Related Terms

• Acute radiation syndrome, autoclave, Basel Convention, bioaccumulation, carcinogens, co-planar PCBs, dioxin, Doctors Without Borders, emissions, furans, genotoxic, hazardous waste, healthcare facilities, healthcare waste management, Healthcare Without Harm, hepatitis B, hepatitis C, Hippocratic Oath, HIV, human immunodeficiency virus, incinerator, infectious waste, Joint Commission on the Accreditation of Healthcare Organizations, JCAHO, lead, medical waste, medical waste management, Medical Waste Tracking Act of 1988, membrane bioreactor system, mercury, mercury poisoning, microwave technology, mutagens, oncology, pharmaceuticals, pollution, polychlorinated biphenyls, PCBs, PCDDs, PCDFs, polychlorinated dibenzo-para-dioxins, polychlorinated dibenzofurans, polyethylene, polystryene, polyvinyl chloride, PVC, radiation burns, radioactivity, recycling, rotoclave, sharps, steam sterilization, Stockholm Convention, sustainable healthcare, Teleosis Institute, teratogen, thermal technology, thermal treatment, waste stream, zooplankton.

Background

• Medical waste refers to clinical waste materials that are produced from healthcare facilities, such as hospitals, doctor's offices, pharmaceutical manufacturing plants, nursing homes, and research laboratories. These materials may include used syringes, soiled dressings, chemicals used to treat illness, equipment and facility chemical cleansers, and radioactive materials. Disposal of this waste is an environmental concern.

• In high-income countries, such as the United States, each person generates about 13 pounds (6 kilograms) of medical waste per year, according to the World Health Organization (WHO). People in lower-income countries, such as Cambodia, generate between 1 pound (0.5 kilograms) and 6.5 pounds (3 kilograms) of medical waste per person each year.

• The WHO suggests that 75-90% of medical waste from healthcare facilities may not be hazardous to humans, animals, or the environment. These waste items include used papers, soda cans, plastic containers, and other office-related disposable items. However, the remaining 10-25% of medical facility waste may be infectious or biohazardous, potentially exposing healthcare workers, patients, and community members to injury, infectious diseases, and toxins.

• Examples of harmful side effects related to medical waste may include acquired immunodeficiency syndrome (AIDS), hepatitis A, drug abuse, and cancer. Toxins, such as mercury, may be spread through skin contact or inhalation. Also, Escherichia coli bacteria may be spread through eating contaminated foods. Furthermore, infectious diseases may be transmitted through contaminated syringes or potentially cause injury.

• Medical waste may pollute the air and water. Pollution refers to substances in the natural environment as a result of human activity that might harm humans, animals, or the environment.

• The WHO suggests that nearly 25% of preventable illnesses are environmentally related. For example, unclean water can transmit bacteria that may cause diseases, such as cholera. It has been suggested that waste from healthcare activities may contribute to environmentally related illnesses. For instance, exhaust from hospital incinerators may cause illness among people living near the incinerator. Exhaust from incinerators has been associated with cancer and developmental problems in children. By minimizing the harmful chemicals in the exhaust, illness may be prevented.

• One of the first tenets of the Hippocratic Oath (an ethics code for medical doctors) states that harm should not be done onto a patient. However, healthcare workers, community members, and politicians may also have an ethical concern to safely manage medical waste and protect the public's health. Although not bound by the same ethical code as doctors, they may be responsible for waste production and have the power to make changes that will ensure the safety of others.

• In the late 1980s, needles and other medical waste items were found washed up on beaches in the United States. In response, the U.S. Environmental Protection Agency (EPA) launched the Medical Waste Tracking Act (MWTA). This act regulated waste management, established disposal guidelines, and implemented an inspection system to enforce hospital compliance. According to an article in the New York Times, one in five inspected healthcare facilities failed during the its two-year induction. However, the MWTA was under-funded and had few resources to enforce compliance. During that time, hospitals may not have registered for state inspections or handle medical waste appropriately. The EPA began to focus more on minimizing medical waste production and occupational risks.

• The healthcare industry is expanding, and environmentalists suggest there may be an increase of medical waste as a result. According to the Bureau of Economic Analysis' (BEA), the healthcare industry currently represents about 8.1% of the gross domestic product versus six percent in 1987. Ongoing efforts to address medical waste management issues and minimize its environmental impact are shared by community members, as well as local, state, national, and international governing agencies.

Technique

• General: Medical waste is often incinerated. However, medical waste can be deposited in landfills, discharged in sewer water, sterilized with an autoclave as it is produced and discarded with non-hazardous waste, or recycled. Hazardous materials, such as chemicals or radioactive items, may require specialized disposal methods.

• Types of waste: According to the World Health Organization (WHO), 75-90% of waste generated by healthcare activities may not be hazardous to humans, animals, or the environment. These items include paper, plastic containers, soda cans, or other office-related disposable goods. However, infectious or biohazardous waste accounts for an estimated 10-25% of all medical waste. Of this total, infectious waste accounts for 15%, whereas cleaning agents and pharmaceuticals comprise three percent. Sharps and genotoxic wastes, including radioactive and heavy metals each account for one percent.

• Hazardous waste: Medical waste travels a long way from its use to its final disposal. For example, if a patient requires a suture to close a wound, bloody cotton swabs are usually produced as waste. The patient might have a disease, such as acquired immunodeficiency syndrome (AIDS) that could be transmitted through contact with blood. Therefore, the soiled cotton swab is considered potentially hazardous, and special waste management procedures are necessary. Healthcare personnel working with the patient may deposit the cotton swab in a specially designed container for hazardous waste.

