Health Care Waste Management PDF

Health Care Waste Management 191 Defining Health Care Wastes The disposal of wastes generated by health care facilities has become growing concern inn...

Health Care Waste Management 191 Defining Health Care Wastes The disposal of wastes generated by health care facilities has become growing concern inn a the country and around the world. In 2015, a joint WHO/UNICEF assessment found that just over half (58%) of sampled facilities from 24 countries had safe disposal of health care wastes. This issue is adequate systems in place for the given special attention as the wastes generated by the health care industry may be hazardous to nature and are detrimental to a person's health and to the environment. As such, all health care facilities are tasked to ensure that there are no adverse health effects and environmental consequences resulting from their generation, segregation, collection, storage, transport, treatment, and disposal of health care wastes. Health care wastes refer to all solid or liquid wastes generated by any of the following activities: 1. diagnosis, treatment, and immunization of humans; 2. research pertaining to diagnosis, treatment, and immunization of humans; 3. research using laboratory animals geared towards improvement of human health; 4. production and testing of biological products; and 5. other activities performed by a health care facility that generates wastes. According to WHO, between 75 and 90 percent of wastes generated by health care activities on average are non-hazardous. The remaining 10 to 25 percent is considered hazardous and may be infectious, toxic, or radioactive. High-income countries typically generating larger volumes of health care wastes produce 0.5 kg of hazardous waste per hospital bed per day while low-income countries generate 0.2 kg on average. However, proper segregation of hazardous and non-hazardous wastes in low-income countries tends to be less implemented, thus making the real quantity of hazardous wastes much higher. In the Philippines, 30.37 percent of wastes from health care facilities are hazardous while the remaining 69.63 percent are general wastes. Philippine hospitals generate an average of 0.34 kg of infectious sharps and pathological wastes and 0.39 kg of general wastes per bed per day. All health care facilities, institutions, business establishments, and other spaces where health care services are offered with activities or work processes that generate health care wastes are called health care waste generators. These include 1. hospitals and medical centers 2. infirmaries 3. birthing homes 4. clinics and other health-related facilities a. medical b. ambulatory c. dialysis  1 Science 192 Principles of Medical Laboratory care centers and dispensaries d. health e. surgical f. alternative medicine 8. dental h. veterinary centers 5. laboratories and research laboratories a. medical and biomedical b. medical research centers collection services C. blood banks and blood d. dental prosthetic laboratories e. nuclear medicine laboratories f. biotechnology laboratories animal research and testing h. drug testing laboratories i. HIV testing laboratories 6. drug manufacturers 7. institutions a. drug rehabilitation centers b. training centers for embalmers c. medical technology internship training centers d. schools of Radiologic Technology e. medical schools f. nursing homes 8 dental schools 8. mortuary and autopsy centers Categories of Health Care Wastes Health care wastes generated by health care facilities are categorized into seven infectious waste, pathological and anatomical waste, sharps, chemical waste, pharmaceutical waste, radioactive waste, and non-hazardous or general waste. 1. Infectious Waste refers to all wastes suspected to contain pathogens or toXII in sufficient concentration that may cause disease to a susceptible host. It includes discarded materials or equipment used for diagnosis, treatment, and managemen of patients with infectious diseases. Examples include discarded microbial solid wastes with infections such as cultures, dressings, sputum cups, urine containers, anu  liquid blood bags, liquid wastes with Health CareWaste Management tions, and food wastesinfections such body secretio blood, urine, vomitus, as 193 infectious diseases. (liquid or solid) coming from and other logical and Anatomical patients with highly ans Waste refers or derived from biopsies, to tissue sections and r autopsies, body fluids examination. Examples include internal for surgical procedures or sent to the nathological examinations. Anatomical waste organs tissues used and for te that refers to recognizable body is a subgroup of parts usually from pathological Charps refer to waste items that can amputation procedures. 