The Journal of the Egyptian Public Health Association (JEPHAss.

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Vol.80, No 3&4, 2005

Assessment of Combustion Products of Medical Waste Incinerators in Alexandria.

Adel M. Zakaria*, Ossama A. Labib**, Mona G. Mohamed***, Waffaa I. El-shall***, Ahmed H. Hussein*** Occupational Health Dept., High Institute of Public Health, Alexandria University. ** Petrojet Company, Alexandria,Egypt. *** Environmental Health Dept. ,High Institute of Public Health, Alexandria University . *

ABSTRACT
The emissions and ashes from medical waste incinerators might perform a threat to the environment and the public health. The aim of the present work is to evaluate the emissions and ashes of six medical wastes incinerators in six hospitals in Alexandria. Five air pollutants were sampled and analyzed in the emissions comprising smoke, lead, carbon monoxide, sulphur dioxide and nitrogen dioxide .Ash samples were analyzed for bacterial count, volatile substances, lead and cadmium. Shape and color of ash were observed visually. The results of the present study have revealed that all the average values of gases in the six incinerators were within the limits stated in Egyptian environmental law, where as carbonaceous particulate (smoke) averages of the six incinerators have exceeded the maximum allowable limit in the law. On the other hand, lead concentration in emissions were far below the maximum allowable limit in the law. Incinerator No 6 emissions have been significantly higher in CO, NO2, SO2 and smoke concentration than the other five incinerators P<0.001, P<0.0006, P<0.0001, and P<0.002 respectively. There was no significant variation in bacterial count of ash samples at 20C and 37C between the six studied incinerators. Volatile substance percentage of ash samples in the six incinerators were much higher than the recommended percentage. There was a highly significant variation between the six incinerators (p<0.005). Lead and cadmium concentrations in ash samples were much higher than those in developed countries, meanwhile, more or less as those in developing countries. It is recommended to state specific realistic emissions limits for medical waste incinerators and to substitute sporadic incinerators in hospitals by two central incinerators in proper places outside the city. Keywords: Medical waste incinerators, stack emissions, bottom ash. Correspondence to: Dr. Adel Zakaria Occupational Health Dept., High Institute of Public Health, Alexandria University. E-mail: zakaria1959@yahoo.com

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INTRODUCTION
The issue of hazardous medical wastes management has acquired an increasing interest in the last few years, as the awareness of their serious health effects has increased on both public and governmental levels. There are a variety of treatment methods of medical wastes including autoclaving, microwaving, chemical disinfection, ionizing radiation, open burning and incineration. (1) Incineration is one of the most abundant treatment methods of medical wastes in Egypt. The optimum incineration of medical wastes might lead to complete destruction of the wastes. Furthermore, it is often possible to reduce the mass, volume, and weight of the waste by more than 95% and carbon is converted into (CO2) and released into the atmosphere. The remaining ash is usually less toxic and easier to handle than the original waste stream. It is composed mainly of minerals oxide, and its heavy metals content is lower than 1.5%. Ash residues are placed in landfill sites, which are specially designed. These pollutants may be a source of groundwater contamination. (2) However, hazardous medical wastes incinerators are potentially significant sources of air pollutants. Air pollutants of concern include particulate matter, toxic metals, toxic organics, carbon monoxide (CO), and the acid gases; hydrogen chloride (HCl), sulfur dioxide (SO2) and nitrogen oxides (NOX), also, products of incomplete combustion, such as plolycyclic aromatic hydrocarbons, dioxins (PCDD), and Furans (PCDF).(2-4) In general, these emissions cause adverse effects on the humans health such as respiratory illness, and long term effects, such as cancer, birth defects, and also, cause damage to the animal life, vegetation, buildings and degradation of visibility. (5-7)

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One of the major concerns in the design of waste incineration processes is the emission of pollutants in flue gases, so that, they don't exceed the regulatory limits.(8) This necessitates the utilization of air emission control measures, such as gravity settlers, mechanical cyclones, fabric filters and electrostatic precipitators for particulate matter; and wet scrubber, dry scrubber and solid sorbent beds for gases and vapors. (8) The aim of the present work is to evaluate the emissions and ashes of six incinerators of medical wastes in Alexandria governorate.

