HCWH-SEA Position Paper On MedWaste Manual

Leading the global movement for environmentally responsible health care
SOUTHEAST ASIA OFFICE Unit 328 Eagle Court Condominium Matalino St. Diliman, Quezon City 1101 Philippines T: 2.928.7572 F: 2.926.2649 E : info@no-harm.org W: www.noharm.org/seasia
Circulation of the Philippine Department of Health 3rd Edition Health Care Waste Management Manual
16 August 2012
Position Paper of Health Care Without Harm-Southeast Asia
AMEND THE PHILIPPINE DEPARTMENT OF HEALTH 3RD EDITION HEALTHCARE WASTE MANAGEMENT MANUAL
In the wake of the Philippine Department of Healths (Phil DOH) Hospital Week Celebration, themed Makabagong Ospital para sa Kalusugang Pangkalahatan or Modernizing Hospitals for Universal Health Care, Health Care Without Harm-Southeast Asia (HCWH-SEA) calls on the department to devote equal attention on improving Philippine hospitals management of healthcare waste through the amendment of the Philippine Department of Healths 3rd Edition Health Care Waste Management (HCWM) Manual. The 920% increase for the Health Facilities Enhancement Program (HFEP) or any increase in health budget should encompass all aspects of healthcare delivery, including healthcare waste management. HCWH-SEA and its allies push for the amendment of the said Manual prior to its distribution for the consumption of healthcare institutions in the country. We have grave concerns on the health risks to healthcare workers, patients and the community that may result from the information contained in the present Manual and apprehensions on the Manual being used as a pretext for improper healthcare waste disposal, or for suppressing the specific mandates of international and local laws on healthcare waste management. The Manual recommends pyrolysis an acceptable technology for treating healthcare waste. This technology was classified by both the United States Environmental Protection Agency (US EPA) and the European Union (EU) under those of incinerators, and has been an identified producer of furans and dioxin, a known human carcinogen (WHO). The country also has an existing ban for medical wastes incineration under the Philippine Clean Air Act. Thus, we call for the exclusion of pyrolysis technology as an acceptable method for healthcare waste treatment from the Manual. We demand that the words waste reduction be placed back under the category of Resource Development (3 Rs), instead of waste recovery in the Manual. This will downplay waste minimization in favour of amassing a certain volume of waste (recovery) in order to produce energy or fuel (as defined in the Manual). The Philippines Ecological Solid Waste Management Act has very specific mandates on the need for waste reduction, to which the recommendation of using waste for fuel production purposes directly contradicts. We likewise demand the removal of the suggestion of waste recovery for energy or fuel production from healthcare waste, which may require the use of a burn technology. This will disregard the specifications of non-incineration of healthcare waste under the Philippine Clean Air Act. In a similar light, in the July 2011 session of the Human Rights Council on the United Nations General Assembly, the adverse effects of the movement and dumping of toxic and dangerous products and wastes on the enjoyment of human rights was cited.
Thus, we call for the term waste recoverys removal in the Waste Minimization chapter, and instead place back the term waste reduction, as was in the original principle. The Manual, which is intended to be a source guidebook for the management of healthcare waste disposal, also needs to be specific in the subject of proper containment, management, non-disposal or storage, or neutralization prior to discharge in wastewater of toxic chemicals which may include but are not limited to mercury, glutaraldehydes, formaldehyde, methanol, acetone, and xylene. We call for the updating of the wastewater and chemicals chapter of the Manual based on recent studies and/or international and national guidelines, where we posit that a clear outline should be included, to ensure primarily the healthcare workers safety, then the patients and community. The Philippine Department of Health needs be true to its battle-cry Universal Healthcare or Health for All, which aims to not only focus on the treatment or rehabilitation of those who are ill, but also on the prevention of disease and promotion of health. Equal attention must be given to the issue of healthcare waste management since improper practices have been globally identified as a human health burden (UNDP-GEF, WHO, HCWH). HCWH-SEA and its allies stand by its belief that in order for the hospitals to be truly modernized, the Phil DOH should stop wasting its energy and resource in trying to promote harmful technologies, and instead focus on developing the mechanisms to source and promote the safer alternatives for healthcare waste management. The time has come for the Philippine DOH to embrace the concept of a modern hospital which operates in a cyclical rather than linear flow. This integrates the principle that all aspects of health care are interconnected, does not end with patient discharge and are part of the larger community beyond the hospital confines. A truly effective health system does not only guarantee healing of patients but provides a healing environment for all.