• Disposal: A trained worker empties the container when it is almost full and transports it to a holding station in the hospital. This holding station is inaccessible to non-hospital staff, and no waste is exposed to the air. Within 48 hours, the waste is moved to a vehicle and transported to an incinerator, where it is burned. An incinerator is a furnace that combusts some medical wastes at extremely high temperatures as a means of disposal, leaving only ash as a byproduct. Only healthcare personnel working with the patient directly handles the soiled cotton swab.

• Sharps: Unused pharmaceuticals and sharps, such as needles and syringes, may be either incinerated or placed in landfills. People with diabetes, who often use sharps to self-administer medication, should place used sharps in a thick plastic or metal container that has a lid. The container should leak-proof, and be thick enough so that no sharp objects can puncture it, and no heavy objects can break it. The container should be marked with a symbol or be red colored to indicate it contains hazardous material. Once full, the patient should throw the container away in accordance with local regulations.

• There are fewer guidelines for consumers to dispose of pharmaceuticals. Consumers may flush unused drugs down the toilet, excrete them in urine, pour them down the drain, or throw them away in the trash.

• Genotoxins: Disposal of genotoxic substances depends on what they are and where they are produced. Genotoxins are substances that are mutagenic (alter genetic information), teratogenic (interfere with fetus development), or carcinogenic (causes cancer). Genotoxins may be used to treat cancer.

• Mercury: Mercury is a genotoxic substance and metallic element used in thermometers, dental amalgam fillings, florescent lamps, and sphygmomanometers (used to measure blood pressure). Mercury is a byproduct of incineration and cremation. In 1998, the U.S. Environmental Protection Agency (EPA) aimed to eliminate mercury waste from hospitals by 2005. Many of the tools that contain mercury have been replaced by other technologies that do not use the metal. If equipment contains mercury, it is usually reclaimed and recycled rather than wasted.

• Disposal of mercury: Technology exists that chemically changes mercury to a less hazardous form, but this practice is legal in Canada and not the United States This chemical process converts elemental mercury into mercury sulfide. It is then blended with certain polymers and formed into a pellet. Many local districts have private or municipal recycling and hazardous waste centers that handle mercury waste. An example of a company that both recycles and chemically changes mercury waste is Bethlehem Apparatus Co., Inc., in Hellertown, Pennsylvania.

• Radioactive waste: Another example of genotoxic waste is radioactive waste. Radiation describes one particle or body emitting energy, which travels through space and is absorbed by another body. Ionizing radiation displaces the electrons in atoms and may cause damage to cells. Radioactive waste is usually separated (liquids from solids) and labeled as radioactive. Then, within the facility that generated the waste, it is stored in an area designated for radioactive waste.

• Disposal of radioactive waste: Which waste is stored and how long it is stored for depends on the type of waste as well as facility and state regulations. Once the radioactive substance decays, it is no longer hazardous. Radioactive decay is the process by which an unstable nucleus emits particles (such as electrons) until the parent atom becomes stable. Some radioactive waste takes many years to decay, and some healthcare facilities are not licensed to store radioactive waste. In either case, the waste is usually transported to a licensed commercial facility for disposal.

• Waste disposal: The Air Pollution Control Association suggests that incineration reduces medical waste by 90%. However, incineration may produce emissions that are hazardous to human health, so new alternatives are being developed and implemented. Also, depending on what is incinerated, the ash byproduct may be hazardous as well. Depending on local laws, ash is usually disposed in hazardous waste landfills. Infectious wastes, such as soiled dressings, syringes, and latex gloves, are often disposed in an incinerator or incinerator-alternative.

• Alternatives to incineration: One example of an alternative to incineration is thermal treatment, such as microwave technologies. During microwave-based sterilization, water is added to medical waste and exposed to microwave radiation, heating to about (210 degrees Fahrenheit (99 degrees Celsius). Another example of an incinerator alternative is an autoclave. This equipment can heat medical waste to 250 degrees Fahrenheit (121 degrees Celsius), a temperature lower than an incinerator, which burns above (1,472 degrees Fahrenheit) (800 degrees Celsius). The remaining material in the autoclave is non-infectious and is shredded and then transported to a landfill. Because the autoclave does not completely burn all materials, it might produce less pollution than an incinerator.

• Developing countries: Incinerators are still used in the United States, but some healthcare initiatives in developing countries rely on them exclusively. Organizations, such as Doctors Without Borders, are immunizing people in developing countries against disease. However, these countries may lack the infrastructure for handling the large amount of medical waste that occurs alongside these immunization campaigns.

• Mass immunizations: For example, the WHO reports that a 2001 mass measles immunization campaign in West Africa generated 300 metric tonnes of injection waste from 17 million vaccinations. Often humanitarian organizations build incinerators for the immunization campaign. This incinerator is left behind after the campaign and is used for other purposes. This places local populations at risk for the negative health consequences of incinerator use. Replacing the incinerator with an alternative disposal method may help to avoid health risks.

• Waste management: The goals of healthcare waste management are to minimize the production of hazardous medical wastes and prevent these wastes from harming healthcare workers, patients, the community, and environment. The WHO outlines five ways these goals may be accomplished: supervision and management, public policy, technology, cost, and awareness.

