Incineration Public Health Impact, Climate Change Implications, and the Ebola Crisis

8/9/2019 Incineration Public Health Impact, Climate Change Implications, and the Ebola Crisis

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Incineration: Public HealthImpact, Climate ChangeImplications and the EbolaCrisis Health Care Without Harm &University of the Philippines College of Public Health

Cocoon Hotel, Quezon City, Philippines January 28, 2015

Jorge Emmanuel


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Precautionary PrincipleEmbodied in international law (UNFramework Convention on Climate Change,Stockholm Convention on PersistentOrganic Pollutants, Rio Declaration, etc.)

Requires that precautionary measuresbe taken when an activity threatensserious harm to human health and the

environment, when the balance ofscientific evidence suggests arelationship between the activity andharmful effects


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Medical Waste Incineration (MWI)is a major global source of Dioxins

Europe: 62% of dioxin emissions due to 4 processes,including MWI

Belgium: MWI accounts for 14% of dioxin emissions Denmark: MWI is 3rd or 4th largest dioxin source of 16

process groups Thailand: MWI - highest dioxin source by far of 7 sources

tested United States:

MWIs third largest source of dioxins: 17% of totaldioxins in 1995Drop in dioxin emissions from MWI in part due to shiftto non-incineration methods: 2470 g TEQ/yr in 1987 to477 g TEQ/yr in 1995

Canada: MWI - largest dioxin source in Ontario province


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Persistence of Dioxinsin the Environment

Environmental half-life on surface soil:9 to 15 years

Environmental half-life in subsurface soil:25 to 100 years

Volatilization half-life in a body of water:

more than 50 years


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Dioxins are Toxic at Extremely LowConcentrations

Lowest observable adverse effect levelsfrom animal studies:

Doses at which increased abortions, severeendometriosis, decreased off-spring survival, etc. areseen in Rhesus monkeys at 3.5-4 years:0.000 000 64 mg/kg/dayDose at which cancer is found in rats at104 weeks: 0.000 007 1 mg/kg/day

US EPA cancer potency factor (2002):(0.000 000 000 001 g TEQ/kg/day) -1


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Health Effects Related to Dioxin

Classified as a known human carcinogen byIARC in 1997

Cancers linked to dioxins: Chronic lymphocytic leukemia (CLL) Soft-tissue sarcoma Non-Hodgkins lymphoma Respiratory cancer (of lung and bronchus,

larynx, and trachea) Prostate cancer


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Health Effects Related to Dioxin

Developmental Effects Birth defects Alteration in reproductive systems Impact on childs learning ability and attention Changes in sex ratio (fewer male births)Immune System Impacts

Suppression of the immune system Increased susceptibility to diseaseMale and Female Reproductive Effects


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Other ToxicPollutantsfromIncineration

ParticulateMatter

CarbonMonoxide

Other OrganicCompounds

Acid GasesDioxin s &

Furans

Trace M etalsincluding

Lead,Cadmium,Mercury

ToxicIncinerator

Ash


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Epidemiological Studies related tohealth effects of incineration

STUDY SUBJECTS CONCLUSIONS REGARDINGADVERSE HEALTH EFFECTS

REFERENCE

Residents livingwithin 10 km of anincinerator, refinery,and waste disposal site

Significant increase in laryngealcancer in men living with closerproximity to the incinerator andother pollution sources

P. Michelozzi et al.,Occup. Environ. Med., 55 ,611-615 (1998)

532 males working attwo incinerators from1962-1992

Significantly higher gastric cancermortality

E. Rapiti et al., Am. J. Ind. Medicine, 31 , 659-661(1997)

Residents livingaround an incineratorand other pollutionsources

Significant increase in lung cancerrelated specifically to theincinerator

A. Biggeri et al. Environ. Health Perspect. , 104 , 750-754 (1996)

People living within7.5 km of 72incinerators

Risks of all cancers and specificallyof stomach, colorectal, liver, andlung cancer increased with closerproximity to incinerators

P. Elliott et al., Br. J.Cancer, 73 , 702-710 (1996)


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STUDY SUBJECTS CONCLUSIONS REGARDINGADVERSE HEALTH EFFECTS

REFERENCE

122 workers at an

industrial incinerator

Higher levels of lead, cadmium, and

toluene in the blood, and higher levelsof tetrachlorophenols and arsenic inurine

R. Wrbitzky et al., Int. Arch.

Occup. Environ. Health, 68,13-21 (1995)