MATERIAL AND METHODS

Methods 1- Air samples from incinerators
Air samples were collected from chimneystack. Four contaminants have been determined in the emissions of medical waste incinerators, Viz., total particulates (smoke), carbon monoxide, sulfur dioxide and nitrogen dioxide. A-Total Particulates Total particulates have been determined gravimetrically on a fiberglass filter. Sampling has been performed isokinetically perpendicular to the flow in the chimney. (9) B- Lead Lead in total particulates was extracted by a mixture of nitric and

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hydrochloric acids. The analysis is subsequently made by atomic absorption spectroscopy using the 217.0 nm lead wave length. (10) C- Gaseous contaminants Carbon monoxide, sulfur dioxide, and nitrogen dioxide have been determined by a direct reading instrument a combustion analyzer/ environmental monitor Bacharach Model 300.

2- Sampling of medical wastes' ash

Simple random representative samples of ash, weighed 1.5-2kg, were taken manually and put in high dense polyethylene plastic sacs.

Analysis of medical waste ash

A-Total bacterial count Ten grams of ash samples was used and proceeded through standard producers of sterilization, diluting and liquefied nutrient agar was added. Incubation at 20 C and 37C for24 2 hrs colonies were counted and recorded for each sample. (11) B-Volatile substance and non volatile substance The volatile substances (VS) is the last fraction of a known weight sample (4 g) after ignition in a muffle furnace at 550 C for 2hrs, whereas the non volatile substances (NVS) is the residue. (12) thus: VS% = Initial weight-final weight 100 Initial weight NVS%=100-VS%

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C-Heavy metals Lead and cadmium were determined in ash samples as mg/kg by atomic absorption spectroscopy standard method. (11)

Material
Incinerators description Six incinerators, allocated in six major hospitals in Alexandria have been studied in the present study ordered serially from 1 to 6. The six incinerators were of batch type, their capacity was almost similar, about 50 kg/hr. They all were using light oil as auxiliary fuel, except No. 6 which was using kerosene. The incineration period was from 3 to 4 hours most of the time once a day, except No. 1, where incineration was twice daily. All the incinerators had two burners except incinerator No. 5 which had only one. Except incinerator No. 1, which had no control measure on stack emissions, the other five incinerators had a scrubber, except that of No.5, mostly primitive, to control stack emissions.

RESULTS
The results of air samples taken from stacks of medical waste incinerators studied in the present study are tabulated in tables (1-6). The concentrations of air contaminants carbon monoxide (CO), nitrogen dioxide (NO2), sulfur dioxide (SO2) and carbonaceous particulate were put in the tables. Table (1) represents the concentrations of the air contaminants in incinerator No.1 CO ranged between 400-2565 mg/m3, NO2 ranged between 16-35 mg/m3, SO2 ranged between 15-580 mg/m3, and smoke (carbonaceous particulate) ranges between 120-1055 mg/m3.

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Table (1): Concentrations of

Air Pollutants Incinerator No.1 (mg/m3).

CO mg/m 520 915 770 2565 400 1034 879.48 2565 400

in

Emissions

of

Medical Waste
Smoke mg/m 320 910 830 1055 120 647 404.28 1055 120

Sample No Sample 1 Sample 2 Sample 3 Sample 4 Sample 5 Mean Standard deviation Maximum Minimum

NO2 mg/m 28 35 22 16 35 27.2 8.28 35 16

SO2 mg/m 50 27 15 580 135 161.4 238.65 580 15

Table (2) represents the concentrations of the air pollutants in incinerator No. 2. CO ranged between 910-2300 mg/m3, NO2 ranged between 25-35 mg/m3, SO2 ranged between 127-590 mg/m3, and smoke ranged between 238-678 mg/m3.
Table (2): Concentrations of

Air Pollutants
3

in

Emissions
SO2 mg/m 565 590 127 427.33 260.39 590 127

of Medical Waste

Incinerator No.2 (mg/m ).

