Biomedical Waste Management (BMW) Let the waste of the sick not contaminate the lives of healthy For MBBS IV Semester 26th April 2017 By: Dr Puneet Kumar Gupta Assistant Professor, Microbiology

Layout Definition What’s need of BMW? Contribution of different waste type Various things required in management Rule governing Categories, Segregation, Transportation Modality of treatment Do & Don’t

Definition Waste generated during laboratory diagnosis, treatment or immunization of human being or animals, or in research activity pertaining thereto, or in production of biologicals

What’s Need for BMW? Attracts flies, insects, birds and animals Filthy and unhygienic conditions Injury(NSI) and infection Reuse of disposables Harmful chemicals and radioactive materials( contaminate wells and tanks) Animals & insects may get inf./ become carriers. Survival & mutation of pathogenic microbes→ epidemics, increase in communicable diseases in the community

Contribution of different waste type Waste generation in Developing countries 0.5-2 Kg/bed/day Developed 1-5 Kg/bed/day Hospital Waste 15-20% 80-85% Hazardous Non- hazardous Bio degradable Non-bio degradable Potentially Toxic 5% Potentially Infectious 15% 15% Chemical Radioactive Organic Lab Sharps Pharmaceutical

Rule governing Biomedical Waste Management & Handling Rule 1998 Amended 2000 2003 2011 Biomedical Waste Management Rule 2016

Bio-Medical Waste Management Rules, 2016

Following Waste Not covered under BMW Management Rule 2016 Solid waste Solid Waste Management Rules, 2016 E waste E-Waste (Management) Rules, 2016 Radioactive wastes Atomic Energy Act, 1962(33 of 1962) and the rules made there under Hazardous chemicals Manufacture, Storage and Import of Hazardous Chemicals Rules, 1989 made under the Act Construction and demolition waste Construction and Demolition Waste Management Rules, 2016 Lead acid batteries Batteries (Management and Handling) Rules, 2001 Hazardous wastes Hazardous and Other Wastes (Management and Transboundary Movement) Rules, 2016 Hazardous microorganisms, genetically engineered microorganisms and cells Manufacture, Use, Import, Export and Storage of Hazardous Microorganisms, Genetically Engineered Microorganisms or Cells Rules, 1989 made under the Act

Biomedical Waste Management Rule 2016 Segregation Biomedical Waste Management Rule 2016

Yellow Red Blue White (Translucent) 4 category of waste: Yellow Red Blue White (Translucent)

Biomedical wastes categories and their segregation, collection, treatment, processing and disposal options (Schedule 1) Category Type of waste Container to be used Yellow Soiled Waste (Items contaminated with blood, body fluids): Dressings, Bandage, Gauze, Linen Plaster casts, Cotton swabs Bed Protection pads Bags containing residual or discarded blood and blood components including blood set tubing’s Diapers, Napkins Discarded linen, mattresses, beddings Yellow coloured non-chlorinated plastic bags common Bio-medical Waste treatment facility

Biomedical wastes categories and their segregation, collection, treatment, processing and disposal options (Schedule 1) Category Type of waste Container to be used Yellow Human Anatomical Waste:Human tissues, organs, body parts and fetus below the viability period (as per MTP act) [copy of official MTP certificate from Obstetrician or the MS of hospital or healthcare establishment must be given] Yellow coloured non-chlorinated plastic bags common Bio-medical Waste treatment facility

Biomedical wastes categories and their segregation, collection, treatment, processing and disposal options (Schedule 1) Category Type of waste Container to be used Yellow Animal Anatomical Waste: Experimental animal carcasses, body parts, organs, tissues, including the waste generated from animals used in experiments or testing in animal houses Yellow coloured non-chlorinated plastic bags common Bio-medical Waste treatment facility Expired or Discarded Medicines (Except cytotoxic drugs) Pharmaceutical waste like antibiotics

Biomedical wastes categories and their segregation, collection, treatment, processing and disposal options (Schedule 1) Category Type of waste Container to be used Yellow Cytotoxic drugs including all items contaminated with cytotoxic drugs along with glass or plastic ampoules, vials etc Yellow coloured non-chlorinated plastic bags with cytotoxic label common Bio-medical Waste treatment facility

Biomedical wastes categories and their segregation, collection, treatment, processing and disposal options (Schedule 1) Category Type of waste Container to be used Yellow Chemical Liquid Waste: Liquid waste generated due to use of chemicals in production of biological and used or discarded disinfectants, Silver X-ray film developing liquid, Discarded Formalin, Infected secretions, Aspirated body fluids, Liquid from laboratories and floor washings, cleaning, house-keeping and disinfecting activities etc. Separate collection system leading to effluent treatment system