3 o cause cuts, pricks, or ae eonsidered the most dangerous puncture wounds. They health care waste because eatuse cau both injury and infection. Examples include potential of their to used syringes in lancets, surgical knives, and broken glasswares. phlebotomy, blood Chemical Waste refers to discarded chemicals (solid, liquid, or during disinfection and sterilization procedures. It also includesgaseous) generated wastes with content of heavy metals and their derivatives. Common examples of this type of high waste are laboratory reagents, X-ray film developing solutions, disinfectants and soaking solutions, used batteries, concentrated ammonia solutions, concentrated hydrogen peroxide, chlorine, and mercury from broken thermometers and sphygmomanometers. Chemicals are considered hazardous when they are toxic (with health and environment hazards) corrosive (acid of pH12.0) flammable (with a flash point below 60 °C) reactive (explosive with waier) wastes found in health care facilities are shown in chemical Examples of common the table below. waste in health carefacilities eble 11.1 Common chemical Chomicat Waste hydrochloric, nitric, suifuric acetic, chromic, Acids ethanol, isopropanol, phenols Alcohols formaldehyde, glutaraldehyde, ortho-phthalaldehyde sodium hydroxide, Aldehydes hydroxide, potassium hydroxide, ammonium iodophors, Bases sodium bicarbonate dioxide, iodine solutions, chlorine hypochlorite (bleach) hypochlorite, sodium calciun Haiogenated sodium d i c h l o r o i s o c y a n u r a t e , p e r c h l o r o e t h y l e n e , refrigerants, disinfectants methylene chloride, ** chioroform, Halogenated solvents t r i c h l o r o e t h y l e n e chromun, lead, mercury, silver formaldehyde cadmiuIm, acetate, ethyl Metals arsenic, acetonitrile, ethanol, xylenes toluene, acetone, Non-halogenated isopropanol, methanol, solvents ***  Science 1 Medical Laboratory 194 Principles of Examples Chemical Waste quaternary amines peroxyacetic acid, hydrogen peroxide, Other disinfectants dichromate, potassium potassium hydrogen peroxide, Oxidizers permanganate sodium sulfite sodium bisulfite, Reducers oxide, herbicides, paints, anesthetic gases, asbestos, ethylene Miscellaneous pesticides, waste oils contaminated pharmaceutical and Pharmaceutical Waste refers to expired, spilt, 5. discarded items used in handling products, drugs, and vaccines including wastes such as It includes antineoplastic, cytotoxic, and genotoxic pharmaceuticals. from patients treated radiotherapy, and biological fluids drugs used in oncology or include empty drug vials, medicine bottles, and with the said drugs. Examples and materials used for their preparation containers of cytotoxic drugs including and vials. administration such as syringes, needles, exposed to radionuclides including radioactive 6. Radioactive Waste refers to wastes radiotherapeutic materials. Residues from shipment diagnostic materials or solutions of radionuclides intended for of radioactive materials and unwanted of radioactive wastes as well as liquids, diagnostic or therapeutic use are examples with radionuclides whose ionizing radiations have gases, and solids contaminated of radioactive wastes include cobalt genotoxic effects. In the hospital, usual examples (Co 90), technetium (99 Te), iodine (131 I) and iridium (192 Ir), irradiated blood products and contaminated waste, patient's excretion, and all materials used by patients exposed to radionuclides within 48 hours. 7 Non-hazardous or General Waste refers to wastes that have not been in contact with communicable or infectious agents, hazardous chemicals, or radioactive substances, and do not pose a hazard. Examples include plastic bottles, used paper products, office wastes, scrap wood, and food waste of non-infectious patients. This type of waste can be further classified as a. Recyclable wastes in health care facilities such as paper products such as used office paper, computer printouts, and corrugated cardboard boxes aluminum from beverage cans an other aluminum containers pressurized gas containers such as oxygen tanks plastic products including polyethylene terephthalate (PET) plastic water bottles, plastic milk containers, and polypropylene plastic bottles for saline solutions and irrigation fluids glass such as used vials for sterile solutions wood such as scrap wood and used wood shipping pallets  Health Care Waste Management 195 durable goods such as used furniture and furnishings electronie devices such used computer as equipment and print cartriadges b. Biodegradable health care wastes such as left-over food from non-infectious patients and garden wastes such as grass trimmings and tree cuttings C. Non-recyclable/non-biodegradable health care wastes that cannot be classified into either of the first two categories Impact of Health Care Wastes ndividuals exposed to health care wastes such as the medical staff (doctors, nurses, medieal technologists, ete.), in- and out-patients, visitors, caregivers, support staff, waste haulers. garbage pickers, and the general public are potentially at risk of being injured or intected. Other potential hazards may include drug-resistant microorganisms that can spread from health facilities into the environment. Exposure of the general population can be mainly through chronic exposure (for prolonged periods in minute quantities) or acute exposure (for short periods in large quantities). Adverse health outeomes associated with health care wastes and by-products also include sharps-inflicted injuries toxie exposure to pharmaceutical products, in particular, antibiotics and cytotoxic drugs released into the surrounding environment, and to substances such as mercury or dioxins, during the handling or incineration of health care wastes chemical burns from disinfection, sterilization, or waste treatment activities air pollution arising as a result of the release of particulate matter during medical waste incineration thermal injuries occurring in conjunction with open burning and the operation of medical waste incinerators radiation burns Treatment and dispOsal of health care wastes may pose health risks indirectly through the release of pathogens and toxic pollutants into the environment. Following are some guidelines in the treatement and disposal of health care wastes The disposal of untreated health care wastes in landfills can lead to the Contamination of drinking, surface, and