Sample No Sample 1 Sample 2 Sample 3 Mean Standard deviation Maximum Minimum CO mg/m 2050 2300 910 1753.3 740.69 2300 910 NO2 mg/m 35 33 25 31 5.29 35 25 Smoke mg/m 560 678 238 492 227.74 678 238

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Table (3) represents the concentration of the air pollutants in incinerator No.3. CO ranged between 170-3690 mg/m3, NO2 ranged between 6-110 mg/m3, SO2 ranged between 8-500 mg/m3, and smoke ranged between 47.2-1610 mg/m3.
Table (3): Concentrations of Air Pollutants in Emissions of Medical Waste Incinerator No. 3 (mg/m3).
Sample No Sample 1 Sample 2 Sample 3 Sample 4 Sample 5 Sample 6 Mean Standard deviation Maximum Minimum CO mg/m 1220 170 3575 3565 3690 1450 2278.3 1521.9 3690 170 NO2 mg/m 6 90 40 30 52 110 54.66 38.75 110 6 SO2 mg/m 85 8 425 500 100 60 196.33 209.8 500 8 Smoke mg/m 301 54.5 47.2 1610 193.5 498 450.7 592.37 1610 47.2

Table (4) represents the concentration of the air pollutants in incinerator No.4. CO ranged between 235-1220 mg/m3, NO2 ranged between 26-340 mg/m3, SO2 ranged between 15-103 mg/m3, and smoke ranged between 25.4-1081 mg/m.
Table (4): Concentrations of Air Pollutants in Emissions of Medical Waste Incinerator No. 4 (mg/m3).
Sample No Sample 1 Sample 2 Sample 3 Sample 4 Sample 5 Mean Standard deviation Maximum Minimum CO mg/m 290 235 365 470 1220 516 403.28 1220 235 NO2 mg/m 70 62 85 26 340 116.6 126.7 340 26 SO2 mg/m 23 15 33 103 80 50.8 38.56 103 15 Smoke mg/m 155.1 25.4 763 880 1081 580.9 464.37 1081 25.4

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Table (5) represents the concentrations of the air pollutants in incinerator No.5. CO ranged between 420-3630 mg/m3, NO2 ranged between 30-262 mg/m3, SO2 ranged between 50-2500 mg/m3, and smoke ranged between 161.1-1716.6 mg/m3.
Table (5): Concentrations of Air Pollutants in Emissions of Medical Waste Incinerator No. 5 (mg/m3).
Sample No Sample 1 Sample 2 Sample 3 Sample 4 Sample 5 Sample 6 Sample 7 Mean Standard deviation Maximum Minimum CO mg/m 750 3630 3100 3570 420 3420 3570 2637.14 1416 3630 420 NO2 mg/m 30 262 244 70 35 38 120 114.14 99.87 262 30 SO2 mg/m 50 475 250 1050 110 145 2500 654.38 883.14 2500 50 Smoke mg/m 720 1200 820 1600 161.1 1716.6 681 985.53 552.02 1716.6 161.1

Table (6) represents the concentrations of the air pollutants in incinerator No.6. CO ranged between 3690-4100 mg/m3, NO2 ranged between 230-290 mg/m3, SO2 ranged between 3500-4310 mg/m3 and Smoke (carbonaceous particulate) ranged between 790-2110 mg/m3.
Table (6): Concentrations of Air Pollutants in Emissions of Medical Waste Incinerator No. 6 (mg/m3).
Sample No Sample 1 Sample 2 Sample 3 Sample 4 Mean Standard deviation Maximum Minimum CO mg/m 3690 3690 4000 4100 3870 211.81 4100 3690 NO2 mg/m 290 230 250 240 252.2 26.29 290 230 SO2 mg/m 4000 3500 4100 4310 3977.5 343.54 4310 3500 Smoke mg/m 850 790 1950 2110 1425 702.06 2110 790

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Table (7) represents the concentrations of lead in air samples in the six studied incinerators. They ranged between 23.5-322.8 g/m3.
Table (7): Maximum and Minimum Concentrations of Lead in the Air Samples in the Medical Wastes Incinerators.
M.E No 1 2 3 4 5 6 Measurements Maximum Minimum Maximum Minimum Maximum Minimum Maximum Minimum Maximum Minimum Maximum Minimum Pb g/m3 68.1 23.5 116.2 44.5 312.8 83.4 121.1 97.5 322.8 107 271.6 98.6

Table (8) presents the bacterial colony count, organic volatile substance percentages, lead and cadmium of the ash samples in the six studied incinerators. Bacterial colony count ranged between 0-570,000 cfu/kg at 20C and 0-940,000cfu/kg at 37C which were recorded in incinerator No.5. Organic volatile substances percentage highest mean has been recorded in incinerator No.5 whereas the lowest mean was recorded in incinerator No. 3. The range of the volatile substances percentage was from 0.22 to 4.04. Lead ranged between 0.01-474.47 mg/kg, whereas cadmium ranged between 0.01-11.66 mg/kg. The highest mean lead concentration was found in incinerator No1. The highest mean cadmium was found in incinerator No. 3.

