unloading
 Easy to clean

The on-site collection vehicles should be cleaned and disinfected daily with an
appropriate disinfectant like chlorine compounds, formaldehyde, phenolic compounds
and acids. All waste bag seals should be in-place and intact at the end of
transportation.

Workers transporting the waste should be equipped with appropriate personal protective
equipment including heavy-duty gloves, coveralls, thick-soled boots and leg protectors.
A. One Refuse Collector with a Handcart of 300
Liters (6 Bins x 50 Liters) with Plastic Bag and Cover

B. Bins from Handcrafts are emptied into a trailer of 6,000 Liters capacity in different coding equivalent to one-day waste (One Tr

D. Two-Bin Handcraft with total capacity 120-200

C. Handcraft with Round Body for refuse Liters according to bin size. The bins are emptied
collection capacity from 52 Gallons emptied by directly into a transfer facility as to color coding
dumping contents to the ground with plastic bag and cover.

E. Six-Bin Handcraft Suitable for daily collection of

different types of hospital waste with plastic bag
and cover and should conform with the color
coding. Total capacity ranges from 300 to 500 liters
emptied directly into a transfer capacity.

Figure 9. Examples of On-Site Collection Vehicle

Off-site Transportation of Health Care Waste

The health care waste generator is responsible for the safe packaging and adequate
labeling of waste to be transported off-site for treatment and disposal. Packaging and
labeling should comply with the national regulation governing the transport of
hazardous wastes (RA 6969) and maintaining that it presents no danger to the public
during transport. Likewise, the waste generators are ultimately responsible for ensuring
that their wastes are properly treated and disposed of in an approved disposal facility.

Tracking of wastes could be done with the implementation of the consignment system.

Consignment Note

All health care waste to be transported to an approved off-site waste treatment facility
shall be transported only by a DENR-accredited transporter or carrier. The authorized
transporter / carrier shall maintain a completed consignment note (see Annex 4 for a
prototype Consignment Note) of all health care waste taken from the health care
establishment for treatment or disposal.

By the time that waste transporter receives the waste, the transporter shall provide the
waste generator with a copy of the consignment note for the generator's waste records.

The transporter and the generator shall separately maintain a copy of the consignment
note. The consignment note shall include, but not limited to the following information:

 The name address, telephone number, and accreditation number of the

transporter, unless the transporter is the generator

 The type and quantity of waste transported

 The name, address, and telephone number of the generator

 The name, address, telephone number, permit number, and the signature of
an authorized representative of the approved facility receiving the waste

 The date that the waste is collected or removed from the generator's facility,
the date that the waste is received by the transfer station, or point
of consolidation, if applicable, and the date that the waste is received by
the treatment facility.

If the waste generators are the ones who transport the wastes or directs a member of
its staff to transport the wastes to an approved waste treatment and disposal facility, the
consignment note for health care wastes should show the name, address and
telephone number of the wastes generator when the wastes are transported to the
waste treatment and disposal facility.

The transporter or generator transporting the waste should have the consignment note
in his or her possession in the vehicle while transporting the waste. The tracking
document should be available upon demand by any traffic enforcement agency
personnel. The transporter shall provide the facility receiving waste with a copy of the
original tracking document.
Contingency Plan for Health Care Waste

The development of a plan of action should be considered in the event of an accidental

spill, loss of containment, equipment failure or other unexpected circumstances.

The owner/operator of vehicles used in the transportation of health care waste should
carry contingency plans for emergencies that address the following:

 Plan for the disinfection of the truck and any contaminated surface if a leaking
container is discovered.

 A notification list of individual or agencies to be contacted in the event of a

transportation accident.

 Clean-up and decontamination of potentially contaminated surfaces; designation

of backup transportation for the health care waste, a description of the plans for
the re-packaging and labeling of health care waste where containers are no
longer intact.

 Procedures for the management of a leaking container.

Requirements for Packaging for Off-site Collection

Waste should be packaged in sealed bags or containers to prevent spilling during

handling and transportation. The bags or containers should be robust for their content
(for example: puncture proof for sharps and resistant to aggressive chemicals) and for
normal conditions of handling and transportation, such as vibration or changes in
temperature, humidity or atmospheric pressure. (In case of plastic bags, minimum
gauge should be at least 0.009 mm)

Radioactive wastes must be packaged for off-site collection and transported in

accordance with the acceptance criteria for low level radioactive wastes established by
PNRI (AO No. 01 series of 1990, Annex 3).

All waste bags or containers should be labeled with the basic information about their
content and about the waste generator. This information may be written directly on the
bag or container or on pre-printed labels, securely attached. Basic information should
include but not limited to the following:

 Type of health care waste

 Form of waste and waste category
 Date of collection
 Volume/quantity of waste
 Precautions to be taken while handling
 Emergency procedures in the event of accident or spillage
 Destination of the waste

Requirements for Off-site Collection Vehicles

Collection vehicles used for the transport of health care wastes should not be used for
the transport of any other materials that could be seriously affected by contamination
such as food, livestock, people or retail goods. The vehicle should have an enclosed
leak
proof body and capable of being locked to secure the waste. Waste can be loaded
directly to especially designed vehicle, but it is safer to place them first in containers
(e.g. cardboard boxes or wheeled, rigid, lidded plastic or galvanized bins). Infectious
and pathological waste should be bagged in appropriate colored-coded bags or other
special containers when transported. Each package should be marked or coded for
easy identification. Containers should be leak-proofed and be fitted with self-sealing lid
and be tight enough to withstand being spilled in the vehicle. The design of the
collection vehicle must conform to the following:

 The body of the vehicle should be of suitable size commensurate with the
design of the vehicle.

 The vehicle should have totally enclosed car body with the driver seat separated
from the loader to prevent coming into contact with the waste in the event of
collision/accident.

 There should be a suitable system for securing the load during transport.

 The vehicle should be easy to clean and the internal surface of the body should
be smooth enough that allows it to be steam cleaned and with all corners/angles
rounded. The vehicle should be cleaned at the end of each working day and in
the event of any spillage.

 The vehicle should be marked with the name and address of the waste carrier.

 The international hazard sign should be displayed on the vehicle or container,

as well as the emergency telephone number.

 Empty plastic bags, suitable protective clothing, cleaning equipment, tools, and
disinfectant, together with special kits for dealing with liquid spills, should be
carried in a separate compartment in the vehicle.

Routing

Health care waste should be transported through the quickest or shortest possible route
and should be planned before the trip begins. After departure from the source, every
effort should be made to avoid further handling. If handling cannot be avoided, it should
be pre-arranged and take place in adequately designed and authorized premises.
Handling requirements can be specified in the contract established between the waste
generator and the transporter.

An efficient and effective collection system route should consider the following:

 Collection schedule either by route or zone

 Assignment of personnel responsible for the zone or area

 Logical planning of the route (should avoid passing the collected package of
waste on congested area)
 Collection system route must be laid out from the farthest point of the
designated transfer station and as collection progresses towards the collection
storage area.
 Routes drawn shall be practicable and must consider the logical progression of
health care waste throughout the area

 Revised routing plan should be established due to circumstances arising to

alteration in the original routing plan.

 Suggested collection frequency on room to room basis is once every shift or as

often as necessary. Time of collection regardless of category should be at the
start of every shift.

C
HOSPITAL BUILDING

HOSPITAL BUILDING
C C

C C

HOSPITAL
BUILDING
OPEN
SPACE
CC

OPEN SPACE

T OPEN SPACE T

R O A D

APPROXIMATE AREA 10,000 SQ.M

C - COLLECTION POINTS (ROLLING CONTAINER DRUM)
T - TRANSFER STATION (TRAILER, CONC. ENCLOSURE TWO LEVEL TRANSFER)

Figure 10. Typical Route Layout of Hospital Collection System

 Figure 11. Simple Two-Level Transfer Station

CONCRETE
ENCLOSURE

TRANSFER
STATION
WALLS GUARD GARBAGE
TRUCK

R O A D
PLAN SECTION

SIMPLE FORM OF TRAILER OR CONCRETE ENCLOSURE ON LEVEL SITE

TRAILER

RAMP

ABOUT 30M

SPLIT LEVEL TRANSFER STATION BY GRAVITY

GARBAGEN AT

ROAD
ELEVATED TRANSFER CONCRETE
STATION ENCLOSURE

RAMP UP GARBAGE
PLAN TRUCK

SECTION
 CHAPTER 6
WASTE TREATMENT
AND
DISPOSAL SYSTEM
Health Care Waste Management
Manual

6.1 Health Care Waste Treatment

The purpose of treating health care waste is to change the biological and chemical
character of the waste to minimize its potential to cause harm. There are a number of
terms used to denote the level of treatment, such as decontamination, sterilization,
disinfection, render harmless and kills. These terms do not provide any mechanism of
measuring the degree of process efficiency. As such, it is critical that terms and criteria
be established that quantitatively define the level of microbial destruction accomplished
by any health care waste treatment process.

Sterilization is defined as a 6log10 survival probability of the most resistant

microorganism of concern in a given process and disinfection is defined as low,
intermediate or high (using the Spaulding system) depending on the survival probability
of specific microbial groups. For medical waste disinfection, however, the emerging
international consensus is to define levels of microbial inactivation as follows:

Level I Inactivation of vegetative bacteria, fungi, and lipophilic viruses at a

6log10 reduction or greater

Level II Inactivation of vegetative bacteria, fungi, lipophilic/hydrophilic viruses,

parasites, and mycobacteria at a 6log10 reduction or greater

Level III Inactivation of vegetative bacteria, fungi, lipophilic/hydrophilic viruses,

parasites, and mycobacteria at a 6log 10 reduction or greater; and
inactivation of B. stearothermophilus spores and B. subtilis spores at a
4log10 reduction or greater

Level IV Inactivation of vegetative bacteria, fungi, lipophilic/hydrophilic viruses,

parasites, and mycobacteria, and B. stearothermophilus spores at a
6log10 reduction or greater

Mechanical grinding devices are sometimes introduced prior to treatment, during

treatment, and/or at the end of the treatment process. A few facilities insist on
shredding the health care waste either as a matter of preference or because they
falsely believe that their liability will somehow be limited. Some technologies, however,
depend upon shredding as an integral part of the treatment process, i.e., those systems
that shred prior to treatment and during treatment. Shredders are typically a high
maintenance item due to unavoidable volumes of trapped waste in the waste stream,
such as high-quality stainless steel found in orthopedic blades, drills, reamers, and
prosthetic devices. Glass is also inherent in the health care waste and over time, glass
wears the cutting surfaces of the shredder blades. Therefore, if the facility intends to
shred waste either pre- or post-treatment, anticipate that a rigorous maintenance
schedule with associated cost would be required. Shredding the waste simply to render
it unrecognizable makes the task more burdensome and more expensive than
necessary and a cost benefit analysis should be conducted prior to making that
decision. Also, consider the potential down time when the shredder is out of
commission with those technologies that depend upon shredding.

Waste Treatment and Disposal 39

System
Selection Criteria of Treatment Technology

On-site treatment of health care waste allows health care facility to have more control
over both the waste disposal process and waste disposal cost. Treatment system
maybe a cost-effective alternative and many manufacturers have already simplified
their systems so that processing is relatively effortless.

Hospital and other health care establishments should perform a preliminary

assessment and determine the issues that are important to the facility. Develop a list of
selection criteria and rank in order of importance. In selecting a technology, the
following key points should be considered:

 Treatment efficiency

 Occupational health, safety and environmental considerations

 Volume and mass reduction

 Types and quantity of wastes for treatment and disposal/capacity of the system

 Infrastructure and space requirements (investment and operational cost)

 Locally available treatment options for final disposal

 Training requirements for operation of the method

 Operation and maintenance considerations

 Location/surrounding of the treatment site and disposal facility

 Social and political acceptability

 Regulatory requirements

These criteria are also applicable in selecting off-site treatment technology for health
care wastes.

Health Care Waste Treatment Technologies/Processes

Incineration used to be the method of choice in treating health care waste. However,
with the implementation of the Clean Air Act of 1999, the use of this method is no
longer allowed. With this development, alternative technologies are being looked into to
address the problem on health care waste management using the aforementioned
selection criteria.

Most common technologies and processes used in health care waste treatment are (1)
thermal, (2) chemical, (3) irradiation, (4) biological processes, (5) encapsulation, and (6)
inertization.
1. Thermal Processes

Thermal processes rely on high heat to destroy pathogens (disease-causing

microorganisms).

 Pyrolysis - Pyrolysis is the thermal decomposition of substance and materials in

the absence of supplied molecular oxygen in the destruction chamber in which
the said material is converted into gaseous, liquid, or solid form. Pyrolysis can
handle the full range of health care waste. Waste residues may be in form of
greasy aggregates or slugs, recoverable metals, or carbon black. These
residues are disposed of in a secure facility i.e. sanitary landfill.

 Wet and Dry Thermal Treatment - Wet thermal or steam disinfection is based
on exposure of shredded infectious waste to high temperature, high pressure
steam, and is similar to the autoclave sterilization process. It inactivates most
types of microorganisms if temperature and contact time are sufficient. For
sporulated bacteria, a minimum temperature of 121 oC is needed and exposure
time of 30 minutes. For sharps, milling or crushing is recommended mainly to
eliminate physical hazards from needles, render syringes unusable, and reduce
waste volume as well as increasing the surface area subject to exposure to high
temperature and high pressure steam subsequently increasing the efficiency of
the treatment.

 Autoclave - Autoclave uses steam sterilization to render waste harmless

and is an efficient wet thermal disinfection process. This technique has been
used for many years in hospitals for the sterilization of reusable medical
equipment.

Autoclaves come in a wide range of sizes. A typical autoclave designed for

medical waste treats about 100 kg per cycle (a cycle being about 1 hour) to
several hundred kilograms per cycle for larger hospitals. Autoclaves used in
centralized treatment facilities can handle as much as 3,000 kg in one cycle.

The microbial inactivation efficacy of autoclaves should be checked

periodically. For autoclaves that do not shred waste during steam
disinfection, color-changing indicator strips may be attached to the outside of
the yellow bag in the middle of each load and that the strip be checked to
ensure that steam penetration has occurred. In addition, a microbiological
test (using for example commercially available validation kits containing
bacillus stearothermophilus spore strips, vials or packs) should be
conducted periodically.

 Microwave – This technology typically incorporates some type of size

reduction device. Shredding of wastes is being done either before
disinfection or after disinfection. In this process, waste is exposed to
microwaves that raises the temperature to 100 oC (237.6oF) for at least 30
minutes. Microorganisms are destroyed by moist heat which irreversibly
coagulates and denatures enzymes and structural proteins.

The efficiency of microwave disinfection should be checked routinely through

bacteriological and virological tests. The microwave process is widely used
in several countries and is becoming popular. However, the system has a
relatively high investment and operating costs. The process is inappropriate
 for the treatment of anatomical waste and animal carcasses, and will not
efficiently treat chemical or pharmaceutical waste.

2. Chemical Disinfection

Chemical disinfection is now being applied for treatment of health care waste.
Chemicals like aldehydes, chlorine compounds, phenolic compounds, etc. are
added to waste to kill or inactivate pathogens present in health care waste.
Chemical disinfection is most suitable in treating blood, urine, stools and sewage.
This method is also applicable in treating infectious wastes containing pathogens. If
possible, wastes should be shredded to increase the extent of contact between
waste and the disinfectant by increasing the surface area and eliminating the
enclosed space. However, application of this method should only be done when
there is no available treatment facility in the area to prevent environmental problems
associated with the disposal of chemical residues.

Some chemical systems use heated alkali to destroy tissues, organs, body parts,
and other pathological wastes that can be used to treat contaminated animal waste
and cytotoxic waste as well.

Chemotherapy waste (including bulk cytotoxic agents) can be treated by chemical

decomposition. Examples are: reaction with 5% sodium hypochlorite; acid
hydrolysis followed by alkaline hydrolysis; reduction using zinc powder; degradation
using 30% hydrogen peroxide; or destruction using heated alkali.

