UNDP GEF Project on Global Healthcare Waste INSTRUCTOR GUIDE MODULE 16: INCINERATION OF HEALTHCARE WASTE AND THE STOCKHOLM CONVENTION GUIDELINES 1 UNDP GEF Project on Global Healthcare Waste MODULE 16: INCINERATION OF HEALTHCARE WASTE AND THE STOCKHOLM CONVENTION GUIDELINES Estimated Time Module Overview Learning Objectives Target Audience Lecture: 1 hour 30 minutes Present the principles and basic approaches for healthcare waste treatment Describe the basics of incineration and types of incinerators for healthcare waste Lay out factors for consideration when selecting waste treatment methods Describe the environmental and health impacts of incinerators Present the Stockholm Convention guidelines for incinerators Describe maintenance and troubleshooting of incinerators and air pollution control devices Understand the factors to consider when deciding upon the proper treatment method Understand the basics of incineration and its environmental and health impacts Be aware of the Stockholm Convention guidelines on incineration Learn basic maintenance and troubleshooting of incinerators and air pollution control devices HCWM coordinators Administrators Healthcare professionals and other staff interested in participating in HCWM planning On-site treatment managers and operators Central treatment plant managers and operators National staff and advisors in the Ministry of Health, Ministry of Environment and other relevant government ministries, country level staff of international organizations or agencies, country level staff of national organizations and NGOs, and others involved in national or regional HCWM planning 2 UNDP GEF Project on Global Healthcare Waste Instructor Preparation Materials Needed Student Preparation Review Questions Make notes pages of PowerPoint slides to hand out to class Read Chapter 8 in Blue Book, and other materials included in the References Global and country specific regulations and guideline for treatment and disposal of healthcare waste. Make copies of any additional documents/readings that may be handed out to class, such as those included in the References Prepare any additional notes to be discussed during the presentation Prepare any additional discussion points or review questions Projector Student handouts: slides, exercise, homework Flip chart and marker pens and/or board and chalk Blue Book Chapter 8 Global and country specific regulations and guideline for treatment and disposal of healthcare waste. Think about incineration of healthcare wastes and the methods used in your own facility. What regulations or policies exist in your country or region regarding treatment and disposal methods? What are viable options for disposal of healthcare waste available in your facility or country? What are some factors that your facility considers when deciding on a waste treatment method? What do think is important when evaluating which method would be most appropriate? Does your facility use incineration, or have they used it as a treatment method in the past? What are some of the cost and benefits of incineration? Discuss air emissions and dioxin formation in relation to incinerators. Does your incinerator meet the Stockholm Convention guidelines and national regulations? What are the barriers to implementing non-incineration treatment and disposal methods? 3 UNDP GEF Project on Global Healthcare Waste PRESENTATION Slide Number/Title Teacher’s Notes Slide 1: Title Slide This module should be modified to meet the needs of the participants. For example, the slides on the types of incinerators, maintenance procedures, and troubleshooting are more appropriate for technology operators and facility engineers. Administrators and the engineering department should be aware of the Stockholm Convention guidelines as well as national regulations related to incineration. All participants should be aware of the environmental and health impacts of incineration. Slide 2: Module Overview Slide 3: Learning Objectives Slide 4: Steps in Healthcare Waste Management Slide 5: Principles of Waste Treatment Slide 6: Treatment Approaches Introduce the outline and major points of the presentation Describe what participants will learn at the end of this module. This module focuses on waste treatment and disposal using incineration. Introduce some principles of waste treatment Different treatment approaches: -on-site -cluster treatment -central treatment There is a fourth treatment approach: mobile treatment. In mobile treatment, the treatment technology is mounted on a vehicle which then goes from hospital to hospital to treat the waste. This is used in some countries mainly with autoclave-type treatment. 