Uni 1

UNIT 1 IMPACT OF HEALTH CARE WASTE ON OUR ENVIRONMENT
Structure
1.0 1.1 1.2 Objectives Introduction Chemicals in Health Care Waste
1.2.1 Case Study 1 1.2.2 Mercury 1.2.3 Lead 1.2.4 Cadmium 1.2.5 Chromium 1.2.6 Disinfectants 1.2.7 Gaseous Pollutants
ImpactImpact of Health of Health Care Waste Care Waste on our onEnvironment Environment
1.3
Impact on Environment
1.3.1 Effect on Atmosphere 1.3.2 Impact on Food and Livestock 1.3.3 Impact on Water and Aquifer 1.3.4 Impact on Marine Ecosystem 1.3.5 Case Study 2: Accidents do Happen
1.4 1.5 1.6 1.7
Let Us Sum Up Key Words Answers to Check Your Progress Further Readings
1.0
l l l l
OBJECTIVES
At the end of the study of this unit, you will be able to: enumerate the chemicals used in health care institutions; explain the impact of chemical waste on environment; describe the alternatives to these chemicals in health care settings; and discuss case studies on the health and environment.
1.1 INTRODUCTION
You have already read in previous blocks about pollutants to the environment. Global concerns, such as ozone layer depletion caused by green house gases, melting of ice caps due to global warming, etc. are already a matter of great concern today. The large volumes of health care waste if not managed properly can lead to a similar global hazard. This could not only lead to the spread of highly contagious diseases but the
Need for a Sound Health Care Waste Management
hazardous chemical waste produced by the use of items can cause considerable damage to the ecosystems and the environment. Thus health care waste, if not managed properly will be a cause in ushering of disasters in making by causing air, water, soil pollutions and helping in emergence of antibiotic resistant strains of microbial ingress of pollutants in the food chain and thus becoming a part of human consumption.
1.2
CHEMICALS IN HEALTH CARE WASTE
Chemical waste consists of discarded solid, liquid and gaseous chemicals, e.g., from diagnostic and experimental work and from cleaning, house keeping and disinfecting procedures. The chemical waste from health care may be hazardous or non-hazardous; in the context of protecting health, it is considered to be hazardous if it has at least one of the following properties:
l l l l l
Toxic Corrosive Flammable Reactive Genotoxic
The various heavy metals and chemicals found in health care waste are: 1) 2) 3) 4) 5) 6) 7) 8) 9) Mercury Lead Arsenic Cadmium Chromium Disinfectants Pesticides Gaseous Pollutants PVC (Poly Vinyl Chloride)
The hazardous effects of these heavy metals/chemical agents will be discussed further in the unit.
1.2.1
Case Study 1
Poisoned in Minamata, Japan It had been a long and sleepless night for the young fisher boy. Now the sun was rising over the bay and he stared sadly at the dead cat lying on the floor. It lay so silent and still. He could hardly believe that only a short while ago it had dashed madly against the walls of the room, screaming in agony. Shuddering at the memory, he picked up his pet and went to the kitchen. So its dead, is it? snapped his mother. Its screaming kept me awake all night. The boy nodded. He kept his head down as he walked past her to the back of the house. He could not understand way his mother had become so irritable over the past few days.
She must be worried about something, he thought as he knelt on the ground to dig a grave for his beloved cat. It was the third cat to die that week. He had heard that one cat, maddened with pain, had jumped from the cliffs into the ocean. What was it in the fishing town on Minamata Bay that was driving the cats to death? Later the question became more serious. What was it that was making the fishermens families ill? The cats are to blame for the epidemic, said many people. It must be a virus or bacteria that pass on from cats to humans. Yet nobody was quite sure, and the disease continued to spread. Irritability was one of the first symptoms of the illness. The fisher boy realized now that the disease must have affected his mother a long time ago. She seemed to be getting worse all the time. She could hardly walk without stumbling, and spent most of her time alone, uncaring of what was happening around her. By 1956, people in Minamata started having extreme muscle spasms, delirium and difficulty in walking and speaking. Cats would run amok and jump into the sea. Birds dropped from the sky. Fingers were pointing to industries in Minamata, in 1907, which dumped its pollutants into the Minamata bay. The Japanese Health Authorities came into study the case of the Minamata disease. It wasnt long before they found a link between the amounts of fish eaten by the stricken families and that eaten by their cats. The scientists then fed cats with the waste from a vinyl chloride plant. The cats developed exactly the same symptoms as those fed on Minamata Bay fish. The waste from the factory, which was thrown out into Minamata Bay contained high levels of mercury. It was concluded that organic mercury from industrial unitChisso was the cause of all the illness. For a long time the authorities did not wanted to blame the vinyl chloride plant. It was a useful material used to make a clean, tough plastic, poly vinyl chloride (PVC). So the people of Minamata continued to suffer. Niigata, Japan (1965) Once again cats committed suicide. One hundred and twenty people were poisoned by mercury and for the second time a vinyl chloride plant was involved. The mercury level was high in the factory waste. Scientists proved that bacteria in the sea ate mercury. Then fish ate the bacteria and when men (and their cats) ate the fish the mercury poisoned them. The authorities then at last forced the factories to do something to control their dangerous waste. (More at: http://www.american.edu/ted/minamata.htm) Check Your Progress 1 1) Enumerate what is chemical waste and the hazardous properties of chemical waste. ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ......................................................................................................................
Impact of Health Care Waste on our Environment
2)
What are the common metals found in health care waste? ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ......................................................................................................................
1.2.2
Mercury
Mercury has been used extensively in health care settings since ages for different purposes including measurement of temperature and blood pressure and as a dental amalgam. The hazards associated with mercury were largely realized by the public only after the Minamata catastrophe in 1956. Mercury Sources Mercury (Hg) is a naturally occurring, highly volatile heavy metal found in traces throughout the environment: rocks, soils and the oceans. Mercury is found in three major types in the environmentmethyl mercury, elemental or metallic mercury [(expressed as Hg (O) or Hg)] or can be bound to other compounds as monovalent or divalent mercury [expressed as Hg (I) and Hg (II) or Hg 2+ respectively]. Sources of mercury in the environment are:
l
Natural mobilization of mercury becomes air borne in large amounts through volcanic eruptions and forest fires. Anthropogenic emissions from mobilization of mercury impurities in fossil fuels, incinerators, industries, mining as well as from health care waste and pharmaceuticals. The most common natural forms of mercury found in the environment are metallic mercury, mercuric sulphide, mercuric chloride and methyl mercury. Some micro-organisms and natural processes can change the mercury in the environment from one form to another, the most common one being methyl mercury. Medical waste incinerators are a significant source of mercury in the environment. Studies have shown that there is 50 times more mercury in the hospital waste than general municipal waste and the amount of mercury emitted by medical waste incinerators averages more than 60 times than that from municipal incinerators. It is worth noting that, of the estimated 158 tons of mercury emitted annually into the atmosphere, 10 per cent comes from incineration of medical waste.
Sources of mercury in hospitals are: 1) Thermometers 2) Blood pressure instruments 3) Feeding tubes 4) Batteries 5) Dental amalgam
8
6) Laboratory chemicals like Zenkers solution and histological fixatives.
Routes of Mercury Exposure As per WHO, sources of mercury found in the human body (mg/day):
l l l l l
Air Fish Non-fish food Drinking-water Mercury vapour from dental amalgams
: 0.040 : 2.34 : 0.25 : 0.0035 : 3-17
Mercury from dental amalgam and in breast milk from fish-eating mothers can be high.
Source: Lurking Menance, Mercury in Health Care Sector, Toxics Link, 2004.
Dumping Mercury in Our Environments All the great lakes in USA have some content of mercury in their water, as well as other sources like small lakes, rivers are also polluted. The people have been advised not to eat or to minimize their intake of certain type of fishes because of contamination. Though a disaster to the scale of Minamata has not occurred but cases of homes and schools being closed because of elemental mercury exposure to children primarily from fish diets have been reported. Kodaikanal (Tamil Nadu), India: The mercury thermometer plant of Hindustan Lever Ltd. (HLL), one of the largest thermometer manufacturing factories in the world, was found guilty of dumping mercury-containing glass waste. Till date, the factory has produced 165 million thermometers with 1,25,000 kg of mercury (with a breakage rate of 30 to 40 per cent). The company, in its report to the Tamil Nadu Pollution Control Board, assesses the amount of mercury released into the environment from its factory site in Kodaikanal at 539 kg (stating a statistical variance of between 43 kg minimum to 1,075 kg maximum). The glass scrap from the mercury-contaminated area contained residual mercury and until 1990 was dumped in the compound. The surrounding ecosystem especially during the monsoon season, received large quantities of mercury, the mercury used to be washed away into water bodies due to runoff, contaminating the water bodies in the area, especially the rivers.
Effect on Environment and Health The current means of disposal of mercury are incineration, regular flushing in sewers and regular dumping in municipal waste bins. Studies show that one gram of mercury will contaminate a twenty acre lake, enough to cause poisoning fishes. When mercurial products are incinerated the mercury becomes air borne (vapours) and eventually settles down in water bodies and foliage, from where via biomagnification in the food chain and bioaccumulation, it reaches humans. If it is flushed in sewers, it enters water bodies directly and if it is thrown in municipal waste bins it could enter the body of animals via skin or inhalation and/or penetrate into the ground causing soil and ground water pollution. Methyl mercury which is formed by evaporation of mercury is an organic mercury compound. It is very toxic (is one of the six most serious pollution threats to the planet) and bioaccumulates and biomagnifies in the food chain. Methyl mercury, bioaccumulates in many edible fresh and saltwater fishes and marine mammals, to levels that are thousands of times greater than levels in the surrounding water. It can be passed from one species to another in the aquatic food chain and can eventually bio-accumulate to higher concentration in some species specially those, which are at the top of food chain such as eagles, panthers and several predatory fishes. Methyl mercury also has a capability to interfere with cell division. It also binds to DNA and interferes with the copying of chromosomes and synthesis of proteins. It
can cross blood brain and placental fluids, pregnant women and children are thus most vulnerable to the effect of mercury. Mercury is a potent neurotoxin, at very low level of exposure it can cause permanent damage to the human central nervous system. The addition of even 0.9 grams of mercury, i.e. 1/7th fraction of a teaspoonful is enough to contaminate a 25 acre lake, rendering fish contaminated and unsafe to eat. At higher concentrations, mercury can damage vital organs such as lungs, liver and kidneys. The exposure to mercury can cause pneumonitis, bronchitis, muscle tremors, irritability, personality changes, memory loss, mood swings, weak muscles, gingivitis and symptoms of neurotoxicity also. If pregnant women eat poisoned fishes, their children are likely to be borne with foetal defects. Infants are special risks of brain damage from mercury exposure. Mercury can accumulate in muscle tissues.
COAL-FIRED UTILITIES
OTHER COMMERCIAL SOURCES
WILDLIFE
HUMAN
MSNBC
Fig. 1.1: Biomagnification (Source: UNEP)
Mercury Biomagnification in the Foodweb

