TABLE OF CONTENTS

1. OBJECTIVE OF THE PROGRAMME

The aim of this programme is to choose technical criteria suitable for tender specification purposes that will enable the South African Department of Health to acquire the equipment and services required for the primary healthcare clinics to carry out small incineration for the disposal of medical waste.

2. STRUCTURE OF THE PROGRAMME

The test programme has been carried out in phases, as follows:

Stage 1 A scoping study to decide the obligation of the different parties and

consensus about the test criteria and bounds of the laboratory tests. The criteria for accepting an incinerator on trial was accepted by all parties involved.

Stage two Laboratory evaluations using a ranking of each incinerator and the selection of the incinerators to be utilised in the field trials.

Stage 3 Completion of field trials, to evaluate the efficacy of each incinerator under field conditions.

Stage 4 Planning of a tender specification and recommendations to the DoH for the implementation of a continuing incineration programme.

This document offers feedback on phases 2 and 3 of their work.

3. COLLABORATORS INVOLVED IN THE PROGRAMME

SA Collaborative Centre for Cold Chain Management SA National Department of Health

CSIR

Pharmaceutical Society of SA World Health Organisation UNICEF

4. STAKEHOLDERS INVOLVED IN THE PROGRAMME

The following stakeholders participated in the steering committee:

Dept of Health (National & provincial levels) (DoH)
Dept of Occupational Health & Safety (National & provincial levels)
Dept of Environmental Affairs & Tourism (National & provincial levels) (DEAT)
Dept of Water Affairs & Forestry (National & provincial levels) (DWAF)
Dept of Labour (National & provincial levels) (DoL)
National Waste Management Strategy Group
SA Local Government Association (SALGA)
SA National Civics Organisation (SANCO)
National Education, Health and Allied Workers Union (NEHAWU)

Democratic Nurses Organisation of SA (DENOSA)
Medecins Sans Frontieres
SA Association of Community Pharmacists
Mamelodi Community Health Committee
Pharmaceutical Society of SA
CSIR
UNICEF
WHO
SA Federation of Hospital Engineers

International visitors:

Dr Luiz Diaz – WHO Geneva and International Waste Management , USA
Mr Joost van den Noortgate – Medecins Sans Frontieres, Belgium

5. LABORATORY TRIALS

5.1. Objective of the laboratory trials

Rank the performance of submitted units to the following criteria:

y Occupational safety

y Impact on public health from emissions

y The destruction efficiency

y The endurance for the accessible staff

The panel of experts for the ranking consisted of a:

y Expert nurse; Mrs Dorette Kotze from the SA National Department of Public Health

y Emission expert; Dr Dave Rogers from the CSIR

y Combustion Engineer; Mr Brian North from the CSIR

5.2. Incinerators received for evaluation

Name used in report	Model no.	Description	Manufacturer
C&S Marketing incinerator	SafeWaste Model Turbo 2000Vi	Electrically operated fan supplies combustion air — no supplemental gas	C&S Marketing cc.
Molope Gas incinerator	Medcin 400 Medical Waste Incinerator	Gas-fired incinerator	Molope Integrated Waste Management
Molope Auto incinerator	Molope Auto Medical Waste Incinerator	Auto-combust incinerator – uses wood or coal as extra fuel to facilitate incineration	Molope Integrated Waste Management

Name used in report

Model no.

Description

Manufacturer

PaHuOy

incinerator

Turbo Stove

Auto-combust unit,

Working with no additional fuel or driven air distribution

Pa-Hu Oy

5.3. Emission testing: laboratory method

Sampling of emissions followed the US-EPA Method 5G dilution tunnel Way of cooker emissions. Adjustments to the layout were created to account for flames extending up to 0.5 m above the suggestion of the incinerator and the drop out of big parts of ash. Emissions were extracted to a duct for isokinetic sampling of particulate emissions. The sampling arrangement is revealed by a schematic in Figure 1. A photograph of this operation over the Molope gas fired incinerator unit is displayed in Figure 2.

All evaluations were performed according to specified operating procedures. The directions provided by the supplier of the equipment were followed in the case of this C&S Marketing Unit. No operating procedures were supplied with the Molope Gas, Molope auto-combustion and PaHuOy units. These procedures were created by the CSIR personnel using their previous experience together with advice offered by the supplier.