1. Health Care Without Harm (HCWH) Health Care Without Harm is an international coalition with over 500 member organizations in 53 countries. Established in US in 1996, it aims to transform the health care sector world-wide, without compromising patient safety or care, so that it is ecologically-sustainable and no longer a source of harm to public health and environment. For more than 15 years, Health Care Without Harm has been working to promote and implement ecologically sound and healthy alternatives to healthcare practices that pollute the environment. The organization was formed when the United States Environmental Protection Agency (US EPA) identified medical waste incineration as the leading source of dioxin, one of the most potent carcinogens. HCWH has been instrumental in the improvement of the healthcare delivery system around the world in terms of human and environmental safety. Specific projects successfully carried out by the organization include the phase-out of mercury-containing devices in the healthcare sector, stopping the use of medical waste incinerators, promotion of safer technologies and/or alternatives for waste treatment, market creation for safe and healthy products, Green Building Program in hospital engineering, and the Healthy Food Project. Health Care Without Harm has regional offices in the US, Europe, Latin America, and Southeast Asia, with strategic partners in Australia, India and Africa. HCWH would like to present its views on the final draft of the Philippine Department of Health (DOH) 3rd edition Healthcare Waste Management Manual, and asks that its position be considered and that the recommendations for amendment to the Manual be included prior to its national circulation for the healthcare facilities consumption. 2. The United Nations Development Programme- Global Environment Facilitys (UNDP-GEF) Global Healthcare Waste Project The United Nations Development Programme-Global Environment Facility (UNDP-GEF), together with the Health Care Without Harm and the World Health Organization (WHO), is currently working on the Global Healthcare Waste Project. The issues below have precipitated the need for this project: Incineration and open burning of healthcare waste are the main sources of dioxins in healthcare, and are major sources of mercury pollution. These harmful contaminants are transported globally on air currents and by other means; they are toxic in small quantities; they bio-accumulate up the food chain; and they have caused documented harm to public health and the environment at locations far from the original source of their release.
Non-segregation of infectious medical waste from regular waste risks the spread of diseases especially among waste handlers, recyclers, and communities living near dump sites.
The projects primary goal is to protect public health and the global environment from the impacts of dioxin and mercury releases. The project, which started four years ago in 2008, is being implemented in seven counties (Argentina, India, Latvia, Lebanon, Senegal, Vietnam and Philippines) and being assisted and monitored in developing and sustaining best healthcare waste management practices in a way that is both locally appropriate and globally replicable. In the Philippines, the project aims to provide access to non-incineration technologies for the treatment of hazardous (infectious) medical waste. Below are the identified objectives for the project: a. Establish model facilities and programs, to exemplify best practices in healthcare waste management. b. Deploy and evaluate commercially available, non-incineration healthcare waste treatment technologies appropriate to the needs of the Philippines. c. Introduce the use of mercury-free devices in model facilities, evaluate their acceptability and efficacy, and develop and disseminate awareness-raising and educational materials related to mercury. d. Establish or enhance training programs to build capacity for the implementation of best practices and technologies both within and beyond the model facilities and programs. e. Review relevant national policies, seek agreement by relevant authorities on recommended updates or reformulations as needed, seek agreement on an implementation plan and, if appropriate, assist in holding a policy review conference for these purposes. f. Disseminate project results and materials to stakeholders and hold conferences or workshops to encourage replication. g. Make project results on demonstrated best techniques and practices available for dissemination and scaling-up regionally. In order that these objectives will be met, the Philippines DOH (Phil DOH) has received technical assistance from the UNDP-GEF and WHO, whereby the need for improvement of the management
