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Republic of Ethiopia (2004) EPA Technical guidelines on the environmentally sound disposal of biomedical and healthcare wastes.pdf

Republic of Ethiopia (2004) EPA Technical guidelines on the environmentally sound disposal of biomedical and healthcare wastes

The Federal Environmental Protection

Technical Guidelines on the Environmentally Sound
Management of Biomedical and Healthcare Wastes

Addis Ababa


Table of Contents

Table of Contents.....................................................................................................I
2. Purpose and scope of the guidelines......................................................................3
3. General definition of biomedical and health-care waste..................................4

3.1 Health-care.................................................................................................................4
3.2 Biomedical and health-care waste.............................................................................5
3.3 Hazardous health-care waste.....................................................................................5
3.4 Infectious health-care waste......................................................................................5
3.5 Biological health-care waste......................................................................................6
3.6 Sharps........................................................................................................................6

4. Hazards of biomedical and health-care waste.....................................................6
4.1 Types of hazards........................................................................................................6
4.2 Persons at risk............................................................................................................7
4.3 Hazards from infectious waste...................................................................................8
4.4 Hazards from sharps..................................................................................................8
4.5 Hazards from chemical and pharmaceutical waste....................................................8
4.6 Hazards from cytotoxic waste...................................................................................9
4.7 Hazards from radioactive waste.................................................................................9

5. Field of application/source identification...........................................................10
6. Waste identification and classification; waste groups....................................11
7. Applicable state-of-the-art management, treatment and disposal

7.1 Avoidance/prevention..............................................................................................24
7.1.1 Packaging..........................................................................................................25
7.1.2 Kitchen and canteen waste................................................................................26
7.1.3 Laboratory waste and chemical residues..........................................................26

7.2 Segregation, collection, labeling and handling of biomedical and health-care waste
7.3 In-house transport and storage.................................................................................29
7.4 Special requirements for packaging and labelling for off-site transport.................32

7.4.1 Packaging requirements....................................................................................33
7.4.2 Labeling............................................................................................................33

7.5 Recycling/recovery..................................................................................................34
7.6 Disposal operation/technologies, accreditation and environmental impacts...........34

7.6.1 Methods of treatment or disposal.....................................................................36 Steam sterilization.........................................................................................38 Dry heat sterilization......................................................................................40 Chemical disinfections/sterilization...............................................................40 Other treatment/disposal methods.................................................................41 Incineration....................................................................................................42 Landfill..........................................................................................................43


7.7 Responsibility (including emergency response and contingency plan)...................47
7.7.1 Assignment of responsibilities..........................................................................47 Duties of the head of the hospital..................................................................47 Duties of the waste management officer (WMO)..........................................48
7.7.2 Emergency response.........................................................................................50 Response to injuries.......................................................................................51 Dealing with spills.........................................................................................51 Reporting accidents and incidents.................................................................53

8. Waste management auditing..................................................................................53
9. Capacity-building.....................................................................................................55

9.1 Education and training of personnel of health-care establishments........................55
9.1.1 Responsibility for training................................................................................57
9.1.2 The training package.........................................................................................57
9.1.3 Selection of participants...................................................................................57

9.1.4 Training recommendations...................................................................................58 Training recommendations for personnel providing health-care...................58 Training recommendations for waste-handling staff.....................................59 Training of health-care waste management operators...................................59 Training for members of staff who transport waste.......................................59 Training of incinerator operators...................................................................60 Training of operators of specially engineered landfill sites...........................61

Annex I: Glossary/terminology.................................................................................62
Annex II: Examples of specific waste reduction, reuse and recycling



Guidelines are preferably set based on country specific baseline information. However,

under the prevailing Ethiopian conditions, the necessary information required for the

preparation of the guidelines is inadequate, outdated and scanty. An alternative approach

is to adopt or adapt the guidelines of international organizations. Accordingly, it has

become imperative to adopt and use the Biomedical and Healthcare wastes of the United

Nation Environment Program.

Therefore, the UNEP guidelines on Biomedical and Healthcare wastes adopted and

introduced throughout the country. The guideline will be amended as more information

on the state of Biomedical and Healthcare wastes is obtained.

1. The disposal of wastes originating from health-care establishments (public and private)

can have an effect on human health and well-being, the environment (air, water, soil,

animals, plants, landscape) and issues relating to public security and order.

2. Nevertheless, experience has proven that wastes originating from health-care

establishments, when properly managed, generally pose no greater risks than that of

properly treated municipal or industrial wastes. This also pertains to the disposal of

biomedical and health-care wastes, in contrast to occasional public perception.

3. The guidelines provide information for the proper treatment of wastes from health-care

establishments (public and private). The information provided takes due consideration

of the waste management requirements of disposal and recovery measures as well as

hygiene requirements. In addition to ecological aspects, the information and

recommendations should be economically feasible and easy to undertake. It and also

makes allowances for technical progress.

4. It has become apparent that the introduction of improved solutions for the segregation

of waste within health-care facilities can result in reduced amounts of waste requiring

special treatment and therefore in reduced waste treatment costs. In addition, new

technologies have become available to treat and disinfect biomedical and health-care

wastes so that they can be of with low risk by landfilling finally.


5. The safe management of biomedical and health-care waste is essential for community

and environmental health. It is also important that the standards for the protection of

the environment and human health are uniform across all health-care establishments,

irrespective of technologies used for treatment and disposal. This in turn ensures a

more viable and efficient industry. However, it should be noted that in many countries,

the national authorities, in addition to industry, are an active participant in health-care,

either providing services or paying for them. In addition, the lack of resources or of

experience in developing standards may be significant factors affecting the capacity to

treat biomedical and health-care wastes.

6. To manage biomedical and health-care waste effectively, the following should be taken

into consideration:

(a) Generation and minimization;

(b) Separation and segregation of sources;

(c) Identification and classification;

(d) Handling and storage;

(e) Packaging and labelling;

(f) Transportation inside and outside health-care establishments;

(g) Treatment;

(h)Disposal of residues (including emissions);

(i)Occupational health and safety; public and environmental health;

(j)Stakeholder and community awareness and education;

(k)Research into and development of improved technologies and environmentally

friendly practices.

7. These guidelines attempt to address all of these issues and provide support for the

achievement of improved environmental performance in managing biomedical and

health-care waste. To be successful, waste management strategies should always take

account of, and interact with, the process that generated the wastes in the first place.


2. Purpose and scope of the guidelines

8. Biomedical and health-care waste is a term for all waste generated in health-care

establishments. Biomedical and health-care waste can briefly be described as waste

from medical or other related practices. In reality, only a small proportion of this

waste causes a higher risk of transmitting infectious diseases than normal household

or municipal waste. These guidelines deal with all biomedical and health-care waste,

with especial focus on the segregation and treatment of hazardous biomedical and

health-care waste.

9. Concern regarding the safe management and disposal of biomedical and health-care

waste has resulted from the perceived or real risk of potential transmission of

infectious diseases through accidental injury or contact with infected body fluids. The

disposal of sharps (needles, scalpels etc.) has attracted particular interest because of

the small number of occupationally acquired hepatitis and HIV human

immunodeficiency virus (HIV) infections suffered by health-care workers attributed

to sharps injuries. The majority of sharps injuries, however, do not result in infection.

It is therefore “good practice” in waste management to reduce the risk of injuries.

Figure 1 describes some possible action points to establish “good practice” in waste



Figure 1 Biomedical and health-care waste strategy

3. General definition of biomedical and health-care waste

10. To get a better understanding of the waste management practice of health-care

facilities, there is a need to have a common and internationally accepted definition

for the waste generated in those facilities.

11. The general definitions below are set forth by these guidelines:

3.1 Health-care

12. Medical activities such as diagnosis, monitoring, treatment, prevention of disease or

alleviation of handicap in humans or animals, including related research, performed

under the supervision of a medical practitioner or veterinary surgeon or another

person authorized by virtue of his or her professional qualifications.


3.2 Biomedical and health-care waste

13. The solid or liquid waste arising from health-care (including collected gaseous


3.3 Hazardous health-care waste

14. This includes:

(a) Infectious health-care waste;

(b)Chemical, toxic or pharmaceutical waste, including cytotoxic drugs


(c) Sharps (e.g. needles, scalpels);

(d) Radioactive waste;

(e) Other hazardous waste.

3.4 Infectious health-care waste

15. All biomedical and health-care waste known or clinically assessed by a medical

practitioner or veterinary surgeon to have the potential of transmitting infectious

agents to humans or animals.

16. For the purpose of these guidelines, infectious health-care wastes are:

(a) Discarded materials or equipment contaminated with blood and its

derivatives, other body fluids or excreta from infected patients with

hazardous communicable diseases (specified in section 6.1, subsection B.5

below). Contaminated waste from patients known to have blood-borne

infections under going haemodialysis (e.g. dialysis equipment such as

tubing and filters, disposable sheets, linen, aprons, gloves or laboratory

coats contaminated with blood);

(b) Laboratory waste (cultures and stocks with any viable biological agents

artificially cultivated to significantly elevated numbers, including dishes

and devices used to transfer, inoculate and mix cultures of infectious

agents and infected animals from laboratories).


17. Wherever appropriate and applicable, waste from basic and fundamental biomedical

and other research shall be managed according to the principles set forth for health-

care waste.

3.5 Biological health-care waste

18. All body parts and other anatomical waste including blood and biological fluids and

pathological waste that are recognizable by the public or the health-care staff and that

demand, for ethical reasons, special disposal requirements.

3.6 Sharps

19. All biomedical and health-care waste with sharps or pointed parts able to cause an

injury or an invasion of the skin barrier in the human body. Sharps from infected

patients with hazardous communicable diseases (specified in section 6.1, subsection

B.5 below), isolated wards or other pointed parts contaminated with the above-

mentioned laboratory waste must be categorized as infectious waste.

4. Hazards of biomedical and health-care waste

4.1 Types of hazards

20. As mentioned in section 1, biomedical and health-care waste includes a large

component of non-risk waste and a smaller proportion of risk waste. Non-risk waste

is similar to municipal waste and does not create more health or other hazards than

mismanaged municipal waste. If the risk waste is not properly segregated from other

waste fractions (e.g. mixture of biological and pathological waste with sharps and

body fluids), the whole mixture has to be handled as infectious waste. In this section,

potential hazards related to exposure to biomedical and health-care waste will be


21. Exposure to hazardous or potentially hazardous biomedical and health-care waste can

induce disease or injury. The hazardous nature of biomedical and health-care waste

may be due to the following or a mixture of the following properties:


(a) It contains infectious agents, including contaminated sharps;

(b) It is cytotoxic or genotoxic;

(c) It contains toxic or hazardous chemicals or pharmaceuticals;

(d) It is radioactive;

(e) It contains sharps.

22. For the purposes of these guidelines, infectious substances are those substances

known or reasonably expected to contain pathogens. Pathogens are defined as micro-

organisms (including bacteria, viruses, rickettsia, parasites, fungi) or recombinant

micro-organisms (hybrid or mutant) that are known or reasonably expected to cause

infectious disease with a high risk for animals or humans. Note that not all pathogenic

micro-organisms can be transmitted by waste as a pathway.

4.2 Persons at risk

23. All persons exposed to hazardous biomedical and health-care waste are potentially at

risk of contamination through accidental exposure. This includes people within

health-care establishments or any other source of biomedical and health-care waste,

and people inside and outside these sources who either handle these wastes or are

exposed to them, for example as a consequence of careless management. The main

groups at risk are the following:

(a) Doctors, nurses, ambulance staff and hospital sweepers;

(b) Patients in health-care establishments or under home care;

(c) Workers in support services to health-care establishments, such as laundries,

waste handling and transportation, waste disposal facilities including incinerators

and other persons separating and recovering materials from waste;

(d) Inappropriate or inadvertent end-users such as scavengers and customers in

secondary markets for reuse (i.e. households, local medical clinics, etc.).

24. Owing to the extension of drug abuse and of home care including home dialysis, the

hazards associated with scattered small sources of biomedical and health-care waste

should not be overlooked.