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Table ( 8 ): Some Chemical and Bacteriological Parameters of Ash.

Ash M.E No. Measurements Minimum Maximum Mean Standard deviation Minimum Maximum Mean Standard deviation Minimum Maximum Mean Standard deviation Minimum Maximum Mean Standard deviation Minimum Maximum Mean Standard deviation Minimum Maximum Mean Standard deviation Total bacterial count, col/kg 20C 37C 0 0 80000 30000 1666.6 13333.33 32041.64 12110.6 0 0 0 20000 0 10000 0 14142.13 0 0 20000 50000 5000 8366.6 0 40000 12000 17888.5 0 570000 108571.43 206674.35 0 10000 2500 5000 30000 14142.13 10000 290000 130000 137840.48 10 940000 178571.42 336869.34 0 50000 12500 25000 Volatile solids % 1.53 3.92 2.31 0.85 0.93 2.69 1.81 1.24 0.22 2.25 1.26 0.68 0.6 3.21 2.19 0.6 2.02 4.04 3.09 0.6681 2 3.58 2.73 0.7 Heavy metals, mg/kg Pb Cd 0.01 0.013 474.47 2.39 118.7 0.69 183.4 1.08 0.89 0.073 19 0.13 9.94 0.1 12.8 0.04 15 1.52 68.96 11.66 39.24 19.63 60.68 157.24 93.64 38.25 12 55.17 39.99 15.78 0.3 18.63 5.05 9.05 4.56 4.83 1.09 3.34 1.79 0.92 1.08 3.05 2.44 0.71 0.01 1.28 0.87 1.28

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DISCUSSION
The emissions of hazardous medical wastes incineration might comprise a real problem in the residential areas, since, almost, all the studied incinerators were allocated in the middle of high-density residential areas. Sometimes, the distance between the stack and the nearest neighbour is few ten meters. This might create a very serious situation, since there is no chance for the pollutants to be dispersed and diluted to the recommended levels of the concentrations of air pollutants in ambient air, and consequently might represent a real threat to the health of inhabitants nearby the incinerator. A very impressive view of a palm tree adjacent to an incinerator stack was observed, its half facing the stack was dead, whereas the other half was alive as shown in figure (1).

Figure ( 1 ): Impact of Emissions on Plant (The nearby Palm Tree Showing Partial Defoliation and Discoloration the Proximate Fronds).

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Formal and informal complains from the inhabitants or institutions in the neighbourhood were claimed against most of the studied incinerators concerning emitted black smoke and offensive odors of gaseous emissions. medical waste environment. The results in the present study would be interpreted in accordance to the differences between the studied incinerators and incineration conditions. In general, average CO, NO2, and SO2 concentrations were lower than maximum allowable concentrations in stack emission, whereas carbonaceous particulate were beyond these limits. The average concentrations of the above mentioned air pollutants are presented in Fig. (2).
5000 CO mg/m 3 NO2 mg/m2 SO 2 mg/m3 Smoke mg/m 3

These are solid evidences of the adverse effects of emissions (MWIE) on surrounding

incinerator

Mean levels of air pollutants mg/m

4000

3000
2278.3

2000

1753.3

2637.14

3870

3977.5 252.2

427.33

450.7

492

196.33

512

580.9

647

54.66

27.2

0 1 2 3 MWI No. 4 5 6

Figure (2): Mean Levels of Air Pollutants Emissions in Medical Waste Incinerators.

31

50.8

114.14

161.4

116.6

654.38

1000

985.53

1034

416

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Generally speaking, in all the studied incinerators, the medical wastes were delivered to the incinerator in closed black plastic bags. The medical wastes were incinerated without any classification or sorting, sometimes domestic wastes were added to medical wastes. The operators of the incinerators were not qualified to take over such a job, they lack knowledge and experience, and they worked out of normal working hours, either very early in the morning or late in the evening without enough incentives. Most of the incinerators were old, lack adequate maintenance and spare parts. Moreover, in an incinerator the control system was designed and implemented by an unspecialized contractor. Carbon monoxide emissions Carbon monoxide emissions are related to shorter residence times, lower temperatures, and poorer mixing conditions than are optimal. When combustion has not proceeded to completion, CO is formed in lieu of carbon dioxide (CO2). (13) Increasing CO concentration in emissions is simply a proof of incomplete combustion and hence bad incineration. Its worth noting that the maximum limits for CO in emissions in law No 4/1994 is 4000mg/m which is concerned with fuel combustion sources, since there is no specific limits for medical wastes incinerators in the Egyptian environmental law. That limit is unrealistic, it is very high compared to the limits in the foreign regulations, which is 100 mg/m.
(4, 13, 14)