Periphyton 2-20 ppb 0.1-0.5 ppb
Mercury Methylmercury H H O Water: 1-5 ppt 0.05-1.0 ppt Sunfish 500-1000 ppb 500-1000 ppb Hemipterans 35-60 ppb Amphipods 2-20 ppb 0.2-0.8 ppb Gambusia 2-200 2-200
Bass
Checkner et al. 1998 Biogeochemistry, 347-361
500-5000 ppb 500-5000 ppb
ppb: parts per billion
10
Fig. 1.2: Biomagnification of mercury in fish (Source: www.sofia.usgs.gov/.../ rooms/acme_sics/acme/how.html)
Mercury in Our Environment The Minamata disaster in Japan is an example of mercury poisoning via biomagnification and bioaccumulation. In India, some of the major rivers tested for heavy metals by Industrial Toxicological Research Center (ITRC), Lucknow were found to contain mercury. National Institute of Oceanography, Goa found increasing mercury concentrations in the Arabian Sea and several species of fish and prawns in Mumbai, Kolkata, Orissa, etc., have reported alarming rates of mercury concentrations, contamination of ground water with levels above permissible limits have been reported from Bhopal, Delhi. Mercury concentrations as high as 4.6 ppm i.e. 460 per cent above the permissible limits have been reported in and around Delhi. Villages in Gujarat, Haria, Atul Complex (12 ppm), Ankleshwar (2 ppm), Vadodara (6 ppm), and Nandesari (1.33 ppm) were shocking high 30-1200 per cent more than the permissible limits of 1 ppm making the water unfit for drinking and the population prone to mercury poisoning. (http://www.teriin.org/terragreen/index.htm, Issue 45, 2003) Mercury Toxicity in Wildlife Methyl mercury affects the central nervous system and its severe neurological effects were already seen in Minamata and Niagata, Japan, prior to human poisoning, where birds experienced severe difficulty in flying and exhibited other grossly abnormal behaviours. Arctic ringed seals and beluga whale in Canadian arctic and Greenland, and humped backed dolphin from Hong Kong show 2 to 4 times high levels of mercury. Small-toothed whale and dolphin liver samples examined in Japan in 2002 contained over 1970 micrograms of mercury per gram of liver i.e. nearly 5000 times the Japanese Governments limit for mercury contamination, 0.4 micrograms per gram. At these concentrations, a 60-kilogram adult eating just 0.15 grams of liver exceeds the weekly mercury intake considered safe by the World Health Organization. ( Source: New Scientist: http://www.newscientist.com/news/news.jsp?id=ns99992362) Mercury in Vulnerable Ecosystems Recent evidence suggests that mercury is responsible for a reduction in microbiological activity vital to the terrestrial food chain in soils over large ports of Europe. The mercury level in soil exceeds the critical limit of 0.07-0.3 mg/kg of total mercury content in the soil, above which the ecological effects occur. Recent studies estimate the annual global mercury pool (atmospheric) as high as 5000 tons while the total mercury content in the ocean is estimated at 10,800 tons. Research indicates that during the pre-industrial age, the global mercury pool contained 1,600 tons of mercury, while the ocean (mixed layers) had a total of 3,600 tons of mercury. This would suggest that the post-industrial level of mercury in global mercury pool is more than three times that of the pre-industrial level of mercury in the global mercury pool, and that the annual anthropogenic contribution to the global mercury pool is about 3,400 tons. ( Source: http://www.environmentalchemistry.com/, 2005) Suggested Tips for Handling Mercury Safely (Source: Lurking Menance, Mercury in Health Care Sector, Toxics Link, 2004)
l
Use mercury in uncarpeted and well ventilated areas. Provide troughs on smooth surfaced tables and benches to collect mercury spills. Reserve a room for mercury use only. Ask workers to remove all jewellery and watches, especially gold. Mercury readily combines with gold. Workers who handle mercury are to wear mercury vapour respirators and protective clothinggloves, disposable gowns and shoe coverings.
11
l l
Prohibit smoking and eating in or near mercury exposed areas. Train employees to understand the dangers and precautions while handling mercury. Also train employees on the properties and hazards of mercury. Proper training on how to dispose off mercury will contribute to the prevention of environmental exposure. Staff training is a key element in the proper prevention and management of mercury spills. Clean and calibrate all mercury-containing equipment to the specifications of the manufacturer. Properly document and lable all containers containing mercury. Have an emergency spill and containment plan in case a spill does occur. Avoid having chemicals such as chlorine dioxide, nitric acid, nitrates, ethylene oxide, chlorine and methylazide in the same area as mercury since they will react violently with mercury. Be sure to keep mercury away from biological waste or anything else that will be incinerated since incineration puts mercury vapour into the air.
Alternatives to Mercury Containing Medical Devices
l l l
Mercury Containing Product Thermometer
Alternatives Electronic (digital): oral/rectal tympanic (also called infrared thermometer) Glass filled with alloy of gallium, indium and tin (liquid at room temperature)
Sphygmomanometer
Aneroid Electronic
Gastrointestinal Tubes Dental Amalgam
Tungsten, considered to be as effective as mercury Ceramic fillings
Check Your Progress 2 1) Enumerate the source of mercury in health care facilities. ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... .....................................................................................................................
12
2)
Fill in the blanks: i) ii) ii) The major disease caused by mercury effluents in Japan was.................. It was due to eating of ................................. The other animal affected was .................................
3)
Write True (T) or False (F): i) ii) Mercury can cross blood brain barrier. Mercury can cross placental barrier. (True/False) (True/False) (True/False) (True/False) (True/False)
iii) Mercury dose not bioaccumulates in fishes. iv) Biomagnification phenomenon can occur with mercury. v) Methyl mercury is the least toxic of all.
1.2.3 Lead
Lead is a highly toxic metal that has been used for around 5000 years in products found in and around our homes. It occurs both in organic and inorganic forms and is a very corrosion-resistant, dense, ductile and malleable blue-gray metal. Sources There are varied sources of lead: General 1) 2) 3) 4) 5) Lead-based house paints ---- Flaking wall paint/crumbling plaster Coloured newsprints ---- Comic books, gift raps Gasoline ---- Petrol, lead batteries Utensils (specially if juices are stored in improperly glazed or fired pottery, decorative glazes) Household items:
l l l
Old painted toys and furniture Old silver plated items Open cans of fruit juices
6) 7) 8)
Drinking water from lead pipes Soil Retained bullet (specially those near the joints)
Lead Preparations Used in Medicine and as Colouring Agents

