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UNDP Istanbul Regional Hub for Europe and the CIS Reducing UPOPs and Key Plaza, Abide-i Hürriyet Cd. Releases from The Health Sector in Africa İstiklal Sk. No/11, Şişli, 34381 İstanbul, Turkey Module 10 Email: [email protected] Tel: +90 xxxxxx

Management of chemicals

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Reducing UPOPs and Mercury Releases from The Health Sector in Africa Module Overview

• Describe sources and types of chemical, cytotoxic and pharmaceutical wastes in a healthcare setting • Discuss risks associated with exposure to these specific wastes • Describe all aspects of management of these specific wastes • Describe treatment and disposal methods

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Learning Objectives

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

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Characteristics of Chemical Waste

Discarded solid, liquid and gaseous chemicals that are: • Toxic • Corrosive • Flammable • Reactive - Explosive, water reactive, shock sensitive • Oxidizing

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Hazardous chemicals in healthcare

► ► Mercury ◼ ◼ Thermometers ◼ ◼ Blood pressure meters ◼ ethylene oxide ◼ Dental ◼ OPA ◼ Fluorescent light tubes ◼ hypochlorite ◼ ► Plastics ► Pharmaceuticals ◼ PVC (DEHP) ◼ Cytotoxics ◼ Polycarbonates (BPA) ► Lab chemicals ► Flame retardants ◼ Formaldehyde ◼ Brominated compounds ◼ Dyes and stains ► Other ◼ Solvents and fixatives ◼ Batteries ► Pesticides ◼ Paints ► Photographic chemicals ◼ Lubricating oils ◼ Fixers and developers

New database on chemical hazards: http://www.istas.net/risctox/

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Hazardous healthcare waste

► Excess / unused chemicals and diagnostic materials ◼ Benzene ◼ flammable organic liquids like acetone, ether, ◼ Non empty sprays ◼ Peroxides ► Excess / unused / organic solvents and residues ◼ Formaldehyde ◼ Disinfectants, ◼ Organic liquids used for analysis ◼ Heavy metal salts /toxic reagents used for chemical reactions ◼ Mercury containing diagnostic items/disinfectants  , , , Diuretika ◼ Godolinium

 Gadodiamid, Gadopentat, Prohance

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Not all hazardous chemicals cause hazardous healthcare waste

► Triclosan: in soaps etc- dispersed during use ► , glutaraldehyde and other disinfectants: Poured away routinely ► Pesticides: Dispersed during use ► PVC: Hazards throughout lifecycle, but easy to handle, perceived safe by many ► Dioxins and furans: Invisible byproducts of incineration ► DEHP/BPA: Plastic components -main impacts during use, not disposal ► Flame retardants: Present in furniture and other products ► Ethylene oxide- gas dispersed during use ► Anesthetic gases- dispersed during use

Chemicals policies should aim to eliminate all hazardous chemicals, not just those which cause hard-to-handle waste

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Health Impacts of Chemical Exposure

► Effects on the lungs ◼ Cancer (asbestos, cadmium) ◼ Asthma (formaldehyde, glutaraldehyde) ◼ Irritation (glutaraldehyde) ► Effects on the eyes and mucous membranes ◼ Irritation (formaldehyde, xylene, methyl ethyl ketone) ◼ Conjunctivitis (glutaraldehyde) ◼ Blurred vision (methyl alcohol)

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Health Impacts of Chemical Exposure

► Effects on the skin ◼ Burns (concentrated acetic acid and sodium hydroxide) ◼ Rashes, irritation (methyl ethyl ketone, other solvents)

► Effects on the nervous system ◼ Mercury, ethylene oxide, xylene, lead, chloroform, other chlorinated solvents, various organochlorine insecticides

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Health Impacts of Chemical Exposure

► Effects on the liver and kidneys ◼ Lead, cadmium, chloroform, tetrachloroethylene and other chlorinated solvents ► Effects on the reproductive system ◼ Various pesticides, lead, ethylene oxide, DEHP, BPA ► Cancers ◼ Ethylene oxide, benzene, formaldehyde, various pesticides, some chlorinated solvents, many cytotoxic agents, vinyl chloride

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Environmental Impacts of Chemical Exposure