ground waters if those landfills are not properly constructed. The treatment of health care wastes with ehemical disinfectants can result in the release of chemical substances into the environment if those substances are not handled, stored, and disposed in an environmentally-sound manner. Incineration of waste is widely practiced, but inadequate incineration or the incineration of unsuitable materials results in the release of pollutants into the air  Science 1 196 Principles of Medical Laboratory and in the generation of ash residue. Incinerated materials containing or treated with chlorine can generate dioxins and furans, which are human carcinogens and hava been associated with a range of adverse health effects. Incineration of heavy metals or materials with high metal content (in particular lead, mercury, and cadmium) can lead to the spread of toxic metals in the environment. Only modern incinerators operating at 850°C to 1100°C and fitted with special gas cleaning equipment are able to comply with the international emission standards for dioxins and furans. It should be noted that disposal of health care wastes by incineration is not allowed in the Philippines. Alternatives to incineration such as autoclaving, microwaving, and steam treatment integrated with internal mixing, which minimize the formation and release of chemicals or hazardous emissions should be given consideration in settings where there are sufficient resources to operate and maintain such systems and disposal of the treated waste. The following are the benefits achieved through proper and strict compliance with standards on the management of health care wastes: protection of patients, health workers, and the general population from the adverse effects of health care wastes to human health; contribution to the collaborative eforts around the world to protect the enviror from pollution and contamination caused by health care wastes; increased compliance of health care institutions to the laws, regulations, and guidelines on health care wastes; and prevention of long-term liabilities and loss of reputation caused by violations to the laws, regulations, and guidelines on health care wastes. Legislation, Policies, and Guidelines Governiny Health Care Wastes Health facilities should be familiar with the laws and care regulations regarding the generation, collection, storage, transport, treatment, and disposal of will ensure that each health care wastes. This facility will be able to develop a sound health care waste system that adheres to established standards. management International agreements pertaining to health care waste management 1. The Montreal Protocol on Substances that adopted in Montreal, Canada on September Deplete the Ozone Layer (1987) was 16, 1987 and came into force, as agreea upon, on January 1, 1989. It sets the final objective of the Protocol to depleting substances in the environment. eliminate ozone  Health Care Waste 2. The Basel Convention Management 197 Hazardous Wastes and Theirthe Control of the on Disposal (1989) Transboundary Movements of movements of hazardous waste. The countries concerned with the transboundary is principle that only legitimate that signed the Convention accepted the from countries that lack transboundary shipments of hazardous waste are exported the facilities or countries that have both facilities expertise to safely dispose certain wastes to other and expertise. 3. The United Nations Framework legally non-binding pledge that Convention on Climate Change (1992) includes a by the year 2000, major industrialized nations would voluntarily reduce their greenhouse gas emissions to 1990 levels. 4. The Stockholm Convention on Persistent Organic Pollutants to protect human health and the environment from (2001) is a global treaty POPs are chemicals that persistent organie pollutants (POFPs). (1) remain unchanged in the environment for long periods of time; (2)) accumulate in the fatty tissues of living organisms; and (3) are toxic to both humans and wildlife. 5. The ASEAN Framework Agreement on the Facilitation of Goods in Transit a coreinstrument that provides nine high level (1998) is protocols that set out generic standards to be put into place for the implementation of an international transit system. Specifically, the framework agreement includes Protocol 9 on Dangerous Goods which provides provisions on the transport of toxic and infectious substances. National laws and policies on health care waste management 1. Republic Act No. 4226 "Hospital Licensure Act" (1965) is an act that requires registration and 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. a. DOH Administrative Order No. 70-A series of 2002 "Revised Rules and Regulations Governing the Registration., Licensure, and Operation of Hospitals and Other Health Fucilities in the Philippines"- includes the application or renewal of license, submission of plans, and other design requirements under the Code of Sanitation of the Philippines, National Plumbing Code of the Philippines, Revised Fire Code of the Philippines, and National Euilding Code of the Philippines. The Manuals on Hospital Waste Management and Health Facilities Maintenance are also required for submission for verification by the DOH- Bureau of Health Facilities and Services (BHFS). b. DOH Administrative Order No. 2005-0029 dated December 12, 2005 4mendment to Administrative Order No. 70-A series of 2002 re: Revised Rules and Regulations Governing the Registration, Licensure and Operation of Hospitals and Other Health Facilities in the Philippines" - requires the HCF to submit a health care waste to BHFS of its requirements for the issuance of license to management Plan as one operate. 