MODULE 18:

Management of Chemical, Cytotoxic,

Pharmaceutical and Radioactive

Wastes

Module Overview

• Describe sources and types of chemical,

cytotoxic, pharmaceutical, and radioactive

wastes in a healthcare setting

• Discuss risks associated with exposure to these

specific wastes

• Describe all aspects of management of these

specific wastes

• Describe treatment and disposal methods

Learning Objectives

• Identify hazardous (non-infectious) wastes in a

healthcare facility

• Identify key steps in collection, handling,

storage, transport, treatment and disposal of

these wastes

Sources & Examples of Hazardous

(Non-Infectious) Wastes

• Examples of Sources

– Chemicals from diagnostic and experimental work

– Cleaning and disinfecting compounds

– Agents used for chemotherapy

– Drugs that are no longer required

– Waste from nuclear medicine

• Examples of Wastes

– Formaldehyde (Haemodialysis)

– Photographic fixing and developing solutions (X-ray Department)

– Solvents and fixatives (Pathology or Histology Labs)

– Engine or vacuum pump oils, solvents, degreasers (Facility Engineering)

– Disinfectants, pesticides, rodenticides (Housekeeping)

– Acids, alkalis or reducing agents (Laboratory)

– Mercury (thermometers), cadmium (batteries), lead (Radiology)

– Gases stored under high pressure, in cans or cylinders (Surgical Theater)

– Ethylene oxide gas (Central Sterile Supply)

– Expired drugs, cytotoxic drugs (Pharmacy, Chemotherapy Ward)

Characteristics of Chemical Waste

Discarded solid, liquid and gaseous chemicals that

are:

• Toxic

• Corrosive

• Flammable

• Reactive

- Explosive, water reactive, shock sensitive

• Oxidizing

General Types of Chemical Wastes

Chemical Waste Examples

Halogenated solvents chloroform, methylene chloride, perchloroethylene, refrigerants, trichloroethylene

Non-halogenated solvents acetone, acetonitrile, ethanol, ethyl acetate, formaldehyde, isopropanol, methanol, toluene, xylenes

Halogenated disinfectants calcium hypochlorite, chlorine dioxide, iodine solutions, iodophors, sodium dichloroisocyanurate, sodium hypochlorite (bleach)

Aldehydes formaldehyde, glutaraldehydes, ortho-pthalaldehyde

Alcohols ethanol, isopropanol, phenols

Other disinfectants hydrogen peroxide, peroxyacetic acid, quarternary amines

Metals arsenic, cadmium, chromium, lead, mercury, silver

Acids acetic, chromic, hydrochloric, nitric, sulfuric

Bases ammonium hydroxide, potassium hydroxide, sodium hydroxide

Oxidizers bleach, hydrogen peroxide, potassium dichromate, potassium permanganate

Reducers

Pharmaceuticals

sodium bisulfate, sodium sulfite

expired drugs, spilled drug, cytotoxic drugs

Miscellaneous anesthetic gases, asbestos, ethylene oxide, herbicides, paints, pesticides, waste oils

Examples of Chemical Waste Containing

Heavy Metals

• Mercury

– Thermometers, sphygmomanometers

– Cantor tubes, esophageal dilators

– Mercury switches, fluorescent lamps

– Dental amalgam

– Some formulations (e.g., Thimerosal)

• Cadmium

– Dry cell batteries

• Lead

– Radiation shielding

Health Impacts of Chemical Exposure

• Effects on the lungs

– Cancer (asbestos, cadmium)

– Asthma (formaldehyde)

– Irritation (glutaraldehyde)

• Effects on the eyes and mucous

membranes

– Irritation (formaldehyde, xylene,

methyl ethyl ketone)

– Conjunctivitis (glutaraldehyde)

– Blurred vision (methyl alcohol)

• Effects on the skin

– Burns (concentrated acetic acid and

sodium hydroxide)

– Rashes, irritation (methyl ethyl

ketone, other solvents)

