Environmental Impact Due to Pharmaceutical Waste

Prof. Yashoda Hirimuthugoda Ph.D.

PUBLISHED ON July, 2021

Introduction

Waste poses the great risk of humans, worldwide. It contaminates the natural environment (air, water, soil, fauna and flora) as well as the man-made environment. All over the world there is evidence of major health effects related to improper disposal of healthcare waste.

In many countries in proper management of waste generated in healthcare facilities causes direct health harm to the community, to people working in health care facilities, and to the environment. In addition, pollution from inadequate treatment of waste can indirect health harm to the community. The disposal of certain types of devices should follow specific safety rules. For example, a syringe is a common item that requires safe disposal. It is usual sight in the vicinity of practically every hospital to find unsterile needles, syringes and containers for sample collection for sale by unscrupulous vendors. The health authorities are aware of this perilous situation, but are unable to act in a meaningful manner due to the absence of a chemical waste management infrastructure. Sri Lanka urgently needs a proper chemical waste management system.

Base management options need to be efficient, safe and environmental friendly to protect people from voluntary and accidental exposure to waste when collecting, handling, storing, transport, treating or disposing of waste. Furthermore, in the Sri Lankan context such options need to be cost effective, taking into account the local logistical needs. Though clinical waste management should be an integral part of the health care delivery system the principal reason for absence of such infrastructure is economic. Health personnel are still to distinguish health care waste from ordinary garbage. So, it is a must to carry out proper research to find out effective ways to dispose health care waste to minimize the damage to the environmental health.

Post Images
Figure 1: Hospital post-details_fuel_waste_plastic

Sri Lankan Condition

Although Sri Lanka has impressive health indicators, the health system has certain shortcomings a major drawback in planning has been the non-inclusion of a clinical waste management system, which is an integral part of any national health system.

Current Status

The state hospital health care waste produced at present in Sri Lanka is disposed of by the following method;

1. Collection by local municipal authority and Subsequent dumping.
2. Burning in the health care facility premises.
3. Dumping at the designated site within hospital premises or at a designated dumping site of the local authority.

Sri Lanka at present is disposing general health care waste according to WHO recommendations. The point at which Sri Lanka departs from these recommendations is that we disposed hazardous waste along with the general waste into a common disposal system. Hazards waste is not treated before releasing into the general waste disposal system to render it non-hazards. Some major hospitals in the island are collecting waste using the internationally accepted colour coded collection system. However, as there is no separate system for final collection, storage, transport and disposal of general and hazards waste there is re-mixing of the two categories. Consequently the initial effort and cost of segregation is lost.

Post Images
Figure 2: Hazards waste is not treated before releasing into the general waste disposal system.

Health Care Waste

All the waste generated by
 Health care establishments,
 Research facilities and laboratories
 And the waste originating from "minor" or "scattered" sources produced in the cause of health care undertaken in the home. (Dialysis, insulin injections, etc.)
 Healthcare waste is dangerous.
 If handled, treated or disposed of incorrectly it can spread disease, poisoning people, livestock, wild animals, plants and entire ecosystems.
Post Images
Figure 3: Health Care Waste

General Waste

• Similar or identical to domestic waste, including materials such as packaging or unwanted paper.
• This waste is generally harmless and needs no special handling.

75-90% of the waste generated by healthcare facilities falls into this category.
Post Images
Figure 4: The tank that hears the same voice will then hear different voices.