176 incinerator workersemployed for more thana year from 1920-1985

Excessive deaths from ischemic heartdisease and lung cancer among workersemployed for at least 1 year; significantincrease in deaths from ischemic heartdisease among workers employed formore than 30 years or followed up formore than 40 years

P. Gustavsson, Am. J. Ind. Medicine, 15, 129-137(1989)

Mothers living close toincinerators andcrematoria in Cumbria,

England, from 1956 to1993

Increased risk of lethal congenitalanomaly, in particular, spina bifida andheart defects around incinerators, and

increased risk of stillbirths andanacephalus around crematoria

T. Drummer, H. Dickinsonand L. Parker, Journal ofEpidemiological and

Community Health, 57,456-461 (2003)

Epidemiological Studies related tohealth effects of incineration


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Best Available Techniques under theStockholm Convention

BAT air emissions performance level: 0.1 nanograms I-TEQ/Normal cubic meter at

11% oxygenBAT wastewater performance level foreffluents from treatment of gas treatmentscrubbers:

0.1 nanograms I-TEQ/liter

To be achieved by a suitable combination of

primary and secondary measures


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Primary measures (partial list) Introduction of waste at 850C or higher;

automation to avoid introducing waste below850C Control of oxygen input Minimum residence time of 2 seconds at 1100C

in the secondary chamber after last addition ofair and 6% O 2 by volume (for waste with >1%halogenated substances)

On-line monitoring for combustion control (T,oxygen, carbon monoxide, dust), and regulationfrom a central console.


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Secondary measures Dedusting

Fabric filter operating below 260CCeramic filter used between 800 to1000C

Cyclones for pre-cleaningElectrostatic precipitators around450CHigh performance adsorption units

with activated carbon


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Secondary measures Techniques for further

emission reductionCatalytic oxidationGas quenching

Catalyst-coated fabric filtersDifferent types of wet or dryadsorption systems using mixturesof activated charcoal, coke, lime andlimestone solutions


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Monitoring Routine monitoring of: CO, oxygen,

particulate matter, HCl, SO 2, NO 2, HF, airflows, temperatures, pressure drops, and pH Periodic or semi-continuous measurement of:

polychlorinated dioxins and furans


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Stringent emission limits

All reference conditions: 273K, 101.3kPa, 11% O 2, dry; Small 200 lbs/hr, medium > 200 to 500 lbs/hr, and large > 500 lbs/hr. For half hour averages, at least 97% of concentrations must meet the first value and 100% must meet the second value.


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Incinerators with Air Pollution Control

Autoclaves

Comparison of Capital Costs


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554

00

200

400

600

1984 2002

O n - S

i t e

M W I s

150

00

50

100

150

200

1990s 2005

M W I s

40

1

0

10

20

30

40

50

1995 2004

M W I s

Some Trends: Medical Waste Incineration (MWI)

Germany Portugal

Ireland

United States Canada


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Non-Incineration Treatment Options

Treatment technologies Autoclaves- various sizes Autoclaves with shredders Hybrid autoclaves Continuous steam treatment systems Batch microwave units Continuous microwave units Frictional heating units


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Medical Waste Management is not aTechnology but a System

Waste ClassificationWaste SegregationWaste MinimizationContainerizationColor CodingLabeling, SignageHandlingTransport

StorageTreatmentFinal DisposalContingency PlansWastewater Treatment

Policies, Roles andResponsibilitiesWritten ProceduresPlans & Roadmap

Training Periodic, multi-level training CertificationOrganization

HCWM committee, HCWMcoordinator

System of Monitoring,Evaluation & Improvement

Champions, IncentivesAllocating Human &Financial Resources


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India Project (2010-2012)King George Medical University Hospital:3000 bed in low-income state, 50 departments No healthcare waste management, no segregation Infectious waste thrown on the floor and swept up

periodically by cleaning staff Infectious waste transported in leaking bicycle carts Waste dumped at uncontrolled dump sites

in the hospital grounds (scavengers) Some waste burned in makeshift incinerator


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India Project Dramatic change to a model facility for HCWM HCWM program sparked development of infection control

program Active HCWM committee, committed hospital leadership Strong environmental champions among the staff Introduction of color-coded segregation bins,

posters, training Vastly improved internal transport system and

addition of a waste tracking and CCTV system On-site storage/treatment facility with autoclave & shredder Post-treatment materials recovery and recycling of plastics,

glass, etc. provides revenues to the hospital Video documentarywww.gefmedwaste.org
http://www.gefmedwaste.org/http://www.gefmedwaste.org/