4.3 Hazards from infectious waste

25. Infectious waste may contain a great variety of pathogenic micro-organisms, but not

all can be transmitted to humans and animals by contact with waste.

26. The pathogens contained in the waste may infect the human body through the

following pathways: absorption through a crack or cut in the skin (injection),

absorption through the mucous membranes, and rarely by inhalation and ingestion.

27. Concentrated cultures of pathogens and contaminated sharps (in particular syringe

needles) are probably the waste items that create the most acute human health


4.4 Hazards from sharps

28. Sharps may not only cause cuts and punctures but also infect the wounds by agents

which previously contaminated the sharps. Owing to this double risk of injury and

disease transmission, sharps are considered problematic. The main diseases of

concern are infections which may be transmitted by subcutaneous introduction of the

agent - for example, viral blood infections.

29. Syringe needles are of particular concern because they constitute an important part of

the sharps and are often contaminated with the blood of patients.

4.5 Hazards from chemical and pharmaceutical waste

30. Many chemicals and pharmaceuticals which are used in health-care establishments

are hazardous chemicals (e.g. toxic, corrosive, flammable, reactive, explosive, shock-

sensitive, cytotoxic or genotoxic). Fractions of these will be found in biomedical and

health-care waste after their use or when they are no longer required.

31. They may have toxic effects, either through acute or chronic exposure, and injuries,

including burns. Intoxications can result from absorption of the

chemicals/pharmaceuticals through the skin or the mucous membranes and from

inhalation or ingestion. Injuries can be provoked by contact of flammable, corrosive

or reactive chemicals with the skin, the eyes or the mucous membrane of the lung


(e.g. formaldehyde and other volatile chemicals). The most common injuries are


32. Mercury is another hazardous product common within hospitals owing to its

prevalent use in literally hundreds of different devices. It is most concentrated in

diagnostic devices such as thermometers, blood pressure gauges and, oesophageal

dilators, Miller Abbott/Cantor tubes. It is also found in other sources such as

fluorescent light tubes and batteries.

33. Disinfectants constitute a particularly important group of hazardous chemicals, as

they are used in large quantities and are often corrosive. It should also be noted that

reactive chemicals may form highly toxic secondary compounds. Chemical residues

discharged into the sewage system may have toxic effects on the operation of

biological sewage treatment plants or on the natural ecosystems of receiving waters.

Pharmaceutical residues may have the same effects, as they may include antibiotics

and other drugs, heavy metals such as mercury, phenols and derivatives and other

disinfectants and antiseptics.

4.6 Hazards from cytotoxic waste

34. The severity of health hazards for health-care workers handling cytotoxic waste arises

from the combined effect of the substance toxicity and of the magnitude of exposure

that may occur during waste handling or disposal. Exposure to cytotoxic substances

in health care may also occur during preparation for treatment. The main pathways of

exposure are inhalation of dust or aerosols, skin absorption and ingestion of food

accidentally in contact with cytotoxic (antineoplastic) drugs, chemicals or waste, or

from contact with the secretions of chemotherapy patients.

4.7 Hazards from radioactive waste

35. Radioactive materials are unique in that they cause harm through both external

radiation (by approaching them or handling them) and through their intake into the

body. The degree of harm depends on the amount of radioactive material present or


taken into the body and on the type of material. Exposure to radiation from high-

activity sources, such as those used in radiotherapy, can cause severe injuries, ranging

from superficial burns to early fatalities. Radioactive waste arising from nuclear

medicine is much lower in activity than the sources referred to above and is unlikely

to cause such harm, but exposure to all levels of radiation is considered to be

associated with some risk of carcinogenesis, however small.

36. There are well-established procedures for minimizing the hazards arising from work

with radioactive materials, and these are normally implemented in hospitals and

laboratories where such materials are used. Similarly, the arrangements for safe

radioactive waste storage and disposal are well established. There should be a person

or persons appointed in the organization with responsibility for ensuring that

radiation protection is observed and that radioactive waste is properly and safely


5. Field of application/source identification

37. These guidelines shall be applicable for the generation of biomedical and health-care wastes from

health-care establishments. Health-care establishments shall specifically include the following:

(a) Large sources:

(i) University hospitals and clinics;

(ii) Maternity hospitals and clinics;

(iii) General hospitals.

(b) Medium sources:

(i) Medical centres;

(ii) Out-patient clinics

(iii) Mortuary/autopsy centres;

(iv) Farm and equine centres;


(v) Hospices;

(vi) Abortion clinics

(vii) Medical laboratories

(viii) Medical research facilities;

(ix) Animal hospitals;

Blood banks and transfusion

(xi) Emergency services.

(c) Small sources:

(i) General medical practitioners;

(ii) Convalescent homes;

(iii) Nursing and remedial homes;

(iv) Medical consulting rooms;

(v) Dental practitioners;

(vi) Animal boarding and hunt kennels;

(vii) Tattooists;

(viii) Acupuncturists;

(ix) Veterinary practitioners;

(x) Pharmacies;

(xi) Cosmetic piercers;

(xii) Zoos, safari parks, etc.

6. Waste identification and classification; waste groups

38.For the purpose of this guidelines the following biomedical and health-care waste

classification is used:

A Health-care wastes with the same composition as household and municipal waste


A1 Normal household and municipal waste

B Biomedical and health-care waste requiring special attention

B1 Human anatomical waste (tissues, organs, body parts, blood and blood bags)

B2 Waste sharps (needles, syringes, scalpels, slides, ampoules, etc.)

B3 Pharmaceutical waste (e.g. expired medicines)

B4 Cytotoxic pharmaceutical wastes

B5 Blood and body fluid waste (materials contaminated with blood or other

body fluids, soiled cotton from non-infected patients) Wastes which only

require special measures to prevent the risk of infection during their


C Infectious wastes

For the purpose of these guidelines, infectious health-care wastes are:

(a) Discarded materials or equipment contaminated with blood and its derivatives,

other body fluids or excreta from infected patients with hazardous

communicable diseases(specified in section 6.1, subsection B.5 below).

Contaminated waste from patients known to have blood- borne infections under

going haemodialysis(e.g. dialysis equipment such as tubing and filters,

disposable sheets, linen, aprons, gloves or laboratory coats contaminated with


(b) Laboratory waste (cultures and stocks with any viable biological agents

artificially cultivated to significantly elevated numbers, including dishes and

devices used to transfer, inoculate and mix cultures of infectious agents and

infected animals from laboratories).

D Other hazardous wastes.


Not exclusive to the medical health-care sector, e.g. solvents, chemicals, batteries,

fixer solutions, etc.

E Radioactive waste from health care.

B1. Human anatomical waste


Non-infectious human body parts, organs and tissues and blood bags.

Examples of such wastes

Tissue waste, removed organs, amputated body parts, placentas, etc.

Waste management guidance

It is primarily for ethical reasons that special requirements must be placed on the

management of waste human body parts, organs and tissue. The waste must be collected

in appropriate containers or bags as soon as possible and at the place where it is

generated. The waste must be kept in tight receptacles (e.g. in the wooden coffins

commonly used in pathology) and under cooled conditions when stored temporarily for a

prolonged period of time, or else be handed over to a waste management facility within a

reasonable period. Intermediate storage takes place at a location which is accessible only

to trained personnel. Normally, the waste must always be incinerated completely, in an

appropriate facility. Household waste incineration plants are, as a rule, not suitable for the

incineration of amputated body parts, removed organs and placentas (cases of exceptions,

such as separate storage and direct feeding, have to be clarified with the responsible

authorities and the management of the incineration plant). In exceptional cases crematoria

can be used for the incineration (disposal) of amputated body parts.

Exemptions and special provisions

Where only small quantities of these wastes are generated (e.g. in medical practices), they

can be collected in appropriate containers (e.g. “hard box”) and managed jointly with

municipal waste at a volume of up to 1 litre per waste bag. The management of animal

waste body parts, organs and tissues is subject to the provisions of relevant special



B2: Waste posing the risk of injury (sharps)


Sharps are all objects and materials which are closely linked with health-care activities

and pose a potential risk of injury and/or infection.

Examples of such wastes

Needles, drain tubes, syringes with the attached needle, butterfly needles, spikes, broken

glassware, ampoules, pipettes, scalpel blades, lancets, vials without content, etc. Waste

management guidance Wastes posing the risk of injury require measures to be taken to

prevent injury and infection during the handling of these wastes within and outside of

health-care establishments. These wastes have to be collected and managed separately

from other waste. The collection containers must be puncture-resistant and leak tight.

Storage of these wastes takes place at a location which is accessible only to trained


Note: Sharps from infected patients, isolated wards, infected patients undergoing

haemodialysis or other pointed parts contaminated with laboratory waste must be

categorized as infectious waste.

Exemptions and special provisions Syringes and needles should not be reused.

B3: Pharmaceutical waste


Pharmaceutical wastes are pharmaceuticals, which have become unusable for the

following reasons:

 Exceeded expiration date;

 Expiration date exceeded after the packaging or the ready-to-use preparation

prepared by the user has been opened;

 Cannot be used for other reasons (e.g. call-back campaign).


Examples of such wastes

The term “pharmaceuticals” embraces a multitude of active ingredients and types of

preparations. The spectrum ranges from teas through heavy-metal-containing

disinfectants to highly specific medicines containing a large variety of different

hazardous or non-hazardous substances. Waste management may therefore be based on a

differentiated approach; for example, pharmaceutical waste could be divided into three

classes and its management carried out in a class-specific manner as follows:

 Pharmaceutical wastes: Class 1

Pharmaceuticals such as camomile tea and cough syrup which pose no hazard during

collection, intermediate storage and waste management. Class 1 pharmaceutical

wastes are not considered hazardous wastes. They are managed jointly with municipal


 Pharmaceutical wastes: Class 2

Pharmaceuticals which pose a potential hazard when used improperly by

unauthorized persons. Class 2 pharmaceutical wastes are considered to be hazardous

wastes. Their management takes place in an appropriate waste disposal facility.

 Pharmaceutical wastes: Class 3

Heavy-metal-containing and unidentifiable pharmaceuticals, heavy-metal-containing

disinfectants, which, owing to their composition, require special management. Class 3

pharmaceuticalwastes are considered to be hazardous wastes. Their management

takes place in an appropriate waste disposal facility. However, owing to the fact that

medicines are not normally labelled in accordance with their hazardous

characteristics, the sorting of medicines into different classes, in particular classes 2

and 3, may often be too difficult in practice. Countries may therefore decide to

consider all or a major part of medicines as hazardous waste or waste requiring

special consideration.

Waste management guidance


Waste prevention: To reduce the generation of pharmaceutical waste, stocks of

pharmaceuticals should be inspected periodically and checked for their durability

(expiration date).

Recovery by specialized facilities: Possibilities for returning old pharmaceuticals to the

producer or handing them over to a special collection system (e.g. pharmacies) for

possible subsequent use could be explored. Such a return of pharmaceuticals in their

original packaging prior to or within a reasonable period after the expiration date is

possible if it is ensured that the producer or collector examines possibilities for

subsequent use of the pharmaceuticals and that pharmaceuticals which are no longer

usable are disposed of in an environmentally sound manner.

Pharmaceutical wastes which are considered to be hazardous wastes have to be collected

separately in appropriate containers. Intermediate storage takes place at a location which

is accessible only to trained personnel. This should be done in a manner to avoid misuse.

Exemptions and special provisions

Cytotoxic pharmaceutical waste: See Group B4: Cytotoxic pharmaceutical wastes.

B4: Cytotoxic pharmaceutical wastes


Cytotoxic (antineoplastic) pharmaceutical wastes are wastes which can arise from use

(administration to patients) and manufacture and preparation of pharmaceuticals with a

cytotoxic (antineoplastic) effect. These chemical substances can be subdivided into six

main groups: alkylated substances, antimetabolites, antibiotics, plant alkaloids, hormones

and others. A potential health risk to persons who handle cytotoxic pharmaceuticals

results above all from the mutagenic, carcinogenic and teratogenic properties of these

substances. Consequently, these wastes pose a hazard, and the measures to be taken must

also include those required by occupational health and safety provisions.

