Risks and Challenges of Hazardous Waste Management: Reviews and Case Studies E-Book
Gabriella Marfe
57,00 €
Mehr erfahren.
- Herausgeber: Bentham Science Publishers
- Kategorie: Wissenschaft und neue Technologien
- Sprache: Englisch
This reference presents reviews and case studies of hazardous waste management in a selection of cities. The overarching themes of the compiled topics include 1) the problems of healthcare waste management, 2) case studies of hazardous waste mismanagement, 3) health risks associated with environmental waste, issues in environmental health and 4) grassroots environmentalism.
The volume initially presents reviews and case studies from developing countries, including countries in South America (Argentina), Africa (Algeria and Nigeria), and Asia (India). The latter chapters of the book focus on environmental issues in Campania, a region in Italy. These chapters also provide an insight into the impact of the COVID-19 pandemic on waste management practices in this region.
Risks and Challenges of Hazardous Waste Management is an insightful reference for management trainees, professionals and researchers associated with waste management and environmental health firms. Readers will gain insights into current issues and practices in the respective industries. The reviews and case studies presented in the reference are also useful to professionals involved in risk assessment studies.
Sie lesen das E-Book in den Legimi-Apps auf:
Seitenzahl: 349
Veröffentlichungsjahr: 2020
Ähnliche
BENTHAM SCIENCE PUBLISHERS LTD.
End User License Agreement (for non-institutional, personal use)
This is an agreement between you and Bentham Science Publishers Ltd. Please read this License Agreement carefully before using the ebook/echapter/ejournal (“Work”). Your use of the Work constitutes your agreement to the terms and conditions set forth in this License Agreement. If you do not agree to these terms and conditions then you should not use the Work.
Bentham Science Publishers agrees to grant you a non-exclusive, non-transferable limited license to use the Work subject to and in accordance with the following terms and conditions. This License Agreement is for non-library, personal use only. For a library / institutional / multi user license in respect of the Work, please contact: [email protected].
Usage Rules:
All rights reserved: The Work is the subject of copyright and Bentham Science Publishers either owns the Work (and the copyright in it) or is licensed to distribute the Work. You shall not copy, reproduce, modify, remove, delete, augment, add to, publish, transmit, sell, resell, create derivative works from, or in any way exploit the Work or make the Work available for others to do any of the same, in any form or by any means, in whole or in part, in each case without the prior written permission of Bentham Science Publishers, unless stated otherwise in this License Agreement.You may download a copy of the Work on one occasion to one personal computer (including tablet, laptop, desktop, or other such devices). You may make one back-up copy of the Work to avoid losing it.The unauthorised use or distribution of copyrighted or other proprietary content is illegal and could subject you to liability for substantial money damages. You will be liable for any damage resulting from your misuse of the Work or any violation of this License Agreement, including any infringement by you of copyrights or proprietary rights.Disclaimer:
Bentham Science Publishers does not guarantee that the information in the Work is error-free, or warrant that it will meet your requirements or that access to the Work will be uninterrupted or error-free. The Work is provided "as is" without warranty of any kind, either express or implied or statutory, including, without limitation, implied warranties of merchantability and fitness for a particular purpose. The entire risk as to the results and performance of the Work is assumed by you. No responsibility is assumed by Bentham Science Publishers, its staff, editors and/or authors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products instruction, advertisements or ideas contained in the Work.
Limitation of Liability:
In no event will Bentham Science Publishers, its staff, editors and/or authors, be liable for any damages, including, without limitation, special, incidental and/or consequential damages and/or damages for lost data and/or profits arising out of (whether directly or indirectly) the use or inability to use the Work. The entire liability of Bentham Science Publishers shall be limited to the amount actually paid by you for the Work.