Nevertheless, all the levels of CO in the emissions of six studied incinerators were below the maximum 4000 mg/m limit in emissions of CO in the Egyptian environmental law. Hospital No. 4 has recorded

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the lowest average level (516 mg/m), whereas the highest levels were recorded in hospitals No. 5&6 respectively. The incinerator in hospital No.4 is the newest one in the six studied incinerators with two chambers, a well performed scrubber control system and good practiced process by an experienced operator. On the contrary, the incinerators in hospitals 5&6 were old, hospital No. 5 was one compartment incinerator, there was a scrubber control system in both, however, was home-made by unspecialized contractors. The operators were unskilled and lack basic knowledge of good incineration practice. There were no temperature indicators of the incinerator, which might lead to uncontrolled incineration. Due to the aforementioned reasons, the CO levels in emissions of incinerators 5&6 recorded the highest levels, (P<0.001). The levels of CO in the emissions of incinerators studied in other countries were 70, and from 1.2 up to 360 mg/m, which are far below the levels recorded in the present study. (13-15) Sulfur dioxide emissions Sulfur is present both in the materials making up medical waste and in auxiliary fuels. Medical waste, like municipal waste, typically contains about 0.2 percent sulfur. (16) The rate of SO2 emissions is directly proportional to sulfur content of the waste and auxiliary fuels. Uncontrolled SO2 emissions from medical waste incinerators are estimated to be on the order of 100 ppm or less. (16) As discussed earlier with CO, the same problem of the very high maximum emission levels of sulfur dioxide in the Egyptian environmental law of 4000mg/m was present. The European limit is only 300 mg/m. (4, 14)

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The auxiliary fuel used was light oil (diesel) in all the six studied incinerators except for incinerator No. 6 which was using kerosene. So, the difference between the six incinerators might be attributed mainly to the difference in the incinerated medical wastes and the existence of effective control measure. In incinerator 4, of the lowest SO2 level, the medical wastes incinerated were, solutions bottles, medical gloves, cartoon, kitchen wastes, pipes, and rarely blood and syringes. It is obvious that the sulfur content of such wastes is within the recorded 0.2% normal levels. The control system of that incinerator is the best operated system, which might decrease SO2 in the emissions. In incinerator No. 6, of the highest SO2 level, (P<0.0001) the medical wastes incinerated are mainly of wasted filters of kidney washing, blood, and the other normal medical wastes as mentioned earlier. The high organic compounds contents, of the wasted filters of kidney washing, the primitive control system and bad practice, besides kerosene as auxiliary fuel, might contribute to the very high levels of SO2 in the emissions of the incinerator. Three out of four samples exceeded the 4000 mg/m limit, which might lead to health problems to patients in the hospital and neighbor population. Nitrogen oxides emissions Nitrogen oxides (NOx) represent a mixture mainly of nitric oxide (NO) and nitrogen dioxide (NO2). In combustion systems, NO predominates due to kinetic limitations in the oxidation of NO to NO2. Nitrogen oxides are formed by one of the two general mechanisms. Thermal NOx is the result of the high temperature reaction between molecular nitrogen and molecular oxygen, both of which enter the combustion zone in the combustion air.

