Journal of Environmental Management 163 (2015) 98e108

Contents lists available at ScienceDirect

Journal of Environmental Management

journal homepage: www.elsevier.com/locate/jenvman

Review

Medical waste management e A review

Elliott Steen Windfeld, Marianne Su-Ling Brooks*
Department of Process Engineering and Applied Science, Dalhousie University, PO Box 15000, Halifax, NS B3H 4R2, Canada

a r t i c l e i n f o a b s t r a c t

Article history: This paper examines medical waste management, including the common sources, governing legislation
Received 12 June 2015 and handling and disposal methods. Many developed nations have medical waste legislation, however
Received in revised form there is generally little guidance as to which objects can be defined as infectious. This lack of clarity has
9 August 2015
made sorting medical waste inefficient, thereby increasing the volume of waste treated for pathogens,
Accepted 12 August 2015
Available online 22 August 2015
which is commonly done by incineration. This review highlights that the unnecessary classification of
waste as infectious results in higher disposal costs and an increase in undesirable environmental impacts.
The review concludes that better education of healthcare workers and standardized sorting of medical
Keywords:
Medical waste
waste streams are key avenues for efficient waste management at healthcare facilities, and that further
Infectious waste research is required given the trend in increased medical waste production with increasing global GDP.
Waste management © 2015 Elsevier Ltd. All rights reserved.
Separate collection
Healthcare

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
2. Medical waste definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
3. Medical waste generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
3.1. Use of a waste production metric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
3.2. Comparison of national waste production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
3.2.1. Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
3.2.2. Data presentation and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
4. Current legislation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
4.1. United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
4.2. Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.3. European Union . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.4. United Kingdom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.5. Developing nations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
5. Current practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
5.1. Medical waste collection and separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
5.2. Medical waste transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
5.3. Medical waste disposal methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
6. Issues with current incineration disposal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
6.1. Incineration emission standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
6.2. Incinerator emissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
6.2.1. Dioxin and furan emissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
6.2.2. Mercury emissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
6.3. Emissions control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
7. Future directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
7.1. Autoclave waste treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

* Corresponding author.
E-mail address: Su-Ling.Brooks@dal.ca (M.S.-L. Brooks).

http://dx.doi.org/10.1016/j.jenvman.2015.08.013
0301-4797/© 2015 Elsevier Ltd. All rights reserved.
 E.S. Windfeld, M.S.-L. Brooks / Journal of Environmental Management 163 (2015) 98e108 99

7.2. Medical equipment substitution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

7.3. Medical waste sorting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
7.3.1. Point-of-disposal waste sorting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
7.3.2. Need for standardization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
7.3.3. Improving management practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
8. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

1. Introduction biologicals” (United States Congress, 1988). It is estimated by the

World Health Organization (WHO) that 20 percent of these medical
Medical waste management is one of the many complex and wastes can be classified as hazardous materials that may be in-
demanding challenges facing humanity as the global population fectious, toxic, or radioactive (Brichard, 2002).
swells and the demand for medical services increase. Medical waste However, there is no globally agreed upon definition of medical
is classified by the World Health Organization (WHO) as: “waste waste, which poses a challenge from a comparative standpoint, as
that is generated in the diagnosis, treatment or immunization of changing definitions make a meaningful comparison between
human beings or animals.” Medical waste that is not properly countries, or even between regions within countries, quite difficult.
handled and disposed of represents a high risk of infection or injury Further, the absence of a standard definition of medical waste has
to healthcare personnel, as well as a lesser risk to the general public led to a lack of standardization of medical waste streams and
through the spread of micro-organisms from healthcare facilities disposal receptacles, as discussed later in this review (Insa et al.,
into the environment (Brichard, 2002; Mohee, 2005). 2010).
Medical waste disposal is an issue of considerable scale. As the Generally, there are four terms used when discussing medical
world's top medical waste producing nation, the United States waste, and all are often used interchangeably, with no universally
alone creates over 3.5 million tonnes of medical waste per year accepted definition for each term (Rutala and Mayhall, 1992). These
with an average disposal cost of $790 per tonne (Lee et al., 2004). are: hospital waste, medical waste, regulated medical waste and
Medical waste production in the developing world is rising quickly infectious medical waste. In order to provide clarity and consis-
due to improved access to medical services, which allow ever- tency throughout this review, the term medical waste will be used
greater numbers of people to receive modern medical care. The to refer to all waste that is generated at any healthcare or
trend away from multi-use medical devices towards safer, single- healthcare-related facility, which is consistent with the definition
use medical devices is further adding to the production of medi- of medical waste given by the United States Environmental Pro-
cal waste in developing nations. These combined trends are causing tection Agency (U.S. EPA, 2012a). The term infectious medical waste
a rapid increase in the amount of medical waste that requires safe will refer to the subset of waste generated at healthcare facilities
disposal in developing nations (Mbongew et al., 2008). In the that is unsuitable for disposal in a municipal solid waste system due
developed world, a rapidly aging population is the major driver of to pathogenic concerns.
increasing medical system usage, and this rising medical system
usage is producing a corresponding increase in medical waste
3. Medical waste generation
production (Canadian Senate Committee, 2002).
This review will give an overview of the issues related to med-
The amount of medical waste generated at different healthcare
ical waste disposal. Firstly, the composition and sources of medical
facilities is of obvious interest, with many studies done on the
waste in multiple jurisdictions around the world will be addressed.
subject. The quantity and composition of medical waste generated
This will be followed by a discussion of both binding legislation and
is dependent on many factors, with a medical waste study focusing
medical waste management guidelines in these regions. Next,
on Italian hospitals finding that the type of sanitary service offered
current medical waste handling practices will be described, with a
greatly impacts the amount of infectious waste produced (Liberti
specific focus on in-facility collection, separation, transportation
et al., 1996). The study found that as much as 52% of overall in-
and disposal methods. Issues with common incineration disposal
fectious medical waste production comes from short-term patients
methods will be discussed, followed by alternate treatment possi-
in rehabilitation service, followed in descending order by analytical
bilities, and the need for reducing the quantity of non-infectious
laboratories (23%), surgeries (14%), dialyses (7%) and first aid (4%). A
medical waste in the infectious medical waste stream. Finally,
similar study done in Taiwan found the dialysis unit to generate the
recommendations for improvement strategies involving both bet-
greatest amount of infectious medical waste (23%), flowed by the
ter education for healthcare workers and standardizing in-facility
intensive care unit (17%), the emergency care unit and the outpa-
waste receptacles will be proposed. This review will show that
tient clinic (12% each) (Cheng et al., 2009).
the amount of infectious waste produced and the associated harm
In evaluating medical waste generation, it is helpful to use a
caused can be reduced through improved point-of-disposal waste
common basis for quantification, so that data from different regions
sorting, standardization of waste disposal streams and through
can be compared. The following sections present an analysis of
better education of healthcare workers.
medical waste production for different countries based on various
indicators.
2. Medical waste definition
3.1. Use of a waste production metric
The United States Medical Waste Tracking act of 1988 defines
medical waste as “any solid waste that is generated in the diagnosis, The selection of an appropriate metric for comparing healthcare
treatment, or immunization of human beings or animals, in facilities and medical waste production levels is challenging. The
research pertaining thereto, or in the production or testing of most common metric for quantifying the amount of medical waste
100 E.S. Windfeld, M.S.-L. Brooks / Journal of Environmental Management 163 (2015) 98e108