General:
Any dispute or claim arising out of or in connection with this License Agreement or the Work (including non-contractual disputes or claims) will be governed by and construed in accordance with the laws of Singapore. Each party agrees that the courts of the state of Singapore shall have exclusive jurisdiction to settle any dispute or claim arising out of or in connection with this License Agreement or the Work (including non-contractual disputes or claims).Your rights under this License Agreement will automatically terminate without notice and without the need for a court order if at any point you breach any terms of this License Agreement. In no event will any delay or failure by Bentham Science Publishers in enforcing your compliance with this License Agreement constitute a waiver of any of its rights.You acknowledge that you have read this License Agreement, and agree to be bound by its terms and conditions. To the extent that any other terms and conditions presented on any website of Bentham Science Publishers conflict with, or are inconsistent with, the terms and conditions set out in this License Agreement, you acknowledge that the terms and conditions set out in this License Agreement shall prevail.Bentham Science Publishers Pte. Ltd. 80 Robinson Road #02-00 Singapore 068898 Singapore Email: [email protected]
PREFACE
This book is written with the objective of providing all the essential information which are of utmost importance to hazardous waste management. The issues of environment protection have already spread far and wide and proper management of hazardous waste is one valuable contribution towards this global concern. The first chapters attempt to simplify the subject and to inculcate the valid concept of biomedical waste management effects.
From chapter one to three, the problems of healthcare waste management are discussed. Moreover, other authors illustrate some case studies of hazardous waste mismanagement that has caused a massive environmental damage in chapter four and five. Then, chapter six analyzes the emerging environmental and public health impacts of e-waste.
Finally, the last chapters describe the waste crisis in Campania. In this regard, the authors provide useful insight into single aspects of the waste system in Campania and their influences on human health impact.
FOREWORD
Interest in solid and hazardous waste management is relatively recent, i.e., in the last three decades, and is driven by regulations in most countries. It began with industrial hazardous waste, followed by municipal solid waste, and subsequently by many other categories of waste. This book features chapters discussing the implications of healthcare waste management and their impact on groundwater and other parts of the environment, as well as principles of as sustainable management and its application in the reuse and recycling of such kind of waste. Moreover, it includes examples of waste to energy. It also covers topics such as life cycle assessment as a tool for developing healthcare integrated waste management systems and an overview of waste management rules, illustrating the importance of technological inputs in the development of regulatory frameworks. This subject matter should be examined with a global standpoint in order to bridge the knowledge gap. Different chapters analyze the management of healthcare waste around the globe and specifically in different countries where it is in a deplorable state and stands out as a major risk factor to the health of both healthcare workers and individuals/communities in and around the healthcare facilities. There is a need to institutionalize healthcare waste management as part of the overall management system of a particular healthcare facility. In addition, healthcare waste management needs to intervene at other higher levels i.e. district, regional and national levels such that these levels will be positioned to provide the necessary or required support to facility and community levels in all matters related to healthcare waste management. The significant support expected from the national, regional and district levels includes, among others, the development of the required policies, legal/regulatory framework and ensures adequate budgetary allocations to meet healthcare waste management input requirements.
In this scenario, it is important to point out that medical care plays a vital role in our life and health. Still, the waste generated from medical activities represents a real problem of living nature and human world. For this reason, the appropriate methods for waste neutralization, recycling and disposal should be identified such management [1]. In particular, all processes should ensure both proper hospital hygiene and safety of health care workers and communities. Among biomedical waste, some chemical and pharmaceutical products that can cause poisoning by absorption through the skin or mucous membranes, by inhalation or by ingestion. Furthermore, they could provoke lesions of skin, eye, and respiratory mucosa. For example, chemical waste an or pharmaceuticals (such as antibiotics or other drugs, heavy metals, disinfectants and antiseptics) removed by the drainage system may cause toxic effects on ecosystems. Furthermore, the elimination of biomedical waste should be associated with safe waste management to protect the human health and the environment. Incineration of medical waste can be very dangerous since the plastic (containing chlorine) derived from such waste generates dioxin. Once formed, dioxin (that is carcinogenic) is able to bind to organic particles. Therefore, it is transported by wind and deposited on land and in water. The half-life of such compound is 25 to 100 years. Furthermore, dioxin it is able to link to nuclear DNA. Its formation is associated to potential cancer promoter, weak-delete immune response and other harmful effects on human health (such endometriosis, birth defects, low testosterone levels) and environment. Also, exposure to low dioxin concentrations causes negative effect on human health. The introduction of a sustainable system of biomedical waste management might allow to store a significant amount of hazardous biomedical waste in safe manner, and it will be possible to recover, treat, neutralize and recycle in terms of environmental protection. Therefore, waste recycling could play a crucial step in the reduction of earth resources. Furthermore, efficient health care waste management can be associated with the control of different diseases (hospital acquired infections), and reduction of community exposure to resistant bacteria. In addition, it could lead to the decrease of sepsis, and hepatitis transmission from dirty needles or uncleaned medical items. In this scenario, a sustainable management system of biomedical waste it is necessary to avoid the harm human health effects.
