CHAPTER 6

WASTE TREATMENT AND

DISPOSAL SYSTEM
Health Care Waste Management Manual

6.1 Health Care Waste Treatment

The purpose of treating health care waste is to change the biological and chemical character of
the waste to minimize its potential to cause harm. There are a number of terms used to denote
the level of treatment, such as decontamination, sterilization, disinfection, render harmless and
kills. These terms do not provide any mechanism of measuring the degree of process efficiency.
As such, it is critical that terms and criteria be established that quantitatively define the level of
microbial destruction accomplished by any health care waste treatment process.

Sterilization is defined as a 6log10 survival probability of the most resistant microorganism of

concern in a given process and disinfection is defined as low, intermediate or high (using the
Spaulding system) depending on the survival probability of specific microbial groups. For
medical waste disinfection, however, the emerging international consensus is to define levels of
microbial inactivation as follows:

Level I Inactivation of vegetative bacteria, fungi, and lipophilic viruses at a 6log 10

reduction or greater

Level II Inactivation of vegetative bacteria, fungi, lipophilic/hydrophilic viruses,

parasites, and mycobacteria at a 6log10 reduction or greater

Level III Inactivation of vegetative bacteria, fungi, lipophilic/hydrophilic viruses,

parasites, and mycobacteria at a 6log10 reduction or greater; and inactivation
of B. stearothermophilus spores and B. subtilis spores at a 4log10 reduction or
greater

Level IV Inactivation of vegetative bacteria, fungi, lipophilic/hydrophilic viruses,

parasites, and mycobacteria, and B. stearothermophilus spores at a 6log 10
reduction or greater

Mechanical grinding devices are sometimes introduced prior to treatment, during treatment,
and/or at the end of the treatment process. A few facilities insist on shredding the health care
waste either as a matter of preference or because they falsely believe that their liability will
somehow be limited. Some technologies, however, depend upon shredding as an integral part of
the treatment process, i.e., those systems that shred prior to treatment and during treatment.
Shredders are typically a high maintenance item due to unavoidable volumes of trapped waste in
the waste stream, such as high-quality stainless steel found in orthopedic blades, drills, reamers,
and prosthetic devices. Glass is also inherent in the health care waste and over time, glass wears
the cutting surfaces of the shredder blades. Therefore, if the facility intends to shred waste
either pre- or post-treatment, anticipate that a rigorous maintenance schedule with associated
cost would be required. Shredding the waste simply to render it unrecognizable makes the task
more burdensome and more expensive than necessary and a cost benefit analysis should be
conducted prior to making that decision. Also, consider the potential down time when the
shredder is out of commission with those technologies that depend upon shredding.

Waste Treatment and Disposal System 39

Health Care Waste Management Manual

Selection Criteria of Treatment Technology

On-site treatment of health care waste allows health care facility to have more control over both
the waste disposal process and waste disposal cost. Treatment system maybe a cost-effective
alternative and many manufacturers have already simplified their systems so that processing is
relatively effortless.

Hospital and other health care establishments should perform a preliminary assessment and
determine the issues that are important to the facility. Develop a list of selection criteria and rank
in order of importance. In selecting a technology, the following key points should be
considered:

Treatment efficiency

Occupational health, safety and environmental considerations

Volume and mass reduction

Types and quantity of wastes for treatment and disposal/capacity of the system

Infrastructure and space requirements (investment and operational cost)

Locally available treatment options for final disposal

Training requirements for operation of the method

Operation and maintenance considerations

Location/surrounding of the treatment site and disposal facility

Social and political acceptability

Regulatory requirements

These criteria are also applicable in selecting off-site treatment technology for health care
wastes.

Health Care Waste Treatment Technologies/Processes

Incineration used to be the method of choice in treating health care waste. However, with the
implementation of the Clean Air Act of 1999, the use of this method is no longer allowed. With
this development, alternative technologies are being looked into to address the problem on
health care waste management using the aforementioned selection criteria.

Most common technologies and processes used in health care waste treatment are (1) thermal,
(2) chemical, (3) irradiation, (4) biological processes, (5) encapsulation, and (6) inertization.

Waste Treatment and Disposal System 40

Health Care Waste Management Manual

1. Thermal Processes

Thermal processes rely on high heat to destroy pathogens (disease-causing

microorganisms).