Table 1
Comparison of medical waste production, both infectious and total, to GDP, health GDP, and healthcare system ranking.

Country GDP per capita GDP spent on healthcare WHO ranking of health Infectious waste Total healthcare waste
2012 (USD) per capita 2012 (USD) system performance generation (kg/bed-day) generation (kg/bed-day)

Norway $99,636 $8967 11 e 3.92

United States $51,496 $9218 37 2.791 10.71
United Kingdom $41,054 $3939 18 e 3.32
France $40,908 $4786 1 e 3.32
Spain $28,993 $2783 7 e 4.42
Taiwan $20,925 e e 0.66 3.266
Brazil $11,320 $1053 125 0.574 3.254
Turkey $10,661 $672 70 e 1.393
South Africa $7314 $644 175 1.241 e
Bulgaria $7198 $533 102 0.405 e
Jordan $4909 $481 83 e 6.101
Vietnam $1755 $116 160 0.31 e
Pakistan $1252 $39 122 e 2.071
Tanzania $609 $43 156 0.081 0.141

Notes: Data for waste generation (Compendium of Technologies for the Treatment/Destruction of Healthcare Waste, 2012) [1]; (Bdour et al., 2007) [2]; (Akbolat et al., 2011)
[3]; (Da Silva et al., 2005) [4]; (Spasov, 2003) [5]; (Cheng et al., 2009) [6]. Data for GDP per capita (The World Bank Group, 2015a), except for Taiwan data from (IMF, 2014). Data
for GDP spent on healthcare (The World Bank Group, 2015b). Health system ranking data (World Health Organization, 2000).

generated at a hospital is calculated by measuring the total kilo-
grams of waste generated by the hospital per day, and then dividing
that total by the number of occupied beds at the hospital. This
yields kg/bed-day, a metric which attempts to adjust waste gen-
eration at hospitals for both the number of illnesses treated and the
seriousness of patient maladies, as a single patient with a serious
illness may occupy a hospital bed for many days, while a patient
with a less serious injury may occupy a bed for a matter of hours.
It is generally accepted that kg/bed-day is the best available
basis for hospital waste production comparison, with studies
finding that the number of beds in service strongly relates to the
amount of medical waste produced at similar hospital facilities
(Liberti et al., 1996).
Taiwan was unavailable.
3.2.1.3. Healthcare system performance. The overall health system
performance of 191 countries was ranked by the World Health
Organization in the year 2000 as part of their World Health Report
for the new millennium (World Health Organization, 2000). The
countries were ranked on three key criteria, these being:

Disability-adjusted life expectancy e average (25%) and equality
of distribution (25%)

Healthcare system responsiveness e average responsiveness
(12.5%) and equality of responsiveness (12.5%)

Fair financial contribution (25%)

3.2. Comparison of national waste production The WHO healthcare system ranking of selected countries is
displayed in Table 1, and is used in this report as indicative of the
Table 1 details the average healthcare waste production, both quality of healthcare provided in each listed country.
infectious and total, for hospitals in 14 countries around the world
and presents these values alongside data showing each country's
3.2.2. Data presentation and analysis
nominal gross domestic product (GDP) per capita, healthcare
Using the three data sets described above, comparisons can be
spending per capita, and each country's healthcare system rank in
made between the quantity of both infectious and non-infectious
the WHO's 2000 millennium healthcare assessment.
healthcare waste generated (measured in kg/bed-day) against per
capita GDP, healthcare spending GDP, and the quality of the
3.2.1. Indicators healthcare system across different countries. All data are summa-
The following subsection details the indicators used in this re- rized in Table 1.
view for national income, healthcare spending and healthcare
quality.

3.2.1.1. GDP per capita. A country's GDP per capita is the gross value
of all goods and services produced per year, measured in a common
currency and then divided by the population of the country (The
World Bank Group, 2015a). The nominal GDP data presented in
Table 1 is from the World Bank, and is based on the 2012 calendar
year, except the data for Taiwan, which is from the IMF's GDP data
for 2012 due to the World Bank not listing data for Taiwan.