198 Principles of Medical Laboratory Science 1 August 22, 2007 Revised Ruleo 2007-0027 dated Administrative Order No. Clinical Laboratorien C.DOH Licensure and Regulation of and Regulations Governing the for the proper disposal of health written procedures n the Philippines" requires - written policy guidelines on substances and required care waste and other hazardous biosafety and biosecurity. Substances and Hazardous and Nuclear 2. Republic Act No. 6969 An Act to Control of waste generators, waste transporters, and wastes (1990) requires the registration treatment facilities with the EMB. The waste operators of toxic and hazardous waste Senerators are required to ensure that their hazardous wastes are properly collected, transported, treated, and disposed in a sanitary landfill. a. DENR Administrative Order No. 36, Series of 2004 "Revising DENR Administrative Order No. 29, Series of 1992, to Further Strengthen the Implementation of Republic ACt 6969 and Prescribing the Use ofthe Procedural Manual"- the Procedural Manual requires a comprehensive documentation on the legal and technical requirements of hazardous waste management. The Manual does not include provisions regarding the management of nuclear wastes. It is composed of ten sections that discuss the 1) classification of hazardous wastes, (2) waste generators, (3) waste transporters, (4) storage and labelling, (5) Treatment, Storage, and Disposal (TSD) facilities, (6) manifest system, (7) monitoring, (8) prohibited acts, (9) schedule of fees, and (10) import of recyclable materials containing hazardous substances and export of hazardous waste. b. DOH-DENR Joint Administrative Order No. 02 series of 2005 dated August 24, 2005 entitled Policies and Guidelines on Effective and Proper Handling, Collectio, Transport, Treatment, Storage, and Disposal of HCW" aims to (a) provide - guidelines to generators, transporters, and operators/owners of TSD Facilities on the proper handling, collection, transport, storage, treatment, and wastes (HCW); (b) clarify the jurisdiction, disposal of health care authority, and responsibility of DENR and DOH with regard to health care waste management (HCWM); and (c) harmonize the efforts of DENR and DOH on HCWM. C. DOH Administrative Order 2007-0014 "Guidelines on the Issuance of Product Registration for Equipment or of Certificate Devices Used for Pathological and Infectious Naste" requires the - Treating Sharps, distributors, including generators of HCW that sell manufacturers, importers, and devices in treating sharps, pathological, and infectious and/or use equipment and waste to secure a f Product Registration (CPR) from DOH Certificate through the Bureau of Health Devices and Technology Republic Act No. 8749 "The Philippine Clean Air incineration of bio-medical wastes effective July 17, 2003.Act It of 1999" prohibits the of-the-art, environmentally-sound, and safe non-burn promotes the use of state- treatment, thermal destruction, utilization, and technologies for the handling biomedical, and hazardous wastes. disposal of sorted, unrecycled,  Health Care Waste Management 199 4. Republic Act No. 9003 "Ecologieal Solid Waste Management Act of 2000" mandates the segregation of solid wastes at the sources including households and institutions like hospitals by using a separate container for each type of waste. 5. Republie Act 9275 "The Philippine Clean Water Act of 2004" pursues a poliey or economie grOwth in a manner consistent with the protection, preservation, and revival of the quality of the country's fresh, brackish, and marine waters. 6. Presidential Decree S13 (1975) and Executive Order 927 (1983) "Strengthening the Funetions of Laguna Lake Development Authority (LLDA)" which further strengthens the powers and functions of the LLDA to include environmental protection and jurisdiction over surface waters of the Laguna Lake basin. Through E.O. 927. the LLDA is empowered to issue permits for the use of surface waters within Laguna de Bay. 7 Presidential Decree 856 "The Code on Sanitation of the Philippines Chapter XVIT - on Sewage Collection and Excreta Disposal" (1998) requires the approval of DOH in terms of the following: (a) construetions of any approved type of toilet in every house and community which may be allowed for a group of small houses of light material or and the sub-surface temporary in nature; (b) plans of individual sewage or sewage system absorption system or other treatment device; (c) location of any toilet or sewage disposal system in relation to a source of water supply; (d) the discharge of untreated effluent sewage treatment plants to bodies of water; (e) manufacture of from septictanks and/or other treatment septic tanks; and () method of disposal of sludge from septic tanks or plants. a. Rules and Regulations Governing the Collection, Handling, Transport, Treatment, and Disposal of Domestic Sludge and Septage, (2004), a "Supplement to the IRR of Chapter XVII on Sewage Collection and Disposal and Evcreta Disposal and Drainage require individuals, firms, public and private operators, owners, and of 1998" - administrators engaged in desludging, collection, handling and transport, treatment, and septage from house and disposal of domestic sewage treatment plants/facilities environmental sanitation clearances from DOH. septic tanks to secure Decree 856 "The Code on Sanitation ofthe Philippines" b. Chapter XVIII ofPresidential on Refuse Disposal (1998) - requires cities and municipalities