l l l l
Lead acetate ---- used to sweeten wine Lead carbonate ---- used in Goulards extract Lead chromate ---- yellow pigment in sweets Lead monoxide ---- used in hair dyes, used for syphilis by quacks
13
Effects on Environment and Health Environmental pollution can occur when the non-hazardous general waste from health care institutions is incinerated or burned in open kilns. Water pollution also occurs when the water sources in health care establishment and municipal water supply are polluted due to erosion of lead from lead line water supply pipes or in those institutions which are still using water line storage tanks or lead containing components in their drinking fountains, this leads to health hazards in patients and health workers who ingest the polluted water. Drinking water can account for approximately 20 per cent of young childrens lead exposure. The disposal of lead containing pharmaceuticals in the sewer may also give rise to ground water pollution. Lead may cause a range of health effects, from behavioural problems and learning disabilities to seizures and death. Small children are most at risk, because their bodies are growing quickly. The target organs affected by ingested lead are bones, brain, heart, kidneys, liver, nervous system and pancreas. The lead toxicity is greatest, even for short-term exposure in infants, children and pregnant women. Exposure to high levels of lead during pregnancy contributes to miscarriage, pre-term delivery, low birth weight and delayed development in infants. Even if the maximum intake of 5 mg of lead/kg body weight is virtually safe, while after ingestion only 10 per cent is absorbed by an adult, up to 50 per cent of the dose can be absorbed by a childs organism. After absorption in the body about 30 per cent of lead after overdose is found in soft tissue including the brain in children below 10 years age. While in adult only 6 per cent of lead after overdose is found in soft tissues while the rest is deposited in bones, like other heavy metals, it also bioaccumulates in the body. Lead is known neurotoxin and excessive blood lead levels in children have been linked to learning disabilities, attention deficit disorders, hyperactivity syndromes and reduced intelligence and school achievement scores. Precautions 1) These include proper segregation, reuse and disposal of general water containing lead, as well that of drugs with leads contents. 2) Use lead free standard pipelines for drinking water supply in hospitals and health care institutions. 3) Substitution of household articles and drugs by non-lead preparations. Use of lead free petrol in vehicles.
1.2.4
Cadmium
The other heavy metal found in health care waste that affect the environment and also the health workers due to environmental pollution, though present in small quantities, but very toxic is cadmium, released through incineration of health care waste. Sources Stainless steel needles, rubber caps of blood collection tubes, rubber material and syringes used in health care facility contain cadmium chloride crystals are used in laboratories. It is also a component of rechargeable batteries along with nickel used in various electronic instrument, cell phones, computers, etc. It is also produced during incineration of health care waste along with other metals like chromium, arsenic, mercury, lead, copper, etc. Effect on Environment and Health The health workers in the incineration facility are prone to its toxic effects, which include increasing facial, pharyngeal and neck oedema, vomiting, pain in the legs, abdominal
14
pain, diarrhoea and hypotension, leading further to pulmonary oedema, generalized oedema, hypothermia, hyperglycemia with acidosis and even respiratory arrest. Precautions
l
Inhalation of cadmium fumes can be avoided by preventing direct exposure to cadmium polluted fumes generated during the incineration of health care waste. Proper disposal of nickel cadmium batteries or its replacement by lithium or other type of batteries should be promoted. The health care facilities should shift to environmentally safe non-cadmium products.
1.2.5
Chromium
This is another heavy metal found in health care settings and is very toxic to environment and human health. Sources Stainless steel needles, rubber materials and syringes used in health care facilities contain chromium. The chromium is used in the form of sodium dichromate and chromic acid for cleaning of glassware in laboratories in health care establishments. It is also produced as pollutant during incineration of hospital waste, along with other toxic metals and can produce environmental pollution. The common source for chromium pollution is incineration of hospital waste and fumes from its use in laboratories and use of disposal of dichromate solutions in sewers. This can cause water pollution if it leaks from sewerage system. The workers who suffer from chromium fumes show corrosive effects resembling 1st or 2nd degree burns. It can also be absorbed in fatal doses through the skin, then the workers suffer from voluminous yellow green vomits with abdominal pain followed by bloody diarrhoea with recurrent vomiting leading to shock and death with acute renal failure and liver damage in 24-72 hours of ingestion in addition to corrosions resembling burns as above. Effect on Environment and Health It can cause air pollution when liberated during incineration of health care waste as fumes or dust, but the quantity released is not significant enough to affect the environment and human. Higher chromium emissions would come from important amount of needles in the waste. It has been reported that the emission levels of chromium when tested during incineration exceeded the European Standards. Persons coming in contact with chromium can absorb it through skin in fatal doses causing corrosion and other lesions as described above. The lethal dose of chromium is 1-3 grams. Fatal toxicity though can be caused by as little as 10 per cent of the corrosion of the metal. Precautions Measures for prevention of skin exposuresafety handling of sodium dichromate and chromic acid should be followed. The dichromate solution should be diluted and should be disposed after reducing it to harmless concentration by keeping it for above three months and then pouring it into sewers.
1.2.6
Disinfectants
Disinfectants are routinely used in hospitals for cleaning purposes. These chemical disinfectants include glutaraldehyde, formaldehyde, bleach, phenols, etc. These chemicals though clean disinfect the surfaces are very toxic chemicals, exposure to which leads to serious health hazards to health care professionals.
15
Glutaraldehyde Glutaraldehyde is a colourless oily liquid, commonly available as a clear, colourless aqueous solution. It is a powerful cold disinfectant used widely in hospitals and health care centres for high level disinfection of medical instruments and supplies and available in market as Cidex, Totacide and Asep. Glutaraldehyde is a fixative particularly with nitrogen, ammonia, amines and proteins. It attacks proteins in the nucleus of microorganisms, DNA and protein sacks of viruses, so that microorganism cannot develop resistance to it. It acts optimally as neutral to alkaline pH. If surfactants are used with glutaraldehyde, its killing efficiency, stability is increased while its volatility is reduced. The exposure limit for glutaraldehyde has been set at 0.20 ppm, which must never be exceeded. Sources Glutaraldehyde is commercially available and commonly used in hospitals in endoscopic unit, operation theatres and intensive care units, labour wards and in dental units for disinfections control. Effects on Environment and Health Glutaraldehyde is toxic and harmful if inhaled or swallowed. It irritates the eyes, respiratory tract and also has a corrosive action on the conjunctiva and skin and may cause permanent injury to the eyes. It is skin-sensitive and may cause severe allergic skin reactions, dermatitis and skin irritation, nasal and throat irritation, headaches, cough and asthma like condition. The main health hazards of glutaraldehyde are mostly associated with its strong irritant action. Vapour levels below 0.2 ppm (0.8 mg/m3 ) cause nose, eyes and throat irritation, nausea and headache, chest discomfort, tightness and difficulty in breathing may also occur. Cases of allergic asthma are also reported with its exposure. Even short term exposure to glutaraldehyde in concentrations of 0.3 ppm results in significant risk of irritation to the eyes, nose and throat. Glutaraldehyde has been found to cause symptoms of irritation even at low concentration below 0.2 ppm. (More at: www.ccohs.ca/oshanswers/chemicals/chem_profiles/glutaraldehyde/ health_glu.html) Disposal of spent glutaraldehyde solution in drainage connected to sewer system can cause two significant problems. The spent glutaraldehyde solution may adversely affect the operation of sewerage facility by having residual antimicrobial activity, which may affect the bacteria required for sewerage treatment. It may also affect the health workers during the physical activity of pouring of very large quantity of glutaraldehyde solutions into a sink or toilet, due to exposure to glutaraldehyde vapours. These problems can be avoided by neutralizing the spent glutaraldehyde. The neutralizing agent by a chemical reaction will transform the glutaraldehyde into a harmless solution, safe for disposal in sewers and which does not give of vapours when poured. The time required for complete neutralization ranges from 10 minutes to 8-12 hours or even longer. The glutaraldehyde concentration of the solution at the end should be 10 ppm or less. Above this concentration glutaraldehyde retains its antimicrobial activity and thus can affect adversely the operation of sewage treatment facility. Properly disposed glutaraldehyde thus will have little or no effect on bacterial ecology.
16
Precautions To eliminate glutaraldehyde over exposure take the following steps: 1) 2) Identify all exposure locations and minimize the number of personnel, which are involved in handling of glutaraldehyde. Monitor the exposure levels by use of passive diffusion monitors (monitoring badges), sample pump and with cassettes which require sophisticated laboratory analysis (OSHA method) and hand held direct reading meters (glutameters or glutaraldehyde meters) which provide a discrete instantaneous measurement. Training in safety precaution and handling of hazardous chemical should be undertaken, including safe working habits, use of proper protective gear or clothing and safe spill-clean up procedures. Use of proper personnel equipment, e.g. protective splash goggles, shield protection with facemasks, gloves, masks and clothing. Protective gloves should be 11 to 13 inches long extending up to the arms, and made of polyethylene or nitrile or rubber which is most impervious to glutaraldehyde. All protective clothing must be made of a material i.e. impervious to glutaraldehyde i.e. liquid resistant or liquid impervious, like polyethylene coated polypropane. Other basic precautions in addition to avoiding skin contact, splashes and exposure to fumes or droplets in air by use of protective gears are: a) b) Use of protective gear and ensure proper ventilation. The rooms in which glutaraldehyde used should have a minimum of 10 air exchange rates per hour. A local exhaust fume hood should be used in any room, which does not have a minimum of 10 airs exchange rates per hour. The fume hood should have glutaraldehyde soaking bins, which will eliminate all exposure problems with it. To ensure proper performance the fume hood should have a minimum velocity of 80 feet per minute. The health care setting can shift to non-glutaraldehyde and formaldehyde free fixative composed of aldehydes.