• Supervision and management: Waste reduction and safe disposal starts when healthcare leaders, politicians, and concerned citizens carefully supervise and manage healthcare facilities. Healthcare leaders must establish clear institutional and individual responsibilities for waste from the time it is generated until it is disposed. Medical waste should be minimized. Then, from its generation it should be handled, stored, transported, and finally disposed according to guidelines that prioritize safety.

• Small versus large facilities: Healthcare facilities are responsible for managing their own waste; however, many large and small facilities hire other companies to manage their waste for them. In fact, three or more companies might manage waste for one facility. For example, one company may collect and transport waste within the facility, while another transports it to a disposal site and a third disposes it. Large facilities are more likely to own their own disposal methods, such as chemical sterilizers, incinerators, and radioactive storage areas. These large facilities are likely to use contract waste management companies for help managing the large amount of waste they generate. Smaller facilities can better handle the amount of waste produced, but are less likely to have disposal equipment, such as incinerators. Therefore, they may seek contract waste management companies for help disposing of waste. Whatever job the facility needs outside waste management companies to fulfill, the facility administration is responsible for oversight. Overall, waste management is always the responsibility of the facility that generated it.

• Personnel involved: Supervising and managing each item of medical waste requires awareness and good training of all staff members that handle waste, including medical assistants, nurses, doctors, administrators, garbage handlers, and transportation workers. Beyond awareness and training, healthcare leaders can outline a waste management plan that clearly defines the plan's objectives, time frame, allocation of resources, and compliance strategy.

• Developing a plan: This plan should minimize waste and emphasize segregating contaminated or toxic waste from non-hazardous, office-related garbage. Also, hazardous waste should be contained and transported to a safe storage place within the facility. Within 48 hours, facility staff should arrange for the waste to be exported using dedicated vehicles. Each type of waste might have different final treatment and disposal techniques. For example, sharps may be transported to an incinerator, while unused pharmaceuticals may be transported to a local landfill along with the rest of non-hazardous waste. Larger hospitals have created an employee position specifically focused on establishing and implementing uniform waste management policies while monitoring compliance with these policies. Beyond generation to disposal management, regulations should also arrange for regular incinerator inspections.

• Public policy: An infrastructure for supporting waste management on a facility level is important for safety. National, state, and local laws should implement and monitor compliance with standard waste management practices at every healthcare facility. In the United States, the U.S. Environmental Protection Agency (EPA), U.S. Food and Drug Administration (FDA), Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and Occupational Safety and Health Administration (OSHA) are four organizations that implement rules and monitor compliance. State and local governments vary in executive and regulating responsibilities. Many states have environmental protection departments and other similar departments that have oversight. Currently, much of waste management oversight in the United States is the responsibility of each state. The U.S. government has created regulations and guidelines, such as those applied to mercury, a hazardous waste.

• International oversight: International agreements set at the Basel and Stockholm conventions have formed global guidelines for waste management and disposal.

• Basel convention: The Basel convention is an international treaty. This treaty limits hazardous waste movement between countries. At the end of the last century, some wealthier countries were paying less wealthy countries to take their hazardous wastes, including hazardous medical waste. This treaty aims to end this practice, making each country responsible for its own waste.

• Stockholm convention: The Stockholm convention is another treaty that restricts human production of persistent organic pollutants internationally. Persistent organic pollutants are substances that do not break down in the environment and can harm human health. An example of a persistent organic pollutant is a polychlorinated dibenzodioxin (PCDD), a type of dioxin that may be released by incinerators. Dioxins harm human health, potentially disrupting hormones and reproductive functions, among other side effects.

• JCAHO: The largest scale example of healthcare facility inspections is the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), also referred to as the Joint Commission. JCAHO is a non-profit organization commissioned by the federal government that inspects healthcare facilities to ensure compliance with federal, state, and local rules.

• JCAHO inspections: JCAHO inspectors make sure that health facilities follow rules governing many areas including patient safety, privacy of medical records, and hazardous waste management. If the inspectors find non-compliance in any area, they may impose monetary fines or not accredit the facility. This means the state will not reimburse the facility for medical bills from people using state-sponsored Medicare and Medicaid insurance. Healthcare facilities that are not compliant with local, state, and federal waste management regulations may experience financial hardships and damaged reputations.

• Technology: Having appropriate equipment for managing healthcare waste may not need to be complicated or expensive. Using safe containers and protective equipment can significantly reduce risks. Technologies and equipment that are optimal for each healthcare facility depends on a number of factors, including how much waste the facility produces; how accessible waste disposal sites are; local environmental laws; and the availability of human, financial, and material resources.

• Examples of technology: Technology is an important part of preventing harm from medical waste. For example, a membrane bioreactor system can clean wastewater and may prevent genotoxic waste from entering water supply areas. This technology may ultimately help prevent health problems. Another example is an autoclave. The EPA recommends this device as an incinerator-alternative. An autoclave uses high-pressure steam to sterilize medical waste, heating it to 248 degrees Fahrenheit (120 degrees Celsius).

• Cost: The risk of medical waste impacting the environment increases when financial resources are limited. For example, some healthcare clinics in developing countries cannot afford an incinerator. Therefore, they might leave infectious waste exposed in a landfill, endangering the local population. For example, the WHO reports that in Vladivostok, Russia, six children contracted smallpox from playing in a landfill near their homes.

