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MODULE 18: Management of Chemical, Cytotoxic, Pharmaceutical and Radioactive Wastes

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Title: MODULE 18: Management of Chemical, Cytotoxic, Pharmaceutical and Radioactive Wastes


1
MODULE 18 Management of Chemical, Cytotoxic,
Pharmaceutical and Radioactive Wastes
2
Module Overview
  • Describe sources and types of chemical,
    cytotoxic, pharmaceutical, and radioactive wastes
    in a healthcare setting
  • Discuss risks associated with exposure to these
    specific wastes
  • Describe all aspects of management of these
    specific wastes
  • Describe treatment and disposal methods

3
Learning Objectives
  • Identify hazardous (non-infectious) wastes in a
    healthcare facility
  • Identify key steps in collection, handling,
    storage, transport, treatment and disposal of
    these wastes

4
Sources Examples of Hazardous (Non-Infectious)
Wastes
  • Examples of Sources
  • Chemicals from diagnostic and experimental work
  • Cleaning and disinfecting compounds
  • Agents used for chemotherapy
  • Drugs that are no longer required
  • Waste from nuclear medicine
  • Examples of Wastes
  • Formaldehyde (Haemodialysis)
  • Photographic fixing and developing solutions
    (X-ray Department)
  • Solvents and fixatives (Pathology or Histology
    Labs)
  • Engine or vacuum pump oils, solvents, degreasers
    (Facility Engineering)
  • Disinfectants, pesticides, rodenticides
    (Housekeeping)
  • Acids, alkalis or reducing agents (Laboratory)
  • Mercury (thermometers), cadmium (batteries),
    lead (Radiology)
  • Gases stored under high pressure, in cans or
    cylinders (Surgical Theater)
  • Ethylene oxide gas (Central Sterile Supply)
  • Expired drugs, cytotoxic drugs (Pharmacy,
    Chemotherapy Ward)

5
Characteristics of Chemical Waste
  • Discarded solid, liquid and gaseous chemicals
    that are
  • Toxic
  • Corrosive
  • Flammable
  • Reactive
  • - Explosive, water reactive, shock sensitive
  • Oxidizing

6
General Types of Chemical Wastes
Chemical Waste Examples
Halogenated solvents chloroform, methylene chloride, perchloroethylene, refrigerants, trichloroethylene
Non-halogenated solvents acetone, acetonitrile, ethanol, ethyl acetate, formaldehyde, isopropanol, methanol, toluene, xylenes
Halogenated disinfectants calcium hypochlorite, chlorine dioxide, iodine solutions, iodophors, sodium dichloroisocyanurate, sodium hypochlorite (bleach)
Aldehydes formaldehyde, glutaraldehydes, ortho-pthalaldehyde
Alcohols ethanol, isopropanol, phenols
Other disinfectants hydrogen peroxide, peroxyacetic acid, quarternary amines
Metals arsenic, cadmium, chromium, lead, mercury, silver
Acids acetic, chromic, hydrochloric, nitric, sulfuric
Bases ammonium hydroxide, potassium hydroxide, sodium hydroxide
Oxidizers bleach, hydrogen peroxide, potassium dichromate, potassium permanganate
Reducers Pharmaceuticals sodium bisulfate, sodium sulfite expired drugs, spilled drug, cytotoxic drugs
Miscellaneous anesthetic gases, asbestos, ethylene oxide, herbicides, paints, pesticides, waste oils
7
Examples of Chemical Waste Containing Heavy Metals
  • Mercury
  • Thermometers, sphygmomanometers
  • Cantor tubes, esophageal dilators
  • Mercury switches, fluorescent lamps
  • Dental amalgam
  • Some formulations (e.g., Thimerosal)
  • Cadmium
  • Dry cell batteries
  • Lead
  • Radiation shielding

8
Health Impacts of Chemical Exposure
  • Effects on the lungs
  • Cancer (asbestos, cadmium)
  • Asthma (formaldehyde)
  • Irritation (glutaraldehyde)
  • Effects on the eyes and mucous membranes
  • Irritation (formaldehyde, xylene, methyl ethyl
    ketone)
  • Conjunctivitis (glutaraldehyde)
  • Blurred vision (methyl alcohol)

9
Health Impacts of Chemical Exposure
  • Effects on the skin
  • Burns (concentrated acetic acid and sodium
    hydroxide)
  • Rashes, irritation (methyl ethyl ketone, other
    solvents)
  • Effects on the nervous system
  • Mercury, ethylene oxide, xylene, lead,
    chloroform, other chlorinated solvents, various
    organochlorine insecticides