to provide an adequate and disposing refuse in their areas of and efficient system of collecting, transporting, of buildings, institutions such as hospitals jurisdiction. They also require occupants sufficient number of receptacles for refuse. and residences to provide a Rules und Regulations Governing Domestic Sludge and C. Operation Manual on the detailed procedures and forms which need to comply Septage (June 2008) provides - with the IRR governing the collection, handling, transport, treatment, and disposal It is designed to guide private and public service of domestic sludge and septage. towards effective sludge and septage providers, as well as government regulators, in the country. management program 200 Principles of Medical Laboratory Science 1 Rules and Regulatiome Revised Implementing d. Administrative Order 2010-0033 Philippines, Chapter XXI on DispOsal of Dead PD 856 Code on Sanitation of the new restriction o open viewing of (December 2010) implemented a Persons - communicable diseases. individual's death was causcd by certain remains when the cadaver bag or other shall be placed in a plastie It explicitly states, "The remains tag attached, a biohazard container at the point of death and u r a b l e airtight other purpose for viewing o r any this container shall not be opened provided that, prior to burial or cremation". Revision of Republic Act No. for the S. Presidential Decree No. 984 "Providing Other Purposes" Control Law, and for 3981, Commonly known as the Pollution substances to air and water. It the discharge of potentially polluting L976) governs on water pollution through its IRR, DENR provides the basis for the DENR regulations was initially set by IRR for air emissions Administrative Order Nos. 34 and 35. The Clean Air Act of 1999 DENR Administrative Order No. 14, but was later replaced by the (R.A. 8749). DENR Administrative Order No. 34, Series of 1990 "Revised Water Usage and a. Section Nos. 68 and 69, Chapter Classification/Water Quality Criteria Amending (NPCC now EMB) Rules and IIIof the 1978 National Pollution Control Commission to their designated uses and did Regulations"- classified bodies of water according the purposes that lower than of the bodies of water for other are not preclude use prejudice quality required for such classification, provided that, such use does not waters. b. DENR Administrative Order No. 35, Series "Eluent Regulations"- lists of 1990, to their water the effluent regulations for the different levels of pollutants according category/class. c. DENR Administrative Order No. 26, Series of 1992, Amending Memorandum Circular No. 02, Series of 1981: Appointment/Designation of Pollution Control Oficers"-requires the appointment/designation ofa Pollution Control Officer (PCO) and lists the qualifications, reporting requirements, and duties and responsibilities of accredited PCOs. 9. Presidential Decree No. 1586 "Environmental Impact Statement (EIS) System" (1978) requires projects, like the construction of new hospital buildings or expansion of existing hospitals, to secure an Environmental Compliance Commitment (formerly Environmental Compliance) Certificate (ECC) prior to the construction and operation of the facility. An ECC is required for the installation and operation of HCW treatment systems like pyrolysis, autoclave, mierowave, and other treatment techuology including landfills. 10. Executive Order No. 301 "Establishing a Green Procurement Program for All Departments, Bureaus, Offices, and Agencies of the Executive Branch of Government" (2004) aims to (a) promote the culture of making environmentally  Health Care Waste Management 201 informed decisions in the government, especially in the purchase and use of Droducts;: (b)include environmental criteria in public different practicable;(e) establish the tenders, whenever possible and be considered specifications and requirements for products services to environmentally advantageous; and (d) develop incentive or suppliers environmentally advantageous of programs for products or services. 1. DOH Administrative Order No. of Mercury in all 2008-0021 dated July 30, 2008 "Gradual Philippine Health Care Facilities and Phaseout health care facilities (HCF) to Institutions" requires all gradually phaseout the use of and equipment. The initial targets of the mercury-containing devices sphygmomanometers in the health care facility.phaseout mercury thermometers and are a. Department Memorandum No. 2011-0145, "Guidelines of Mercury Wastes in HCF in Accordance with No. for s.the Temporary Storage Phaseout of Mercury in AUl AO 0021, 2008 on the Gradual Philippine health care Facilities and Institutions" provides the detailed guidelines on the - temporary storage of devices and the management of mercury spills to enhance patientmercury-containing HCF, to protect health care safety measures in workers from potential hazards from and to minimize the accumulation of mercury exposures, mercury in the environment. 