Environmental

Communication

Biosci. Biotech. Res. Comm. 10(3): 438-444 (2017)

Composition and quantity of cytotoxic waste

from oncology wards: A survey of environmental

characterization and source management of medical

cytotoxic waste

Y. Ghafuri

1,2

and R. Nabizadeh

Department of Environmental Health Engineering, School of Public Health, International Campus, Tehran

University of Medical Sciences, Tehran, Iran

Environmental Research Center, Qom University of Medical Science, Qom, Iran

Department of Environmental Health Engineering, School of Public Health. Tehran University of Medical

Sciences, Tehran, Iran

ABSTRACT

Interest in waste drugs as a part of hospital waste in relation to their negative impact on the environment has increased during

the past years. Cytotoxic drugs play an important role in the treatment of various neoplastic conditions and are most often used in

specialized departments such as oncology and radiotherapy units. In this study an initial inventory of pharmaceuticals and unused

pharmaceuticals including hazardous waste drugs and antineoplastic (cytotoxic) chemotherapeutics was provided. By providing

a questionnaire, the rate of cytotoxic consumption, residuals of drugs, vial and syringes, needles, gloves and the other cytotoxic

waste was measured during a 30-day period in two oncology wards of Qom hospitals in Iran. The results determined that mean

production rate of medical waste in two hospital is 435 kg/d and equal to 1.73kg/bed/d, including: 97% infection waste (1.67 kg/

bed/d), 2.5% sharp and syringe waste (43.25 g/bed/d) and 0.5% pharmaceutical waste (8.65 g/bed/d). The rate of cytotoxic waste

in the investigated hospitals was 293.5(gr/d) and equal to 0.07 total medical waste. On the other hand the average rate of cytotoxic

waste in the oncology departments was 21.5 gr/bed and 16.5 gr / patient. The results determined that over 66% of residuals cyto-

toxic drug compounds can be converted in to nontoxic and no genotoxic by chemical degradation. Lack of awareness of health

hazards, insuf cient  nancial and human resources and poor control of waste disposal are the most common problems connected

with healthcare wastes.

KEY WORDS: CYTOTOXIC-WASTE-QOM-COMPOSITION

438

ARTICLE INFORMATION:

*Corresponding Author:

Received 12

July, 2017

Accepted after revision 28

Sep, 2017

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007 CODEN: USA BBRCBA

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2017: 4.31 Cosmos IF: 4.006

reserved.

Online Contents Available at: http//www.bbrc.in/

DOI: 10.21786/bbrc/10.3/17

Ghafuri and Nabizadeh

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS COMPOSITION AND QUANTITY OF CYTOTOXIC WASTE FROM ONCOLOGY WARDS 439

INTRODUCTION

Healthcare activities can lead to the generation of

hazardous of wastes that may have adverse effects on

human health and on the environment. Interest in waste

drugs as a part of hospital waste in relation to their neg-

ative impact on the environment has increased during

the past years. Many of the chemicals and pharmaceu-

ticals used in health care are hazardous. They are com-

monly present in small quantities in health-care waste,

whereas larger quantities may be found when unwanted

or outdated chemicals and pharmaceuticals are sent for

disposal, (Drug, 2015).

Considering the classi cation of hazardous health-

care waste by WHO the Categories of hazardous health-

care waste are: sharps, Infectious, Pathological, Pharma-

ceutical and cytotoxic, Chemical waste, and Radioactive

waste. The types and nature of hospital waste depends

upon the nature of the hospital and the service avail-

able in hospital (WHO, 2014). Exposure to genotoxic

substances in health care may also occur during the

preparation of, or treatment with, particular drugs or

chemicals. The main pathways of exposure are inhala-

tion of dust or aerosols, absorption through the skin,

ingestion of food accidentally contaminated with cyto-

toxic drugs, ingestion as a result of bad practice, such

as mouth pipetting, or from waste items. Exposure may

also occur through contact with body  uids and secre-

tions of patients undergoing chemotherapy. Genotoxic

waste is highly hazardous and may have mutagenic,

teratogenic, or carcinogenic properties. Genotoxic waste

may include certain cytostatic drugs, vomit, urine, or

faeces from patients treated with cytostatic drugs, chem-

icals, and radioactive material (Ansell, 2015).