Hazards Waste

Hazards healthcare wastes including infectious waste (except sharps and waste from patients with highly infectious diseases), small quantities of chemicals and pharmaceutical and non-recyclable pressurized Containers.
Post Images

Highly Hazards Waste

Includes clinical waste, large quantities of expired or unwanted pharmaceutical and hazards chemicals and radioactive wastes.
Post Images

Clinical Waste

Any substance, matter or thing generated in connection with,

 A dental, medical, nursing or veterinary practice,

 Any other practice, or establishment that provides medical care and services for the sick, injured , infirm or those who require medical treatment ;

 Dental, medical, nursing, veterinary, pathological or pharmaceutical research; or

 A dental, medical, veterinary or pathological laboratory practice

Post Images
Figure 7: Clinical waste

Types of chemical waste

Infection waste
Contain pathogen (bacteria, viruses, parasites, or fungi)
Pathological waste
Tissues, organs, body parts, human foetuses and animal carcasses, blood , and body fluids
Sharps
Items that could cause cuts or puncher wounds, including needles, hypodermic needles, scalpel and other blades, knives, infusion sets, saws, broken glass, and nails
Gene toxic waste
Certain Cytoxan drugs, vomit, urine, or faces from patients treated with Cytoxan drugs, chemicals and radioactive material.
Chemical waste
Discarded solid, liquid and gaseous chemicals,
Waste with high content of heavy metals
As, Hg, Cd
Pressurized containers
Many types of gasses used in health care are often stored in pressurized cylinders, cartridges, and aerosol cans

Post Images
Figure 8: Types of chemical waste

Radioactive Waste

Radioactive wastes are the leftovers from the use of nuclear materials for the production of electricity, diagnosis and treatment of disease, and other purposes The materials are either naturally occurring or man-made. Certain kinds of radioactive materials, and the waste produced from using these materials, are subject to regulatory control by the federal government or the states

The commercial radioactive waste that is regulated by the NRC or the agreement states and that is the subject of this broacher is three basic types: high-level waste, mill tailings, and low-level waste.

Mill tailings wastes are the residues remaining after the processing of natural ore to extract uranium and thorium. Commercial radioactive wastes that are not high level wastes or uranium and thorium milling wastes are classified as low level radioactive waste. The low level wastes can include radioactively contaminated protective clothing, tools, filters, racks, medical tubes, and many other items.

NRC licensees are encouraged to manage their activities so as to limit the amount of radioactive waste they produce.

Techniques include avoiding the spread of radioactive contamination, surveying items ensure that they are radioactive before placing them in a radioactive waste container, using care to avoid mixing contaminated waste with other trash, using radioactive materials whose radioactivity diminishes quickly and limiting radioactive material usage to the minimum necessary to stablish the objective.

Licensees take steps to reduce the volume of radioactive waste after it has been produced. Common means are compaction and incineration. Approximately 59 NRC licensees are authorized to incinerate certain low level waste, although most incineration is performed by a small number of commercial incinerators.

The radioactivity of nuclear waste decreases with the passage of time, through a process called radioactive decay. (“Radioactive " refers to the spontaneous disintegration of an unstable atomic nucleus, usually accompanied by the emission of ionizing radiation. ) Radioactivity naturally decays overtime, so radioactive waste has to be isolated and confined in appropriate disposal facilities for a sufficient period of tie until it no longer poses a hazard.

Current major approaches to managing radioactive waste have been segregation and storage for short-lived waste, near -surface disposal for low and some intermediate level waste, and deep burial or transmutation for the high level waste.

Biomedical waste may also include waste associated with the generation of biomedical waste that visually appears to be of medical or laboratory origin (e.g. packaging, unused bandages, infusion kits, etc.) As well research laboratory waste containing biomolecules or organisms that are restricted from environmental release. As detailed below, discarded sharps are considered biomedical waste whether they are contaminated or not, due to the possibility of being contaminated with blood and their propensity to cause injury when not properly contained and disposed of. Biomedical waste is a type of bio-waste.

Bio medical waste may be solid or liquid. Examples of infections waste include discarded blood, sharps , unwanted microbiological cultures and stocks , identifiable body parts, other human or animal tissue , used bandages and dressings, discarded gloves , other medical supplies that may have been contract with blood and body fluids ,and laboratory waste that exhibits the characteristics described above. Waste sharps include potentially contaminated used (and unused discarded) needles, scalpels, leafiest and other devices capable of penetrating skin.

