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Public health and environment1|
Overview of Wastes fromHealth Care Activities
UNEP IETC Osaka, Japan
19 July 2012
Susan Wilburn, Technical Officer
Public Health and Environment
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Public health and environment2|
Key Points
Of the total amount of waste generated by health-careactivities, about 80% is general waste.
The remaining 20% is considered hazardous material that
may be infectious, toxic or radioactive.
Every year an estimated 16 000 million injections areadministered worldwide, but not all of the needles and
syringes are properly disposed of afterwards.
Health-care waste contains potentially harmful
microorganisms which can infect hospital patients, health-care workers and the general public.
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Public health and environment3|
What is health-care waste?
Health-care waste includes all the waste generated by health-care
establishments, research facilities, and laboratories. In addition, it
includes the waste originating from minor or scattered
sources--such as that produced in the course of health care
undertaken in the home (dialysis, insulin injections, etc.).
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Public health and environment4|
Categories of health care waste
Sharps: Used or unused sharpse.g. hypodermic, intravenous or other needles; auto-disable syringes;
syringes with attached needles; infusion sets; scalpels; pipettes; knives;
blades; broken glass
Infectious: Infectious waste is material suspected to containpathogens (bacteria, viruses, parasites or fungi) in sufficient
concentration or quantity to cause disease in susceptible hosts. This
category includes: waste contaminated with blood or other body fluids,cultures and stocks of infectious agents from laboratory work, waste from
infected patients in isolation wards; dressings, bandages and other materialcontaminated with blood or other body fluids
Pathological: Human tissues, organs or fluids; body parts;fetuses; unused blood products
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Public health and environment5|
Categories of waste (cont)
Pharmaceutical : Pharmaceuticals that are expired or nolonger needed; items contaminated by or containing pharmaceuticals;
Cytotoxic waste containing substances with genotoxic properties waste
containing cytostatic drugs (often used in cancer therapy) genotoxic
chemicals)
Chemical: Waste containing chemical substances(e.g. laboratory reagents; film developer; disinfectants that are expired
or no longer needed; solvents; waste with high content of heavy
metals, e.g. batteries; broken thermometers and blood pressure gauges)
Radioactive: Waste containing radioactive substances(e.g. unused liquids from radiotherapy or laboratory research;contaminated glassware, packages, or absorbent paper; urine and
excreta from patients treated or tested with unsealed radionuclides;
sealed sources)
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Public health and environment6|
General definition and
characteristics
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Public health and environment7|
Health Care Waste
Improper management of health care waste can haveboth direct and indirect health consequences for health
personnel, community members and the environment.
Direct consequences when disposable materials (especiallysyringes) are intentionally re-used
Indirect consequences in the form of toxic emissions frominadequate burning of medical waste, or the production ofmillions of used syringes in a period of three to four weeksfrom an insufficiently well planned mass immunizationcampaign
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Public health and environment8|
Health Care Waste Management
Exposed groups and associated risks
Health-care workers
UK 96 to 2004, 2140 reported occupational exposures to bloodborneviruses. 21% of the injuries occurring during the disposal process(Gabriel 2009)
Waste handlersStudy in Mexico city showed that out of 69 interviewed waste handlers34% (13) reported 22 needle stick injuries between them during thefirst 12 months and 96% had seen needles and syringes in waste(Thompson et al, 2010).
Scavengers retrieving items from dumpsitesIn Pakistan on average scavenger boys who were going throughmedical waste, for collection and resale, experienced three to fiveneedle stick injuries a day (Altaf and Mujeed 2002)
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Public health and environment9|
Children who may come into contact with contaminated waste
Dozen of children in Sadr City, largest suburb of Baghdad, have beenadmitted to hospitals with symptoms of infectious diseases due to contactwith waste (Integrated Regional Information Networks, 2007).