Cytotoxic drugs (CDs) are primarily used as anti- can-

cer drugs because they are toxic to cells. These drugs

have been associated with human cancers at high (thera-

peutic) levels of exposure and are carcinogens and ter-

atogens in many animal species. They are most often

used in specialized departments such as oncology units,

whose main role is cancer treatment. Cytostatic drugs

can be categorized as: alkylating agents which cause the

alkylation of DNA nucleotides, leading to the cross-link-

ing and miscoding of the genetic stock; antimetabolites

which inhibit the biosynthesis of nucleic acids in the

cell; and mitotic inhibitors which prevent cell replica-

tion (Antell, 2013). Medical waste is incorrectly managed

throughout the majority of hospitals in Iran. Healthcare

workers are not trained to conceive that a large pro-

portion of medical waste generated in hospitals is Non-

infectious waste. A structured waste management strat-

egy together with clear deﬁnitions and staff training will

lead to a decrease in waste volumes, and consequently

to a reduction of costs in healthcare settings. Generated

amounts of the health care waste are not available (for

example Ireland) or the de ned amount of wastes is too

low (for example Bulgaria, Finland) or too high (in case

of Belgium). Among other issues, this might be an indi-

cation of improper waste management practice or poor

data collection in the country; Askarian et al, 2010; Far-

zadkia et al, 2009; Abduli, 2010 Nabizadeh, 2016).

In recent years, the rate of cancer disease and con-

sumption of cytotoxic drugs in oncology wards of Qom

hospital has increased. In this work composition, the

quantity and possibility of chemical degradation of

cytotoxic drug waste have been studied.

MATERIALS AND METHODS

This study was performed in 2015, in the oncology wards

of two hospitals in Qom, Iran including Shahid Beheshti

Hospital with 400 active beds and Hazrat Masoumeh

Hospital with 120 active beds, located in the central part

of Qom Province

. The studied hospitals provide general

medical, surgical, maternity, pediatric, and a range of

specialist services.

Considering the methods of medical waste manage-

ment and the main generation of medical waste in the

two investigated hospitals, the total medical waste was

classi ed in three categories: infection, sharp and Phar-

maceutical waste. Several methods were used to collect

data, namely site visits, interviews, and questionnaires.

An initial inventory of pharmaceuticals and unused

pharmaceuticals including hazardous waste drugs and

antineoplastic (cytotoxic) chemotherapeutics was pro-

vided. Moreover, data

collection consisting of health-

care waste generation, separation, collection, storage,

transportation, and disposal was performed during site

visits to the hospitals.

With the cooperation and coordi-

nation of the personal and management of hospitals and

using the questionnaire, the rate of cytotoxic consump-

tion on, residuals of drugs, vial and syringes, needles,

gloves and the other cytotoxic waste was measured in a

30 day period.

The Chemical degradability of cytotoxic waste was

assessed with exposure to chemical oxidants (WHO,

2014). Speciﬁc physico-chemical properties such as:

dissociation constant (pKa), solubility, octanol–water

partition coef cient (Kow) and organic carbon parti-

tion coef cient (Koc), bio-concentration factor (BCF),

atmospheric hydroxyl radical reaction rate and photoly-

sis tendency play critical roles in determining the envi-

ronmental behaviors and fate of cytotoxic waste (Cheng

et al, 2009; Andrew et al, 2008; Toolaram et al, 2014;

Zhang et al, 2013; Besse et al, 2012). The Prediction of

environmental fate and other physico-chemical proper-

ties was carried by a theoretical model (EPI Suite 4.1)

Ghafuri and Nabizadeh

440 COMPOSITION AND QUANTITY OF CYTOTOXIC WASTE FROM ONCOLOGY WARDS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

(EPA, 2014). Two criteria contain octanol–water parti-

tion coefﬁcient (Kow) and solubility was considered. A

logKow<1suggests that the compounds are highly mobile

in an aquatic environment. About solubility, adding or

existance of polar functional groups that increase of

hyrophilicity of drug compound were considered (Zhang

et al, 2013; Besse et al, 2012).