Lab & highly infectious BMW generated shall be pre-treated by equipment like autoclave or microwave Microbiology waste and all other clinical laboratory waste shall be pre-treated by sterilisation to Log 6 or disinfection to Log 4, as per the WHO & NACO guidelines before packing & sending to CBMWTF Use of Non-chlorinated chemicals No chemical pretreatment before incineration, except for microbiological, lab & highly infectious waste

Autoclave conditions for BMW handling Should not be less than 1210C x 15psi x 60 minutes 1350C x 31psi x 45 minutes 1490C x 52psi x 30 minutes Biological Indicator: (Maintain record) First Validate with 4 biological indicator Then Daily testing with chemical indicator (>1 strips per bag of discard at different locations Once a Week biological indicator testing

Biomedical wastes categories and their segregation, collection, treatment, processing and disposal options (Schedule 1) Category Type of waste Container to be used Yellow Microbiology, Biotechnology and other clinical laboratory waste: Blood bags, Vacutainers containing blood Dishes and devices used for cultures Laboratory cultures, stocks or specimens of microorganisms, Live or attenuated vaccines, human and animal cell cultures used in research, production of biological, Residual toxins Autoclave safe plastic bags or containers Autoclave/ Microwave common Bio-medical Waste treatment facility

Red Category Type of waste Container to be used Contaminated Waste (Recyclable) Wastes generated from disposable items such as All plastic tubings (Ryle’s, ICD, ET, drains) Intravenous tubes and sets, Catheters (Foley’s, suction etc) Cardiac cannulas Plastic iv Bottles Uro bags, syringes (without needles and fixed needle syringes) vacutainers with their needles cut Red coloured non-chlorinated plastic bags or containers common Bio-medical Waste treatment facility

Red Category Type of waste Container to be used Gloves Nebulization masks Surgical disposable face mask, caps, gown, Shoe cover Needle caps (If infected) Plastic Test tubes Pipettes Disposable tips Plastic Trough Red coloured non-chlorinated plastic bags or containers common Bio-medical Waste treatment facility

White (Translucent) Category Type of waste Container to be used Waste sharps including Metals: Needles (including Hypodermic needles, I/v set needles, suture needles, LP needles etc.) Stylets of IV cannula syringes with fixed needles, Needles from needle tip cutter or burner, scalpels, blades, Lancets Saws Any other contaminated sharp object that may cause puncture and cuts includes used, discarded and contaminated metal sharps Puncture proof, Leak proof, tamper proof containers common Bio-medical Waste treatment facility

Alternative Heavy duty plastic containers But, they should be Examples leak resistant, Remain upright during use without sharp able to come out Tight fitting, puncture resistant lid Translucent which has to be marked Examples Plastic laundry detergent container, Plastic bottles Empty detergent metal cans Disinfectants empty plastic container Empty dry media containers A tin or a plastic box with a small opening at top with a lid for closure of the Box

Alternative Clearly labelled “Sharp Metallic waste” with “biohazard symbol” A line should be drawn on the box to mark ¾ of the volume Needles should be filled only till this line

Locally made Sharp Waste containers

Syringes should be either mutilated or needles should be cut and or stored in tamper proof, leak proof and puncture proof containers for sharps storage

Blue Category Type of waste Container to be used Glassware: Broken or discarded and contaminated glass including medicine vials and ampoules except those contaminated with cytotoxic wastes Broken petri dishes, Slides and cover slips, Broken pipettes and other glass material Metallic Body Implants Cardboard boxes with blue colored marking (If soiled with infectious waste: treat by disinfectants or autoclaving) common Bio-medical Waste treatment facility

Methods of disposal of microbiological samples & cultures Sputum, LJ media, container soaked in 5% phenol overnight The container is autoclaved The phenol solution poured of in to drain and the container is sent to the final disposal site in red bag/blue bag Disposal of sputum container with specimen and LJ culture:

Disposal of blood samples Blood samples and container 10%sodium hypochlorite Container sent to disposal site and the disinfectant to the drain Clotted blood samples along with the container Autoclave Container sent to the common disposal site in appropriate bag

Other infectious samples 5% phenol Urine pus Stool Sputum

Disposal of Microbiological cultures 10%sodium hypochlorite overnight Discharge into the drain Petri dishes 1.Autoclave if reusable or 2. Disposal site for recycling Autoclavable bags Autoclave and reuse the petri dishes and the culture medias can be disposed off into the drain