Furthermore, the coronavirus disease 2019 (COVID-19) pandemic has led to a great increse of medical and domestic waste. In this context, the safe managing of this waste plays a crucial role to successfully containing the disease. Therefore, the current pandemic brings a new challenge for medical waste management in every country.
In this context, some chapters of this book underline the relationship between adverse health effects due to waste management practices, in particular of hazardous waste, that potentially represent a public health issue in many countries because of growing waste production, inadequate waste management practices, lack of appropriate legislation and control systems, as well as of growing illegal hazardous waste transboundary movements [2, 3].
In this frame, various chapters describe different aspects on the occurrence and severity of health effects related to illegal waste disposal in Campania, an Italian region. Since 1980, this region has been characterized waste mismanagement [4-7], which led to the deterioration of land, as well as ground and surface water, also impacting air quality. In recent times, some oncologists, pathologists and toxicologists have reported that the continuous exposure of Campania citizens to toxic contaminants produced by the illegal dumping of waste in the region could become a big health issue. Furthermore, in these years, many grassroots movements against waste mismanagement are born in Campania. For example, in 2012, three main groupings of associations: Fires Coordination Committees, Campania Citizens for an Alternative Waste Management Plan, and Commons Net have created a social coalition called Stop Biocide [8]. Today, the citizens fight to obtain:
a better management of urban waste.the remediation of the contaminated sites.the halting of illegal waste trafficking.a systematic health screening of the Campania population who live close to illegal dumping of toxic waste.The faces of the children, who died and continue to die from cancer, represent the icons of biocide movement and they are shown during several demonstrations in the region. Furthermore, the movement has sent to the President of the Italian Republic and Pope Francis a lot of postcard with their faces printed on them to ask for direct intervention [9, 10].
Moreover, an article entitled “Triangle of death” linked to waste crisis, was published in The Lancet Oncology [11], and the authors reported a possible correlation between hazardous waste and high incidence of cancer in Naples and Caserta provinces. In this regard, people living close to illegal waste sited located in different municipalities of Naples and Caserta reported some adverse health effects. Many descriptive studies reported an early mortality rate (0–14 years) and congenital malformations. Furthermore, the cause-specific mortality and morbidity rates in Campania are very different when compared with the Italian national average. Future studies should be carried out to better understand the correlation between waste-related exposures and health profile of the Naples and Caserta provinces by analysis of mortality, hospital discharge records, cancer incidence, congenital malformations in newborns.
I recommend this book since it offers a broad look on the interaction between hazardous waste management and human health impacts. Through the chapters, it examines the way we affect and disrupt our health and the health of ecosystem around us. Now I believe that we have got to work together for the future. If we change now, we have an opportunity to decide what kind of world our children and our grand children and their children will grow up in.
Green Economics Institute Economics and Social and Environmental Justice http://www.greeneconomicsinstitutetrust.org/
REFERENCES
[1]McDougall F, White P, Franke M, Hundle P. Integrated Solid Waste Management: A Life Cycle Inventory 2001.[http://dx.doi.org/10.1002/9780470999677][2]Harjula H. Hazardous waste: recognition of the problem and response. Ann N Y Acad Sci 2006; 1076: 462-77.[http://dx.doi.org/10.1196/annals.1371.062] [PMID: 17119225][3]Senior K, Mazza A. Triangle of death linked to waste crisis. Lancet Oncol 2004; S5(9):525-7. HYPERLINK. https://www.ncbi.nlm.nih.gov/pubmed/15384216[4]Piscitelli P, Santoriello A, Buonaguro FM. Human Health Foundation Study Group. Incidence of breast cancer in Italy mastectomies and quadrantectomies performed between 2000 and 2005. J Exp Clin Cancer Res 2009; 19:28:86. [http://dx.doi.org/10.1186/1756-9966-28-86] https://www.ncbi.nlm.nih.gov/pubmed/19545369[5]Altavista P, Belli S, Bianchi F, et al. Cause-specific mortality in an area of Campania with numerous waste disposal sites. Epidemiol Prev 2004; 28(6): 311-21.[6]Greyl L, Vegni S, Natalicchio M, Cure S, Ferretti J. The Waste Crisis in Campania, Italy 2010 Sito web CEECEC (disponibile in linea: http://www.ceecec.net/case-studies/waste-crisis-incampania-italy/[7]Trinca S, Comba P, Felli A, Forte T, Musmeci L, Piccardi A. Childhood mortality in an area of southern Italy with numerous dumping grounds: Application of GIS and preliminary findings. In Proceeding of the First European Conference “Geographic Information Sciences in Public Health”, Sheffield, UK, 19–20 September 2001; p. 19.