Communities living near landfill and waste sites or near treatment facilities
Low income households are more likely to live close to waste sitesresulting in more direct contact with health care waste (Appleton and Ali,2000)
Local populations affected by the utilization of products recycled fromhealth care waste and the reuse of untreated medical equipment
In India more than 30% of the injections administered each year werecarried out using re-used or inadequately sterilized medical equipment andthat nationally, 10% of health care facilities sold used syringes to waste
pickers (IndiaCLEN 2004).
Communities impacted by pollution from poorly operated incinerators
Research suggests that population living within 3 km of old incineratorssaw an increase of 3.5% in the risk of contracting cancer (Porta et al, 2009)
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Public health and environment10|
Process of HC Waste management
Waste classification
Waste segregation
Waste minimization
Containerization
Color coding
Labeling and signage
Handling
Transport
Storage
Treatment
Final disposal of
waste.
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Public health and environment11|
Waste management hierarchyMost preferable
Least preferable
Prevent
Reduce
Reuse
Recycle
Recover
Treat
Dispose
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Public health and environment12|
Waste segregation is key
Careful segregation and separate
collection of hospital waste is the key
to safe, sound management of health-care waste.
Segregation can substantially reduce
the quantity of health-care waste thatrequires specialized treatment.
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Public health and environment13|
Segregation of health-care waste
(continued)In any area that produces
hazardous waste hospital
wards, treatment rooms,
operating theatres,
laboratories, etc.
bins plus separate
sharps container will be
needed.
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Public health and environment14|
Segregation of health-care waste
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Public health and environment15|
Sharps wasteSharps are items that can cause
cuts or puncture wounds,
including:
needles,
hypodermic needles,
scalpel and other blades,
knives,
infusion sets,
saws,
broken glass,
and pipettes
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Public health and environment16|
Sharp waste management
Sharps Handling Recommendations
Do not recap needles
Never pass used sharps from one
person to another
Locate needle destroyer andcontainer near the point of
generation to have good visibility
Sharps should be disposed of in
puncture-resistant sharps
containers
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Public health and environment17|
Highly hazardous healthcare wasteHighly hazardous healthcare wastes, which should be given special
attention, includes
highly infectious non-sharp waste such as laboratory supplies,
highly infectious physiological fluids, pathological and anatomical
waste, stools from cholera patients,
and sputum and blood of patients with highly infectious diseasessuch as TB and HIV/AIDS.
They also include large quantities of expired or unwanted
pharmaceuticals and hazardous chemicals,
as well as all radioactive or genotoxic wastes.
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Public health and environment18|
Sub-categories of hazardous waste: Infectious
waste and highly infectious waste
Infectious waste includes:
cultures and stocks of infectious agents from
laboratory work;
waste from surgery and autopsies on patients
with infectious diseases; waste from infected patients in isolation
wards;
waste that has been in contact with infected
patients undergoing haemodialysis;
infected animals from laboratories;
any other instruments or materials that have
been in contact with infected persons or
animals.
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Public health and environment19|
Infectious waste management
Infectious waste should go into
yellow leak-proof plastic bags or
containers.
Bags and containers for
infectious waste should be
marked with the internationalinfectious substance symbol
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Public health and environment20|
Sub-categories of hazardous waste:
Chemical waste and pharmaceutical
waste Chemical waste consists ofdiscarded solid, liquid, andgaseous chemicals, forexample from diagnostic andexperimental work and from
cleaning, housekeeping, anddisinfecting procedures.
Pharmaceutical waste includesexpired, unused, spilt, and
contaminated pharmaceuticalproducts, drugs, vaccines, andsera that are no longer requiredand need to be disposed ofappropriately.
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Public health and environment21|
Chemical and pharmaceutical waste
management Small amounts of chemical or
pharmaceutical waste may be
collected together with infectious
waste.
Large quantities of chemical
waste should be packed in
chemical-resistant containers.
The identity of the chemicals
should be clearly marked on the
containers: hazardous chemical
wastes of different types should
never be mixed.
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Public health and environment22|
Radioactive wasteThe waste produced by health-care and research activities
involving radionuclides, and related activities such as
equipment maintenance, storage, etc., can be classified as
follows:
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 from 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.