• Effects on the nervous system

– Mercury, ethylene oxide, xylene, lead,

chloroform, other chlorinated

solvents, various organochlorine

insecticides

Health Impacts of Chemical Exposure

• Effects on the liver and kidneys

– Lead, cadmium, chloroform,

tetrachloroethylene and other

chlorinated solvents

• Effects on the reproductive system

– Various pesticides, lead, ethylene oxide

• Cancers

– Ethylene oxide, benzene, various

pesticides, some chlorinated solvents,

many cytotoxic agents

Health Impacts of Chemical Exposure

Segregation of Chemical Waste

• Chemical Waste

– Separate from infectious waste, radioactive

waste, and general non-risk waste

– Segregate based on compatibility

• Toxic, Corrosive, Flammable, Reactive

Containers and Color Coding for

Chemical Waste

• WHO recommendation

Waste Color and Markings Container Type

Chemical and

pharmaceutical waste

Brown Plastic bag or container

Labeling of Chemical Waste

o Waste container label should have:

– Name, address, telephone of the generator

– Point of generation (if applicable)

– Start date of accumulation of waste

– Estimated quantity

– Description of contents

– Waste classification

– Hazard symbols

– Precautionary statement

– Emergency contact information

International Chemical Waste Symbols

– Toxic

– Corrosive

– Flammable

– Explosive

– Oxidizer

Handling of Chemical Waste

• Proper personal protective

equipment (PPE) should be used

when handling hazardous chemicals

• Type of PPE required is specific for

each chemical

Handling of Chemical Waste

• Appropriate transferring methods

must be used

• Bonding, grounding, and explosion

proof devices for flammable waste

• Spill kit accessible

• Different spill kits for different hazards

• All materials in the kit are hazardous

after use

• Secondary containment

On-Site Transport of Chemical Waste

• Use wheeled trolleys, containers, or carts

designated for chemical waste transport with

the following specifications

• Easy to load and unload

• No sharp edges that could damage waste

bags or containers during loading and

unloading

• Easy to clean

• Leak proof

Storage of Chemical Waste

• Use a separate and enclosed area, room, or

building

• Provide good ventilation

• Have easy access to safety shower and

eyewash station

• Equip with a liquid or chemical proof sump

(secondary containment in case of leaks)

Storage of Chemical Waste

• No mixing of chemical waste (according to

manufacturers’ specifications)

• Incompatible wastes should be stored

separately, e.g. acids and bases

• Temperature should be controlled or kept

within the acceptable range based on

manufacturers’ requirements

Sample Sketch of a Chemical Waste

Storage Area

Storage of Chemical Waste

o Storage rooms and facilities should be labeled

on the exterior with a sign:

- NO ENTRY: Hazardous waste

o Other symbols if needed:

– No Smoking

– No Eating or Drinking

Off-Site Transport

• Transport vehicles should meet basic

requirements – E.g., well maintained, bulkhead to separate driver from

vehicle load, system to secure load, proper placards

and markings including hazard symbol and emergency

contacts, spill kit, easy to decontaminate, etc.

• Driver should be trained on: – Laws, risks, safe handling methods, labeling,

documentation and emergency procedures

• Consignment or manifest system

Treatment of Chemical Waste

• Chemical and Physical Treatment

– Neutralization

– Detoxification

– Chemical reduction or oxidation

– Electrolytic oxidation

– Hydrogenation, hydrolysis

• Biological Treatment

– Biodegradation

• Thermal Treatment

– High-temperature

incineration with

air pollution control

Treatment of Chemical Waste in Low-

Income Countries

• Encapsulation

• Inertization with cement

• Burial of encapsulated or

inertized waste in

engineered, controlled and

secure landfills

• Return of chemicals to

manufacturers

Chemical Wastes Containing Heavy Metals • Chemical Wastes containing toxic metals, in general

Should not be burned or disposed in dumpsites

Some heavy metals, like silver in x-ray processing, can be recovered

Return to supplier for reprocessing or disposal if possible

If no options currently exist, store the waste safely in a medium-term storage site

Refer to the Secretariat of the Basel Convention’s guidelines on the environmentally

sound management or reclamation of metals including mercury and lead

• Mercury

Develop safe clean-up, handling and storage procedures

Sequester mercury waste safely in a long-term storage facility

Reduce unnecessary use of mercury equipment

Replace mercury-containing products with mercury-free alternatives

Develop plans to become a mercury-free facility

• Cadmium and Lead

Send to facilities that specialize in recovery of heavy metals

Return to suppliers if possible

Send to a treatment, storage and disposal facility for hazardous industrial waste