of healthcare waste was recognized and acknowledged; as a result the revision of the previous Phil DOH HCWM Manual was conceptualized. 3. HCWH-SEAs Position on the 3rd Edition of the Philippine DOH HCWM Manual HCHW-SEA, being a major partner of the UNDP-GEF and the WHO in the development, implementation, and information dissemination of the HCW Project, has been fully supportive of the projects objectives and goals. We have also been supportive of the process that has led to the decision of revising the old HCWM Manual. HCWH-SEA, with its office based in the Philippines, has also been previously consulted in the drafting of the first two Phil DOH HCWM Manuals. However, in the drafting of the 3rd Edition HCWM Manual, there are some aspects in the process that has left much in question with the DOH HCWM Policy TWGs transparency with HCWH-SEA in the formers decisions which has led to the finalization of the Phil DOH 3rd Edition HCWM Manual. HCWH-SEAs participation and involvement as consultants in the drafting of the Phil DOHs 3 rd Edition HCWM Manual are summarized below: December 2010: prior to the Manual drafting, HCWH-SEA was invited and able to attend two (2) consultation meetings facilitated by the Phil DOH. HCWH-SEA has also received an initial draft of the Phil DOH 3 rd Edition HCWM Manual. 2011: HCWH-SEA has not been invited to attend any other consultation meetings on the drafting of the Phil DOH 3rd Edition HCWM Manual. May 2012: HCWH-SEA was invited and attended a meeting facilitated by the Phil DOH entitled: Meeting of the National Working Group for the project, Demonstrating and Promoting Best Techniques and Practices for Reducing HCW to Avoid Environmental Releases of Dioxins and Mercury. In the meeting, no draft of the Manual was provided by the Phil DOH HCWM Policy TWG for the perusal of HCWH-SEA, despite verbal requests for a draft copy by the latter. The Phil DOH TWG on the HCWM Policy expressed their intent to incorporate into the 3rd Edition HCWM Manual revisions the contents of a separate HCWM Manual created by experts and academicians from the University of the Philippines Manila- College of Public Health. This separate training Manual has been created by UP-Public Health under contract with the Phil DOH HCWM Policy TWG.
June 2012: HCWH-SEA was invited to and attended a four- day seminar-workshop by the Phil DOH HCWM Policy-TWG entitled: Workshop on the Development of Healthcare Waste Management Training Modules based on Healthcare Waste Management Manual, 3rd Edition, 2012.
During the seminar-workshop, the following issues were raised: The seminar-workshop was the first venue in which HCWH-SEA was able to view the Phil DOH 3rd Edition HCWM Manual.
Copies of the draft were given to the seminar-workshop participants but not to HCWH-SEA, reason cited for not providing the copy was because it was not final yet. The agenda for the seminar-workshop was not to critique the Manual as was implied in the previous DOH meeting, but to create training materials for the healthcare institutions in the country:
1. One significant addition to the Manual was the insertion of Waste-toEnergy technologies as the "recovery" scheme for the 3R's: Re-use, Recycle, and Recovery (replaced the previous word Reduction, Chapter 4). 2. Despite the concerns raised by HCWH-SEA representatives during the workshop regarding their inclusion of pyrolysis as an acceptable technology for waste management, the DOH HCWM Policy-TWG has resolved not to review and revise the Manual. They have stated that the acceptable technologies part of the Manual was final and that they have already printed and prepared several copies of the Manual for national circulation.
July 6, 2012: HCWH-SEA sent an email to the Director Rebecca Peafiel of the National Center for Health Facilities Development (NCHFD-DOH) and Adviser of the Phil DOH HCWM Policy TWG, and Engr. Zoraida Cuadra of the NCHFD-DOH, asking for an updated/final copy of the Phil DOH 3rd Edition HCWM Manual. To date, no reply was given by the email recipients. HCWH-SEA sent an email to Dr.Jorge Emmanuel-Chief Technical Advisor, and Ms Ashley Iwanaga-Global Project coordinator of the UNDP-GEF Global Healthcare Waste Project, communicating our difficulty in getting a final copy of the Phil DOH 3rd Edition HCWM Manual, Ms Ashley Iwanaga then sent an email to the same persons listed above asking for the final draft of the Manual.
July 27, 2012: HCWH-SEA received the final copy of the Phil DOH 3rd Edition HCWM Manual from Ms Ashley Iwanaga, sent to her official email address by Engr.Zoraida Cuadra.
Upon reviewing the final copy of the Phil DOH 3rd edition HCWM Manual, HCWH-SEA infers that it contain information that could pose health risks to healthcare workers, clients, and the
community. Some parts, however, lack salient information which could prevent the exposure to such risks. Both omissions of important facts and provision of erroneous information run against the very purpose of revising the previous Manual. An attachment of the Phil DOH 3rd Edition HCWM Manual parts needing major changes highlighted by HCWH-SEA is attached as Appendix. The objectives of the proposed changes are: Recognize the role proper healthcare waste management plays in the prevention of serious and/or debilitating health conditions to healthcare workers, patients, and community. Recognise the need for recommending environmentally-sound technologies in healthcare waste management, especially in the light of its financial benefits, as compared to newer yet poorly-tested technologies. Safeguard the protection of human rights and other local/ international legislations promoting cleaner air, safe water, and the right to information. Limit the impact of this Manual on The Philippine Clean Air Act, Philippine Clean Water Act, and Human Rights.