4 UNDP GEF Project on Global Healthcare Waste Slide 7: Processes The Blue Book discusses five main processes for the treatment of hazardous components in HCW: Used in the Treatment -thermal of Healthcare Waste -chemical -irradiation -biological -mechanical Slide 8: Thermal Treatment Processes Rely on heat to kill pathogenic organisms; divided into low-heat and high-heat designs. Slide 9: Incineration Introduce the incineration process. Pyrolysis: thermal degradation of a substance through the application of heat in the absence of oxygen; most commonly used for organic materials. Disadvantage of these processes is the release of combustion by-products into the air and the generation of residual ash. Combustion generally produces gas emissions in the form of steam, carbon dioxide, nitrogen oxides, a wide range of volatile substances, and particulate matter. Gasification and pyrolysis operate at sub-stoichiometric air levels and can also take place in parts of an incinerator. Larger healthcare facilities may have the means to reuse the heat generated form the combustion of waste, but most incinerators are too small for energy recovery to be very effective. Slide 10: Incineration Identify some of the required waste characteristics of incinerators Slide 11: Incineration Go through the bulleted list of points taken from the Blue Book, in which no pre-treatment will be needed as long as the wastes are not present or are kept to a minimum. 5 UNDP GEF Project on Global Healthcare Waste Slide 12: Types of Incinerators for Healthcare Waste Slide 13: Types of Incinerators for Healthcare Waste Slide 14: Types of Incinerators for Healthcare Waste Slide 15: Types of Incinerators for Healthcare Waste Slide 16: Construction and Installation of Incinerators Slide 17: Operation of Incinerators Slide 18: Why Preventive Maintenance is Essential Slide 19: Preventive Maintenance Slide 20: Maintenance of Incinerators Common types of incinerators: Dual-chamber incinerators Multiple-chamber incinerators Rotary kilns Go over the construction and installation of incinerators General operational procedures include: - Waste charging - Combustion - Air pollution control - Ash removal Describe why preventive maintenance of healthcare waste technologies is essential This and subsequent slides on maintenance are intended primarily for incinerator plant manager and operator, and facility engineers. Go over the maintenance of incinerators – hourly, daily, weekly, biweekly, monthly, semi-annually 6 UNDP GEF Project on Global Healthcare Waste Slide 21: Maintenance of Incinerators (cont’d) Slide 22: Factors in the Selection of Treatment Methods Slide 23: Factors in the Selection of Treatment Methods, cont’d. Slide 24: Air Emissions From a Medical Waste Incinerator Slide 25: Pollutants Measured From Medical Waste Incinerators Slide 26: Pollutants Measured From Medical Waste Incinerators Slide 27: Epidemiological Studies Related to Health Effects of Incineration Slide 28: Epidemiological Studies Related to Health Effects of Incineration Go through the listed points in this and the following slide to show that there are many factors to consider when deciding upon a treatment method. Diagram showing some of the pollutants emitted from medical waste incinerators. Air pollutants measured from medical waste incinerator emissions include: trace metals, acid gases, dioxins and furans, other organic compounds, CO, particulate matter, and pathogens Bottom ash contains: dioxins and furans, other organics, and leachable metals In the next five slides inclusive, present the major findings of a number of epidemiological studies about the health effects of incineration. 