Examples of such wastes


Specific lists of pharmaceuticals which contain cytotoxic substances are available.

Discernible liquid residues of cytotoxic concentrates, post-expiration-date cytotoxic

pharmaceuticals and materials proven to be visibly contaminated by cytotoxic

pharmaceuticals must be disposed of as cytotoxic pharmaceutical waste.

Waste management guidance

The risks posed by cytotoxic pharmaceuticals are primarily of relevance for persons who

come into contact with them during preparation and during or after their use. It has long

been common practice in hospitals to see to it that the number of persons who come into

contact with these products is small. Specific guidance on this is available. These wastes

usually arise at central locations, i.e. in pharmacies and laboratories and they are also

often found at places where the ready-to-use cytotoxic solutions are prepared.

Intermediate storage of these wastes takes place under controlled and locked conditions.

The precautions taken during the use of cytotoxic pharmaceuticals must also be applied

on their journey outside the respective establishment, as releases of these products can

have adverse environmental impacts. The management of these wastes, in covered and

impermeable containers, must therefore be strictly controlled. Solid containers must be

used for collection. The use of coded containers is recommended. For reasons of

occupational safety, cytotoxic pharmaceutical wastes must be collected separately from

pharmaceutical waste and disposed of in a hazardous waste incineration plant.

Exceptions and special provisions


B5: Wastes with blood and body fluid


These are wastes from health-care establishments not categorized as infectious wastes

which are contaminated with human or animal blood, secretions and excretions. It is

reasonable to assume that these wastes might be slightly contaminated with pathogens (in

nearly the same way as household waste).

Examples of such wastes


Dressing material, swabs, syringes without the attached needle, infusion equipment

without spikes, bandages, etc.

Waste management guidance

Special requirements must be imposed on the management of these wastes from the

viewpoint of infection prevention inside the health-care establishments. Double bags or

containers made of strong and leak-proof material are used for the collection of these

wastes within health-care establishments.

Proper management of these wastes is by incineration in a household waste incineration

plant but they can also be disposed of together with household waste on a controlled

landfill site.

Exemptions and special provisions

This mixture of wastes should not be recycled.

C: Infectious wastes


Special requirements regarding the collection and management of infectious wastes must

be imposed whenever waste is known or, on the basis of medical experience, expected to

be contaminated by causative agents of the diseases listed below and when this

contamination gives cause for concern that the disease might spread. The list comprises

diseases which make particular demands on infection prevention when the following

factors are taken into account:

 The associated risk of infection (contagiousness, infection dose, epidemic potential);

 The viability of the pathogen (infection capacity/infectiousness);

 The route of transmission;

 The extent and nature of the potential contamination;

 The quantity of contaminated waste;

The severity and treatability of the disease that might be caused.


The wastes belonging to this group may occur in the context of diagnosis and treatment

of patients suffering from the following diseases (relevant pathogen-containing

excretions are given in brackets):

 Acquired immunodeficiency syndrome (AIDS)* (blood)

 Viral hepatitis* (blood, faeces)

 Creuzfeld-Jacob disease (CJD), transmissible spongiform encephalopathy (TSE)*

(tissue, cerebrospinal fluid)

 Cholera# (faeces, vomit)

 Typhoid fever/paratyphoid fever# (faeces, urine, bile)

 Enteritis, dysentery, enterohaemorragic Escherichia coli (EHEC)-induced haemolytic

uraemicsyndrome (HUS)# (faeces)

For the purpose of these guidelines, infectious health-care wastes are:

(a) Discarded materials or equipment contaminated with blood and its derivatives, other

body fluids or excreta from infected patients with hazardous communicable diseases.

Contaminated waste from patients known to have blood-borne infections undergoing

haemodialysis (e.g. dialysis equipment such as tubing and filters, disposable sheets,

linen, aprons, gloves or laboratory coats contaminated with blood).

(b) Laboratory waste (cultures and stocks with any viable biological agents artificially

cultivated to significantly elevated numbers, including dishes and devices used to

transfer, inoculate and mix cultures of infectious agents and infected animals from


 Active tuberculosis (respiratory tract secretions, urine, faeces)

 Meningitis/encephalitis (respiratory tract secretions, cerebrospinal fluid)

 Brucellosis (blood)

 Diphtheria (respiratory tract secretions, secretions from infected wounds)

 Leprosy (secretion from nose/infected wounds)

 Anthrax (respiratory tract secretions, secretion from infected wounds)

 Plague (respiratory tract secretions, secretion from infected wounds)


 Poliomyelitis (respiratory tract secretions, faeces)

 Q fever (respiratory tract secretions, blood, dust)

 Glanders (respiratory tract secretions, secretion from infected wounds)

 Rabies (respiratory tract secretions)

 Tularaemia (pus)

 Virus-induced haemorrhagic fever, including hantavirus-induced renal (HFRS)

and pulmonary (HPS) syndromes (blood, respiratory tract secretions, secretion

from infected wounds, urine)

Waste of this kind is typically generated in the following places: isolation wards of

hospitals; dialysis wards or centres caring for patients infected with hepatitis viruses

(yellow dialysis); pathology departments; operating theatres; and medical practices and

laboratories which mainly treat patients suffering from the diseases specified above.

The relevant wastes are wastes contaminated with pathogen-containing blood, excretions

or secretions (see list) or containers containing blood in liquid form.


The infections marked with (*) are usually transmitted through inoculation. Therefore, the

wastes of relevance here are not taken to include dry contaminated waste from sporadic

patients suffering from diseases in question (AIDS, viral hepatitis, CJD), such as

contaminated swabs (e.g. from taking of blood samples), cotton plugs used in dental

practices, etc. However, they do include blood-filled vessels and waste drenched with

blood or secretions from surgeries performed on infected patients, used dialysis systems

from yellow dialysis as well as wastes drenched with blood/secretions from medical

practices and laboratories mainly treating patients who have contracted the diseases in


The infections marked with (#) are transmitted via faeces and oral ingestion of

contaminated material. Relevant bodily discharges may be fed to the waste-water stream

in observance of hygienic requirements. Management under conditions that would result

from categorization as infectious waste must be considered only when the waste is

heavily contaminated with excretions from diagnosed patients.


Infectious wastes in any case include the following:

(a) All microbiological cultures generated, for example, in institutes working in the

fields of hygiene, microbiology and virology as well as in medical laboratories,

medical practices and similar establishments and in which a multiplication of

pathogens of any kind has occurred;

(b) Experimental animals as well as litter and animal faeces from animal test

laboratories, if transmission of the above-mentioned diseases is to be expected.

Waste management guidance

Infectious wastes must be collected in tear-resistant and leakproof containers and

transported to a central storage facility/delivery point in carefully sealed condition and

without any transfer into other containers or sorting (containers marked with the

“biohazard” symbol). They must be collected and transported in a way that precludes

direct contact, and they may not be transferred into other containers at the central storage

facility or during delivery. They must be stored in such a way that gas formation in the

collection containers is avoided. To this end, efforts must be made to ensure that storage

periods are as short as possible depending on climatic conditions (e.g. storage at

temperatures below +15°C for not more than one week or at a temperature of 3°C to 8°C

for a longer storage period).

Infectious waste must either be incinerated (approved incineration plant) or be disinfected

prior to final disposal using a recognized method, preferably treatment with saturated live

steam. Disinfected wastes may be disposed of in the same way as domestic waste. The

disinfection plants must be operated under the operating parameters prescribed for waste

disinfection, and this mode of operation must be documented. The use of a mobile

disinfection plant to treat infectious waste is permissible only if the waste disposer

furnishes proof that the plant has been checked by the competent authority or an

approved institution for its functional and operational reliability on a regular basis.

Exceptions and special provisions


Body fluids and excreta of infected patients with hazardous communicable diseases can

be discharged to the sewerage system if there is a strict separation between the waste and

drinking water installations and the sewerage system is connected to a waste-water plant.

In other cases, the body fluids and excreta have to be disinfected before being discharged

to the sewerage system. Exceptionally if wastewater plant doesn’t exist , infectious waste

can be disposed of by using a special area in a controlled landfill if there is no risk of

contamination of ground or drinking water and the infectious waste is directly covered

with earth or other material.

E: Radioactive waste


Material contaminated with a radioisotope which arises from the medical or research use

of radionuclides. It is produced, for example, during nuclear medicine, radio

immunoassay and bacteriological procedures, and may be in a solid, liquid or gaseous


Examples of such wastes

Radioactive waste includes solid, liquid and gaseous waste contaminated with

radionuclides generated from in vitro analysis of body tissue and fluid, in vivo body

organ imaging and tumour localization, and investigative and therapeutic procedures.

Waste management guidance

Where activity limits for immediate or simple disposal methods cannot be met (clearance

levels), health-care establishments should segregate radioactive waste and store it during

the required period to reduce the activity level. If the activity concentration is below these

clearance levels, the material may be disposed of by normal methods. Since the half-life

of most radioactive materials used in hospitals is in the range of hours or days, storage for

a period of one or two months can be followed by disposal to the ordinary waste system

with appropriate monitoring. Decayed non-infectious radioactive waste is placed inside


black plastic bags if they are intended for landfilling. Decayed but infectious radioactive

wastes are placed in yellow plastic bags in preparation for disinfection. They should not

be used as landfill prior to disinfection.

All radioactive waste designated for storage to allow decay should be kept in suitable

containers which prevent dispersion of the content. A plastic bag in a large can or drum is

an appropriate container. Containers used for the storage of radioactive waste should be

clearly labelled to show the activity of the radionuclide on a given date and the period of

storage required. These containers should be stored in a specifically marked area in a

lead-shielded storage room for radioactive substances or for radioactive waste. The

storage record should be endorsed specifically to indicate which items are “radioactive

waste”. Containers of radioactive waste should be marked “RADIOACTIVE WASTE”

and should carry the radiation symbol.

High-level and usually long-half-life radionuclides used in health-care activities are used

for therapeutic purposes, conditioned as sealed sources, in the format of pills, seeds,

ribbons, tubes or needles. These sealed sources are recovered after use, washed,

disinfected and stored under lead-shielding for reuse on other patients. These items may,

however, become waste if their conditioning is damaged, if they have lost too much of

their activity, or if they are no longer required. Spent radionuclide generators also

become waste. In countries without a nuclear industry equipped to dispose of high-level

radioactive waste, hospitals should package these items appropriately or place them

inside the same boxes in which they were originally supplied, and send them back to their

original supplier for reprocessing, eventual recycling or safe final disposal. In countries

with the appropriate nuclear industry, hospitals may alternatively send non-recyclable

high-level waste to the national radioactive waste disposal agency, which will take care

of them. These items are usually valuable, and, in most cases, it is possible to reprocess

them for recycling.

Exceptions and special provisions

Any health-care establishment using radioactive substances should hire a specialized

radiation officer who, among other duties, will monitor the management and disposal of


radioactive waste and the storage of radioactive items.

7. Applicable state-of-the-art management, treatment and disposal


39. It is generally recognized that waste management plans provide the best mechanism

for improvement of environmental performance in waste management. A waste

management plan can help generators to conserve resources and minimize waste

through improved purchasing and reuse practices and through cost-effective,

environmentally sound source separation, segregation, collection, transport, treatment

and disposal of all waste streams generated within their facilities.

40. It is recommended that the plan be in the form of an environmental management

system based on the ISO 14001 series of environmental management standards. This

systems approach helps to ensure that auditable, verifiable documentation is available

to demonstrate that operations are taking place as required. Such a system will also

assist with the provision of quality data and information on which a state-of-the-

environment report can be prepared. A prerequisite for developing or updating such a

plan is adequate characterization and analysis of the existing waste stream and a

detailed assessment of existing waste management practices. This process is

commonly referred to as a waste audit.

7.1 Avoidance/prevention

41. The generation of hazardous wastes and other wastes within it is reduced to a

minimum and that adequate disposal facilities for the environmentally sound

management of hazardous wastes and other wastes are available.