Chemical Waste Management

• Integrate chemical waste management into the HCWM

plan, program and organization

• Identify chemical waste sources and hazards

• Control hazards by using less hazardous materials,

modifying equipment to reduce exposures, implementing

safe practices, PPE and administrative controls

• Train workers on the proper use of PPE

• Provide workers with information such as material safety

data sheets (MSDS) and international chemical safety

cards (ICSC)

• Comply with the country’s chemical waste regulations

• Develop strategies for waste minimization

Workers’ Right to Know

• Principle 10 of the Rio Declaration on Environment and

Development

– “Each individual shall have appropriate access to information …

on hazardous materials and activities ….”

• Principle 10 is embodied in many national and regional

laws on “Workers’ Right To Know” about the hazards of

chemicals they are working with

• Facilities can provide chemical hazard information by

making available or International Chemical Safety Cards

or Safety Data Sheets (SDSs), which are also called

Material Safety Data Sheets (MSDSs)

Safety Data Sheets

• Sections of a safety data

sheet

1. Identification

2. Hazard identification

3. First-aid measures

4. Fire-fighting measures

5. Accidental release measures

6. Handling and storage

7. Exposure controls/personal

protection

8. Exposure controls/personal

protection

9. Physical and chemical

properties

10. Stability and reactivity

11. Toxicological information

12. Ecological information

13. Disposal considerations

14. Transport considerations

15. Regulatory information

16. Other information, including

date

Example of an ICSC

ICSCs can be found at: http://www.ilo.org/dyn/icsc/showcard.home

Example of a Safety Data Sheet

MSDSs can be found on the Internet or obtained from manufacturers.

Chemical Waste Minimization

• Source Reduction (most desirable method of

waste minimization)

– Segregate hazardous chemical waste

– Evaluate possible substitutions using less

hazardous or non-hazardous materials

– Use steam cleaning or non-toxic cleaners

– Control the inventory of chemicals

– Minimize unnecessary dilution of wastes

– Develop plans for a mercury phase-out

Chemical Waste Minimization

• Recycling

– Select vendors that are willing to reprocess or

recycle their products

– Use a silver recovery unit for photographic

waste

– Use a distillation column to recover solvents

– Purchase compressed gas cylinders from

manufacturers who accept return of empty or

partially used cylinders

Chemotherapeutic Waste

• Chemotherapeutic waste – waste generated from the use

of chemical agents for treatment, especially cancer

therapy

• Cytotoxic agents – substances capable of killing or

stopping the growth of cells

• Cytostatic agents – capable of suppressing growth and

multiplication of cells

• Antineoplastic agents – inhibiting the development of

abnormal tissue growth

• Genotoxic agents – capable of inducing genetic mutation

• Teratogenic agents – capable of causing defects in an

embryo or fetus

Examples of Cytotoxic Waste

• Examples of sources

– Contaminated materials from drug preparation including vials and

syringes

– Contaminated materials from drug administration including gloves,

gauze, needles

• Examples of specific agents

– Alkylating agents (e.g., mechlorethamine, chlorambucil,

cyclophosphamide, ifosfamide, melphalan, streptozocin,

carmustine, busulfan, dacarbazine, thiotepa cisplatin)

– Antimetabolites (e.g., 5-fluorouracil, methotrexate)

– Anti-tumor antibiotics (daunorubicin, doxorubicin, bleomycin)

– Topoisomerase inhibitors (etoposide, teniposide)

– Mitotic inhibitors (paclitaxel, vinblastine, vincristine)

Segregation of Cytotoxic Waste

• Cytotoxic/Genotoxic Waste – Should be stored separately from other waste in

designated secure location

– Collect in strong containers

– Containers should be leak-proof

– Clearly label containers “cytotoxic wastes”

– Do not dispose in dumpsites or discharged into

sewerage systems

Treatment and Disposal of

Chemotherapeutic Waste Chemical degradation

– Convert chemo waste into non-toxic residues by alkaline

hydrolysis, chemical oxidation with potassium permanganate or

sulfuric acid, denitrosation with hydrobromic acid, or other

effective methods for the particular type of cytotoxic waste

High-temperature incineration with air pollution control

Options for low-income countries:

UNDP GEF technology developed in Argentina

www.gefmedwaste.org

Safely package and return to original supplier

Encapsulation as a last resort

Do not disposed in dumpsites nor discharged into sewer

systems

Chemotherapeutic Waste Minimization

• Segregate chemotherapy wastes through worker

training and separate waste containers

• Use degradable chemo agents instead of

environmentally persistent agents

• Purchase drug volumes based on need

• Return expired agents to manufacturer

• Develop spill containment and clean-up

procedures that minimize waste clean-up

volume

Characteristics of Radioactive Wastes

• Waste contaminated with radionuclides

• Produced as a result of:

in-vitro analysis of body tissue and fluid

in-vivo organ imaging and tumor localization

investigative and therapeutic practices

• Can be sealed (encapsulated in pins, seeds or needles) or unsealed

(liquids administered directly)

• Some have relatively short half-lives causing them to lose activity

quickly (e.g., technitium-99m – 6 hours; iodine-123 – 13 hours;

phosphorus-32 – 14 days)

• Others have long half-lives (carbon-14 – 5730 years)

Sources of Radioactive Wastes in Healthcare

• Sealed sources

• Spent radionuclide generators

• Low-level solid waste, e.g. absorbent paper, swabs, glassware, syringes,

vials

• Residues from shipments of radioactive material and unwanted solutions of

radionuclides intended for diagnostic or therapeutic use

• Liquid immiscible with water, such as liquid scintillation-counting

• Residues used in radioimmunoassay, and contaminated pump oil

• Waste from spills and decontamination of radioactive spills

• Excreta from patients treated or tested with unsealed radionuclides

• Low-level liquid waste, e.g. from washing apparatus

• Gases and exhausts from stores and fume cupboards

Health Risks of Radioactive Waste

• Health impacts determined by type and extent of

exposure to ionizing radiation

– Chromosomal damage

– Headaches, dizziness, vomiting

– Tissue destruction, hemorrhage, hair loss,

diarrhea, death at high doses

• An extreme case from Brazil (1988)

– Sealed radioactive source was removed from a

radiotherapy institute and broken open – 249

people exposed, several died or suffered severe

health problems

Containers for Radioactive Wastes

• Low-level radioactive infectious waste (swabs,

syringes) may be collected in bags or

containers

• There is no recommended color code for

radioactive waste containers

• Containers should have the radioactive symbol

Segregation of Radioactive Waste

• Separate radioactive wastes based on

• Half-life

– Short-lived (<60 days) versus long-lived (>60 days)

• Activity and radionuclide content

• Physical and chemical form

– Liquid: aqueous and organic

– Non-homogeneous (e.g. contain sludge or suspended solids)

– Solid: combustible/non-combustible and compactable/non-compactable

• Sealed versus non-sealed sources

– Spent sealed sources

• Waste content

– Waste containing hazardous (e.g. pathogenic, infectious, toxic) material

Labeling of Radioactive Waste

Radioactive wastes

• “Radioactive waste” marking and symbol

• Identification number

• Radionuclide

• Activity and date of measurement

• Period of storage required

• Origin of the waste (room, lab, etc.)

• Potential/actual hazards

• Surface dose rate and date of measurement

• Quantity (weight or volume)

• Responsible person

Storage of Radioactive Waste

• Secure cabinet, dedicated area, room or small building

• Waste segregated according to the time needed for storage

• Extremely short half lives (<5 days), short half lives (5 to 30 days), longer half lives

(30 to 60 days)