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Public health and environment23|
General healthcare waste
General healthcare
waste, similar or
identical to domestic
waste, includingmaterials such as
packaging or unwanted
paper. 7590% of waste
generated by healthcare
facilities falls into this
category.
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Public health and environment24|
General waste management
This waste is generally
harmless and needs no
special handling; and
General health-care waste
should join the stream of
domestic refuse for disposal.
Bags and containers for
general healthcare waste areblack.
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Public health and environment25|
Waste recycling
Only 15% of the hospital waste stream is classified
regulated or potentially infectious, and must be
handled as such.
The majority of hospital waste is similar to that found in
an office building or hotelmostly paper, cardboard,
metal and food waste.
Much of this waste can be diverted from landfills and can
reduce waste disposal costs through waste recycling.
l f
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Public health and environment26|
Examples of
Reuse, Recycle
of Waste, Water
Thailand GREEN &
CLEAN Hospitals
Biogas from food waste used for
hospital cooking
Recycling plastic IV bottles
India Bhopal
Sambhavna Trust Clinic
Harvests rainwater for hospital use
Solar water heaters and passiveventilation reduce energy use
Tropical gardens, irrigated by
recycled water, provide fresh fruits
and vegetables for staff and patients
G i h lth t b fit f
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Public health and environment27|
Greening health sector: co-benefits for
patients, health workers and climate
mitigation
Chemical hazards:
Capture and reuse
of waste anesthetic
gases: reproductive
hazards and potent
GHGases*
*Estimated to have a globalwarming potential of 500-3700 X CO2
"Risking their health while
caring for others:
Reproductive health
hazards of germ-killers"NIOSH, Harvard School of Public
Health and Brigham & Women's
Hospital surveyed of 7,000 women
nurses and found numerous potentialoccupational chemical exposures that
doubled or tripled miscarriage risk.
Lawson C et al. Am J Obstet Gynecol.2011 Dec 30Ryan, SM, Nielsen CJ. Global warming potential of
inhaled anaesthetics: application to clinical use.
International Anesthesia Research Society, July 2010,
111(1).
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Public health and environment28|
. . . Examples of mercury elimination
New Delhi, India: the citys public healthsystem is substituting mercury in itshospitals. To date 12 hospitals are inthe process of substitution. (Poster
from campaign on right)
Sao Paulo, Brazil:more than 100 privatehospitals and 34 public hospitals havegone mercury-free
Mexico City, Mexico:The health secretariatannounced in September 2009 that its
system of 28 hospitals and more than200 health clinics would join the WHO-HCWH Initiative and phaseoutmercury-based medical devices.
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Public health and environment29|
Global Policy and Driving forces
SIXTY-THIRD WORLD HEALTH ASSEMBLY (WHA63.25)Agenda item 11.18 - Improvement of health through safe andenvironmentally sound waste management
The Libreville Declaration on Health and Environment in Africa:
Framework for Health Care Waste Management (Douala 2010)
Global Alliance for Vaccines and Immunization
72 countries receiving support for health care waste
WHOSafe Management of Wastes from Health-care activitiesSecond edition - September 2012
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Special Rapporteur on hazardous waste,
The improper
management and
disposal of medical
waste has an
adverse impact on
the enjoyment of
human rights inmany countries.
Refers to the Stockholm
Convention on POPs
Source with the potential
for comparatively high
formation of dioxins &
furans: Medical Waste
Incinerators
40,000 times higher thanemission limits set forth.