Overall, HCWH-SEA calls the attention of Phil DOH on paying careful attention so as to ensure that the Manual will not be used as a pretext for improper disposal, or for suppressing the specific mandates of international and local laws on HCW management. HCWH-SEA therefore asks that the Phil DOH take the following specific concerns into account prior to circulation of the Phil DOH 3rd Edition HCWM Manual: 3.1. Pyrolysis Recommended as an Acceptable Method of HCW Management: The following issues have been associated with pyrolysis as a technology for waste management: In the August 2010 project presentation of Dr. Jorge Emmannuel, Chief Technical Advisor of the UNDP-GEFs HCW Project, he has questioned the inclusion of Pyrolysis in the previous Phil DOH HCWM Manual based on the following arguments: Along with gasification and plasma, pyrolysis is a technology classified as incinerators by the European Union (EU) and the United States Environmental Protection Agency (US EPA). Through the Clean Air Act, the Philippines has an existing national ban on all types of incineration, including medical waste. Dioxin, a byproduct of incineration, has been declared by the WHO as a Known Human Carcinogen.
Pyrolysis is one among other waste-to-energy (WTE) technologies now being phased-out from countries which were economically-stable initially and which ended up having massive financial losses and environmental consequences.
Examples of these facilities around the world are: North American Power Company (2003) a pyrolysis proposal in California, USA that could not provide evidence to their claim that their company does not produce harmful emissions, in which company later disappeared and project died a few days later; Brightstar Environmental in Wollongong, Australia (2001-2004) closed in April 2004 because of financial and technical problems, today facility no longer exists since it was demolished; Integrated Environmental Technologies & InEnTec (Washington & Hawaii, USA) cancelled its project on June 2008; Allied Technology Group, Inc. (Richland, Washington, USA) which had chronic operational problems and repeated problems from emissions equipment, they later on filed for bankruptcy; Asia Pacific Environmental Technologies (Honolulu, Hawaii) never had emissions testing and shut down in August 2004 due to equipment damage, Hawaii Department of Health took serious enforcement actions against the facility and later sued the same company.
These plants claimed not to cause any emissions, but were unable to produce proof of their claims. Biochar, a byproduct of pyrolysis, has been studied and suspected to actually suppress plant growth after two harvests (Steiner et.al, 2007). One glaring fact is that there are no long-term studies (more than 50 years old) and so it is not known whether the increased plant growth sometimes observed with the addition of charcoal would be sustained over the longer term. Thus, the much advertised benefits of biochar in enriching soil are therefore dangerously unfounded. HCWH-SEA believes that the DOH, being the main regulating body for all areas of healthcare in the countryfrom prevention to rehabilitationshould not recommend technologies that have been proven to pose deleterious effect on human health, and which may negatively impact the countrys economy, which a developing country like the Philippines could possibly not recover from. Instead, the DOH should promote technologies which are locally available, locally operated and are known to economically benefit healthcare facilities, communities and local operators without compromising health and environment.
It is in the light of the aforementioned arguments that HCWH submit the exclusion of pyrolysis as an acceptable method for health care waste treatment in the Phil DOH 3rd Edition HCWM Manual. 3.2 Definition of Waste Recovery as a Mode for Waste Minimization under the Resource Development (3 Rs) Technique By choosing to replace the waste reduction under the category of Resource Development (3 Rs) with waste recovery in the Manual, the legislation ruling the need for proper waste segregation (Ecological Solid Waste Management Act) is weakened overall. The definition of the inclusion of the word recovery in waste minimization in order to convert waste to fuel, wherein a certain volume of waste has to be met before the fuel can be generated, directly contradicts the principle of waste minimization. Waste recovery is the precipitating principle for the development of Waste-to-Energy (WTE) Facilities. WTE facilities have also been known to be unreliable in producing fuel over the years. These facilities, which utilize technology that produce energy or fuel, have been linked to massive economic losses to operators, state or country where they are situated. Examples of such facilities are mentioned in the previous page. Pyrolysis is a waste-to-energy technology. Economically, healthcare facilities would be able to minimize costs and generate more income if they promote wise procurement, waste reduction, and safe recycling of waste. HCWH-SEA suggests that the term waste reduction be placed back in this portion of the Phil DOH 3rd Edition HCWM Manual instead of waste recovery, and that a clear and restrictive wording be applied in the definition of waste minimization. The term waste recovery should be removed from this chapter. 