[8]De Rosa PS. The remaking of toxic territories: grassroots strategies for the re-appropriation of knowledge and space in the socio-environmental conflicts of Campania, Italy. Presented at the Political Studies Association Conference; Voice and Space: new possibilities for democracy in Southern Europe? Manchester, 2014, April 14-16.[9]Iengo I, Armiero M. The politicization of ill bodies in Campania, Italy. J Polit Ecol 2017; 24: 44-58.[http://dx.doi.org/10.2458/v24i1.20781][10]D'Alisa G, Germani AR, Falcone PM, Morone P. Political ecology of health in the land of fires: A hotspot of environmental crimes in the south of Italy. J Politic Ecol 2017; 24:59-86.[11]Senior K, Mazza A. Italian “triangle of death” linked to waste crisis. Lancet Oncol 2004; 5(9): 525-7.[http://dx.doi.org/10.1016/S1470-2045(04)01561-X] [PMID: 15384216]List of Contributors
Healthcare Waste: A Challenge for Best Management Practices in Developing Countries
Ernesto de Titto1,Atilio Savino2,*Abstract
Healthcare waste (HCW) is the waste generated by the activities of healthcare facilities, educational institutions and medical research which is harmful to both human and animal health. About 10 to 15% of HCW presents hazardous characteristics, including a broad range of materials from sharps, used needles and syringes to soiled-dressings, body fluids or wastes contaminated by chemical and/or containing a high concentration of microorganisms. Such kind of waste requires very specific treatment to ensure proper final disposal. Its generation depends on different factors such as the economic development of the country and the type of service provided by the above-mentioned institutions. In this context, HCW management (HCWM) is a public health and environmental concern worldwide, especially for non-developed countries. Furthermore, HCWM is a complex and challenging process that covers a wide variety of actions, including segregation, minimization, previous treatment, packaging, temporary storage, collection, internal transportation and external storage of HCW. The first priority in this waste management should be the segregation and reduction in order to decrease the contaminated solid waste and to ensure selective collection. Furthermore, a great part of HCW can be recycled. In order to encourage successful best management practices, the results of a GEF-funded national development report headed by the Ministry of Health of Argentina are hereby exposed including proposed actions for training, guidelines, supervision, appropriate utility supply, management support and specific regulations to face future challenges. Improvements in the management system through HCW indicators may prove failures in segregation procedures, showing an opportunity for continual advances. To reduce potential problems that expose the healthcare facility staff, patients and their attendants to the risk of serious health hazards, there should be sufficient resource allocation, periodic training and strict supervision by stakeholders. Institutional planning for an efficient HCWM will assure HCF to both save money and provide a safe environment for patients and healthcare personnel.
INTRODUCTION
As far as the WHO is concerned, let's remember that “by trying to achieve their goals of reducing health problems and eliminating potential risks to people's health, health services inevitably produce waste that can be dangerous on their own for health”. Waste produced in the course of health-care activities has a greater potential for infection and injury than any other type of waste. Wherever waste is generated, safe and reliable methods for handling are therefore essential. Inadequate and inappropriate management of healthcare waste (HCW) can have serious public health consequences and a significant impact on the environment. Therefore, the proper management of HCW is a crucial component of environmental health protection” [1]. The rising demand for healthcare services in developing countries, at the world level, is causing a significantly high amount of HCW generation that requires both efficient management and proper disposal [2]. Special concern deserves limitations of healthcare facilities (HCF) –global denomination for places that provide healthcare, including hospitals, clinics, outpatient care centers, and specialized care centers, such as birthing centers and psychiatric care centers- to adequately segregate infectious or hazardous waste from ordinary domestic waste to treat this type of waste with proper technologies [3]. Healthcare waste management (HCWM) poses technical problems and is largely influenced by cultural, social and economic circumstances [1]. Developing countries need well-designed HCWM policies as well as a legislative framework and plans to achieve local implementation. Actions involved in the implementation of effective HCWM programs require multisectoral cooperation at all levels. The change has to be gradual and must be technically and financially sustainable in the long term.