10
Health Impacts of Chemical Exposure
  • Effects on the liver and kidneys
  • Lead, cadmium, chloroform, tetrachloroethylene
    and other chlorinated solvents
  • Effects on the reproductive system
  • Various pesticides, lead, ethylene oxide
  • Cancers
  • Ethylene oxide, benzene, various pesticides, some
    chlorinated solvents, many cytotoxic agents

11
Segregation of Chemical Waste
  • Chemical Waste
  • Separate from infectious waste, radioactive
    waste, and general non-risk waste
  • Segregate based on compatibility
  • Toxic, Corrosive, Flammable, Reactive

12
Containers and Color Coding for Chemical Waste
  • WHO recommendation

Waste Color and Markings Container Type
Chemical and pharmaceutical waste Brown Plastic bag or container
13
Labeling of Chemical Waste
  • Waste container label should have
  • Name, address, telephone of the generator
  • Point of generation (if applicable)
  • Start date of accumulation of waste
  • Estimated quantity
  • Description of contents
  • Waste classification
  • Hazard symbols
  • Precautionary statement
  • Emergency contact information

14
International Chemical Waste Symbols
  • Toxic
  • Corrosive
  • Flammable
  • Explosive
  • Oxidizer

15
Handling of Chemical Waste
  • Proper personal protective equipment (PPE) should
    be used when handling hazardous chemicals
  • Type of PPE required is specific for each
    chemical

16
Handling of Chemical Waste
  • Appropriate transferring methods must be used
  • Bonding, grounding, and explosion proof devices
    for flammable waste
  • Spill kit accessible
  • Different spill kits for different hazards
  • All materials in the kit are hazardous after use
  • Secondary containment

17
On-Site Transport of Chemical Waste
  • Use wheeled trolleys, containers, or carts
    designated for chemical waste transport with 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
  • Leak proof

18
Storage of Chemical Waste
  • Use a separate and enclosed area, room, or
    building
  • Provide good ventilation
  • Have easy access to safety shower and eyewash
    station
  • Equip with a liquid or chemical proof sump
    (secondary containment in case of leaks)

19
Storage of Chemical Waste
  • No mixing of chemical waste (according to
    manufacturers specifications)
  • Incompatible wastes should be stored separately,
    e.g. acids and bases
  • Temperature should be controlled or kept within
    the acceptable range based on manufacturers
    requirements

20
Sample Sketch of a Chemical Waste Storage Area
21
Storage of Chemical Waste
  • Storage rooms and facilities should be labeled on
    the exterior with a sign
  • - NO ENTRY Hazardous waste
  • Other symbols if needed
  • No Smoking
  • No Eating or Drinking

22
Off-Site Transport
  • Transport vehicles should meet basic requirements
  • E.g., well maintained, bulkhead to separate
    driver from vehicle load, system to secure load,
    proper placards and markings including hazard
    symbol and emergency contacts, spill kit, easy to
    decontaminate, etc.
  • Driver should be trained on
  • Laws, risks, safe handling methods, labeling,
    documentation and emergency procedures
  • Consignment or manifest system

23
Treatment of Chemical Waste
  • Chemical and Physical Treatment
  • Neutralization
  • Detoxification
  • Chemical reduction or oxidation
  • Electrolytic oxidation
  • Hydrogenation, hydrolysis
  • Biological Treatment
  • Biodegradation
  • Thermal Treatment
  • High-temperature incineration with air pollution
    control

24
Treatment of Chemical Waste in Low-Income
Countries
  • Encapsulation
  • Inertization with cement
  • Burial of encapsulated or inertized waste in
    engineered, controlled and secure landfills
  • Return of chemicals to manufacturers

25
Chemical Wastes Containing Heavy Metals
  • Chemical Wastes containing toxic metals, in
    general
  • Should not be burned or disposed in dumpsites
  • Some heavy metals, like silver in x-ray
    processing, can be recovered
  • Return to supplier for reprocessing or disposal
    if possible
  • If no options currently exist, store the waste
    safely in a medium-term storage site
  • Refer to the Secretariat of the Basel
    Conventions guidelines on the environmentally
    sound management or reclamation of metals
    including mercury and lead
  • Mercury
  • Develop safe clean-up, handling and storage
    procedures
  • Sequester mercury waste safely in a long-term
    storage facility
  • Reduce unnecessary use of mercury equipment
  • Replace mercury-containing products with
    mercury-free alternatives
  • Develop plans to become a mercury-free facility
  • Cadmium and Lead
  • Send to facilities that specialize in recovery of
    heavy metals
  • Return to suppliers if possible
  • Send to a treatment, storage and disposal
    facility for hazardous industrial waste

