According to Biomedical Waste (Management and Handling) Rules, 1998 of India “Any waste which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining thereto or in the production or testing of biologicals. 4
The Government of India (notification, 1998) specifies that Hospital Waste Management is a part of hospital hygiene and maintenance activities. This involves management of range of activities, which are mainly engineering functions, such as collection, transportation, operation or treatment of processing systems, and disposal of wastes. 4
One of India’s major achievements has been to change the attitudes of the operators of health care facilities to incorporate good HCW management practices in their daily operations and to purchase on-site waste management services from the private sector. (Bekir Onursal, 2003)
World Health Organization states that 85% of hospital wastes are actually non-hazardous, whereas 10% are infectious and 5% are non-infectious but they are included in hazardous wastes. About 15% to 35% of Hospital waste is regulated as infectious waste. This range is dependent on the total amount of waste generated (Glenn and Garwal, 1999).5
Classification of Bio-Medical Waste
The World Health Organization (WHO) has classified medical waste into eight categories:
´ General Waste
´ Infectious to potentially infectious waste
´ Pressurized containers
Sources of Biomedical Waste
Hospitals produce waste, which is increasing over the years in its amount and type. The hospital waste, in addition to the risk for patients and personnel who handle them also poses a threat to public health and environment.
Problems relating to biomedical waste
A major issue related to current Bio-Medical waste management in many hospitals is that the implementation of Bio-Waste regulation is unsatisfactory as some hospitals are disposing of waste in a haphazard, improper and indiscriminate manner. Lack of segregation practices, results in mixing of hospital wastes with general waste making the whole waste stream hazardous. Inappropriate segregation ultimately results in an incorrect method of waste disposal.
Inadequate Bio-Medical waste management thus will cause environmental pollution, unpleasant smell, growth and multiplication of vectors like insects, rodents and worms and may lead to the transmission of diseases like typhoid, cholera, hepatitis and AIDS through injuries from syringes and needles contaminated with human.6
Various communicable diseases, which spread through water, sweat, blood, body fluids and contaminated organs, are important to be prevented. The Bio Medical Waste scattered in and around the hospitals invites flies, insects, rodents, cats and dogs that are responsible for the spread of communication disease like plague and rabies. Rag pickers in the hospital, sorting out the garbage are at a risk of getting tetanus and HIV infections. The recycling of disposable syringes, needles, IV sets and other article like glass bottles without proper sterilization are responsible for Hepatitis, HIV, and other viral diseases. It becomes primary responsibility of Health administrators to manage hospital waste in most safe and eco-friendly manner6.
The problem of bio-medical waste disposal in the hospitals and other healthcare establishments has become an issue of increasing concern, prompting hospital administration to seek new ways of scientific, safe and cost effective management of the waste, and keeping their personnel informed about the advances in this area. The need of proper hospital waste management system is of prime importance and is an essential component of quality assurance in hospitals.
All human activities produce waste. We all know that such waste may be dangerous and needs safe disposal. Industrial waste, sewage and agricultural waste pollute water, soil and air. It can also be dangerous to human beings and environment. Similarly, hospitals and other health care facilities generate lots of waste which can transmit infections, particularly HIV, Hepatitis B & C and Tetanus, to the people who handle it or come in contact with it.
Most countries of the world, especially the developing nations, are facing the grim situation arising out of environmental pollution due to pathological waste arising from increasing populations and the consequent rapid growth in the number of health care centres. India is no exception to this and it is estimated that there are more than 15,000 small and private hospitals and nursing homes in the country. This is apart from clinics and pathological labs, which also generate sizeable amounts of medical waste.
India generates around three million tonnes of medical wastes every year and the amount is expected to grow at eight per cent annually. Creating large dumping grounds and incinerators is the first step and some progressive states such as Maharashtra, Karnataka and Tamil Nadu are making efforts despite opposition.
Barring a few large private hospitals in metros, none of the other smaller hospitals and nursing homes have any effective system to safely dispose of their wastes. With no care or caution, these health establishments have been dumping waste in local municipal bins or even worse, out in the open. Such irresponsible dumping has been promoting unauthorized reuse of medical waste by the rag pickers for some years now.