Pyrolysis - Pyrolysis is the thermal decomposition of substance and materials in the

absence of supplied molecular oxygen in the destruction chamber in which the said
material is converted into gaseous, liquid, or solid form. Pyrolysis can handle the full
range of health care waste. Waste residues may be in form of greasy aggregates or
slugs, recoverable metals, or carbon black. These residues are disposed of in a secure
facility i.e. sanitary landfill.

Wet and Dry Thermal Treatment - Wet thermal or steam disinfection is based on
exposure of shredded infectious waste to high temperature, high pressure steam, and is
similar to the autoclave sterilization process. It inactivates most types of microorganisms
if temperature and contact time are sufficient. For sporulated bacteria, a minimum
temperature of 121oC is needed and exposure time of 30 minutes. For sharps, milling or
crushing is recommended mainly to eliminate physical hazards from needles, render
syringes unusable, and reduce waste volume as well as increasing the surface area
subject to exposure to high temperature and high pressure steam subsequently increasing
the efficiency of the treatment.

Autoclave - Autoclave uses steam sterilization to render waste harmless and is an

efficient wet thermal disinfection process. This technique has been used for many
years in hospitals for the sterilization of reusable medical equipment.

Autoclaves come in a wide range of sizes. A typical autoclave designed for medical
waste treats about 100 kg per cycle (a cycle being about 1 hour) to several hundred
kilograms per cycle for larger hospitals. Autoclaves used in centralized treatment
facilities can handle as much as 3,000 kg in one cycle.

The microbial inactivation efficacy of autoclaves should be checked periodically.

For autoclaves that do not shred waste during steam disinfection, color-changing
indicator strips may be attached to the outside of the yellow bag in the middle of
each load and that the strip be checked to ensure that steam penetration has
occurred. In addition, a microbiological test (using for example commercially
available validation kits containing bacillus stearothermophilus spore strips, vials or
packs) should be conducted periodically.

Microwave – This technology typically incorporates some type of size reduction

device. Shredding of wastes is being done either before disinfection or after
disinfection. In this process, waste is exposed to microwaves that raises the
temperature to 100oC (237.6oF) for at least 30 minutes. Microorganisms are
destroyed by moist heat which irreversibly coagulates and denatures enzymes and
structural proteins.

The efficiency of microwave disinfection should be checked routinely through

bacteriological and virological tests. The microwave process is widely used in
several countries and is becoming popular. However, the system has a relatively
high investment and operating costs. The process is inappropriate

Waste Treatment and Disposal System 41

Health Care Waste Management Manual

for the treatment of anatomical waste and animal carcasses, and will not efficiently
treat chemical or pharmaceutical waste.

2. Chemical Disinfection

Chemical disinfection is now being applied for treatment of health care waste. Chemicals
like aldehydes, chlorine compounds, phenolic compounds, etc. are added to waste to kill or
inactivate pathogens present in health care waste. Chemical disinfection is most suitable in
treating blood, urine, stools and sewage. This method is also applicable in treating
infectious wastes containing pathogens. If possible, wastes should be shredded to increase
the extent of contact between waste and the disinfectant by increasing the surface area and
eliminating the enclosed space. However, application of this method should only be done
when there is no available treatment facility in the area to prevent environmental problems
associated with the disposal of chemical residues.

Some chemical systems use heated alkali to destroy tissues, organs, body parts, and other
pathological wastes that can be used to treat contaminated animal waste and cytotoxic waste
as well.

Chemotherapy waste (including bulk cytotoxic agents) can be treated by chemical

decomposition. Examples are: reaction with 5% sodium hypochlorite; acid hydrolysis
followed by alkaline hydrolysis; reduction using zinc powder; degradation using 30%
hydrogen peroxide; or destruction using heated alkali.

Studies showed that chlorine-based technologies using sodium hypochlorite and chlorine
dioxide as well as its by products in wastewater may possibly have long-term environmental
effects. Non-chlorine based technologies are quite varied in the way they operate and the
chemical agents they employ. Others use peroxyacetic acid, ozone gas, lime-based dry
powder, acid and metal catalyst, or biodegradable disinfectants. Also, occupational and
safety exposures should be monitored when using the chemical processes.

3. Biological Processes

The process uses an enzyme mixture to decontaminate health care waste and the resulting
by-product is put through an extruder to remove water for sewage disposal. The technology
is suited for large applications and is also being developed for possible use in agricultural
sector. The technology requires regulation of temperature, pH, enzyme level, and other
variable. Design application is mainly for regional health care waste treatment center.