Studies showed that chlorine-based technologies using sodium hypochlorite and

chlorine dioxide as well as its by products in wastewater may possibly have long-
term environmental effects. Non-chlorine based technologies are quite varied in the
way they operate and the chemical agents they employ. Others use peroxyacetic
acid, ozone gas, lime-based dry powder, acid and metal catalyst, or biodegradable
disinfectants. Also, occupational and safety exposures should be monitored when
using the chemical processes.

3. Biological Processes

The process uses an enzyme mixture to decontaminate health care waste and the
resulting by-product is put through an extruder to remove water for sewage
disposal. The technology is suited for large applications and is also being developed
for possible use in agricultural sector. The technology requires regulation of
temperature, pH, enzyme level, and other variable. Design application is mainly for
regional health care waste treatment center.

Composting and vermiculture as biological processes for treating and disposing of

placenta waste, as well as food waste, yard trimmings and other organic waste is
also recommended.

4. Radiation Technology

The disposal of biologically contaminated waste from hospitals, clinics and

laboratories is of particular concern. Waste containing potentially infectious
microorganisms (sewage sludge, biomedical wastes, wastewater) are treated using
irradiation systems which are currently being used in waste treatment operations.
The four main elements of the waste handling system are: (1) identification of the
contaminated waste, (2) collection, (3) sterilization and (4) final disposal or
recycling.
 Machines generating high energy electron beams, among other types, can sterilize
a wide range of waste. If regulations permit, the processed material can then be
directed to general waste disposal or recycling operations.

Sterilization is achieved by breaking down the DNA molecules of the contaminated

organism. Ionizing radiation is very efficient at DNA disruption, and requires far less
total energy than would be used in an equivalent thermal process. Their use in the
disinfection of sewage sludge has been demonstrated on a full-scale basis at a
plant near Munich, Germany; and at a biomedical waste sterilizer in Arkansas, USA
for the treatment of hospital waste.

5. Encapsulation

Encapsulation involves the filling up of containers with waste, adding and

immobilizing material, and sealing the containers. The process uses either cubic
boxes made of high-density polyethylene or metallic drums, that are three quarters
filled with sharps or chemical or pharmaceutical residues. The containers or boxes
are then filled up with a medium such as plastic foam, bituminous sand and cement
mortar. After the medium has dried, the containers are sealed and disposed of in
landfill sites. The process is particularly appropriate for the disposal of sharps and
chemical or pharmaceutical residues. The main advantage of the process is that it is
very effective in reducing the risk of scavengers gaining access to the health care
waste.

6. Inertization

Especially suitable for pharmaceutical waste is the process of inertization that

involves the mixing of the waste with cement and other substances before disposal.
This is to minimize the risks of toxic substances contained in the waste migrating
into surface water or groundwater. For the inertization of pharmaceutical waste, the
packaging should be removed, the pharmaceuticals ground, and a mixture of water,
lime and cement added. The homogenous mass produced can be transported to a
suitable storage site. Alternatively, the homogenous mixture can be transported in
liquid state to a landfill and poured into municipal waste. The process is relatively
inexpensive and can be performed using relatively unsophisticated equipment. The
following is the typical proportion for the mixture: 65 % pharmaceutical waste, 15 %
lime, 15 % cement, and 5 % water.

Siting of Waste Treatment Facilities

Some treatment facilities particularly larger ones would require a new structure to
house the technology or renovate existing space. Each technology have different
requirements for space, foundation, utility service connections, ventilation, and support
equipment. In determining a safe location for the facility, one must take into account the
safe transfer routes, average distances from waste sources, temporary storage
requirements, as well as space allowances needed by workers to maneuver safely
around the treatment unit. The location of the facility should not cause traffic problems
as waste is brought in and out. Odor, noise, the visual impact of medical waste
operations on patients and visitors, public access, and security should also be
considered.

In the past, the decision involving the location of the treatment system have been the
responsibility of engineers dealing with the foundation, electrical connections, sewer,
HVAC (heating ventilation and air conditioning) and utilities. By taking a team approach
and involving facility engineering, environmental services, housekeeping, safety or
industrial hygiene, infection control, and occupational health, important aspects such as
occupational safety and health become part of the decisions relative to siting and
installation.

6.2 Waste Disposal Systems

Sanitary Landfill

Sanitary landfill is an engineered method designed to keep the waste isolated from the
environment. Appropriate engineering preparations should be completed before the site
is allowed to accept waste. There should be trained staff present on site to control
operations, organize deposits and daily coverage of waste. Some essential elements
for the design and operation of sanitary landfill are:

 Access to site and working areas possible for waste delivery and site vehicles

 Presence of site personnel capable of effective control of daily operations

 Division of the site into manageable phases, appropriately prepared, before

landfill starts

 Adequate sealing of the base and sides of the site to minimize the
movement of wastewater (leachate)

 Adequate mechanisms for leachate collection and treatment systems are

necessary

 Organized deposit of waste in a small area, allowing them to be spread,

compacted and covered daily

 Surface water collection trenches around site boundaries

 Construction of a final cover to minimize rainwater infiltration when each

phase of the landfill is completed.

Safe Burial on Hospital Premises

In remote locations and rural areas, the safe burial of waste on the health care
premises may be the only viable option available at the time. However, certain rules
need to be established for the proper health care waste management. These include:

 Access to the disposal site should be restricted to authorized personnel only.

 The burial site should be lined with a material of low permeability, such as clay,
if available, to prevent pollution of any shallow groundwater that may
subsequently reach nearby wells.

 Only hazardous health care waste should be buried. If general health care
waste were also buried on the premises, available space would be quickly filled-
up.
 Large quantities (>1kg) of chemical/pharmaceutical wastes should not be buried.

 The burial site should be managed as a landfill, with each layer of waste
covered with a layer of earth to prevent odor, as well as to prevent proliferation
of rodents and insects.

 Burial site should not be located in flood prone areas.

 Hospital ground should be secured. (e.g. fenced with warning signs).

 The location of waste burial pit should be downhill or down-gradient from any
nearby wells and about 50 meters away from any water body such as rivers or
lakes to prevent contaminating sources of water.

 Health care facilities should keep a permanent record of the size and location of
all their on-site burial pits to prevent construction workers, builders, and others
from digging in those areas in the future.

 The safe burial of waste depends critically on rational operational practices. The
bottom of the pit should be at least 1.50 meters higher than the ground water
level. It should be noted that safe on-site burial is practicable only for relatively
limited period, say 1 to 2 years, and for relatively small quantities of waste, say
up to 5 to 10 tons in total. Where these conditions are exceeded, a longer-term
solution will be needed.

Figure 12. Schematic Cross Section of a Secure Landfill

Septic/Concrete Vault

This method is especially suitable for the disposal of used sharps and syringes. The
following procedures for the safe burial of sharps and syringes through septic/concrete
vault are recommended:

 Dig a pit (minimum size of 1 m x 1 m x 1.8 m depth), enough to accommodate

sharps and syringes for an estimated period of time without reaching the
groundwater level. The site must be isolated and at least 500 feet away from the
groundwater supply sources and dwelling units.

 Construct concrete walls and slabs of the pit. Provide slab with opening or manhole
for easy deposition of collected sharps and syringes. The manhole should be
extended a few centimeters above the soil surface to overcome infiltration of
surface water.

 Deposit the collected safety boxes filled with used sharps and needles inside the
septic/concrete vault.

 Install a security fence around the site.

 Figure 13. Burial Pit (Volume = 1x1x1.8)

W=1.
SECURITY FENCE

SOIL COVER 1% SLOPE

H=1.8m

SHARP WASTE 10 cm SOIL LAYER

SHARP WASTE LINER OF LOW PERMEABILITY

VARIABLE

(i.e. clay, hdpe, cement)

2.0 - 3.5m

GROUND H2O

Figure 14. Septic/Concrete Vault

0.10m

FOR
FUTURE USE
1.8m

1.0m 1.0m
 CHAPTER 7
WASTE MANAGEMENT
7.1 Characteristics of Wastewater from
Health Care Establishments

The basic principle underlying the effective wastewater management in health care
establishments is a strict limit on the discharge of hazardous liquids to sewers. The
quality of wastewater from health care establishment contains potentially hazardous
elements including:

 Microbiological pathogens (bacteria, viruses, and helminths), which are easily

transmitted through water;

 Small amounts of hazardous chemicals from cleaning and disinfection operations;

 Hazardous chemicals and pharmaceutical waste being generated from other

business establishments (clinics, laboratories and research centers, drug
manufacturers, mortuary and autopsy centers, cosmetics and tattoo parlors);

 Trace amounts of radioactive effluents from nuclear medicine laboratories;

 Wastewater or sewage from health care establishment can be discharged into

domestic (municipal or city) sewers without pre-treatment, provided that the
following requirements are met:

 The municipal sewers are connected to efficiently operate sewage treatment

plant that ensure at least 95 % removal of bacteria;

 The sludge resulting from sewage treatment plant is subjected to anaerobic

digestion, leaving no more than one helminth egg per liter in the digested
sludge;

 The hazardous wastewater having significant quantities of toxic chemicals such

as formaldehyde, pharmaceuticals, radionuclides, cytotoxic drugs and
antibiotics, coming from laboratories and research centers, clinics, mortuary and
autopsy centers should be discharged to a pre-treatment/neutralization tank for
sewage (toxic) neutralization and disinfection by chlorination prior to discharge
or connected to the sewage treatment plant; and

 Excreta from patients being treated with cytotoxic drugs are collected separately
and adequately treated (as for other cytotoxic waste).

7.2 On-Site Treatment of Wastewater

When a health care facility cannot access a community sewage treatment plant it is
recommended that the establishment should have their own waste water treatment
plant. An efficient on-site wastewater treatment plant should include the following
operations:

Waste 49
Management
 Figure 15. Schematic Diagram of Wastewater Treatment

Chemical Waste

Preliminary TreatmentSecondary Treatment Final Treatment Effluent

Domestic Waste

Sludge Treatment

Disposal

 Primary Treatment - this includes multi-chamber septic tank, comprising of

primary sedimentation tank and digestive chamber. This action results in partial
biodegradation of organic pollutants. The effluent should be conveyed to the
secondary treatment facility for further oxidation of sewage.

 Secondary Treatment - this employs a complete biological process of treatment

including aeration and sedimentation system. It involves the importance of
aerobic microorganisms that will actually degrade the organic pollutants in the
effluent. The aeration phase is the introduction or supply of oxygen to the
system for the aerobic microorganisms. The sedimentation phase is the settling
of sludge and separation of clear water effluents. This combined system
signifies the higher purification and degradation of parameters such as BOD,
COD, TSS, Oil and Grease. The clear water should be conveyed to the tertiary
treatment while the sludge shall be conveyed to the sludge treatment.

 Tertiary Treatment - In order to meet the standard parameters prescribed by the

DENR Administrative Order No. 35 series 1990, this stage should therefore
serve as the final treatment. The clear water will pass through micro filter and
chlorine disinfection before being discharged to the nearest drainage or body of
water. Due to outbreaks of enteric diseases and occurrence of waterborne
diseases and other critical periods, UV-Hygienization is further recommended.
This process involves the use of UV-Radiation of 254 - mm wavelength.

 Sludge Treatment - A supplement to the Implementing Rules and Regulations

(IRR) of Chapter 17, “Sewage Collection and Disposal and Excreta Disposal
and Drainage” of PD 856 or the Sanitation Code of the Philippines, details the
collection, handling, transport, treatment and disposal of “Domestic Sewage and
Septage”.

Health care establishments may apply a combination of the treatment process

enumerated in the above section depending on the volume and characteristics of their
wastewater.

Waste 50
Management
7.3 Factors to be Considered in the
Establishment of Wastewater Treatment Plant

To have an efficient and cost-effective establishment of on-site wastewater treatment

plant, it is important to have an objective approach in considering the following factors:

 Quantity of wastewater for treatment and disposal

 Type of wastewater for treatment and disposal
 Location of the treatment and disposal facility
 Infrastructure requirements
 Treatment efficiency
 Locally available equipment and parts
 Space availability
 Investment and operating cost
 Operation and maintenance
 Training requirement for operation
 Regulatory requirements

7.4 Safety Requirements

Measures to minimize health risks should be implemented in health care establishments

that cannot afford any sewage treatment plant such as:

 Patients with enteric diseases should be isolated in wards where their excreta
can be collected for chemical disinfection. This is of utmost importance in case
of cholera outbreaks, for example, and strong disinfectants will be needed.

 No chemicals or pharmaceuticals should be discharged into the sewer.

 Sewage from health care establishments should never be used for agriculture or
aqua cultural purposes.

 Health care sewage should not be discharged into natural water bodies that are
used to irrigate fruit or vegetable crops, to produce drinking water, or for
recreational purposes.

 Grease, oil and paints should not be discharged into the sewer line

Waste 51
Management
7.5 Sanitary Requirements

Human excreta are the principal vehicle for the transmission and spread of a wide
range of communicable diseases, and excreta from health care patients may be
expected to contain far higher concentration of pathogens, and therefore are far more
infectious, than excreta from households. This underlines the prime importance of
providing access to adequate sanitation in every health care establishment. The health
care establishment should ideally be connected to a sewerage system.

7.6 Regulatory Requirements

All implementing rules and regulations of all concerned agencies (local and national)
and all existing laws shall be strictly followed. Chapter 9 provides a discussion of
applicable environmental laws and regulations for health care establishments.
 CHAPTER 8
FINANCING OPTIONS FOR
HEALTH CARE WASTE MANAGEMENT

53
Health Care Waste Management
Manual

The shift to a regime that improves health care waste management to conform to
current laws and policies of the government entails additional costs to health care
establishments. An understanding of the costs of the waste management hierarchy is
necessary in order for the establishments to determine what options it needs to take.
Each step in the waste management hierarchy should therefore be examined with
respect to the costs it will entail.

 Can the investment be done by the organization/establishment itself with its own
funds?
 Does it need to partner with other organizations/establishments?
 Does the organization/establishment need to take out a loan to invest in such
technologies and facilities?
 Can the treatment be done off-site by an accredited treater?

This manual lists a few of the options available to establishments to treat their wastes
and this chapter allows these options to be examined in relation to the effort and
resources that are needed to operationalize them.

8.1 Cost and Benefits of Source Reduction,

Recycling, and Reuse

As discussed in Chapter 4, source reduction and recycling or reuse are the first
approaches in the waste minimization hierarchy that could help reduce the bulk of
health care wastes for disposal. Source reduction either means elimination of the waste
by using other materials or using less of the material through improved practices.
Reuse and recycling consider alternative uses for the materials that are otherwise
already regarded as wastes that will be bound for disposal. Some of these efforts may
mean less cost to the establishment in the long run. What is advantageous to health
care establishments is that even the companies that supply their needs are themselves
practicing waste reduction. An example is the increasing use of repairable and reusable
products which companies are re-engineering to lessen its disposal cost. The main cost
to health care establishment is the in-depth study of all the waste streams of the
establishment to determine what alternatives can be made with regards to source
reduction, reuse, and recycling. Alternatives can include the following:

 Reduction of the amount of material used to accomplish tasks. An

example of this is to use email to reduce the use of paper in the facility. A
smaller amount of disinfectant may be adequate to clean rooms.

 Purchase of materials that may be reused and recycled. This may mean a
higher initial cost at the onset but cost savings more than makes up for these
initial costs. What must be needed is a firm accounting of all the costs attributed
to a material, including disposal costs. For example, the purchase of reusable
salad plates for the hospital cafeteria by Itasca Medical Hospital in Minnesota
may have been more expensive at the onset but it reduced wastes by 94% and
generated savings of about US$2200 per year. Examples of sterilization
methods for recyclable materials include the following:

Financing Options for Health Care Waste 54

Management
 o Thermal sterilization

 Dry sterilization Exposure to 160 °C for 120 minutes or 170 °C

for 60 minutes in a “Poupinel” oven.
 Wet sterilization Exposure to saturated steam at 121°C for
30 minutes in an autoclave.

o Chemical sterilization

 Glutaraldehyde Exposure to a glutaraldehyde solution for 30

minutes. This process is safer for the operators than the use
of ethylene oxide but is microbiologically less efficient.

 Reduction of the toxicity of the materials used. This diminishes both the
disposal costs and the hazards to the health workers. An example is the use
of non-toxic x-ray developing solution at the same cost that does not diminish
the quality of processed x-ray film.