• However, some programs to better manage waste in healthcare facilities can cut operating costs. For example, a recycling program in a Baltimore-based hospital cut garbage removal fees by $300,000 per year, according to the Urbanite magazine. Evaluating a facility's needs, researching options, purchasing equipment, and implementing new disposal procedures may be costly up front, but they may be a key long-term investment for the facility.

• Awareness: Raising awareness about safe medical waste disposal requires formulating a different message for each concerned party. Policy makers should understand the risks to the wellbeing of their constituents. Community members should learn ways to keep themselves safe. Healthcare workers should understand how to properly dispose of waste, how to organize and support proper waste disposal within the entire facility, and understand the importance. Many new hospital employees attend lectures, read material, and take quizzes about safe waste disposal methods; some employees are required to review waste management and other hospital safety measures each year.

• Factors affecting waste management: Many variables can change the waste stream, or how waste is managed as it moves from creation to disposal. Some healthcare facilities have more resources than others, and some nations have a better infrastructure for regulating medical waste than others. Furthermore, factors such as local climates and population densities might affect how waste can be disposed. For example, disposing the medical waste of a clinic in a high-population density area might be dangerous if landfills are too close to human habitation. Additionally, a facility in a location that receives a lot of rain might need to be more careful with landfill disposal, as chemicals are more likely to wash away into water supply areas. Medical waste disposal plans balance standard levels of safety with flexibility to respond to the facility's needs and restrictions.

Theory/Evidence

• General: In high-income countries, such as the United States, each person generates about 13 pounds (6 kilograms) of medical waste per year, according to the World Health Organization (WHO). People in lower-income countries, such as Cambodia, generate between 1 pound (0.5 kilograms) to 6.5 pounds (3 kilograms) of waste per person, each year. Medical waste places healthcare workers, waste transporters, hospital patients, the general public, and the environment at risk.

• Failure of waste management: There are two main reasons why waste management practices fail to keep people safe from medical waste. In some cases, the practices established to keep people safe are not followed. In other cases, the ways to keep people safe are not clear. There are no set best practices of managing waste that apply universally to every healthcare facility. Each may have different disposal mechanisms available, different types of waste, and different budgets for managing waste. Therefore, there may be some room for error.

• Lack of follow through: Established practices might not be followed for a number of reasons. Perhaps, a health facility lacks awareness about health hazards. Another facility may have insufficient financial and human resources to handle, store, transport, and dispose of medical waste properly. Poor government regulation and enforcement could reflect the low priority society places on medical waste management. Also, the volume of waste might be too much for a small health facility to handle. For example, the WHO reports that a 2001 mass measles immunization campaign in West Africa generated 300 metric tonnes of injection waste from 17 million vaccinations. Reducing the amount of waste this campaign produced, as well as properly managing each waste item, may be difficult.

• Lack of knowledge: In some cases, healthcare waste management procedures fail to keep people safe because ways to safely manage medical waste are unknown or poorly understood. This failure may occur because environmental and human health effects of medical waste are poorly understood. Perhaps, more research is necessary before scientists, the community, and healthcare and political leaders can formulate guidelines for safer pharmaceutical waste management. Currently, there may be insufficient guidance regarding how to more safely dispose of medication. In some areas, medication disposal programs allow consumers to bring unused medication to drop-off areas.

• Accidents: Accidents may occur when healthcare workers follow waste management guidelines and procedures. For example, mercury is a toxic metal used in medical equipment such as thermometers; it poses a low chance of toxic exposure because it is usually encased in protective coverings. However, if mercury-containing equipment breaks, mercury poisoning can occur. Poisoning causes nausea, rapid and weak pulse, shallow respiration, and loss of coordination, among other effects.

• Waste and the environment: The WHO estimates that nearly 25% of preventable illnesses may be related to the environment in some way, whether from medical waste, bacteria-contaminated water, harmful pesticide use, industrial processes, or other sources. A clean environment is important for good health, and healthcare that prioritizes a clean environment represents a holistic approach to good health.

• Environmental impact of waste: Even when waste is minimized, handled, and disposed of properly, it may still adversely affect human health through its impact on the environment. Air and water pollution are the two main avenues for these negative impacts.

• Air pollution: Incinerators release pollutants into the air, water, soil, and foliage. Harmful contaminates are released when plastics that contain polyvinyl chloride (PVC) are incinerated, or when the incinerator is not hot enough. When plastics containing PVC are incinerated, they produce dioxin. Dioxins and other pollutants from incinerators are water soluble, meaning they are dissolved in bodies of water near the incinerator. Once in water, these pollutants can become part of drinking water and become integrated into the food humans eat. Dioxins are harmful to humans, potentially impairing the immune system, disrupting hormones and reproductive functions.

• Reducing air pollution: Alternatives to incineration have not yet been integrated into most medical waste management procedures. Because the exhaust from incinerators is linked with a negative impact on health, effective alternatives have been created. The U.S. Environmental Protection Agency (EPA) currently encourages healthcare facilities to explore different incineration alternatives such as microwave-based sterilization. During microwave-based sterilization, water is added to medical waste and exposed to microwave radiation, heating to about 99 degrees Celsius (210 degrees Fahrenheit). However, microwave radiation and other alternatives have not yet replaced all incinerators.

• Water pollution: Pharmaceuticals and other chemicals dumped in landfills may leach into water bodies. Furthermore, people who take pharmaceuticals excrete small amounts of those drugs in urine and sometimes may pour unused drugs down the drain. Genotoxic materials are included in the wastewater of some hospital oncology (cancer treating) units.