3)
4)
5)
c)
(Source: www.ccohs.ca and http://edoc-co-za/disclaimern(html)) Sodium Hypochlorite This is the most widely used chemical disinfectant in health care settings and household due to its disinfection efficacy and to its affordability. It is widely used as a disinfectant for body substance spillages, baths, bed pans of infected persons, babys feeding bottles, sterilization of non-autoclavable instruments like endoscopes, disinfection of infected plastic syringes, etc., before final disposal. It acts by releasing chlorine slowly, which acts as an effective germicidal. This is due to formation of hypochlorous acid, which is formed when free chlorine reacts with water, which is further decomposed to release nascent oxygen that destroys the bacteria by oxidation, also the combination of chlorine with cell membrane proteins and enzymes cause the death of bacteria. Under normal household use sodium hypochlorite is broken down in the environment into table salt, oxygen and water. Other substances may also be formed to a small extent, these by-products are most often referred as AOX (absorbable organic halides). The amount of AOX is very small both in absolute terms and relative to other human activities and natural sources. The effectiveness of sodium hypochlorite depends mainly on its concentration and contact period. Studies indicate that it is effective to kill HIV virus with as low as 0.5 per cent for a minimum contact period of half hour. The effectiveness of hypochlorite
17
also depends on the kind of waste when highly organic waste like blood is treated, greater concentration and longer contact period are required for the disinfectant for killing the germs. Therefore, sodium hypochlorite depending upon the concentration used can be an irritant or corrosive. At concentrations greater than 5 per cent it causes skin and mucus membrane irritation. It is not a mutagenic, carcinogenic, teratogenic or skin sensitizor. The potential health hazards are similar to glutaraldehyde and involve eye, respiratory tract and skin. On ingestion, it causes nausea and vomiting. Effects on Environment It does not produce any substantial ecological disturbance. Precautions They are similar to glutaraldehyde. Use of protective gear and clothing, training in safe use and spill clean ups should be given to the employees handling sodium hypochlorite disinfectants. Formaldehyde Formaldehyde at room temperature is a colourless gas with a pungent irritating odour. It is highly reactive, readily undergoes polymerization, is highly flammable and can form explosive mixture with air. It decomposes at temperatures above 150C. It is readily soluble in water, alcohol and other polar solvents. In aqueous solutions formaldehyde gets hydrated and polymerizes. It becomes turbid at high concentration above 30 per cent as its polymer gets precipitated. Sources Formaldehyde is generally found in hospital setting as an aqueous solution known as formalin. The formalin is most commonly used at a concentration of 37 per cent for embalming bodies, for dissection and for preservation of specimens in pathology and anatomy museums. It is primarily used for preservation of tissues, bodies and also as a fixative for histological specimens. In addition, formalin solutions are also used to fumigate the operation theatres for disinfection. It is in the operation theatres, autopsy rooms or embalming rooms, the highest air levels of formalin can be expected. Effects on Human Health Significant exposure of health workers to formaldehyde and formalin can occur by virtue of unintentional exposure during the course of working or intentional ingestion. Following inhalation exposure to low concentration of formaldehyde most individuals will experience initial mucus membrane irritation leading to conjunctivitis and sore throat which may be followed by development of pulmonary irritation with coughing, shortness of breath and difficulty in breathing. At high concentrations (50 to 100 ppm) pulmonary edema and death have been reported. Though it is a known animal carcinogen, its carcinogenicity in humans is not established. Precautions
l l
Wear protective gears while handling formaldehyde Shift to non-formaldehyde disinfectants.
Other Disinfectants
18
Other disinfectants commonly used are phenolic chemicals, chlorhexidine and cetrimide, povidone iodine, alcohol, etc. They may cause some varied adverse effects on the
environment, even small discharges may have cumulative effects. Their use is limited mainly in operation theatre and other patient care areas. The phenolic disinfectants are used as 2 per cent solution for disinfection of spillage of body fluids and substances on carpets, soft furnishing, etc. Chlorhexidine 0.5 per cent in 70 per cent alcohol is used for pre-operative and preprocedural skin preparation for disinfection of clean hand dressing, nursing procedures, and for cleaning of infected wounds and genitalia prior to urinary catheterization and in concentration of 4 per cent in 70 per cent alcohol for hand washing prior to clinical and surgical procedures. Chlorhexidine and cetrimide in 0.015 per cent to 1.15 per cent concentration are used for cleaning of operation theatres for emergency and pre-operative preparation of sensitive areas e.g. face, scrotum and for obstetric examination. Povidone iodine one per cent solution, spray, etc., is used for care of skeletal pin sites, infected pressure sores, ulcers and for surgical scrub and preoperative and pre-procedural skin preparations. Alcohol 70 per cent used for skin preparation prior to injection, cleaning of thermometers etc. The amounts of these disinfectants used on individual patients is not substantial to produce any ecological disturbance, also as their use is very limited in operation theatre and injection rooms or other areas. Small discharges of these drugs would not have cumulative adverse effects on the environment in the places of use, unless large quantities of these disinfectants are routinely disposed off in sewers or health care waste after their use. Protective Measures Gloves and protective eyeglasses should be worn during handling of chemical disinfectants to protect skin and eyes. In case of skin contact, the affected area should be rinsed abundantly with water. In case of eye contact, the eyes should be rinsed abundantly with water for at least 15 minutes followed by medical examination and treatment, if necessary. Check Your Progress 3 1) What safety precautions are to be taken to prevent pollution by lead? ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... 2) What is the effect of environment pollution by cadmium on human health? ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ......................................................................................................................
19
3)
What safety action plan is used to eliminate glutaraldehyde over exposure? ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... .....................................................................................................................
1.2.7
Gaseous Pollutants
The main source of gaseous pollution in health care institutions is the use of anaesthetic gases for surgical procedures, formaldehyde gas for disinfection. Another emission source is during the disposal of health care waste in low temperature incinerators and open kiln burning which can produce air, water and soil pollution through toxic emissions. Anaesthetic Gases Anaesthetic gases are used in hospitals and dental clinics, producing a stage of unconsciousness or loss of feeling (anaesthesia), loss of pain (analgesia) and adequate muscle relaxation to carry out any surgical procedures or operations on the patients. Surgeons, anaesthetists, dentists, operation threatre nurses and operation theatre staff and many other workers like orderlies, technicians may be exposed to anaesthetic gases during and after operations. Exposure comes from unused fresh gases released from the anaesthetic delivery system and from waste gases exhaled by patients. The highest exposure areas are operating and recovery rooms. But anaesthetic gases may also be used in labour, delivery and emergency rooms as well. The most commonly administered inhalation anaesthetics are as follows:
l l l l
Nitrous oxide Halothane Enflurane, Iso flurane and other halogenated anaesthetics Ether
All these anaesthetics belong to the group of inert compounds, which are first absorbed through the alveolar-capillary membrane and then distributed to the different biological tissues in accordance with their liposolubility. Effect on Environment and Health Anaesthetic gases especially nitrous oxide (N2 O) can be released into work areas such as operating rooms, dental clinics, recovery rooms and delivery rooms. Faulty seals in equipment account for majority of gas leaks. Other cases include poor administration techniques and exhalation by patients. It is estimated that about 10 per cent of workers in health sector are exposed to anaesthetic gases used in operating theatres. Possible Consequences Inhalation of anaesthetic gases may cause:
l l l
Reduce dexterity Impaired mental performance Headache, nausea and skin irritation Adverse reproductive effects
20
Chronic Effects The principal health concerns regarding occupational exposure to anaesthetic gases are carcinogencity, neurobehavioural effects, reproductive effects, interference of nitrous oxide with vitamin B12 metabolism and potential renal and hepatic effects. The reproductive effects to exposure of anaesthetic gases are well documented and are of particular concern. These include loss of fertility, spontaneous abortions, miscarriages and damage to the foetus causing birth defects. Some of them have mutagenic or teratogenic effects and can harm reproductive system of an exposed worker. However, the task force on trace anaesthetic gases has published an article in which the work of Spence is quoted, stating that there is no relation between exposure and increased risk of reproductive effect, cancer or neuropathy in relation to the profession. (More at: http://www.asahq.org/Newsletters/1997/05_97/Trace_Gases.html) Precautions and Safety Measures 1) 2) 3) 4) 5) Practice safe work procedures Introduce scavenging systems Undertake training of employees in safety precautions and use of protective gear Preventing the pregnant health workers from working in areas where anaesthetic agents are in use that they are not exposed to waste anaesthetic gases Minimizing exposure of pregnant patients to waste anaesthetic gases by always using scavenging systems by periodically testing anaesthetic machines for gas leaks and by not emptying or filling vaporizers.
Gaseous Pollutants from Health Care Waste Incineration: Dioxins and Furans Burning health care waste at low temperature or other single chamber incinerators, which produce heat below 550 to 600C are major sources of environmental pollution and release into the air a host of pollutants (shown in Table 1.1) including highly toxic dioxins and furans, metals such as mercury, lead, cadmium, chromium and particulate matter. Further, acid forming gases, carbon monoxide, hydrogen chloride which are formed when chlorinated plastics commonly found in medical waste are incinerated readily forms hydrochloric acid in contact with moisture and is corrosive and toxic to the plants and humans. Dioxin is toxic in smaller doses than any other chemical known. It is measured as in part per trillion and smaller. Table 1.1 : Typical Pollutants from Low Temperature Medical Waste Incinerators