3.3 Specific Guidelines on the Safe Management of Mercury Spills and Proper Disposal of Chemicals HCWH-SEA acknowledges the Manuals emphasis on the need for mercury phase-out for mercury-containing healthcare devices and equipment, and on the importance of safe management and recovery of mercury spills, and the proper disposal of chemical wastes. The Manual, however, did not provide a clear set of guidelines to follow in the storage of mercury and chemicals. Department Memorandum 2011-0145 was cited as the source guidebook for mercury spills management, but the contents of the memorandum were not outlined in the Manual. Also, recommendations for proper chemical disposal, especially with regards to wastewater management, were not outlined. Both of these points seem to contradict the intent of the Manual, which is to serve as a reference for effective and efficient waste management program. HCWH-SEA therefore suggests the specification of these guidelines, and also the inclusion of end-of-life storage, and in cases of breakage, proper mercury spill management of
fluorescent lamps or bulbs, which are known to contain mercury and which are utilized and discarded on a regular basis in all healthcare facilities. These are information pertinent to the HCW Projects aim of prevention of mercury releases into the environment and provision of safe water to the general populace. 3.4 Need for update in the Wastewater Treatment Chapter. To ensure safety of healthcare workers handling chemicals, and to ensure limitation of exposure to such among patients and nearby communities, a clear and specific guideline must be provided in the Manual containing information on proper containment, management, nondisposal or storage, or neutralization prior to discharge in wastewater of toxic chemicals which may include but are not limited to mercury, glutaraldehydes, formaldehyde, methanol, acetone, and xylene. Recent studies are now documenting the need to ensure proper guidelines in the storage, handling and management of hospital chemicals: WHO states glutaraldehyde waste should never be discharged in sewers; it may be neutralized through careful addition of ammonia or sodium bisulfite. A 2006 Manual produced by the US District of Columbia Water and Sewer Authority and DC Department of the Environment entitled Wastewater Management and Minimization Guidelines for Healthcare Facilities specified the chemicals formaldehyde, methanol, acetone, and xylene which should not be discharged in the wastewater. Other identified toxic chemicals are listed in a summary table which included the concentration prior to wastewater discharge. HCWH-SEA cites the above information as reasons for the need of the inclusion of an update in this chapter. 3.5 Other Issues The following HCWM practices listed below has been subjected to updates by local and international agencies because of the health risks it may pose or has posed to healthcare workers, patients and the communities: a. Suggestion of the Spaulding system as the sole method of Sterilization- a chemical process which includes the highly- toxic disinfectants like glutaraldehydes, o According to the US Occupational Safety and Health Administration, glutaraldehydes have been known to cause occupational hazards to healthcare workers such as respiratory tract (occupational asthma) and dermatological conditions (contact dermatitis). In their 2006 Manual entitled Best Practices for the Safe Use of Glutaraldehyde in Health Care, they have outlined the recommended exposure controls, area engineering controls, work practices, and
employee information and training to minimize the effects of glutaraldehyde exposure and occupational hazards to healthcare workers. HCWH-SEA therefore recommends that a similar guide be provided to healthcare providers and be cited if not included in the Manual to ensure the healthcare facilitys compliance to occupational safety standards. b. Unsupported claim of shredders as a high maintenance feature of microwave technologies, suggesting the total exclusion of this feature to the technology-which has been known to greatly reduce the HCW volume. o A 2004 cost-benefit study in Maryland, USA entitled Medical Waste in Maryland: Alternatives to Incineration concluded that burn technologies cost more than the safer alternatives equipped with shredders. In the study, authors state The cost of microwaving regulated medical waste is estimated at $0.08 per pound, compared to $0.35 per pound for incineration. o This portion of the Manual cites the inclusion of metal parts as the reason for the deterioration of the shredder feature of the microwave technology. Compliance to proper segregation, especially with sharps disposal will minimize the incidence of the machines deterioration, shredding will mainly involve treated