UNDP GEF Project on Global Healthcare Waste
INSTRUCTOR GUIDE
MODULE 16: INCINERATION OF HEALTHCARE WASTE AND THE
STOCKHOLM CONVENTION GUIDELINES
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UNDP GEF Project on Global Healthcare Waste
MODULE 16: INCINERATION OF HEALTHCARE WASTE AND THE STOCKHOLM CONVENTION
GUIDELINES
Estimated Time
Module Overview
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Learning Objectives
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Target Audience
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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
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UNDP GEF Project on Global Healthcare Waste
Instructor Preparation
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Materials Needed
Student Preparation
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Review Questions
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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?
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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.
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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.
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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
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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.
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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)
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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
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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
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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
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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
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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
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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.
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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.
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