Pollutant Dioxins and furans Other organic compounds Heavy metals Acid gases Carbon monoxide Particulate matter Bottom ash residues Example 2,3,7,8 tetra chloro-dibenzo-p-dioxin (TCDD) Benzene, carbon tetra chloride, chlorophenols, polycyclic aromatic hydrocarbons, vinyl chloride Arsenic, mercury chromium, lead, cadmium, nickel, manganese, copper Hydrogen chloride, hydrogen fluoride, hydrogen sulphurdioxide, nitrogen oxide Product of incomplete combustion Fly ash Usually contaminated with dioxins, furans, other organics and leachable heavy metals
These toxins have grave health effects on human if not trapped in pollution control devices, they can enter the food chain via the air and if trapped they become part of fly ash. The fly ash becomes very toxic to dispose off as it contains heavy metal impurities.
21
If it is not disposed off in secured landfills, it can contaminate soil, air and ground water. The dioxins and furans are extremely toxic and consist of polycyclic aromatic hydrocarbons formed when chlorinated plastics such as blood bags, IV tubes and plastic syringes or any other chlorine containing material like bleaching paper are incinerated. The heavy metals in waste stream act as catalyst and hasten the formation of dioxins. Sources Dioxins are mainly by-products of incineration of health care waste and of industrial processes but can also result from volcanic eruptions and forest fires. In terms of dioxin release into the environment, solid, municipal and medical waste incinerators have been the worst culprits. (See also, Batterman, S., Assessment of Small Scale Incinerators for Health Care Waste , WHO, 2004). Main sources of dioxin emissions are shown in Table 1.2.
Table 1.2 : Sources of Dioxin Sources of Dioxin
l l l l l l l
Toxic Equivalency Quotients (TEQ) Per Year 130 >10,000 30-1000 40-900 30-130 30-150 10-100 50-100
Medical waste incineration Cement kilns and boilers Forest fires Petroleum communication Residential wood burning Sewage sludge incineration Coal combustion
USEPA reported that medical waste incinerators were the highest source of dioxin in US and of a total of 9300 TEQ (Toxic Equivalency Quotients) produced there, 5100 TEQ were contributed by medical waste incineration (Source: USEPA Report, 1994). The fate of anthropogenic sources of dioxins are shown in Fig. 1.3 below:
Fish Human Planktons Cattle
Waste
Air
Soil
Plants
Secondary copper smelting
Dioxin
Automobile exhaust
Incinerator
PVC production disposal
Backyard burning waste
Pesticide
Building fires
22
Fig. 1.3: Anthropogenic Sources of Dioxins (Source: Down to Earth, August 31, 2001)
Environmental Effects and Health Risk Associated with Dioxins Incinerators are the single largest source of dioxin emissions. The acid gases, introduced by incineration which include sulphur dioxide can cause acid rains. Acid rains can cause denudation of forests, stunting of forest growth and deforestation. It can also cause damage to the buildings and monuments and pollute water supplies. Dioxins are omni-present in our environment and reach all corners of the world. They are produced mainly by burning of chlorinated plastics. It is transported by water and atmospherically by air. Because of their ability to travel, dioxins can enter the food chain far from its point of origin, though the higher levels of concentration are usually found near to its source of production, when PVC plastic is incinerated. Dioxins and furans are some of the most toxic chemicals known to science. Dioxin is lipophilic and bioaccumulative. Dioxin is first absorbed into plants. Animals and humans eat the plants, humans eat the animals allowing the poison to move up the food chain. Common human dietary sources of dioxin, which account for 60 per cent of human exposure, include meat, dairy products, eggs and fish. At the top of the food chain are nursing infants, who are exposed up to 50 times the permissible adult dose due to the high fat content of breast milk. They may receive more than 10 per cent of their life time exposure during the nursing period. A study carried out in industrialized countries and in Vietnam showed that although dioxin is found in breast milk world wide, the concentration is highest in women living near incinerators. According to a Japanese government survey dioxin levels were found to be higher in breast milk of women who eat meat more often. (Times of India, 30th December, 2000.) Effects of Dioxin on Human Health In human being it affects the respiratory and cardiovascular systems. As large amounts of plastic are incinerated, hydrochloric acid is produced causing acid attacks on respiratory system, skin, eyes and lungs with symptoms like coughing, nausea, vomiting. Table 1.3 describes the effects of dioxins on humans.
Table 1.3: Health Effect of Dioxins on Humans
l
Male Reproductive Effects Reduce sperm count Abnormal testes Reduced size of genital organs Lower testosterone levels Male feminization Decreased sex drive
Foetal Effects Birth defects Alternation in reproductive system Neurological and developmental problems Foetal death Delayed puberty Other Effects Immune suppression Altered glucose response Altered fat metabolism Diabetes Wasting syndrome Liver, spleen and bone marrow damage Lung, liver, stomach, and soft and connective tissue cancers Non-Hodgkins lymphoma Chloracne, Hirsutism and hyper pigmentation
Female Reproductive Effects Decreased fertility Inability to maintain pregnancy Miscarriage Ovarian dysfunctions Endometriosis Hormonal changes
23
Dioxins are proven carcinogens and disrupt endocrines, weaken the immune system and damage male and female reproductive organs. Precautions 1) 2) Do not burn chlorinated plastics. Use more environment friendly technologies such as chemical disinfection by wet sterilization units such as autoclaves, hydroclaves, vapoclave, microwaving and chemicals for steam disinfection. These are non-burn technologies which are safer, easier to use, and even more economical. If incinerators are used, they should satisfy the new international standards and/or those laid down by the concerned national authorities in the countries.
The purchase and use of low temperature, single chamber incinerator cannot be the answer to the problem, on the contrary, it can lead to environmental pollution. Stockholm Convention: Eliminating the 12 POPs, Including Dioxins and Furans The Stockholm Convention is a global treaty to protect human health and the environment from persistent organic pollutants (POPs). POPs are chemicals that remain intact in the environment for long periods, become widely distributed geographically, accumulate in the fatty tissue of living organisms and are toxic to humans and wildlife. POPs circulate globally and can cause damage wherever they travel. In implementing the Convention, Governments will take measures to eliminate or reduce the release of POPs into the environment. The current list of these are: Aldrin, DDT, Dieldrin, Chordane Endrin, Hexachlorobenzene, Heptachlor, Mixex, Polychorinated biphenyls (PCBs), Toxaphene, Dioxin and Furans. More at: www.pops.int/ Check Your Progress 4 1) Fill in the blanks: a) b) c) 2) The most important source of air pollution is ............................ of hospital waste. The corrosive gases due to incineration of hospital waste are ........................., .......................... and ........................... The toxic metal fumes released during incineration of hospital waste are of .......................... and ...........................
What is the cause of acid rains? ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ......................................................................................................................
24
3)
What is the impact of sulphurdioxide pollution? ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ......................................................................................................................
4)
Enumerate the most toxic pollutant released in the air when PVC plastics are incinerated. ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ......................................................................................................................
1.3
IMPACT ON ENVIRONMENT
The improper management of bio-medical waste causes serious environmental problems in terms of air, water and soil pollution. The nature of pollutants can be classified into biological, chemical and radioactive. The environmental problem can arise due to mere generation of bio-medical waste and from the process of handling, treatment and disposal. The potential environmental hazards can be direct or indirect. The direct impacts of biohazards are due to disease causing potential of medical waste, which is greatest at the point of generation, and naturally taper off after that point, thus presenting more of an occupational concern than a generalized environmental concern. This aspect is discussed in the next unit. Alternatives to PVC should be used in the hospitals. Environmentally preferable products are generally:
l l l l l l l
Less toxic Minimally polluting More energy efficient Safer and healthier for patients, workers and the environment With higher recycled content With less packaging Fragrance-free
1.3.1
Effect on Atmosphere
The air pollution is defined as the presence of gases, particulate matter or elements and substance which are not normally a part of air, originally and in concentrations that interfere with human health safety or comfort or is deleterious to other biological life present in the environment. Air pollution can occur both indoors and outdoors and may be due to biological, chemical or radioactive wastes. Indoor Air Pollution Pathogens present in the waste can enter and remain in the air in health care institution for a long period in the form of spores or as pathogens itself. This can result in hospital
25
acquired infections (Nosocomial infections) or occupational health hazards. The health worker, patients and their attendants are at risk of contracting infections caused due to air borne pathogens or spores. Indoor air pollution can also be caused by the use of chemicals like mercury, disinfectants (glutaraldehyde), fumigants like formalin, etc., that produce acidic or other hazardous gases. Outdoor Air Pollution Outdoor air pollution can be caused by: a) When waste without pre-treatment is being transported out of the health care establishments or if it is dumped openly, pathogens can enter the atmosphere. These pathogens can find their way to drinking water, food stuffs, etc., and/or remain in the ambient air and cause disease in human beings and animals. Chemical pollutants are a result of open burning and incinerators. Open burning of biomedical waste is the most harmful practice. The presence of plastics and hazardous materials in the waste will generate harmful corrosive gases such as sulphur dioxide, hydrogen chloride, oxides of nitrogen and suspended particulate matter. While the toxic products released during incineration of bio-medical waste, include dioxins and furans, toxic metal fumes of mercury, cadmium, chromium, lead, corrosive gases like sulphur dioxide, hydrogen chloride and particulate matters, fly ash and bottom ash are today responsible for causing ecological imbalance by polluting our total environment.
b)
1.3.2
Impact on Food and Livestock
As you have already read in this unit that dioxin and methyl mercury produced as byproducts of incineration and use of heavy metals are capable of travelling long distances by water and by air atmospherically. Because of their ability to travel, dioxins can enter the food chain far from its point of origin, though the higher levels of contamination are found near incinerators or closer to the sources of production.
1.3.3 Impact on Water and Aquifer