• Incinerators produce ash as a byproduct; if not properly disposed, toxins in the ash may leech into waterways. Most conventional sewage plants do not remove all these residues; therefore, trace amounts of the drugs and toxins join the water that supports ecosystems and may eventually pollute drinking water. This phenomenon is widespread across the United States.

• The Teleosis Institute, a sustainable healthcare advocate, suggests that more than 80% of waterways tested in the United States show traces of common medications such as painkillers, hormones, antidepressants, antihypertensives, and antibiotics. There is insufficient evidence regarding the impact of ingesting small amounts of these medications over time has any impact on human health or the environment.

• Sustainable healthcare: According to the green healthcare advocate Teleosis Institute, sustainable healthcare refers to looking beyond the practice of medicine to include public health and the environment. Sustainable healthcare means using medical resources wisely, managing medical waste, and other initiatives that decrease healthcare's impact on the environment. The goal is to make medicine available to everyone in the future. There are established techniques healthcare facilities and community members can practice to reduce medical waste's impact on the environment, further preventing side effects.

• Minimizing the use of chemicals: Healthcare workers can substitute more hazardous chemicals with less hazardous chemicals. For example, when cleaning hospital rooms, the housekeeping staff could use organic cleaners for patient rooms or staff areas and save more toxic cleaners for common areas. If medications are unused, prescribing less may cut costs and waste.

• Changing medicines: Healthcare practitioners may substitute more toxic medicine with less toxic medicine or limit the amount of medicine prescribed. Many pharmaceuticals remain unused and are discarded. The Teleosis Institute estimates consumers who participated in a pharmaceutical recycling program discarded 40% of their prescribed medications in 2007. Recycling and pharmaceutical take-back programs are growing in popularity in the United States. Prescribers who monitor their patient's drug use and adjust the prescription accordingly may potentially reduce waste.

• Sorting waste: Reducing waste may also be achieved when healthcare workers carefully sort medical waste as it is generated. Often non-medical waste, such as papers and other office trash, is combined in hazardous waste bins and incinerated. When non-hazardous wastes are incinerated, levels of air pollution may be increased. Carefully sorting hazardous waste from non-hazardous waste as it is generated may reduce the amount of waste being incinerated and can make recycling easier. With fewer materials in an incinerator, fewer harmful emissions will be produced. Providing conveniently placed and clearly labeled waste disposal bins may encourage hospital staff to sort trash as it is generated.

• Understanding waste: Healthcare facilities that know exactly where each type of harmful medical waste is generated and specific techniques for managing it may reduce risks to the environment and people. For example, testing the wastewater of an oncology unit may reveal the presence of some genotoxic substances. Implementing specific cleaning mechanisms, such as a membrane bioreactor system and advanced downstream wastewater treatment processes, may potentially reduce health risks to humans, plants, and animals.

• Finding alternatives: There are potentially safer medical waste disposal alternatives that have not been fully implemented in each country. More healthcare facilities and initiatives are using alternatives to incineration. According to Healthcare Without Harm, a global coalition of 473 healthcare organizations, 130,000 kilograms of soiled sharps were produced in 2004 after a mass immunization campaign in the Philippines. Instead of incinerating the waste, the products were treated with autoclaving technologies, treated with microwave technologies, encased in a concrete septic vault, or buried in a waste pit.

Health Impact/Safety

• General: The impact of medical waste on human health may indirectly come from breathing air or drinking water. Medical waste can pollute the environment and may negatively impact human health. To understand the impact of medical waste on human health, medical waste's impact on the environment must also be understood.

• Types of waste: Each type of medical waste and disposal method has a different potential impact on human health. Healthcare workers must balance sound medical decisions with the knowledge that these decisions can indirectly have a negative impact on health.

• Radioactive materials: Radiotherapy is a treatment for disease, particularly cancer, by exposure to radioactive materials and produces radioactive waste. Imaging equipment can also produce radioactive waste. According to the World Health Organization (WHO), examples of radioactive material included in healthcare waste are from cobalt 60Co, technetium 99mTc, iodine 1311, and iridium 192lr. Accidental exposure to radioactive waste is rare, especially since most radioactive substances decay quickly. Decay refers to a process by which the radioactive atom loses energy and transforms into a different, less dangerous atom.

• Impact on health: Exposure may have serious health consequences, such as radiation burns or acute radiation syndrome. Acute radiation syndrome results from exposure of the body to high amounts of radiation. It is characterized by nausea, vomiting, headaches, fatigue, fever, infection, diarrhea, hair loss, low blood pressure, and death. Radiation exposure may increase the risks of other ailments, such as tumor growth, cancer, and genetic damage. Depending on the extent of exposure, treatment might entail blood transfusions and bone marrow transplants.

• Genotoxic materials: Genotoxic materials, or cancer- or mutation-causing waste, are sometimes found in the wastewater of oncology (cancer treating) units in hospitals. Environmentalists suggest that 82% of 31 water samples from oncology units contained genotoxic substances. Hospitals can implement cleaning techniques to reduce the risk these substances pose to animals, plants, and people. One technique under investigation is a membrane bioreactor system, which combines filtration with biological-based treatment. This harm-reduction technique exemplifies the importance of preventing rather than treating the health impact of medical waste. Preventing hazardous waste from entering the environment is may be safer and more economical than treating its effects.

