UNDP GEF Project on Global Healthcare Waste
INSTRUCTOR GUIDE
MODULE 2: HEALTH AND E NVIRONMENTAL IMPACTS HEALTH CARE WASTE
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UNDP GEF Project on Global Healthcare Waste
MODULE 2: HEALTH AND ENVIRONMENTAL IMPACTS HEALTHCARE WASTE
Estimated Time
Module Overview
Learning Objectives
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Target Audience
Instructor Preparation
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Lecture: 45 minutes
Activity: 45 minutes
Describe hazards of healthcare waste
Describe who is at risk of exposure
Describe the chain of infection, routes of exposure, how to intervene
List common pathogens associated with healthcare waste
Describe potential public health and environmental impacts of healthcare waste
Characterize the main types of hazards associated with healthcare wastes and their
health effects
Identify who is at risk of exposure
Identify key routes of exposure
Describe the public and environmental impacts of mismanagement of healthcare
wastes in your country
Administrative personnel
HCWM coordinators
Facility managers
Healthcare professionals
Healthcare waste workers
Facility support staff
Other positions within facility
Make notes pages of PowerPoint slides to hand out to class
Make copies of class exercise for distribution at start of class
Read Chapters 2 and 3 in Blue Book, and other materials included in the References
Find regional and national data to fill in country-specific slides
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
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UNDP GEF Project on Global Healthcare Waste
Materials Needed
Student Preparation
Review Questions
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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 2, 3
Begin thinking about healthcare waste, what role you play in its
generation/removal, and how it is dealt with in your facility
What are some of the major routes of exposure to healthcare wastes? Who do you
think is at risk of exposure to hazards from healthcare waste at your facility? What
are some of the hazards that are often present? Do certain hazards present greater
risk than others?
How does your facility deal with the major categories of healthcare wastes (sharps,
chemical, etc.)? Do you know of any interventions that can reduce exposure to
healthcare wastes?
Think about the chain of infection. Can you give an example of this process within
the healthcare setting?
What are some public health and environmental impacts of mismanaged healthcare
wastes, both within and beyond the facility? How might people outside of the
immediate medical setting be exposed to healthcare waste hazards?
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UNDP GEF Project on Global Healthcare Waste
PRESENTATION
Slide Number/Title
Teacher’s Notes
Slide 1: Title Slide
Slide 2: Module Overview
Slide 3: Learning Objectives
Slide 4: Types of Hazards of
Healthcare Wastes
Begin this module with the exercise
Introduce the outline and major points of the presentation
Describe what participants will learn at the end of this module.
Infectious and anatomic wastes together represent the majority of the hazardous waste, up
to 15% of the total waste from healthcare activities.
Sharps represent for about 1% of the total waste, but they are a major source of disease
transmission if not properly managed. Chemicals and pharmaceuticals account for about
3% of waste from healthcare activities while genotoxic waste, radioactive matter, and
heavy metal content account for around 1% of the total healthcare waste, depending on the
types of services provided by the facility.
Slide 5: What is Risk?
Risk is the chance that exposure to a substance or an activity will lead to a harmful effect.
Risk assessment is a process of characterizing the nature of the risk, identifying the
person(s) or environmental entities at risk, determining the hazards posed by the
substance or activity, and evaluating the extent and duration of exposure of those at risk to
the hazardous substance or activity, thereby assessing the extent of the risk.
Slide 6: Persons at Risk
Ask participants to list who is at risk of exposure to hazards from healthcare waste at their
specific facility and why.
Slide 7: Effects of Exposure to
Healthcare Wastes
Describe the key qualities of the agent (infectious/toxic), environment, host and disease.
For example, if it is an infectious agent- we want to know the life cycle or incubation
period, pathogenicity and can we test for this agent?
We want to know the circumstances of the exposure- was it a needle stick? do we have
protective gear? why did this happen? could we have prevented this?
We want to know who was exposed- a pregnant nurse, or elderly sweeper?
We want to know more about the outcome- what disease can this cause? what are the
symptoms? do we have prophylactic treatment options?
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UNDP GEF Project on Global Healthcare Waste
Slide 8: Infectious Waste,
Including Sharps
Slide 9: Chain of Infection
Introduce the basics of infectious waste and sharps
Use the links below to :
Describe transmission of infections via the chain of infection and the significance of chain
of infection to implement control measures and protect workers.
Infectious agent: a microbial organism that can cause disease
Reservoir: a place where micro-organisms can thrive and reproduce e.g. in humans, animals, inanimate
objects
Portal of exit: a means for a micro-organism to leave the reservoir e.g. respiratory, genitourinary, and
gastrointestinal tracts, skin and mucous membranes and the placenta
Mode of transmission: how the organism moves from one place to another e.g. contact, droplets, airborne
Portal of entry: an opening allowing the micro-organism to invade a new host; usually the same as the portal
of exit
Susceptible host: a person susceptible to the disease, lacking immunity or physical resistance to prevent
infection
How can we break the chain of infection? Can participants think of any examples of
interventions?