26
Chemical Waste Management
  • Integrate chemical waste management into the HCWM
    plan, program and organization
  • Identify chemical waste sources and hazards
  • Control hazards by using less hazardous
    materials, modifying equipment to reduce
    exposures, implementing safe practices, PPE and
    administrative controls
  • Train workers on the proper use of PPE
  • Provide workers with information such as material
    safety data sheets (MSDS) and international
    chemical safety cards (ICSC)
  • Comply with the countrys chemical waste
    regulations
  • Develop strategies for waste minimization

27
Workers Right to Know
  • Principle 10 of the Rio Declaration on
    Environment and Development
  • Each individual shall have appropriate access to
    information on hazardous materials and
    activities .
  • Principle 10 is embodied in many national and
    regional laws on Workers Right To Know about
    the hazards of chemicals they are working with
  • Facilities can provide chemical hazard
    information by making available or International
    Chemical Safety Cards or Safety Data Sheets
    (SDSs), which are also called Material Safety
    Data Sheets (MSDSs)

28
Safety Data Sheets
  • Sections of a safety data sheet
  • Identification
  • Hazard identification
  • First-aid measures
  • Fire-fighting measures
  • Accidental release measures
  • Handling and storage
  • Exposure controls/personal protection
  • Exposure controls/personal protection
  1. Physical and chemical properties
  2. Stability and reactivity
  3. Toxicological information
  4. Ecological information
  5. Disposal considerations
  6. Transport considerations
  7. Regulatory information
  8. Other information, including date

29
Example of an ICSC
ICSCs can be found at http//www.ilo.org/dyn/icsc
/showcard.home
30
Example of a Safety Data Sheet
MSDSs can be found on the Internet or obtained
from manufacturers.
31
Chemical Waste Minimization
  • Source Reduction (most desirable method of waste
    minimization)
  • Segregate hazardous chemical waste
  • Evaluate possible substitutions using less
    hazardous or non-hazardous materials
  • Use steam cleaning or non-toxic cleaners
  • Control the inventory of chemicals
  • Minimize unnecessary dilution of wastes
  • Develop plans for a mercury phase-out

32
Chemical Waste Minimization
  • Recycling
  • Select vendors that are willing to reprocess or
    recycle their products
  • Use a silver recovery unit for photographic waste
  • Use a distillation column to recover solvents
  • Purchase compressed gas cylinders from
    manufacturers who accept return of empty or
    partially used cylinders

33
Chemotherapeutic Waste
  • Chemotherapeutic waste waste generated from the
    use of chemical agents for treatment, especially
    cancer therapy
  • Cytotoxic agents substances capable of killing
    or stopping the growth of cells
  • Cytostatic agents capable of suppressing growth
    and multiplication of cells
  • Antineoplastic agents inhibiting the
    development of abnormal tissue growth
  • Genotoxic agents capable of inducing genetic
    mutation
  • Teratogenic agents capable of causing defects
    in an embryo or fetus

34
Examples of Cytotoxic Waste
  • Examples of sources
  • Contaminated materials from drug preparation
    including vials and syringes
  • Contaminated materials from drug administration
    including gloves, gauze, needles
  • Examples of specific agents
  • Alkylating agents (e.g., mechlorethamine,
    chlorambucil, cyclophosphamide, ifosfamide,
    melphalan, streptozocin, carmustine, busulfan,
    dacarbazine, thiotepa cisplatin)
  • Antimetabolites (e.g., 5-fluorouracil,
    methotrexate)
  • Anti-tumor antibiotics (daunorubicin,
    doxorubicin, bleomycin)
  • Topoisomerase inhibitors (etoposide, teniposide)
  • Mitotic inhibitors (paclitaxel, vinblastine,
    vincristine)

35
Segregation of Cytotoxic Waste
  • Cytotoxic/Genotoxic Waste
  • Should be stored separately from other waste in
    designated secure location
  • Collect in strong containers
  • Containers should be leak-proof
  • Clearly label containers cytotoxic wastes
  • Do not dispose in dumpsites or discharged into
    sewerage systems