• Mercury: Some medical equipment, such as thermometers, requires mercury, and some medically related processes, such as incineration, produce mercury. An incinerator is a furnace that combusts medical wastes at extremely high temperatures as a means of disposal. Mercury used in medical equipment has no toxic effects, but exposure can occur when it is improperly disposed of or if equipment malfunctions. Furthermore, mercury released in the air may accumulate, contaminating water and food.

• Eliminating mercury: The U.S. Environmental Protection Agency (EPA) set a goal to eliminate mercury waste from hospitals by 2005. Purchases of new mercury containing equipment have declined since this goal was set in 1998. However, healthcare facilities should replace existing devices with alternatives to meet this goal. An article in the New York Times suggests that doctors believe some of these alternatives are more expensive, less durable, and less accurate. For example, if a mercury-free blood pressure monitor (aneroid) replaced a standard sphygmomanometer, over time this device may become less accurate with blood pressure readings.

• Impact on health: Mercury, whether it is spilled or emitted from an incinerator, becomes a toxic vapor, and those that inhale it may experience symptoms such as burning in the mouth and throat, abdominal pain, cramps, nausea, vomiting, diarrhea, bloody stools, rapid and weak pulse, slow and shallow respiration, loss of coordination, and impaired vision and hearing. Mercury in the environment can contaminate food, whether it occurs naturally (as methylmercury), as a pollutant from industrial processes, or as medical waste. For example, fish that swim in mercury contaminated water absorb mercury. If humans eat the fish, they too then retain mercury (methylmercury). Ingesting too much mercury can have serious health effects, including headaches, fatigue, lack of concentration, and damage to the nervous system. This damage results in numbness in the hands and feet and in exposed children, slowed attention span and poor memory occurred.

• Treatment for mercury poisoning: Treatment for mercury poisoning is chelating agents. A chelating agent is a type of compound that combines ions, usually metal ions, and is believed to help the body rid itself of metals. Research on the efficacy of chelating agents conflicts. Careful attention to which chelating agent is used for each type of mercury compound present in the body may be is necessary. Experts suggest that healthcare facilities should not purchase new equipment containing mercury. Also, there are recycling programs and services for hospitals and all other mercury waste producers to reclaim and recycle mercury. This might help reduce the amount of mercury in the environment.

• Incinerated materials: Many contaminated medical wastes, including latex gloves, sharps, bags used to contain soiled bandages, and body parts, are incinerated. Incinerating these materials releases pollutants into the air, including mercury, lead, and carbon monoxide. Burning waste, particularly plastic containing polyvinyl chloride (PVC), produces three notably harmful substances: dioxins; furans; and co-planar PCBs (also called polychlorinated dibenzo-para-dioxins (PCDDs), polychlorinated dibenzofurans (PCDFs) and polychlorinated biphenyls (PCBs). A plasticizer and toxin, di(2-ethylhexyl) phthalate (DEHP) is often used in plastics that also contain PVC. The ash that is produced as a byproduct of incineration may also be hazardous.

• Bioaccumulation: Incinerators release dioxins and furans into the air; some of these materials end up in water. Animals exposed to dioxins in the air and the water retain this toxin in their body fat, and plants can absorb it as well. If humans eat the contaminated animal or plant, they too then retain the dioxin. The more contaminated food humans eat, the more dioxins build up. This process, called bioaccumulation, may cause cancer or immune-, hormone-, and reproductive-related complications. There is a wide range of dioxin levels in fish, vegetable oil, beef, pork, and leafy vegetables. This range has prohibited scientists from determining which foods contain the most dioxins. The level of contamination likely depends on a number of known factors, such as geographic proximity to pollution sources and the amount of fat in animal-based foods, as well as a number of unknown factors.

• Impact on health: According to the WHO, long-term exposure to dioxins, furans, and co-planar PCBs, even at low levels, may impair the immune system, the development of the immune system in children and fetuses, and disrupt hormones and reproductive functions. Furan and dioxin levels can become particularly high in breast milk. Animal research suggests that exposure to dioxins and furans at nuisance levels (10mg/m3) for only two weeks causes skin lesions. Dioxins also cause cancer. According to the National Resources Defense Council (NRDC), these chemicals collect in not only humans, but also the animals that humans eat, compounding their ill-health effects. Any exposure to DEHP, whether it is burned or not, can damage the liver, kidneys, and lungs. It may also disrupt hormones and harm the developing fetus.

• Lack of research: The health risks of incinerator-produced dioxins and furans lack sufficient evidence. Reliable assessments of health complications from long-term exposure to dioxins and furans are difficult to conduct. Most studies that document their toxic effects use samples of factory workers that are chronically exposed to high concentrations of these chemicals. Average community members are unlikely to experience this level of exposure. Exactly how many people are affected by incinerator-produced dioxins, furans, co-planar PCBs, and other pollutants, and how serious these effects are, may prove difficult to determine.

• Reducing impact: Curbing the health effects of dioxin and furan remains in preventing these chemicals from being emitted. Stricter emission regulations instated in Europe 10 years ago according to the WHO, may be responsible for substantial decreases in dioxin and furan concentrations in food, including mothers' milk.

• Sharps: Sharps are needles, blades, syringes, or any other tool that could cut or puncture skin. Unsafe disposal within the healthcare facility can lead to accidents when healthcare or waste handlers are punctured with contaminated needles. Sharps unsafely deposited in landfills or dumpsites can be scavenged and reused. Some evidence suggests that injections with contaminated syringes may cause 32% of all new hepatitis B virus infections (21 million cases), 40% of all new hepatitis C virus infections (two million cases), and 5% of new HIV infections (260,000 cases) annually. In healthcare facilities, used sharps are placed in puncture-proof, covered boxes, and disposed in incinerators or incinerator alternatives.