Evaluation facilities were set up at the CSIR and measurements have been carried out under an ISO9001 system using standard EPA test procedures or modifications made at the CSIR.

Figure 1. Schematic diagram of the laboratory set-up

Figure 2:Photograph of air intake sampling hood over Molope gas incinerator

5.4. RANKING RESULTS OF THE LABORATORY TRIALS

Using the criteria listed under section 4.1 above, the incinerators were rated as followed:

	Molope gas-fired unit	Molope wood-fired unit	C&S electric unit	PaHuOy wood-fired unit
Safety	6.8	4.8	5.5	3.3
Health	5.5	3.5	4.3	2.3
Destruction	9	2	6	1
Usability	2	3	3	5
Average	5.8	3.3	4.7	2.9

5.5. EMISSION RESULTS OF THE LABORATORY TRIALS

Quantitative measurements were utilized to rank the units in terms of destruction efficiency and also the potential to produce hazardous emissions.

Conformance into the South African Department of Environmental Affairs and Tourism’s (DEAT) recommended guidelines on emissions from Big Scale Medical Waste Incinerators is outlined in Table 1. The measurements are listed1 in Table 2.

Table 1: Summary qualitative results

Parameter Measured	Units	Molope Gas-fired	Molope Wood-fired	C&S Electric	PaHuOy Wood-fired	SA DEAT Guidelines
Stack height	m	×	×	×	×	3 m above closest building
Gas velocity	m/s	×	×	×	×	10
Residence time	s	×	×	×	×	2
Minimum combustion temperature	ºC	4	×	×	×	> 850
Gas combustion performance	%	×	×	×	×	99.99
Particulate emissions	mg/Nm3	4	×	4	×	180
Cl as HCl	mg/Nm3	×	4	4	×	< 30
F as HF	mg/Nm3	4	4	4	4	< 30
Metals	mg/Nm3	4	×	×	4	< 0.5 and < 0.05

1 Fragrant concentrations are reported in accordance with the South African reporting requirements, ie, normalized to Regular Temperature (0

oC) and Stress (101.3 kPa) and adjusted to a nominal concentration of

8% of CO2 on a dry gas basis. If a measurement dropped below the detection limit for the method is it either reported as the detection limit or as N.D., ie, not detectable.

Table 2: Detailed quantitative results

Parameter Measured *

Components

Molope gas

Molope Automobile

C&S

PaHuOy

SA Procedure Guide1

Comments

Stack height

1.8

1.9

0.3

3 m above closest building

none of those unite has a stack. The elevation of the exhaust vent is accepted as the pile height. If it is above the respiration zone of the operator it provides some protection against exposure to smoke.

Gas speed

m/s

0.8

0.5

1.1

0.5

Gas velocities vary across the pile to get the Molope gas, Molope auto-combustion, and also the PaHuOy units.

Residence time

0.4

0.7

0.6

0.4

two

Residence time is taken to be the total combustion time, and the highest possible

Minimum combustion zone temperature

800 -900

400 – 650

600 – 800

500 – 700

> 850

Molope auto-combustion temperatures are anticipated to become higher as the middle of the combustion zone is not predicted to be at the measurement location.

CO2 at the stack tip

percent vol

2.64

3.75

4.9

3.25

8.0

Actual emission concentrations are less than the values reported here, that can be normalized to 8% CO2 and standard temperature and pressure for reporting purposes. They’re lower between 4 to 8 times.

Particulate emissions entrained in exhaust gas

102

197

130

338

180

The overall emissions are the sum of the both entrained and un- entrained particulates. Emissions are lower than anticipated for these units and this can be attributed to the absence of raking which is the major source of particulate emissions from incinerators without an emission management

system.

Combustion

99.70

99.03

the duct where mixing of exhaust

efficiency

gases is complete. Results of two

Particulate fall- out

mg/Nm3

105

n.d.

–

Big pieces of cardboard and paper ash rained out of the emissions. Totalling 0.8 to 2 gram over a +/- two minute interval.

Soot in particulates

percent

42.2

mg/Nm3

58.1

48.7

84.8

–

Correlates right with gas combustion efficiency

1 Emission concentrations have been reported in accordance with the South African reporting requirements, ie, Normalized to Regular Temperature (0

oC) and Stress (101.3 kPa) and adjusted to a nominal concentration of

8% of CO2 on a dry gas basis. If a measurement dropped below the detection limit for the method is it either reported as the detection limit or as N.D., ie, not detectable.