Review of Health Impacts from Microbiological Hazards in Healthcare Wastes
http://www.who.int/water_sanitation_health/medicalwaste/en/microbhazards0306.pdf
Chain of Infection: Diagram and Explanations
http://faculty.ccc.edu/tr-infectioncontrol/chain.htm
Slide 10: Common Pathogens
and Routes of Transmission
Slide 11: Examples of Hazards of
Infectious Waste including
Sharps
Describe some acute potential hazards. Sharps pose a double risk.
World Health Organization, 2006. Management of Waste from Injection Activities at
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UNDP GEF Project on Global Healthcare Waste
District
Level: Guidelines for District Health Managers.
http://www.who.int/water_sanitation_health/medicalwaste/mwinjections.pdf
Slide 12: Risks of Infections from
Sharps
Instructor:
HBV = Hepatitis B virus
HCV = Hepatitis C virus
HIV = Human Immunodeficiency virus
You may use these articles to familiarize yourself with some reports.
Dziekan, Gerald, et al. The Cost-Effectiveness of Policies for the Safe and Appropriate Use
of Injection in Healthcare Settings. Bulletin of the World Health Organization, 2003. 277285
http://www.who.int/bulletin/volumes/81/4/Dziekan0403.pdf
Wilburn, S., Eijkemans G. Preventing Needlestick Injuries Among Healthcare Workers. Int.
J. Occup. Environ. Health, 2004, vol. 10. 451-456
http://www.who.int/occupational_health/activities/5prevent.pdf
DHHS, NIOSH. Preventing Needlestick Injuries in Health Care Settings, November 1999.
http://www.cdc.gov/niosh/docs/2000-108/pdfs/2000-108.pdf
Prüss-Üstün, Rapiti & Hutin, 2003. Estimation of the Global Burden of Disease Attributable
to Contaminated Sharps Injuries Among Health-care Workers.
http://www.who.int/quantifying_ehimpacts/global/7sharps.pdf
Slide 13: Risks of Infections from
Sharps
Slide 14: Risks of Infections from
Sharps
Slide 15: Rates of Injury at
Regional or National Level
Please find some regional or national data about injury rates. Any reports or published
articles about sharps injury rates in your country? Any injury rates available for this
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UNDP GEF Project on Global Healthcare Waste
particular facility? You may include non-published data as well.
Slide 16: Examples of Other
Hazards Related to Healthcare
Wastes
Slide 17: Chemical Wastes
MDR-TB: Multidrug-resistant tuberculosis
MRSA: Methicillin-resistant Staphylococcus aureus
Slide 18: Hazardous Properties
Replace this slide with the country’s definition of hazardous waste properties, if available.
Slide 19: Hazardous Properties
Some countries define a toxic substance based on acute LD50 values for ingestion and
dermal exposures; acute LC50 values for inhalation and for aquatic species; as well as
evidence that the substance poses a hazard to human health or environment because of its
carcinogenicity (carcinogen, mutagen, teratogen), acute toxicity, chronic toxicity,
bioaccumulative properties, or persistence in the environment.
An acute exposure is a single exposure to a hazardous substance for a short time. Chronic
exposure occurs over a much longer period of time, usually with repeated exposures in
smaller amounts.
Symbols shown are commonly used pictograms.
LD50 = Lethal Dose, which causes the death of 50% of the test animals
LC50 =Lethal Concentration
Slide 20: Hazardous Properties
Slide 21: Some Examples of
Hazardous Chemical Wastes
Find out more about mercury thermometers at:
http://watoxics.org/files/mercury-thermometers
Slide 22: Some Examples of
Hazardous Chemical Wastes
Toxic laboratory chemicals include glutaraldehyde and formaldehyde, among others
Slide 23: Some Examples of
Hazardous Chemical Wastes
Provide examples of chemical wastes that are flammable or reactive, and disinfectants that
are both reactive and corrosive
Give some examples of corrosive acids and bases found in the healthcare setting
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UNDP GEF Project on Global Healthcare Waste
Slide 24: Hazards from
Pharmaceutical Wastes
Pharmaceutical waste includes expired, unused, spilt and contaminated pharmaceutical
products, prescribed and proprietary drugs, vaccines and sera that are no longer required;
because of their chemical and biological nature, they need to be carefully disposed of.
WHO (1999). Guidelines for Safe Disposal of Unwanted Pharmaceuticals In and After
Emergencies.
http://www.who.int/water_sanitation_health/medicalwaste/unwantpharm.pdf
Slide 25: Chemotherapeutic
Wastes
Slide 26: Examples of
Chemotherapy Agents
Slide 27: Hazards of
Chemotherapy Wastes
Slide 28: Hazards of
Chemotherapy Wastes
Slide 29: Hazards from
Radioactive Wastes
Go through table
Genotoxic substances possess the ability to interact with DNA, making them potentially
mutagenic and carcinogenic to humans (and other animals). Describe exposure to
genotoxic wastes and pathways into the body.