3.2.1.2. Healthcare spending per capita. Healthcare spending per

capita is calculated by taking the percentage of GDP for each
country that is spent on healthcare, retrieved from World Bank
2012 data, and then multiplying this percentage by each county's
per capita GDP. Healthcare spending includes both public and pri-
vate expenditures on health services (preventive and curative),
family planning activities, nutrition activities, and emergency aid Fig. 1. Total medical waste generated [kg/bed-day] vs. GDP per capita in United States
designated for health (The World Bank Group, 2015b). Data for dollars.
 E.S. Windfeld, M.S.-L. Brooks / Journal of Environmental Management 163 (2015) 98e108 101

The relation between the amounts of medical waste generated

in kg/bed-day against each country's GDP per capita is shown in
Fig. 1, with all countries displayed as B except for the United States
and Jordan, which are displayed as D. Fig. 2 shows the amount of
medical waste generated in kg/bed-day against each country's
healthcare spending per capita, with the same symbols used in
Fig. 1.
In Figs. 1 and 2, logarithmic trend-lines were fitted to the data,
which reveal that there is a positive correlation between medical
waste generation and both higher GDP per capita and healthcare
expenditure per capita. In both Figs. 1 and 2, the dashed trend-line,
calculated when excluding the United States and Jordan, gives a
better fit to the data in comparison to the dotted trend-line which is
calculated when the United States and Jordan are included in the
data sets. This exclusion was deemed reasonable as both the United
States and Jordan have privatized.medical systems (whereas other
countries considered in this study with similar GDP levels have
Fig. 2. Total medical waste generated [kg/bed-day] vs. healthcare spending per capita
publically-funded systems) and produce disproportionately high
in United States dollars.
amounts of medical waste compared to their peer nations. While it
is beyond the scope of this paper to speculate on the precise
by medical waste during the late 1980s, when large amounts of
structural differences that lead to higher waste production in the
improperly disposed of medical waste were routinely found
United States and Jordan, Figs. 1 and 2 demonstrate that there is a
washed up on beaches, creating public outrage (Wagner and
marked increase in medical waste production in these countries.
Arnold, 2008). The MWTA of 1988 came into effect on June 24,
The trends of increased GDP and healthcare spending leading to
1989, and has been the basis for medical waste classification,
higher waste production and of private funding of hospitals leading
handling, transportation, treatment and disposal in the United
to higher waste production at similar GDP levels are consistent
States ever since (United States Congress, 1988).
with trends found by other researchers (Cheng et al., 2009).
The MWTA established:
Data regarding infectious waste is not compared to GDP or
healthcare spending metrics, as the data set for infectious waste is

A definition for medical waste
more limited than the data available for total medical waste.

Criteria to determine which medical wastes would be subject to
However, a brief inspection of the data indicates a similar trend to
program regulations
total medical waste, with higher GDP and healthcare spending per

A cradle-to-grave tracking system utilizing a generator initiated
capita associated with increased infectious medical waste
tracking form
generation.

Management standards for segregation, packaging, labeling and
Fig. 3 shows the amount of medical waste generated against the
marking, and storage of the medical waste
quality of each country's healthcare system, as ranked by the WHO

Record keeping requirements and penalties that could be
in 2000. If the United States and Jordan are excluded, as in the
imposed for mismanagement (U.S. EPA, 2012b)
previous analysis, there is a reasonable correlation between a
higher quality healthcare system and increased medical waste
In addition to governing the collection and transport of medical
generation.
waste, the MWTA also required the EPA to examine various treat-
ment technologies available at the time for their ability to reduce
4. Current legislation
the disease causing potential of medical waste (U.S. EPA, 2012b).
The technologies that EPA examined in 1990 included incinerators,
In this section, the legislation governing the classification,
autoclaves, microwave units and various chemical and mechanical
collection, transportation and disposal of medical waste for the
systems (U.S. EPA, 2012b). The EPA continues to conduct research
United States (U.S.), Canada, the European Union (EU), the United
on improving infectious medical waste treatment methods.
Kingdom (UK) and developing nations is discussed.
It should be noted that the United States, Canada, and the United
Kingdom are all wealthy G7 member countries with developed
economies, while the European Union is a group of nations
(including the UK) and includes some countries that are classified
as upper middle income nations, rather than high income nations
like Canada, the U.S. and UK (UN, 2012). Developing nations are
considered as there is considerable scope for improvement in
medical waste management in many of these countries.

4.1. United States

Medical waste is highly regulated in the United States, with the

main piece of legislation governing American medical waste being
the Medical Waste Tracking Act (MWTA) of 1988. The MWTA was
passed by Congress as an amendment to the Solid Waste Disposal
Act, itself written in 1965 to address how to safely dispose of large
volumes of industrial and municipal solid wastes (U.S. EPA, 2013). Fig. 3. Total medical waste generated [kg/bed-day] vs. WHO healthcare system
Many see the MWTA as a product of the media attention received ranking.
102 E.S. Windfeld, M.S.-L. Brooks / Journal of Environmental Management 163 (2015) 98e108
Incineration is the most common method of medical waste
disposal in the United States, and until recently the only limitation
placed on incineration facilities was that they could not cause
nuisance to nearby areas. This was generally interpreted to mean
that they could not create detectable odours and had to operate
within prescribed opacity limits (Glasser et al., 2012). In 1997, the
United States EPA enacted regulations regarding the emission limits
of existing and new waste incineration facilities (Healthcare
Without Harm, 2004). These regulations required existing in-
cinerators to be equipped with air pollution control devices to
comply with the new legislation requirements, which were too
expensive for many on-site waste incineration facilities and resul-
ted in the closure of more than five thousand medical waste in-
cinerators (Healthcare Without Harm, 2004). Issues relating to the
incineration of medical waste in the United States are discussed
further in Section 6, which focuses on incineration emissions and
regulations.
4.2. Canada
Canadian provinces have been given broad authority to regulate
medical waste as they see fit, with the majority of Canadian prov-
inces not having specific regulation relating to the disposal of
medical waste. Instead, most provinces use umbrella waste legis-
lation to regulate medical waste disposal, with the notable excep-
tion to this approach being the province of Quebec, which has
medical-waste-specific legislation (Walkinshaw, 2011). The Cana-
dian Council of Ministers of the Environment (CCME), a body
comprised of the 14 environment ministers from the federal, pro-
vincial and territorial governments, has developed a medical waste
directive by which all provinces are expected to abide (CCME,
2014). However, the implementation of these standards regarding
medical waste is left up to each province.
The CCME standard states that:

Landfills should only accept medical waste that has been
decontaminated

Healthcare facilities should prearrange required disposal vol-
umes with landfill operators

Medical waste treatment facilities should provide evidence of
treatment of their waste before sending it to landfills

Decontaminated waste should be buried immediately or in
compliance with a designated schedule

Treated waste should be covered with earth or other waste to
prevent direct contact with landfill equipment (Walkinshaw,
2011).
The CCME directive discusses the need for a standardized defi-
nition of medical waste, provides an outline of what these defini-
tions should encompass and suggests suitable sub-categories for
medical waste categorization. The CCME medical waste guidelines
also provide direction for the transport and final disposal of med-
ical waste, including stringent emission limits for medical waste
incineration (Canadain Standards Association, 1992). Indeed, hos-
pitals in Canada show a marked trend towards centralized pro-
vincial medical waste incineration facilities, with many provinces
passing laws outlawing the incineration of medical wastes on-site
at healthcare facilities (Walkinshaw, 2011).
4.3. European Union
In the European Union, the European Commission (EC) sets di-
rectives for waste regulations and standards, and then member
nations are responsible for enacting legislation that complies with
and serves to fulfill these EC directives. As such, the EC has directed
countries in the European Union to classify their waste according to
chapter 18 of the European Waste Catalogue (EWC), in which the EC
has established a list of waste descriptions for the different com-
ponents of medical waste. The EWC itself was established by Eu-
ropean Commission Decision 2000/532/EC in the year 2000 (Insa
et al., 2010).
Underlying chapter 18 of the EWC is European Commission
decision 94/904/EC, which on December 22, 1994 established a list
of hazardous wastes to be used by member EU countries (European
Council, 1994). Since 1994, the Directory on Hazardous Waste (94/
904/EC) has regulated hazardous waste in the European Union,
defining and governing 237 types of hazardous waste, including
medical waste.
Adoption of the Directory on Hazardous Waste is mandatory for
all EU member nations, but national classifications and definitions
are still used for a considerable portion of government data
collection and compliance enforcement (Bertram et al., 2002). This
use of national definitions makes it difficult to draw valid com-
parisons among data from different countries, as the classification
systems can differ significantly between countries, despite the di-
rection of the EWC. A lack of adequate description of what consti-
tutes hazardous waste within the Directory on Hazardous Waste
helps to explain this variation in national definitions (Bertram et al.,
2002).
In 2000, the European Union enacted stricter emission limits for
medical incineration facilities. This has caused a trend towards the
shutdown of waste incineration facilities in favor of non-
incineration methods of treatment, such as autoclave sterilization.
However, Europe has not been as quick to adopt these new tech-
nologies as the United States (Healthcare Without Harm, 2004).
4.4. United Kingdom
The United Kingdom is an EU member country, therefore UK
regulations must bring the country into compliance with the EU
directives discussed above.
The basis for medical waste regulation in the UK is the Envi-
ronmental Protection Act of 1990, which made it unlawful to de-
posit, recover or dispose of medical waste without a waste
management licence. The act further requires that practices of the
licensee are not contrary to the terms of the waste management
licence, and provides criminal penalties for violation of the licence
terms (U.K. Dept. for Environment, Food & Rural Affairs, 2013).
4.5. Developing nations
A recent study on the state of healthcare in Asia found that very
few developing nations in Asia have specific, integrated legislation
governing the collection, treatment and disposal of infectious
medical waste (Ananth et al., 2010). Where medical waste legisla-
tion does exist it is frequently relegated to a sub-section of other
waste legislation, rather than specifically addressed in a dedicated
piece of legislation (Ananth et al., 2010).
Even when a developing nation has enacted medical waste
legislation, there is often a marked disconnect between the thor-
oughness of the legislation and the reality of medical waste man-
agement in that country. For example, Botswana enacted a clinical
waste code of practice in 1996 which defines clinical waste, details
collection and handling hazards for the waste, and requires the
waste to be carefully separated into color-coded waste streams.
However, studies have found that the majority of healthcare
workers in Botswana are not aware that this waste management
legislation exists in their nation (Diaz et al., 2005).
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5. Current practices
This section gives a brief overview of the current practices for
infectious medical waste disposal, with a focus on the practices
found in developed nations. This overview is subdivided into the
three basic steps of waste disposal: collection in the healthcare
facility, transport to the treatment site, and final treatment and
disposal.
5.1. Medical waste collection and separation
At hospitals and other healthcare facilities, waste is generally
sorted into color-coded bins or bags, with each receptacle denoting
a different waste stream or waste type. The color selected for each
waste type, along with what types of waste go into each stream,
varies from region to region, with some using the source of the
waste as a basis for sorting, while others use the likelihood of an
objects pathogenicity to determine its disposal waste stream
(Muhlich et al., 2003). This lack of standardization makes effective
waste sorting difficult for healthcare workers, and causes workers
to err on the side of caution, disposing objects in the infectious
waste stream and causing unnecessary infectious waste generation
(Almuneef and Memish, 2003).
Indeed, most studies in academic literature have found that the
majority of waste produced by hospitals is not infectious, meaning
that it could be disposed of in municipal landfills and recycling
programs (Garcia, 1999). This improper sorting has significant
ramifications, as there is a substantial cost premium to dispose of
waste that is infectious. For example, in the United States it costs
$0.79 per kilogram to dispose of infectious waste, which represents
a 560 percent cost premium over the typical non-infectious waste
disposal cost of $0.12 per kilogram (Lee et al., 2004). In the UK,
typical infectious waste disposal costs are similarly high at about