7 UNDP GEF Project on Global Healthcare Waste Slide 29: Epidemiological Studies Related to Health Effects of Incineration Slide 30: Epidemiological Studies Related to Health Effects of Incineration Slide 31: Epidemiological Studies Related to Health Effects of Incineration Slide 32: Medical Waste Incineration (MWI) is a Major Global Source of Dioxins Slide 33: Where are Dioxins Formed in a Medical Waste Incinerator? Slide 34: What are “Dioxins”? Slide 35: How Far Do Dioxins Travel? Go through some country statistics on the presence of dioxins related to MWI Describe basic characteristics of dioxins Dioxins may travel long distances in the air (up to hundreds of kilometers) 8 UNDP GEF Project on Global Healthcare Waste Slide 36: How Long do Dioxins are very persistent in the environment. Dioxins Remain in the Environment? Environmental half-life on surface soil: 9-15 years Environmental half-life in subsurface soil: 25-100 years Volatilization (process in which a substance is vaporized) half-life in body of water: > 50 years Slide 37: Bioconcentration of Dioxins Go over the listed bioconcentration factors for 2,3,7,8-TCDD. Slide 38: Health Effects Associated with Dioxin In the next four slides, go over the major health effects associated with dioxins. Bioconcentration factor = the ratio of a contaminant’s concentration in biota to its concentration in the surrounding medium Classification as a known human carcinogen by the IARC (1997). A number of cancers are linked to dioxins. Slide 39: Health Effects Associated with Dioxin Developmental effects: birth defects, alterations in reproductive system, impact on child’s learning ability and attention, changes in sex ratio Slide 40: Health Effects Associated with Dioxin Slide 41: Health Effects Associated with Dioxin Male and female reproductive effects Immune system impacts Other health effects: -chloracne (acne-like spread of blackheads, cysts, pustules) -hirsutism (excessive hairiness) -hyperpigmentation (darkening of skin or area under nails) -altered fat metabolism -diabetes -nerve system damage -liver, spleen, thymus, and bone marrow damage 9 UNDP GEF Project on Global Healthcare Waste Slide 42: Dioxin Toxicity at Extremely Low Concentrations Give some of the values for toxicity at low concentrations: LOAELs, TDIs (WHO), cancer potency factor (US EPA) Slide 43: Health Risk Assessment Study Refer to the following article in the next few slides: LOAEL = lowest observed adverse effect level Batterman, Stuart, Environmental Health Services, University of Michigan. Assessment of Small-Scale Incinerators for Healthcare Waste. January, 2004. http://www.who.int/immunization_safety/publications/waste_management/en/assessment_SSIs.pdf Recommended criteria for evaluating small-scale incinerator options for HCW: -effectiveness -cost-effectiveness -safety -simplicity -robustness Slide 44: Health Risk Assessment Study Three classes of small-scale incinerators: best practice, expected practice, worst case Slide 45: Health Risk Assessment Study Slide 46: Findings of the Risk Assessment Study Go through three usage scenarios Other elements of best practice: -effective waste reduction and waste segregation to ensure that the smallest amount of waste is incinerated -siting of incinerators away from populated areas or where food is grown in order to minimize risks and exposures -construction that follows detailed dimensional plans, thus avoiding flaws that could lead to incomplete destruction of waste, higher emissions, and premature failures of the incinerator Use the table to provide a summary of the results 10 UNDP GEF Project on Global Healthcare Waste Slide 47: Dioxins in Breast Milk Chart showing dioxin concentrations in breast milk in selected countries, most of which exceed the permissible limit for dioxins in cow’s milk. Slide 48: Incineration and the Stockholm Convention Slide 49: Incineration and the Stockholm Convention Incinerator emissions should comply with national standards and be in compliance with the Stockholm Convention’s best available technology (BAT) and best environmental practices (BEP) guidelines if the country has signed the agreement. Slide 50: Best Available Techniques Guidelines under the Stockholm Convention Incineration equipment should be chosen based upon local needs and available resources. Slide 51: Best Available Techniques Guidelines under the Stockholm Convention In the next batch of slides, go through specific BAT guidelines under the Stockholm Convention. Slide 52: Best Available Techniques Guidelines under the Stockholm Convention General measures Single-chamber, drum-and-brick incinerators are not acceptable under the Stockholm Convention. An incinerator should consist of: -furnace or kiln -afterburner chamber -flue gas cleaning system -wastewater treatment if wet flue gas cleaning is used BAT air emissions performance levels and wastewater performance levels will be achieved by a combination