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Fuel NOx results from the oxidation of nitrogen that is chemically bound within the fuel structure. Thermal NOx formation is extremely sensitive to temperature, whereas fuel NOx is not. At the lower adiabatic temperatures, which characterize medical waste incinerators (MWIs), fuel NOx accounts for most NOx emissions, while thermal NOx generally contributes less than 10 ppm.
(4, 14, 16)

Incinerator data indicate that NOx levels are on the order of 200 ppm. All the results of NOx concentrations in the emissions of the six studied incinerators are below the limits of 300 mg/min the law 4/1994. However the European limit is 100 mg/m. (14, 16) Hospital No. 1 has recorded the lowest average concentration, whereas hospital No.6 has recorded the highest concentration (P<0.0006). The great difference between hospital No.1 and hospital No. 6 might be attributed to the fact that the majority of the waste was the wasted filters of kidney washing with its rich component of organic compounds containing nitrogen, which might be converted to NOx in the combustion zone. Smoke Smoke is emitted as a result of incomplete combustion of organics (i.e., soot). Inorganic matter is not destroyed during combustion; most of this material leaves the incinerator as bottom ash. However, some does become entrained in the stack gas as particulate matter. In general, good combustion conditions, which depends on residence time, temperature, and turbulence (good air/fuel mixing), minimize smoke emissions. (13)

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All the average values of smoke concentrations and the majority of the individual levels were in excess of the limit of smoke in the emissions of sources of fuel combustion of 250 mg/m. This limit is higher than the foreign limits, which ranges between 30-180 mg/m.
(13, 14, 17)

The high levels of smoke in the emissions of the six studied incinerators in the present study indicate the bad incineration practice and incomplete combustion. The incinerator in hospital No. 6 was the worst one, and has recorded the highest average level of smoke in the emissions, (P<0.002). It is worth noting that, hospital No. 6 incinerator has recorded the highest levels of CO, SO2, and NO2. The high levels of smoke are always accompanied by high levels of CO, since both of them is a result of incomplete combustion. Hospital No. 6 incinerator was old, had a primitive improperly working scrubber control system, lack maintenance and the operator lack basic knowledge about proper incineration and lack experience. The results of six similar incinerators in the States of the particulate emissions have revealed a range between 60 to 902 mg/m,(14) however four incinerators emissions were below 200 mg/m. The results of particulate emissions in the present study are much higher than those of American incinerators, indicating bad practice of incineration process and incomplete combustion of the medical wastes. Lead emissions Organo-metallic compounds and inorganic wastes present in the waste stream can be volatilized and oxidized under high temperatures and oxidizing conditions in an incinerator. The type and amount of trace (heavy metals) in the flue gas are directly related to the metals contained in the incinerator waste. Some trace metal sources in the waste include surgical blades, batteries, measuring devices, foil

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wrappers, and plastics. Plastic objects made of PVC contain lead (Pb) heat-stabilizing compounds, additionally, Pb may be found in paints and/or dyes. The volatilized organo-metallic compounds condense uniformly on all available particulate surface area. Since submicron particles contribute most of the available surface area, these particles have a higher concentration of volatile metals per unit of mass. (13) The results of lead concentrations in particulate matter in the emissions of the six incinerators are presented in table (7). There is no limit for lead emissions from incinerators in law 4/1994, however, there is a limit for lead emissions from industrial sources which is 20 mg/m. It is obvious that lead concentrations in the emitted particulate from the six studied incinerators are far below the limit stated in law No 4/1994. It is worth noting that the Foreign limits are not specified for lead alone, the limit for lead, chromium, cupper, and manganese is 5 mg/m. (13) It is not easy to interpret the results of lead emissions from the six studied incinerators or correlate them to the original medical waste, since there was no known source of lead in the incinerated medical wastes, but it might be traces in all. Ash total bacterial count Proper and effective incineration of medical wastes should eradicate pathogens. In the most primitive incinerators pathogens destruction is 99% at temperatures as low as 300C however, conditioned by the correct operation of the incinerator. (8) In the past work, incineration temperature were not less than 400 C, according to available temperature gauges in some incinerators, and residence time between 2.5 to 4 hours, under these conditions bacterial

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colonies in ash samples ranged between 0-570 CFU/g at 20Cand 0-940 CFU/g at 37C In the raw medical wastes bacterial colonies might range mostly between 105-107 CFU/g. Thus, at least 99%of pathogens destruction could be achieved. (8) There was no significant variation between the levels of ash bacterial count at 20 C and 37 C in the six studied incinerators. However, incinerator No. 5 ranked the worst position within the six incinerators since it recorded the highest levels of CFU/g in ash samples at 20C and 37C, and 13 samples out of 14 samples contained bacterial count which was also the highest among the six incinerators. This might be relatively a sign of non effective incineration and incomplete combustion which should be put in consideration on evaluating the incinerators. Volatile substance Volatile substances content in ash is inversely related to complete combustion. It is supposed that the percentage destruction of organic hazardous substance is 99.99% so the volatile substance content of ash should be less than 0.01%. (17) In the present study organic volatile substances of ash ranged between 0.22-4.04% which are far higher than those of ash of U.S incinerators which were 0.003%. (14) There was a highly significant variation between organic volatile substances percentage of ash samples among the six incinerators (P<0.005). Incinerator No.5 has recorded the highest range and mean indicating, as previously with bacteria count for the same incinerator, the worst incomplete combustion among the six incinerators.