 Practice just in time delivery. This allows the establishment to minimize on

wastes incurred because of expiry of items like drugs and chemicals. Many
industries already practice this. It also allows them less space for storage of
materials and places the burden of storage on the supplier. A supply chain
management cycle must be instituted within the establishment to make this
work; big firms like Nestle, for example, have supply chain structures in place to
insure that only adequate amounts of raw materials are purchased for
production to meet the demand forecast for the week.

 Practice good management and control measures at the hospital level.

This means that the purchase and use of chemicals and pharmaceuticals
should be centralized with a central monitoring of chemical flows within the
hospital premises.

The central idea in accounting for these costs is to allow health care establishments to
understand that source reduction, recycling, and reuse may result in lower operating
costs for the facility in the long run. While these may entail a change in the way the
establishment conducts business, the tangible benefits should provide the impetus for
change. Costs like the staff time required to set up a waste minimization plan and the
implementation of information and education strategy for the personnel should also be
included; all of which would result in a better understanding of waste streams and better
operations for the establishment as a whole.

8.2 Cost and Benefits of Health Care Waste

Treatment Options

A major portion of health care wastes still has to be treated to remove its toxic and
infectious nature prior to final disposal. This amounts to about 7 to 15% of the
establishment’s total wastes, if we look into statistics from American hospitals 1. Several

1
Medical Waste Treatment Technologies. Evaluating Non-Incineration Alternatives. Health Care
Without Harm. May 2000
technologies are available to treat these wastes. Investment in on-site treatment
facilities may be costly but allows the establishment to control the manner by which the
waste is treated and the costs associated with treatment. Off-site treatment facilities,
when available, may be more costly in the long run but allows the establishment to
concentrate on its basic occupational function and not on operations it is not built to do,
which is the treatment of wastes.

In some of the health care treatment technologies, waste is first subjected to shredding,
mainly to increase the contact of the reducing agent with the waste, to decrease the
volume of the final output, or to render the waste unrecognizable at the output streams.
The world’s most common technologies are based on steam or steam and vacuum and
microwave sanitation.

Health care establishments should evaluate the technologies indicated in Chapter 6 of

this guide to determine which is most appropriate for the wastes they produce and is
within the budget they have appropriated for the facility. Since the Clean Air Act has
banned incineration, there is a need to scour the marketplace for less expensive but
complete treatment systems, i.e. systems that remove all infectious and toxic character
of hospital wastes without introducing new pollutant streams into emission and effluent
systems.

A general discussion of the cost and capacities of the technologies discussed in

Chapter 6 are presented below. The indicated prices are for the equipment purchase
only from suppliers in the United States. Such prices do not include freight charges for
shipment, which may increase the purchase cost by 10% or more. Additional cost items
such as a building for the equipment and auxiliary facilities may increase the total
capital cost depending on the facility design.

High Temperature Systems / Pyrolysis

Pyrolysis involves the thermal decomposition of substance and materials in the

absence of supplied molecular oxygen in the destruction chamber during which the
material is converted into gaseous, liquid, or solid form. Included among these zero-
oxygen pyrolysis technologies are:

 Plasma pyrolysis
 Induction-based pyrolysis
 Laser-based pyrolysis

Pyrolysis can handle the full range of medical toxic and infectious wastes, including
bulk chemotherapy waste, many hazardous substances, spent solvents and chemicals
(e.g., formaldehyde, glutaraldehyde, xylene, isopropanol, etc.), expired
pharmaceuticals, low- level radioactive waste, except mercury. The waste residue is
practically sterile and low combustible gas emissions can be expected. Waste mass for
disposal is drastically reduced. However, poorly designed pyrolysis systems may still
emit dioxins and may be prone to equipment failures. The installation costs may also be
very high for a small throughput. Electricity costs may also be substantial.

The economics of pyrolysis systems become better if energy is recovered from the
pyrolysis gases of medical wastes. Induction-based pyrolysis is still in the planning and
demonstration stage. Plasma pyrolysis is likewise new and has little experience in the
health care waste as is laser-based pyrolysis.
Plasma pyrolysis uses a plasma arc torch in a pyrolysis chamber that heats the waste
to about 1,650oC. The wastes here are completely destroyed, forming a product gas
that has hydrocarbons and has a significant heating value. The solid residue from
plasma technologies may include carbon black, vitrified glassy aggregates, and metallic
residues and are inert. Plasma pyrolysis, however, are designed mainly for high
capacity, large- scale operations and have high capital and operating costs.

Laser plasma pyrolysis technology uses a high-energy laser that creates temperatures
of 3,300 to 5,500oC. It produces the same outputs as a plasma pyrolysis system
although is much more expensive. The technology has been tested to treat hazardous
solvents, shredded tires, PCBs, waste oils, diesel fuel, and municipal solid waste.
Capacities range from five to 100 tons per day.

Table 2 shows the comparative approximate capital costs of the pyrolysis systems.

Table 2. Approximate Capital Costs of Pyrolysis Systems

Pyrolysis Operating Approximate Range of Cost

Capacity and Technology (PhP)2
PLASMA PYROLYSIS
One to 10 ton/day units 33,000,000 – 55,000,000
LASER BASED PYROLYSIS
5 to 100 tons/day 440,000,000 to 1.375 billion

Wet and Dry Thermal Systems

This type of treatment technology includes the following:

 Autoclaves and Retorts

 Microwave systems
 Electro Thermal Deactivation Systems
 Dry heat Treatment Systems
 Vacuum Steam Compaction

Autoclaves and retorts (which are similar to autoclaves but without a steam jacket) are
easy to operate and are available in various sizes. It is a proven technology to disinfect
infectious wastes but does not reduce the waste volume as pyrolysis does nor does it
deactivate toxic chemical components in the waste stream. These toxic chemical
substances may find their way into the output streams. Costs for autoclaves vary
across vendors. Front end engineering devices such as one-stage and two stage
shredders and conveyor systems must also be installed. Shredders and compactors
after the process may also be needed. Additionally, wastewater systems and air
pollution control devices should be installed to guard against the introduction of both
organics and toxics into the air and water waste streams. Autoclave bags must also be
purchased.

The types of waste commonly treated in autoclaves are: cultures and stocks, sharps,
materials contaminated with blood and limited amounts of fluids, isolation and surgery
wastes, laboratory wastes (excluding chemical waste), and soft wastes (gauze,
2
Ibid. Costs are taken from US costs and based on an exchange rate of P55/US$
bandages, drapes, gowns, bedding, etc.) from patient care. Volatile and semi-volatile
organic compounds, bulk chemotherapeutic wastes, mercury, other hazardous
chemical wastes, and radiological wastes should not be treated in an autoclave or
retort. Huge and bulky bedding material, large animal carcasses, sealed heat-resistant
containers, and other waste loads that impede the transfer of heat should be avoided. 3
Poorly segregated wastes (i.e. wastes with mercury, heavy metals, some drugs) may
allow the release of toxics into the air and may cause bad odors. Hence, autoclaves
should be coupled with a good segregation regime. The waste is not diminished in
appearance and may even increase in volume and mass (due to water retention) after
autoclaving. Hence, a significant amount of waste still has to be disposed of.

Capacities of autoclaves vary widely depending on the intended use. The sizes may
start from small autoclaves having a capacity of 18 lbs/hr to large systems capable of
more than 6,000 lb per cycle. Autoclaves can even be custom designed. Depending on
the size of the autoclaves and the engineering units that are installed before and after
the process unit, the costs may fall from a few hundred thousand to over PhP15 million
with complete systems. Most of these systems require steam at 55-60 psig. The
following table shows the approximate cost ranges of autoclave systems at various
capacities.

Table 3. Approximate Capital Costs of Autoclave Systems

Autoclave Operating Approximate Range of Cost

Capacity (PhP)4
100 lbs/ cycle5 1,000,000 to 5,000,000
250 lbs/cycle 1,500,000 to 5,600,000
450 lbs/cycle 1,800,000 to 6,200,000
750 lbs/cycle 2,000,000 to 6,700,000
1,500 lbs/cycle 2,500,000 to 9,600,000
SHREDDERS 2,750,000 to 4,300,000
COMPACTOR 1,000,000
AUTOCLAVE BAGS (100s) 1,000 to 7,000
AUTOCLAVE CARTS 55,000 – 80,000

In the last decade, second generation of steam-based systems have been developed
for the purpose of improving the transfer of heat into the waste, achieving more uniform
heating of the waste, rendering the waste unrecognizable, and/or making the treatment
system a continuous (rather than a batch) process. These new systems have
sometimes been referred to as advanced autoclaves. These systems basically function
as autoclaves or retorts but they combine steam treatment with pre-vacuuming and
various kinds of mechanical processing before, during, and/or after steam disinfection.
These technologies, similar to autoclaves, include:

 Vacuum/Steam Treatment/Compaction
 Stream Treatment-mixing-fragmentation/drying/shredding or Rotoclaves
 Shredding/Steam Treatment-Mixing/Drying and Chemical Cleaning
 Steam Treatment-Mixing-Fragmenting/Drying or the Hydroclave
 Shredding-Steam Treatment-Mixing/Drying or Steam Sterilization Macerator

3
4
Non-Incineration Medical Waste Treatment Technologies. Health Care Without Harm. August 2001
Ibid. Costs are taken from US costs and based on an exchange rate of P55/US$
5
Cycle = about 1 hour
Health Care Waste Management
Manual

 Shredding-Steam Treatment-Mixing-Compaction

These technologies are generally more expensive than autoclaves since they integrate
into their systems the shredding, compacting, and other innovations needed by ordinary
autoclaving systems. Some systems, specifically those with integrated shredders, allow
the treatment of anatomical wastes previously untreatable in autoclave systems
because of aesthetic reasons.

A Vacuum/Steam Treatment/Compaction treatment device operates as a part-

autoclave, part compactor system. The autoclave cycle begins with a high vacuum to
remove air, followed by exposure to 150°C steam. The chamber is allowed to reach
temperatures of 140oC (about 38 psig). After treatment, the waste is automatically
conveyed to the compaction chamber. The compactor section can be used separately
for regular trash. Capacities range from 25 lbs to 2,240 lbs/hr. Capital costs vary and is
given in the following table

Table 4. Approximate Capital Costs of Vacuum/Steam Treatment/Compaction

Operating Capacity (lbs/hr) Approximate Range of Cost (PhP)6

25 1,430,000
160 8,470,000
560 15,730,000
2,240 Over 27,500,000

Steam Treatment-mixing-fragmentation/drying/shredding device changes the standard

autoclave into a rotating drum, thereby combining steam treatment with agitation that
serves to break up or fragment the waste. Drying and shredding are added. Capacities
are from 109 cu ft per cycle (50 mins) to 1,038 cu ft per cycle. The smallest units cost
PhP21,000,000.00.

Shredding/Steam Treatment-Mixing/Drying and Chemical Cleaning devices are

primarily steam treatment units, with a chemical disinfectant process (hypochlorite)
mainly for cleaning the equipment during shutdown or maintenance and for odor
control. 600 and 1000 lb per hour systems are available and should cost about
PhP20,200,000 and PhP23,500,000 respectively.

The Hydroclave steam treatment units combine the idea of an autoclave (except that
steam is applied to an outside jacket only) and agitation in a way that breaks up or
fragments the waste for more even heating. Model capacities are from 250 to 2000 lbs /
hour and capital costs are from PhP11,000,000 to over PhP27,500,000, depending on
the size.

Shredding-Steam Treatment-Mixing/Drying device combines internal shredding or

maceration with steam treatment and mixing, followed by a dewatering process. In
1996, the device was installed and tested at John Hopkins University School of
Medicine, and later at Franklin Square Hospital/Helix Health System. A model that
handles 150 lbs of waste / hour costs about PhP11,000,000.

8
Ibid. Costs are taken from US costs and based on an exchange rate of
P55/US$
59
Financing Options for Health Care Waste Management
Shredding-Steam Treatment-Mixing-Compaction devices feed health care waste into a
funnel through a hydraulic lift mechanism and then shredded after the funnel lid is
closed. Steam is added. The waste is then carried by a rotating screw that is heated
using an oil jacket heating system. The waste is both heated and compressed on its
way to the discharge end. A model that can handle 440 lbs per hour of waste would
cost about PhP52,500,000.00.

Microwave systems are more expensive than autoclaves but are easier to use and
operate. Some systems have the additional advantage of producing no effluents.
However, toxics are not deactivated by this method and may be released into the air or
remain in the waste. If segregation is practiced, these toxics may be reduced in the
ensuing emissions. Microwaves typically treat the same kind of wastes as autoclaves
and retorts.

Before the process, the waste is shredded, then granulated. The waste is then
humidified, and the air, permeated with hot steam up to the temperature of 110°C, is
removed through a system of filters. The waste is moved to a waste collection chamber
where it is heated by microwave generators for 20 to 30 minutes. The waste volume is
reduced by up to 80%, however, weight remains unchanged. Odors may be less
significant than microwave systems. Any large metal object in the waste could likewise
damage the system. The electricity required is nominally about 0.1 kWh per pond of
waste 7A full microwave system may cost from PhP27 Million to PhP33 Million.

Table 5. Approximate Capital Costs of Microwave Systems

Microwave Operating Approximate Range of Cost (PhP)8

Capacity (lbs/cycle)
220-400 27,000,000
550-900 33,000,000

Chemical Disinfection

This type of technology includes the following:

 Sodium Hypochlorite-Hammermill
 Sodium Hypochlorite-Shredding (mobile)
 Chlorine Dioxide-Shredding/Grinding
 Ozonation
 Electrocatalytic Wet Oxidation
 “Stericid”-Shredding-Mixing MCM Environmental Technologies (Gilboa, Israel)
 Dry Inorganic Chemical-Shredding
 Peracetic Acid-Grinding
 Alkaline Hydrolysis

Chemical disinfection systems have been in use for decades and are well understood.
Liquid effluents can generally be disposed of in the sanitary sewers; however, the large-
scale use of chlorine agents may introduce toxic substances in the air and wastewaters.
Chemical disinfection generally can treat the same wastes as autoclaves. Chemical and
radiological wastes generally cannot be treated through chemical disinfection. Likewise,

7
Non-Incineration Medical Waste Treatment Technologies. Health Care Without Harm. August 2001
Health Care Waste Management
Manual
body parts and animal carcasses are excluded for aesthetic reasons. Segregation
should be practiced prior to chemical disinfection processes to eliminate these chemical
and radiological wastes from entering; otherwise these wastes may be found in the
process end-streams. Chlorine systems may cost about PhP15 Million for a 3,000-
lb/hour system.

Non-chlorine processes are quite varied – from systems that use gas such as ozone, a
liquid such as alkali (sodium or potassium chloride) to a dry chemical such as calcium
oxide. Ozone does not physically alter the waste, while some may initiate chemical
reactions that change the physical and chemical characteristics of the wastes.
However, most of these chemicals are corrosive and poisonous, and some are irritants.
Care has to be taken to limit worker exposure. Since some of the systems initiate
chemical reactions, toxic chemicals may be treated. Alkaline hydrolysis, for example,
may treat aldehydes, fixatives, and cytotoxic agents apart from tissue wastes, animal
carcasses, anatomical parts, blood, and bodily fluids. Such systems are mainly
specialized and costs may vary widely.

Table 6. Approximate Capital Costs of Chemical Disinfection Systems

Pyrolysis Operating Capacity Approximate Range of Cost (PhP)9
and Technology
SODIUM HYPOCHLORITE -HAMMERMILL
3,000 lb/hr 16,250,000
PERACETIC ACID GRINDING
5-8 lbs/ 10 min 110,000
ALKALINE HYDROLYSIS
600 lbs/hr 20,000,000
1000 lb/hr 23,500,000

Biological Processes

There had been a very few biological systems made for medical wastes10. These are
still in the planning and development stages and are not yet mature for the commercial
market. Establishments which would like to go into biological treatment process should
study first the pros and cons of investing in such technologies.