► Toxicity to aquatic organisms ◼ Lead, cadmium, chloroform, tetrachloroethylene and other chlorinated solvents ► Contamination of the food chain ◼ Various pesticides, mercury, silver ► Atmospheric pollution inc climate change ◼ Anesthetic gases, ethylene oxide, some chlorinated solvents ► Antibiotic resistant bacteria ◼ Antibiotics, silver

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Hierarchy of controls

► Elimination: Removing the hazard entirely eg switching from chemical to steam disinfection. This is the most reliable way to protect staff. ► Substitution: replacement of a hazardous material or process with one that is less hazardous eg replacing mercury thermometers with alcohol ones ► Minimization: is the reduction of a hazard rather than the complete elimination of the hazard ► Engineering controls: Changing the work environment to reduce exposure to chemical hazards- eg fume hoods. ► Administrative & work practice controls: Changing practices to reduce exposure eg pouring cleaning chemicals on surfaces to disinfect instead of spraying cleaning chemicals which reduces the risk of inhaled exposure. ► Personal protective equipment (PPE): PPE is the least effective method for protecting workers from hazards. PPE should be used in addition to other methods of control, while other more effective controls are being developed or installed, or if there are no other more effective ways to control the hazard. This is the last line of defense.

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Precautionary action

►Action to reduce risks before full proof of harm is available, especially if impacts could be serious or irreversible; ►Reversal of the burden of proof- chemicals are not “innocent until proven guilty” ►Research and monitoring for the early detection of hazards; ►A general reduction of environmental burdens and human exposure; ►The promotion of ‘clean production’ and innovation

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Workers’ Right to Know

• Principle 10 of the Rio Declaration on Environment and Development – “Each individual shall have appropriate access to information … on hazardous materials and activities ….”

• Principle 10 is embodied in many national and regional laws on “Workers’ Right To Know” about the hazards of chemicals they are working with.

• Facilities should provide information to workers – eg via • International Chemical Safety Cards (ICSCs) • Safety Data Sheets (SDSs) • Material Safety Data Sheets (MSDSs),

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Safety Data Sheets ► Sections of a safety data sheet 9. Stability and reactivity 1. Identification 10. Toxicological information 2. Hazard identification 11. Ecological information 3. First-aid measures 12. Disposal considerations 4. Fire-fighting measures 13. Transport considerations 5. Accidental release 14. Regulatory information measures 15. Other information, 6. Handling and storage including date 7. Exposure controls/personal protection 8. Physical and chemical properties

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Example of a Safety Data Sheet

SDSs and MSDSs can be found on the Internet or obtained from manufacturers.

Note- they rarely contain useful information about waste disposal

Reducing UPOPs and Mercury Releases from The Health Sector in Africa WHO/ILO International Chemical

Safety Cards

ICSCs can be found at: be found can ICSCs http://www.ilo.org/dyn/icsc/showcard.home

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Steps in substituting chemicals

► Step 1: Create a multidisciplinary team to lead the process ► Step 2: Formally agree to gradually phase-out hazardous chemicals across the facility ► Step 3: Evaluate and identify all hazardous chemicals used in the facility and their available alternatives ► Step 4: Launch a program for the actual phasing-out and safe handling of harmful chemicals ► Step 5: Test and evaluate new alternatives; select alternatives and phase in, with training for staff if product requires it ► Step 6: Document progress achieved towards reducing hazardous chemicals usage and assess the overall plan ► Link to tool kits on chemicals substitution: https://www.osha.gov/dsg/safer_chemicals/basics.html, http://ehs.mit.edu/site/content/green-chemical-alternatives-purchasing- wizard

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Priority for elimination

►Mercury- Minamata Convention ►Ethylene oxide- carcinogenic ►Glutaraldehyde- asthmagen ►Silver as disinfectant- ineffective, promotes antibiotic resistance ►Silver in X-ray development- go digital ►Hypochlorite for waste disinfection- Ineffective ►PVC and DEHP- dioxin generation, reprotoxic ►Triclosan- no more effective than soap and water