RESULTS AND DISCUSSION

QUANTITIES OF MEDICAL WASTE GENERATION

There were 120 active beds in the Hazrat Masoumeh

Hospital and the rate of medical waste was identi ed

as 220 kg/d. Also there were 400 active beds in Sha-

hid Beheshti Hospital with the medic production rate of

650 kg/d. Table 1 shows the average daily production of

total medical in two hospitals. Medical waste from Haz-

rat Masoumeh hospital equaled 1.83 kg/occupied bed/d,

of which 96.36% was infectious, 3.1% sharp waste and

0.45% Pharmaceutical waste .Shahid Beheshti hospital

medical waste was 1.62 kg/occupied bed/d of which

98% was infectious, 1.7% sharp and 0.3% pharmaceuti-

cal waste.

Category of cytotoxic waste

The rate of cytotoxic waste was assessed in oncology

wards of two hospitals separately. The results are shown

in table 2.

Table 3 shows the mean production rate and category

of cytotoxic drug waste in the hospitals under study.

Characteristics and chemical degradation of

cytotoxic drugs

Twelve chemical structures of conventional cytotoxic

drug compounds used in the oncology wards of hospi-

tals under study were assessed. The results pertaining to

the solubility and degradability of cytotoxic drug when

exposed to chemical oxidants, the results are shown in

Table 4.

Results of the present study determined that mean

production rate of medical waste in the two hospitals

was 435 kg/d and equal to 1.73kg/bed/d, including:

97% infection waste (1.67 kg/bed/d), 2.5% sharp and

syringe waste (43.25 g/bed/d) and 0.5% pharmaceutical

waste (8.65 g/bed/d). The results of study about hospital

waste management status in Iran by farzadkia and at al

showed that the waste generation rate was 2.5 to 3.01 kg

bed(-1) day(-1), which included 85 to 90% of domestic

waste and 10 to 15% of infectious waste. Waste genera-

tion rate in the hospitals varied from 1.25 to 14.8 kg/

bed/d (Zhang et al, 2013; Besse et al, 2012).

Medical waste production depends on factors such

as type of hospital, number of beds, socio-economic

and cultural status of patients and waste management

processes (Cheng et al, 2009). In Thailand, Italy, USA,

India, Peru, Vietnam, and Tanzania 1, 3–5, 5–7, 0.5–2,

0.76–2.6, 1.42, and 0.84 kg/bed/d, of medical waste are

respectively generated, are generated (Dehghani, 2008).

According to a study of the composition and production

rate of pharmaceutical and chemical waste in Greece,

the production rate for total pharmaceutical waste was

7.48 g/bed/d (Voudrias, 2012).

Results of Table 2 and 3 exhibited that the rate of

cytotoxic waste in the investigated hospitals was

293.5(g/d) equal to 0.07 total medical waste. On the

other hand the average rate of cytotoxic waste on the

in the oncology departments was 21.5 g/bed equal to

16.5 g/patient. Moreover, the total amount of genera-

tion waste from cytotoxic drug residuals was 120.2 mg/d

(mean 4.92mg/d and standard deviation ±8.88mg/d

for any cytotoxic drug) and the total amount other

Table 1. Estimated medical waste generation rate of hospital waste for two hospitals investigated

Name of

hospitals

Number of

active beds

Rate of total medical

waste (kg/d)

Separation of medical waste

Infection

waste (kg/d)

Sharp waste

(kg/d)

Pharmaceutical

waste(kg/d)

Hazratmasoumeh 120 220 212 7 1

Shahidbeheshti 400 650 637 11 2

Table 2. Rate of cytotoxic waste in the hospitals investigated

Name of

hospitals

number of active beds in

oncology department

rate of total

cytotoxic waste

rate of cytotoxic

waste

rate of cytotoxic

waste

(gr/d) (gr/bed/d) (gr/patient/d)

Hazrat masoumh 12 337 22.5 18

Shahid beheshti 15 250 20 15

Ghafuri and Nabizadeh

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS COMPOSITION AND QUANTITY OF CYTOTOXIC WASTE FROM ONCOLOGY WARDS 441

Table 3. Average production rate and category of cytotoxic drug waste in hospitals investigate