12. DOH Administrative Order No. 2008-0023 dated July 30, 2008 "National on Patient Safety" requires the establishment and maintenance of a culture of Policy safety in the HCF as the responsibility of its leaders. As patient such, HCF shall ensure that enabling mechanism/strategy is in place to ensure an in patient safety patient safety. The key priority areas include, but are not limited to, proper of blood safety, safe clinical and patient identification, assurance surgical procedures, provision and maintenance of safe quality drugs and technology, strengthening infection the environment of care control standards, maintenance of standards, and energy and waste 13. management standards. DOH "Manual on Health Care Waste Health Care Waste Management Management" in 2011 (Revising the 2007 Manual) serves as a reference for HCF administrators in the implementation of an effective and efficient waste requirements for doing such are provided in the manual management program. The by listing the standards of performance, defining the mandatory requirements, providing new and citing examples and tools. The Manual is designed to be used by all workers concepts, within the HCF. 14. Philhealth Benchbook for Quality Assurance in health care (2006) includes health care waste management as one of its parameters in the quality assurance of healthcare. 15. BFAD Memorandum Circular No. 22, Series of 1994, "Inventory, and/or Destruction of Used Vials o r Bottles" and BFAD Bureau Proper Disposal, Cireular No. 16, Series of 1999: "Amending BFAD MC No. 22 dated September 8, 1994, Regarding Inventory, Proper Disposal, and/or Destruction of Used Vials or Bottles" - these circulars are released to the proliferation of adulterated, misbranded, and prevent counterfeit drugs brought about by the recycling of used t contains pharmaceutical bottles and vials. the guidelines on the proper inventory and destruction of bottles and vials.  Science 1 Laboratory Medical 202 Principles of System Health Care Waste Management I1-defined low follow a well-defined t generally care facilities In alth care wae t h e health care waste Health c care wastes a r e wa generated by health treatment and disposal. and Health their of wastes d down to the generation o from the point of generation preferable to prevent of reusing, recycling. and a hierarchy, it is highly different methods management wastes by using reduce the quantity of generated recovering wastes. More Preferable Prevent Green Procurement Reduce Reuse Resource Development Recycle Recover Treat End of Pipe Dispose Least Preferable Figure 11.1 Health Care Waste Management Hierarchy in the proper management of health care wastes is waste The most important step minimization using an approach knowm as the Green Procurement Policy. This policy involves two aspects-waste prevention and waste reduetion. Through proper procurement planning wastes are minimized even before their generation. Health care facilities are encouraged to avail of services that are the least harmful to the environment and to purchase less polluting products. Also, waste reduction from the source is implemented by encouraging proper waste segregation to determine the nature and volume of generated wastes to allow efficient waste management at the least cost. Safely reusing, recycling, and recovering wastes are collectively termed as resource development. Reusing refers to either finding a new application for a used material or using the same product for the same application repeatedly. Safety and efficienev, however, shoula be considered when reusing medical items and devices. For like glass culture tubes can be used repeatedly after example, laboratory glassware decontamination. Reeycling refers to tne processing of used materials into new products. Computer example, can be sold and recycled into new paper printouts from the hospital, 10 other hand, is defined in two ways: (1) energy products. The recovery of waste, on e recovery, generating electricity or for direct heating of premises whereby waste is converted to fuel i and (2) as a term used to three subsets of waste recovery: recycling, encompa composting, and energy recovery.  Health Care Waste Management20 Har wastes that cannot be sately reused, recycled, or recovered, the end of pipe approach inblemented. This approach health care waste to management involves two aspects: atment and dispOsal. Waste treatment is the process of changing the biological and hemical characteristics of waste to minimize its potential to cause harm. Waste the other hand, refers to discharging, depositing, disposal, on placing, releasing any health care waste or into air, land, or water. Not all types of wastes require trcatment. For example, food wastes from in-patients can be disposed of through composting without the need for treatment. However, some materials need to be treated first before disposal. Efluent wastewater from hospitals, tor example, needs to undergo sewage treatment prior to its release to the environnment. Segregation, Coliection, Storage, and Transport of Health Care Wastes Health facilities are tasked to ensure that generated wastes are properly and safely care managed. To ensure this, health care wastes must be segregated, collected, stored, and transported while considering risk and occupational safety and compliance with existing laws, policies, and guidelines. Hazardous wastes must never be mixed with general wastes and there must be a waste management officer responsible for the management of the health care wastes of a facility The effective management of health care wastes considers the basic elements of waste minimization, identification, and segregation. Segregation at the source of waste generation should be the responsibility of the waste generator. Segregation is the process of separating different types of waste at the point of generation until their final disposal. To improve the efficiency of the segregation and minimize the incorrect use of bins; proper placement, labelling of waste bins, and use of color-coded plastic liners must be strictly implemented. The purpose of color coding is to make it easier for personnel in a health care facility to put waste into