Sept 2011 A/HRC/18/31
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Despite major driving forces - HCWM
remains weak
Lack of existing policies developed and implemented at countrylevel
Resources are mobilized but remains limited and not in phase with
the magnitude of the public health problemDifficulty to find ways or platform to influence decision, e.g.: howlong needle removers will remain as a Yes or No decision while it isintroduced in some countries without safety guaranties
Mass campaigns are to be prepared long in advance to ensure thatthe strategy on site will be able to safely handle huge amounts ofwaste
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Public health and environment32|
Affordable technologies for waste treatment arenot developed in and for low income countriesand are mostly geared towards industrializedcountries
Low cost technologies are often notenvironmentally friendly and safe
In low income countries the trade-off is betweendirect health risks / indirect health risks related topoor strategy or environmental pollution
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Public health and environment33|
Supply Chain
Look for solutions to reduce waste to contribute to improvingsome of the health care waste management problem countriesface
Ultimately, the waste management problem must be addressed at
all levels, from upstream technology development to downstreamwaste minimization and management, to ensure that health carecan be delivered without side effects on health care workers,communities, or the environment
Improvements made by countries by adopting purchase policiesthat consider the waste stream
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Public health and environment34|
Health waste managementSome 25% of health waste is hazardousdeveloping countries are most at
risk due to poor waste management practices.
Energy benefits of energy-waste systems are clearbut may involve a healthpenalty (e.g. emissions of dioxins, pollutants)
- Environmental benefits of mechanical/thermal treatment (e.g.microwaving/autoclaving) are also clearenergy aspects needs more
exploration.
Hydroclave: for health waste steam sterilization and
griding/volume reduction - GuyanaOpen health waste incineration pit Haiti
T l t t W t S it ti H i d h lth
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Tools to support Water, Sanitation, Hygiene and health
care waste interventions in settingsWORLDHEALTH ORGANIZATION
Safe health-carewaste management
POLICY PAPER
1- Unsafehealth-carewastemanagementleadstodeathanddisability
Health-careactivitiesleadtothe productionof wastethatmay leadto adversehealtheffects. Mostof this wasteis not moredangerous thanregular householdwaste. However,sometypes of health-carewasterepresent ahigher risk tohealth. Theseincludeinfectious waste(15%t o25% of totalhealth-care waste)amongwhich aresharps waste (1%),bodypart waste (1%), chemicalor pharmaceutical waste (3%), andradioactiveandcytotoxic wasteor brokenthermometers (less than1%).
Sharps waste, although produced insmallquantities,is highly infectious.Poorlymanaged,they expose health-
careworkers,waste handlers and the communityto infections. Contaminatedneedles andsyringes representaparticular threat andmay bescavengedfrom wasteareas anddump sitesand be reused. WHOhas estimatedthat,in 2000,injectionswithcontaminatedsyringescaused: 21millionhepatitis Bvirus(HBV) infections(32%of allnewinfections); twomillionhepatitis Cvirus (HCV) infections (40%of allnew infections); 260000HIV infections (5% of allnewinfections).
Epidemiologicalstudiesindicatethata personwhoexperiencesoneneedle-stick injuryfrom aneedle usedonaninfectedsourcepatient has risks of 30%,1.8%,and 0.3% respectivelyto becomeinfectedwithHBV,HCVandHIV. In2002,the results of aWHOassessmentconductedin22 developingcountriesshowedthattheproportionof health-carefacilitiesthatdonot use proper wastedisposalmethods ranges from 18%to64%.
2- Health-carewastemanagementmayalso represent a riskto health
Health-carewaste management options may themselves leadto risks to health andno perfect readi lyachievable solution to manage health-carewaste exists. Health-care waste,whether generated atsmaller ruralclinics or larger facilities,can bemanaged where adequatewell-operatedinfrastructuresexist. However, thevolumesof waste generatedwithinlarge facilitiesand targetedpublic efforts (e.g., immunization campaigns) aremorechallenging, particularlyin developing countrieswhereresources maybe limited.In these difficultsituations for whichwaste disposaloptionsare limited,small-scaleincinerators havebeen usedand arestillusedasan interim solution inless developedand transitionalcountries.However, small-scaleincinerators oftenoperateatt emperatures below800degreesCelsius.This mayleadt othe productionof dioxins,furans or othertoxic pollutants as emissions and/or in bottom/flyash. Transportto centraliseddisposalfacilities may alsoproducehazardsto health-carehandlers,if notsafely managed.