Composting and vermiculture as biological processes for treating and disposing of placenta
waste, as well as food waste, yard trimmings and other organic waste is also recommended.

4. Radiation Technology

The disposal of biologically contaminated waste from hospitals, clinics and laboratories is of
particular concern. Waste containing potentially infectious microorganisms (sewage sludge,
biomedical wastes, wastewater) are treated using irradiation systems which are currently
being used in waste treatment operations. The four main elements of the waste handling
system are: (1) identification of the contaminated waste, (2) collection, (3) sterilization and
(4) final disposal or recycling.

Waste Treatment and Disposal System 42

Health Care Waste Management Manual

Machines generating high energy electron beams, among other types, can sterilize a wide
range of waste. If regulations permit, the processed material can then be directed to general
waste disposal or recycling operations.

Sterilization is achieved by breaking down the DNA molecules of the contaminated

organism. Ionizing radiation is very efficient at DNA disruption, and requires far less total
energy than would be used in an equivalent thermal process. Their use in the disinfection of
sewage sludge has been demonstrated on a full-scale basis at a plant near Munich, Germany;
and at a biomedical waste sterilizer in Arkansas, USA for the treatment of hospital waste.

5. Encapsulation

Encapsulation involves the filling up of containers with waste, adding and immobilizing
material, and sealing the containers. The process uses either cubic boxes made of high-
density polyethylene or metallic drums, that are three quarters filled with sharps or chemical
or pharmaceutical residues. The containers or boxes are then filled up with a medium such
as plastic foam, bituminous sand and cement mortar. After the medium has dried, the
containers are sealed and disposed of in landfill sites. The process is particularly appropriate
for the disposal of sharps and chemical or pharmaceutical residues. The main advantage of
the process is that it is very effective in reducing the risk of scavengers gaining access to the
health care waste.

6. Inertization

Especially suitable for pharmaceutical waste is the process of inertization that involves the
mixing of the waste with cement and other substances before disposal. This is to minimize
the risks of toxic substances contained in the waste migrating into surface water or
groundwater. For the inertization of pharmaceutical waste, the packaging should be
removed, the pharmaceuticals ground, and a mixture of water, lime and cement added. The
homogenous mass produced can be transported to a suitable storage site. Alternatively, the
homogenous mixture can be transported in liquid state to a landfill and poured into
municipal waste. The process is relatively inexpensive and can be performed using relatively
unsophisticated equipment. The following is the typical proportion for the mixture: 65 %
pharmaceutical waste, 15 % lime, 15 % cement, and 5 % water.

Siting of Waste Treatment Facilities

Some treatment facilities particularly larger ones would require a new structure to house the
technology or renovate existing space. Each technology have different requirements for space,
foundation, utility service connections, ventilation, and support equipment. In determining a safe
location for the facility, one must take into account the safe transfer routes, average distances
from waste sources, temporary storage requirements, as well as space allowances needed by
workers to maneuver safely around the treatment unit. The location of the facility should not
cause traffic problems as waste is brought in and out. Odor, noise, the visual impact of medical
waste operations on patients and visitors, public access, and security should also be considered.

In the past, the decision involving the location of the treatment system have been the
responsibility of engineers dealing with the foundation, electrical connections, sewer, HVAC
(heating ventilation and air conditioning) and utilities. By taking a team approach

Waste Treatment and Disposal System 43

Health Care Waste Management Manual

and involving facility engineering, environmental services, housekeeping, safety or industrial

hygiene, infection control, and occupational health, important aspects such as occupational
safety and health become part of the decisions relative to siting and installation.

6.2 Waste Disposal Systems

Sanitary Landfill

Sanitary landfill is an engineered method designed to keep the waste isolated from the
environment. Appropriate engineering preparations should be completed before the site is
allowed to accept waste. There should be trained staff present on site to control operations,
organize deposits and daily coverage of waste. Some essential elements for the design and
operation of sanitary landfill are:

Access to site and working areas possible for waste delivery and site vehicles

Presence of site personnel capable of effective control of daily operations

Division of the site into manageable phases, appropriately prepared, before landfill
starts

Adequate sealing of the base and sides of the site to minimize the movement of
wastewater (leachate)

Adequate mechanisms for leachate collection and treatment systems are necessary

Organized deposit of waste in a small area, allowing them to be spread,

compacted and covered daily

Surface water collection trenches around site boundaries

Construction of a final cover to minimize rainwater infiltration when each phase

of the landfill is completed.