correct bins and maintain segregation during collection, storage, transport, treatment, and disposal. sble1.2 Guidelines for the proper labeling, marking, and color codingfor waste segregation in health care facilities Infectious Waste BIN with labelled "Infectious" with biohazard Strong leak-proof bin cover symbol LINER with 0.009 mm thickness Yellow plastic that can withstand autoclaving Waste" with a tag indicating source and weight and labelled "Infectious or may not have biohazard symbol of waste and date of collection; may  1 Laboratory Science 204 Principles of Medical Specifioations Type of Waste Pathological and BIN "Pathological/Anatomical cover labelled bin with Anatomical WasteS Strong leak-proof biohazard symbol Waste" with LINER 0.009 mm thickness autoclaving with can withstand Yellow plastic that Waste" with a tag indicating "Pathological/Anatomical and labelled collection. Biohazard symbol is PATHOLOUrCAL date of ANATOMiCAL WAS source and weight of waste and optional. BIN Sharps wide mouth and cover labelled "Sharps" Puncture-proof container with with biohazard symbol LINER SAARPS Not applicable Chemical Waste BIN For liquid chemical waste, inside the bin Labelled "Chemical Waste"; amber-colored glass with at least 4 liters is disposal bottle made of a chemical-resistant, and leak-proof. capacity that is strong, CHEMICAL WADIC LINER 0.009 mm thickness and labelled Yellow with black band plastic wiith source and weight of waste and "Chemical Waste" with a tag indicating date of collection Pharmaceutical Waste BIN "Pharmaceutical Waste" for Strong leak-proof bin with cover labelled Waste" for cytotoxic, expired drugs and drug containers and "Cytotoxic genotoxic, and antineoplastic waste PHARMACEUTICAL LINER Yellow with black band plastic with 0.009 mm thickness and labelled "Pharmaceutical Waste" with a tag indicating source and weight of waste and date of collection Radioactive Waste BIN Radiation proof repositories, leak-proof, and lead-lined container labelled with name of radionuclide and date of deposition with radioactive symbol LINER Co90 Orange plastic with 0.009 mm thickness and labelled "Radioactive w a tag indicating name of radionuclide and date of deposition General Waste BIN Optional recycle symbol for recyclable non-hazardous wastes; varying sizes depending on the volume of waste. LINER Black or colorless plastic for non-biodegradable and green for biodegradable with a thickness of 0.009 mm with a tag indicating sOurce, weight of waste, and date of collection  Health Care Waste Management 205 In the implementation of a color-coding system for health care wastes, the following should be observed: practices 1. Highly intectious waste nust be disinfected at source. 2. Anatomical waste including recognizable body parts, placenta waste, and organs should be disposed through safe burial or cremation. 3. Pathological waste must be refrigerated if not collected or treated within 24 hours. 4. Sharps must be shredded or erushed before they are transported to the landfil. Chemical and pharmaceutical wastes shall be segregated and collected separately. Wastes with high content of heavy metals, except mercury, should be collected Separately and sent to the waste treatment facility. Waste containing mercury must be collected separately. Hazardous chemical waste shall never be mixed or disposed down the drain but shall be stored in strong chemical resistant leak-proof containers or amber disposal botles. Expired and discolored pharmaceuticals should be returned to the pharmacy for temporary storage to be returned to the manufacturer/ supplier. Pharmaceuticals shall be kept in their original packaging for proper identitication and prevention of possible reaction with other chemicals. 6. Radioactive waste has to be decayed to background radiation levels. If it has reached the background radiation level and is not mixed with infectious or chemical waste, the radioactive waste is considered as regular non-infectious waste. 7. All waste bins must be properly covered to prevent cross contamination. 8. Aerosol containers can be collected with the general waste. Aside from the information placed on the tag, yellow plastic liners should also be labelled with symbols appropriate for the types of waste they contain. The following are the symbols used by the DENR Environmental Management Bureau together with other universally accepted hazard symbols. Recycle Biohazard CORROSIVE Corrosive Symbol Symbol New Radiation Old Radiation Symbol Explosive lonizing Symbol Symbol Radiation Sign Infectious Reactive Cytotoxic Symbol Symbol Infeotiou Symbol Poison/ Flammable Flammable FLAMABTESAL Toxic Symbol Liquid solid Symbol TOXIC Symbol  Science 1 206 Principles of Medical Laboratory for general wastes, recyclable materials have storage areas wastes must be stored facilities should Health care devices. Cytotoxic wastes must mercury radioactive and phased-out while hazardous wastes, secured location their in a designated during the period that other wastes separately from dispersion of radiation containers that can prevent be stored in to decay. radionuclide contents are being allowed important components in health wastes are health care collection and transport of commitment and cooperation among Froper requires c o l l e c t i o n of wastes C a r e waste management. Their implementation on-site There must be a regular all the workers in the health c a r e facility. waste treatment area trolleys to the facility's the personnel hauling the designated cld these must be transported using collection and transport, on-site