Improving HCWM by enforcing knowledge and technical capacity for implementing and sustaining pollution-prevention measures, waste minimization and segregation practices are viable alternatives to the “business as usual” scenario. Developing countries need to adopt new strategies and treatment technologies that are affordable, that can be developed and serviced locally, requiring low-cost energy inputs, and are appropriate to HCF in urban and rural areas including, at worst, the need to operate at locations that may lack reliable electricity service and other utilities.
We will not discuss radioactive wastes since they are usually under strict rules and supervision established by the National Atomic Energy Organizations, aside from health authorities.
The remaining wastes can be grouped into two broad categories: bio-hazardous and chemicals, as summarized in Table 1, which represent different types of risks as well as require different preventive actions.
THE HEALTH-CARE CONTEXT
A WHO assessment conducted in 22 developing countries in 2002 showed that the proportion of HCF that do not use proper waste disposal methods ranged from 18% to 64% [4].
Probably for its more evident and immediate impact, greater attention has been given to bio-hazardous waste. Even in facilities properly managing their waste, healthcare workers are exposed through a mucosal cutaneous or percutaneous route to accidental contact with human blood and other potentially infectious biological materials while carrying out their occupational duties.
A significant portion of the infections arising from blood-borne pathogens may be due to injuries from contaminated sharp objects (needles, blades, etc.) injuries. Literature has reported that incidence rates of sharps injuries range from 1.4 to 9.5 per 100 healthcare workers, resulting in a weighted mean of 3.7/100 healthcare workers per year. Sharps injuries have been reported to be associated with infective disease transmissions from patients to healthcare workers resulting in 0.42 hepatitis B virus (HBV) infections, 0.05-1.30 hepatitis C virus (HCV) infections and 0.04-0.32 Human Immunodeficiency Virus (HIV) infections per 100 sharps injuries per year [5]. The greatest risk is for nurses and auxiliary staff at the facility level.
Additional personnel at risk include landfill workers, waste pickers, scavengers and recyclers after HCW leaves the facility. Therefore, one key element required to install best practices for HCWM is to address the problem of the spread of blood-borne pathogens associated with improper handling and disposal of HCW. It has been long recognized by the WHO’s policy on safe HCWM which calls for a long-term strategy “for the final disposal of HCW to prevent the disease burden” [1].
Furthermore, some years ago WHO estimated that overuse and unsafe use of healthcare injections caused annually 32% of new infections with HBV (21 million cases), 40% of new infections with HCV (2 million cases), and 5% of new infections with HIV (260,000 cases) [4, 6]. However, a significant portion of these could be linked to injections administered with devices reused in the absence of sterilization -practice that fortunately decreased in developing countries from 39.8 to 5.5% between 2000 and 2010 [7] - rather than to HCWM failures.
On the other hand, “emerging” diseases related to environmental exposure to chemicals have increased in recent years around the world [8]. Cancer and reproduction disorders (infertility, malformations, reproductive diseases), hormonal dysfunctions (diabetes, thyroid problems), immune diseases (dermatitis, allergies) and neurological diseases (learning problems, autism, hyperactivity, Alzheimer's, Parkinson's), among others, are increasingly linked to exposure to toxic chemicals. Environmental pollution to air, water and soil, as the result of the incorporation of toxic substances, wastes or residues incorrectly managed at the HCF, not only affects health workers but also far away populations. In fact, several studies on pharmaceutical contamination and HCW carried out have demonstrated that drugs represent a new class of contaminants including antibiotics, hormones, painkillers, tranquilizers, and chemotherapy products that are applied to cancer patients and can be found both on the surface and in deep waters, and also in the treatment plants of many hospitals [9]. International consensus on improving the management of chemical substances, including the health sector, has already been achieved through several specific conventions (Basel, Rotterdam, and Stockholm) now improved with the Strategic Approach to International Chemicals Management [10].