Biomedical waste is generated from biological and medical sources and activities, such as the diagnosis, prevention, or treatment of diseases. Common generators ( or producers) of biomedical waste including hospitals , health clinics, nursing homes , medical research laboratories , offices of physicians, dentists , and veterinarians , home health care, and funeral homes. In health care facilities (i.e. hospitals, clinics, doctors’ offices, veterinary hospitals and clinical laboratories), waste with these characteristics may alternatively be called medical or clinical waste.

Biomedical waste is distinct from normal trash or general waste, and differs from other types of hazardous waste, such as chemical, radioactive, universal or industrial waste. Medical facilities generate waste hazardous chemicals and radioactive materials. While such wastes are normally not infectious, they require proper disposal. Some wastes are considered multi hazardous, such as tissue samples preserved in formalin.

Post Images
Figure 9: Radioactive waste

Pharmaceutical Waste

Pharmaceutical waste may be a hazardous chemical waste, controlled substance or biomedical waste. Proper classification is necessary to be in compliance with the laws regulating each waste type.

Hazardous chemical pharmaceutical waste: A number of common pharmaceutical are regulated as hazardous chemical waste. These include but are not limited to;

• Arsenic Trioxide Epinephrine Nitro-glycerine Saccharin.
• Chloroform Formaldehyde Phenacetine selenium Sulphide.
• Chorambucil Hexachlorophene phenol streptozotein.
• Cyclophophamide Lindane Physostigimine Salicylate Uracil mustard.
• Dauomycin Melphalan Physostigmine Warfarin > 0.3%.
• Dichlorodifluoromethane Mitomycin C Reserpine.
• Diethylstilbestrol Nicotine Resorcinol.
Post Images
Figure 10: Pharmaceutical waste

How Do We Generate Pharmaceutical Waste ?

In the past, much of the pharmaceutical waste occurring at a pharmacy was due to expired pharmaceuticals. The development of rivers distribution companies has enabled pharmacies to ship all outdated drugs as products back through these firms for the purpose of returning them to the manufacturer for credit. Any outdated items that do not meet the manufacturers return policy become waste at the rivers distributor which becomes the waste generator, since this is where the decision to discard the item is made.

Pharmaceutical Classes

• Cytostatic
• Glucocorticoids
• Beta-blockers
• Psychoactive drugs
• Fibrates
• Barbiturates
• Antiphogistics

The environmental impact of pharmaceutical and personal care products is controversial. PPCPs are substances used by individuals for personal health or cosmetic reasons and the products used by agribusiness to boost growth or health of livestock. PPCPs have been detected in water bodies throughout the world and ones that persist in the environment are called Environmental Persistent Pharmaceutical Pollutants. The effects of these chemicals on humans and the environment are not yet known, but to date there is no scientific evidence that they have an impact on human health.

Source Pathways

 The waste stream-domestic wastewater ( via septic systems or waste water treatment plants)
 Domestic solid wastes (via landfill leachates).
 Commercial - industrial discharges ( such as from hospitals, other healthcare facilities, and manufacturing facilities ).
 Animal agriculture ( such as animal feeding operations (AFOs)
 Aquaculture facilities and
 Food protection facilities

Post Images
Figure 11: Source Pathways

Effects on Human Health

If waste is not treated, dangerous quantities of disease causing agents (viruses, bacteria, parasites or fungi) will be present in the waste.

These agents can enter the body through punches and other breaks in the skin, mucous membranes in the mouth, by being inhaled into the lungs, being swallowed, or being transmitted by a vector organism.

Threat comes from syringes or needles used on infected patients is infection of people with HIV/Aids and the hepatitis B and C viruses through accidental pricks or reuse of syringes/ needles.

The unthreatened infectious stools or bodily fluids are flushed into the sewer system, or due to the contamination of water supply by them can create or extend epidemics. Since hazardous chemical wastes may be toxic, corrosive, flammable, reactive, and /or explosive, they can harm people who touch, inhale or are in close proximity to them. If burn, they may explode or produce toxic fumes.