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Chemical Waste Minimization

◼ Use steam cleaning or non-toxic cleaners ◼ Control the inventory of chemicals ◼ Select vendors that are willing to reprocess or recycle their products ◼ Use a silver recovery unit for photographic waste ◼ Use a distillation column to recover solvents ◼ Purchase compressed gas cylinders from manufacturers who accept return of empty or partially used cylinders ◼ Minimize unnecessary dilution of wastes ◼ Neutralise acids and bases

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Reducing impacts from disinfectants

Reduce amounts and Ensure effective toxicity procedures ► Not all surfaces need to ► Change cleaning be disinfected. Good chemicals regularly cleaning is enough for ► Test efficacy of the some applications disinfectant ► Choose non-chemical ► Test devices for sterility disinfection where possible ► Choose the most effective chemicals and ► Select the least toxic procedures for each and polluting substance application possible ► Wash cleaning cloths ► Set green purchasing (for floors etc) regularly policy

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Vienna disinfectants database

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Alternatives for disinfectants and laboratory chemicals

Chemical For Substitution/ Alternative Disinfectant Cleaning, washing Disinfectant Cleaning, washing Herbal- Zingiber cassumunar, Cilantro Reagent, detergent, DNA Acetonitrile, isopropyl acetate, Choloroform extraction dimethoxylethane, DNA extraction kits Decolorization, cleansing Xylene detergent Limonene, citrus-based solvent Ethidium bromide DNA dye staining SyBr green, Gel red, Gel green, Eva green Kathon CG/ICP, methyl paraben, propyl Sodium azide Preservative reagent paraben Diethyl ether Lipid extraction heptane, 2-propanol Acetone Fixing Diacetone alcohol (DAA) Benzene Freezing point lowering Cyclohexane; Regular acids/bases Acids and bases Vinegar and sodium bicarbonate Toluene Solvent; cleaner Alcohols

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Management issues

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

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Handling of Chemical Waste

► Proper protective equipment (PPE) ◼ should be used when handling hazardous chemicals ◼ Type of PPE required is specific for each chemical ► Segregate ◼ Separate from infectious waste, radioactive waste, and general non-risk waste ◼ Segregate based on compatibility  Toxic, Corrosive, Flammable, Reactive ► Appropriate transferring methods must be used ◼ Bonding, grounding, and explosion proof devices for flammable waste ► Spill kit accessible ◼ Different spill kits for different hazards ◼ All materials in the kit are hazardous after use ► Secondary containment

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Containers and Color Coding for Chemical Waste

►WHO recommendation

Waste Color and Markings Container Type

Chemical and Brown Plastic bag or container pharmaceutical waste

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Labeling of Chemical Waste o Waste container label should have:

– Name, address, telephone of the generator

– Point of generation (if applicable)

– Start date of accumulation of waste

– Estimated quantity

– Description of contents

– Waste classification

– Hazard symbols

– Precautionary statement

– Emergency contact information

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Global harmonized system

Toxic Flammable

Harmful Oxidising Harmful (specific organ Oxidising toxicity)

Harmful to the Corrosive environment

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Storage of Chemical Waste

► Use a separate and enclosed area, room, or building ► Provide good ventilation ► Have easy access to safety shower and eyewash station ► Liquid/chemical proof containers in case of leaks ► No mixing of chemical waste (comply with manufacturers’ specifications) ► Incompatible wastes should be stored separately ► Temperature to be kept within manufacturers’ requirements ► Storage areas should be labeled on the exterior with a sign: ► NO ENTRY: Hazardous waste

► Other symbols if needed: ► No Smoking ► No Eating or Drinking

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Sample Sketch of a Chemical Waste Storage Area

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Off-Site Transport

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

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Non-incineration Treatment of Chemical Waste in Low-Income Countries

► Return of chemicals to manufacturers ► Encapsulation ► Inertization with cement ► Neutralise ► Burial of encapsulated or inertized waste in engineered, controlled and secure landfills

Reducing UPOPs and Mercury Releases from The Health Sector in Africa Conclusions

►Healthcare uses many hazardous chemicals ►There is a lot of scope for reducing the amount used and/or substituting with less hazardous alternatives ►Chemical wastes must be handled, collected and stored carefully to reduce risks ►Treatment options are limited at present, especially for small quantities ►Supplier takeback and central treatment are generally recommended

Reducing UPOPs and Mercury Releases from The Health Sector in Africa