Transportation Always collect waste in a covered bin/bags Dispose bags every day or whenever ¾ filled Handover waste to dedicated waste collection team Collection team should tie properly labelled bag, weight, record particular in waste collection register Then collection team should keep the waste bag/container in transportation trolley/container Transportation should be done safely without spillage & leakage

Transportation Collection container should then be cleaned with soap and water/disinfectant by housekeeping staff and new suitable bag/ container will be applied and to be checked by staff nurse or technician (OT, Laboratory) of respective area No waste to be stored >24 hours at point of segregation Collection team then transport waste in closed container to storage area in a pre-defined path of least crowding Waste in common storage area will be delivered to the authorised person from common biomedical treatment facility

Every Biomedical waste bags/container must have biohazard sign and label with details

What's differences b/w 1998/2011/2016 BMW Rules?

BMW (Management and Handling) Rules, 1998, 2000, 2003, 2011 BMW Management Rules, 2016 Word Handling Handling word omitted Management’ includes Handling Not cover these Cover healthcare activity undertaken outside the healthcare facility: vaccination camps, blood donation camps, surgical camps or any other ----- Additional Duties of occupier Added: Provision of safe, ventilated and secured location for storage of segregated BMW Pre-treat the laboratory waste, microbiological waste, blood samples and blood bags through disinfection or sterilisation on-site as per WHO or NACO guidelines & then sent to CBMWFs Phase out use of chlorinated plastic bags, gloves and blood bags within two years of notification of rule

BMW (Management and Handling) Rules, 1998, 2011 BMW Management Rules, 2016 ------ Additional Duties of occupier Added: Immunise all its HCP and others involved in handling of BMW for protection against diseases including Hepatitis B & Tetanus Establish a Bar- Code System for bags or containers Report major accidents including accidents caused by fire hazards, blasts during handling of BMW -------- Operator of CBMWFs Ensure timely collection of BMW from HCFs, assist the HCFs in conduct of training ------- Not to establish on-site treatment & disposal facility if a service of CBMWFs available at a distance of 75Km

BMW (Management and Handling) Rules, 2011 BMW Management Rules, 2016 8 category (10 in 1998 Rule) 4 category No storage beyond 48 hrs Permission required to be taken Untreated human anatomical waste, animal anatomical waste, soiled waste and, biotechnology waste shall not be stored beyond a period of 48 hrs In case for any reason it becomes necessary to store such waste beyond such a period, the occupier shall take appropriate measures to ensure that the waste does not adversely affect human health & environment Inform the SPCB along with reasons Hospitals treating ≥ 1000 patients/month to obtain authorization from SPCBs/PCCs One time Authorisation for Non-bedded HCFs. Validity of authorization shall be synchronised with validity of consent orders for Bedded HCFs

BMW (Management and Handling) Rules, 2011 BMW Management Rules, 2016 To strengthen advisory committee of Government of every State/Union Territory- Additional members added 150 mg/nm3 1 sec ...Nil.. Emission standards Incineration SPM in Incinerator’s Emission 50 mg/nm3 Residence Time in Secondary chamber of incinerators =2 Sec Standards for Dioxin and furans 1% Chemical Treatment 10% sodium Hypochlorite Black color Cytotoxic waste in Yellow Blue/ white bags Sharp 2 types

Final disposal Modalities: Thermal Processes High Temperature Processes Incineration Pyrolysis Plasma Technology Gasification Non-Burn/Low-Temperature Treatments Autoclave Hydroclave Microwave Dry heat Steam auger (waste is shredded prior to t/t)

Modalities: Chemical Disinfection

Incinerator Incineration is a high heat system process of burning combustible solids at very high temperature in a furnace. Burning of waste material in 10 Chamber stages (850±500C) Followed by combustion of gases in 20Chamber (1050±500C) Cleaning of flue gas through a number of pollution control devices End product is devoid of infectious organisms Not to be done: Burning of Plastic waste & Sharp -

AUTOCLAVE Gravity displacement type – Operates at Not<121°C at 15psi for not < 60 minutes Pre vacuum type Vacuum pumps are utilized to evacuate air in the chamber of autoclave Steam under pressure is pushed Operates at Not<121°C at 15psi for not < 45 minutes Not<135°C at 31psi for not < 30 minutes Not Recommended for pathological Waste