• Restricted access for safety

• Radiation shielding depending on radiological hazard

• Radiation monitoring and surveillance

• Fire protection

• Periodic inspections for leakage

• Recordkeeping, inventory log

Disposal of Radioactive Waste

• Return to supplier

• “Decay in Storage” or storage for decay

Store the waste for at least 10 times the half-life of

the longest lived radionuclide in the waste

Conduct a radiation survey to confirm that

radioactivity is below the clearance level

Disinfect mixed radioactive infectious waste before

discarding with regular waste

• Long-term storage at an authorized radioactive waste

disposal facility

Radioactive Waste Minimization

• Develop a radioactive waste management plan

• Substitute long-lived radionuclides with short-lived

radionuclides

• Substitute stable isotopes for radionuclides where

possible

• Limit the quantity of radioactive items purchased

• Improve procedures to avoid contamination and to

minimize the volume of waste generated

Sources of Pharmaceutical Waste

• Expired pharmaceuticals

• Discontinued drugs

• IV preparations

• Partially used vials and syringes

• Compounding of drugs

• Breakage and spills of pharmaceuticals

• Unused single-dose repackaged drugs

• Patients’ personal medications

Characteristics of Pharmaceutical Waste

• Pharmaceuticals can be

– Acutely hazardous (e.g., arsenic trioxide,

epinephrine, nitroglycerin, warfarin >0.3%)

– Toxic (e.g., barium, chloral hydrate, chloroform,

chlorambucil, cyclophosphamide, mitomycin C,

streptozotocin, lindane, phenol, thimerosal)

– Flammable or ignitable (e.g., isopropanol,

paregoric, collodion-based preparations)

– Corrosive (e.g., acetic acid used for

compounding)

Environmental Impact of

Pharmaceutical Waste

• Pharmaceuticals are present in most hospital

wastewater

• More than 100 different types of pharmaceuticals or

their metabolites are found in water bodies in Europe

and the U.S.

• Some pharmaceuticals can seep into the groundwater

• Environmental concentrations could affect fish and

other wildlife

• Antibiotics found in streams worldwide raise concerns

of the possible rise of antibiotic-resistant organisms

Segregation of Pharmaceutical Waste

• Pharmaceutical Waste

– Should be segregated from other infectious

and radioactive wastes

– National and local regulations must be

followed

Treatment and Disposal of

Pharmaceutical Waste

• Chemical Treatment

• Chemical Absorption

• Denaturing (e.g., alkaline hydrolysis)

• High Temperature Incineration

• Recovery of active pharmaceutical ingredients

through solvent extraction, separation, distillation,

filtration, etc.

Disposal of Pharmaceutical Waste in Low-

Income Countries • Reverse distribution (return to supplier)

• Safe burial on hospital premises

• Encapsulation or inertization

Solid, liquid, or semi-liquid waste can be encapsulated in metal drums

Solids ground up; mixed with cement, lime and water; made into pellets or blocks

• Landfill disposal

Landfilling large quantities of pharmaceuticals is not recommended, unless waste is encapsulated and disposed in a sanitary landfill where there is no risk of leaching into the groundwater

• Discharge to a sewer

Only for relatively mild liquid or semi-liquids (vitamins, cough syrups, eye drops, saline solution, glucose, electrolytes, etc.)

Discharge into a large flow of water and into municipal sanitary sewers

Antibiotics and cytotoxic drugs should not be discharged in a sewer

Pharmaceutical Waste Minimization

• Good inventory control – Increase inventory turnover

– Apply inventory control strategies (e.g., ABC

classification, First In First Out, Just-In-Time

management, etc.)

• Avoiding unnecessary prescriptions, especially

antibiotics

• Reformulation of drugs

Discussion

• What are some sources of chemical, cytotoxic, and pharmaceutical

wastes in your facility? What are some examples of these

healthcare wastes that may occur both inside and outside of your

facility? What are some major hazards and risks that are posed by

these wastes?

• What are some sources of radioactive wastes in your facility? Give

some examples, as well as their hazards and risks.

• How does your facility segregate chemical and pharmaceutical

wastes? What about specific wastes that have cytotoxic and/or

genotoxic properties? What handling and safety procedures are

followed by those who deal directly with the wastes?

Discussion

• How does your facility store chemical, cytotoxic, pharmaceutical,

and radioactive wastes? What treatment and disposal methods

does it use or has it used in the past for each category of waste?

• What are country/region-specific policies and guidelines for

chemical and radioactive waste management? What about

international guidelines specifically meant for radioactive wastes? Is

your facility able to follow these guidelines?

• How does your facility regulate mercury? Are there plans to use

alternative sources in place of mercury and to eventually phase out

its use in most medical equipment?