Safe Burial on Hospital Premises

In remote locations and rural areas, the safe burial of waste on the health care premises may be
the only viable option available at the time. However, certain rules need to be established for the
proper health care waste management. These include:

Access to the disposal site should be restricted to authorized personnel only.

The burial site should be lined with a material of low permeability, such as clay, if
available, to prevent pollution of any shallow groundwater that may subsequently reach
nearby wells.

Only hazardous health care waste should be buried. If general health care waste were also
buried on the premises, available space would be quickly filled-up.

Waste Treatment and Disposal System 44

Health Care Waste Management Manual

Large quantities (>1kg) of chemical/pharmaceutical wastes should not be buried.

The burial site should be managed as a landfill, with each layer of waste covered with a
layer of earth to prevent odor, as well as to prevent proliferation of rodents and insects.

Burial site should not be located in flood prone areas.

Hospital ground should be secured. (e.g. fenced with warning signs).

The location of waste burial pit should be downhill or down-gradient from any nearby
wells and about 50 meters away from any water body such as rivers or lakes to prevent
contaminating sources of water.

Health care facilities should keep a permanent record of the size and location of all their
on-site burial pits to prevent construction workers, builders, and others from digging in
those areas in the future.

The safe burial of waste depends critically on rational operational practices. The bottom
of the pit should be at least 1.50 meters higher than the ground water level. It should be
noted that safe on-site burial is practicable only for relatively limited period, say 1 to 2
years, and for relatively small quantities of waste, say up to 5 to 10 tons in total. Where
these conditions are exceeded, a longer-term solution will be needed.

Figure 12. Schematic Cross Section of a Secure Landfill

Waste Treatment and Disposal System 45

Health Care Waste Management Manual

Septic/Concrete Vault

This method is especially suitable for the disposal of used sharps and syringes. The following
procedures for the safe burial of sharps and syringes through septic/concrete vault are
recommended:

Dig a pit (minimum size of 1 m x 1 m x 1.8 m depth), enough to accommodate sharps and
syringes for an estimated period of time without reaching the groundwater level. The site
must be isolated and at least 500 feet away from the groundwater supply sources and
dwelling units.

Construct concrete walls and slabs of the pit. Provide slab with opening or manhole for easy
deposition of collected sharps and syringes. The manhole should be extended a few
centimeters above the soil surface to overcome infiltration of surface water.

Deposit the collected safety boxes filled with used sharps and needles inside the
septic/concrete vault.

Install a security fence around the site.

Waste Treatment and Disposal System 46

Health Care Waste Management Manual

Figure 13. Burial Pit (Volume = 1x1x1.8)

W=1.
SECURITY FENCE

1% SLOPE
SOIL COVER
H=1.8m

SHARP WASTE 10 cm SOIL LAYER

SHARP WASTE LINER OF LOW PERMEABILITY

VARIABLE

(i.e. clay, hdpe, cement)

2.0 - 3.5m

GROUND H2O

Figure 14. Septic/Concrete Vault

0.10m

FOR
FUTURE USE
1.8m

1.0m 1.0m

Waste Treatment and Disposal System 47

 CHAPTER 7
WASTE MANAGEMENT
7.1 Characteristics of Wastewater from
Health Care Establishments

The basic principle underlying the effective wastewater management in health care
establishments is a strict limit on the discharge of hazardous liquids to sewers. The quality of
wastewater from health care establishment contains potentially hazardous elements including:

Microbiological pathogens (bacteria, viruses, and helminths), which are easily

transmitted through water;

Small amounts of hazardous chemicals from cleaning and disinfection operations;

Hazardous chemicals and pharmaceutical waste being generated from other business
establishments (clinics, laboratories and research centers, drug manufacturers, mortuary
and autopsy centers, cosmetics and tattoo parlors);

Trace amounts of radioactive effluents from nuclear medicine laboratories;

Wastewater or sewage from health care establishment can be discharged into domestic
(municipal or city) sewers without pre-treatment, provided that the following
requirements are met:

The municipal sewers are connected to efficiently operate sewage treatment plant that
ensure at least 95 % removal of bacteria;

The sludge resulting from sewage treatment plant is subjected to anaerobic digestion,
leaving no more than one helminth egg per liter in the digested sludge;

The hazardous wastewater having significant quantities of toxic chemicals such as

formaldehyde, pharmaceuticals, radionuclides, cytotoxic drugs and antibiotics, coming
from laboratories and research centers, clinics, mortuary and autopsy centers should be
discharged to a pre-treatment/neutralization tank for sewage (toxic) neutralization and
disinfection by chlorination prior to discharge or connected to the sewage treatment
plant; and

Excreta from patients being treated with cytotoxic drugs are collected separately and
adequately treated (as for other cytotoxic waste).