Hydroclave Expansions of Autoclave Steam sterilization technology Steam Introduced into hollow walls of hydroclave Steam does not come in contact with waste Volume & Weight Reduction much more than autoclave Cycle time 1 hr

Use electromagnetic waves 300-300,000 MHz Radiation produced by microwave break molecular chemical bonds Heat up waste material from inside, unlike the external heat given in autoclave & hydro clave Work at temp 97-100 0C Cycle time 40-45 min Not to be used with Body parts & tissue

Deep Burial Pit A pit or trench 2m deep 1/2 with waste, then covered with lime within 50 cm of surface, before filling the rest of pit with soil On each occasion, when wastes are added to pit, layer of 10 cms of soil shall be added to cover the wastes Ensure that animals do not have any access to burial site Covers of galvanized iron / wire meshes Should be distant from habitation Should be relatively impermeable & no shallow well should be close to the site. Burial must be performed under close & dedicated supervision

Sharp Pit Dug according to the requirement of hospital All sides of the pit should be plastered with cement A cylindrical metal pipe of 4 inches diameter or more is fixed at the ceiling of the pit The opening of the metal pipe should have locking facility The sharps are deposited in this pit through the pipe from the puncture proof translucent container after mutilating.

Building a protected sharp Barrel

Do’s FOR WASTE M/M Generate waste when essential Segregate waste at source into specified categories of waste with biohazard logo Mutilate waste at source if possible to prevent unauthorized reuse Destroy needle by using needle cutter or needle burner Keep the needles in puncture proof, translucent container Clean the bins regularly with soap & water and disinfect the bins regularly. All liquid chemical waste should be drained out in to ETP

Don’ts Do not generate waste unnecessary (e.g. avoid injection by prescribing oral medicines) Never mix infectious & non- infectious waste Never mix chlorinated wastes with such wastes those which have designated for incineration. Never overfill the bins. Never store waste beyond 48 hrs. There should not be any spillage on the way of transport.

Don’ts Avoid transport of waste through crowded areas Do not throw infectious waste into general waste without any pre- treatment and mutilation Don’t dispose the solid waste (plastic) and sharp waste without mutilation

Q1: How much percentage of waste will come under biomedical waste? 5% 15-20% 25-30% 85%

Q2: Nursing sister finds expired chemotherapeutic drugs stored in glass ampoules in RCC ward. She tells the sister in charge to dispose those expired drugs . The sister in-charge is confused regarding the disposal . Suggest the appropriate BMW management Chemotherapeutic drugs has to be disposed into red bag Chemotherapeutic drugs being in a glass ampoule dispose in a puncture proof box Chemotherapeutic drugs has to be disposed in black bag Chemotherapeutic drugs has to be disposed in yellow bag

Blood sample has to be discarded in yellow bag Q 3: There was a blood sample from a HIV pateint. The lab personnel wanted to discard the blood in a safe manner. Tell the appropriate BMW management Blood sample has to be discarded in yellow bag Blood sample has to be pretreated with 10% sodium hypochlorite and then disposed Blood samples should be autoclaved and then disposed. Both b and c are correct methods of disposal

Yes , as the right chemical pretreatment is 10% sodium hypochlorite Q4: A TB patient coming to mycobacteriology lab gives a sputum sample for drug susceptibility testing. The lab personnel after processing the sputum sample discards the sample into 10 % sodium hypochlorite. Is this the appropriate method of disposal? Yes , as the right chemical pretreatment is 10% sodium hypochlorite No, 5% lyzol should be used. No, 5% phenol should be used. No pretreatment required as it has to be disposed in the sewage effluent plant .

Q5: According to rules 2016, the BMW management should be done Inside the hospital campus Outsource it if the disposal site is within 125km radius from the hospital Outsource it if the disposal site is within 75km radius from the hospital Can be stored and disposed after a month to the outsourcing unit

Q6: Which among these waste is not included under biomedical waste? a. expired medicines b. Laboratory cultures c. Lead acid batteries d. e- waste e. Both c and d

Q7:Bags used for the BMW management should be Plastic/ chlorinated Plastic/ nonchlorinated Plastic/ flurinated Nonplastic/ nonchlorinated

So Everyone Responsibility

References Biomedical Waste Management Rule 2016 Safe management of wastes from health-care activities. WHO 2nd Edition 1st Edition of Essential of Medical Microbiology by Apruba Shankar Sastry & Santhiya Bhat K. 5th Edition of Texbook of Microbiology by Dr CP Bhaveja NACO Manuals