• Landfills: The WHO reports that in 2000, six children contracted smallpox (Vaccinia virus) after playing with an expired vaccine container at a garbage dump in Russia. Leaving contaminated wastes exposed in open garbage dumps places children and people scavenging the dumps at risk.

• Impact on health: Since 1988, the EPA has monitored some chemicals that are used as pharmaceuticals, such as the epilepsy medicine phenytoin. Phenytoin (Dilantin®) is an anticonvulsant used to treat recurrent seizures that characterize this neurological disorder. The agency found that 572 million pounds of phenytoin and 21 other drugs were disposed in landfills nationally. Some of these drugs can dissolve in rainwater and leach into local bodies of water, eventually contaminating drinking water. Currently, there are no protocols associated with safe pharmaceutical disposal.

• Pharmaceuticals: Pharmaceuticals enter the water by leaching out of landfills, through urine excretion, drain pouring, and through pharmaceutical and industrial manufacturing processes. According to secondary sources, trace amounts of pharmaceuticals have been found in the drinking water of 51 million Americans nationwide.

• Impact on the environment: Researchers suggests that fish living in city rivers near waste water treatment plants contained trace amounts of chemicals, including medications used to treat allergies, high cholesterol, high blood pressure, and mood disorders. However, fish in rural rivers contained no drugs or chemicals. According to the EPA preliminary data analysis, anticonvulsants were the most common medication found in the environment in Chicago, Dallas, Orlando, and Phoenix. The EPA's early results may be limited because of measuring techniques used or water sources tested. Furthermore, preliminary research from the Teleosis Institute suggests central nervous system (CNS) agents are the most commonly discarded medication among people participating in a drug recycling program in San Francisco, California. CNS agents include acetaminophen (Tylenol®), aspirin, and topiramate (Topamax®) (treats migraines). The health impacts of drinking water with low levels of pharmaceuticals are unclear, according to the EPA and the U.S. Food and Drug Administration (FDA). There is insufficient evidence that any humans have been harmed, but research in this area is minimal.

• Reducing waste: Conventional filtering methods, such as those used in sewage treatment facilities or home filtration systems, do not remove pharmaceutical residues from water.

• Impact on health: The impact of low levels of water-borne pharmaceuticals and genotoxic waste on the environment is unclear. Laboratory research suggests that trace levels of some pharmaceuticals effect aquatic invertebrates, such as zooplankton. Scientists consider zooplankton a cornerstone of the world's ecosystem because many animals depend on them as a food source. According to an article in the New York Times, experts at the ESWE Institute for Water Research and Water Technology in Germany suggest that aquatic animals' chronic exposure to toxicants may accumulate so slowly and be detectable until it is too late to reverse the damage. Currently, there is insufficient data regarding this topic. Biologists are currently studying the effects of pharmaceuticals on simple life forms, but have not yet collected enough data.

Future Research or Applications

• Reducing environmental impact: Small changes to healthcare waste management may help reduce the environmental impact of medical waste on humans. For example, Mercy Medical Center in Baltimore, Maryland, instituted a program that recycles 20% of all hospital waste. Rather than combine medical waste with common office trash and incinerate both types of waste, trained employees separate the both types of waste. The program cut air pollution and reduced the garbage bill at Mercy Medical Center by $300,000 annually. Not all hospitals have recycling programs, but results from this recycling program may increase motivation to initiate similar programs at other healthcare facilities.

• Limiting prescriptions: There is evidence that medical professionals may limit the amount of medicine they prescribe without impacting patient health. Preliminary data from Teleosis Institute, which collects information from people who return medications to local drop off points, suggests that 40% of their pharmaceuticals were unused in 2007. Prescribers who monitor patient use and adjust the prescription accordingly may potentially reduce waste. The Teleosis Institute estimates the total wholesale value of returned medicines exceeded $112,000 in 2007.

• Pharmaceutical companies: Pharmaceutical companies are joining the effort to reduce medication impact on the environment. For example, Pfizer aims to conserve water, deepen their understanding of the risks of pharmaceutical-contaminated water, and participate in local medication take-back programs.

• Mass immunizations: Mass immunization campaigns occurring in developing countries can produce and incinerate a large amount of hazardous waste. The World Heath Organization (WHO) reports that a 2001 mass measles immunization campaign in West Africa generated 300 metric tonnes of injection waste from 17 million vaccinations. According to Without Harm, a global coalition of 473 healthcare organizations, 130,000 kilograms of soiled sharps were produced in 2004 after a mass immunization campaign in the Philippines. Instead of incinerating the waste, the products were treated with autoclaving technologies, treated with microwave technologies, encased in a concrete septic vault, or buried in a waste pit. treated soiled sharps in an autoclave facility or a microwave facility, or encased or buried the sharps.

• Improving oversight: Governments and oversight committees are working to improve healthcare waste management. The World Health Organization (WHO) recommends reducing waste, better state-based regulations governing incineration use, and supporting developing countries' waste management procedures in the long term. The U.S. Environmental Protection Agency (EPA) aims to increase their role in helping hospitals to reduce waste, eliminate mercury waste, and find new ways to prevent pollution. The WHO encourages federal-government based healthcare waste management initiatives. This means national governments, not just state, provincial, or local governments, should initiate and enforce both specific and comprehensive regulations for medical waste management.