When chemical and pharmaceutical waste is disposed of in unlined landfills or pits, the leachate make contaminate ground and surface water.

Such contamination may threaten people who use the water for drinking, bathing and cooking and damaging local plans and animals.

Burning or incineration of health care waste may produce toxic air pollution such as acid gasses, nitrogen oxide, (NOx) particulates, dioxins and heavy metals and distribute them over a wide area.

Dioxins, believe to be potent cancer - causing agents, do not biodegrade, and accumulate in progressively higher concentration as they move up the food chain. Heavy metals such as mercury and cadmium are toxic and can concentrate in the food chain and / or cause birth defects, even in small quantities.

• If waste is not threated, dangerous quantities of microscopic disease - cause in agents - viruses, bacteria, parasites or fungi - will be present in water.

• These agents can be enter the body through punctures and other breaks in the skin, mucous membranes in the mouth, by being inhaled into the lungs, being swallowed, or being transmitted by a vector organism.

• Threat comes from syringes or needles used on infected patients is infection of people with HIV/Aids and the hepatitis B and C viruses through accidental pricks or reuse of syringes/ needles.

• The unthreatened infectious stools or bodily fluids are flushed into the sewer system, or due to the contamination of water supply by them can create or extend epidemics. • Chemical and pharmaceutical wastes, especially large quantities, can be a threat to the environment and human health.

• Since hazardous chemical wastes may be toxic, corrosive, flammable, reactive, and/or explosive, they can harm people who touch, inhale or are in close proximity to them.

• If burned, they may explode or produce toxic fumes. Some pharmaceuticals are toxic as well.

• When chemical and pharmaceutical waste is disposed of in unlined landfills or pits, the leachate make contaminate ground and surface water.

• Such contamination may threaten people who use the water for drinking, bathing and cooking and damaging local plans and animals.

• Burning or incineration of health care waste may produce toxic air pollution such as acid gasses, nitrogen oxide, (NOx) particulates, dioxins and heavy metals and distribute them over a wide area.

• Dioxins, believe to be potent cancer – causing agents, do not biodegrade, and accumulate in progressively higher concentration as they move up the food chain.

• Heavy metals such as mercury and cadmium are toxic and can concentrate in the food chain and / or cause birth defects, even in small quantities.

Environmental Impacts of Pharmaceuticals

Post Images

• Most pharmaceutical have harm for environment because they may act unpredictably when mixed with other chemicals from environment or concentrate in the food chain.
• Some pharmaceuticals are active at very low concentration, are often released continuously in large or widespread quantities.
• Because of the high solubility of most pharmaceuticals, aquatic organisms are especially susceptible to their effects.
 Steroid compounds found in aquatic lives.
 Anti-depressants (SSRI's)
 Non-steroidal anti-inflammatories (NSAIs)

Steroid compounds

• Estragon can have feminization effects of male fish.
o The increased presence of estragon and other synthetic hormones in waste water due to birth control and hormonal therapies has been to increased feminization of exposed fish and other aquatic organisms.
• Androgens can have masculinization effects on female fish.

Anti – depressants

Serotonin Reuptake Inhibitors

Post Images

o Changes in fish and shrimp behaviours
o Metamorphosis delays in frogs
o Induce mussel spawning.
This is caused by Norfluoxetine/Fluvoxamine, o African frog tadpoles were raised in clean water and in tanks of water mixed with 38ppb fluoxetine ( Prozac)
o Days after the tadpoles hatched, the controlled group had begun to development legs, but the "treated" tadpoles had no legs.

Non-steroidal anti-inflammatory

o In the early 1990's white-backed vultures experienced dramatic population declines (-95%) in India, Pakistan and Nepal.

o Diclofenac (Voltaren, Cataflam ) was heavily used in cattle.

o And the cattle carcasses were a major food source for the vultures. Birds died of acute renal failure

Antibacterial resistance.