Severity of hazards depend on substance toxicity and duration of exposure
Radioactive wastes are materials that are contaminated with radionuclides, produced as a
result of certain medical procedures, such as in vitro analysis of body tissue and fluids.
Provide some examples
Slide 30: Effects of Improper
Healthcare Waste Disposal
Slide 31: Some Data on Public
Health & Environmental Impacts
of Healthcare Waste
Slide 32: Some Data on Public
Health & Environmental Impacts
Talk about some major public health and environmental impacts from healthcare wastes
Describe impacts from scavenging, illegal re-use of medical devices and uncontrolled
discharging of HCW.
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UNDP GEF Project on Global Healthcare Waste
of Healthcare Waste
You may choose to view a series of videos (or some portion of them) of an investigation
into illegally recycled medical instruments in Cairo, totaling about 35 minutes and titled
“Medical Waste Recycling: Uncovering a Lucrative Trade”. It may be found at
http://www.icfj.org/content/medical-waste-recycling-uncovering-lucrative-trade
Slide 33: Public Health &
Environmental Impact
Slide 34: Public Health &
Environmental Impact
Slide 35: Some Data on Public
Health & Environmental Impacts
of Healthcare Waste
Slide 36: Other Public Health &
Environmental Impacts
Problems associated with improper disposal of waste from radiotherapy treatment
Slide 37: Discussion
References (in order as they
appear in slides)
Go over major points from the module that tie in with review questions.
Blue Book, chapter 2, 3
Additional public/environmental health problems due to incinerators, mercury release,
and public sensitivity
Infection Control for Nursing Students: Chain of Infection Diagram & Explanation.
http://faculty.ccc.edu/tr-infectioncontrol/chain.htm
World Health Organization, Salkin, Ira F. Review of Health Impacts from Microbiological
Hazards in Healthcare Wastes, 2004.
http://www.who.int/water_sanitation_health/medicalwaste/en/microbhazards0306.pdf
World Health Organization, 2006. Management of Waste from Injection Activities at
District
Level: Guidelines for District Health Managers.
http://www.who.int/water_sanitation_health/medicalwaste/mwinjections.pdf
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UNDP GEF Project on Global Healthcare Waste
Dziekan, Gerald, et al. The Cost-Effectiveness of Policies for the Safe and Appropriate Use
of Injection in Healthcare Settings. Bulletin of the World Health Organization, 2003. 277285
http://www.who.int/bulletin/volumes/81/4/Dziekan0403.pdf
Wilburn, S., Eijkemans G. Preventing Needlestick Injuries Among Healthcare Workers. Int.
J. Occup. Environ. Health, 2004, vol. 10. 451-456
http://www.who.int/occupational_health/activities/5prevent.pdf
DHHS, NIOSH. Preventing Needlestick Injuries in Health Care Settings, November 1999.
http://www.cdc.gov/niosh/docs/2000-108/pdfs/2000-108.pdf
Prüss-Üstün, Rapiti & Hutin, 2003. Estimation of the Global Burden of Disease Attributable
to Contaminated Sharps Injuries Among Health-care Workers.
http://www.who.int/quantifying_ehimpacts/global/7sharps.pdf
Washington Toxics Coalition: Mercury Thermometers Fact Sheet. May 2002
http://watoxics.org/files/mercury-thermometers
WHO (1999). Guidelines for Safe Disposal of Unwanted Pharmaceuticals In and After
Emergencies.
http://www.who.int/water_sanitation_health/medicalwaste/unwantpharm.pdf
International Center for Journalism. Medical Waste Recycling: Uncovering a Lucrative
Trade (video). 2009
http://www.icfj.org/content/medical-waste-recycling-uncovering-lucrative-trade
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UNDP GEF Project on Global Healthcare Waste
ACTIVITY: MODULE 2: EXERCISE (45 MINUTES)
This module exercise picks up where Module 1 left off. The purpose of this exercise is to have participants continue thinking
about the health and environmental impacts of healthcare waste.
Instructor: Break class into groups of three or more, and distribute exercise at beginning of class. You may group participants
by facility, department, or job type. Participants will complete the activity in groups and then present their answers.
Instructor should record participant/group responses on a wipe board, flip chart, or transparency, categorize their responses.
In the de-brief following the presentation, you will go over the activity once again.
Module 2 Exercise: Health and Environmental Impacts of Healthcare Waste
Instructor should use the lists of wastes written down by the participants in the Table from Module 1 Exercise, review the
hazards listed and ask participants to discuss the following questions:
1.
2.
3.
4.
Can you discuss ways in which these hazards are contained or should be contained in your facility?
Discuss any personal experiences with exposures to hazards.
Have accidents happened with any of your staff? How can they be prevented in the future?
What are some possible negative impacts on your environment if hazardous wastes from your facility are disposed of
improperly?
5. Have you thought about how your waste disposal methods can impact your surrounding communities? Should you feel
responsible? What can you do about this?
De-brief
Instructor will categorize and discuss the public health impacts of healthcare waste and how it relates to the rest of the course.
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