Surveys carried out by various agencies show that the health care establishments in India are not giving due attention to their waste management. After the notification of the Bio-medical Waste (Handling and Management) Rules, 1998, these establishments are slowly streamlining the process of waste segregation, collection, treatment, and disposal. Many of the larger hospitals have either installed the treatment facilities or are in the process of doing so.
Bio-medical waste means “any solid and/or liquid waste including its container and any intermediate product, which is generated during the diagnosis, treatment or immunization of human beings or animals.
Biomedical waste poses hazard due to two principal reasons – the first is infectivity and other toxicity.
Bio Medical waste consists of
The Central Government, to perform its functions effectively as contemplated under sections 6, 8, and 25 of the Environment Protection Act, 1986, has made various Rules, Notifications and Orders including the Bio-medical wastes (Management & Handling) Rules, 1998.
A brief summary of the provisions in Bio-medical wastes (Management & Handling) Rules, 1998 is given below.
Even after the June, 2000 deadline most of the large hospitals have not complied with these Rules, as there is no specified authority to monitor the implementation of these Rules. But, the fact is that in most of the states, the pollution control boards that are connected with waste in general do not have adequate powers or commitment to enforce the Rules.
Applicability of BMW Rules, 1998
The BMW Rules are applicable to every occupier of an institution generating biomedical waste which includes a hospital, nursing homes, clinic, dispensary, veterinary institutions, animal houses, pathological lab, blood bank by whatever name called, the rules are applicable to even handlers.
Common Biomedical wastes treatment facility [CBWTFs]
The Common Biomedical wastes treatment facility, (see rules 14, amended in June 2000, which cast the responsibilities on municipal bodies to collect biomedical wastes/treated biomedical wastes and also provide sites for setting up of incinerator.) The owner of CBWTFs are service providers, who are providing services to health care units for collection of BMWs for its final disposal to their site.
Inventory of Tamilnadu
The Tamilnadu Pollution Control Board enforces the Biomedical Waste (Management and Handling) Rules, 1998 as amended in 2000. As part of this process, the Board has so far inventoried 317 Government hospitals and 1,835 private hospitals. The Board has issued directions to the Government and private hospitals to take time-bound action for identifying sites and setting up common facilities for management of biomedical wastes in coordination with the Indian Medical Association.
So far 11 sites have been identified for the above said purpose
6 units under operation are
5 units under establishment are
The components of a common biomedical waste treatment and disposal facility [CBWTFs] are autoclave, shredder, compactor, and incinerator for anatomical waste, secured landfill facility, laboratory and vehicles for transportation of wastes.
The biomedical waste (BMW) management requires its categorisation as a first step. The BMW Rules classify the BMW into ten categories.
|CATEGORIES OF BIOMEDICAL WASTE SCHEDULE – I|
@@ Chemical treatment using at least 1% hypochlorite solution or any other equivalent chemical reagent. It must be ensured that chemical treatment ensures disinfection.
** Mutilations / Shredding must be such as to prevent unauthorised reuse.
@ There will be no chemical pre-treatment before incineration. Chlorinated plastics shall not be incinerated.
* Deep burial shall be an option available only in towns with population less than five lakh and in rural areas.
The typical Hospital solid waste composition is as follows (based on CPCB report)
Segregation refers to the basic separation of different categories of waste generated at source and thereby reducing the risks as well as cost of handling and disposal. Segregation is the most crucial step in bio-medical waste management. Effective segregation alone can ensure effective bio-medical waste management. The BMWs must be segregated in accordance to guidelines laid down under schedule 1 of BMW Rules, 1998.
How does segregation help?
Proper labelling of bins
The bins and bags should carry the biohazard symbol indicating the nature of waste to the patients and public.
Schedule III (Rule 6) of Bio-medical Waste (Management and Handling) Rules, 1998 specifies the Label for Bio-Medical Waste Containers / Bags as:
Label shall be non-washable and prominently visible
The collection of biomedical waste involves use of different types of container from various sources of biomedical wastes like Operation Theatre, laboratory, wards, kitchen, corridor etc. The containers/ bins should be placed in such a way that 100 % collection is achieved. Sharps must always be kept in puncture-proof containers to avoid injuries and infection to the workers handling them.