equipment Or waste storage facility. During personal protective should w e a r appropriate Wastes must be properly trained and of health care wastes, For off-site transport minimize the risk of infection and injury. to transport PPE) to collectors are allowed and official waste to the Only accredited DENR transporters or Treatment/Storage/Disposal (TSD) tacility w a s t e s from the health care facility to a final disposal site. Health Care Wastes Treatment and Disposal of care wastes do not pose harm that health necessary to ensure Proper waste treatment is and largely waste treatment usually varies and the environment. The m a n n e r of to the people needs to be inactivated and its potential impact. Health the of waste that depends on type Sterilization kills sterilization or disinfection. care wastes can decontaminated either be by present in the all microorganisms while disinfection reduces the level of microorganisms material of health and methods used in the treatment Listed below are the acceptable technologies care wastes. wastes in the absence of Pyrolysis is the thermal decomposition health of care 1. the destruction chamber where the said waste supplied molecular oxygen in solid form. This can handle the full range is converted into gaseous, liquid, or of health care wastes. Waste residues may be in the form of greasy aggregates or carbon black. These residues are disposed in a or recoverable slugs, metals, landfill. 2. Autoclave is the use of steam sterilization to render waste harmless and is an efficient wet thermal disinfection process, This method of using pressure and heat is widely used and the usual setting is at 121 °C with a pressure of 15 psi for 15 to 30 minutes. Indicators such as color-changing tapes or biological test ampules containing spores can be used to check the validity of the bacterial sterilization. 3. Microwave is a technology that typically incorporates some type of size reduction device. Shredding of wastes is done before disinfection. In this process, waste is exposed to microwaves that raise the temperature to 100 °C (237.6 °F) for at  Health Care Waste Management 201 least 30 minutes. Microorganisms are destroyed by moist heat which irreversibly coagulates and denatures enzymes and structural proteins. 4, In chemical disinfection, chemicals like sodium hypochlorite, hydrogen peroxide, peroxyacetic acid, and heated alkali are added to health care wastes to kill or inactivate present pathogens. It is recommended that sodium hypochlorite (bleach) with a concentration of 5 percent be used for chemical disinfection. This method, however, generates chemical wastes from the used chemical disinfectants. 5. Biological process uses an enzyme mixture to decontaminate health care wastes. The resulting by-product is put through an extruder to remove water for wastewater disposal. The technology is suited for large applications and is also being developed for possible use in the agricultural sector. 6. Encapsulation involves the filling 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 chemicals or pharmaceutical residues. The containers or boxes are then filled up with a medium such as plastie foam, bituminous sand, and cement mortar. After the medium has dried, the containers are sealed and disposed in a landfill. 7 Inertization is especially suitable for pharmaceutical waste that involves the mixing of waste with cement and other substances before disposal. For the inertization of pharnmaceutical waste, the packaging shall be removed, the pharmaceuticals ground and a mixture of water, lime, and cement will be added. The homogenous mass produced can be transported to a suitable storage site. Alternatively, the homogeneous 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. wastes are in landfills. A landfill is an usually disposed After treatment, health care waste isolated from the environment. This site must secure engineered site designed to keep wastes. Health care wastes that are properly DENR before it can accept proper permits from the DOH that the wastes provided that it is certified by treated can be mixed with general are inert and cannot regenerate. For health care facilities in organisms in the waste products is usually through safe burial. As a disposal with no access to landfills, disposal far-flung areas to treated infectious wastes, sharps, pathological method, safe burial is only applicable solid chemical and small quantities of encapsulated/inertisized and anatomical wastes, facilities located in remote areas. Used and only allowed in health care pharmaceutical wastes or concrete vaults if the health care using septic can also be disposed Sharps and syringes to a TSD facility. Tacility has no access  Science Medical Laboratory 208 Principles of KEY POINTS health care facility. activities performed by a H e a l t h care wastes are by-products of the be harmful to patients. of wastes which can amounts H e a l t h care facilities generate large environment. population, and the health personnel, the general with designated colors, labels, markings, care wastes There are seven categories of health and specifications for their disposal. segregation, collection, storage, for the generation, There must be a proper procedure of health care wastes. transport, treatment, and disposal waste health wastes should focus primarily on The proper management of care minimization. on the adherence of waste management systems depends The success of health care and policies all the personnel of a health care facility on the existing laws, guidelines regarding health care wastes.