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 make it possible for the South African Department of Health to acquire the equipment and services required for the primary healthcare clinics to perform small incineration for the disposal of medical waste.

2. STRUCTURE OF THE PROGRAMME

The evaluation programme has been carried out in stages, as follows:

Stage 1 A scoping study to determine the obligation of the various parties and

consensus on the evaluation criteria and boundaries of the laboratory tests. The criteria for accepting an incinerator on trial was approved by all parties involved.

Stage two Laboratory tests with a ranking of each incinerator and the choice of the incinerators to be utilised from the field trials.

Stage 3 Completion of field trials, to assess 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 record provides feedback on stages 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 engaged 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 usability for its accessible staff

The panel of experts for the ranking consisted of a:

y Professional nurse; Mrs Dorette Kotze in the SA National Department of Health

y Emission specialist; Dr Dave Rogers in the CSIR

y Combustion Engineer; Mr Brian North in 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 auxiliary fuel	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 additional 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 gas or forced air supply

Pa-Hu Oy

5.3. Emission testing: laboratory method

Sampling of emissions followed the US-EPA Method 5G dilution tunnel method for stove emissions. Adjustments to the design were made to account for fires extending up to 0.5 m above the suggestion of the incinerator and the drop out of big pieces of ash. Emissions were extracted to a duct for isokinetic sampling of particulate emissions. The sampling arrangement is shown with a schematic in Figure 1. A photo of this operation within the Molope gas fired incinerator unit is displayed in Figure 2.

All tests were conducted based on specified operating processes. The instructions provided by the provider of the gear were followed in the case of this C&S advertising Unit. No operating procedures were supplied with the Molope Gas, Molope auto-combustion and PaHuOy units. These processes were created by the CSIR staff with their prior experience together with advice provided by the provider.

Evaluation facilities were set up in the CSIR and measurements were carried out under an ISO9001 system using standard EPA test procedures or modifications made in 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 ranked 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 dimensions were utilized to rank the components Concerning destruction efficiency and also the potential to produce hazardous emissions.

Conformance to the South African Department of Environmental Affairs and Tourism’s (DEAT) urged guidelines on emissions from Large Scale Medical Waste Incinerators is outlined in Table 1. The dimensions 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 nearest building
Gas velocity	m/s	×	×	×	×	10
Residence time	s	×	×	×	×	2
Minimum combustion temperature	ºC	4	×	×	×	> 850
Gas combustion efficiency	%	×	×	×	×	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 Normal Temperature (0

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

8 percent of CO2 on a dry gas basis. If a dimension dropped below the detection limit for the procedure is it reported as the detection limit or as N.D., ie, not detectable.

Table 2: Detailed quantitative results

Parameter Measured *

Units

Molope gas

Molope auto

C&S

PaHuOy

SA Process Guide1

Comments

Stack height

1.8

1.9

0.3

3 m above nearest building

None of those unite has a stack. The height of the exhaust vent is taken as the stack height. If it is above the respiration zone of the operator it provides some protection from exposure to smoke.

Gas speed

m/s

0.8

0.5

1.1

0.5

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

Home time

0.4

0.7

0.6

0.4

two

Home time is taken to be the entire combustion time, along with the maximum possible

Minimum combustion zone temperature

800 -900

400 – 650

600 – 800

500 – 700

> 850

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

CO2 in 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 percent CO2 and standard temperature and pressure for coverage purposes. They are reduced between 4 to 8 times.

Particulate emissions entrained in exhaust gas

102

197

130

338

180

The total emissions will be the sum of the both entrained and un- entrained particulates. Emissions are lower than anticipated for such units and this can be attributed to the absence of raking which is the major source of particulate emissions from incinerators with no 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.

–

Large pieces of paper and cardboard ash rained out of the emissions. Totalling 0.8 to 2 g within 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 are reported in accordance with the South African coverage requirements, ie, Normalized to Normal Temperature (0

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

8 percent of CO2 on a dry gas basis. If a dimension dropped below the detection limit for the procedure is it reported as the detection limit or as N.D., ie, not detectable.

Parameter Measured *

Units

Molope gas

Molope auto

C&S

PaHuOy

SA Process Guide1

Comments

% ash remaining from medical waste

percent

14.8

12.9

15.6

21.7

–

Measurement of destruction efficiency of the incinerator. Typical commercial units function in 85-90% mass decrease. PaHuOy is reduced due to the melting and unburnt plastic.

Cl as HCl

35 & 542

< 30

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

F as HF

< 6

< 1

mg/Nm3

< 1

< 30

Fluoride not found in this waste.

Arsenic (As)

< 0.2

mg/Nm3

< 0.2

0.5

Arsenic is not anticipated as a strong. Higher sensitivity not hunted 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 might be a part from the stainless steel needle.

Nickel (Ni)

< 0.1

0.3

mg/Nm3

< 0.1

0.5

Nickel may be a part from the needle.

Barium (Ba)

< 0.5

mg/Nm3

< 0.5

0.5

Lower sensitivity due to presence in the filter material

Silver (Ag)

< 0.2

mg/Nm3

< 0.2

0.5

Not anticipated in this waste.