• Improving organization: Hospitals may benefit from creating a designated employee position whose job responsibility is to establish uniform policies, as well as implement and monitor compliance. The types of medical wastes vary, as does the methods of disposal. A person or team focused on these variables may reduce error, increase compliance, and increase the sufficiency of safety protocols in the hospital.

• Changing materials: When incinerated, medical plastics containing polyvinyl chloride (PVC) produce dioxins and furans, which are air pollutants that cause many different health problems among humans and fetuses. If healthcare facilities used medical plastics with low chlorine contents, such as those composed of polyethylene and polystyrene, they may reduce dioxin and furan production during incineration. Also, excluding any plastic that contains di(2-ethylhexyl) phthalate (DEHP) could reduce the risks associated with this plasticizing chemical.

• New technologies: New technology to reduce the pollution generated by incinerators is emerging. Urbanite magazine reports that the Johns Hopkins Medical Institution uses an autoclave, which heats medical waste to 250 degrees Fahrenheit (121 degrees Celsius), a temperature lower than an incinerator, which burns above 1,472 degrees Fahrenheit (800 degrees Celsius). The remaining material in the autoclave is non-infectious and is shredded and transported to a landfill. The U.S. Environmental Protection Agency (EPA) recommends thermal technology, such as microwave technologies. During microwave-based sterilization, water is added to medical waste and exposed to microwave radiation, heating to about 210 degrees Fahrenheit (99 degrees Celsius).

• Disposal programs: Pharmaceutical disposal programs, such as the program organized by the Teleosis Institute and its partners supported by networks of local healthcare facilities, can reduce the amount of medication contamination in waterways. Rather than pouring unused medications down the drain or depositing them in a landfill, people in the San Francisco Bay area in California can bring their unused medication to local drop-off points. This program collected 900 pounds of unused and expired medication within nine months. Sometimes healthcare facilities can send unused medications back to pharmacies for re-use. For example, nursing homes, which distribute medications to patients as needed, can send unused, unexpired, and untouched medications back to pharmacies. The pharmacies can then give them to other patients in need for free or at a discount. Less than half of U.S. states have instituted re-use programs, each with different restrictions and guidelines.

• Non-profit involvement: Some non-profit organizations are joining the effort to control the health effects of medical waste. The Global Environment Facility is funding a $10 million initiative implemented by the World Health Organization (WHO), the United Nations (UN), and Healthcare Without Harm. This project, called "Demonstrating and Promoting Best Techniques and Practices for Reducing Health Care Waste to Avoid Environmental Releases of Dioxins and Mercury," focuses on Argentina, India, Latvia, Lebanon, the Philippines, Senegal, Tanzania, and Vietnam. Each country will partner with area resources, such as local non-profits, professional organizations, and universities, to develop ways to eliminate dioxin and mercury wastes from hospitals. The initiative also plans to educate and train workers and waste managers on the medical waste practices that best suit the needs of each hospital.

• Research: Scientists at universities, hospitals, governments, and non-profit organizations are initiating research projects to better understand medical waste. Specifically, they are researching where waste comes from, how healthcare workers and consumers can reduce it, how to dispose of waste in a less harmful way, what health and environmental effects it has, and how people can keep safe from its effects. Examples of organizations supporting research include the EPA, the ESWE Institute for Water Research and Water Technology at Johannes Gutenberg University in Germany, and the Berkley-based Teleosis Institute. These projects focus on the impact of medical waste on the environment and humans as well as new and alternative waste management techniques and technology.

• Awareness: There are a number of non-profit organizations and healthcare facility programs dedicated to sustainable healthcare. For instance, the Teleosis Institute, Healthcare Without Harm, The Eco-Dentistry Association, Practice Greenhealth, and Physicians for Social Responsibility are working to institute new best practices for medical waste management and waste reduction. These organizations are raising awareness about the dangers of medical waste among policy makers, healthcare consumers and workers, and the general public. An addition, these organizations find and promote alternative healthcare solutions that minimize waste or do not produce any waste at all.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

1. Bureau of Economic Analysis. www.bea.gov

2. Falk H, Waxweiler RJ. Epidemiological studies of vinyl chloride health effects in the United States. Proc R Soc Med. 1976 Apr;69(4):303-6. View Abstract

3. Jolibois B, Guerbet M. Hospital wastewater genotoxicity. Ann Occup Hyg. 2006 Mar;50(2):189-96. View Abstract

4. Lenz K, Mahnik SN, Weissenbacher N, et al. Monitoring, removal and risk assessment of cytostatic drugs in hospital wastewater. Water Sci Technol. 2007;56(12):141-9. View Abstract

5. Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com

6. Richards RJ, Cobb LM, Hardy CJ, et al. Effects in the rat of inhaling PVC dust at the nuisance dust level (10 mg/m3). Arch Environ Health. 1981 Jan-Feb;36(1):14-9. View Abstract

7. Richards SM, Kelly SE, Hanson ML. Zooplankton chitobiase activity as an endpoint of pharmaceutical effect. Arch Environ Contam Toxicol. 2008 May;54(4):637-44. View Abstract

8. Sullivan JB and Krieger GR. Clinical environmental health and toxic exposures. Philadelphia: Lippincott Williams & Wilkins, 2001.

9. The U.S. Environmental Protection Agency (EPA). www.epa.gov

10. U.S. Food and Drug Administration (FDA). www.fda.gov

11. World Health Organization (WHO). www.who.int/en