42. For the various health-care establishments, waste management in observance of the

waste avoidance and recovery obligation presupposes a system that is practice-

oriented, clearly structured and manageable with clearly defined logistics. This can

be achieved only if everyone who works in the health services sector gives increased

thought to this issue and takes action to ensure that the volume and hazardousness of


wastes are minimized.

43. The increasing relevance of the waste management problem demands an ecologically

oriented reorganization. This should start with procurement, by giving preference to

environmentally sounder products and replacing harmful or disposable products with

reusable or alternative products, if these meet the relevant requirements in terms of

hygiene and patient safety.

44. A noticeable reduction in waste volume can be achieved only if disposable products

already in use are scrutinized as to their necessity. In principle, disposables such as

disposable cutlery, disposable linen (including covering sheets), disposable

instruments and equipment (scissors, scalpels, forceps) and disposable containers

(kidney dishes, infusion bottles) should be replaced by reusable products and long-

lived alternatives. For examples of specific reuse, waste reduction and waste

recycling activities, see annex III?

7.1.1 Packaging

45. An issue closely related to the procurement of products is their packaging. It is

possible to reduce the amount of waste generated noticeably if attention is paid in the

selection of products to the associated amount of packaging. The latter should not

exceed the minimum necessary to meet transportation, storage, hygiene and sterility

requirements. Before orders are placed, the material input for the product and the

packaging as well as the resulting input required for waste management should be

taken into account.

46. The input required for the management of packaging waste can be reduced when:

(a) Preference is given to products involving small amounts of packaging;

(b) Preference is given to product packaging which can be refilled, reused or

otherwise used as a supply or disposal receptacle within or outside the

facility at which the product is used;

(c) Preference is given to demand-oriented package sizes;

(d) The manufacturer or supplier of the product is required, when placing the

order, to take back the associated transport packaging and containers.


47. Where it cannot be avoided, packaging should be collected separately and fed to an

appropriate recovery process. Appropriate recovery is common for cardboard, paper,

glass and metals. Plastics can best be recovered if they are collected as type-specific


7.1.2 Kitchen and canteen waste

48. Kitchen and canteen waste can be utilized as feed substitute if it is disinfected in a

manner that is appropriate for such use or if such use conforms with the conditions

imposed by the authorities.

7.1.3 Laboratory waste and chemical residues

49. An effort should be made to establish which hazardous products and substances in the

health-care industry can be avoided completely. Chemical residues can be reduced by

adapting laboratory apparatus to the “state of the art” and performing laboratory tests

and analyses if they meet medical needs. In the procurement of laboratory devices,

attention should be paid to the aspect of relative chemical consumption.

50. The use of mercury contained in hospital diagnosis devices such as blood pressure

gauges and thermometers has been targeted for elimination and future avoidance in

many countries. Elemental mercury is toxic and such uses present hazards during use

and at end-of-life. Mercury can neither be safely landfilled nor incinerated.

Fortunately, safer alternatives now exist for each of these mercury-containing

products. Thus the problem is best avoided in the first instance through procurement


51. With regard to laboratory chemicals, a priority task is to find out whether the use of

chlorinated hydrocarbons as solvents is unavoidable. The aim should be to replace

such laboratory procedures. Laboratory chemicals and solvents should be collected

and recovered, if the cost of recovery entailed is reasonable in comparison with that

of other forms of waste management. The best possibilities for solvent recovery exist

in pathology, histology and anatomy because relatively large amounts of fat and

blood-contaminated solvents (xylene, toluene and others) arise in these sectors.


7.2 Segregation, collection, labeling and handling of biomedical

and health-care waste

52. Segregation is the key to effective biomedical and health-care waste management. It

ensures that the correct disposal routes are taken, personnel safety is maintained,

environmental harm is minimized and recycling consumes the least resources.

Biomedical and health-care waste should be segregated and collected in accordance

with the specific treatment or disposal requirements.

53. Segregation should be carried out under the supervision of the waste producer and as

close as possible to the point of generation. Segregation must therefore take place at

source, that is, in the ward, at the bedside, in the theatre, in the laboratory, in the

delivery room, etc., and must be carried out by the person generating the waste, for

example the nurse, the doctor or the specialist, in order to secure the waste imme-

diately and to avoid dangerous secondary sorting. It should be undertaken on the basis

of the types of waste listed in the definition for biomedical and health-care waste.

54. Each health-care institution should prepare and follow a waste plan. Correct and

efficient segregation will be achieved only through rigorous training and education of

employees, supervisors and managers, and policies should take this into account.

55. The segregation must be applied from the point of generation throughout the entire

waste stream to the point of final disposal, whether or not it is on-site. All storage and

transportation methods must also follow this segregation system.

56. Segregated wastes of different categories need to be collected in identifiable

containers. Every room, such as wards, laboratories and operating theatres, should

have containers/bags for the types of wastes that are generated in that room. The

waste segregation and identification instructions should be placed at each waste

collection point to ensure proper procedure. Waste containers made of non-

halogenated leakproof combustible materials should always be given preference.

Plastic bags for storing the waste may be suspended inside a frame or placed inside a

sturdy container. A lid should be provided to cover the opening of the bag. Sharps

must always be collected in puncture-proof containers (not made of glass) to avoid


injuries to and infection of the workers handling them.

57. Clinical and sanitary personnel should ensure that the waste bags are removed and

sealed when they are not more than three-quarters full. The preferred method of

sealing involves a plastic sealing tag of the self-locking type; bags should never be

closed by stapling. Each bag should be labelled with the point of generation (ward

and hospital) and content.

58. A common system of labelling and coding of packaging should be developed for

biomedical and health-care waste. A possible way of identifying biomedical and

health-care waste categories is by sorting the waste into colour-coded bags or

containers. As an example, a WHO-recommended colour coding is given in table 1.

The use of internationally recognized symbols and signs is of very basic importance

and is essential for the safety of handling and disposal of waste. It is recommended

that the colour coding, the symbols and signs should be part of the waste management

instructions and should be made known, e. g. by a poster on the wall at the waste

collection points.

Table 1

WHO - recommended colour coding for biomedical and health-care waste as an example
of a colour-coding system

TYPE OF WASTE Colour of container and markings* Type of container

Highly infectious waste Yellow, marked “HIGHLY
INFECTIOUS” Strong, leak proof plastic bag, or

container capable of being

Other infectious waste, pathological Yellow
Plastic bag or containers

Sharps Yellow, marked “SHARPS” Puncture-proof containers

Chemical and pharmaceutical waste Brown Plastic bag or container

Radioactive waste** Lead box

General health-care waste Black Plastic bags

* Proposed colour coding and marking system; the use of other colour coding in a

country is possible.

** Generated only in major hospitals.


59. Certain recommendations should be followed by the ancillary workers in charge of

waste collection. They include:

(a) Waste should be collected daily from the wards, or as frequently as required,

and transported to the central storage place;

(b) No bags should be removed without labelling indicating the point of generation

(hospital and ward) and content;

(c) The workers should immediately replace the bags or containers with new ones

of the same type.

60. Empty collection bags or containers should be readily available at the point of

waste generation.

7.3 In-house transport and storage

61. It is important to ensure that waste does not accumulate at the point of generation. A

routine for the collection of waste should be established in the waste management

plan. Wastes should be moved through the facility in such a manner as to prevent

unnecessary exposure to staff and others. Handling and transportation of waste

containers should be minimized to reduce the likelihood of exposure to the waste.

Specific routes should be planned through the facility to minimize the passage of

loaded carts through patient care and other clean areas.

62. Carts used for moving biomedical and health-care waste through the health-care

facility should be designed to prevent spills, and should be made of materials able to

withstand exposure to common cleaning agents. They should have the following


(a) Easy loading and deloading;

(b) No sharp edges which could damage waste bags or containers during loading and


(c) Easy to clean.

63. All seals should be in place when movement of the bag has been completed. The carts

should be cleaned regularly to prevent odour and as soon as possible if the waste

material leaks or spills in the carts. The biohazard symbol should be clearly displayed

on carts for the transport of infectious waste. These carts must be thoroughly cleaned


before any maintenance work is performed on them. The facility’s infection control

committee, biosafety officer or other appointed person should be consulted about the

frequency of cleaning and the type of cleaning agent to be used.

64. After biomedical and health-care waste has been collected and moved from the point

of generation, it must be held in storage areas to await disposal. These storage areas -

either a separate area, room or building - should be dimensioned according to the

quantities of waste generated and the frequency of collection. These areas must be

totally enclosed and separate from supply rooms or food preparation areas. Re-

commendations for properties and equipment of the storage facilities are listed in box


65. Storage areas must be identified as containing infectious waste, with the biohazard

symbol clearly displayed. It is unacceptable for materials other than waste to be

placed in the same storage area as infectious waste. Floors, walls and ceilings of

storage areas must be thoroughly cleaned in accordance with the established

procedures of the facility.

Box 1 Recommendations for storage facilities for biomedical and health-care waste in
health-care establishments, e.g. hospitals

Properties and equipment
Impermeable hard-standing base with good drainage, easy to clean and disinfect and
equipped with water supply;
Readily accessible to staff in charge of handling the waste;
Fitted with a lock, to prevent access by unauthorized persons;
Easily accessible to collection vehicles (carts);
· Inaccessible to animals, insects and birds;
· Good lighting and ventilation;
· Not situated in the proximity of fresh food stores or food preparation areas;
Situated close to the supply of cleaning equipment, protective clothing and waste bags or

66. Unless a cooled storage room is available the proposed storage periods recommended

by WHO between the generation and treatment of biomedical and health-care waste

are the following:

Temperate climate: maximum 72 hours in winter maximum 48 hours in summer


Warm climate: maximum 48 hours during the cool seasond maximum 24 hours

during the hot season

67. Anatomical waste should be stored at a temperature of 3° C to 8° C. All infectious

waste must be refrigerated at a temperature of 3° C to 8° C if stored for more than a

week. Health-care facilities should determine the maximum storage time of

refrigerated or frozen biomedical and health-care waste based in the light of their

storage capacity, rate of waste generation and any applicable local regulatory


68. Facilities refrigerating or freezing stored waste should use a lockable, closed storage

facility or a lockable domestic-type freezer unit. Either type must be used only for

storing anatomical and infectious waste, must display the biohazard symbol visibly

and must be identified as containing infectious waste. Note that glass or plastic items

containing infectious agents may fracture at lower temperatures.

69. The compacting of untreated infectious waste or waste with a high content of blood or

other body fluids destined for off-site disposal (for which there is a risk of spilling) is

not permitted. Cytotoxic waste should be stored in a specific place, separate from the

storage room devoted to other biomedical and health-care waste.

70. Depending on the local legislation, radioactive waste should be stored in containers

preventing dispersion, behind lead shielding. Waste designated for storage to allow

decay should be labelled with the type of radionuclide, date and required storage


7.4 Special requirements for packaging and labelling for off-site


70. Risks may occur during the storage, handling, transportation and disposal of the


infectious waste. For this reason, biomedical and health-care waste generators are

responsible for safe packaging, adequate labelling and authorization of the

destination of the waste to be transported off-site. Hazardous biomedical and health-

care waste should be packaged and labelled to comply with national regulations

regarding the transport of hazardous wastes (dangerous goods), and with

international agreements if they are shipped abroad for treatment. Where there are no

such national regulations, the responsible authorities may refer to the

“Recommendations on the Transport of Dangerous Goods” published by the United

Nations, and specifically section 2.6.3 on infectious substances.

71. The control strategy for hazardous biomedical and health-care waste shall have the

following components:

(a) A consignment note should accompany the waste from production to final

disposal; after the journey, the transporter should complete the part of the

consignment note especially reserved for him and return it to the generator;

(b) The transporting organization should be registered with, or known to, the waste

regulation authority;

(c) Handling and disposal facilities should hold a permit issued by a waste

regulation authority, allowing the facilities to handle and dispose of hazardous

biomedical and health-care waste.