Radiation Technology

Radiation technology is well understood in the health industry since it is used in other
applications like cancer therapy. It does not produce any toxic emissions (except for a
small amount of ozone) and produces no liquid effluents. An advantage is that nothing
is added to the waste; no steam, water, chemicals nor heated air. It also has a low
operating cost. The main disadvantages are also integral to radiation systems; workers
should have radiation protective wear, concrete or tin shields should be built, low-level
radiation may be induced. Radiation systems also do not diminish the amount of waste
nor make them unrecognizable. Again volatile and semi-volatile compounds,
chemotherapeutic wastes, hazardous wastes, and radiologic wastes should be treated
in radiation treatment systems.

9
10
Ibid. Costs are taken from US costs and based on an exchange rate of P55/US$
Ibid

Financing Options for Health Care Waste 61

Management
A system that treats wastes at a rate of 400 to 550 pounds/hr may cost about PhP19.25
Million. However, this type of technology is still in its demonstration stage and the
feasibility of partnering with the technology provider for a demonstration unit has to be
studied.

The following table presents a comparison of the different treatment methods that are
applicable to health care wastes.

Table 7. Side-by-Side Comparison of Different Treatment Methods of

Health Care Wastes That Are Commercially Available

Features Autoclave Microwave Pyrolysis Chemical

Systems Treatment
Treatment Steam treatment Microwave Pyrolysis chamber at Chemical (sodium
Method generator elevated hypochlorite) and
frequency temperatures mechanical
(hammermill)
Feed Shredding after Shredding and Boxed Shredding and
preparation disinfection granulation grinding
Operating 120-160oC 110oC max Plasma Pyrolysis: None
Temperature 1650 oC

Laser Pyrolysis:
3,300oC-5,500 oC
Energy Boiler 75 kW 300 kW 400 Volts
Capacity 100-1,500 lbs/hr 230-900 lbs/hr Plasma Pyrolysis: 30-3,000 lbs/hr
1-10 tons/day

Laser-Based
Pyrolysis:
5-100 tons/day
Unrecognizable Yes Yes Yes Yes
waste
Waste Volume 80-85% with 80-85%, 80-95% reduction 60-90% with
% Reduction shredder, mass however, mass both in mass and in shredding and heat
essentially the remains volume depending treatment
same essentially the on the waste matrix
same
Residues Inert waste Inert waste Inert slag and Chemical wastes for
combustible gases treatment
Treatment Level IV III IV IV
Environmental Possible odors Odor problem in No liquid effluent Very high noise levels,
Pollutants immediate offensive odor, liquid
vicinity effluents
Environmental Closed system Closed system Scrubber HEPA filters
Control with HEPA filters
 Features Autoclave Microwave Pyrolysis Chemical
Systems Treatment
Capital costs Autoclave: PhP1- PhP27-33 Million Plasma pyrolysis: Sodium hypochlorite-
4.6 Million PhP33-55 Million hammermill:
PhP16.25 Million
Shredders: Laser-based
PhP2.75-4.3 pyrolysis: PhP440- Paracetic acid-
Million 1,357 Million grinding:
PhP0.11 Million
Compactors: 1
Million Alkaline hydrolysis:
PhP20-23.5 Million
Autoclave bags =
PhP1,000-7,000;
advanced
autoclaves are
much higher in
capital costs
Advantage Waste suitable Waste suitable Waste suitable for Well-proven
for landfill; well- for landfill; well- landfill; Recovers at technology
proven proven least 80% heat in the
technology technology form of hot water
steam
Disadvantage Possible odors Possible odors;
Relatively high Chemical
large metal capital cost; maybe management and
object can extensive disposal required
damage the maintenance cost. because of use of
system May produce dioxins chemical reagents.
and furans at very
small quantities
Limitations No body parts, No body parts, No lead, cadmium, No human and animal
chemical and liquid blood and and mercury remains, chemical
pharmacological hazardous wastes
wastes; however, chemical
advanced substances
autoclaves can
treat anatomical
parts.
8.3 Other Factors to Consider in Selecting
Health Care Waste Treatment Technology

The decision about what health care waste technology to utilize goes far beyond cost
implications since this may have significant impact on the environment, the workers in
the establishment, and the surrounding community. Several questions need to be
asked and answered regarding this. 11 The following are some guide questions that
health care establishments can use when deciding what technology to use.

ON-SITE TREATMENT TECHNOLOGIES

 How important is volume reduction in choosing a technology? What is the ratio

of waste produced by your establishment to the waste treated by the treatment
technology? Is the technology dependent on a certain volume of material?
 How would waste reduction programs affect the process? If the waste volume
changes radically for any reason (e.g., reduced patient-days, merger, better
waste minimization efforts) will this technology still meet the treatment needs?
 Have staff from your establishment talked to colleagues at other establishments
about their disposal options, made comparisons, discussed technologies,
contracts and services, as well as violation histories and ranges of service
costs?
 What is the Philippine regulatory climate for onsite treatment technologies?
(Some types of technologies require more complicated permits than others)
Does your establishment have staff on-site that are trained and certified to fulfill
the testing requirements, time, etc., involved in these permits? If not, consider
those staffing and testing costs in your evaluation.
 How long has the treatment technology been in use, and where?
 What is the estimated “life” of this equipment?
 What volume of waste can the technology treat?
 Will it always be operating at peak capacity, or will there be wide variations in
the amount of waste treated?
 What are the operational cost implications of using this technology? What are
the environmental and fiscal impacts of utilities usage (electricity, water and
sewer)?
 What is the safety and repair history of the waste disposal equipment?
 What worker safety and ongoing equipment education is required and who
provides it?
 What are the cost(s) of equipment failure and need for a back-up or alternative
system?
 Is waste fed into the treatment system automatically (by machine) or by hand
(stop feed)? What impact does this have on your establishment’s staff
limitations?
 Can equipment repair be completed within 24 hours without an emergency
clause and/or additional costs?
 Does the technology require ancillary equipment such as shredders? Are they
an integral part of the treatment process?
 What are the total associated costs for this equipment?
 Are there any worker-safety concerns with this equipment?
 How is the volume and weight of the waste measured with the disposal
equipment? Who measures it? Is it cost-effective to weigh the wastes on-site?
11
Ibid.
OFF-SITE TREATMENT ISSUES (COMMERCIAL TREATMENT FACILITIES)

 How many trucks will enter and leave the facility daily? Will traffic vary by day of
the week, or remain fairly constant?
 From what geographic area will waste be accepted? What sort(s) of waste will
be treated?
 Is it possible to bargain collectively with area healthcare establishments for
waste treatment disposal services?
 Are there any environmental violations against the treatment facility your
establishment is considering? Is the facility fully permitted?
 Are there any community or environmental health concerns associated with this
off-site facility?

If the decision is to let an offsite facility treat the wastes, then the cost to be considered
would only be the charge of the waste treater and the associated transportation cost.
However, if the decision is to invest in an on-site facility, then the following costs need
to be considered:

 Capital equipment costs

 Installation and facility costs: installation labor, facility modifications - cement
pad(s), curb cuts, sewers, electricity, space, security, etc.
 Costs of pollution control equipment if required to control emissions and
effluents from the facility
 Direct labor costs: number of employees needed to operate the treatment and
disposal equipment
 “Down time” costs: including repair (parts and labor), and alternative treatment;
 Operating costs if the facility uses special chemicals and catalysts
 Utility Costs
 Permitting and compliance fees: water and air quality monitoring fees
 Fines: depending upon permitting requirements and state and federal
regulations, violations of permits or emissions may result in fines
 All transportation, processing and tipping fees
 Supply costs – Personal protective equipment, spill supplies, special bags (for
example, some autoclaving systems require particular bags), collection
containers (boxes or reusable containers)
 Community approval costs if a public hearing is required

8.4 Credit Financing for Environmental

Investments in Health Care Waste
Management

In case in-house funds are not available, there are numerous loan facilities that may be
availed by hospitals for its environmental investment projects particularly for waste
treatment. One of them is the Environmental Infrastructure Support Credit Program
(EISCP) of the Development Bank of the Philippines (DBP).
Environmental Infrastructure Support Credit Program - Phase II (EISCP II)

Type of Loans for financing the improvement of the quality of the environment through
Assistance: reduction or prevention of pollution.
Wholesale Development Bank of the Philippines
Establishment:
Eligible The program is available in Philippine Pesos for lending to investment
Borrowers: enterprises in the industry, mining and service sectors.
Eligible  Cleaner Production / Waste Minimization / Pollution Prevention
Projects:  Waste Recycling / Waste Treatment or Disposal System
 Conservation of Natural Resources (e.g., energy, materials)
 Occupational Health and Safety Improvements
 Wastewater Treatment Facilities
 Air Pollution Control Equipment
 Alternative Fuel Vehicles and Infrastructure
 Environmental Monitoring Instruments and Equipment
 Establishment of Environmental Management Systems (EMS)
and certification under ISO 14001
 Relocation of Pollutive Industry from Residential Area
Loan Features: Loan Area Nationwide
Interest Area Fixed throughout the term of the loan
Loan amount per Eligible expenditures up to a maximum of 80% of the
project total project cost
Repayment Period From 3 to 15 years with a maximum 5 years grace
period. Amortization payments shall be at least on a
semi-annual basis
Eligible Investment Filipino Citizens or corporations with at least 70%
Enterprises Filipino capital
Commitment Fee 0.75% per annum of the undisbursed amounts

Health care establishments and off-site waste treaters can avail of credit financing for
the operation of health care waste treatment equipment, wastewater treatment facilities,
and air pollution control devices.

Health care establishments can also apply for a loan under the Environmental
Infrastructure Credit Support Program (EISCP) Phase II for the acquisition of
hospital equipment that promotes cleaner technology. Examples of projects of
health care establishments that have been financed under EISCP are sterilization
equipment that eliminates the use of generation of toxic and hazardous gases,
diagnostic equipment that will replace old and inefficient equipment, conserve
energy, increase patient load, minimize worker exposure to radiation, and minimize
wastes.

8.5 Other Cost Factors in Health Care Waste

Management

Waste Segregation and Handling

The proper segregation and handling of wastes will entail some additional costs that
may or may not be offset by lower treatment and disposal costs since only the right
kinds of wastes go to specific disposal streams. These investments include:
  Costs of color-coded containers that should be placed in appropriate places in
the hospital.
 Cost of proper labels for the wastes.
 Cost of training personnel to place wastes in the appropriate container and to
handle them in a safe manner
 Cost of storage spaces within the facility for the wastes that should include
whatever measures should be put in place to secure and protect the wastes
when needed.
 Costs of personal protective equipment needed to safely and properly handle
wastes
 Cost of packaging the wastes for transport if the treatment facility is sited a
distance from the establishment
 Transportation costs if this will be borne by the establishment.

Segregation of wastes follows the waste management paradigm. This effectively

reduces the amount of wastes needed for transport to (if located off-site), treatment,
and disposal at the treatment facility. When done at the source, the facility may be able
to save on the maintenance personnel needed to sort through and segregate the
wastes when they are brought to the storage area. Segregation likewise may entail a
change in the operations management of the establishment. Investments in training and
equipment may not be offset by lower treatment costs. However, total costs to the
environment will diminish because the inclusion of materials that may release harmful
substances to the environment during treatment processes is lessened.

Disposal

Costs with regards to final disposal of treated waste streams should also be
considered. When systems that do not deactivate chemical and toxic agents are used
to treat wastes, additional processes such as encapsulation and inertization should be
considered. Disposal to a sanitary landfill is considerably more costly than disposal in
open dumpsites. Sanitary landfills may charge a higher fee for wastes coming from
medical establishments. In evaluating treatment options, costs with relation to final
disposal should be inputted since some treatment systems can almost eliminate wastes
altogether (pyrolysis) but some even increase the weight of wastes (steam systems
without dryers). Care should also be taken to render the wastes unrecognizable. Some
costs that should be considered when an on-site facility is used include the following:

 Construction of temporary storage and hauling areas for treated wastes

 Landfill tipping fees
 Labor costs for hauling, labeling, waste documentation, security, and
maintenance of temporary storage areas.
 Hauling costs
 Transport containers
 Costs related to wastes not handled by the hauler
 Cost of encapsulation, inertization, septic vault
 CHAPTER 9
POLICIES AND LEGISLATION
Health Care Waste Management
Manual
Several legislations have been enacted that form the basis of improving health care
waste management in the country. The implementation of these laws will enable the
different agencies concerned to provide the legal controls and permits for health care
facilities to operate within the framework and with due consideration to protect public
health or safely manage health care waste.

Some of these laws that were passed and are considered significant to an effective
management of health care waste are discussed hereunder and are grouped according
to the lead implementing agency.

9.1 DOH

Republic Act No. 4226

“Hospital Licensure Act”

The Hospital Licensure Act requires the licensure of all hospitals in the country and
mandates the DOH to provide guidelines for hospital technical standards as to
personnel, equipment, and physical facilities.

The revised rules and regulations (DOH Administrative Order No. 70-A) provides for the
registration, licensure, and proper operation of hospitals and other health care facilities.
Prior to application or renewal of license, submission of plans and other design
requirements of the Sanitation Code of the Philippines, National Plumbing Code,
National Fire and Building Code of the Philippines, Manual on Hospital Waste, and
Health Facilities Maintenance Manual are verified by the DOH. The planning and
design considers the following criteria:

 Location and the environment

 Occupancy
 Security
 Patient movements
 Lighting and ventilation
 Water supply
 Waste disposal

Presidential Decree No. 856

“The Code on Sanitation of the Philippines”

The Code of Sanitation of the Philippines mandates the DOH to promote and preserve
public health and upgrade the standard of medical practice. In line with the DOH
mandate, a Manual on Hospital Management was published in 1997 and the
Implementing Rules and Regulations of Chapter XVIII, Refuse Disposal of PD 856 was
promulgated.

The Manual on Hospital Management recommended color-coding scheme for

segregated wastes to avoid any accidents or hazards to personnel. When the DOH
released the IRR of Chapter XVIII, the classification of refuse/solid waste was
expanded by recognizing the existence of different types of hospital waste such as
biodegradable waste, chemical waste, infectious waste, pharmaceutical waste,
pathological waste, and radioactive waste. The IRR also provides the detailed sanitary
requirements for the segregation, storage, collection, transportation, and disposal of
refuse/solid waste.

Policies and 69
Legislations
In 2002, the Bureau of Health Facilities and Services of the DOH requires hospitals to
submit the approved plan on health care waste management prior to issuance or
renewal of license. The said office likewise required hospital establishments to submit
plans of wastewater treatment facilities.

Other DOH Requirements:

DOH Department Circular No. 156-C, series of 1993

“Provides guidelines on hospital waste management”

Specific instructions include:

"All undevolved government hospitals, clinics, laboratories, and research offices shall
incorporate satisfactory segregation, treatment, collection and disposal systems."

"All infectious and hazardous hospital waste shall be treated before storage, collection
and disposal."

"The use of appropriate technologies and indigenous materials for storage, treatment,
collection and disposal of hospital waste shall be utilized to support the country's
socioeconomic development program."

"All hospitals and other related institutions shall inform their staff and personnel about
the proper treatment, segregation (color coding) and storage, collection and disposal of
hospital waste"

DOH Memorandum No. 1-A, series of 2001

“Requiring the Department of Health Central Office, Centers for Health Development,
and all concerned hospitals to practice proper solid waste management”.

9.2 DENR

Presidential Decree No. 1586

“Environmental Impact Statement (EIS) System”

The Environmental Impact Statement (EIS) System of the Philippines or PD 1586

requires projects like construction of new hospital buildings or expansion of existing
hospitals to secure an Environmental Compliance Certificate (ECC) prior to
construction and operation of the facility. An ECC is required for the installation and
operation of health care waste treatment systems like pyrolysis, autoclave, microwave,
landfills, and other similar treatment technology discussed on Chapter 6.

Under the EIS System, a project proponent is tasked to undertake an environmental

impact assessment (EIA) study and to prepare an EIS or an IEE, depending on the
scope of the project. The EIS/IEE is a written report containing an assessment of the
most likely impacts of the project on the environment and on the people in the areas to
be affected by the project. The EIS/IEE is submitted to the DENR for review and forms
the basis for the approval or denial of the project’s ECC application.
Republic Act No. 8749
“Clean Air Act of 1999”

The Clean Air Act of 1999 prohibits the incineration of biomedical wastes effective July
17, 2003. It promotes the use of state-of-the-art, environmentally sound, and safe non-
burn technologies for the handling, treatment, thermal destruction, utilization, and
disposal of sorted, unrecycled biomedical and hazardous wastes.