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Ash properties Observation of ash properties such as shape, color and odor could be taken as a qualitative indicator of completeness. However, these properties might differ from batch to batch in the same incinerator. Accordingly, it is difficult to depend on these properties to differentiate between incinerators and to judge the completeness of combustion. However, they might support the more distinctive parameters of combustion completeness. Shape of ash might be granular, lumped or fine .The completeness of combustion is inversely proportion to the shape and the size of ash. Thus lumped ash is the least combusted. The majority of ash samples of incinerators No. 1, 2, 3 were granular. The majority of those of incinerators No.4, 6 were fine, whereas the majority of incinerator No.5 samples were lumped, assuming moderate combustion for incinerators 1, 2, 3 and almost complete combustion for incinerators 4, 6 and poor combustion for incinerator 5. The color of ash ranged between gray and yellowish brown to black. Black ash indicated the presence of unburned carbonaceous compounds and also refers to incomplete combustion. The range from gray to yellowish brown indicated complete combustion. The majority of ash sample of incinerator No. 3 were yellowish brown indicating almost complete combustion. The majority of ash samples of incinerators 2, 5, 6 were dark gray indicating moderate combustion, where the majority of ash samples of incinerators 1, 4 were black assuming poor combustion.

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It is apparent the conflict between the conclusion which are taken from observation of shape and color of ash samples in the six studied incinerator e.g. incinerator No. 4 has undergone complete combustion according to ash shape and poor combustion according to ash color. This emphasizes that ash properties cannot be used to judge the combustion unless they are coinciding with precise parameters of completeness of combustion.

Heavy metals
Heavy metals are not destroyed by incineration but are simply concentrated in the remaining ashes or released to the environment via stack emission. The concentration of heavy metals in the ashes are highly dependent on the amounts of these metals in the wastes being incinerated. (13) In the present work, lead ranged between 0.1-474.47 mg/kg and cadmium ranged between 0.01-11.6 mg/kg in ash samples collected from the six studied incinerators. These values were much higher than those of ash samples collected from an incinerator in U.K, which where 0.00116 mg/kg for cadmium and 0.00173 mg/kg for lead. (18) In a study which has been done by the EPA, less than 3%of samples have exceeded EPA levels of heavy metals in ash. (14) In contrary, levels of heavy metals in developing countries are much higher than those in developed countries such as U.K and U.S.A. Levels of ash heavy metals in Argentina and India ranged between 0.8-11.3 and 8.35-2301mg/kg for cd and pb respectively. (19, 20) The levels of the ash heavy metals in the present study are more or less falling in the same range of those in other developing countries.

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There were no statistical significant variation between levels of cadmium and lead in ash samples in the six studied incinerators. This might be attributed to the similar origin of medical wastes among the six incinerators. The great difference between levels of heavy metals in developed and developing countries might be attributed to sorting out and exclusion of sources of heavy metals in the raw waste before incineration in developed countries.

CONCLUSION AND RECOMMENDATIONS

The present survey of stack emissions of six incinerators of medical wastes in Alexandria has pointed out the potential serious impact of the incinerators emissions, since all of them undergone incomplete combustion by different extent on the surrounding environment. The Egyptian Environmental law (law No-4 -1994) is lacking specific emission limits of medical waste incinerators. In the mean time, the limits which could be applied (emission limits of fuel combustion sources) were unrealistic and much higher than those, concerning medical waste incinerators, in developed countries' laws. Ash samples contained bacterial count, high volatile substances percentage indicating incomplete combustion and similar heavy metals content of ash samples in developing countries. The present work recommendations are: 1. To set specific reasonable emission limits for medical waste incinerators in Egyptian Environmental law. 2. To transfer, the present incinerators out of the residential areas and/or.

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3.

To substitute them by two central incinerators in sub urban areas one in the east and one in the west of Alexandria.

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