36
Treatment and Disposal of Chemotherapeutic Waste
  • Chemical degradation
  • Convert chemo waste into non-toxic residues by
    alkaline hydrolysis, chemical oxidation with
    potassium permanganate or sulfuric acid,
    denitrosation with hydrobromic acid, or other
    effective methods for the particular type of
    cytotoxic waste
  • High-temperature incineration with air pollution
    control
  • Options for low-income countries
  • UNDP GEF technology developed in Argentina
    www.gefmedwaste.org
  • Safely package and return to original supplier
  • Encapsulation as a last resort
  • Do not disposed in dumpsites nor discharged into
    sewer systems

37
Chemotherapeutic Waste Minimization
  • Segregate chemotherapy wastes through worker
    training and separate waste containers
  • Use degradable chemo agents instead of
    environmentally persistent agents
  • Purchase drug volumes based on need
  • Return expired agents to manufacturer
  • Develop spill containment and clean-up procedures
    that minimize waste clean-up volume

38
Characteristics of Radioactive Wastes
  • Waste contaminated with radionuclides
  • Produced as a result of
  • in-vitro analysis of body tissue and fluid
  • in-vivo organ imaging and tumor localization
  • investigative and therapeutic practices
  • Can be sealed (encapsulated in pins, seeds or
    needles) or unsealed (liquids administered
    directly)
  • Some have relatively short half-lives causing
    them to lose activity quickly (e.g.,
    technitium-99m 6 hours iodine-123 13 hours
    phosphorus-32 14 days)
  • Others have long half-lives (carbon-14 5730
    years)

39
Sources of Radioactive Wastes in Healthcare
  • Sealed sources
  • Spent radionuclide generators
  • Low-level solid waste, e.g. absorbent paper,
    swabs, glassware, syringes, vials
  • Residues from shipments of radioactive material
    and unwanted solutions of radionuclides intended
    for diagnostic or therapeutic use
  • Liquid immiscible with water, such as liquid
    scintillation-counting
  • Residues used in radioimmunoassay, and
    contaminated pump oil
  • Waste from spills and decontamination of
    radioactive spills
  • Excreta from patients treated or tested with
    unsealed radionuclides
  • Low-level liquid waste, e.g. from washing
    apparatus
  • Gases and exhausts from stores and fume cupboards

40
Health Risks of Radioactive Waste
  • Health impacts determined by type and extent of
    exposure to ionizing radiation
  • Chromosomal damage
  • Headaches, dizziness, vomiting
  • Tissue destruction, hemorrhage, hair loss,
    diarrhea, death at high doses
  • An extreme case from Brazil (1988)
  • Sealed radioactive source was removed from a
    radiotherapy institute and broken open 249
    people exposed, several died or suffered severe
    health problems

41
Containers for Radioactive Wastes
  • Low-level radioactive infectious waste (swabs,
    syringes) may be collected in bags or containers
  • There is no recommended color code for
    radioactive waste containers
  • Containers should have the radioactive symbol

42
Segregation of Radioactive Waste
  • Separate radioactive wastes based on
  • Half-life
  • Short-lived (lt60 days) versus long-lived (gt60
    days)
  • Activity and radionuclide content
  • Physical and chemical form
  • Liquid aqueous and organic
  • Non-homogeneous (e.g. contain sludge or suspended
    solids)
  • Solid combustible/non-combustible and
    compactable/non-compactable
  • Sealed versus non-sealed sources
  • Spent sealed sources
  • Waste content
  • Waste containing hazardous (e.g. pathogenic,
    infectious, toxic) material

43
Labeling of Radioactive Waste
  • Radioactive wastes
  • Radioactive waste marking and symbol
  • Identification number
  • Radionuclide
  • Activity and date of measurement
  • Period of storage required
  • Origin of the waste (room, lab, etc.)
  • Potential/actual hazards
  • Surface dose rate and date of measurement
  • Quantity (weight or volume)
  • Responsible person

44
Storage of Radioactive Waste
  • Secure cabinet, dedicated area, room or small
    building
  • Waste segregated according to the time needed for
    storage
  • Extremely short half lives (lt5 days), short half
    lives (5 to 30 days), longer half lives (30 to 60
    days)
  • Restricted access for safety
  • Radiation shielding depending on radiological
    hazard
  • Radiation monitoring and surveillance
  • Fire protection
  • Periodic inspections for leakage
  • Recordkeeping, inventory log

45
Disposal of Radioactive Waste
  • Return to supplier
  • Decay in Storage or storage for decay
  • Store the waste for at least 10 times the
    half-life of the longest lived radionuclide in
    the waste
  • Conduct a radiation survey to confirm that
    radioactivity is below the clearance level
  • Disinfect mixed radioactive infectious waste
    before discarding with regular waste
  • Long-term storage at an authorized radioactive
    waste disposal facility