of primary and secondary measures. TEQ = Toxic Equivalent Quantity 11 UNDP GEF Project on Global Healthcare Waste Slide 53: Best Available Techniques Guidelines under the Stockholm Convention Slide 54: Best Available Techniques Guidelines under the Stockholm Convention Slide 55: Best Available Techniques Guidelines under the Stockholm Convention Slide 56: Best Available Techniques Guidelines under the Stockholm Convention Slide 57: Best Available Techniques Guidelines under the Stockholm Convention Slide 58: Best Available Techniques Guidelines under the Stockholm Convention Primary measures Primary measures Secondary measures: Top drawing: fabric baghouse filter Middle drawing: cyclone Bottom: electrostatic precipitator Secondary measures Top drawing: dry absorption system (dry scrubber) using line Bottom: Wet absorption system (wet scrubber) Disposal of residues Drawing: example of a landfill design Monitoring 12 UNDP GEF Project on Global Healthcare Waste Slide 59: Examples of Other Environmental Requirements Slide 60: National Regulations Pertaining to Incineration Slide 61: Maintenance of Air Pollution Control To be developed according to specific country’s regulations on incineration. Note: This and subsequent slides on maintenance and troubleshooting are intended for technology managers, operators and facility engineers. Go through an example of a wet scrubber maintenance schedule – daily, weekly, monthly, semiannually Slide 62: Maintenance of Air Pollution Control Slide 63: Troubleshooting Incinerators Go through an example of a baghouse filter maintenance schedule – daily, weekly, monthly, quarterly, semi-annually, annually Slide 64: Troubleshooting Incinerators Slide 65: Troubleshooting Incinerators Slide 66: Troubleshooting Incinerators Slide 67: Troubleshooting Incinerators Symptom: Steady white or blue-white smoke from stack Discuss troubleshooting of incinerators and air pollution control devices in the next series of slides. Symptom: Black smoke from the stack Symptom: White smoke or white haze appears a short distance from the stack Symptom: Smoke coming out of the primary chamber Symptom: Incinerator uses too much fuel 13 UNDP GEF Project on Global Healthcare Waste Slide 68: Troubleshooting Incinerators Slide 69: Troubleshooting Air Pollution Control Devices Symptom: A lot of combustible materials remaining in the ash (poor ash quality) Slide 70: Troubleshooting Air Pollution Control Devices Symptoms: Fan vibration, stuck dampers, or poor nozzle spray patter in the wet scrubber Erosion of fans, dampers and duct work (dry components of the wet scrubber) Erosion of scrubber and spray nozzle (wet components of wet scrubbers with recirculating systems) Slide 71: Troubleshooting Air Pollution Control Devices Symptoms: Unusually high pressure readings of the baghouse filter Unusually low pressure readings of the baghouse filter or high opacity Symptom: Corrosion of wet scrubber parts Slide 72: Resources Slide 73: Some Trends The graphs show some trends in MWI in different countries in Medical Waste Incineration (MWI) Slide 74: Treatment Technologies That Do Not Generate Dioxins/Furans (covered in Module 15) Slide 75: Discussion Generate a discussion with the class using these points and the review questions as a basis. 14 UNDP GEF Project on Global Healthcare Waste References (in order as they appear in slides; refer to individual slides about epidemiological studies for their respective sources) Blue Book, Chapter 8 USGS: Toxic Substances Hydrology Program – Bioconcentration. http://toxics.usgs.gov/definitions/bioconcentration.html Batterman, Stuart, Environmental Health Services, University of Michigan. Assessment of Small-Scale Incinerators for Healthcare Waste. January, 2004. http://www.who.int/immunization_safety/publications/waste_management/en/assessment_SSIs.pdf United Nations, UNEP: Stockholm Convention. http://www.pops.int/ European Commission, Integrated Pollution Prevention Control (IPPC). Reference Document for the Best Available Techniques for Waste Incineration, August 2006. http://eippcb.jrc.es/reference/BREF/wi_bref_0806.pdf Emmanuel, Jorge and Stringer, Ruth (2007). FOR PROPER DISPOSAL: A Global Inventory of Alternative Medical Waste Treatment Technologies. http://www.gefmedwaste.org/downloads/For%20Proper%20Disposal.pdf GEF Medical Waste Project: www.gefmedwaste.org US EPA: Hospital Incinerator Operator Training Course, 1989. 15