£0.45 per kilogram (Blenkharn, 2005).
Another issue with medical waste disposal is ensuring that
persons do not come into contact, whether accidentally or on
purpose, with disposed-of infectious items. In most jurisdictions,
healthcare facilities have a legal responsibility to ensure that pa-
trons and staff do not come into contact with infectious waste once
it has been placed in a disposal bin (Blenkharn, 2005). Studies,
focused mainly on the UK, have found that hospitals do not have
adequate safeguards to prevent these contacts with hazardous
medical waste, and that safe-handling procedures are frequently
neglected (Blenkharn, 2005). This inadequacy is both a source of
infection and a legal liability for hospitals, should patients become
ill from poor waste management practices. Further reinforcing the
need for adequate safeguards in healthcare facilities, the EPA has
concluded that the disease-causing potential of medical waste is
greatest at the point of generation and naturally tapers off after that
point. Thus, safeguarding of infectious medical waste within
healthcare facilities ought to be made a top waste management
priority (U.S. EPA, 2012b).
5.2. Medical waste transportation
Medical waste transportation refers to the haulage and handling
of waste from inside healthcare facilities to treatment sites, which
can either exist on-site at a hospital or be a central off-site facility. A
second transportation phase typically occurs when the treated
waste residual, typically ash from an incinerator or waste sterilized
through autoclaving or microwaving, is moved to a landfill for final
disposal (Tata and Beone, 1995). It is common practice for health-
care facilities to have their infectious waste stream transported by a
third-party firm, contracted to take the waste from the healthcare
facility to an appropriate waste depot (Brichard, 2002). These firms
103
typically collect the waste from a few central points in a healthcare
facility and then transport the waste to a disposal facility that is
able to safely handle medical waste. However, there are issues with
the process of contracting out waste disposal.
The use of third party disposal firms poses a challenge from an
incentives point of view, as the waste disposal firms, or the in-
dividuals who work for them, can pocket large sums by improp-
erly disposing of the waste. Disposal fees for medical waste in
developed countries are very high, with hospitals in the UK
frequently paying in excess of £450 per tonne for contractors to
dispose of their medical waste and hospitals in the United States
typically paying $790 per tonne for medical waste disposal
(Blenkharn, 2005; Lee et al., 2004). These high prices create an
incentive for third-party medical waste haulage firms to dispose of
the medical waste without treatment in unregulated and less
expensive ways, rather than transport the waste to a proper
treatment facility for sterilization. In Ireland, waste truck operators
can pocket over $2000 by illegally dumping a truck full of medical
waste rather than taking it to a regulated disposal site, thus
creating a very strong incentive for illegal dumping (Brichard,
2002). Developed nations are increasingly having to grapple
with the problem of illegal medical waste dumping, which can be
particularly chronic if the country has a weak infectious medical
waste tracking system. Illegal dumping is a significant issue, as
these untreated infectious waste deposits present a health risk to
the public due to potential for pathogen release, and a drain public
funds as cleanup costs for medical wastes are extremely high
(Brichard, 2002).
Another problem relating to illegally disposing of infectious
medical waste occurs in developing countries such as India, where
governments are grappling with disease outbreaks due to third-
party firms receiving medical waste from healthcare facilities and
then reselling items such as sharps on the black market for re-use
(Solberg, 2009). Indeed, a study by the Indian Clinical Epidemi-
ology Network in 2004 found that almost 10% of health facilities in
India sold their used syringes to waste-pickers, who manually sort
the medical waste in search of any items that can be reused and
sold to healthcare facilities. The recovered sharps are not subjected
to any sort of sterilization process before being reused, thus these
objects present considerable scope for infection of healthcare pa-
tients through transmission of a blood-borne pathogens from the
previous patient (Solberg, 2009). It should be noted that medical
experts do not allow infectious medical waste to be reused or
recycled, regardless of the use of a sterilization process (Zhao et al.,
2009).
5.3. Medical waste disposal methods
Safe disposal of infectious medical wastes is a problem of
considerable scope, with the WHO stating that “at present, there
are practically no environmentally friendly, low-cost options for
safe disposal of infectious wastes” (Brichard, 2002). In the United
States, studies have found that 49e60% of medical waste is incin-
erated, 20e37% is autoclaved, and 4e5% is treated by other tech-
nologies (Rutala and Mayhall, 1992; Zhao, van der Voet and Huppes,
2009). However, concerns over air pollution have raised questions
about the suitability of incineration as treatment method. Further,
medical waste contains a significantly higher plastic content than
typical municipal solid waste, and as a result the combustion of
medical waste leads to the formation of polychlorinated dibenzo-p-
dioxins (dioxins) and polychlorinated dibenzofurans (furans), both
highly toxic substances (Lee et al., 2004). This has led to an
increased focus on alternate treatment methods such as auto-
claving and microwaving to kill any pathogens present.
104 E.S. Windfeld, M.S.-L. Brooks / Journal of Environmental Management 163 (2015) 98e108
6. Issues with current incineration disposal
The leading method of disposing infectious medical waste in
developed nations is through incineration, whereby the wastes are
burned at very high temperatures so that nothing but a residual ash
remains. This ash is then sent to a landfill facility to be buried.
Incineration has the advantage of ensuring sterilization by reducing
the infectious waste to an unrecognizable ash, and of reducing
waste volumes which reduces transport and landfill impacts and
costs (Lee and Huffman, 1996). However, a major drawback of the
medical waste incineration process is the release of undesirable
toxins into the atmosphere. Because of its composition, infectious
healthcare waste produces toxic gases in meaningful quantities
when incinerated, and thus incinerator emissions are tightly
regulated in most developed nations. The three toxins that are of
greatest concern with medical waste incineration are dioxins, fu-
rans, and mercury (Insa et al., 2010).