Parameter Measured *

Components

Molope gas

Molope Automobile

C&S

PaHuOy

SA Procedure Guide1

Comments

% ash residual from clinical waste

percent

14.8

12.9

15.6

21.7

–

Measurement of destruction efficiency of the incinerator. Typical industrial units operate at 85-90% mass decrease. PaHuOy is lower due to the melting and unburnt plastic.

Cl as HCl

35 & 542

< 30

PaHuOy chloride concentrations varied considerably. This is expected as a result of the variability of the feed composition.

Lead (Pb)

< 0.4

mg/Nm3

< 0.4

0.5

Lead not anticipated in waste

Cadmium (Cd)

< 0.2

mg/Nm3

< 0.2

0.05

Sensitivity of this x-ray method is sufficient for ranking. Greater sensitivity not sought with this trial.

Chromium (Cr)

< 0.1

0.7

mg/Nm3

0.7

< 0.1.

0.5

Chromium comparative to iron ranges between 12 and 25% which is consistent with stainless steel needles

Manganese (Mn)

< 0.1

0.3

mg/Nm3

0.3

< 0.1

0.5

Manganese may be a part in the stainless steel frame.

Nickel (Ni)

< 0.1

0.3

mg/Nm3

< 0.1

0.5

Nickel may be a part in the needle.

Barium (Ba)

< 0.5

mg/Nm3

< 0.5

0.5

Reduced sensitivity due to presence in the filter material

Silver (Ag)

< 0.2

mg/Nm3

< 0.2

0.5

Not anticipated in this waste.

Cobalt (Co)

< 0.1

mg/Nm3

< 0.1

0.5

Cobalt might be present in stainless steel.

Copper (Cu)

< 0.5

mg/Nm3

< 0.5

0.5

Reduced sensitivity due to copper in the sample blanks. May be background in the analytical equipment.

Vanadium (V)

< 0.1

mg/Nm3

0.4

< 0.1

0.5

Vanadium might be present in stainless steel.

Thallium (Tl)

< 0.4

mg/Nm3

< 0.4

0.05

Not anticipated in this waste. Sensitivity of this x-ray method is sufficient for ranking. Greater sensitivity not sought with this trial.

mg/Nm3

The main conclusions drawn from the trials are as follows:

::: All four units can be utilized to leave medical waste non-infectious, and to ruin syringes or leave needles unsuitable for reuse.

::: The biggest potential health hazard originates from the emissions of smoke and soot. (the combustion efficiency of all units lies outside the

regulatory criteria ). The risk to health can be reduced by training operators to steer clear of the smoke or by installation of a chimney at the site.

::: The emissions from small scale incinerators are predicted to be lower than those from a wood fire, but higher than a traditional fire-brick-

mg/Nm3

lined multi-chambered incinerator.

::: Incomplete combustion, and the significant creation of smoke at reduced elevation rendered the PaHuOy unit unacceptable for field trials. Figure 3

below shows this unit during a trial burn. Molten plastic flowed out of

that the incinerator, blocked the main combustion air feed ports, and burnt out the unit.

mg/Nm3

The CSIR performed a qualitative trial in the area for gas combustion efficiency, temperature profiles and mass destruction speed on the Molope Auto wood-fired unit at the Mogale Clinic.

The outcomes of this trial are contrasted to the laboratory trial outcomes under:

mg/Nm3

Temperatures were higher but for a shorter time and this was

correlated with the type of wood available to this clinic. The gas was burnt out before the medical waste was destroyed completely and this resulted in lower temperatures, lower combustion efficiency and higher emissions while burning the waste.

prior to complete ignition of the waste.

It was concluded that:

mg/Nm3

The following recommendations are created as the result of the laboratory trials:

::: A detailed operating manual must be supplied with each unit.

Adequate training in the operation of these units have to be supplied, particularly focussed on safety issues.

::: It is suggested that the elevation of the exhaust vent on all units be

addressed. In order to facilitate the dispersion of emissions and lessen the exposure risk of these operators.

::: The providers of this incinerators must provide directions for the safe handling and disposal of ash.