RA 8749 defines non-burn technologies as those technologies used for the destruction,
decomposition or conversion of wastes other than through the use of combustion and
which comply with at least one of the following conditions (Section 2, Rule XXVIII, RA
8749):

 The environment within the destruction chamber is free of oxygen

 Fire is not used in the destruction chamber
 The source of heat is not fire
 A heat conducting material or medium whether it is a solid, liquid, gaseous, sol
or gel form is used to destroy the waste

Supreme Court Ruling on the Ban of Incinerators

In a decision promulgated by the Supreme Court involving a case between the Metro
Manila Development Authority (MMDA) and JANCOM Environmental Corporation in
January 2002, it held in agreement with the ruling of the Court of Appeals on 13
November 2001 that Section 20 of RA 8749 does not prohibit incineration of wastes
except those burning processes which emit poisonous and toxic fumes. An excerpt
from the decision read as follows,

"Section 20 does not absolutely prohibit incineration as a mode of waste

disposal, rather only those burning processes which emit poisonous and toxic
fumes are banned."

Memorandum Circular No. 05, series of 2002 dated July 12, 2002
“DENR Clarificatory Statement on Incinerator Ban”

In connection with the Supreme Court ruling, the DENR clarifies that any thermal
treatment technology, whether burn or non-burn as defined in DAO 2000-81, that meets
the emission standards for stationary sources as listed in Section 19 of RA 8749 and
complies with all other relevant provisions of RA 8749 and other applicable laws of the
Republic is allowed to operate in the country.

Permitting Requirements of RA 8749

Based on RA 8749, operators of air pollution source installations and its corresponding
air pollution control system are required to secure the necessary permits from DENR
prior to construction and during the operation of the equipment. These permits are:

1. Authority to Construct for air pollution source installations such as boiler,

generator set, and its pollution control system (prior to
construction/installation)

2. Permit to Operate for air pollution source installations such as boiler,

generator set, and its pollution control system (prior to operation and
renewed annually thereafter).
Republic Act No. 9003
“Ecological Solid Waste Management Act, 2000”

The Ecological Solid Waste Management Act of 2000 mandates the segregation of
solid wastes at the source including households and institutions like hospitals by using
a separate container for each type of waste from all sources (Section 21, Article 2, RA
9003). However, the term “solid waste” specifically excludes infectious waste from
hospitals such as equipment, utensils, laboratory wastes, pathological specimens,
disposable fomites, and similar disposal materials (Section 3(2), Article 2, RA 9003;
Section 1, Rule III, DENR AO 2001-34).

Collection and transport of segregated general wastes or non-infectious wastes are

covered by RA 9003 and may be bought to a landfill for disposal. The collection and
transport of infectious biomedical wastes or hazardous wastes are governed by RA
6969 and cannot be disposed in open dumps or landfill. The infectious wastes once
disinfected may be treated similar to a general waste.

Presidential Decree 984

“Pollution Control Law”

The Pollution Control Law is the primary legislation that governs discharges of
potentially polluting substances to air and water. It provides the basis for the DENR
regulations on water pollution through its IRR, DENR Administrative Order Nos. 34 and
35. The IRR for air emissions was initially set by DENR AO 14, but was later replaced
by the Clean Air Act of 1999 (RA 8749).

DENR AO 34 classifies water bodies in accordance with its use and degree of
protection required with Class AA and SA requiring the most stringent water quality.
The prescribed allowable concentration of effluent from a hospital or health care waste
facility is outlined in DENR AO 35 (Revised Effluent Standards).

Under PD 984, hospitals and other health care establishments are required to secure
from the DENR the following permits related to the generation and discharge of
wastewater into the environment:

1. Authority to Construct for wastewater treatment plant (prior to construction)

2. Permit to Operate for wastewater treatment plant (prior to operation and

renewed annually thereafter).

The Permit to Operate has a maximum validity of one year from the date of issuance.

With the enactment of the Clean Water Act, it is expected that these provisions of PD
984 will be subsumed under the new law.
Republic Act No. 6969
“An Act to Control Toxic Substances and Hazardous and Nuclear Wastes”

The law and its implementing rules and regulations classify infectious, pathological, and
pharmaceutical wastes as hazardous (Table 1, Section 25, Chapter VII of DENR AO
29) that require proper treatment and disposal.

RA 6969 requires the registration of waste generators, waste transporters, and

operators of toxic and hazardous waste treatment facilities with the EMB. The waste
generators (i.e., hospitals) are required to ensure that its hazardous or biomedical
waste is properly collected, transported, treated, and disposed. Quarterly monitoring
reports should be submitted to the EMB.

Health care facilities also have the option to contract the services of off-site waste
treaters. However, these off-site waste treaters should be accredited/recognized by
DENR and should have all the necessary permits from DENR.

9.3 Laguna Lake Development Authority

(LLDA)

The LLDA is a quasi-government agency organized in 1966 by virtue of Republic Act

4850. The LLDA is empowered to provide regulatory and proprietary functions.

Presidential Decree 813 and Executive Order 927

By virtue of Presidential Decree 813 in 1975 and Executive Order 927 in 1983, the
powers and functions of the LLDA were further strengthened to include environmental
protection and jurisdiction over surface waters of the lake basin. In 1993, the
administrative supervision over LLDA was transferred to the DENR by virtue of
Executive Order 149.

Through EO 927, the LLDA is empowered to issue permits for use of surface waters.
The LLDA requires the following permits from health care establishments located within
its area of jurisdiction:

1. LLDA Clearance

Facilities in the watershed of the Laguna de Bay are required to get a clearance
from the LLDA. The Laguna de Bay watershed consists of the provinces of Rizal (13
towns) and Laguna (28 towns), chartered cities of Pasay, Caloocan, Quezon,
Manila, Muntinlupa, Pasig, San Pablo, Tagaytay, Antipolo, Calamba, and Tanauan;
the towns of Sto. Tomas, and Malvar in Batangas; SIlang, Carmona, and GMA in
Cavite; Lucban in Quezon; and Taguig and Pateros in Metro Manila. An ECC issued
by the DENR is a prerequisite for the LLDA Clearance. In addition, companies have
to present a description of the business activity, Locational Clearance, water supply
and disposal methods.

2. Discharge Permit

The Discharge Permit is a legal authorization for the establishment to discharge

wastewater into the tributary rivers within the Laguna de Bay region. It is based on
the Environmental User Fee System (EUFS) which was launched by LLDA in
January 1997. The EUFS is a market-based instrument that applies the “Polluter
Pay Principle”. It encourages companies to invest in and operate pollution
prevention and/or abatement systems. The LLDA issues and renews the Discharge
Permit only if the wastewater effluent complies with the effluent standards set under
DENR AO 35. The company also needs to appoint a Pollution Control Officer whom
LLDA or EMB will accredit.
 CHAPTER 10
ADMINISTRATIVE REQUIREMENTS
Health Care Waste Management
Manual

10.1 Organization and Functions

Appropriate health care waste management practices depend largely on the

administration and organization and require adequate legislative and financial support
as well as the active participation by trained and informed staff. The entire
organizational structure and services of the health care facility must be responsible in
the proper storage, collection and disposal of waste generated by the health care
facility. However, there are certain units and individuals in the establishment that
usually have more responsibility related to health care waste management. Particular
services/units within the health care establishment identified to have a major role in
health care waste management are:

Office of the Administrator of Health Care Facility

 Form a waste management committee to develop a written waste management

plan for the health care facility.

 Designate a Waste Management Officer / Pollution Control Officer to supervise

and coordinate the waste management plan.

 Keep an up-to-date waste management plan.

 Allocate sufficient financial and personnel resources to ensure efficient

operation of the plan. For example, the Waste Management Officer should be
complimented with sufficient staff to ensure efficient implementation of the waste
management plan.

 Ensure that monitoring procedures are incorporated in the plan. The efficiency
and effectiveness of the disposal system should be monitored so that the
system can be updated and improved when necessary.

 Appoint/designate immediately a successor in the event of personnel leaving

key positions in the waste management committee or temporarily assign
responsibility to another staff member until a successor can be formally
appointed/designated.

 Ensure adequate training for key staff members and designate the staff
responsible for coordinating and implementing training courses.

 Attend to complaints and legal matters regarding existing and unforeseen

problems arising from the implementation of the program

 Establish good working relationship with other related agencies by proper

referral, consultation and cooperation concerning health care waste
management.

Housekeeping Services

 Maintain cleanliness and orderliness of the health care premises for aesthetic
reasons.

 Assist in the preparation of the health care waste management plan.

Administrative 76
Requirements
  Initiate a sanitary manner of implementing the pre-treatment processes,
appropriate collection system/procedures and disposal of waste either by
individual group or municipal system.

 Establish baseline data and maintain proper filing system and update program
records.

 Maintain constant good working relationship with all health care facility
personnel for their support and full participation in implementing the program.

 Enhance or provide continuous training program for housekeeping/janitorial

services on waste management and government policies.

Maintenance and Ground Services

 Assist in the proper collection, pre-treatment and disposal of health care waste.

 Carry out directly the activities related to the operation and maintenance of pre-
treatment, collection and disposal system as soon as possible with importance
to the drainage system and plumbing facilities of the establishment.

 Attend immediately to problems arising from the repair/installation of waste

equipment.

Motorpool Services

 Assist in the provision of vehicle for transporting health care waste to transfer
station or disposal sites.

 Prepare and plan the collection system routes and frequency of collection of
health care waste.

 Inspect and schedule maintenance work on vehicles use for transporting health
care waste.

10.2 Health Care Waste Management

Committee (HCWMC)

Functions of the HCWMC

 Promulgate a policy formalizing the commitment of the health care institution to

proper management of its waste with the goal of protecting health and the
environment.

 Establish baseline data and develop the facility’s health care waste
management plan which should include a minimization plan, training, and
written guidelines on waste management.

 Implement the health care waste management plan; and review and update the
policy, plans, and guidelines on an annual basis.
  Ensure adequate financial and human resources for implementation of the
health care waste management plan.

Assignment of Responsibilities

The Administrator of the health care facility will have the overall responsibility of
ensuring that health care waste is disposed of in accordance with the national policies
and guidelines. He or she is required to form a waste management committee to
comprise of the following members:

 Administrator of the Health Care Facility - Chairperson

 Heads of the Departments
 Infection Control Officer
 Chief Pharmacist
 Radiation Officer
 Senior Nursing Staff
 Health Care Facility Engineer
 Financial Controller
 Waste Management Officer
 Health Educator/Information Officer

However, for other health facility, the composition may vary depending upon the
category of health facility or availability of personnel. In some health care
establishments, the structure may be different. It may include a hygienist or instead an
Infection Control Officer, to address specific problems relating to health care hygiene.
The Administrator of the health care facility should formally appoint/designate the
members of the waste management committee in writing, informing each of them of
their duties and responsibilities. The appointment/designation of a Waste Management
Officer with overall responsibilities for the development of the waste management plan
will also be responsible for the subsequent day-to-day operation and monitoring of
waste disposal system. Depending on the availability of relevant staff, this post maybe
assigned to the Health care Facility Engineer, or to any other appropriate staff member
at the discretion of the Administrator of the Health care Facility.

The sharing of duties of key personnel in large health care facilities is described in the
following paragraphs. In smaller facilities, one or more individual may fulfill two or more
sets of responsibilities, but the same principles will apply. The plan should clearly define
the duties and responsibilities of all members of staff, both clinical and non-clinical, in
respect of handling of health care waste.

Waste Management Officer (WMO)

The WMO is responsible for the day-to-day operation and monitoring of the waste
management system. It is therefore essential that he/she have direct access to all
members of the HCWMC. The WMO is directly responsible to the Administrator of the
Health care Facility. He or she should liaise with the Infection Control Officer, the Chief
Pharmacist, and the Radiation Officer in order to become familiar with the correct
procedures for handling and disposing of pathological, pharmaceutical, chemical and
radioactive waste. The responsibilities of the WMO include among others:

 The internal collection of waste and their transport, ensuring availability of waste
bags, protective clothing and collection carts, and directly supervising collection
crews;
  Ensure correct use of central storage facility, which should be kept locked but is
accessible to authorized staff at all times;

 Coordinate and monitor waste disposal operations, waste transport for both on-
site and off-site;

 For training, liaise with the Senior Nursing Officer and Department Heads to
ensure that nursing staff and medical assistants as well as doctors and other
qualified clinical staff are aware of their responsibilities for segregation and
storage of waste; and

 Ensure that written emergency procedures are available and that personnel are
aware of the action to be taken in the event of an emergency. Investigate and
review reported incidents concerning the handling of health care waste.

Department Heads

Department heads are responsible for the segregation, storage, and disposal of waste
generated in their departments. Among their responsibilities are:

 Ensure that all doctors, nurses, and clinical and non-clinical professional staff in
their departments are aware of the segregation and storage procedures and that
all personnel comply with the highest standards in health care waste
management;

 Liaise with the WMO to monitor working practices against failures or mistakes;

 Ensure that key staff members in their departments are given training in waste
segregation and disposal procedures; and

 Encourage medical and nursing staff to be vigilant so as to ensure that hospital

attendants and ancillary staff follow correct procedures at all times.

Senior Nursing Officer

The Senior Nursing Officer is responsible for the training of nursing staff, medical
assistants, hospital attendants, and ancillary staff in the correct procedures for
segregation, storage, transport, and disposal of waste. They should therefore:

 Liaise with the WMO and the advisers (Infection Control Officer, Chief
Pharmacist, and Radiation Officer) to maintain the highest standards in health
care waste management;

 Participate in staff introduction to, and continuous training in, the handling and
disposal of waste; and

 Liaise with the Department Heads to ensure coordination of training activities,

other waste management issues specific to particular departments.
Infection Control Officer

The Infection Control Officer should liaise with the WMO on a continuous basis and
provide advice concerning the control of infection and the standards of the waste
disposal system. His or her duties are to:

 Identify training requirements according to staff grade and occupation;

 Organize and supervise staff training courses on safe waste management;

 Liaise with the department heads and Senior Nursing Officer regarding training
of staff.

The Infection Control Officer also has the overall responsibility for chemical disinfection,
sound management of chemical stores, and chemical waste minimization.

Chief Pharmacist

The Chief Pharmacist is responsible for the sound management of pharmaceutical

storage and for pharmaceutical waste minimization. His or her duties are to:

 Liaise with the Department Heads, the WMO, the Senior Nursing Officer and
give advice, in accordance with the national policy and guidelines, on the
appropriate procedures for pharmaceutical waste disposal;

 Coordinate continuous monitoring of procedures for the disposal of

pharmaceutical waste;

 Ensure that personnel involved in pharmaceutical waste handling and disposal

receive adequate training; and

 Ensure safe utilization of genotoxic products and the safe management of

genotoxic waste.

Radiation Officer

The duties and responsibilities of the radiation officer are the same as those of the
Pharmaceutical Officer but related to radioactive waste management.

Supply Officer

The Supply Officer should liaise with the WMO to ensure a continuous supply of the
items required for waste management (plastic bags and containers of the right quality,
spare parts for on-site health care waste treatment equipment, etc.). These items
should be ordered in reasonable time to ensure that they are always available, but
accumulation of excessive storage should be avoided. The Supply Officer should also
investigate the possibility of purchasing environmentally friendly products (e.g. PVC-
free plastic items).
Health Care Facility Engineer

The Health Care Facility Engineer of the facility is responsible for installing and
maintaining waste storage facilities and handling equipment that comply with the
specifications of the national guidelines. He or she is also accountable for the adequate
operation and maintenance of any on-site waste treatment equipment and is
responsible for the staff involved in waste treatment, ensuring that: (a) staff should
receive training on the principles of waste disposal and are aware of their
responsibilities under the health care waste management plan and (b) staff operating
the on-site waste treatment facilities are trained in their operation and maintenance.