infectious waste without the sharps, which should be disposed of separately. Sharps should not undergo shredding; instead they should be disinfected through autoclaving and disposed of separately. HCWH-SEA thereby recommends that adequate support in terms of a national costbenefit analysis be provided or if not available, be conducted prior to making this claim. c. Non-inclusion of the Philippine BFAD Circular no.16 s. 1999 regarding Inventory, Proper Disposal and/or Destruction of Used vials or Bottles o The circular stipulates that the Chief Pharmacist of government and private hospitals to conduct at least, a semestral inventory of the proper disposal and destruction of used vials or bottles, and to submit same to the Bureau within five (5) days from the date of inventory; o In all cases, and consistent with the provisions of RA 5921 (Pharmacy Law), the dispensing of drugs in vials/bottles must only be done by the hospital pharmacist. The nurse administering the drugs must be under strict instruction to return all empty vials to the hospital pharmacy for destruction on a quarterly basis; and
o All inventories and/or destruction shall be done under the supervision of duly authorized representative of BFAD, in which case proper notification shall be made to this Office. Saint Paul de Chartres Hospital-Tuguegarao City is one hospital that has successfully complied with this guideline, after inventory, they have mixed the crushed vials with cement to be used as part of the decorative pavement on the grounds outside their hospital. HCWH-SEA recommends the inclusion of the BFAD regulation in the disposal of vials and/or ampules in the Manual. HCWH-SEA suggests the amendment of the abovementioned parts of the Manual in compliance to standards set by international and local policies on HCWM. 4. Protection of Human Rights In the 18th session of the Human Rights Council on the United Nations General Assembly, held on 4 July 2011, Special Rapporteur Calin Georgescu cited the Adverse Effects of the Movement and Dumping of Toxic and Dangerous Products and Wastes on the Enjoyment of Human Rights. Specifically, his report focuses on: Human rights impact of medical waste to Right to life/right to health Right to safe and healthy working conditions Right to an adequate standard of living The Special Rapporteur calls on health-care establishments to take all appropriate measures to improve health and safety conditions for those handling medical waste in and outside healthcare establishments. Such measures should include: (a) Access to information on the specific occupational risks to which different categories of workers are exposed, and the safety measures to minimize such risks; (b) The provision of appropriate personal protective equipment for persons handling hazardous healthcare waste; (c) Access, on a voluntary basis, to vaccination against such common infectious diseases as tetanus and hepatitis; (d) The organization of training opportunities and safety workshops designed for and targeting different categories of hospital personnel (such as medical doctors, nurses, hospital cleaners and waste handlers); (e) Regular drills in emergency prevention, preparedness and response procedures.
HCWH-SEA then calls for the Phil DOH to ensure that the 3rd Edition HCWM Manual will provide updated, environmentally and legally-acceptable guidelines in HCW management, and to keep the data as complete as possible. 5. WHO Policy Paper on Safe Healthcare Waste Management Recognizing the issues associated with improper management of healthcare waste, the WHO has released a Policy Paper on Safe Healthcare Waste Management in 2004. In this policy paper WHO recommends that countries should conduct assessments prior to any decision as to which healthcare management methods be chosen. WHO has also specified following planning strategies for a sound basis for adopting an appropriate healthcare waste management system: Short-term: Identification and development of recycling options wherever possible (e.g.: for plastic, glass, etc.) Research and promotion on new technology or alternative to small-scale incineration; Medium Term: Research into the health effect of chronic exposure to low levels of dioxin and furan Risk assessment to compare the health risks associated with: (1) incineration; and (2) exposure to healthcare waste. Long-term: Effective, scaled-up promotion of non-incineration technologies for the final disposal of healthcare waste to prevent the disease burden from: (a) unsafe healthcare waste management; and (b) exposure to dioxins and furans; support to countries in developing a national guidance manual for sound management of healthcare waste HCWH-SEA calls for the Phil DOH to then recommend sound alternatives for healthcare waste treatment which do not utilize incinerator or burn technologies in its 3rd Edition HCWM Manual, in the light of the WHOs recommendations in their Safe HCWM Policy Paper. 6. For Further Information Comments on the final Manual draft from HCWH-SEA are included in the attachment. HCWH-SEA is open to work with the Policy TWG according to the intention and purposes that has brought about the revision of this Manual.
For further information please contact