5.6. MAIN FINDINGS OF THE LABORATORY TRIALS

After conclusion of the laboratory trials, the project steering committee recommended that the Molope Gas and C&S Marketing units be submitted for field testing. The Molope Auto was advocated for field testing on the state that the manufacturer altered the ash grate so as to stop the spillage of partly burnt needles and syringes.

The aim of this field trials was to acquire information in the area and evaluate the strengths and weaknesses of all the incinerators during usage at primary healthcare clinics.

A participative decision making process was utilized for the trials. It was based on expert technical evaluation by the CSIR and the National Department of Health as well as participation in the trials by experienced end users and engaging advisors. All decisions were made by the Steering Committee, which consisted of representatives of stakeholders in the medical and clinical waste disposal process. These included representatives from the National, Provincial, and Local Government departments of Health, Safety and the Environment, as well as Professional Associations, Unions, NGOs, UNICEF, the WHO and local community representatives.

Figure 3: Photo of PaHuOy incinerator during trial burn

5.7. COMPARISON OF THE FIELDS TRIALS WITH THE LABORATORY TRIALS

The Provinces where the trials were done selected clinics for the field trials. The criteria determined by the Steering Committee for the selection of the clinics were the following:

y No clinical waste elimination

y No existing incineration

y No transport

Waste loading: Disposable rubber gloves were observed in addition to needles syringes, glass vials, bandages, dressings, and paper w
Temperatures and combustion efficiency: The same performance in gas combustion efficiency was obtained for wood .

The clinics that were selected were as follows:

Emissions: Large amounts of black smoke were observed and this was correlated directly to cooling of the unit as the wood fuel was exhausted

Destruction efficiency: The destruction efficiency was similar to that in the laboratory measurem
Usability: The unit is difficult to control as the result of the variability of the quality of wood
Acceptability: the smoke was not acceptable to the clinic, the community, or the local

The performance with fuel alone indicates that laboratory trial data can be used to predict emissions in the
The Molope Auto unit is too difficult to control for the available staff and fuel at the

incinerator, wood-fired.

incinerator

5.8. RECOMMENDATIONS FROM THE LABORATORY TRIALS

MAP OF SOUTH AFRICA INDICATING WHERE THE CLINICS ARE SITUATED

5.9. RECOMMENDATIONS FROM THE STEERING COMMITTEE

NORTHERN PROVINCE

GAUTENG PROVINCE

6. FIELD TRIALS

6.1. OBJECTIVE OF THE FIELD TRIALS

NORTH WEST PROVINCE

6.2. CLINIC SELECTION

MPUMALANGA PROVINCE

Location must be rural or under-serviced with

It must be in a high-density population area
Acceptable environmental conditions must prevail
Community acceptance must be obtained
Operator skill level to be used must be at a level of illiteracy

FREE STATE PROVINCE

Steinkopf Clinic – Northern Cape Province – Gas incinerator

NORTHERN CAPE PROVINCE

Marydale Clinic – Northern Cape Province – Gas incinerator
Mogale Clinic – Gauteng Province – Auto combustion

Chwezi Clinic – KwaZulu-Natal Province – Gas incinerator
Ethembeni Clinic- KwaZulu-Natal Province – Auto-combustion electrical

KWAZULU-NATAL PROVINCE

I’m /UnitPublic/Valerie/Technet 99/Working papers/Session 3/rogers.doc

EASTERN CAPE PROVINCE

WESTERN CAPE PROVINCE

The criteria for the ranking of the incinerators based on functionality in the area were:

The South African National Department of Health coordinated the field trials.

Information regarding the field trials as well as surveys were supplied to the coordinators in the participating states.

The team in the area consisted of this operator, manager and inspector (planner ). The maker of this incinerators did the practice of those operators.

The research used during the trials have been set so as to receive information with regard to the criteria set for the standing of their incinerators according to functionality in the area. The questionnaires were received from the clinics at two-weekly intervals.

Queries Concerning the criteria were the following:

y Volume and thickness

y Colour

y Odour

y Complete

y Partial

y Minimum

y Residue content

y Operator

y Nurse

y Head of this clinic

y Local Authority agent

y Community leader

6.3. COORDINATION OF THE TRIALS

Throughout the trials that the clinics were seen and the incinerators assessed by members of the Steering Committee and the CSIR as well as Dr L Diaz from WHO, Mr M Lainejoki from UNICEF and the planner from the National Department of Public Health.