10.3 Health Care Waste Management Plan

A comprehensive health care waste management plan is the key ingredient to a

successful waste management within a health care facility. It is important that the plan
should be understood or followed to be of great value to the institution. Training of staff
to ensure that they are familiar with and understand the plan is critical to the successful
implementation of the plan and effective handling of health care waste.

Assessment of Waste Generation

In developing a waste management plan, the waste management committee needs to

make an assessment of all waste generated in the health care facility. The WMO
should be responsible for coordinating such a survey and for the analysis of the results.
The study should determine the average daily quantity of waste per category generated
in each department. Survey results should include an assessment of any future
changes in facility, departmental growth, or the establishment of new department. Data
from the waste production survey should form the basis on which an appropriate waste
management plan can be developed.

Procedures for Developing the Health Care Waste Management Plan

Step 1. Understanding of the existing government policies, laws and regulations

related to health care waste management.

Step 2. Review of the Current Waste Management System within the Facility before
the drafting or revising a health care waste management plan, is important to
assess the current waste management system. Some of the issues that
need to be addressed are:

 Where the waste is generated

 What types of health care waste are being generated
 How the wastes are being stored. Where it is stored
 The cost effectiveness of the current handling processes.

Step 3. Designing of the Plan - Primary consideration in the design of the health care
waste management plan is that it must address the existing and future
needs of the facility. Care must be taken in the design phase of the planning
process to ensure that the plan is capable of handling the current waste
stream as defined in steps one and two.
Step 4. Training - Comprehensive training and orientation on how the plan is to be
implemented must be provided to employees. In carrying- out the plan, each
of the staff should know their individual roles.

Step 5. Plan Evaluation - The plan should be regularly reviewed and updated to
reflect the improvements made in the handling of waste within the health
care facility.

Plan Implementation

The overall in-charge of implementing the waste management plan is the Administrator
of the Health Care Facility. The implementation of the plan involves the following
activities:

1. Interim measures to be introduced as a precursor to complete implementation of the

new waste management system, should be developed by a designated WMO in
collaboration with a waste management team, and be appended to the plan. A bar
chart should be added, showing dates of implementation of each part of the new
system.

2. Provision for future expansion of the health care facility or of waste storage facilities
should be made.

3. The Chief of Hospital or Medical Director appoints personnel to the post who would
be responsible for the waste management. Notices of this appointment should be
circulated and updates should be issued when changes occur.

4. In collaboration with the WMO and other members of the HCWMC, organize and
supervise training program for all the staff. Key staff members, including medical
staff, who should be urged to be vigilant in monitoring the performance of waste
disposal duties by non-medical staff, should attend the initial training sessions.

5. As soon as the activities in items 1-4 have been completed and necessary
equipment for the waste management is available, the operations described in the
waste management plan can be put into practice.

6. The HCWMC should review the plan annually and initiate changes to upgrade the
system. Interim revisions may also be made if and when necessary.

7. The Chief of Hospital or Medical Director should prepare an annual report for the
disposal of health care waste, providing data on waste generation, disposal of
personnel and equipment requirements, and the costs.

8. Failures in the waste handling, segregation, storage, transport, or disposal system,

or waste management incidents that result in injury should be reported as soon as
possible to the infection control officer.

9. Feedback/reporting of violations and compliance made thereto should be reported

to the Chief of Hospital/Medical Director copy furnish the DOH.
 CHAPTER 11

HEALTH AND SAFETY PRACTICES

Health Care Waste Management
Manual
Because wastes are produced in so many different areas within the health care
establishment, it takes a team effort to properly manage health care waste. Support
from the Chief of the health care establishment is one critical factor in ensuring the
success of the program.

Policies or plans on health care waste management should consider the continuous
monitoring of the health and safety of health care personnel and that proper collection,
treatment, storage and disposal procedures are being followed. Essential occupational
health and safety measures include the following:

 Proper training of health care workers

o No training/no hiring policy should be instituted

o Immunization at the first day of work

 Provision of personal protective equipment (from head to toe)

 Establishment of an effective occupational health program that includes

immunization, post exposure prophylactic treatment, and continuous medical
surveillance

 Information, Education and Communication (IEC) activities

Everyone within the health care establishment can play a role in the management of
health care waste. For this reason, the training program should cast a wide network.
Every employee and manager should be made aware of the policy, the significant
health and environmental impacts of their work activities, their roles and responsibilities,
the procedures that apply to their work and the importance of conformance with the
requirements. The staff should understand the potential consequences of NOT
following the requirements.

Worker's Protection

All personnel who are directly involved in the handling of potentially hazardous health
care waste must be provided with adequate protection from the hazards associated
with it. Protection against personal injury is very important for all workers at risk. The
individual responsible for the management of health care waste should ensure that all
these risks are identified and that suitable protection from those risks is provided. The
installation of the required protection measures will proceed after the conduct of a
comprehensive risk assessment of the activities in health care waste management. The
design of the measure will focus on the prevention of workers exposure or at least an
exposure within safe limits. Suitable training should be provided to the health care
workers on this aspect.

Personal Protective Equipment

Health care waste management program requires that the following personnel
protective equipment be made available to all health care personnel who collect and
handle health care waste:

 Hard hats with or without visor - depending on the nature of operation

 Face masks - depending on the nature of operation
 Eye protectors/Safety goggles - depending on the nature of operation
 Overalls (coveralls) - obligatory

Health and Safety 84

Practices
  Industrial aprons - obligatory
 Leg protectors and/or industrial shoes/boots - obligatory
 Disposable gloves (medical staff) or heavy duty gloves (waste workers) -
obligatory
 Respirators (HEPA) filters - depending on the nature of operation

Industrial boots and heavy-duty gloves are particularly important for waste workers. The
thick soles of the boots offer protection in the storage area, as a precaution from spilled
sharps, and where floors are wet and slippery. If segregation is inadequate, needles or
other sharp items may have been place in plastic bags; such items may also pierce
thin- walled or weak plastic containers. If it is likely that health care bags will come into
contact with workers' leg during handling, leg protectors may also need to be worn.

Personal Hygiene

Provision for washing facilities (with soap and warm water) should be made available to
personnel.

Immunization

Health care personnel should be given immunization against the potential infection from
virus causing hepatitis B and tetanus infection.

Special Precautions for Clearing up Spillage of Potentially Hazardous Substances

The place to be cleared must be secured or cordoned. Only authorized personnel or the
pollution control officer should be allowed in the area.

In clearing-up spillage of body fluids or other potentially hazardous substances,

particularly if there is a risk of splashing, eye protectors and facemask should be worn,
in addition to gloves and overalls. The need for respirators/gas masks is also necessary
if an activity is particularly dangerous, for example, if it involves toxic dust, chemical
reagents, the clearance of incinerator residues, or the cleaning of contaminated
equipment. Residues should be recovered as completely as possible using hand tools
(e.g. shovel), and then packed safely. It is especially important also to recover spilled
droplets of metallic mercury. If a leakage or spillage involves infectious material, the
floor should be cleaned and disinfected after most of the waste has been recovered.

It is important that the correct type of respirator be used for each situation and that the
workers be trained and fit-tested.

Response to Injury and Exposure

All staff that handles health care waste must be trained to deal with injuries and
exposures. Health care establishment should develop a program that would prescribe
the actions taken in the event of injury or exposure to a hazardous substance. Essential
elements of the program should include the following:

 Immediate first-aid measures, such as cleansing of wounds and skin, and

irrigation (splashing) of eyes with clean water
 An immediate report of the incident to a designated responsible person
 Retention, if possible, of the item involved in the incident; details of its source for
identification of possible infection
  Additional medical attention in an accident and emergency or occupational
health department, as soon as possible
 Medical surveillance
 Blood or other test if indicated
 Recording of the incident
 Investigation of the incident, and identification and implementation of remedial
action to prevent similar incident in the future

In case of needle stick injury, bleeding of the wound should be encouraged and the
area should be washed under running water. The remaining elements of the accident
response plan should then be followed. The purpose of the incident reporting should
not be seen as punitive; active support by managers should encourage prompt and
accurate reporting.

Safe Use of Cytotoxic Drugs

In order to ensure safe use of cytotoxic drugs, the senior pharmacist of the health care
establishment should be appointed to supervise the safe management of cytotoxic
waste. To minimize exposures, the following measures should be observed:

 Written procedures that specify safe working methods for each process;
 Data sheets, based on the suppliers specifications, to provide information on
potential hazards;
 Established procedures for emergency response in case of spillage or other
occupational accident
 Appropriate education and training for all personnel involved in the handling of
cytotoxic drugs.

If it is difficult to ensure safe use of cytotoxic and radioactive materials, it is advisable

that the use of these substances be limited to specialized (e.g. oncological) health care
establishment that are better able to implement appropriate safety measures.

Guidelines in safe handling cytotoxic products should include rules on the following
waste handling procedures:

 Separate collection of waste in leak proof bags or containers, and labeling for
identification
 Return of outdated drugs to suppliers
 Safe storage separately from other health care waste
 Provision for disposal of contaminated material, for the decontamination of
reusable equipment, and for the treatment of spillage;
 Provision for the treatment of infectious waste contaminated with cytotoxic
products, including excreta from patients and disposable linen used for
incontinent patients.
 CHAPTER 12
EMERGENCY RESPONSE
Health Care Waste Management
Manual
Training in emergency response should be provided to health care personnel, and the
necessary equipment should be at hand and readily available at all times to ensure that
the required measures can be implemented safely and rapidly.

Spillage is probably the most common type of emergency involving infectious and other
hazardous material or waste. Spills are inadvertent discharges that occur at various
places in the health care facility. Spills include accidental tipping over of containers, and
dropping and breaking of containers as well as spills which occur mainly because of
splashing during manual transfer, overfilling, and leaks in process equipment and
piping.

Regardless of whether the spillage involves waste or material in use, the response
procedures are practically the same and should ensure that: (i) the waste management
plan is respected; (ii) contaminated areas are cleaned and, if necessary, disinfected;
(iii) exposure of workers is limited as much as possible during the cleaning-up
operation; (iv) the impact on patients, medical and other personnel, and the
environment is limited as much as possible.

12.1 Spill Control

In the past, many employees did not realize that mercury was an extremely hazardous
waste and would rinse the mercury from broken thermometers down the sink. Although
there may only have a few small spills, spill control can help reduce wastes generated
by unnecessary clean ups.

Spillage usually requires clean up only of the contaminated area. For spillage of
infectious material, however, it is important to determine the type of infectious agent; in
some cases, evacuation of the area may be necessary. Procedures for dealing with
spillage should specify safe handling operation and appropriate protective clothing. In
case of skin and eye contact with hazardous substance, there should be immediate
decontamination. The exposed person should be removed from the area of the incident
for decontamination, generally with copious amounts of water. Special attention should
be paid to the eyes and any open wounds. In case of eye contact with corrosive
chemicals, the eyes should be irrigated continuously with clean water for 10-30
minutes; the entire face should be washed in a basin, with the eyes being continuously
opened and closed.

12.2 General Guidance for Spill Control

1. Vacate and secure the area to prevent further exposure of other individuals.

2. Provide first aid and medical care to injured individual.

3. Inform the designated person (usually the waste management officer) who should
coordinate the necessary actions.

4. Determine the nature of the spill.

5. Provide adequate protective clothing to personnel involved in cleaning-up.

6. Limit the spread of spill.

Emergency 88
Response
7. Vacate all people not involved in cleaning up if the spillage involves particularly
hazardous substance.

8. Neutralize or disinfect the spilled or contaminated material if indicated.

9. Collect all spilled and contaminated material (sharps should never be picked up by
hand; brushes and pans or other suitable tools should be used). Spilled material
and disposable contaminated items for cleaning should be placed in the appropriate
waste bags or containers.

10. Decontaminate or disinfect the area, wiping up with absorbent cloth. The cloth (or
other absorbent material) should be turned during this process, because this will
spread the contamination. Working from the least to the most contaminated part,
with a change of cloth at each stage should carry out the decontamination. Dry cloth
should be used in the case of liquid spillage, spillage of solids, cloth impregnated
with water (acidic, basic, or neutral as appropriate) should be used.

11. Decontaminate or disinfect any tools that were used.

12. Seek medical attention if exposure to hazardous material has occurred during the
operation.

12.3 Reporting Accidents and Incidents

Health care employees should be encouraged to report any spillage. They should be
educated on what hazardous wastes are so that spill can be properly reported.
Accidents or incidents, including near-misses, spillage, damaged containers,
inappropriate segregation, and any incidents involving sharps should be reported to the
waste management committee (if waste is involved) or to another designated person.
The report should include the details of:

1. The nature of the accident or incident

2. The place and time of the accident or incident
3. The staff who are directly involved
4. Any other relevant circumstances

The waste management officer or other responsible officer, who should also take all
possible action to prevent recurrence, should investigate the cause of the accident or
incident. The records of the investigation and subsequent remedial measures should be
kept.
 CHAPTER 13
COMMUNICATION AND
TRAINING
Health Care Waste Management
Manual
The increasing awareness of the health and environmental hazards related to health
care waste has greatly increased public demand for information and guidance on the
issue. The need to promote appropriate handling and disposal of health care waste is
important for community health and every member of the community have the right to
be informed about the potential health hazards associated to health care waste.

Public education plays an important role in health care waste management. The three
objectives of public education related to health care waste are:

1. To inform the public about the risks linked to health care waste, focusing on
people either living or working in close proximity to, or visiting health care
establishment, families of patients being treated at home, and scavengers on
waste dumps.

2. To create awareness and foster responsibility among hospital patients and

visitors to health care establishments regarding hygiene and health care waste
management.

3. To prevent exposure to health care waste and related health hazards; this
exposure may be voluntary, in the case of scavengers, or accidental, as
consequence of unsafe disposal methods.

In communicating the hazards of health care waste to the public, the following methods
can be considered:

 Information, Education and Communication (IEC) campaign materials

development, reproduction and dissemination. Poster exhibitions of health care
waste issues, including the risk involved in scavenging discarded syringes and
hypodermic needles.

 Policy dissemination - responsible staff of the health care establishment should

be able to explain to incoming patients and visitors the health care waste
management policy.

 Information poster exhibitions in health care establishment, at strategic points

such as waste bin location that provides instructions on waste segregation.
Poster should be explicit, using diagrams and illustrations to convey the
messages to a large number of audiences as possible, including illiterate
people.

13.1 Training of Health Care Personnel

Personnel and patients should be fully aware of the need to exercise caution when
handling health care waste. All personnel should receive appropriate training. Such
training should be tailored to the different needs at various levels or functions in the
health care establishment. The overall aim of the training is to develop awareness on
the health, safety and environmental issues relating to health care waste, and how
these can affect employees in their daily work. It should also highlight the roles and
responsibilities of the health care personnel in the overall management program.

Separate training activities should be designed for each of the following targeted
categories of personnel:

Communication and 91
Training
  Health care facility managers and administrative staff responsible for
implementing regulations on health care waste management
 Medical doctors
 Nurses and assistant nurses
 Cleaners, porters, auxiliary staff, and waste handlers

The training needed from those producing the waste as well as the waste handlers, is
equally important. Medical doctors may be educated through senior staff workshops
and general hospital staff through formal seminars. The training of waste managers and
regulators, however, could take place outside the hospitals, at public health schools or
university departments.

Basic education program for health care staff should include:

 Information on, and justification for, all aspects of the health care waste policy;
 Information on the role and responsibilities of each health care staff member in
implementing the policy;
 Technical instructions, relevant for the target group, on the application of waste
management practices.

All personnel must receive initial and annual training. A trained individual must be
available during training sessions. The instructors should have experience in teaching
and training, and be familiar with the hazards and practices of health care waste
management; ideally, they should also have experience in waste handling.

13.2 Suggested Training Package for each

Target Group

The development of a training package should be suitable for the various types of
health care establishments, including government, private, teaching, and dental clinics,
polyclinics, health centers, health care research institutions, clinical laboratories and
similar establishments.