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Kyrgyzstan Project (2005-2013)

One of the poorest of the former SovietcountriesPROBLEM before the project:

No national regulations on medical waste Little or no segregation of waste Some hospitals treated infectious waste with

hypochlorite Many needle-stic k injuries and occupational

health issues Most waste was either dumped untreated

along with regular waste or burned in openpits


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Approach

National assessment (2004)Developed a model with stakeholderparticipation included reusable containers,waste minimization, and recycling (2005-2006)Tested and refined the model at selectedhospitals (2006)

Worked on national regulationsExpanded model nationwide training, localorganization, technology deployment,monitoring (2007-2013)


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Autoclave-based Technology


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Results (as of end of 2013)

All hospitals in the country (> 25 beds), allprimary health centers, and many privateclinics use the model ( 67% of hospital beds )

Hospitals found an average 33% cost savingscompared to previous system ofhypochlorite treatment

Needle-stick injuries and cuts andoccupational exposures were reducedEvery hospitals generated revenue from saleof recycled plastic and metal


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Advantages of re-designing healthcare wastemanagement around a steam-based technology

The color-coded container can now be reusable Getrid of the single-use color-coded plastic bags and boxes.

Previously infectious materials can be recycled if they areproperly segregated, sterilized and crushed/shredded.Expand recycling and waste minimization to recyclable andcompostable non-infectious non-hazardous materials.

Promote segregation to maximize the advantages of steam-based technologies.Shift from a waste management framework to aresource management framework.


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Highlights of the Ebola CrisisUp to 90% case fatality rateNo know cureEntire communities were wiped outOne town alone in Sierra Leone has 1,455 orphans


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Highlights of the Ebola CrisisPeople started dying in the streets in major citiesHospitals and clinics treating Ebola patients wereoverwhelmed some driven away, others on the floorAll schools and businesses shut down, economy groundto a halt


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Highlights of the Ebola Crisis

Doctors, nurses, nurses aides, ambulancedrivers, and burial workers started dying As of December, 570 doctors, nurses, health

workers have died Sierra Leone only had 95 doctors and 991

nurses nationwide


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Ebola Waste Project (2014)

21296 Ebola cases so far8,420 deaths so farMostly in 3 countries:Liberia, Guinea, andSierra Leone

Problem: What to do with highly infectiouswaste at Ebola Treatment Centers?


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Initial Solution: Incineration

Heavy black smoke and high levels of HCland dioxins

Strong opposition by nearby communities No technical support provided


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Initial Solution: IncinerationProblems PPE has a seam coating that melts at 98C PPE has flash ignition point of 343C PPE material has a heat release capacity of about

1560 J/g-K self-sustaining combustion PPE has a heating value of 46.3 MJ/kg (same as gasoline)


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Non-Incineration SolutionAutoclaves by Africans for Africa Uses mechanical controls instead of computer controls

easier to fix Rides through power outages that are common in Africa

Uses steam ejectors instead of vacuum pumps lessmaintenance problems, waste volume reduced by 40-60% Installs in one day Exceeded international

standards by an orderof magnitude


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Autoclaving

Ebola is destroyed by autoclaving in secondsNo smoke, no dioxins, no HCl, no toxic airpollutantsSafe for workers with PPESpecial barrel trolley protects workers from EbolaexposureCheaper than an incinerator


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1

23

4

567

8

Place waste inside stainless steelbarrel and close the lid

When barrel is full, take to autoclave

Slide barrel into autoclave Close sliding door

Start heating, multi-vacuum andsterilization cycles

When finished, open door and

remove sterilized barrel

Unlock & rotate barrel to dumptreated waste at the bottom

Barrel and trolley are ready to pickup more waste

www.medi-clave.co.za


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Photos of the Ebola Work


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Global Carbon Dioxide Levels

Sources: National Oceanic and Atmospheric Administration, US Department of Commerce; ScrippsInstitution of Oceanography

CO 2 levels reached 400 ppmfor the first time in human history

on May 9, 2013
http://www.washingtonpost.com/blogs/capital-weather-gang/files/2013/05/5_2_13_news_andrew_co2800000yrs.jpg


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Multiple Indicators of Global Climate Change

Source: Climate Change2013: The Physical ScienceBasis, Working Group Icontribution to the IPCCFifth Assessment Report,September 2013.