Yvette S. Montecillo MedWaste Campaigner yvette@no-harm.org Faye V. Ferrer Safer Chemicals Campaigner faye@no-harm.org Merci V. Ferrer Executive Director merci@no-harm.org *other contact details on the upper portion of this page
References:
District of Columbia Water and Sewer Authority.(2006). Wastewater Management and Minimization Guidance for Healthcare Facilities. Retrieved from: http://www.dcwater.com/wastewater/HealthCare_Guidance.pdf European Union (EU). (2000). Directive of the European Parliament and of the Council on the Incineration of Waste, Official Journal of the European Communities, L 332/92.Retrieved from http://www.central2013.eu/fileadmin/user_upload/Downloads/Document_Centre/OP_Resources/Incineration_Direct ive_2000_76.pdf Greenaction for Health and Environmental Justice and Global Alliance for Incinerator Alternatives (GAIA). (2006). Incinerators in Disguise: Case Studies of Gasification, Pyrolysis, and Plasma in Europe, Asia, and the United States. Retrieved from: http://www.greenaction.org/incinerators/documents/IncineratorsInDisguiseReportJune2006.pdf Georgescu, C. (2011). Report of the Special Rapporteur on the adverse effects of the movement and dumping of toxic and dangerous products and wastes on the enjoyment of human rights, United Nations Human Rights Council General Assembly, Retrieved from: http://www2.ohchr.org/english/bodies/hrcouncil/docs/18session/A-HRC-18-31_en.pdf Health Care Without Harm (HCWH). Health Care Without Harm: About Us, History and Victories. Retrieved from http://www.noharm.org/all_regions/about/history.php Hogg, D. Baddeley, A. Gibbs, A. North, J. Curry, R. and Maguire, C. (2008). Greenhouse Gas Balances of Waste Management Scenarios: Report for the Greater London Authority. Eunomia and EnviroCentre Report. Retrieved from: http://static.london.gov.uk/mayor/environment/waste/docs/greenhousegas/greenhousegasbalances.pdf Occupational Safety and Health Administration (OSHA). (2006). Best Practices for the Safe Use of Glutaraldehyde in Health Care. Retrieved from: http://www.osha.gov/Publications/glutaraldehyde.pdf Philippine Department of Health-Bureau of Food and Drugs. (1999). Bureau Circular No.16 s. 1999 on Amending BFAD MC#22 Dated Sept. 8, 1994 regarding Inventory, Proper Disposal, and/or Destrution of Used Vials or Bottles. Retrieved from: http://www.fda.gov.ph/BC/bc%2016%20s%201999.pdf
Ridlington, E. Heavner B. (2004) Medical Waste in Maryland: Alternatives to Incineration. MaryPIRG Foundation , p. 16-17, Retrieved from: http://www.policyarchive.org/handle/10207/bitstreams/5161.pdf United Nations Development Programme- Global Environment Facilitys (UNDP-GEF), World Health Organization (WHO), and Health Care Without Harm (HCWH). Global Healthcare Waste Project. Retrieved from http://gefmedwaste.org/article.php?list=type&type=3 United States Environmental Protection Agency (US EPA). (1998) The Inventory of Sources of Dioxin in the United States, Retrieved from http://www.epa.gov/ncea/pdfs/dioxin/dioxin.pdf World Health Organization (WHO).(1999). Safe Management of Waste from Health Care Activities. Geneva, Switzerland: WHO. World Health Organization (WHO).(2004). Policy Paper on Safe Health-Care Waste Management. Retrieved from: http://www.who.int/water_sanitation_health/medicalwaste/en/hcwmpolicye.pdf

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Leading the global movement for environmentally responsible health care

Position Paper of Health Care Without Harm-Southeast Asia

Leading the global movement for environmentally responsible health care

Leading the global movement for environmentally responsible health care

Leading the global movement for environmentally responsible health care

Leading the global movement for environmentally responsible health care

Leading the global movement for environmentally responsible health care

Leading the global movement for environmentally responsible health care

Leading the global movement for environmentally responsible health care

Leading the global movement for environmentally responsible health care

Leading the global movement for environmentally responsible health care

Leading the global movement for environmentally responsible health care

Leading the global movement for environmentally responsible health care

Leading the global movement for environmentally responsible health care

Leading the global movement for environmentally responsible health care

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Leading the global movement for environmentally responsible health care

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