The famous Minamata case study discussed earlier in this unit is a typical example of the impact of mercury on livestock. The solid waste from hospitals that is not properly managed especially excreta, other liquid and solid waste from households and that from community mixed with hospital waste are of serious health hazard and can lead to the spread of infectious disease. Waste lying around attracts flies, rats and other scavengers many of which are vectors of diseases. Usually it is the wet waste that decomposes and releases a bad odour leading to adverse impact on human health. The unscientific disposal of solid waste pollutes the water supply and contaminates it either by dumping of waste near it or by leaching into aquifer from landfill sites. The fermentation of organic waste creates favourable conditions for survival and growth of microbial pathogens and can lead to spread of diseases through vectors like flies, rats, fleas, ticks and mites. The recent plague like epidemic of 1994 in Surat was due to an increase in the rat population carrying the plague organisms. Bio-medical waste can cause water pollution. If the waste is dumped in low-lying areas or into lakes or water bodies, it can cause severe water pollution. The liquid waste generated when let into sewers can also lead to water pollution if not treated. Water pollution can either be caused due to biological, chemical or radioactive substances. The pathogens present in the waste can leach out and contaminate the
26
ground water or surface water. Harmful chemicals present in biomedical waste, heavy metal pollution in the form of leachates, excess nutrient leachates such as nitrates and phosphates from landfills can cause a phenomenon called eutrophication (where surface of the water body develops algal blooms). Water pollution can alter parameters such as pH, BOD (Biological Oxygen Demand), DO (Dissolved Oxygen), COD (Chemical Oxygen Demand), etc. Waste effluents from hospital contain high numbers of resistant bacteria and antibiotic residues at concentration able to inhibit the growth of bacterial species. Accordingly, the hospital waste effluent can increase the numbers of resistant bacteria/microbes in recipient sewers by mechanisms of replication and proliferation and by selection to develop resistant bacterial strains. The principal area of concern is waste water with a high content of enteric pathogens, including bacteria, viruses and helminthes that are easily transmitted through water and can cause outbreaks of diarrhoeal disease and cholera. The waste effluents have been shown to have higher concentration of both single and multiple antibiotic strains. Indiscriminate use of antibiotics in human medicine, animal husbandry and agriculture may disrupt the microbiological balance in favour of resistant bacteria. The antibiotic resistance can develop not only in humans and animals treated with antibiotics but also in aquatic environment where antibiotics are present as residue, derived from contamination of water sources. Sewage Disposal The human excreta and waste water in sewage has been implicated in transmission of many infectious diseases including cholera, typhoid, infectious hepatitis, polio, cryptosporidiosis and ascariasis. WHO estimates that at least 2.1 million people die annually from diarrhoeal diseases and that 10 per cent of the population of the less industrialized world suffers from parasitic worm infestations related to improper waste and excreta management. Cholera has swept in world in recurrent pandemics since 1817. The seventh and ongoing pandemic began in 1961. When EL TOR biotype of vibrio cholerae 01 emerged in Indonesia and spread to India, Bangladesh and South-East Asian countries, Asia and Africa and finally reached Latin America in 1991. In 1992, V. Cholerae 0139 Bengal caused epidemics in Asia and Latin America, e.g. uncontrolled discharge of sewage from field hospital has contributed to the spread of cholera in Chile and Peru. Chemicals and disinfectant discharged into the sewage system may have adverse effects on operation of biological sewage treatment plants and/or toxic effect on the natural ecosystems of receiving water including destruction and death of planktons, algae, fishes and other aquatic animals. Depending upon the concentration of the pollutant, if human being consumes the polluted water, they may also suffer from its harmful effects, as discussed earlier. Similarly, toxic substance from fly ash collected from the incinerator waste and dumped in secured landfills can also go into water supplies, aquifers, ground and subsoil water, if there are heavy rains, flooding, with seepage from these areas. This will also affect human health in addition to that of cattle and livestock. In addition to the above well known problems of pathogens and viruses, some emerging causes of concern are the presence of endocrine disrupters such as estrogens, steroids, dioxins, phthalates, alkyl phenol oxalates which would all pose a threat to food chain if they got into rivers or the sea. These drugs specially act on male and female reproductive systems causing feminizing effects, declining sperm count, testicular cancer, reproductive disorders in men, breast cancer in women and childhood disorders, such as undescended testicles.
27
1.3.4
Impact on Marine Ecosystem
Impact on marine ecosystem occur when the sewage opens into the sea and drains the chemicals into it. It will affect the sea planktons and fishes and other marine animals and will produce specific effects including death as has occurred in mercurial effluents being released in the sea in Japan leading to death of fishes, which were washed on the coast and eaten by cats which died and also caused Minamata disease in human beings. The sulphurdioxide pollution, caused death of fish in Scandinavian lakes while that from USA had devastating effect on lakes in North America. After acid rains the acidity in lakes dropped below pH 5.6 and the fishes like Trout, Salmon and Eels died first followed by Carp. Fish and the insect eating species like Ospreys, Dippers and Otters also declined partly due to the toxic effects of acidity and partly due to dwindling food stocks all over the industrialized world. It is not the sulphur itself that kills the fish, but the more acidic the condition, the more aluminium is dissolved from the soil and when this enters the water, it impairs the gills of the fish and interfere with their breathing. If the limestone is present in the bedrocks, the acid gets neutralized, which explains why other areas, while receiving similar amounts of acid rains, remain relatively unaffected. The acid rains caused deaths of trees, in late 1970, in Germany the silver fir were first affected followed by Scots Pine, Norway Spruce and Beech. The forest soil also gets acidified to the depth of a meter or more and leads to death of forests. Hospital waste got the public and media attention during the period 1987-88 when hundreds and thousands of needle and syringes and other medical waste were found on several beaches along the East Coast of United States in the Eastern Seaboard from Maine to Florida, the West Coast, the Great Lakes and Gulf Coast. This showed that large quantities of these waste would travel large distances and create disturbance in the marine ecosystem.
1.3.5 Case Study 2: Accidents Do Happen