3 Balancingriskstomakesoundpolicydecisionsin health-carewastemanagement
In additionto risks tohealthfrom infectious agents,long-term low-levelexposure of humans todioxinsandfurans maylead toimpairmentof theimmune system,and impaireddevelopmentof thenervous system,theendocrinesystem andthe reproductivefunctions.Short-term highlevel exposuremay resultin skinlesionsandalteredliver function.
TheInternational Agencyfor Researchon Cancer (IARC) classifies dioxins as a known humancarcinogen.However, most of the evidence documentingthe toxicity of dioxinsand furans is based uponstudies ofpopulationsthat havebeen exposedto highconcentrations of dioxinseither occupationallyor throughindustrialaccidents.Thereis littleevidenceto determinewhether chronic low-levelexposuretodioxinsand furans causescancer inhumans.Overall, itis notpossibletoestimate theglobalburden of diseasesfrom exposureto dioxinsandfurans becauseof largeareas of uncertainty.
Inthe last 10years, theenforcement of stricteremissionstandards for dioxinsandfurans bymany countriessignificantlyreducedthe releaseof these substancesintotheenvironment
*.
*Standards:0.1ng TEQ/m
3 (ToxicityEquivalence)inEuropeto0.1ngto 5ngTEQ/m
3 inJapanaccordingto
incinerator capacity.
WORLDHEALTH ORGANIZATION
Mercury inHealth Care
POLICY PAPER
1- BackgroundMercuryis anaturallyoccurring heavymetal. At ambient temperaturea ndpressure, mercuryis asilvery-whitel iquidthat readi l yvapor izes andmaystayintheatmosphereforuptoa year. Whenreleasedtotheai r , mercury
is transported and depositedglobally. Mercuryultimately accumulates in lakeb ottom sediments, whereit istransformedinto its moretoxic organic form, methylmercury, whichaccumulates infishtissue.
Mercuryis highlytoxic, especiallywhenmetabolized intomethyl mercury. It maybefatal if inhaled andharmfulifabsorbedthrough theskin. Around 80% of theinhaledmercuryvapour is absorbedinthebloodthroughthe
lungs. It maycause harmfulef fects tothe nervous, digestive,respirato ry, immunesystems andtothe kidneys,besides causinglung damage. Adversehealth effectsfrom mercuryexposurecan be: tremors, impairedvisionand hearing, paralysis, insomnia, emotional instability, developmental deficits during fetal development, and
attentiond eficit andde velopmentaldelays during childhood. Recent studies suggest thatmercury mayhave nothresholdbelowwhichsomeadverseeffects donot occur.
2- Contribution fromthe health-carese ctorand RegulationHealth-carefacilities areoneof themainsources of mercuryrelease intothe atmospherebeca useof emissionsfrom theincineration of medicalwaste. TheEnvironment Minister of theCana dianprovince of Ontariodeclared
onDecember 2002 thatemissions from incinerators werethe fourth-largest sourceof mercury.IntheUni tedStates, accordingto US Envi ronmentalProtectionAgency(EPA) in a1997report, medicalwasteincinerators mayhave beenrespo nsiblefor as muchas 10%of allmercuryair releases.
Health-carefacilities are alsoresponsiblefor mercurypollution taking placeinwate r bodies from therelease of
untreatedwastewater. Accordingto a1999report, heal th-carefaci l iti es mayalso havebeenresponsiblefor asmuchas 5%of allmercuryreleases inwastewat er. Environment Canadaestimates that morethan one-third ofthemercury loadinsewage systems i s due todentalpractice.
Dentalamalgam is the most commonlyuseddental fi l l ingmater ial . It i s amixtureof mercuryanda metalal loy.