72. The consignment note should be designed taking into account the waste control

system in operation in the State concerned and also taking into account the forms

issued in pursuance of the Basel Convention. 9 Anyone involved in biomedical and

health-care waste generation, handling or disposal should be subject to a general

“duty of care”, i.e. ensure that documentation and transmission of waste comply with

the national regulations.

7.4.1 Packaging requirements

73. In general, the waste should be packaged in resistant and sealed bags or containers to

prevent spilling during handling and transportation. The bags or containers should be

resistant to their content (puncture proof for sharps, resistance to aggressive


chemicals) and to normal conditions of handling and transportation such as vibration

and changes in temperature, humidity or pressure (resulting from altitude, for


In general packaging should include the following essential elements:

(a) An inner packaging comprising:

(i) Watertight primary receptacle of metal or plastics with leakproof seal (e.g. a

heat seal, a skirted stopper or a metal crimp seal);

(ii) A watertight secondary packaging;

(iii) Absorbent material in sufficient quantity to absorb the entire contents placed

between the primary receptacle and the secondary packaging; if several

primary receptacles are placed in a single secondary packaging, they shall be

individually wrapped so as to prevent contact between them;

(b) An outer packaging of adequate strength for its capacity, mass and intended use,

and with a minimum external dimension of 100 mm.

7.4.2 Labeling

74. All waste bags or containers should be identified by labels containing basic

information on producer and content. This information may be directly written on

the bag or container or by pre-printed labels. The following major information

should appear on the label:

 the type of waste;

 the total quantity of waste covered by the description (by mass or volume);

 the packaging should be appropriately marked with the month and the year of

manufacture; and

 the body authorizing

7.5 Recycling/recovery

75. Recovery and recycling constitute one step in a systematic priority approach for

environmentally sound waste management. Waste segregation at source is the basic


requirement for cost-effective normal recycling operations on the non-hazardous

component of biomedical and health-care waste. Some examples for the recycling of

non-hazardous waste components are given in annex II.

76. Opportunities for chemical waste recycling can be described as follows:

(a) Unused or waste chemicals in quantity can often be returned to the supplier

for reprocessing;

(b) Larger health-care facilities should establish internal reuse of chemicals;

(c) Certain material such as mercury from broken thermometers, unused batteries

containing mercury, cadmium, nickel and lead-acid and halogenated or non-

halogenated solvents should be given to specialized recyclers.

7.6 Disposal operation/technologies, accreditation and

environmental impacts

77. Biomedical and health-care waste should, if required, be inactivated or rendered safe

before final disposal or discharge. The decision to treat biomedical and health-care

waste and the choice of treatment method should be determined in accordance with

the following considerations:

(a) The type and nature of the waste material;

(b) The hazard and viability of the organisms in the waste;

(c) The efficiency of the treatment method;

(d) The operating conditions of the treatment method.

Table2 Examples of waste treatment methods related to the type of waste

Type of waste

Gas Liquid Solid


Thermal Possible Recommended Recommended

Chemical Appropriate Appropriate a/

Irradiation b/ b/ b/

Incineration Appropriate c/ Recommended

Filtration Recommended Possible Not applicable

a/ Not possible for mixed wastes.

b/ Only for small amounts of wast

c/ Recommended if the calorific value is high enough to reach a sufficiently high


78. The treatment method should be amenable to validation and independent of any

packaging, and should be monitored. Monitoring can involve sampling and analysis

or testing of the effluent for hazardous organisms or the use of suitable physical

engineering or other process controls to demonstrate effective operation within the

prescribed operating criteria.

79. Treatment of the waste should be validated with regard to the inactivation of the

organisms and of any residual contamination of the packaging or containers. The

process should not significantly increase the risk of exposure of laboratory staff or

other waste handlers to the hazard itself or to other risks from the concomitant

hazardous agents, equipment and substances which are employed in the treatment.

Outlines of the main advantages and drawbacks of the treatment and disposal options

addressed in these guidelines are shown in table 3.

7.6.1 Methods of treatment or disposal

80. The validated chemical and physical methods for the treatment or inactivation of

waste include: steam sterilization, chemical disinfection/sterilization, dry heat


sterilization and other methods.

81. The relative effectiveness of these and other treatment methods depends on a number

of factors including the volume, concentration, type and hazard caused by the

organisms and the physiological state, the diffusion resistance of the material to be

disinfected and the operating parameters and conditions of the treatment method. In

general, steam sterilization should preferably be used in the treatment of infectious

waste. Thermal methods are generally easier to validate and monitor than chemical

treatment and are less damaging to the environment.

82. Methods other than steam sterilization should be selected only if this is impracticable

or inappropriate. For example, effluent from veterinary research, contaminated

laboratory equipment, fixtures and furniture which cannot readily be removed may

be effectively treated using a gaseous fumigant such as formaldehyde. These

methods of treatment can be used alone or in combination, depending on the risk

assessment requirements and/or discharge consent standards, to enable the waste to

be inactivated and safely discharged.

Table 3: Summary of the main advantages and drawbacks of treatment and

disposal options



Advantages Drawbacks

Pyrolytic incineration/two-
stage incineration with
efficient gas cleaning

Very high disinfection
efficiency; adequate for all
infectious waste and most
pharmaceutical and
chemical waste.

Incineration temperature above
800°C, destruction of cytotoxics;
relatively high costs of investment
and ope-ration. Care has to be taken
on the management of the
incineration residues (e.g. bottom
ashes, fly ashes) because they can ex-
hibit hazard characteristics.

Single chamber
incineration with dust

Good disinfection
efficiency; Drastic
reduction of the weight
and volume of waste; the
residues may be disposed
of in a

Generation of significant emissions
of atmospheric pollutants and
periodic slag and soot removal; with
temperature below 800°C, inefficient
in destruction of

landfill; no need for highly
qualified operators;
relatively low investment
and operation

thermally resistant chemicals and
drugs such as cytotoxics.

Drum or brick incinerator Reduction of the weight

and volume of the waste;
the residues may be
disposed of in a landfill;
no need for highly
qualified operators; very
low investment and
operating costs.

Only 99 per cent destruction of
microorganisms; no complete
destruction of many chemicals and
pharmaceuticals; massive emission of
black smoke, fly ash and toxic flue
gas. Exception only for disposal of
infectious waste under certain
circumstances outside urban areas
(e.g., no other treatment method
available during an emergency
situation like acute outbreak of
communicable) diseases).


Table 3 cont…

Advantages Drawbacks

Chemical disinfection Efficient disinfection
under good operating
conditions with special
waste; costly if the
chemical disinfectants are

Requirement of highly qualified
technicians for operation of the
process; use of hazardous substances
which require comprehensive safety
measures; inadequate for
pharmaceutical, chemical and most
types of infectious waste (mixed
solid waste).

Autoclave wet-thermal

Environmentally sound;
relatively low investment
and operation costs. Good
for infec-

Shredders are subjected to many
breakdowns and bad functioning;
operation requires qualified
technicians; inadequate

tious and microbiological

for pharmaceutical and chemical
waste or waste which is not easily
by steam; without shredding or other
methods of destruction although
equate for anatomic waste.

Microwave irradiation Good disinfection
efficiency under
appropriate operational
environmentally sound.

High investment and operation costs;
potential operation and maintenance
problems; only for wet infectious
waste or for infectious waste with a
high water con

Encapsulation(e.g. with Simple and safe; low costs. Only for sharps.
concrete or gypsum)
Special engineered landfill Safe if access is restricted

and where natural
infiltration is limited.

Safe if access to site is limited and
there is no risk of water
contamination. Steam sterilization

83. Steam sterilizing or autoclaving is the exposure of waste to saturated steam under

pressure in a pressure vessel or autoclave. Autoclaves should meet the requirements

of internationally agreed standards. Autoclavable waste containers should be of a

design and material, which allows steam to penetrate the load. They should have


sufficient stability and resistance to the maximum operating temperature and


84. In addition to any devices such as gauges or indicators which measure and record the

basic operating criteria (e. g. temperature, vacuum, pressure), a biological or chemical

indicator should be placed in the waste load for validation to indicate that the

necessary sterilization conditions have been achieved. The operational parameters, e.

g. time, pressure and temperature, should be maintained and checked during the

sterilization cycle.

85. While the temperature and time depend upon the total volume of the material to be

treated, the number and type of organisms and their resistance against steam, it is

necessary first to remove all the air from the autoclave, the waste and the waste

containers to ensure that the required sterilization temperature will be maintained. In

the case of closed containers included in waste material, the validation (with

biological indicators) should take place within the material being sterilized.

Sterilization should commence only when the air has been removed from the

autoclave and the operating temperature has been reached.

86. The potential of complete air removal is affected by factors such as the type of waste,

the amount of waste, the packaging, the water content of the waste and the form and

material of the container. The whole treatment process, including loading, the load,

the suitability of the packaging or the container, air removal and filtration of the

removing gas and liquid effluent discharge should be validated.

87. A record should be retained of all monitoring, maintenance and performance tests

carried out on the autoclave together with a logbook or similar record of all routine

disposals including the temperature charts and details of the load. When appropriate,

air removed from the autoclave should be discharged into the environment after

passing through a microbiologically validated filter.

88. Details of sterilization procedures, including the operational parameters and

conditions, should be written down as a standard operating procedure document or

operating manual which is to be used by all waste handlers. The document should be

kept under review. A suitable biological indicator for steam sterilization is the spores

of Bacillus stearothermophilus. Autoclaving may not change the visible appearance


of the waste and it may be necessary to distinguish treated from untreated waste by

careful removal or obliteration of biohazard warning labels from treated containers

or by labeling such containers as “autoclaved” or “sterilized”.

89. Alternatively, chemical indicators may be added to the load to indicate that the load

has been autoclaved. Aesthetic concerns may require that the autoclaved waste is

further treated to render it acceptable for final disposal, e.g. if the waste contains

human or animal material or tissue. Autoclaving may not remove or reduce the non-

biological hazards arising from the presence of chemical or physical agents or other

materials in the waste. Dry heat sterilization

90. Dry heat sterilization is the exposure of the waste to heat at a temperature and for a

time sufficient to ensure sterilization of the entire waste load. The sterilization

process should be monitored by the addition of a suitable indicator or measuring

device to the waste load, and where appropriate by monitoring the organism(s)

present in the waste. The sterilizing unit or equipment should incorporate a suitable

thermal cut-out device which is independent of the device used for indicating or

monitoring. Chemical disinfections/sterilization

91. This method involves the exposure of waste to chemical agents which possess

antimicrobial activity. General disinfectants may not inactivate organisms such as

spores, some fungi and viruses and should not be used as the principal treatment

methods unless thermal procedures are inappropriate because of the nature of waste

or contaminated material. Thermal sterilization should be given preference over

chemical disinfections for reasons of efficiency and environmental considerations.

92. The choice of an appropriate chemical agent and conditions of use should be

determined by the risk assessment, taking into account the identity of the

organism(s) to be treated, the nature of the waste and the presence of organic, protein


or particulate matter, and the nature of the surfaces, items or equipment which will

be exposed to the chemical disinfectant.

93. Chemical agents should be used at the manufacturers’ recommended concentrations

and exposure times according to the requirements and conditions of use. The

chemical agent selected should be compatible with other substances or material that

may be present in the waste load so that its efficiency is not reduced, and also to

ensure that toxic or hazardous products are not thereby formed or released. The

efficiency of any chemical agent against a particular organism or type of organism

may be confirmed by reference and adherence to manufacturers’ data and

instructions. Ethylene oxide, formaldehyde (alone or with low-temperature steam)

and certain other agents may be used as gaseous fumigants, particularly for

equipment and items that should be treated in situ. This method can also be used for

the disinfection of body fluids and excreta before being released to the sewer system

if no thermal treatment is available. Other treatment/disposal methods

94. The options available for the treatment/disposal of waste and waste effluent which

cannot be recycled or reused are incineration and landfill.