Death in Bhopal (1984) In the early hours of the morning on 2nd December, 1984 a yellowish-white cloud of gas, leaking from a storage tank at the Union Carbide (India) factory in the city of Bhopal, spread out across the neighbouring shanty town, into the old quarter of the city. It carried death with it: many died while asleep; others woke choking and vomiting, their throats and eyes burning, and staggered helplessly into the street to die. Within 40 minutes the cloud of methyl isocyanate, a chemical used in the manufacture of insecticides, had spread over 40 kms (25 miles) of the city. Worst affected were the hundreds of families in the makeshift homes of wood and tarpaulin, with corrugated iron roofs, which offered no protection from the choking fumes. As the thick mist settled over the nearby railway station, passengers and staff alike rolled on the ground, frothing and vomiting. The station superintendent signaled an approaching train to drive on without stopping, saving the lives of hundreds of passengers before being affected by the gas. Most of those who could still walk or stagger, piled out into the streets, trying to flee the lethal cloud, and roads already littered with dead animals became a seething mass of terrified humanity. Within the first hour the hospital was full overflowing with the injured, lying on tables, benches and the floor. Doctors set up makeshift clinics outside and treated the crowds of victims as best they could. By 07.00 a.m., 20,000
28
patients had arrived at the hospital and the dead were laid out in rows on the lawns, their faces covered with white cloths. Three thousand people died as a result of the accident and 40,000 were seriously injured. Many were left with damaged lungs, sight problems and bronchial ailments; the rate of miscarriages trebled, the infant mortality rate doubled among babies born to mothers who had been exposed to the gas. Many were left with long-term psychological complaints. The babies borne to the mothers exposed to MIC gas gave births to children with congenital deformities. Thus the MIC (Methyl-Isocynate) gas had a teratogenic effect on the victims of Bhopal tragedy. The leak was caused when a tank valve malfunctioned and caused increase in pressure and later the valve burst releasing the cloud of gas in the atmosphere. It was a callous attitude towards maintenance. The fact that the valve was not functioning properly was brought to the notice of higher management but they did not pay any heed. The pressure was building up from the afternoon of the previous day and timely intervention could have probably prevented the tragedy. It was a case of poor maintenance. Union Carbide, one of the worlds largest corporations, was to suggest sabotage but the report of government scientists blamed the accident on faulty design, poor construction and a lack of appreciation of potential hazards. When Warren Anderson, president and chief executive of Union Carbide since 1977, flew to Bhopal on 6th December, he was arrested along with the Indian executives of the plant, and charged with criminal negligence and conspiracy, but he was released a few hours later. At a press conference when he returned to the United States, he said The name of the game is not to nail me to the wall but to provide for the people. Along, legal wrangle between the Indian government and Union Carbide was to follow, providing little comfort for the survivors of the worlds worstever industrial accident. When the plant was reopened a few days after the disaster in order to neutralize the chemicals in the remaining tanks and make it safe in the long term, there was a mass exodus from Bhopal as up to 200,000 fled the old city, leaving it like a ghost town until after the process was completed (Source: Joyce Robins, The Worlds Greatest Disasters, Hamlyn Patteri Group Ltd., London, 1990). Check Your Progress 5 1) What are the effects of effluents containing resistant bacteria and antibiotic residues from hospitals drained in sewers? ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... 2) State the health impacts of solid waste. ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... 3) What are the effects of chemicals and disinfectant dumped in sewage? ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... .....................................................................................................................
29
1.4
LET US SUM UP
In this unit you have learnt about the impact of health care waste on environment and the common types of environmental pollution like air, water, chemical, gaseous, noise and soil. You have also learnt about the sources, effects on environment and safety precaution to be taken when chemicals like mercury, lead, arsenic, cadmium and chromium, disinfectants like glutaraldehyde and sodium hypochlorite are used as well as about gaseous pollutants specially those released from incineration of health care waste such as dioxins, furans, toxic metal fumes, fly ash and bottom ash released by incineration of PVC plastics. You have further learned about the impact on environment of health care waste like above with emphasis on their effects on atmosphere, food and livestock, water and aquifers and on marine ecosystems.
1.5
KEY WORDS
(The definitions given in this section refer to the use of terms in this unit and are not necessarily valid in other contexts.) Antineoplastic Antisepsis Cytostatic Decontamination Disinfectant Disinfection Flue gas (or exhaust gas) Genotoxic : Inhibiting or preventing the development of neoplasms. : Prevention of infection by inhibiting the growth of infectious agents. : Causing suppression of growth and multiplication of cells. : Reduction of microbiological contamination to a safe level. : Chemical agent i.e. able to reduce the viability and concentration of micro-organisms. : Treatment aimed at reducing the number of vegetative microorganisms to safe or relatively safe levels. : Gases and suspended particles emitted from an industrial stack or chimney. : Descriptive of a substance i.e. capable of interacting directly with genetic material, causing DNA damage that can be assayed. The term may refer to carcinogenic, mutagenic or teratogenic substances. : The water contained in porous underground strata as a result of infiltration from the surface. : The functions associated with the movement of solid waste materials, including storage, processing and ultimate disposal. : Intrinsic potential property or ability (e.g. of any agent, equipment, material or process) to cause harm. Note: Harm is an injury or damage to health of people and/or the environment. Incineration : The controlled burning of solid, liquid or gaseous combustible wastes to produce gases and residues containing little or no combustible material. : Liquid from a landfill containing substances that were present in the waste, either as liquids or as solids, and were dissolved by the water passing through the waste.
Groundwater Handling Hazardous
Leachate
30
Micro-organism Municipal waste Pyrolysis
: Any microbiological entity, cellular or non-cellular, capable of replication or of transferring genetic material. : General waste for collection by municipalities, generated mainly by households, commercial activities and street-sweeping. : The decomposition of organic material by heat in the absence or with a limited supply of oxygen.
Radioactive waste : Material that contains, or is contaminated with, radionuclides at concentration or activities greater than clearance levels and for which no use is foreseen. Residue : The material remaining after combustion of wastes such as ash or slag. Also refers to materials extracted from a liquid or gas stream. : The systematic separation of solid waste into designed categories. : A communitys water supply after it has been fouled by various uses. Its source may be a combination of the liquid or water carried wastes from domestic, municipal and industrial premises, together with such ground water, surface water and storm water as may be present (WHO Definition). Waste matter as carried in sewers (Oxford Dictionary). : A system for the collection and transport of sewage, including conduits, pipes and pumping stations. : A reduction in microorganisms of more than 106 (more than 99.9999% of the microorganisms are killed), achieved by physical, chemical or mechanical methods or by irradiation.
Segregation Sewage
Sewerage Sterilization
1.6
1)
ANSWERS TO CHECK YOUR PROGRESS