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S C f Gl b l


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Some Consequences of Global Warming

Global rise in sea level (1870-2008, and 2100 projection)

Source: Rahmstorf S. et al. 2012: Environ ResLett 7 044035

A 40-inch sea level rise is projectedto inundate 5,000 hectares of

Manila Bays coast and affect 2.5million people.

-- Hulme, M and Sheard, N. 1999:Climate Research Unit, Norwich


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Climate Change Impacts in Southeast Asia (IPCC 4 th Assessment and ADB Reports)

Increased coastal hazard due to largertidal variations and intense typhoonscoupled with increased rainfallMore land loss and coastal erosiondue to sea level riseBleaching of coral reefs from higher temperaturesand ocean acidification

Desiccation and shrinkage of freshwater wetlandsMore salt-water intrusion affecting coastal freshwaterand groundwater resources due to sea level rise

Sources: Climate Change 2007: Impacts, Adaptation and Vulnerability, Working Group II Contribution to the Fourth Assessment, IPCC Report,2007; The Economics of Climate Change in Southeast Asia: A Regional Review, Asian Development Bank, April 2009


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Climate Change Impacts in Southeast Asia(ADB Report)

Possible drop in agricultural productivity, increase incrop stress and reduced yields in the Philippines(versus increased rice yields in Indonesia and

Malaysia)

Graph from: The Economics of ClimateChange in Southeast Asia: A RegionalReview, Asian Development Bank, April

2009

Philippines


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Climate Change Impacts in Southeast Asia(IPCC 4 th Assessment and ADB Reports)

Possible increased intensity and spread of forest fires

Disappearing endemic flora and fauna due to changes inrainfall patterns and climate-related pest infestation (e.g.,

Philippine teak trees [ Tectona philippinensis])Landward migration of mangroves and tidal wetlands (whichwill be constrained by human infrastructure)

Possible increased outbreaksof malaria and dengue


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Socioeconomic Impacts of Climate Change

More deaths, destruction and loss of livelihoods due to intense

typhoons, landslides and flash floodsEconomic losses due to the impact of water shortage on crops ,especially rice, corn, sugarcane and coconutReduced production of fish and marine products due to changes in

ocean circulation, seawater temperature, etc.Greater food insecurity due to lower agricultural and fish yields,and worsening social inequalityHigher morbidity & mortality due to thermal stress, vector-borne(malaria, dengue) and water-borne diseasesLoss in GDP

Philippines, Indonesia, Thailand& Vietnam (left) vs global (right)GDP loss projection

[ADB Report, 2009]


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Projected Timing of Climate ChangeWhen will the climate change to a state continuouslyoutside the bounds of historical variability?

Unprecedented climates will occur earliest in the tropicsand among low-income countries .

Source: C. Mora et al., The projected timing of climate departure from recentvariability, Nature 502, 183-187 (10 December 2013).

Collaborative study by(University of Hawaii atManoa and University ofRyukus, Okinawa)


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CONCLUDING SLIDES


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Likely Consequences of a Return to Incineration

More health facilities will ignore segregationand waste minimizationIncinerators will not meet increasinglystringent dioxin standards due to cost dioxins released during transient conditionsDioxin limits will not be enforced due tocost, lack of enforcement mechanisms, and

inability to test in-country (or unqualifiedlabs will manipulate results)Dioxins will impact the health of currentand future generations


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VISION OF AN ALTERNATIVE PATH

Conservation of earths resourcesTowards Zero-WasteRenewable clean energy

If we install roof-top solar panels on 6 millionhomes, we can generate the equivalent of all ofthe countrys annual electricity consumption.

(California added 6 GWin rooftop solar alonein 2013)

My dream / my vision:


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My dream / my vision:

Most homes, schools, governmentoffices, and commercial and industrial buildings

have rooftop solar PVs.Large-scale concentrated solar and wind farms and other clean

renewable sources provide the bulk of grid power.Reforestation is successful, mangrove forests protect more coastal areas,

and urban centers have more green spaces.Communities, especially on the coasts and flood plains, are resilient to climate change and no

one dies during intense typhoons, storm surges, and flash floods.The agricultural, fisheries, and other sectors have adapted to climate change; no one goes

hungry, and everyone has access to quality health care.

The air is cleaner, cars run on solar, and cities are healthier and more livable.There is greater social equity and the country follows a green,

low-carbon, climate-resilient path of development.There is a critical mass of professionals, researchers

and e ducators committed to sustaining

this vision.

.


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Documents

Incineration Public Health Impact, Climate Change Implications, and the Ebola Crisis