The development of resistance to antimicrobial agents males treatment of infections very difficult to cure, therefore this issue is an important consideration for the treatment of waste water, especially that which is discharged from hospitals, veterinary clinics, or other locations where large amounts of antibiotics are used.

Another synthetic chemical found in the environmental are quaternary ammonium compounds (QACs).

o AQCs are cationic compounds that are important ingredients to disinfectants, which are used in hospitals as well as households.
o They are known to inhibit the proper functioning of aquatic microorganisms, and they have a low biodegradability.


(Some specific hospitals in the country whose names are not exposed in this research that waste is produced & issued directly to the environment)

Base Hospital A

o Waste produce at this base hospital can be divided into two categories.
o That is clinical waste and general waste.
o Normally they produce 10kg of clinical waste per day.
o Some patients throw away the medicines which they take from the OPD at the hospital premises.
o Also some drugs enter to the environment from the urine and the faeces of the patients.
o The pieces of cotton wool that are thrown away by patients may also cause for the spread of diseases(HIV/Aids)
o Normally they incinerate the clinical waste at high temperatures for complete burning.
o And also bottles, needles, sharps are buried at the hospital premises.
o Expired drugs are returned to the collecting points.
o But a major problem that we identified there is, the remixing of most of the clinical waste with the general waste.
o They dispose all of the waste at a common place and it will badly affect the environmental health

Cancer Hospital A

o Godigamuwa is a village in Maharagama, close to the national cancer institute, and the villager notices a strong chemical odor in the air.
o The Maharagama cancer hospital uses a number of radioactive sources to treat patients.
o A waterway that flows Godigamuwa carries waste water and chemical effluents discharged by the cancer hospital.
Most of the houses in this highly populated part of Maharagama are permeated by the chemical odor
o Residents say the colour of the waste water changes from red to black, and even discarded syringes, pieces of used gauze, saline tubes and medical vials are seen floating in the waste water.
o The discharge ends up in a field where children play and residents grow rice and vegetables.
o The houses are flooded by this stinking waste water, it attributes to unhealthy living conditions.
o Black spots on feet. The doctors say skin is burnt by chemicals.
o Respiratory diseases, due to burned plastic materials, and the whole area is filled with smoke.
Hospital releases waste water into the drains at least three times a day

Suggestions to overcome this problem

o Waste would be buried into hospital premises
o Urine from thyroid cancer patients is kept in a delay tank for at least one month, to give time for the radiation effect to wear off.
Ideally, the urine should be released into large bodies of water. There should be a proper drainage facility, one that reaches large bodies of water. This would minimize any ill- effects

Cancer Hospital B

o Waste management of Galle area has been done by the Galle Municipal Council.
o The Karapitiya Teaching hospital is the main hospital that caters to the public of the Southern Province and that waste also collected by GMC.
A small portion of biodegradable waste is used to produce compost and rest of the waste is disposed on a semi controlled dumpsite.
o Gin river is flowing by the side of the dumpsite therefore controls and measures are needed at this dumpsite.
o Because highly contaminated leachate may enter the ground and surface water if there is no appropriate method to collect and treat leachate.
o When those clinical waste are added to the waterways, they may added to the food chains.
o Because there are lots of livestock industries such as;
o Poultry
o Goats Etc..
o Thus, should dispose and remove clinical waste properly.

How to minimize the effects of health care waste

Depending on the source and ingredients, there are various ways in which the public can dispose of pharmaceutical and personal care products. In the case of pharmaceutical products, the most environmentally safe disposal method is to take advantage of a community drug take back programs that collect drugs at a central location for proper disposal. Currently, take back programs are funded by state health department or are volunteer programs through pharmacies or health care providers take back programs should exist in every community.

1. Take the prescription drugs out of their original containers
2. Mix drugs with cat litter or used coffee grounds
3. Place the mixture into a disposal container with a lid, such as a sealable bag
4. Cover up any personal identification with a black marker that is on the original pill
5. Place these containers in the bag with the mixture, seal them, and place them in the trash.