95 Other waste treatment methods are available but are not yet validated for general use

and have only limited application. These include irradiation (e. g. with microwave,

gamma and ultraviolet radiation) and other treatment methods (e. g. encapsulation

and filtration). If such methods are used, validation and monitoring procedures should

be performed.

96 The selection of an appropriate option should be based on a number of considerations,


(a) The nature of the waste and its intrinsic hazard;

(b) Whether the waste has been inactivated by a reliable and validated method;

(c) The aesthetic acceptability of the discharged waste;

(d) The potential deleterious effect of the discharged waste on the environment;


(e) The ease and reliability of the disposal method;

(f) The disposal and other costs;

(g) The general occupational hazards and risks to waste producers, handlers and


(h) The overall impact of the disposal or discharge plant or equipment on the local

and general environment. Incineration

97. Incineration can be used as one important method for the treatment and

decontamination of biomedical and health-care waste. Oxidation at high temperature

converts the organic compounds into their gaseous oxides, mainly carbon dioxide

and water. Inorganic components are mineralized and converted into ash, unless they

pass into the flue gas.

98. Depending on the type of incinerator, the following objectives can be achieved:

(a) Destruction of pathogens;

(b) Reduction of the hazard and pollution potentials as far as possible;

(c) Reduction of volume and quantity;

(d) Conversion of remaining residues into a form which is utilizable or suitable

for landfill;

(e) Use of the released heat.

99. For reasons of emission control and operational safety and reliability, it is desirable to

incinerate the biomedical and health-care waste from as many hospitals as possible in

one central unit. In specific cases, even smaller separate incinerators may be justified.

With a view to minimizing the environmental impact of incineration plants, emissions

in the air, water and soil shall be reduced by the use of effective and advanced

incineration and emission control techniques under technically and economically

viable conditions, taking into account the location of the plant.

100. Incineration leads to a significant reduction of the volume and quantity of the treated

waste. Waste which has not been previously treated to inactivate it or to render it


safe should be incinerated in a plant suitably designed and operated for the

destruction of biomedical and health-care waste or other hazardous waste. If

biomedical and health-care waste can be incinerated only in inadequate conditions

(low temperature, inadequate emission control system), waste fractions like

cytotoxic drugs, chemicals, halogenated materials or waste with a high content of

heavy metals (batteries, broken mercury thermometers, etc.) should not be consigned

to such an incinerator. Landfill

101. To date, there is no adequate risk assessment of the use of landfills for untreated

biomedical and health-care waste which may contain infectious organisms and

hazardous chemicals. Best practice would require that any landfill used for

biomedical and health-care wastes be engineered and secured (specially engineered


102. There are ongoing health and safety issues (and hence legal implications) associated

with disposal of untreated biomedical and health-care wastes. With the availability

of suitable landfill sites being reduced, the physical problem of disposing of large

volumes of waste must be considered.

103. Disposing of infectious wastes into a landfill greatly increases the risks to human

health and the environment of exposure to infection from this source. If the waste is

disturbed by any means, or not properly covered, further risks will arise. It is

therefore not good practice to dispose of infectious waste directly into a landfill. To

guard against these risks, where landfill is the only available option, infectious

wastes should be treated in order to destroy/remove their infectivity, preferably at

the site of generation of the waste. This can be done by using known effective

techniques such as autoclaving, microwave treatment, dry heat sterilization or

chemical disinfection.

104. The following is a description of the features of a “specially engineered landfill”

which are necessary for the safe and environmentally acceptable disposal of

biomedical and health-care wastes:


(a) Impermeable clay and/or synthetic liner to minimize groundwater pollution;

(b) Collection, treatment and environmentally acceptable disposal of leachate;

(c) Monitoring systems for groundwater surrounding the site to check integrity of

leachate contamination protection;

(d) Daily and final covers to restrict the potential for disease vectors, reduce

odours and reduce water infiltration;

(e) Monitoring for gas migration in the unsaturated zone surrounding the site,

together with control measures if necessary.

105. It is generally accepted that untreated biomedical and infectious health-care waste

disposal into landfills is not “best practice”. Where health-care wastes are disposed

of at a specially engineered landfill site, the following should apply:

(a) Biomedical and infectious health-care wastes should be deposited at the lowest

edge of the working face of the landfill or in an excavation;

(b) An operator or representative should supervise immediate cover with solid

waste or cover soil to a depth of at least 1 metre;

(c) Any compacting should be only on the cover material;

0 (d) Biomedical and health-care disposal areas should be at least 3 metres from

the proposed

1 edge of the landfill;

(e) No access of unauthorized persons to the site of the landfill;

(f) Any biomedical and health-care waste should be at least 2 metres below the

final surface of the landfill i.e. not in the final lift.

106. The following biomedical and hazardous health-care wastes are generally

considered unsuitable for disposal at a landfill site:

(a) Identifiable body tissue;

(b) Cytotoxic wastes;

(c) Pharmaceutical, laboratory or domestic chemicals;

(d) Radioactive wastes;

(i) Infectious wastes.


107. Landfill is recognized as the terminal site for all wastes including ash from

incineration and residues from other processes. Some residues of the treatment

process residues may contain chemicals that could interact with other materials in a

landfill. Consideration needs to be given to the stability and nature of such process

residues and any potential impacts prior to disposal into a landfill. Some of the

treatment processes may also contribute excess water to the landfill. Resultant

leachate considerations require that engineered landfills should be used to ensure

maximum environmental protection.

108. The application of treatment and disposal methods to biomedical and hazardous

health-care waste categories is shown in table 4. It provides a broad overview of

suitable treatment and disposal methods for the different health-care waste



Table 4 Overview of disposal and treatment methods suitable for hazardous health-care waste categories

Waste types

incineration (with after

burning zone, e.g.
rotary kiln)

incineration or







(e.g. with con-

gypsum, etc.
only minimal




Yes Yes (special
like direct


Yes Yes (wet

No Yes b/

Anatomic Yes Yes b/ No c/ c/ No Yes b/

Sharps Yes Yes b/ Yes Yes No Yes Yes b/

ical waste

Small quantities or (at
high temperature >850

Yes b/ No No No Yes Small


At high temperature
>850 °C

No No No No No In excep-
tional cases
if special


Small quantities c/ No No No No In excep-
tional cases
if special
are met

waste d/

Low-level infectious

Low-level infec-
tious waste

No No No No No

b/ Not the preferred method.

c/ Uncertainty still prevails as to the unsuitability of the disposal operation. There could be cases where the disposal option could be used, provided a number

of safeguards are in place. d/ Only if the clearance levels set by IAEA are met. Note: Entries in bold indicate preferred methods.

7.7 Responsibility (including emergency response and
contingency plan)

7.7.1 Assignment of responsibilities

109. The proper management of biomedical and health-care waste is largely dependent

on good administration and organization. These should be supported by adequate

legislation and financing as well as active participation of trained and informed


110. The head of the hospital /clinic should establish a waste management team to

develop a waste management plan. The head of the establishment should formally

appoint the members of the waste management team in writing, informing each of

them of their duties and responsibilities as outlined below.

111. In institutions where no direct patient care service is available, such as medical

research institutions, the head of the establishment should use his discretion to

appoint members of the waste management team. Depending on the availability of

relevant staff, the post of waste management officer may be assigned to the hospital

engineer, the hospital manager, or any other appropriate staff member, at the

discretion of the head of the hospital. Duties of the head of the hospital

112 The head of the health-care establishment is responsible for the following tasks:

(a) Formation of a waste management team to formulate a written waste

management plan for the hospital; within this plan, the duties and

responsibilities of all members of staff, both clinical and non-clinical, shall

be clearly defined in respect of the handing of health-care waste. A clear line

of accountability shall be indicated in both the clinical and non-clinical

management structures;

(b) Designation of the waste management officer (WMO) to supervise and

coordinate the waste management plan; such an appointment shall not relieve

him of his overall responsibilities in ensuring that biomedical and health-care

and other waste are disposed of in accordance with the national guidelines;

(c) Keeping the management plan up to date;

(d) Allocation of sufficient financial and manpower resources to ensure efficient

operation of the plan for example, he has to ensure that adequate manpower

is assigned to the WMO to ensure efficient operation of the waste

management plan;

(e) Ensuring that monitoring procedures are incorporated to assess the

efficiency and effectiveness of the disposal system and to effect the

continuous improvement and updating of the system where appropriate;

(f) Appointing a successor immediately in the event of personnel leaving key

positions in the waste management team, or assigning temporary

responsibility until a successor is appointed;

(g) Ensuring adequate training for key staff members; he shall designate staff

responsible for coordinating and implementing training courses;

(h) Ensuring adequate emergency response planning. Duties of the waste management officer (WMO)

113. The WMO is responsible for the day-to-day operation and monitoring of the waste

management system. He shall have direct access to all members of hospital staff to

facilitate his control function. The WMO will be directly responsible to the head of

the hospital. He shall liaise with the infection control officer, the pharmaceutical

officer and the radiation protection officer to familiarize himself with the correct

procedures for handling and disposing of pathological, pharmaceutical, chemical

and radiological wastes.

114. Concerning waste collection, the WMO should undertake the following tasks:

(a) Controlling internal collection of waste containers and their transport to the

central waste storage facility of the hospital, on a day-to-day basis;

(b) Ensuring the supply of items required for waste collection and handling; he

should liaise with the supplies department to ensure that an appropriate and

acceptable range of health-care waste bags and containers, protective

clothing and collection trolleys are available at all times;

(c) Ensuring that hospital attendants and ancillary staff immediately replace used

bags and con tainers with the correct new bag or container as appropriate;

(d) Directly supervising hospital attendants and ancillary workers assigned to

collect and trans port health-care waste.

115. Concerning waste storage, the WMO should:

(a) Ensure the correct use of the central storage facility for health-care waste at

the health-care establishment, which shall be fenced with a lock on the

entrance; hospital attendants and ancillary staff should always have

immediate access to the storage area;

(b) Prevent unsupervised dumping of waste containers on the hospital grounds,

even for short periods of time.

116. To supervise evacuation or disposal of the waste, the WMO should:

(a) Coordinate and monitor all waste disposal operations;

(b) Monitor methods of transportation of wastes on-site and off-site and ensure

that wastes collected from the hospital are transported by an appropriate

vehicle to the designated incinerator;

(c) Ensure that waste is not stored on the hospital grounds for periods longer

than specified in the guidelines and that the required frequency of collection

is maintained; he should therefore liaise with the transport organization,

which may be the local authority or a private contractor.

117. For staff training and information, the WMO should:

(a) Liaise with the matron and the hospital supervisor to ensure that the nursing

staff and medical assistants are familiar with their responsibilities for

segregation and storage of waste and of the limited responsibilities of hospital

attendants and ancillary staff in the handling and trans port of sealed waste

bags and containers;

(b) Liaise with departmental heads to ensure that all doctors and other qualified

clinical staff are aware of their responsibilities regarding segregation and

storage of waste and of the limited responsibilities of hospital attendants and

ancillary staff in the handling and transport of sealed bags and containers;

(c) Ensure that hospital attendants and ancillary staff are not involved in waste

segregation and that they handle only waste bags and containers sealed in the

correct manner.

118.For incident management and control, the WMO should:

(a) Ensure that emergency procedures are available and in place at all times and

that personnel are aware of the appropriate action to be taken;

(b) Investigate or review incidents reported during the handling of health-care


7.7.2 Emergency response

119. For health-care establishments, spills of infectious or other hazardous material or

waste are probably the most common emergencies related to hazardous material.

Basically, the same response procedures are applied, regardless of whether the

spills are from material or waste. The response to emergencies should ensure the


(a) The waste management plan should be respected;

(b) Contaminated areas should be cleared and, if necessary, disinfected;

(c) The exposure of workers should be limited as much as possible during the


(d) The impact on the environment should be limited to the extent possible.