6.1. Incineration emission standards
Healthcare waste incineration standards in the United States
became stricter in November 1990, when the United States
Congress passed amendments to the Clean Air Act, establishing
emission limits for, among other pollutants, dioxins, furans and
mercury (Hg). These additions to the Clean Air Act were crafted to
encourage the adoption of pollution control equipment on source
exhausts, as the new limits in the act were based on the maximum
achievable pollution reduction through control technology
(Kilgroe, 1996). American regulations then targeted emissions from
municipal and healthcare waste incineration, after the EPA released
its 1994 inventory of dioxin emission sources, which identified
healthcare waste incinerators as the leading source of dioxin and
furan emissions in America (Thorton et al., 1996). Based on the
EPA's findings and their own research, most developed nations
have followed the American example and have attempted to reduce
their dioxin and furan emissions from waste incineration.
6.2. Incinerator emissions
In this section, significant emissions from medical waste in-
cinerators are discussed.
6.2.1. Dioxin and furan emissions
Research has shown that one of the major issues associated with
incineration of infectious waste from healthcare facilities is the
formation of dioxins, furans, and similar compounds during the
combustion process (Verma, 2014). Dioxins are organic compounds
with two benzene rings connected by two oxygen atoms, and
contain four to eight chlorines substituted for hydrogen atoms on
the benzene rings (Schecter et al., 2006). Dioxins are extremely
persistent toxins, with an estimated half-life in humans of 7e11
years, and result primarily from human activity. They are known to
be highly carcinogenic and to cause reproductive harm in humans
(Environment Canada, 2013; Schecter et al., 2006). Furans are
structurally similar to dioxins, but with only one oxygen atom be-
tween the two benzene rings, and have similarly toxic properties.
Hereafter in this paper, the term dioxin is used to refer to dioxin,
furan, and similar compounds.
The United States EPA estimates that medical waste incineration
emitted 2570 g toxicity equivalence (TEQ) of dioxin in 1987, rep-
resenting 18 percent of total atmospheric anthropogenic dioxin
emissions. By 2000, the dioxin emissions from medical waste
incineration facilities were down 85 percent from 1987 levels to
378 g TEQ, or 27 percent of total anthropogenic dioxin emissions
that year (National Center for Environmental Assessment, 2006).
The EPA notes that while the individual dioxin emissions from each
of the over 6000 medical waste incinerators in the United States is
relatively small, the large number of facilities means that their
collective contribution to atmospheric dioxin levels is quite large. In
fact, the small size of most waste incinerators used by hospitals
increases total atmospheric dioxin emissions from infectious
medical waste disposal, as these smaller incinerators are not
equipped with the highly sophisticated dioxin control technologies
that larger incineration facilities can afford (EPA Exposure
Assessment Group, 1994).
In Canada, waste incineration has historically been responsible
for a significant portion of atmospheric dioxin emissions. Despite
Canada greatly tightening its air quality standards over the past
several decades, dioxin emissions from waste incineration facilities
remain the second largest source of dioxin emissions and are
estimated to account for 22.5% of total dioxin emissions within the
country (Environment Canada, 2013).
It is important to note that these macro-scale emission figures
that are reported, do not give a full picture regarding the impact of
emissions associated with incineration facilities. Indeed, the per-
centage increase in airborne dioxin levels that are experienced by
people living near incineration facilities, is substantially higher
than the increase in overall atmospheric concentration (Batterman,
2004). This is of particular concern as developing nations
frequently burn medical waste in uncontrolled conditions and
without any flue gas treatment systems, leading to high levels of
dioxin emissions from these waste disposal facilities (Ananth et al.,
2010). Therefore, populations living near medical waste incinera-
tion facilities in developing nations are frequently exposed to very
high dioxin levels.
6.2.2. Mercury emissions
Incineration of waste, both medical and municipal, is estimated
to represent 13 percent of anthropogenic mercury emissions in
North America, making it second only to coal combustion (at 55
percent) as an emissions source (Pacyna et al., 2006). In Canada,
infectious medical waste incinerators are estimated to account for 9
percent of annual atmospheric mercury emissions (Weir, 2002).
Further, at least 3 percent of global anthropogenic mercury emis-
sions come from waste incineration (Pacyna et al., 2006). Atmo-
spheric mercury emissions pose a significant health and
environmental risk, as airborne mercury can readily enter the body
through the lungs where it accumulates in fatty tissue. This is
concerning, as elevated mercury levels in the body have been
shown to damage the nervous, excretory and reproductive systems
(Wolfe et al., 1998).
6.3. Emissions control
According to the U.S. EPA Office of Air Quality Planning and
Standards, atmospheric emissions of dioxins and mercury are the
pollutants associated with waste incineration of greatest environ-
mental concern (Kilgroe, 1996). The two leading methods for dioxin
emission control from incineration facilities are fabric filter bag
houses and dry scrubbers in combination with electrostatic pre-
cipitators. However, the use of fabric filters is generally accepted to
be a more effective method of dioxin control (Kilgroe, 1996).
Further, incinerator operating conditions play an important role in
dioxin emission levels, with dioxin formation greatly increasing
when combustion is incomplete due to lack of oxygen or when
combustion occurs as temperatures below 800  C. Flue gas tem-
peratures in the range of 250  Ce450  C must also be avoided
(World Health Organization, 2011). By operating incineration fa-
cilities at optimal conditions the dioxin emissions associated with
medical waste incineration can be greatly reduced.
 E.S. Windfeld, M.S.-L. Brooks / Journal of Environmental Management 163 (2015) 98e108
The control of mercury emissions commonly involves injecting
powdered activated carbon into the flue gas stream, onto which the
gas-phase mercury adsorbs. The particles of carbon onto which the
gaseous mercury has been adsorbed can then be removed using
such particulate matter control technologies as fabric filters or
electrostatic precipitators (Kilgroe, 1996).
7. Future directions