Post Images
After these products are properly disposed, the process of treating them for minimizing environmental impact begins. Water treatment facilities use different processes in order to minimize or fully eliminate the amount of these pollutants. This is done by using sorption where suspended solids are removed by sedimentation another method used is biodegradable, and through this method microorganisms, such as bacteria, feed or break down these pollutants thus eliminating them from the contaminated media.

Green pharmacy is the design of pharmaceutical products and processes that eliminate or reduce the use and generation of hazardous substances. Following these principles, pharmaceutical can be generated with reduced impact on the environment during production or after use. The introduction of such processes and pharmaceutical is currently not a high priority for the pharmaceutical industry.

A written waste management plan should describe all of the practices for handling, storing, treating, and disposal of hazardous and non-hazardous and prone to more damages or both the environment and human it is a must to follow WHO rules and regulations. For an example, when considering about the storage there is a standard colour code as shown below.

Post Images
Labelling plays on an important role as well. In the case of labelling name of the waste and the origin of that are required as well. If a bag holder (e.g., an ordinary type rubbish bin) is used for holding the plastic bag which is in use, it should be in good condition and should follow the same labelling requirements as for the plastic bag itself. The colour of the bag holder should preferably be the same as that of the bag for easy identification. Another precaution is to engaging trained personalities in this waste management and handling. They must be aware about they are not handling normal waste. Due to a little mistake perform by them, it may pave the way for a disaster or a tragedy. So, the awareness should be given to them and PPE or Personal Protective Equipment like boots gloves, and other protective clothing must be given them to be used. Those people should be aware about the responsibilities they have.

Treatment for hazardous and highly hazardous waste are another option or a precaution that can be taken. The most important function of treatment is disinfection. In the case of treatment is a must to treat some kinds of health care waste such as radioactive ingredients before they are being released. The Sri Lanka government is to get US Government assistance to remove radioactive waste to solve the Maharagama Cancer Hospital waste problem. They are to be provided with funds and technical support to achieve those goals.

For rural facilities, burning in the open air in single chamber incinerator, drum or brick incinerator, preferably combined with good waste segregation practices is the recommended option. In the visit to the Karapitiya Teaching hospital we were got to know that when the incinerator is being used, the whole area is covered from black smoke.

Autoclaving of infectious waste combined with encapsulation of sharps may be the best option for urban facilities. In 2001-2, a World Bank team with local collaboration did a review of the clinical waste disposal system in Sri Lanka. The team recommended the installation of an autoclave to decontaminate clinical waste generated in the government sector before release into the general waste disposal system (personal communication, Dr. R. Fernando). Through using this we can use Higher Temperature and pressure to destroy micro organisms presented. Small-scale facilities should bury waste on site, ideally in a pit lined with clay or a similarly impermeable material to prevent contamination of ground water. If not those waste may get in to pure water sources and can spread diseases etc quickly. Landfills can be used where through an impermeable layer the waste is restricted to be contaminated in to soil and water sources. That would be fine option to avoid adding that waste into food chains and avoid bio magnifications of some toxic compounds.

And also Carcasses should be evaluated in a proper way so that we could ensure that those foods are free contamination of such kinds of waste materials.

So it is very much essential to handle this health care waste with care.

If not they may contaminated into soil water etc and they may be included in to livestock production. In the case of Piggery, they are given waste to be eaten and if they are being contaminated with above, we have to get those things to our body through food chains.

Conclusion

• Sri Lanka's population is projected to reach 23.35 million in 2040.

• With increase in the number of health care facilities and the use of sophisticated equipment, the generation of hazardous waste is sure to rise.

As clinical waste management is a relatively new concept for Sri Lanka, which needs to be integrated into the existing health care system, all levels of health professionals should be made aware of the usefulness and need for it.

Eng. Lanka Ramanayaka - CEO
Design Knigdom Lk
BSc(Eng), PG Dip.(BSE), CEng., MIE(SL), MEC(SL)
Chartered Engineer

Instagram