Safety (occupational and public health)
Destruction capability
Usability
Community acceptability

As a result of the thick, dark smoke emission the device was not acceptable to the community.

Type Of Incinerator: C&S Auto-Combustion (Uses an electrically actuated enthusiast )

A. SAFETY (occupational and public health)

Smoke Emission

Ash Content
Are the filled sharps boxes and soiled dressings stored in a locked location while waiting to be incinerated?

B. DESTRUCTION CAPABILITY

Destruction Rate

Considered user friendly by operator, manager and inspector.

C. USABILITY (for the available staff)

Can the incinerator be used easily?

The incinerator was accepted by the community and was not considered to be harmful.

Is the process of incineration safe?
Has training been successful?
Is protective clothing such as gloves, goggles, dust masks and safety boots available?

D. COMMUNITY ACCEPTABILITY

What is the opinion of the following persons on the use of the incinerator?

The incinerator was accepted by the community and was not considered to be harmful.

6.4. QUESTIONNAIRE RESULTS

6.4.1. MOGALE CLINIC

Two

timber, coal also an alternative )

(Uses Electricity)

Great

Combust Incinerator

Figure 4 & 5: Molope Auto wood-fired incinerator during field trials at Mogale clinic

A. SAFETY (occupational and public health)

The process of incineration with this unit was considered by the operator, supervisor and the inspector as unsafe because there is no protective cage around the During the process the incinerator becomes very hot and this could result in injury to the operator.

The smoke emission of this incinerator had a volume and thickness which was heavy and black, with a distinct unpleasant odour, and was considered This could cause a pollution problem.

B. DESTRUCTION CAPABILITY

The needles and vials were not completely destroyed but were rendered unsuitable for re-use.

The soft medical waste was completely destroy

C. USABILITY

Difficulty in controlling the operating temperature and avoiding smoke emissions made this incinerator user unfriendly.

D. COMMUNITY ACCEPTABILITY

As a result of the heavy, black smoke emission the unit was not acceptable to the community.

6.4.2. ETHEMBENI CLINIC:

Figure 6: C&S Marketing Auto Combust Electrical Incinerator At Ethembeni Clinic

Type Of Incinerator: C&S Auto-Combustion (Uses an electrically actuated fan)

A. SAFETY (occupational and public health)

The operator, supervisor and inspector considered this incinerator easy to operate with no danger to the Removal of the ash from the drum for disposal in a pit is, however, considered difficult, as the drum is heavy. Removal of the incinerator lid before it has been allowed to cool has been identified as a potential danger to the operator.

Emission of smoke from this incinerator was not considered ex The volume and thickness was evaluated as moderate with no pollution experienced.

B. DESTRUCTION CAPABILITY

The needles and vials were not completely destroyed but were rendered unsuitable for re-use.
The soft medical waste was completely destroy

C. USABILITY

Considered user friendly by operator, supervisor and inspector.

D. COMMUNITY ACCEPTABILITY

The incinerator was accepted by the community and was not considered to be harmful.

6.4.3. CHWEZI CLINIC, MARYDALE CLINIC AND STEINKOPF CLINIC:

Type of incinerator: Molope Gas incinerator

Figure 7: Molope Gas incinerator during field trials at Marydale clinic

A. SAFETY (occupational and public health)

The operator, supervisor and inspector considered this incinerator easy to operate with minimal danger to the
Smoke emissions were not excessive and were reported to be minim

B. DESTRUCTION CAPABILITY

Sharps not completely destroyed but were rendered unsuitable for re-use.

Soft medical waste completely destroy

C. USABILITY

This incinerator was considered user friendly.

D. COMMUNITY ACCEPTABILITY

The incinerator was accepted by the community and was not considered to be harmful.

6.5. RANKING

INCINERATOR	RANKING
Molope Gas	1
C&S Auto-Combustion (Uses electrical fan)	2
Molope Auto- Combustion (Fired with wood, coal also an option)	3

6.6. OUTCOME OF THE FIELD TRIALS

Incinerator	Safety	Destruction Capability	Usability	Community Acceptability
Molope Gas	Good	Good	Good	Good
C&S Auto- Combustion (Uses Electricity)	Good	Good	Good	Good
Molope Auto- Combust Incinerator	Un-Acceptable	Good	Un-Acceptable	Un-Acceptable