Thenormalcomposi tionis 45-55%mercury; approximately30%si l verandothermetals suchas copper, ti nandzinc. In 1991,the WorldHeal thOrganizationconfi rmedthatmercurycontainedin dentalamalgam is thegreatest sourceof mercuryvapour innon-industrialized settings, exposingthe concernedp opulationto mercury
levels s igni fi cantlyexceedingthosesetforfoodand for ai r .(Source:http://www.who.int/ipcs/publications/cicad/en/cicad50.pdf )
Accordingto arepo rt submitted tot heOSPAR Commission, in theU nitedKing dom, annually 7.41 tonnes ofmercuryfrom dental amalgam aredischarged to the sewer, atmosphereor land, with another11.5 tonnes sent
forrecyclingordisposedwi ththe c l inicalwastestream. Together, mercurycontainedindentalamalgam andinlaboratoryand medicaldevices, accountforabout 53% of thetota lmercurye missions.
Wasteincineration andcrematoria arealso listed as majorsources of mercuryemissions. Manycountries, suchas Armenia, Cameroon,Ghan a, Honduras, Pakistan, and Peru, recognize the contributions from hospital
thermometers, dental amalgams, hospital wastea nd/or medicalwaste incinerators but lack quantitativedata.Despi tethelack of data, thereis good reasontobel ievethat mercuryreleases from theheal thsector ingeneral
aresubstantial.
Somecountries have restr ic tedthe useof mercurythermometers orhavebannedthem wi thoutprescr iption. A
varietyof associations haveado ptedresolut ions encouraging physicians andh ospitals toredu ceand eliminatetheir useof mercurycontainingeq uipment.
3 Occupationalhea lth hazardThemost commonpotentialmodeof occupationalexposureto mercury is v ia inhalationof metal li c l i quidmercuryvapours. If not cleanedup properly, spills of evensmalla mounts of elementalmercury, suchas from
breakage of thermometers,can contaminateindoor air above recommended limits and leadto serious healthconsequences. Sincemercuryva pour is odourless andcolourless, people can breathemercuryva pourand not
knowit. Forliquid metallic mercury, inhalationis the routeof exposurethat poses thegreatest healthrisk.
WHO core principles
for achieving safe and
sustainable
management
of health-care waste
- Rapid Assessment Tool
- e. Monitoring Tool
http://www.healthcarewaste.org
"Water and Sanitation is one of the primary drivers of public health
http://www.healthcarewaste.org/http://www.healthcarewaste.org/http://www.healthcarewaste.org/http://www.healthcarewaste.org/http://www.healthcarewaste.org/http://www.healthcarewaste.org/http://www.healthcarewaste.org/http://www.healthcarewaste.org/5/27/2018 1-Wilburn Ppt on Unep
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Public health and environment36|
Yves CHARTIER
http://www.who.int/water_sanitation_health
http://www.healthcarewaste.org
"Water and Sanitation is one of the primary drivers of public health.
I often refer to it as Health 101, which means that once we can
secure access to clean water and to adequate sanitation facilities for
all people, irrespective of the difference in their living conditions, ahuge battle against all kinds of diseases will be won."
Dr LEE Jong-wook, Director-General, World Health Organization.
For More Information
http://www.who.int/water_sanitation_healthhttp://www.healthcarewaste.org/en/115_overview.htmlhttp://www.healthcarewaste.org/en/115_overview.htmlhttp://www.healthcarewaste.org/en/115_overview.htmlhttp://www.who.int/water_sanitation_healthhttp://www.who.int/water_sanitation_health5/27/2018 1-Wilburn Ppt on Unep
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For More Information
WHO Health in theGreen Economy
www.who.int/hia/green_economy
www.who.int/water_sani
tation_health
http://www.healthcarewa
ste.org
Health care wastewww.gefmedwaste.org
Mercury-free health carewww.mercuryfreehealthcare.org
http://www.who.int/hia/green_economyhttp://www.who.int/hia/green_economyhttp://www.who.int/water_sanitation_healthhttp://www.who.int/water_sanitation_healthhttp://www.mercuryfreehealthcare.org/http://www.mercuryfreehealthcare.org/http://www.mercuryfreehealthcare.org/http://www.mercuryfreehealthcare.org/http://www.who.int/water_sanitation_healthhttp://www.who.int/water_sanitation_healthhttp://www.who.int/water_sanitation_healthhttp://www.who.int/hia/green_economyhttp://www.who.int/hia/green_economy