Once collection occurs then biomedical waste is stored in a proper place. Segregated wastes of different categories need to be collected in identifiable containers. The duration of storage should not exceed for 8-10 hrs in big hospitals (more than 250 bedded) and 24 hrs in nursing homes. Each container may be clearly labelled to show the ward or room where it is kept. The reason for this labelling is that it may be necessary to trace the waste back to its source. Besides this, storage area should be marked with a caution sign.
The waste should be transported for treatment either in trolleys or in covered wheelbarrow. Manual loading should be avoided as far as for as possible. The bags / Container containing BMWs should be tied/ lidded before transportation. Before transporting the bag containing BMWs, it should be accompanied with a signed document by Nurse/ Doctor mentioning date, shift, quantity and destination.
Special vehicles must be used so as to prevent access to, and direct contact with, the waste by the transportation operators, the scavengers and the public. The transport containers should be properly enclosed. The effects of traffic accidents should be considered in the design, and the driver must be trained in the procedures he must follow in case of an accidental spillage. It should also be possible to wash the interior of the containers thoroughly.
Personnel safety devices
The use of protective gears should be made mandatory for all the personnel handling waste.
Gloves: Heavy-duty rubber gloves should be used for waste handling by the waste retrievers. This should be bright yellow in colour. After handling the waste, the gloves should be washed twice. The gloves should be washed after every use with carbolic soap and a disinfectant. The size should fit the operator.
Aprons, gowns, suits or other apparels: Apparel is worn to prevent contamination of clothing and protect skin. It could be made of cloth or impermeable material such as plastic. People working in incinerator chambers should have gowns or suits made of non-inflammable material.
Masks: Various types of masks, goggles, and face shields are worn alone or in combination, to provide a protective barrier. It is mandatory for personnel working in the incinerator chamber to wear a mask covering both nose and mouth, preferably a gas mask with filters.
Boots: Leg coverings, boots or shoe-covers provide greater protection to the skin when splashes or large quantities of infected waste have to be handled. The boots should be rubber-soled and anti-skid type. They should cover the leg up to the ankle.
Brooms: The broom shall be a minimum of 1.2 m long, such that the worker need not stoop to sweep. The diameter of the broom should be convenient to handle. The brush of the broom shall be soft or hard depending on the type of flooring.
Dustpans: The dustpans should be used to collect the dust from the sweeping operations. They may be either of plastic or enamelled metal. They should be free of ribs and should have smooth contours, to prevent dust from sticking to the surface. They should be washed with disinfectants and dried before every use.
Mops: Mops with long handles must be used for swabbing the floor. They shall be of either the cloth or the rubber variety. The mop has to be replaced depending on the wear and tear. The mechanical-screw type of mop is convenient for squeezing out the water.
Vacuum cleaners: Domestic vacuum cleaners or industrial vacuum cleaners can be used depending on the size of the rooms.
It is very important to assess the quantity of waste generated at each point. Dustbins should be of such capacity that they do not overflow between each cycle of waste collection. Dustbins should be cleaned after every cycle of clearance of waste with disinfectants. Dustbins can be lined with plastic bags, which are chlorine-free, and colour coded as per the law.
The use of trolleys will facilitate the removal of infectious waste at the source itself, instead of adding a new category of waste.
Wheelbarrows are used to transfer the waste from the point source to the collection centres. There are two types of wheelbarrow – covered and open. Wheelbarrows are made of steel and provided with two wheels and a handle. Care should be taken not to directly dump waste into it. Only packed waste (in plastic bags) should be carried. Care should also be taken not to allow liquid waste from spilling into the wheelbarrow, as it will corrode. These are ideal for transferring debris within the institution. Wheelbarrows also come in various sizes depending on the utility.
Chutes are vertical conduits provided for easy transportation of refuse vertically in case of institutions with more than two floors. Chutes should be fabricated from stainless steel. It should have a self-closing lid. These chutes should be fumigated everyday with formaldehyde vapours. The contaminated linen (contaminated with blood and or other body fluids) from each floor should be bundled in soiled linen or in plastic bags before ejecting into the chute.
Alternately, elevators with mechanical winches or electrical winches can be provided to bring down waste containers from each floor. Chutes are necessary to avoid horizontal transport of waste thereby minimizing the routing of the waste within the premises and hence reducing the risk of secondary contamination.