Among chemicals, a particular reference should be given to Mercury, a non-essential metal that has been frequently employed in health services in several devices and even as a component of pharmaceutical products, which does not fulfill any biochemical or nutritional function. In all its forms (elemental, organic and inorganic) it is an important environmental toxic and causes adverse effects on human health, especially in the fetal and infantile stages that are especially vulnerable to its harmful effects, highlighting toxicity neurological, renal and to the immune system.
Chemical waste generated at HCF, which may include the liquid waste from cleaning materials and disinfectants, expired and unused pharmaceutical products and cytotoxics are all considered hazardous waste products and they must be disposed of via an authorized system at approved sites (e.g., industrial landfills). Thus, the main issue is the proper indoor management of chemical waste.
Dentistry waste deserves particular consideration since dentistry is commonly a private practice outside institutionalized HCF. Several studies indicate that the knowledge, attitude and practice of dental practitioners towards the management of dental waste still require strong improvement. Evaluations in Bangkok [11], New Zealand [12] and Kenya [13], for example, indicated that few dentists complied with all recommendations for the disposal of wastes with most waste being disposed of as domestic garbage.
Dental wastes, materials that have been utilized in dental clinics and are no longer accepted for use and are therefore discarded, may include biohazardous wastes, which may contain pathogenic organisms causing transmission of diseases such as HBV and HIV, especially in the presence of open wounds, as well as hazardous wastes, such as barium, cadmium, chromium, lead, polystyrenes, strontium, all of which may cause harm if improperly managed and disposed of.
BEST MANAGEMENT PRACTICES
Many health professionals have only limited awareness about environmental health issues, including risks linked to toxic contaminants released into the environment. Moreover, waste management or the impacts of waste treatment choices are scarce or mostly absent in curricula in academic training programs for physicians, nurses, health specialists and administrators.
However, healthcare professionals are generally very receptive to environmental risk information and the extent of the harm they can cause. When made aware of this environmental health threat, they can be expected to support alternative waste management approaches that avoid generating and/or releasing toxic pollutants to the environment, as long as these alternatives are practical and do not compromise patient safety or care. Hence, the health sector has to be seen as a valuable ally in awareness-raising and advocacy with regard to minimizing or eliminating releases of contaminants to the environment.
Requirements for sustainable HCWM include both practices as well as technology. Adverse environmental and public health impacts of HCWM can be traced to both improper practices and the use of non-environmentally sound technologies. Poor practices that lead to high rates of HCW generation in HCF may include incomplete or even lack of segregation, unsafe handling of waste, dumping of untreated waste, extensive use of disposable materials, inadequate procedures for clean-up and containment of spills, weak inventory controls of time-sensitive pharmaceuticals and reagents, and inappropriate classification of non-infectious waste as bio-hazardous waste. Years ago incineration appeared as a promising solution to deal with HCW but experiences in many developing countries failed to fulfill adequate standards since the incinerators of choice cause objectionable smoke and odors, break down frequently and are difficult to properly operate and maintain. Moreover, small-scale incinerators often operate at temperatures below 800 degrees Celsius, thus leading to the production of dioxins, furans or other toxic pollutants as emissions and/or in bottom/fly ash. Last but not least, the installation of incinerators discourages efforts at segregation, recycling and waste minimization. The solution, therefore, must address both the practices and technologies applied.
There is no doubt that proper treatment of hazardous HCW must be part of an HCWM system, which must start by institutionalizing best management practices at HCF in order to minimize the production of HCW. In doing so, attention must be paid to the concerns for health services providers regarding both the quality and the costs of healthcare services.
Adopting good HCWM practices include pollution prevention and waste minimization through correct classification and segregation, proper containerization and color-coding, safe handling and collection of waste, labeling and signage, and proper storage, transport and final disposal of waste. It is evident that pollution prevention and waste minimization must be taken as priorities.
Waste minimization requires environmentally sound practices: reduction at source, material substitution, as well as safe reuse, recycling and composting of waste whenever possible. Limitations on these practices have been documented all over the world [14], including in Brazil [15-17], Botswana [18], Ethiopia [19, 20], Australia [21], Iran [22, 23], Lebanon [24] and other Asian [25] and African [26] countries.