The following section discusses autoclave waste treatment as an
alternative to incineration. In addition, substituting medical prod-
ucts with those that are less detrimental when incinerated and the
need for better hospital waste sorting practices are put forward as
areas for future improvement. All of these possibilities have the
potential to mitigate the growing problem of infectious medical
waste disposal.
7.1. Autoclave waste treatment
Considering the high costs and environmental impacts of
medical waste disposal through incineration, many researchers and
firms are devoted to developing alternate treatment methods for
infectious medical wastes. The leading alternative to waste incin-
eration is autoclaving, a process whereby infectious waste is treated
with the addition of dry heat or steam to raise the temperature of
infectious waste to levels sufficient to kill microbial contamination,
with these systems generally operating at temperatures between
121 and 163  C (Lee et al., 2004). After treatment, the autoclaved
waste can be taken to a municipal solid waste (MSW) landfill site
and disposed of in the same manner as non-infectious waste
(Klangsin and Harding, 1998).
Autoclave treatment of infectious medical waste is considered
environmentally advantageous when compared with incineration,
as it does not release the poisonous dioxin and mercury emissions
into the atmosphere (Lee et al., 2004). However, there are draw-
backs to the use of autoclaving as an infectious waste treatment
method. Because autoclave treatment merely heats the waste to
sufficient temperature to kill pathogens, the waste does not change
in appearance after autoclave treatment, giving the appearance that
untreated infectious waste is being disposed of in landfill sites
(Klangsin and Harding, 1998). As a result, autoclaved waste is often
re-treated via incineration before final disposal due to the reluc-
tance of many communities to allow non-incinerated infectious
waste into their landfills, making the autoclave treatment redun-
dant (Jang et al., 2005). This double treatment of infectious medical
waste unnecessarily increases the cost of disposal and creates
needless environmental impacts due to the use of energy in the
autoclaving process.
Another argument against autoclaving infectious waste is that it
does not significantly reduce the volume of waste to be landfilled,
whereas incineration leaves only 20 to 30 percent of the original
waste volume behind as ash, greatly reducing the amount of space
the waste occupies in a landfill (Verma, 2014). However, the
Table 2
Waste disposal bin colors strategies in various countries.
Country Infectious waste
Germany Grey
Greece Red
Saudi Arabia Orange
South Africa Yellow
Notes: Data for Germany (Hoffmann and Schubert, 2010). Data for Greece (Tsakona et al., 2006). Data for Saudi Arabia (Almuneef and Memish, 2003). Data for South Africa
(Nemathaga et al., 2007).
105
drawbacks of autoclave infectious medical waste treatment must
be considered alongside the drawbacks of medical waste inciner-
ation. The macro-scale benefit of waste volume reduction in the
incineration treatment method may be dubious, as medical waste
represents a very small fraction of the total volume of waste
generated per year compared to other types of waste sent to landfill
(Cheng et al., 2009).
A variation of autoclave treatment is microwave treatment,
which involves a process similar to the autoclave process outlined
above but instead uses microwaves to add heat (Lee and Huffman,
1996). However, one major difference between microwaving and
autoclaving waste is that with microwaves, metal cannot be present
in the waste, as microwaves impacting on metal can cause large,
potentially dangerous sparks. Further, some question the ability of
the microwave process to sufficiently reduce the pathogen content
of infectious medical waste (Lee et al., 2004).
7.2. Medical equipment substitution
Literature suggests that incineration is likely to remain a
prominent method of infectious medical waste disposal, which has
prompted some researchers to suggest that medical equipment
suppliers should create products that can be incinerated without
releasing dioxins or mercury (Lee et al., 2004). Indeed, it has been
shown that reducing the amount of dioxin precursor-compounds in
waste entering an incinerator can limit dioxin pollution from
incineration facilities, hence material substitutions by medical
product manufacturers could be reasonably expected to achieve
incinerator dioxin emission reductions (Buekend and Huang, 1998).
Materials containing polyvinyl chloride (PVC) are the leading
source of chlorine content in medical wastes, and the presence of
chlorine in waste is suspected to be the leading cause for the high
dioxins emissions from waste incineration facilities (Thorton et al.,
1996). Therefore, medical equipment suppliers should strive to
reduce or eliminate PVCs from their products as this would almost
certainly lead to a reduction in dioxin emissions associated with
infectious waste incineration (Thorton et al., 1996). Reducing the
amount of PVCs disposed of by hospitals in infectious waste would
be a significant challenge, as PVCs are a prevalent material in
medical products. As a result, any attempt at PVC elimination would
require manufactures to find substitute materials for PVCs, and
healthcare providers may be reluctant to adopt these substitutes if
they perceive any compromise in equipment performance.
Mercury emission reductions require similar substitution ef-
forts, as several medical devices currently contain mercury e
particularly those measuring pressure and temperature. In many
countries, the move to ban mercury from medical equipment use
has been met with opposition, as in many devices, such as the
sphygmomanometer, there is no accurate substitute for mercury.
However, some European countries, such as Sweden and the
Netherlands, have successfully banned mercury-containing equip-
ment from hospitals without unduly compromising healthcare
quality (O'Brien, 2000).
Non-infectious waste Other
Black Infusions bottle ¼ clear
Black Sharps ¼ yellow
Black N/A
Black Chemical and pharmaceutical ¼ brown
106 E.S. Windfeld, M.S.-L. Brooks / Journal of Environmental Management 163 (2015) 98e108
100
Percentage of medical waste classified as
y = 109.98x-0.97
infecƟous (%)
R² = 0.6959
10
1 with a study of five hospitals in five different European countries
1 10
InfecƟous medical waste cost mulƟple
Fig. 4. Percentage of medical waste classified as infectious vs. infectious medical waste
cost multiple (data from Muhlich et al., 2003).
7.3. Medical waste sorting
Most studies conclude that 70 to 80 percent of the infectious
waste stream leaving hospitals is composed of non-infectious
wastes that have been erroneously mixed into the infectious
waste stream due to poor sorting practices (Garcia, 1999). After