Technology options for ‘treatment’
There are mainly five technology options available for the treatment of Bio-Medical Waste or still under research can be grouped as
1. Chemical processes
1. Chemical processes
These processes use chemical that act as disinfectants. Sodium hypochlorit, dissolved chlorine dioxide, peracetic acid, hydrogen peroxide, dry inorganic chemical and ozone are examples of such chemical. Most chemical processes are water-intensive and require neutralising agents.
2. Thermal processes
These processes utilise heat to disinfect. Depending on the temperature they operate it is been grouped into two categories, which are Low-heat systems and High-heat systems
Autoclaving is a low heat thermal process and it uses steam for disinfection of waste. Autoclaves are of two types depending on the method they use for removal of air pockets are gravity flow autoclave and vacuum autoclave.
Incinerator & Hydroclaving are high heat systems. Hydroclaving – is steam treatment with fragmentation and drying of waste
These processes are used to change the physical form or characteristics of the waste either to facilitate waste handling or to process the waste in conjunction with other treatment steps. The two primary mechanical processes are
Compaction – used to reduce the volume of the waste
Shredding – used to destroy plastic and paper waste to prevent their reuse. Only the disinfected waste can be used in a shredder.
exposes wastes to ultraviolet or ionizing radiation in an enclosed chamber. These systems require post shredding to render the waste unrecognizable.
5. Biological processes –
using biological enzymes for treating medical waste. It is claimed that biological reactions will not only decontaminate the waste but also cause the destruction of all the organic constituents so that only plastics, glass, and other inert will remain in the residues.
Points to ponder in processing the waste
The autoclave should be dedicated for the purpose of disinfecting and treating biomedical waste.
1. When operating a gravity flow autoclave, medical waste shall be subjected to:
2. When operating a vacuum autoclave, medical waste shall be subjected to a minimum of one per vacuum pulse to purge the autoclave of all air. The waste shall be subjected to the following :
Radioactive waste from medical establishments
Wastes containing Mercury due to breakage of thermometer and other measuring equipment need to be given
Standard For Liquid Waste
The effluent generated from the hospitals must confirm to the following:
These limits are applicable to those hospitals which are either connected with sewers that have no terminal sewage treatment plant or not connected to public sewers that have terminal facilities. In addition, the general standards as notified under the Environment (Protection) Act, 1986 shall be applicable.
Waste minimization: Waste minimization is an important first step in managing wastes safely, responsibly and in a cost effective manner. This management step makes use of reducing, reusing and recycling principles. There are many possible routes to minimize the amount of both general waste and biomedical wastes within the health care or related facility. Alternative technologies for biomedical waste minimization (e.g., microwave treatment; hammer mill) have been investigated and are not considered to be practical. Some of the principles of waste minimization are listed below and will be developed further in the long-term strategy.
Infectious: material-containing pathogens in sufficient concentrations or quantities that, if exposed, can cause diseases. This includes waste from surgery and autopsies on patients with infectious diseases, sharps, disposable needles, syringes, saws, blades, broken glasses, nails or any other item that could cause a cut;
Pathological: tissues, organs, body parts, human flesh, foetuse, blood and body fluids, drugs and chemicals that are returned from wards, spilled, outdated, contaminated, or are no longer required;
Radioactive: solids, liquids and gaseous waste contaminated with radioactive substances used in diagnosis and treatment of diseases like toxic goiter; and
Others: waste from the offices, kitchens, rooms, including bed linen, utensils, paper, etc.
According to the WHO, the global life expectancy is increasing year after year. However, deaths due to infectious disease are also increasing. A study conducted by the WHO reveals that more than 50,000 people die everyday from infectious diseases. One of the causes for the increase in infectious diseases is improper waste management. Blood, body fluids and body secretions which are constituents of bio-medical waste harbour most of the viruses, bacteria and parasites that cause infection.
This passes via a number of human contacts, all of whom are potential ‘recipients’ of the infection. Human Immunodeficiency Virus (HIV) and hepatitis viruses spearhead an extensive list of infections and diseases documented to have spread through bio-medical waste. Tuberculosis, pneumonia, diarrhea diseases, tetanus, whooping cough etc., are other common diseases spread due to improper waste management.
Occupational health hazards
The health hazards due to improper waste management can affect
Hazards to the general public
The general public’s health can also be adversely affected by bio-medical waste.