Copper (Cu)

< 0.5

mg/Nm3

< 0.5

0.5

Lower sensitivity due to copper from the sample blanks. May be background from the analytical equipment. Sensitivity of this x-ray way is sufficient for position. Higher sensitivity not hunted with this trial.

mg/Nm3

The principal conclusions drawn in the trials are as follows:

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

::: The largest potential health hazard arises in the emissions of smoke and soot. (the combustion efficiency of units lies away from the

regulatory criteria ). The risk to health can be reduced by training operators to avoid the smoke or by installation of a chimney in the website.

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

mg/Nm3

lined multi-chambered incinerator.

::: Incomplete combustion, along with the substantial formation of smoke at reduced height rendered the PaHuOy unit unacceptable for field trials. Figure 3

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

the incinerator, blocked the primary combustion air feed vents, and burnt out of the unit.

mg/Nm3

The CSIR conducted a qualitative trial in the field for gas combustion efficiency, temperature profiles and mass destruction rate on the Molope Vehicle wood-fired unit in the Mogale Clinic.

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

mg/Nm3

Temperatures were greater but for a shorter time and this was

connected with the type of wood available to this practice. The gas was burnt out before the medical waste was ruined completely and this caused reduced temperatures, reduced combustion efficiency and greater emissions while reducing the waste.

before complete ignition of the waste.

It was reasoned that:

mg/Nm3

these recommendations are made 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, especially focussed on safety difficulties.

::: It is recommended that the height of the exhaust vent on all components be

addressed. To be able to facilitate the dispersion of emissions and lessen the vulnerability risk of these operators.

mg/Nm3

::: The suppliers of this incinerators must supply instructions for its safe handling and disposal of ash.

mg/Nm3

After completion of the laboratory trials, the project steering committee urged that the Molope Gas and C&S Marketing units be submitted for field testing. The Molope Vehicle was advocated for field testing on the condition that the manufacturer altered the ash grate so as to prevent the spillage of partly burned off needles and syringes.

The aim of this field trials would be to acquire information in the field and assess the strengths and weaknesses of all the incinerators during usage at primary healthcare clinics.

mg/Nm3

A participative decision making process was utilized for its trials. It was based on expert technical analysis from the CSIR and the National Department of Health in addition to involvement 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, in Addition to Professional Associations, Unions, NGOs, UNICEF, the WHO and local community representatives.

The Provinces in which the trials were done chosen clinics for its field trials. The criteria set by the Steering Committee for the choice of the clinics were the following:

y No medical waste removal

y No existing incineration

y No transport

5.6. MAIN FINDINGS OF THE LABORATORY TRIALS

The clinics that were chosen were as follows:

incinerator, wood-fired.

incinerator

MAP OF SOUTH AFRICA INDICATING WHERE THE CLINICS ARE SITUATED

Figure 3: Photo of PaHuOy incinerator during trial burn

5.7. COMPARISON OF THE FIELDS TRIALS WITH THE LABORATORY TRIALS

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 .

NORTHERN PROVINCE

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

GAUTENG PROVINCE

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

5.8. RECOMMENDATIONS FROM THE LABORATORY TRIALS

NORTH WEST PROVINCE

MPUMALANGA PROVINCE

FREE STATE PROVINCE

5.9. RECOMMENDATIONS FROM THE STEERING COMMITTEE

NORTHERN CAPE PROVINCE

KWAZULU-NATAL PROVINCE

6. FIELD TRIALS

6.1. OBJECTIVE OF THE FIELD TRIALS

6.2. CLINIC SELECTION

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

Steinkopf Clinic – Northern Cape Province – Gas incinerator

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

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

EASTERN CAPE PROVINCE

WESTERN CAPE PROVINCE

The criteria for the ranking of the incinerators in accordance with performance from the field were:

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

Info concerning the field trials in addition to surveys were supplied to the coordinators from the participating provinces.

The team in the field consisted of this operator, supervisor and inspector (planner ). The manufacturer of this incinerators did the training of those operators.

The questionnaires used throughout the trials were set so as to obtain information with regard to the criteria set for the standing of their incinerators according to performance in the field. The questionnaires were obtained from the clinics in two-weekly intervals.

Queries with regard to the criteria were the following:

y Volume and thickness

y Colour

y Odour

y Total

y Partial

y Minimal

y Residue articles

y Operator

y Nurse

y Head of this practice

y Local Authority agent

y Community leader

Throughout the trials the clinics were visited and the incinerators evaluated by members of the Steering Committee along with the CSIR in Addition to Dr L Diaz from WHO, Mr M Lainejoki from UNICEF and the coordinator in the National Department of Health.

As a consequence of the heavy, black smoke emission the device wasn’t acceptable to the community.

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

6.3. COORDINATION OF THE TRIALS

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

Considered user-friendly by operator, supervisor and inspector.

The incinerator was approved by the community and wasn’t regarded as harmful.

Sort of incinerator: Molope Gas incinerator

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

This incinerator was believed user friendly.

C. USABILITY (for the available staff)

Can the incinerator be used easily?

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

The incinerator was approved by the community and wasn’t regarded as harmful.

D. COMMUNITY ACCEPTABILITY

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

Two

timber, coal also an alternative )

6.4. QUESTIONNAIRE RESULTS

6.4.1. MOGALE CLINIC

(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