For Personnel Providing Health Care

The training course should provide an overview of the waste management policy and
underlying rationale and information on practices relevant to the trainees’
responsibilities. Waste segregation is a key element for this training in waste
management. All staff who produces health care waste should be responsible for its
segregation, and should therefore receive training in the basic principles and practical
applications of segregation. Training should make the staff aware of the potentially
serious implications of the mismanagement of waste for the health of waste handlers
and patients, provide them with an overview of the fate of waste after collection and
removal from ward, and teach them the importance of proper segregation of waste.

For Waste Handlers

Topics covered may include the waste management policy, health hazards, on-site
transportation, storage, safety practices, and emergency response. Among staff who
routinely handles health care waste, awareness of the need for safety may decrease
with time, which will increase the risk of injury. Periodic refresher course is therefore
recommended.
For Health Care Waste Management Operators

The training course should include:

 Information on the risks associated with the handling of health care waste;
 Procedures for dealing with spillage and other accidents;
 Correct use of protective clothing.

For Staff who Transport the Waste

In carrying out the responsibility of waste transportation, the drivers and waste handlers
should be aware of the nature and risk of the transported waste. Transport staff should
be able to carry out all procedures for:

 Handling, loading and unloading of waste bags and containers;

 Dealing with spillage or accidents;
 The use of Personal Protective Equipment (PPE); and,
 Documentation and recording of health care waste, e.g. by means of
consignment note system to allow waste to be traced from the point of collection
to the final place of disposal.

For Treatment Plant Operators

Health care establishment should make arrangement to provide training to prospective

treatment plant operators specifically on the following areas:

 General operation of the treatment facility;

 Health, safety, and environmental implications of treatment operations;
 Technical procedures for plant operation;
 Emergency response, in case of equipment failures and alarms for example;
 Maintenance of the plant and record keeping;
 Surveillance of the quality of emissions and discharges, according to the
specifications.
GLOSSARY OF TERMS
 Glossary of Terms

Autoclaving shall refer to the method of disinfection using an apparatus for

effective sterilization by steam under pressure.

Ancillary or Auxiliary Workers shall refer to all support staff in the health care
establishments aside from those in the ancillary services i.e., institution
workers, nursing attendants, dental aides, laboratory aides, etc.

Collection shall refer to the act of removing health care waste from the source or from
a communal storage point.

Cytostatic refers to a substance causing suppression of growth and multiplication

of cells.

Cytotoxic refers to a substance possessing a specific destructive action on certain

cells; used in particular in referring to the lysis (disintegration or dissolution) of cells
brought about by immune phenomena and to antineoplastic drugs that selectively
kill dividing cells.

Decontamination refers to the reduction of microbiological contamination to a safe level.

Disinfection shall refer to the process of killing infectious agents or other harmful
organisms by the application of chemical agents or through physical means.

Disposal shall refer to the discharge, deposit, dumping, placing or release of any
health care waste into or on any air, land, or water.

Half-life shall refer to the rate that a radiation element decays.

Infectious Waste shall refer to those that contain pathogens like bacteria,
viruses, parasites or fungi in sufficient concentration or quantity to cause
disease in susceptible hosts.

Genotoxic refers to a substance that is capable of interacting directly with

genetic material, causing DNA damage that can be assayed. The term may
refer to carcinogenic, mutagenic, or teratogenic substances.

Leachate shall refer to the liquid produced when health care waste undergoes
decomposition, and when water percolates through solid waste undergoing
decomposition. It is a contaminated liquid that contains dissolved and
suspended materials.
Municipal Waste shall refer to wastes produced from activities within the local
government units which include a combination of domestic, commercial,
institutional, industrial and street litters.

Pyrolysis refers to the thermal decomposition of substance and materials in the

absence of supplied molecular oxygen in the destruction chamber in which the
said material is converted into gaseous, liquid, or solid form.

Radioactive Waste refers to material that contains, or is contaminated with,

radionuclides at concentrations or activities greater than clearance levels and for
which no use is foreseen.

Recyclable shall refer to any waste material retrieved from the waste stream and free
from contamination that can still be converted into suitable and beneficial use or
for other purposes, including, but not limited to cardboard, glass, office paper,
drink cans, newspapers, magazines and plastics.

Recycling shall refer to the process of reducing the size of hospital waste by
extracting domestic trade waste for industrial use such as paper for re-pulping,
metals for re-smelting and plastic for the production of an inferior grade.

Re-use shall refer to the process of recovering materials intended for the same or
different purpose without the alteration of physical and chemical
characteristics.

Sanitary Landfill shall refer to a waste disposal site designed, constructed,

operated and maintained in a manner that exerts engineering control over
significant potential environmental impacts arising from the development and
operation of the facility.

Segregation shall refer to a health care waste management practice of separating

different waste materials found in health care establishment in order to promote
recycling and re-use of resources and to reduce the volume of waste for collection
and disposal.

Sludge refers to the accumulated solids that separate from liquids such as water or
wastewater during processing, or deposits on the bottom of streams or other
bodies of water.

Sterilization refers to the reduction in microorganisms of more than 106 (more

than 99.9999% of the microorganisms are killed), achieved by physical,
chemical, or mechanical methods or by irradiation.

Storage shall refer to the interim containment of health care waste after generation
and prior to collection for ultimate recovery or disposal.
REFERENCES
 References

 “Healthcare Without Harm” Materials and References

o Chapter 2 in “Biohazardous Waste: Risk Assessment, Policy and Management”,

Wayne L. Turnberg, John Wiley & Sons, Inc., New York, 1996

o Chapter 2.2 for “Epidemiological Data on Incinerator Emission in Environmentally

Responsible Management of Health care Waste with a Focus on Immunization
Waste”, (working draft), Jorge Emmanuel, Glen McRae and Firuzeh Mahmoudi,
Healthcare Without Harm, Washington DC, 2002 available in the web at:
http://www.noharm.org/library/docs/Environmentally_Responsible_Management_of_
H_2.pdf

o Review of “Health Impacts from Microbiological Hazards in Health care

Wastes”, (draft), Ira F. Salkin, WHO, Geneva, 2001; available in the web at:
http://www.who.int/water_sanitation_health/Environmental_sanit/Health
carewaste/himpacts.pdf

 “Philippine Nuclear Research Institute” Reference Materials

 “Safe Management of Wastes from Health care Activities”, World Health

Organization, Geneva, 1999

 “Urban Solid Waste Management”, WHO 1991-1993 Edition

 DENR Administrative Order No. 2000-81, Implementing Rules and Regulations of

Republic Act 8749, November 2000

 DENR Administrative Order No. 2001-34, series of 2001, Implementing Rules

and Regulations of Republic Act 9003

 Department of Environment and Natural Resources Administrative Order 29,

Implementing Rules and Regulations of Republic Act 6969

 Implementing Rules and Regulations of Chapter XVIII, Refuse Disposal of the Code
on Sanitation of the Philippines (P.D. 856), Department of Health, May 12, 1998.

 Manual on “Hospital Waste Management”, Environmental Health Service, Department

of Health, Manila, 1997

 Non-Incineration Medical Waste Treatment Technologies, Health Care Without Harm,

World Health Organization, August 2001
 Philippine Environmental and Natural Resources Accounting Guidebook,
Resource, Economics, Environmental Center for Studies (REECS), 2000

 Presidential Decree No. 1586, “Establishing an Environmental Impact Statement

(EIS) System Including Other Environmental Management Related Measures and
For Other Purposes”, Malacañang, Manila, June 11, 1978

 Presidential Decree No. 856, The Code of Sanitation of the Philippines, Malacañang,
Manila, December 23, 1975

 Presidential Decree No. 984, “Providing for the Revision of RA 3931, Commonly Known
as the Pollution Control Law, and for Other Purposes”, Malacañang, Manila, August 18,
1976

 Report on World Health Organization, “Management of Waste from Hospitals”, June 28 -

July 1, 1983

 Republic Act 8749, “An Act Providing for a Comprehensive Air Pollution Control Policy and
for Other Purposes”, June 23, 1999

 Republic Act 8749, Clean Air Act of 1999, Department of Environment and Natural Resources

 Republic Act 4226, Hospital Licensure Act, Department of Health

 Republic Act 6969, “Toxic Substances and Hazardous and Nuclear Wastes Control
Act”, 1990

 Republic Act 9003, “An Act Providing for an Ecological Solid Waste Management Program,
Creating the Necessary Institutional Mechanisms and Incentives, Declaring Certain Acts
Prohibited and Providing Penalties, Appropriating Funds Therefore, and for Other
Purposes”, Metro Manila, January 26, 2001

 Training Guide on “Hospital Waste Management”, Environmental Health Service,

Department of Health, Manila, 1995
ANNEXES
 ANNEX 1
HANDLING, STORAGE, COLLECTION AND TRANSPORTATION,
TREATMENT AND DISPOSAL OF SHARPS
(Department of Health)

Packaging and Storage

Sharps should be stored in a puncture-proof (made of metal and high-density plastic) containers
and fitted with covers. Containers should be rigid and impermeable to retain or contain residual
liquid from syringes. This should also be temper-proof (difficult to open or break).

In the absence of metals or plastic containers, the use of containers made of dense cardboard
with plastic lining is recommended.

Needles should not be removed from the syringe because of the risk of injury however, if
removal is required, special care must be taken. No healthcare waste other than sharps should
be deposited in sharp containers, as these (containers) are more expensive. The sealed sharp
containers must be properly labeled in accordance with the Revised DOH Healthcare Waste
Management Manual. Supply of sharp containers should be readily available at the source of
(sharps) waste generation.

Collection and Transport

Sealed sharp containers should be collected regularly or as frequently as required and

transported to the designated on site or off-site disposal area. The waste generator is
responsible for safe packaging and adequate labeling of waste to be transported off-site.
Packaging and labeling must conform to the manual to prevent spilling during handling and
transport.

Treatment and Disposal

Satisfactory treatment process prior to disposal of sharp wastes in healthcare establishments is

necessary to maximize the promotion of health, safety and protection of environment. The
following are the recommended methods of disposal of used sharps.

 Chemical Disinfection

Chemical disinfection is used to destroy or kill microorganisms on healthcare wastes like

sharps. The types of chemical used for disinfection of healthcare waste are mostly
aldehydes, chlorine compounds, and phenolic compounds. Used syringes and needles
shall be put into containers with 1:10 solution of 5-10% sodium hypochlorite or other
approved disinfectants for at least 30 minutes.

 Wet and Thermal Treatment (Autoclaving)

Wet thermal – or steam – disinfection is based on exposure of shredded infectious waste

to high temperature, high pressure steam, and is similar to the autoclave sterilization
process. Sharps must be milled or crushed to increase disinfection efficiency.

Annex
1
 Land Disposal

Sanitary Landfill is an engineered method of disposing solid waste on land in a manner

that protects the environment, e.g. by spreading the waste into layers, compacting it to
the smallest particle volume, and covering it with soil by the end of each working day,
constructing barriers to infiltration, evacuating the gases produced.

Encapsulation is the process of pre-treating sharps and other healthcare wastes. This
process involves filling container with sharps, adding an immobilizing materials and
sealing the containers. Examples of the immobilizing materials are plastic foam,
bituminous sand, cement, mortar or clay material. Encapsulation process used either
cubic boxes of high density polyethylene (HDPE) or metallic drums. Once sharp waste
was encapsulated, this can be disposed of in a sanitary landfill. The cell site for this
waste should be separated from general wastes.

Safe Burial on Hospital/Health Center Premises, when there is no available disposal

facility within the area, safe burial on health establishment premises is considered as the
only viable option. However, certain basic rules should be established such as:

- Access to the disposal site should be restricted to authorize personnel only.

- The burial site should be lined with a material of low permeability, such as clay
to prevent ground water contamination

Annex
1
 ANNEX 2

GUIDELINES FOR DISCARDING DISPOSABLE SYRINGES AND NEEDLES

(Department of Health)

Objectives:

 To prevent accidental needle prick injury and possible HEPA A & B, HIV infection
to medical and health personnel.
 To render all used disposable syringes and needles useless from use by potential
users (drug addicts)

Precautions:

To avoid needle prick injuries:

 Do not recap or re-sheath needles after collecting blood or giving injection

 Do not bend disposable needles by hand
 Do not re-use or sterilize disposable needles

Methods for Disposal

Recommended disposal methods and procedures:

a. Autoclave

 The used disposable needles and syringes are directly placed into a puncture-
proof container.
 At the end of each working day, (sharp) wastes are gathered centrally and
autoclave at 121C for at least 20 minutes.

b. Burial

 The used disposable needles and syringes are directly placed into a puncture-
proof container.
 At the end of each working day, (sharp) wastes are gathered centrally, bury in
designated site within the healthcare establishment premises.
 The burial site are lined with materials of low permeability rate and properly marked
that such types of waste are buried there.
 The burial site are isolated and covered with fence.

c. Encapsulation

 Put the used needles and syringes in a container made of high density polyethylene
or metallic drums.
 Once the container is already three-quarters filled with needles and syringes, the
container is filled with a medium such as plastic foam, bituminous sand, cement mortar
or clay material.
 After the medium has dried, the containers are sealed and disposed off in a
sanitary landfill.

Occupational Health and Safety

Annex
2
Persons directly involved in the collection and disposal of used sharps and syringes are at greater
risks and therefore need suitable protection from such risks. Workers and personnel shall be
trained on proper sharp management and must be oriented on the hazards associated with the
improper handling and disposal of sharps and syringes.

Workers must be provided with protective clothing like gloves, mask, boots and long-sleeved shirt.

Supervision and Responsible Personnel

Within the healthcare establishment i.e. clinics, a supervisor or person in-charge must be
identified and shall be responsible in ensuring the safety of workers and personnel. He/she must
ensure that the used needles and syringes are properly disposed off.

Annex
2
 ANNEX 3
March 1990

P
h
i
l
i
p
p
i
n
e

N
u
c
l
e
a
r

R
e
s
e
a
r
c
h

I
n
s
t
i
t
u
t
e

A
D
M
I
N
I
S
T
R
A
Annex
3
 T document apply to offsite
I waste generators who are
V authorized to collect and
E transport unconditioned low-
level radioactive wastes for
O conditioning and interim
R storage at the PNRI. A waste
D generator who is authorized
E to collect and transport
R radioactive wastes to PNRI is
an agency, firm, or institution
N using radioactive materials
O and possessing a valid
. Radioactive Material License.
Radioactive wastes
generated may be in the form
0
of solid or liquid materials
1
contaminated with radioactive
S
e substances or spent
r radioactive sealed sources.
i
e The PNRI is establishing
s specific requirements within
the framework of the proposed
o
NRMC Low- level Waste
f
Disposal Site, discussed in the
1 Appendix VI of the Regional
9 Fuel Cycle Center Project
9 (National Radwaste
0 Management Center dated
April 1986) for each category
of waste materials. Each
RADIOACTIVE WASTES BY PHILIPPPINE waste category has to meet
NUCLEAR RESEARCH INSTITUTE (PNRI) the requirements.
FROM OFF-SITE WASTE GENERATORS
The segregation, collection,
By authority of Section 16(a) of Republic Act packaging and transport
Mo. 2067, as amended, and E.O. 128 and requirements established in
pursuant to Section 3(g) of P.D. 606 and this criteria guarantee the
Section 26(a) of Part 3 of The Code of effective treatment and
PAEC Regulations, the following guidelines conditioning procedures in the
for the acceptance of low-level radioactive Radwaste Management
wastes from off-site generators by the Facility at the PNRI. PNRI
Philippine Nuclear Research Institute (PNRI) requires that the size and
is hereby established: configuration of the waste
packages for transport should
The Philippine Nuclear Research be standardized. Proper
Institute (PNRI) provides radwaste segregation of low-level
management services through its wastes at the placed of origin
Radiation Protection Section (RPS). will permit processing of
wastes with the appropriate
The guidelines for the acceptance of low- method or procedure. This will
level radioactivated wastes as set forth in this
Annex
3
considerably extend the space available for
the interim storage of conditioned wastes at
the PNRI Radwaste Management Facility.

The acceptance criteria contained in this

document are based on current practices
optimized to the extent possible and in no
way supersede PNRI Regulations and
Standards.