7.2 On-Site Treatment of Wastewater

When a health care facility cannot access a community sewage treatment plant it is recommended
that the establishment should have their own waste water treatment plant. An efficient on-site
wastewater treatment plant should include the following operations:

Waste Management 49
 Figure 15. Schematic Diagram of Wastewater Treatment

Chemical
Waste
Preliminary Secondary Final Effluent
Treatment Treatment Treatment
Domestic
Waste
Sludge
Treatment

Disposal

Primary Treatment - this includes multi-chamber septic tank, comprising of primary

sedimentation tank and digestive chamber. This action results in partial biodegradation
of organic pollutants. The effluent should be conveyed to the secondary treatment
facility for further oxidation of sewage.

Secondary Treatment - this employs a complete biological process of treatment

including aeration and sedimentation system. It involves the importance of aerobic
microorganisms that will actually degrade the organic pollutants in the effluent. The
aeration phase is the introduction or supply of oxygen to the system for the aerobic
microorganisms. The sedimentation phase is the settling of sludge and separation of
clear water effluents. This combined system signifies the higher purification and
degradation of parameters such as BOD, COD, TSS, Oil and Grease. The clear water
should be conveyed to the tertiary treatment while the sludge shall be conveyed to the
sludge treatment.

Tertiary Treatment - In order to meet the standard parameters prescribed by the DENR
Administrative Order No. 35 series 1990, this stage should therefore serve as the final
treatment. The clear water will pass through micro filter and chlorine disinfection before
being discharged to the nearest drainage or body of water. Due to outbreaks of enteric
diseases and occurrence of waterborne diseases and other critical periods, UV-
Hygienization is further recommended. This process involves the use of UV-Radiation
of 254 - mm wavelength.

Sludge Treatment - A supplement to the Implementing Rules and Regulations (IRR) of

Chapter 17, “Sewage Collection and Disposal and Excreta Disposal and Drainage” of
PD 856 or the Sanitation Code of the Philippines, details the collection, handling,
transport, treatment and disposal of “Domestic Sewage and Septage”.

Health care establishments may apply a combination of the treatment process enumerated in the
above section depending on the volume and characteristics of their wastewater.

Waste Management 50
7.3 Factors to be Considered in the
Establishment of Wastewater Treatment Plant

To have an efficient and cost-effective establishment of on-site wastewater treatment plant, it is

important to have an objective approach in considering the following factors:

Quantity of wastewater for treatment and disposal Type of

wastewater for treatment and disposal Location of the
treatment and disposal facility Infrastructure requirements
Treatment efficiency
Locally available equipment and parts Space
availability
Investment and operating cost
Operation and maintenance Training
requirement for operation Regulatory
requirements

7.4 Safety Requirements

Measures to minimize health risks should be implemented in health care establishments that cannot
afford any sewage treatment plant such as:

Patients with enteric diseases should be isolated in wards where their excreta can be
collected for chemical disinfection. This is of utmost importance in case of cholera
outbreaks, for example, and strong disinfectants will be needed.

No chemicals or pharmaceuticals should be discharged into the sewer.

Sewage from health care establishments should never be used for agriculture or aqua
cultural purposes.

Health care sewage should not be discharged into natural water bodies that are used to
irrigate fruit or vegetable crops, to produce drinking water, or for recreational purposes.

Grease, oil and paints should not be discharged into the sewer line

Waste Management 51
7.5 Sanitary Requirements

Human excreta are the principal vehicle for the transmission and spread of a wide range of
communicable diseases, and excreta from health care patients may be expected to contain far
higher concentration of pathogens, and therefore are far more infectious, than excreta from
households. This underlines the prime importance of providing access to adequate sanitation in
every health care establishment. The health care establishment should ideally be connected to a
sewerage system.

7.6 Regulatory Requirements

All implementing rules and regulations of all concerned agencies (local and national) and all
existing laws shall be strictly followed. Chapter 9 provides a discussion of applicable
environmental laws and regulations for health care establishments.

Waste Management 52