46
Radioactive Waste Minimization
  • Develop a radioactive waste management plan
  • Substitute long-lived radionuclides with
    short-lived radionuclides
  • Substitute stable isotopes for radionuclides
    where possible
  • Limit the quantity of radioactive items purchased
  • Improve procedures to avoid contamination and to
    minimize the volume of waste generated

47
Sources of Pharmaceutical Waste
  • Expired pharmaceuticals
  • Discontinued drugs
  • IV preparations
  • Partially used vials and syringes
  • Compounding of drugs
  • Breakage and spills of pharmaceuticals
  • Unused single-dose repackaged drugs
  • Patients personal medications

48
Characteristics of Pharmaceutical Waste
  • Pharmaceuticals can be
  • Acutely hazardous (e.g., arsenic trioxide,
    epinephrine, nitroglycerin, warfarin gt0.3)
  • Toxic (e.g., barium, chloral hydrate, chloroform,
    chlorambucil, cyclophosphamide, mitomycin C,
    streptozotocin, lindane, phenol, thimerosal)
  • Flammable or ignitable (e.g., isopropanol,
    paregoric, collodion-based preparations)
  • Corrosive (e.g., acetic acid used for compounding)

49
Environmental Impact of Pharmaceutical Waste
  • Pharmaceuticals are present in most hospital
    wastewater
  • More than 100 different types of pharmaceuticals
    or their metabolites are found in water bodies in
    Europe and the U.S.
  • Some pharmaceuticals can seep into the
    groundwater
  • Environmental concentrations could affect fish
    and other wildlife
  • Antibiotics found in streams worldwide raise
    concerns of the possible rise of
    antibiotic-resistant organisms

50
Segregation of Pharmaceutical Waste
  • Pharmaceutical Waste
  • Should be segregated from other infectious and
    radioactive wastes
  • National and local regulations must be followed

51
Treatment and Disposal of Pharmaceutical Waste
  • Chemical Treatment
  • Chemical Absorption
  • Denaturing (e.g., alkaline hydrolysis)
  • High Temperature Incineration
  • Recovery of active pharmaceutical ingredients
    through solvent extraction, separation,
    distillation, filtration, etc.

52
Disposal of Pharmaceutical Waste in Low-Income
Countries
  • Reverse distribution (return to supplier)
  • Safe burial on hospital premises
  • Encapsulation or inertization
  • Solid, liquid, or semi-liquid waste can be
    encapsulated in metal drums
  • Solids ground up mixed with cement, lime and
    water made into pellets or blocks
  • Landfill disposal
  • Landfilling large quantities of pharmaceuticals
    is not recommended, unless waste is encapsulated
    and disposed in a sanitary landfill where there
    is no risk of leaching into the groundwater
  • Discharge to a sewer
  • Only for relatively mild liquid or semi-liquids
    (vitamins, cough syrups, eye drops, saline
    solution, glucose, electrolytes, etc.)
  • Discharge into a large flow of water and into
    municipal sanitary sewers
  • Antibiotics and cytotoxic drugs should not be
    discharged in a sewer

53
Pharmaceutical Waste Minimization
  • Good inventory control
  • Increase inventory turnover
  • Apply inventory control strategies (e.g., ABC
    classification, First In First Out, Just-In-Time
    management, etc.)
  • Avoiding unnecessary prescriptions, especially
    antibiotics
  • Reformulation of drugs

54
Discussion
  • What are some sources of chemical, cytotoxic, and
    pharmaceutical wastes in your facility? What are
    some examples of these healthcare wastes that may
    occur both inside and outside of your facility?
    What are some major hazards and risks that are
    posed by these wastes?
  • What are some sources of radioactive wastes in
    your facility? Give some examples, as well as
    their hazards and risks.
  • How does your facility segregate chemical and
    pharmaceutical wastes? What about specific
    wastes that have cytotoxic and/or genotoxic
    properties? What handling and safety procedures
    are followed by those who deal directly with the
    wastes?

55
Discussion
  • How does your facility store chemical, cytotoxic,
    pharmaceutical, and radioactive wastes? What
    treatment and disposal methods does it use or has
    it used in the past for each category of waste?
  • What are country/region-specific policies and
    guidelines for chemical and radioactive waste
    management? What about international guidelines
    specifically meant for radioactive wastes? Is
    your facility able to follow these guidelines?
  • How does your facility regulate mercury? Are
    there plans to use alternative sources in place
    of mercury and to eventually phase out its use in
    most medical equipment?
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