Annex
3
 GENERAL GUIDELINES

1. REQUEST FOR RADWASTE MANAGEMENT SERVICES

PNRI will consider requests from waste generators on the basis of their compliance to PNRI
requirements. The waste generator must submit a written request addressed to the Director of
PNRI, attention of Head of the RPS. The request should provide the required information for
evaluation purposes.

The waste generator shall provide separate information sheet for each type/category of waste
materials that they want to send to PNRI for conditioning and interim storage.

The following information must be provided as an attachment to each request submitted:

a. Waste Coordinator - provide the name, position, address, and telephone number of
the person/s responsible for the segregation, collection,
packaging, and transport of the waste generated.

b. Proposed Schedule - provide the proposed date of shipment and the expected arrival
at PNRI.

c. Waste Material - provide the information corresponding to the type of radwaste

material.

For Spent Sealed Sources - provide the following information for each package containing a
specific type of:

1. Type of casing (specify the type of device where the

source is
encased)
2. Number of units
3. List of Radionuclides present (indicating the elements
and the corresponding mass number
4. The marked activity, the reference data and the
corresponding name of manufacturer and serial number
of each unit of spent sealed source
5. Dimension of waste package
6. Weight of the completed transport package
7. Handling device (Rigging, tie-down, etc.)
8. Maximum radiation dose-rate reading at contact and at one
(1) meter distance from surface of packaging

For Other Solid Waste Materials - the following information must be declared
for each package of solid waste

1. Volume of waste material in m3

2. Waste category (See Table 1)
3. List of radionuclides present
4. Beta-gamma/alpha contamination level per cm2 in the
waste materials
5. List of non-radioactive waste components (such as glass,
metal sheets, paper, and destroyed biological
components)

Annex
3
 6. Radiation dose-rate reading at surface of package and
at one (1) meter distance from surface
7. Total weight of completed package
8. Type of transport container (Refer to Required
Transport Containers)

For Liquid Waste - provide the following information for each container of liquid
waste

1. Waste Category (See Table 1)

2. List of radionuclides present
3. Approximate activity per unit volume of waste
4. Type of solvent/chemicals present (indicate if organic,
acidic, or aqueous)
5. Other non-radioactive components (include
destroyed biological or pathogenic components)
6. Waste Volume in liters
7. Type of waste container (glass, plastic, carboy, etc.
8. Transport container (Refer to the Required
Transport Containers)

PNRI will evaluate the request upon receipt and respond with 15-30 days for offsite waste
generators. If the request is acceptable, the waste generator will be sent two copies of the PNRI
forms (NRLSD/RP-101 for radwaste, or NRLSD/RP-102 for spent sealed sources) to be
accomplished. Offsite waste generators will be required to comply with Transport Regulations
prior to shipment of waste materials to PNRI. The accomplished PNRI forms, the Certificate of
Transport, and other documents that may be required (e.g. radioactive sealed source
specifications or brochure), should accompany the radioactive wastes/spent sealed sources on its
arrival to PNRI. Request is only valid for one shipment which may contain several packages of
waste materials.

2. TRANSPORT EXPENSES

The waste generator shall have budgetary responsibility for all cost necessary to deliver
wastes/spent sealed sources to PNRI.

Any radioactive waste/spent sealed source received at the PNRI for conditioning and storage that
violate the criteria stated herein may not be accepted by PNRI. The material may be returned to
the waste generator or PNRI may perform the corrective action. The cost of either of the two
actions will be charged against the account of the waste generator.

3. ACCEPTANCE CRITERIA

The following materials shall not be accepted for conditioning and/or interim storage at
the PNRI:

a. Materials containing radioisotopes of half-lives less than two years and

with exempt quantities of radioactivity as stated in NRLSD Bulletin No. 89-
4.

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3
 b. Contaminated pressurized containers such as aerosol cans. These cans
will qualify for acceptance only if pressure is released by punching holes on
the container.

c. Materials containing explosive chemicals. The explosive chemicals must be

chemically converted to a stable state by the waste generator before they are
sent to PNRI for disposal. Procedure for the conversion/chemical destruction
done shall be attached to the waste generator’s request for evaluation.

d. Waste materials containing biological or pathogenic components. Treatment

such as autoclave method must be done by the waste generator, so as to
destroy these components prior to packaging. A certification indicating that
such procedures were done and that the waste no longer contain active
pathogenic components shall be attached to the accomplished request forms
upon submission.

4. TRANSPORT REQUIREMENTS

All waste shipments shall be accompanied by all the required documents. They should be
packaged and contained in a transport container as provided for under the Requirements on
Transport Containers. Radiation levels from waste container must conform with the values
provided by the Rules and Regulations on the Safe Transport of Radioactive Materials in the
Philippines specified in Part 4 of the Code of PAEC Regulations.

Radiation and waste package contamination levels declared by the waste generator shall be
verified at the PNRI. If the radiation and contamination readings obtained by the waste generator
at the time of transport and the PNRI reading at the time of receipt vary by a factor of 20%, the
attention of waste generator may be called to provide explanation.

The exterior of all packages sent to PNRI shall be reasonably free of dirt, moisture, rust, and
removable surface contamination.

Waste packages shall be identified. Labeling shall either be painted, stenciled, or neatly hand-
lettered using 1-inch block lettering. The following information shall be on each waste package:

a. Sign indicating “Radioactive Waste Material” and radiation symbol

b. Generator’s Name
c. List of radionuclides present
d. Maximum radiation level at contact and at 1 meter distance from surface
e. Waste transport package gross weight

Transport containers shall also be labeled with sign indicating “Radioactive Material” and a
radiation symbol which shall be placed neatly and clearly on top and on side of each drum.
Boxes shall be labeled on the upper right quadrant of each of the two long sides and shall be
visible during transport.

Spent sealed sources packages shall be provided with permanent/auxiliary handle or lifting
device.

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Bulky and heavy waste material such as heavy spent sealed source metal casing shall be
blocked and braced inside the waste package to prevent a shift of the waste item material during
transport and handling.

5. WASTE CHARACTERIZATION, SEGRAGATION, AND PACKAGING

Radioactively contaminated materials that are identified as waste must be properly characterized
and segregated by the waste generators according to the waste categorization system provided
in Table 1. This will enable PNRI to treat and condition wastes in the most efficient manner
available and to optimize the interim storage capacity at the PNRI site.

The above mentioned waste materials must be collected and packaged as follows:

a. Contaminated Solid Materials

Radwaste materials belonging to the same waste category must be collected in a 100 liter
drum lined with polyethylene plastic bag. When the container is full the plastic bag must
be tightly closed by wrapping a tape around the empty side near the open end of the
plastic bag.

b. Liquid Waste

Liquid waste belonging to the same waste category may be collected in 2-liter
glass containers or in 20-liter plastic carboy with dependable screw cap, depending
on
whichever will be appropriate for the type and the amount of substance to be contained.

Spent Sealed Sources belonging to the same type of radionuclides can be packaged in the same
transport container, provided that Transport Regulations are not violated, e.g. Transport Index,
package classification.

6. REQUIRED TRANSPORT CONTAINERS

The waste generator shall load the prescribed containers to ensure that the container volume
loading is optimum. Optimum loading is necessary to reduce the number of shipments or delivery
to PNRI and will enhance space utilization at the PNRI Radwaste Management Facility. This will
also help to obtain maximum benefit from its waste processing system.

a. Standard 200 liter (55-gal.) steel drum with removable head is prescribed for packages
of solid wastes and liquid wastes contained in glass or plastic containers. The drums
must be provided with head gasket, bolt ring and bolt lock. It can also be used for spent
sealed sources.

b. Steel boxes which can withstand 73.30 g/cm2 (150 lbs/ft2) is the minimum prescribed for
packaging spent sealed sources whose original casings cannot fit the 200 liter (55-gal)
drums. Installed or permanent handle must be provided for safe and convenient
handling and transport. The maximum weight allowed per package is 1000 kilograms.

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 Table 1

RADIOACTIVE WASTE MATERIAL CATEGORIES

Waste Category Content (Single radionuclide or combination

of what are listed in a specific
category)

A - 1 radionuclides with half-lives  one month ex. I - 131

A - 2 radionuclides with half-lives  one year but  one year
B - 1 radionuclides with half-lives  one year but  five
years ex. Cs - 134, Co - 60
B - 2 radionuclides with half-lives  five years but  20
years ex. H - 3
B - 3 radionuclides with half-lives  20 years but  100
years ex. Cs - 137
C - 1 radionuclides with half-lives  100 years but  500
years ex. Am - 241
C - 2 radionuclides with half-lives  500 years
Ex. C - 14, U - 238, Pu - 239, Th - 230

This Administrative Order repeals prior Administrative Orders inconsistent herewith and
takes effect after fifteen (15) days of notification of PNRI licenses.

Quezon City : March 1990

B. R. Aleta
Officer-in-Charge

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 ANNEX 4

CONSIGNMENT NOTE
(Sample Format)

A. TRANSPORTER

Name: Address:
Telephone No.: Accreditation No.:
Type of Waste Transported: Quantity (kg):

B. GENERATOR

Name: Address:
Telephone No.:

C. TREATMENT FACILITY

Name of Manager/Authorized Representative:

Address: Telephone No.:
Permit to Operate: (Permit No.)
Signature of Manager/Authorized Representative:

C. DATE WASTES ARE COLLECTED/TRANSPORTED/RECEIVED

Date Collected/Removed from Generator’s Facility:

Date Received by the Transfer Station (Point of Consolidation):
Date Received by the Treatment Facility:

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 ANNEX 5

Segregation of Healthcare Waste According to Types of Waste and Sources

 Needles & syringes

 Scalpel blades
 Glass vials -tuberculin/ insulin
 Stylet
RED  Capillary tubes
 Ampules
(Sharps and  Test tubes
Pressurized  Blood evacuation tubes
 Pipette slides/ cover slips
Containers)  Aluminum Cover
 Blood Lancets
 Empty Aerosol Cans
 Rusty pins, nails, clips and screws
 Broken Glasses
 Gauze, cotton bandage, cotton applicators soaked
with blood/body fluids from dressing of infected
wounds and post operative cases, procedures such as
Paps smear, immunization
 Foreign bodies removed from any body parts
 Placenta, umbilical cord
 Used gloves
 Used foley catheters
 Used tubing – IV, nebulizer
 Used diapers, sanitary napkins
 Used suction tubes
 Used NGT
 Used test strips
 Used urine bags
 Used drains-penrose
 Used cord clamp
 Used plaster
 Empty colostomy bag
 Used swabs
YELLOW  Heplock endo-tracheal tubes
 Used tongue guard
(Infectious &  Used oxygen tubing
 Used gladwrap
Pathological Wastes)  Used mask/face mask
 Used thoracic tube
 Used hemovac
 Used sensor/ electrodes
 Used bandages
 Used rubber sheet
 Used rubber tubing
 Used CVP tubes
 Used t-tubes
 Used central lines
 Used oxygen catheter
 Amputated limbs, toes, fingers, organs, extracted tooth
 Tissues from minor/major operation
 Specimen containers of blood and body fluids
 Used culture media, tissue culture plate
 Used test strips
 Used beads/plates
 Used kit from laboratory analyzer
 Used reaction pads, foils
 Used plastic wares/ disposables

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  Used Hemoline Diphasique
 Used T & B cell separator
 Used tissue typing/x-matching trays for discards
 Used filter
 Used blood products bags and tubing
 Empty bottles of acids - HCl, H2SO4, HNO3, etc.
 Empty bottles of betadine, Iodine, KMNO3
YELLOW WITH  Empty bottles of laboratory reagents (Formaline,
Tolouene, Xylene)
BLACK BAND  Empty bottles/cans of Kerosene, Acetone, Alcohol,
Anaesthetic, lacquer
(Chemical and  Empty bottles of disinfec-tants
Pharmaceutical  Busted Flourescent bulb
 Defective thermometer
Wastes)  Empty cans of glue, epoxy and floor wax
 Expired and adulterated drugs and medicines
 Used batteries
 Paper and paper products
- used papers
- newspapers
BLACK - tetra packs, paper cups
- boxes/cartons
(Non-Infectious Dry  Bottles
- Glass & plastic
Wastes)  Packaging materials
- styropore
- aluminum
- plastic, candy/food wrapper
 Kitchen left- over food
GREEN  Used cooking oil
 Fish entrails, scale and fins
Non-Infectious Wet  Fruits and vegetables peelings
Wastes)  Rotten fruits and vegetables
 Non-infectious left-over foods
 1125 (Iodine 125)
 Iodine 131
 H3 – Thymidine
 Cesium-137
 Chromium – 51
 Things contaminated with these radio-active materials
ORANGE - Gloves
- tissue papers
(Radioactive/Nuclear - cotton swabs
- aluminum foil
Wastes) - gauze
- test tubes
- pipette tips
- repetitive syringes
- technecium 99m
- tridium
 Used x-ray films, developers, and fixers

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 ANNEX 6

Characteristics of Formaldehyde (HCHO) as

A Chemical Disinfectant

Inactivating effect against all microorganisms, including bacteria, viruses, and bacterial spores,
may be applied to dry, solid waste, in combination with steam at 80 oC. Contact time: 45 minutes.

Physical and chemical properties

Gas at ambient temperature, flammable and explosive in mixtures with air at concentrations of 7-
73%; reactive at ambient temperature; polymerizes at temperature below 80 oC. Formalin is a
37% solution of formaldehyde. Formaldehyde odor threshold: 0.1-1ppm.

Health hazards
WHO guideline value for the general public: 0.1 ppm. WHO guideline value for occupational
exposure: 1 ppm for 5 minutes, with no more than 8 peaks in one working period (of up to 8
hours). Irritant effects may be experienced at concentrations of 1-3 ppm upwards; exposure to
concentrations above 10 ppm may result in severe irritation of eyes or respiratory tract.
Occupational Safety limit: 1 ppm in the USA. Formaldehyde has been classified as a probable
human carcinogen by the International Agency for Research on Cancer; all precautions should
therefore be taken to avoid inhalation of this compound during handling. NIOSH IDLH: 20
ppm.

Protective measures
Gloves and protective eyeglasses should be worn during handling of formaldehyde to protect skin
and eyes; in case of skin contact, the affected area should be rinsed abundantly with water.

Corrosiveness
Formalin is slightly corrosive to most metals except stainless steel and aluminum; it should be
stored in stainless steel, aluminum, or polyethylene containers, in well ventilated and leak-proof-
room.

Fire
Firefighters should wear breathing masks when tackling fires involving formaldehyde.

Comments
Formaldehyde is suitable for use as a chemical disinfectant only in situations in which a high level
of chemical safety can be maintained.

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 ANNEX 7
Characteristics of Sodium Hypochclorite (NaOCl) as a Chemical Disinfectant

Application
Active against most bacteria, viruses, and spores; not effective for disinfection of liquids with high
organic content such as blood or stools; widely used for treatment of wastewater. For waste,
operating parameters should be adjusted on the basis of bacteriological tests.

Physical and chemical properties

Available as aqueous solution with 2-12% of active chlorine; at ambient temperature slowly
decomposes into sodium chloride, and oxygen; solutions of low concentration are more stable;
solutions should be protected from light which accelerates decomposition; reacts with acids to
produce hazardous chlorine gas.

Health hazards
Irritant to skin, eyes, and respiratory tract; toxic.

Protective measures
Gloves and protective eye glasses should be worn during handling of sodium hypochlorite to
protect skin and eyes; in case of eye contact, the eyes should be rinsed abundantly with water.

Corrosiveness
Aqueous solutions are corrosive to metals, usually stored in plastic containers in well ventilated,
dark, and leakage-proof rooms; should be stored separately from acids.

Comments
Sodium hypochlorite may be widely used because of relatively mild health hazards. Unused
solutions should be reduced with sodium bisulfite or sodium thiosulfate and neutralized with acids
before discharge into sewers. Large quantities of concentrated solutions should be treated as
hazardous chemical waste.

Annex 7
 Development Bank of the Philippines
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Tel. No. 818-9511 (connecting all departments)

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DBP Head Office, Gil Puyat Avenue, Makati City
Tel. Nos.: 818-9511 locals 2920 &2906
Tel / Fax Nos.: 812-8088

EISCP2 Project Office

Suite 305 Executive Building Center,
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Tele/Fax +632 899-5985
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