120. The staff should be well prepared for emergency response, and the required

equipment should be easily available at all points in time and within reasonable

distance to ensure that an adequate response can be made safely and routinely. The

procedures for the different types of emergencies should be written down. For

dangerous spills, clean-up should be carried out by designated, specifically trained

personnel. Response to injuries

121. A response programme should be established for immediate reaction to injuries or

exposure to a hazardous substance. All staff handling biomedical and health-care

waste should be trained in dealing with injuries. Such a programme should include

the following elements:

(a) Immediate first aid measures, such as cleansing of wounds and skin and

splashing of eyes;

(b) Immediate reporting to a responsible designated person;

(c) Retention, if possible, of the item and details of its source for identification

of possible infection;

(d) Additional medical care from an accident, emergency or occupational health

department as soon as possible;

(e) Medical surveillance;

(f) Blood or other tests if indicated;

(g) Recording of the incident;

(h) Investigation, determination and implementation of remedial action. Dealing with spills

122. Spills usually require only clean-up of the contaminated area. In spills of infectious

agents, it is important to determine the type of infectious agent, as some may

require immediate evacuation of the area, whereas others require fewer precautions.

The more hazardous spills usually occur in laboratories rather than in health-care


123. Spill-cleaning procedures should specify safe handling operations and appropriate

protective clothing. An example of such a procedure is provided in box 2.

Appropriate equipment for collecting the waste and placing it in new containers,

and for disinfection, should be provided. Table 6 provides an example of the

required items.

Box 2 Example of general procedure for spill-cleaning
(a) Evacuate the contaminated area;
(b) Eye and skin decontamination (disinfection) of exposed personnel should take place

(c) Inform the designated person (usually the waste management officer);
(d) Determine the nature of the spill;
(e) Evacuate all the people not involved in cleaning up if agent is particularly hazardous;
(f) Provide first aid and medical care to injured persons (see response to injuries);
(g) Secure the area to prevent additional exposure of persons;
(h) Provide adequate clothing to personnel involved in cleaning up;
(i) Limit the spread of the spill;
(j) Neutralize or disinfect the spill or contaminated material if indicated;
(k) Collect the spill and the contaminated material; Sharps should never be picked up by hand, but

with tools, e.g. pans or brushes. Spilled material and contaminated items used for cleaning
should be placed into the appropriate bags or containers;

(l) Decontaminate or disinfect the area, and absorb; (m)Rinse the area, and absorb;
(n) Decontaminate or disinfect the used tools;
(o) Take off protective clothing and decontaminate or disinfect it if necessary;
(p) Seek medical care if exposure to hazardous material has occurred during the operation.

Table 5 Example of a list of items for spillage-cleaning

Action Tools or items

Approaching the spillage Protective equipment

Containing the spillage
Neutralizing or disinfecting the
spillage (if necessary)

Absorbent material (e.g. absorbent paper, towels, gauze pads) For
infectious material: disinfectant a/

For acids: sodium or calcium carbonate or other base

For cytotoxic material: special chemical degradation substances

For bases: citric acid powder or other acid

Collecting the spillage
For liquids: absorbent paper, gauze pads, wood shavings, calcium
bentonite, diatomaceous earth

For solids: forceps, broom, dust pan or shovel

Containment for disposal Mercury: mercury sponge or vacuum pump

Plastic bag (red, yellow or brown, as appropriate), sharps container

Decontamination or For infectious material: disinfectants a/

disinfection of the area For hazardous chemicals: suitable solvent or water

Source: WHO.

a/ Such as bleaching powder, which is a mixture of calcium hydroxide, calcium chloride

and sodium hypochlorite, used in the powder form or in solution of varying dilutions (1:1

to 1:100), depending on the nature of the spilled material. Reporting accidents and incidents

124. All waste management staff should be trained in emergency response and made

aware of the correct procedure for prompt reporting of accidents and incidents.

Accidents or incidents, including near-misses, spillages, damaged containers,

inappropriate segregation or any incidents involving sharps should be reported by

the WMO if waste is involved, or otherwise to another designated person. The

report should include:

(a) The nature of the accident or incident;

(b) Where and when it occurred;

(c) Which staff were directly involved;

(d) Other relevant circumstances.

125. The incident should be investigated by the responsible officer (WMO in cases of

waste) to establish its causes and if possible action taken to prevent recurrence.

Records should be kept.

8. Waste management auditing

126. The purpose of a waste audit is to help a hospital to determine which initiatives will

be most beneficial. It does this by developing a detailed picture of the current status

of waste generation and disposal for the hospital. It then identifies potential areas

for improvement and develops action plans for each area. The ultimate impact of

environmental action is judged in terms of a positive impact on the environment and

cost savings for the institution.

127. There are three major steps involved in the waste audit. They include information

gathering, waste stream analysis and the development of action plans. First, a waste

audit must collect information on the following:

(a) The total volume of each type of waste generated by the entire hospital;

(b) The volume of each type of waste generated by each specific area in the

(c) The current costs associated with the disposal of each type of waste;

(d) The waste management initiatives currently in place. Typically, these include

reuse, reduction, recycling and recovery programmes.

128. Much of the information can be found in purchase records and requisitions,

estimates made by the facility, and a search of the literature, and from interviews

with staff concerning their experience in handling waste in the facility.

129. The next step in the waste audit is to proceed with the sorting and weighing of the

components of the waste stream or to conduct a waste stream analysis. This second

task will be referred to as the comprehensive study of general waste. This task is

usually accomplished by personnel from the housekeeping staff over a period of

two weeks. For safety reasons, no types of waste that could threaten the staff in any

way are sorted - that is, biomedical waste, sharps, chemicals and so on are weighed


130. The third stage of a waste audit is to develop action plans for reuse, reduction,

recycling and recovery initiatives. This involves analysing the data collected and, in

the first part of the audit, identifying potential areas of opportunity. Each of these

areas is then investigated to identify potential benefits associated with realistic


131. For each area where benefits can be achieved, an action plan is developed to

implement the initiative. The plan identifies where existing systems and work habits

can be modified and where new systems could be introduced to achieve the desired

results. While the action plan covers the entire hospital, the recommendations for

action may focus on specific areas within the hospital where the most benefit can be


132. Hospital managers or personnel making decisions need specific information about

which types of waste are being generated, the volumes of these wastes and the

locations of their generation. This information allows initiatives to be targeted to the

specific hospital locations and/or types of waste for which the most significant

benefits can be obtained. For example, waste recycling is most effective when the

segregation of recyclables from non-recyclables occurs at the point where the waste

is generated. By the time waste has reached the disposal hopper or compactor, it is

too late to consider waste reduction, reuse or recycling options. Knowing the

specific locations where most of the recyclable waste is generated permits

assessment of the recycling opportunity and the development of appropriate plans.

9. Capacity-building

133. The objectives of a comprehensive capacity-building strategy could include the


(a) To provide a basic legal, technical and logistical framework;

(b) To introduce options for the sound management of biomedical and health-care


(c) To develop a logical framework for the completion of national biomedical and

health-care waste profiles and the preparation of national health-care waste


134. The elements of a comprehensive capacity-building programme are:

(a) Establishment of a committee for the environmentally sound

management of bio medical and health-care wastes; Completion of

national (local) health-care waste profiles;

(b) Development of a national (local) health-care waste management

programme, including a technical and financial plan;

(c) Preparation of national regulations on the environmentally sound

management of biomedical and health-care wastes;

(d) Undertaking of training programmes for health-care personnel, waste

disposers, enforcement institutions, etc., including development of

decision-supportive tools for policy makers and waste handlers.

9.1 Education and training of personnel of health-care


135. A biomedical and health-care waste management policy is not effective unless it is

applied daily by all involved staff in a consistent and accurate way. Training

employees in implementing the policy is a critical step for a successful biomedical

and health-care waste management programme. The overall aim of the training is to

develop in the participants awareness of health, safety and environmental protection

issues relating to biomedical and health-care waste and how these can affect them in

their daily work. It should highlight the responsibilities and role of the employees in

the overall management programme. Health and safety at the workplace and

environmental awareness are the responsibility of everyone.

136. All hospital personnel, including senior medical doctors, should be educated with a

view to convincing them of the importance of the comprehensive health-care waste

management policy of the hospital and of its value for the health and safety of

everyone. This is the best way to obtain their collaboration in the implementation of

this policy.

137. Training activities should be designed for and targeted at four main categories of

personnel: managers and regulatory staff, e.g. safety advisers; medical doctors;

nurses and assistant nurses; and hospital cleaners, waste handlers and drivers.

138. Medical doctors may be educated through high-level workshops chaired by the head

of the hospital, while general hospital staff may be educated through formal

seminars. The training of waste managers and/or regulators does not usually take

place in the hospitals but in public health schools or university departments of

hospital engineering.

139. Education programmes should include: information on each aspect of the health-care

waste policy and its justification; informing each hospital staff member of his or her

responsibilities and role in implementing this policy; and technical instructions on

the application of the practices relevant to the target group.

140. As the best way of learning is probably through practice, hands-on training in small

groups should be considered where relevant. Testing the participants at the end of

the course, by simple true/false or multiple-choice questions, often provides an

incentive for learning and gives the course organizers an idea of the actual

knowledge acquired by the participants. The more detailed course contents are

presented below.

141. The instructors should have experience in teaching and training, be familiar with the

hazards and practices of biomedical and health-care waste management and, ideally,

have experience in waste handling.

142. Periodic repetition of courses will refresh the acquired knowledge, provide

orientation for new employees and for existing employees with new responsibilities,

and provide continuous updating on policy changes. Follow-up training will provide

data about the retention of information and the need for refresher courses.

9.1.1 Responsibility for training

143. The head of the health-care establishment should appoint a responsible person such

as the infection control officer, the doctor for hygiene or the WMO for all training

related to segregation, collection, storage and disposal of health-care waste. He

should ensure that staff at all levels are aware of the hospital waste management

plan and policy and of their responsibilities and obligations within the framework of

this plan and policy. A record of all training sessions should be kept. The content

of the training programmes should be periodically reviewed and updated where

necessary. For smaller sources of biomedical and health-care waste, a central

training function could be established at the regional health authority.

9.1.2 The training package

144. A training package could be developed by the national government agency

responsible for the disposal of biomedical and health-care wastes.

145. The training package on biomedical and health-care waste should be suitable for

various types of health-care establishment, including government hospitals,

teaching hospitals, dental hospitals, polyclinics, health centres, health-care research

institutions, clinical laboratories and other establishments where health-care wastes

are generated. Such a training package would also be useful for educational

establishments and the sectors providing services for biomedical and health-care

waste disposal. The package should contain numerous illustrations, such as

drawings, figures, photographs, slides or overhead transparencies.

9.1.3 Selection of participants

146. The ideal number of participants for a training course is 20 to 30 because larger

groups may render discussions and exercises difficult. Training courses should be

organized and targeted for all personnel categories. The discussions may, however,

be easier if the group is composed of personnel from various disciplines (e.g.

supervisors, medical and nursing staff, laboratory staff, engineers, ancillary staff) or

if the group is laced with one or two medical assistants and nurses.

147. It may be beneficial to include senior administration staff and heads of department

in certain training groups to demonstrate their commitment to the policy to other

staff members and to show that the policy is the responsibility of all personnel of

health-care establishments. Line managers may find it worthwhile to run the

training sessions themselves, with their own personnel attending.

9.1.4 Training recommendations Training recommendations for personnel providing health-care

148. As mentioned above, the content of the training course should provide an overview

of the waste management policy and its inherent rationale and provide information

on relevant practices for the targeted group. For example, personnel providing

health-care will mainly be informed that with respect to waste segregation practices:

(a) Care should be taken while removing needles from syringes during operations

which require this;

(b) In no event should the staff correct segregation mistakes by removing items

from a bag or container once disposed of, or by placing a bag into a bag of

another colour;

(c) Hazardous and general waste should not be mixed. However, where this has

occurred, the mixture should be treated as health-care risk waste;

(d) Nursing and clinical staff should ensure that adequate numbers of bag holders

and health-care waste containers are provided for the collection and on-site

storage of medical waste in the wards, clinics, operating theatres and other

sources of waste generation. These on-site receptacles should be located close

to the source of waste generation.