Hazardous HCW (bio-hazardous and chemical waste) typically comprise about 25% or less of the total waste generated by HCF [1, 4]. However, rigorous segregation, as well as pollution prevention measures, can reduce significantly the amount of waste requiring special treatment. This is achievable by changing HCF practices through the development and effective implementation of effective plans with clear definitions of roles and responsibilities which must include changes in administrative policies established as well as installing motivational programs to promote process changes and regular training at all levels of the facility [27, 28]. It is also essential to install monitoring, periodic evaluation, continuous program improvements and full consideration of occupational safety and personal protection.
Alternative technologies suitable for HCW treatment must be capable of achieving international standards on microbial inactivation, being easy to operate and maintain and be affordable enough to become acceptable by HCF. Possible low-cost designs for resource-limited areas include locally made, small- to medium-scale pressure containers using electricity, gas, solar or other local fuels, as well as small manual and electrical shredders. Other alternative technologies available include autoclaves or retorts, with or without shredders to reduce waste volume and render unrecognizable HCW; advanced steam systems such as rotating autoclaves, combined pressurized steam-internal shredding units, hydroclaves, microwave systems, and alkaline hydrolysis to decompose tissues, anatomical and animal wastes, and possibly chemotherapeutic waste. These technologies became well-established and have been in operation for years. A number of other alternative technologies, such as chemical disinfection systems using chlorine and emerging technologies such as irradiation and plasma pyrolysis raise occupational safety or environmental issues including dioxin formation.
A summary of Best Management Practices is presented in Table 2. In particular, mercury waste management requires the development of a mercury reduction plan that considers critical opportunities for material substitution, training, spill response and recovery, personal protection, segregation, containment, long-term engineered storage and encapsulation or amalgamation.
Mercury-free technologies include digital, glass alcohol, galinstan and tympanic thermometers, as well as aneroid sphygmomanometers. Mercury-free substitutes that are now commercially available can replace mercury-containing medical preservatives, fixatives and reagents. Increasing the demand for mercury-free products will help to lower the cost of these devices and mercury-free formulations.
Many HCF have already successfully switched to mercury-free thermometers and sphygmomanometers. A number of governments representing low-, middle- and high-income countries have also instituted policies for phasing out such devices in favor of accurate and affordable alternatives. Almost one hundred countries all around the world made a commitment to protect human health from anthropogenic emissions and releases of mercury and mercury compounds by signing the Minamata Convention on Mercury agreed in Kumamoto, Japan, in October 2013. WHO and numerous Health Ministries around the world are actively supporting the implementation of the Convention, including actions taken within the health sector. The 67th World Health Assembly in resolution WHA67.11 further affirmed this commitment. A phase-out date of 2020 for the manufacture, import and export of mercury thermometers and sphygmomanometers was included in the Convention. In 2015, WHO published a thoughtful guidance, available on the internet, to provide advice to Health Ministries on the leading role they will need to play in this regard [29].
Mercury in dentistry deserves particular attention. Since the XIX century amalgam became the dental restorative choice material to fill cavities caused by tooth decay, due to its low cost, ease of application, strength, and durability. Dental amalgam is a liquid mercury and metal alloy mixture commonly made of mercury (50%), silver (~22–32%), tin (~14%), copper (~8%) and other trace metals. Although there is a strong agreement to replace mercury-based amalgams for much less harmful materials already available in the market and legal regulations pushing in that direction, like the July 2018 prohibition by the European Union of using amalgam for dental treatment of children under 15 years and of pregnant or breastfeeding women [30], we are still far from complete replacement. Especially in less developed countries.
TRENDS IN THE USE OF MEDICAL WASTE INCINERATORS
The use of medical waste incinerators (MWIs) appeared as a practical solution to deal with hazardous waste produced in HCFs. MWIs could be produced at different shapes so as to serve HCFs with different sizes and complexities and could be located locally thus minimizing waste transportation. Initial success in many industrialized countries was later hampered for difficulties to deal with toxic emissions to the environment. Consequently, MWI facilities fell into decline and were to be gradually phased out in many industrialized countries. For example, the number of MWIs in the United States dropped from 6,200 in 1998 to 111 in 2004 [31-33]; while in Canada dropped from 219 in 1995 to 120 in 2000 until December 2003 when the province of Ontario phased out all of its 56 MWIs further dropping the number of incinerators nationwide to 64 [34]. Similar trend can be seen in Europe. In Czech Republic, after its accession to the EU in 2004, all operational incinerators had to meet EU standards considering waste incineration and air protection (0,1 ng I-TEQ/m3