entering the infectious waste stream, non-infectious materials
become contaminated and so must be treated as infectious,
necessitating disposal at significantly higher cost. Therefore,
healthcare facilities can reduce their medical waste disposal ex-
penditures by ensuring that only infectious materials are disposed
of in the infectious waste stream (Hoffmann and Schubert, 2010).
7.3.1. Point-of-disposal waste sorting
It is generally accepted that the best way to prevent non-
infectious waste from entering the infectious waste stream is by
point-of-disposal sorting, whereby healthcare facility staff divide
the medical waste into infectious and non-infectious waste streams
when they deposit the waste into receptacles (Bai et al., 2012).
However, it is often difficult for healthcare staff to determine if
waste is pathogenic, due to the plethora of waste sources within a
hospital and a lack of clear sorting protocols (Tsakona et al., 2006).
Indeed, many hospital studies have discovered that workers lack
guidance regarding waste sorting to such an extent that individual
workers develop their own sorting system based on personal sen-
sibilities, rather than sorting waste based on hospital criteria
(Almuneef and Memish, 2003). This lack of guidance shows poor
institutional operation, and almost certainly requires attention if
infectious waste volumes and disposal costs are to be reduced.
Other venues that generate large volumes of waste, such as food
courts, hire full-time employees work as waste sorters, with their
only role being to sort waste into the correct disposal streams.
Further research is needed to determine if hiring employees into a
similar role at healthcare facilities would create a significant
improvement in waste sorting performance, and if the savings from
lower infectious waste generation is large enough to justify the
sorter's wages.
7.3.2. Need for standardization
A lack of standardized medical waste streams and associated bin
colors is likely a major driver of the aforementioned poor point-of-
disposal waste sorting performance, as this lack of standardization
makes it difficult for educational facilities to train workers and
confuses healthcare staff who transfer from one facility to another
(Almuneef and Memish, 2003). To illustrate the lack of
standardization, the waste streams and associated color coding
systems used by several countries are shown in Table 2.
Even within countries that use their own unique classification
system, colors for each waste type are not standardized between
regions, causing further confusion. Further, differences in waste
classification around the world make it difficult to comparatively
measure infectious medical waste production from region to region
(Insa et al., 2010).
7.3.3. Improving management practices
Studies indicate that incentives for better waste management at
hospitals are capable of reducing the amount of waste generated,
100 illustrating the point particularly well (Muhlich et al., 2003). The
study first presents the disposal cost of both infectious and non-
infectious waste according to the metric calculated using Equa-
tion (1).
Infectious medical waste cost multiple
Cost of disposing 1 ton infectious medical waste
¼ (1)
Cost of disposing 1 ton municipal solid waste
Muhlich et al. (2003) then details the percentage of total med-
ical waste that each hospital sends out in the infectious waste
stream. By fitting a power trend-line to this data (Fig. 4), it is
possible to see a correlation between a higher infectious waste cost
multiple and a lower percentage of waste sent out in the infectious
medical waste stream. This suggests that the implementation of
incentives, monetary or otherwise, for hospitals to improve sorting
practices will encourage management to implement better waste
sorting practices.
8. Conclusion
Medical waste disposal is a field that requires further study to
meet the growing global demand for medical waste disposal. Rising
healthcare usage, driven by a variety of factors, is increasing med-
ical waste production which in turn is putting stress on current
disposal systems. Current disposal strategies involve sorting waste
at the point-of-disposal within healthcare facilities, and then
transporting the infectious medical waste to a safe disposal site,
where it is treated by incineration or autoclaving and the residual
product landfilled. Both incineration and autoclave treatment
methods have drawbacks, with incineration creating undesirable
atmospheric emissions which cause adverse health and environ-
mental impacts, and autoclave treatment not able to handle all
types of waste nor producing a treated product that is universally
accepted at landfills.
The best way to control the impact of medical waste is to pro-
duce less, and one of the most effective ways to do this is to ensure
that only infectious medical waste is sent for treatment e other
hospital waste should be treated in the same manner as municipal
household waste. This could be accomplished through better
training of healthcare workers along with the implementation of
standardized medical waste streams and disposal bin colors.
Further, there are a number of moves that governments could
make to reduce the problems of excess infectious medical waste
generation and to improve treatment and disposal of all types of
medical waste. Firstly, governments should provide highly explicit,
standardized definitions of infectious and non-infectious medical
waste and should tightly regulate the disposal of infectious waste to
prevent illegal dumping of waste. Secondly, governments should
provide healthcare facilities with incentives, monetary or other-
wise, to reduce medical waste production. These incentives will
help convince local healthcare facility management to make waste
 E.S. Windfeld, M.S.-L. Brooks / Journal of Environmental Management 163 (2015) 98e108
reduction, particularly infectious medical waste production, a pri-
ority. Finally, governments should seek to increase research in the
area of medical waste reduction and treatment though research
grants and industry research partnerships. In particular, priority
should be given to research with medical equipment suppliers to
develop and produce products that release negligible amounts of
dioxins or mercury when incinerated. These products will be
particularly valuable to developing nations where many waste
disposal facilities lack the advanced pollution control technologies
used in the developed world to prevent the release of toxic sub-
stances produced by waste incineration. As such, these
incineration-safe medical products reduce the risk of exposing
populations in developing nations to the harmful emissions pro-
duced by the incineration of infectious medical waste.
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