149. Upon completion of the training course, the members of staff should be aware of

their responsibilities. Training recommendations for waste-handling staff

150. Relevant training chapters may constitute a basis for the training course. Topics

covered may include the waste management policy, health hazards, on-site

transportation, storage, safety practices and emergency response. The attention of

members of staff who routinely handle biomedical and health-care waste may

decrease with time, which will increase the risk of injury. Periodic training is

therefore recommended. Training of health-care waste management operators

151. The minimal training requirements for waste management operators should

include the following:

(a) Information on the risks associated with the handling of biomedical and

health-care waste;

(b) Training on the procedures for dealing with spillages and accidents;

(c) Instructions on the use of protective clothing.

152. The training needs will depend on the type of operations the staff perform.

Depending on the duties, training on specific areas (e.g. operation of incinerators,

waste transportation) will be required. Training for members of staff who transport waste

153. The health-care establishment may either transport the waste itself or contract an

authorized waste transporter. Drivers and waste handlers should be specifically

trained and be aware of the nature and risks of the waste being transported. In

particular, transport staff should be trained in the following issues, and be able to

carry out the procedures and respect the instructions without any help from others:

(a) Correct procedures for handling, loading and unloading waste bags and


(b) Procedures for dealing with spillages or accidents; for these procedures, written

instructions should be available in the vehicle;

(c) Protective clothing and footwear should be worn at all times.

154. The vehicles dedicated to waste collection should at all times carry a supply of

plastic bags, protective clothing, cleaning tools and disinfectants to clean and

disinfect any spillage which may occur during loading, transport or unloading.

Documentation and recording of health-care waste, e.g. by using a consignment

note system, are necessary because they make it possible to trace the waste from the

point of collection to the final disposal facility. The head of the health-care

establishment should liaise with the transport contractor to ensure that the waste

collection crew is well trained. Untrained personnel should never be allowed to

handle biomedical and hazardous health-care waste. Training of incinerator operators

155. Operation of incinerators requires qualified incinerator operators. It should be

remembered that the availability of such operators in certain regions should be

verified before purchasing high-technology incinerators. If qualified operators are

not available, health-care establishments should either resort to alternative health-

care waste disinfection technologies or contract the incineration out through a

regional facility.

156. Incinerator operators should have received at least secondary technical education.

They should be specifically trained in the following subjects:

(a) Overall functioning of the incineration facility, including heat recovery and

flue-gas cleaning technologies, if they exist;

(b) Health, safety and environmental implications of their operations;

(c) Technical procedures for the operation of the plant;

(d) Emergency response, e.g. in case of equipment failures, alarms;

(e) Maintenance of the plant;

(f) Surveillance of ash quality and emissions according to the specifications. Training of operators of specially engineered landfill sites

157. The training of landfill operators is important for limiting subsequent risks presented

by buried biomedical and health-care waste, both in relation to preventing

scavenging and to protecting the quality of water. Operators should be trained in the

following areas:

(a) Health risks related to biomedical and hazardous health-care waste;

(b) Hazards related to sorting of this type of waste, which should in no event be

practised by the landfill operators or other people;

(c) Handling of biomedical and health-care waste by drivers or site operators,

which should be limited to a minimum;

(d) Use of protective equipment and personal hygiene;

(e) Application of safe procedures to dispose the wastes into a landfill;

(f) Procedures for emergency response.

Annex I: Glossary/terminology

Activity Disintegration of an amount of a radionuclide in a particular
energy state at a given time per time interval at a given moment.

Air pollution The presence of a material or substance in the air which may be
harmful to either the natural or human environment, which
includes any material present in sufficient concentrations for a
sufficient time, and under certain circumstances, to interfere
significantly with the comfort, health or welfare of persons or with
the full use and enjoyment of property.

Air quality standards The level of pollutants that cannot by law be exceeded during a
specified time in a defined area.

Solid or liquid waste arising from health-care (medical) activities
such as diagnosis, monitoring, treatment, prevention of disease or
alleviation of handicap in humans or animals, including related
research, performed under the supervision of a medical practitioner
or veterinary surgeon or another person authorized by virtue of his
professional qualifications.

Bottom ash The non-airborne combustion residue from burning fuel and other
materials in an incinerator. The material falls to the bottom of the
incinerator and is removed mechanically.

Capacity The quantity of solid waste that can be processed in a given time
under certain specified conditions, usually expressed in terms of
mass per 24 hours.

Chemical waste Wastes generated from the use of chemicals in medical, veterinary
and laboratory procedures, during sterilization processes and

Collection The act of removing accumulated containerized solid waste from
the generating source. Private collection of solid and liquid waste
by individuals or companies from residential, commercial, health
facility or industrial premises; the arrangements for the service are
made directly between the owner or occupier of the premises and
the collector.

Cytotoxic waste Material which is visibly contaminated with a cytotoxic drug
during the preparation, transport or administration of cytotoxic

Decontamination The process of reducing or eliminating the presence of harmful
substances such as infectious agents so as to reduce the likelihood
of disease transmission from those substances.

Disinfection Process of reducing the viability of micro-organisms by various physical and chemical methods.

Emergency A situation created by an accidental release or spill of hazardous chemicals
or infectious material which poses a threat to the safety of workers,
residents, the environment or property.

The amount of radiation or pollutant present in a particular environment
(i.e. human, natural) which represents a potential health threat to the living
organisms in that envi ronment.

Fly ash
The finely divided particles of ash entrained in the flue gases arising from
com bustion. The particles of ash may contain incompletely burned material.
The par ticles are frequently glassy spheres but may also be crystalline or
even fibrous in structure.

Health-care waste See biomedical and health-care waste.

Human tissue
The tissue, organs, limbs, blood, and other body fluids that are removed
during surgery and autopsy.

The controlled burning of solid, liquid or gaseous combustible wastes to
produce gases and residues containing little or no combustible material.

Irradiation Exposure to radiation of wavelengths shorter than those of visible light
(gamma, x-ray or ultraviolet) for medical purposes, the destruction of
bacteria in milk or other foodstuffs or initiation of polymerization of
monomers or vulcanization of rubber.

Liquid wastes Any waste material that is determined to contain “free liquids” - liquids
which readily separate from the solid portion of waste under ambient
temperature and pressure.

Periodic or continuous surveillance or testing to determine the level of
compliance with statutory requirements and/or pollutant levels in various
media or in humans, animals and other living things.

Off-site facility
A clinical and related waste treatment, storage or disposal facility that is
located away from the generating site.

On-site facility
A clinical and related waste treatment, storage or disposal facility that is
located on the generating site.


Wastes from the production, preparation and use of pharmaceutical

The decomposition of organic material by heat in the absence of or with a
limited supply of oxygen.

Radioactive waste Material contaminated with a radioisotope which arises from the medical or
research useof radionuclides. It is produced, for example, during nuclear
medicine, radio immunoassay and bacteriological procedures, and may be
in a solid, liquid or gaseous form.

Residual wastes Those materials (solid or liquid) which still require disposal after the
completion of
a treatment or resource recovery activity, e.g., slag and liquid effluents
following a
pyrolysis operation and the discards from front-end separation systems.

The control of all the factors in the physical environment that exercise or can
a deleterious effect on human physical development, health, and survival.

All objects and materials which are closely linked with health-care activities
pose a potential risk of injury and/or infection.

Sterilization A process used to reach a state free of viable micro-organisms. Note that in a
sterilization process, the nature of microbiological death or reduction is
by an experimental function. Therefore, the number of micro-organisms that
a sterilization process can be expressed in terms of probability. While the
may be reduced to a very low number, it can never be reduced to zero.


The application of activities such as waste reduction, reuse and recycling to
the amount of waste that requires disposal.


The process of keeping source-separated wastes apart during handling,
tion (interim storage), storage and transport to assist resource recovery and to en

sure that appropriate designated treatment and/or disposal methods are utilized.

Waste segregation should be practised by both generators and waste-handling com

panies for efficient waste management.

Annex II: Examples of specific waste reduction, reuse and recycling

Purchasing practices

· Purchase recycled content material where appropriate (e.g. office paper, envelopes,
toilet tissue, paper towels) and look for environmental labels. Work with purchasing
committees to determine which products may be suitable

· Work with suppliers to have oversized packaging materials returned or recycled

Use building construction products with recycled content materials (e.g. drywall,

· Use environmentally responsible vehicles and maintenance products (e.g. propane as

fuels, re-refined oils, retreated tyres, recycled antifreeze).


 Use two-sided photocopying
Use electronic mail (i.e. personal computers or phone messages)
Buy in bulk (e.g. food and drink containers in the cafeteria and soaps and detergents
in house keeping)

 Avoid products with excess packaging and work with suppliers to reduce it

 Reroute publications such as magazines, newspapers and journals

 Circulate memos or documents

 Use bulletin boards for posting announcements

 Single-space texts

 Use two-way envelopes for billing

 Make sure staff understand how to use equipment to reduce wastage

 Use the reduction feature on your copier to fit more than one paper per page

 Use permanent tape dispensers, not disposable ones

 Use refillable pens instead of disposable ones

 Purchase durable equipment, furnishings and supplies

 Install energy-efficient appliances (e.g. lighting)

 Use water-saving devices

 Turn off lights and office equipment when not in use

 Use incinerators that meet the new discharge guidelines and have an energy

recovery system

 Use computer fax software to send facsimiles without making hard copies

 Use non-solvent liquid scintillation cocktails in laboratories

 Use less hazardous radioactive materials where appropriate

 Develop microtesting procedures to reduce chemical usage

 Make sure biomedical waste is properly segregated from general waste to reduce dis-

posal costs and increase materials for recycling

 Explore opportunities to reduce formalin usage in sample analysis by replacing with

cold, physiological saline solutions where appropriate

 Replace formalin solutions with commercially available, less toxic cleaning solutions

in dialysis machines.


· Newspapers and telephone books can be given to farmers or
charitable organizations as bedding

· Give used towels and rags to rag recyclers · Use plain-paper
fax machines; the paper is recyclable and the messages
will not fade

· Recycle juice bottles or baby formula; juice and food material
containers; newspapers; and plastic containers (e.g.
polyethylene containers or other types where

· Recycle cardboard with a commercial recycler or through your
supplier · Recycle pallets with a commercial recycler or
through your supplier · Include pick-up of containers as
part of the supplier’s role in your contracts

· Work with suppliers to help them design workable packages
that are recyclable

· Pool local businesses that recycle material and contract for the
services of the same recycler t o reduce pick-up costs

· When purchasing products, ensure that all packages can be
returned to the supplier or recycled at your facility

· Use a distribution network to recycle materials back to a
central location for better marketing of material

· Explore waste-recycling options for food waste either as
human food, as animal feed either directly or through a
commercial processor - or as composting or for
vermiculture, and use compost at your facility in

· Contract a shredding company that recycles your shredded

· Involve ambulatory patients in waste minimization
programmes (e.g. psychiatric and geriatric patients in
composting projects)

· For large waste generators, explore processing equipment such
as balers or compactors for recyclable materials

· Locate markets for recyclable materials which are generated in sufficient quantities,
such as office paper, cardboard, plastics, solvents (xylenes, toluenes, CFCs),
oils (vegetable and hydraulic) and construction and demolition materials such
as drywalls, asphalt, concrete, wood Install silver recovery units for photo
processing waste waters

· Evaluate opportunities for anaesthetic gas recycling.


· Donate used publications to doctors’ surgeries, nursing homes or the local library.

· Reuse worn cloth nappies and towels as rags.

· Reuse scrap paper for notepads and draft copies.

· Reuse old envelopes by applying labels (with non-solvent glues) on top of old


· Use reusable nappies, incontinence pads and underpads where appropriate.

· Use reusable urine trays.

· Use reusable drapes and gowns where appropriate.

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and health

care waste


risk waste waste

Use 7



Risk + Non- Reuse - recycling of

a Possible action points a

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Definition > 4 Risk ) < Treatment > Disposal
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INFECTIOUS —p i for landfill or, A disposal
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Law clause

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