Chemical waste are discarded solids, liquids and gaseous chemicals from laboratories or house keeping areas. Disinfectants, antiseptics, sterilents possess the following properties, they are:
l l l l l
Check Your Progress 1
Toxic Corrosive Flammable Reactive Genotoxic
2)
Common metals, which are found in health care waste are:

l l l l l
Mercury Lead Arsenic Cadmium Chromium

31
Check Your Progress 2 1) The sources of mercury in the hospitals are:

l l l l l l
Thermometers Blood pressure instruments Feeding tubes Dilators and batteries Dental Amalgam Laboratory chemicals like Zenkers solutions and histological fixatives Minamata disease. fishes.
2)
i) ii)
iii) cats. 3) i) ii) True True
iii) False iv) True v) False
Check Your Progress 3 1) Safety precautions to prevent pollution by lead are:

l l l
Use of lead free petrol in vehicles or use of CNG gas as fuel for vehicles. Use of standard pipelines of water supply. Proper disposal of municipal waste containing the household general waste containing paint and newsprints etc.
2)
Effects of environmental cadmium pollution on human health are: increasing facial, pharyngeal and neck oedema, vomiting, pain in legs, abdominal pain, diarrhoea and hypotension, leading to pulmonary oedema, generalized oedema, hypothermia and hyperglycemia with acidosis and even respiratory arrest. The safety action plan to eliminate glutaraldehyde over exposure consists of following steps:
l
3)
Identification of all exposure location and minimization of personnel involved in handling of glutaraldehyde. Monitor the exposure levels, use passive diffusion monitors or other methods. Train the personnel in safety precautions in handling of hazardous chemicals, safe working habits and proper use of protective gears and safe spill-clean up procedures. Use protective gears with following specifications:- The gloves should be 1113 inches long and made of nitrile or polyethylene or rubber. Clothes must be liquid resistant or impervious and made of polyethylene coated polypropane.
l l
32
Check Your Progress 4 1) a) b) c) 2) 3) incineration sulphurdioxide, nitrous oxide, hydrogen chloride. mercury, cadmium.
The acid rains are caused by contamination of air with acid sulphur dioxide gases which in turn release sulphuric acid in atmosphere. The acid rains cause water and soil pollution and produce harmful effects onfishes, animals and denudation of forests and later on acidification of soil and watermaking it unsuitable for agriculture and human consumption, respectively. The most toxic pollutant released by burning of PVC in incinerators are dioxins and furans in addition to acid gases and heavy metal vapours.
4)
Check Your Progress 5 1) The affluent from hospital infectious waste mostly consists of high numbers of resistant bacteria and antibiotic residues at concentrations able to inhibit the growth of susceptible bacteria. They can increase the number of resistant bacteria in recipient sewers by both mechanisms of introduction and selection for resistant bacteria and may cause gastrointestinal, diarrhoeal diseases and cholera and can also affect the operation of sewage system. Health impacts of solid waste if not properly managed especially excreta and other liquid and solid waste can lead to spread of infectious diseases. Unattended waste attracts flies and rats and other scavengers, which in turn spread the disease (vector borne). The wet waste decomposes and releases bad odour and causes air pollution. If it is not disposed off properly it can pollute the water supply by leakage from landfill sites, organic waste fermentation can also act as media for growth of bacteria and can cause epidemics. 3) Chemicals and disinfectant when discharged into sewage cause adverse effects on operation of biological sewage treatment plants. They cause death of planktons, algae, fishe and other aquatic animals. Consumption of polluted water is also hazardous to humans.
2)
1.7
FURTHER READINGS
Agrawal, Praveen and Jyoti Prakash Wale, Diagnosis and Management of Common Poisoning, Oxford University Press, 1997. IGNOU, Support and Utility Services and Risk Management, Block 4, Practical Manual, PGDHHM-05, 2001. NIHE, Eleven Recommendations for Improving Medical Waste Management, 2003, online at: http://www.nihe.org/elevreng.html Smith, R.S. , Sanitation Controlling Problems at Source, 2001, WHO/WSH/WWD/ TA.8 online at : www.who.int/entity/water_sanitation_health/sanitproblems/en/ UNEP, Global Mercury Assessment Report, 2002, online at : www.chem.unep.ch/ mercury/Report/Final%20Assessment%20report.htm
33
WHO, Assessment of Small Scale Incinerators for Health Care Waste, 2004, online at: www.who.int/water_sanitation_health/medicalwaste/smallincinerators/en/ index.html WHO, Information on chemicals: http://www.inchem.org/ WHO, Water Quality: Guidelines, Standards and Health, Assessment of Risk and Risk Management for Water Related Infectious Disease, TWA Publishing, U.K., 2001.
34

Uni 1

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Uni 1

Hochgeladen von

Copyright:

Verfügbare Formate

UNIT 1 IMPACT OF HEALTH CARE WASTE ON OUR ENVIRONMENT

1.4 1.5 1.6 1.7

Need for a Sound Health Care Waste Management

CHEMICALS IN HEALTH CARE WASTE

Toxic Corrosive Flammable Reactive Genotoxic

Impact of Health Care Waste on our Environment

Need for a Sound Health Care Waste Management

6) Laboratory chemicals like Zenkers solution and histological fixatives.

Impact of Health Care Waste on our Environment

: 0.040 : 2.34 : 0.25 : 0.0035 : 3-17

Need for a Sound Health Care Waste Management

OTHER COMMERCIAL SOURCES

Fig. 1.1: Biomagnification (Source: UNEP)

Mercury Biomagnification in the Foodweb

500-5000 ppb 500-5000 ppb

ppb: parts per billion

Fig. 1.2: Biomagnification of mercury in fish (Source: www.sofia.usgs.gov/.../ rooms/acme_sics/acme/how.html)

Impact of Health Care Waste on our Environment

Need for a Sound Health Care Waste Management

Mercury Containing Product Thermometer

Gastrointestinal Tubes Dental Amalgam

Tungsten, considered to be as effective as mercury Ceramic fillings

Impact of Health Care Waste on our Environment

Lead Preparations Used in Medicine and as Colouring Agents

Need for a Sound Health Care Waste Management

Impact of Health Care Waste on our Environment

Need for a Sound Health Care Waste Management

Impact of Health Care Waste on our Environment

Need for a Sound Health Care Waste Management

Wear protective gears while handling formaldehyde Shift to non-formaldehyde disinfectants.

Impact of Health Care Waste on our Environment

Need for a Sound Health Care Waste Management

Impact of Health Care Waste on our Environment

Need for a Sound Health Care Waste Management

Secondary copper smelting

PVC production disposal

Backyard burning waste

Impact of Health Care Waste on our Environment

Need for a Sound Health Care Waste Management

Impact of Health Care Waste on our Environment

Need for a Sound Health Care Waste Management

Impact on Food and Livestock

1.3.3 Impact on Water and Aquifer

Impact of Health Care Waste on our Environment

Need for a Sound Health Care Waste Management

Impact on Marine Ecosystem

1.3.5 Case Study 2: Accidents Do Happen

Impact of Health Care Waste on our Environment

Need for a Sound Health Care Waste Management

Groundwater Handling Hazardous

Micro-organism Municipal waste Pyrolysis

Impact of Health Care Waste on our Environment

ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1

Toxic Corrosive Flammable Reactive Genotoxic

Common metals, which are found in health care waste are:

Mercury Lead Arsenic Cadmium Chromium

Need for a Sound Health Care Waste Management

Check Your Progress 2 1) The sources of mercury in the hospitals are:

iii) cats. 3) i) ii) True True

iii) False iv) True v) False

Check Your Progress 3 1) Safety precautions to prevent pollution by lead are:

Impact of Health Care Waste on our Environment

Need for a Sound Health Care Waste Management