Rate of other cytotoxic waste

that produced from expose to

cytotoxic drug (gr/d)

Waste from residual

of cytotoxic drug

(mg/d)

Daily average

dosage used

(mg/d)

Drug compoundNumber

258120Cytarabine1

186100Etoposide2

248170Vincristine3

28970Carboplatin4

62.727oxaliplatin5

121.515Fluorouracil (5-FU)6

83120Cisplatin7

1618170Cyclophosphamide8

20760bleomycin9

2613130Erinotekan10

3015200mesna11

10850Dacarbazine (DTIC)12

2510130Methotrexate13

10880L-asparaginase14

2517170Ifosfamide (Ifex)15

282120.21512Sum

Table 4. Characterization of solubility and degradability of conventional cytotoxic drug

compounds in oncology departments

Hydrophilicity of

cytotoxic drug with

consider to(Kow)

Solubility of cytotoxic

drugs with consider to polar

functional group

Chemical FormulaCytotoxic drug

compound

++C

Carboplatin

++C

Vincristine

-+C

PCyclophosphamide

++H

PtCisplatin

_+C

Bleomycin

++C

Etoposide

++C

Cytarabine

++C

Erinotekan

__C

NaO

Mesna

+_C

ODacarbazine (DTIC)

+_C

Fluorouracil (5-FU)

++C

Methotrexate

Notes: + sign exhibit that cytotoxic drug with log K

<1 or cytotoxic drug has polar functional group

cytotoxic waste generated from contact was 282 g/d

(mean 7.92g/d and standard deviation ±18.8g/d for

any cytotoxic drug). Figure1 indicated that maximum

production rate of daily average administrated dosage

of cytotoxic drugs is related to Mesna (200 mg/d) and

maximum production rate for waste from residuals is

related to Cyclophosphamide (18mg/d)

Figure 2 with R

= 0.59 and Figure 3 with R

0.47exhibited a small correlation between daily average

dosage and waste from residuals of cytotoxic drug and

a smaller one daily average dosage and rate of other

cytotoxic waste generated from contact.

The results of the by Tasakona showed that the rate

of cytotoxic waste was 120 l/day and 0.03 from total

Ghafuri and Nabizadeh

442 COMPOSITION AND QUANTITY OF CYTOTOXIC WASTE FROM ONCOLOGY WARDS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

FIGURE 1. Comparison between daily average dosage and waste from residuals of

cytotoxic drug waste

FIGURE 2. Daily average dosage versus waste from residuals of cytotoxic drug

amount of medical waste, was different (medical waste

density in Iran is 170 kg/m

) but approve the Bill Brewer,

Andrew Antel study that rate of cytotoxic waste from

chemutraputic drug such as Cyclophosphamide (CP),

Mitomycine, Mycophenolate was 0.08 ib/bed/day (Tsa-

kona, 2010). Results of a survey by Evanglos Vondari-

als, suggested that rate of pharmaceutical’s waste was

3.9% of hazardous waste in agreement with our results

(Voudrias, 2012).

Cytotoxic waste residue as a source of cytotoxic drugs

in the Environmental

With survey of medical waste management in two hos-

pitals, direct disposal as the municipal solid waste is

still a common way for the unused pharmaceuticals.

Four primary sources (hospital ef uent, household

wastewater, and production discharge and drug waste

disposal) of cytostatic residues. Hospitals produce large

quantities of chemically- and which carry high poten-

tial ecotoxicity, and should not be considered as pos-

sessing the same pollutant nature as urban wastewa-

ter. The measured cytostatic levels in hospital sewage

indeed correlated with the daily consumption and the

pharmacokinetic excretion pattern (Zhang et al, 2013;

Besse et al, 2012). At present study, results of predic-

tion model (EPI Suite 4.1) was shown that, cytotoxic

drug waste residue including: Carboplatin, Vincristine,

Cyclophosphamide, Cisplatin, Bleomycine, Etoposide,

Cytarabin, Erinotekan and Methoterexate with con-

sidering excration pattern and discharge in to hospital

sewage, have been increased toxicity of aquatic envi-

ronment (EPA, 2013).

Ghafuri and Nabizadeh

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS COMPOSITION AND QUANTITY OF CYTOTOXIC WASTE FROM ONCOLOGY WARDS 443

Implementation of cytotoxic waste management plan

and selection of treatment methods

Risk control measures for cytotoxic waste management

including: identi cation, containment and segregation.

Other requirements contain handling or storage of cyto-

toxic waste, disposal and treatment, in the process of

waste management plan must be considered.

The choice of treatment system involves considera-

tion of waste characteristics, technology capabilities

and requirements, environmental and safety factors,

and costs, many of which depend on local conditions.

The results of study about solubility and degradability

of conventional cytotoxic waste is depicted in Table 4.

For decrease of environmental risks and degradation

of these compounds by chemical degradation methods

as an option that appropriate for developing countries

were investigated. results determined that over 66% of

residuals cytotoxic drug compounds can be converted

in to nontoxic and no genotoxic by chemical degrada-

tion including oxidation by potassium permanganate

(KMNO

) or sodium hypochlorite (NaCLO,5.25%) readily

available in Iran hospitals. It must be noted that this

process is not suitable for other cytotoxic waste contain-

ing vial, syringe, and gloves for which the appropriate

process is handling (Drug, 2015).

CONCLUSION

The implementation of medical waste management is

one of the most signiﬁcant healthcare issues currently

requiring attention in Iran. Hospital waste materials pose

FIGURE 3. Daily average dosage versus rate of other cytotoxic waste from contact

a wide variety of health and safety hazards for patients

and healthcare workers. Many of hospitals in Iran have

neither a satisfactory cytotoxic waste disposal system

nor a waste management and disposal policy. Provision

of a cytotoxic waste management planning and mon-

itoring systems in hospitals is a prerequisite issue for

effective reduction of health care waste associated risks.

ACKNOWLEDGEMENTS

This research has been carried by cooperation of Qom

University of Medical Science and the authors express

gratitude to all hospital staff of Qom University of Medi-

cal Science for their support through this study.

REFERENCES

Abduli M.A., ET. Al, 2010. Municipal Waste Reduction Poten-

tial and Related Strategies in Tehran, Int. J. Environ. Res., 4(4):

901-912, 1735-6865.

Almuneef, M., Memish, Z.A., 2003. Effective medical waste

management: it can be Done, American Journal of Infection

Control, 31, 188–192.

Andrew C. Johnson, Monika D. Ju rgens a, 2008. Richard J.

Williams a, Kummerer. K, Kortenkamp. A, John P. S. ,Do cyto-

toxic chemotherapy drugs discharged into rivers pose a risk

to the environment and human health ? An overview and UK

case study, Journal of Hydrology, 348, 167– 175

Anju Priya Toolaram, Klaus Ku¨mmerer.2014. Environmental

risk assessment of anti-cancer drugs and their transformation

products: A focus on their genotoxicity characterization-state

Ghafuri and Nabizadeh

444 COMPOSITION AND QUANTITY OF CYTOTOXIC WASTE FROM ONCOLOGY WARDS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

of knowledge and short comings. 2014- Mutation Research

760, 18–35

Ansell Healthcare Products LLC, 2015. Handling Cytotoxic

Drugs; A HEALTH AND SAFETY REVIEW. www.ansellhealth-

care.com

Bdour, A., Altrabsheh, B., Hadadin, N., Al-Shareif, M., 2007.

Assessment of medical wastes management practice: a case study

of the northern part of Jordan. Waste Management, 27, 46–759

Blenkharn, J.I, 2007. Standards of clinical waste management

in hospitals – a second look. Public Health, 121, 540–545.

Blenkharn, J.I., 2007. Lowering standards of clinical waste

management: do the hazardous waste regulations conﬂict with

the CDC’s universal/standard precautions?, Journal of Hospital

Infection 62, 467–472.

Brewer. B, Antell .A, 2013. A case study of the management

of hazardous waste drugs in a large university hospital,http://

dx.doi.org/10.1016/j.jchas.10.003

Bureau of National Health Insurance, National Health Insur-

ance Annual Statistical Report ,Bureau of National Health

Insurance,2003, Taiwan, ROC.

Cheng, Y.W., Sung, F.C., Yang, Y., Lo, Y.H., Chung, Y.T., Li,

K.-C, 2009, Medical waste production at hospitals and associ-

ated factors, Waste Management, 29: 440–444.

Cheng, Y.W., Sung, F.C., Yang, Y., Lo, Y.H., Chung, Y.T., Li,

K.-C., 2009. Medical waste Production at hospitals and associ-

ated factors. Waste Management, 29, 440– 444.

Clair N. Sawer, McCarty .Perryl, 2003. Chemistry for Environ-

mental Engineering and Science, McGraw -Hill

Dehghani. M.H, Azam, K., Changani, F., DehghaniFard.E.,

2008, Assessment of medical waste management in educa-

tional hospitals of Tehran University Medical Sciences. Iranian

Journal of Environmental Health Science and Engineering,

5(2): 131–136.

Drug and Related waste, 2015. Government of south Auster-

alia Cytotoxic epa.gov/opptintr/exposure/pubs/episuitedl.htm

(accessed 1.11.13.).

Farzadkia .M, Moradi.A, Shah Mohammadi.M., Jor .S, Hospi-

tal waste management status in Iran: a case study in the teach-

ing hospitals of Iran, 2009, University of Medical Sciences.

Waste Management and Research, 27: 384–389.

Ferrando-Climent. L, S. Mozaz. R, Barcel. D, 2014. Incidence

of anticancer drugs in an aquatic urban system: From hospital

ef uents through urban wastewater to natural environment,

Environmental Pollution 193, 216e223

Ferreira. V, Ribau Teixeira. S, 2010. Healthcare waste manage-

ment practices and risk perceptions: Findings from hospitals

in the Algarve region, Portugal, Waste Management 30. 2657–

2663

Jang, Y.C., Lee, C., Yoon, O.S., Kim, H., 2006, Medical waste

management In Korea. Journal of Environmental Manage-

ment, 80: 107–115.

Jean-Philippe Besse, Jean-François Latour, Jeanne Garric.

2012. Anticancer drugs in surface waters, what can we say

about the occurrence and environmental signi cance of cyto-

toxic, cytostatic and endocrine therapy drugs? 2012- Environ-

ment International 39. 7386

Johannessen.L.M, Dijkman.M, Bartone.C, Hanrahan.D,

Boyer.M.G, Chandra, C., 2000. Health Care Waste Management

Guidance Note. The World Bank, Washington, DC.

Mehrdad Askarian, Peigham Heidarpoor, Ojan Assadian, 2010.

A total quality management approach to healthcare waste

management in Namazi Hospital, Iran. waste Management,

2010, 30, 2321-2326

Nussbaumer. S, Bonnabry. P, Jean-Luc Veuthey, Fleury-Sou-

verain. S, 2011. Analysis of anticancer drugs: A review, Jour-

nal home page: www.elsevier.com/locate/talanta, Talanta 85,

2265– 2289

Ra ee. A, Nabizadeh. R. 2016. Infectious Waste Management

in Imam Khomeini Hospital Complex in Tehran and Recom-

mending Appropriate Managerial Solutions” Journal of Health,

Vol. 7, No. 4, autumn, Pages 446-457

Tsakona. M, Anagnostopoulou. E, Gidarakos.E . 2010. Hospi-

tal waste management and toxicity evaluation: A case study.

Waste Management 27. 912–920

U.S. EPA, 2013. Exposure Assessment Tools and Models. EPI

Suite v4.1. http://www.

Vijay R, Puneet G. and M C Joshi, Practical guidelines for dis-

posing cytotoxic waste. India’s No.1 Weekly for the Pharma-

ceutical Industry

Voudrias. E, Goudakou.L, Kermenidou. K, Softa. A, 2012. Com-

position and production rate of pharmaceutical and chemical

waste from Xanthi General Hospital in Greece, Waste Manage-

ment 32. 1442–1452

WHO, 2014. Safe management of wastes from Health-care

activities. 2nd edition.

Zhang.J, Victor .W.C, Chang, 2013. Removal of cytostatic

drugs from aquatic environment: A review, 2013- Science of

the Total Environment 445–446. 281–298