Biomedical waste management Presenter: Dr.L.Karthiyayini Moderator: Dr. A.Mehendale

Framework Definition Burden of biomedical waste Sources of waste Types of health care waste & its health hazards Legislations Waste generation Principles of managing waste Waste minimization Managing sharps Chemical disinfectants Handling of health care waste Waste segregation & labeling Waste storage & transport Waste treatment & disposal Infection control BWM at MGIMS BMWM in national programs Biomedical waste audit

Definition “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 biological” [Source: Biomedical Waste (Management and Handling) Rules, 1998 of India]

MAGNITUDE OF THE PROBLEM GLOBALLY: Developed countries generate 1 to 5 kg/bed/day Developing countries: 1-2kg/pt/day WHO Report: 85% non hazardous waste 10% infective waste 5% non-infectious but hazardous. (Chemical, pharmaceutical and radioactive) 2002, 22 countries, health care facilities not using proper disposal 18%-64%

Hazardous waste generation

No national level study Hospitals generate 1-2 kg/bed/day INDIA: No national level study Hospitals generate 1-2 kg/bed/day BMW generation : 4,05,702 kg/day 2,91,983 kg/day is disposed 28% of the wastes is untreated 53.25% HCE – not authorized

Top 5 biomedical waste generating states Biomedical waste generation & disposal (kg/ day) Waste Disposal Karnataka 62,241 43,971 Uttar Pradesh 44,392 42,237 Maharashtra 40,197 Kerala 32,884 29,438 West Bengal 23,571 12,472 All India 4,05,702 2,91,983

Sources of biomedical wastes Major Sources: Govt. hospitals/private hospitals/nursing homes/ dispensaries. Primary health centres. Medical colleges and research centres/ paramedic services. Veterinary colleges and animal research centres. Blood banks/mortuaries/autopsy centres. Biotechnology institutions.

Minor Sources: Physician’s/ dentist’s clinics Animal houses/slaughter houses. Blood donation camps. Vaccination centres. Acupuncturists/psychiatric clinics/cosmetic piercing. Funeral services. Institutions for disabled persons

Health hazards of various waste Waste materials Potential hazards Human anatomical waste Psychological stress Human anatomical waste, soiled waste, microbial waste, sharps Infections & disease Animal wastes Infectious rabies, Anthrax & other Sharps, cytotoxic & radioactive drugs, incinerator wastes Injuries Chemical, cytotoxic, radioactive, incinerator wastes Dermatitis, conjunctivitis, bronchitis Cytotoxic, radioactive drugs & materials, chemical wastes Cancer, genetic mutation Cytotoxic & other drugs, liquid & chemical wastes Poisonings

CATEGORIES OF BIO MEDICAL WASTE OPTION WASTE CATEGORY TREATMENT & DISPOSAL Category No. 1 Human Anatomical Waste Incineration / deep burial Category No. 2 Animal Waste Category No. 3 Microbiology & Biotechnology Waste Local autoclaving / microwaving / incineration Category No. 4 Waste Sharps Disinfection by chemical treatmet / atoclaving / microwaving and mutilation / shredding Category No. 5 Discarded Medicines and Cytoxic drugs Incineration / destruction and drugs disposal in secured landfills Category No. 6 Solid Waste Incineration / autoclaving / microwaving Category No. 7 Disinfection by chemical treatment / autoclaving / microwaving and mutilation / shredding Category No. 8 Liquid Waste Disinfection by chemical treatment and discharge into drains. Category No. 9 Incineration Ash Disposal in municipal landfill Category No. 10 Chemical Waste Chemical treatment and discharge into drains for liquids and secured land for solids Source: Bio-medical Waste Management Rules, 1998, Schedule I.

LEGISLATIONS ENVIRONMENTAL REGULATIONS FROM MoEF: Environment protection act,1986: Bio-medical waste management rules,1998(RENEWED 2011) Municipal solid waste rules,2000 Hazardous waste rules,1989 EIA Notification, July 2004

Bio-Medical Waste Rules 2011 Elaborate, stringent and several new provisions have been added Not applicable: Radioactive waste, Hazardous waste, Municipal solid waste Battery waste

Accident reporting must HCE- BMWM unit & meetings Mandatory treatment & disposal Adequate treatment facilities Promote new technologies Omitted- Incinerator & deep burial District level monitoring committee Allocation : Funds & Equipments Lacking: guidelines for linen & mattress, blood bags & pressurized containers

Schedules Schedule I : Categories of Biomedical waste Schedule II : Color coding Schedule III : Labels for Hazardous waste Schedule IV : Label for transport of BMW container/bags Schedule V : Standards for – incineration , autoclaving, sewerage, deep burial Schedule VI : Deadlines for implementation

SCHEDULE III LABEL FOR TRANSPORT OF BIO-MEDICAL WASTE CONTAINERS BAGS

SCHEDULE-IV LABEL FOR TRANSPORT OF BIO-MEDICAL WASTE CONTAINERS BAGS Day... ...Month ….……. Year…………Date of generation Waste category No ... Waste Class ……… Waste description …………………………………………………. Sender's Name & Address Receiver's Name & Address . In case of emergency please contact……….

Forms FORM-I : Application for authorization/ renewal of authorization FORM II : Annual report(To be submitted to the prescribed authority by 31 January every year FORM III :- Accident reporting FORM IV: Authorization granting format FORM V : Application for filing appeal against order passed by the prescribed authority FORM VI: Operator of CBMWTF filing against HCE- if no proper segregation

ANNEXURE-I

ANNEXURE-II GUIDELINES FOR DESIGN AND CONSTRUCTION OF BIO-MEDICAL WASTE INCINERATOR Air Pollution Control Device (APCD) Emission limit - 150 mg/Nm3 (corrected to 12% CO2) for Particulate Matter

BMW Rules 2011 vs. 1998 2011 1998 Every occupier irrespective of the quantum of wastes requires to obtain authorisation Occupiers with more than 1000 beds required authorisation Duties of the operator listed Operator duties absent Categories of BMW eight Ten categories Treatment and disposal of BMW mandatory for all the HCEs Restricted to HCEs with more than 1000 beds A format for annual report No format Form VI present Form VI absent

COLOUR CODING AND TYPE OF CONTAINER FOR DISPOSAL OF BIOMEDICAL WASTES WASTE CATEGORY TREATMENT OPTIONS Yellow Plastic Bag Cat.. 1, 2, 3 and 6 Incineration / deep burial Red Disinfected container / Plastic Bag Cat. 3, 6, and 7 Autoclaving / Microwaving / Chemical Treatment Blue / White Translucent Plastic Bag / puncture proof container Cat. 4, Cat. 7 Autoclaving / Microwaving / Chemical treatment and destruction shredding Black Cat. 5, 9 and 10 (Solid) Disposal in secured landfill Source: Bio-medical Waste Management Rules, 1998,

Colour Coding and Type of Container for Disposal of BMW Type of container to be used Waste Category Number Yellow Non Chlorinated plastic bags Category 1,2,5,6 Red Non Chlorinated plastic bags/puncture proof container for sharps Category 3,4,7 Blue Non Chlorinated plastic bags container Category 8 Black Municipal Waste

Number of CTF against HCEs in major states Health Care Establishments Common Treatment Facility Maharashtra 12,753 38 Gujarat 21,779 13 Karnataka 11,248 14 Delhi 1900 3 West Bengal 2747 6

PRINCIPLES OF MANAGING HEALTH CARE WASTE Waste minimization Safe reuse & recycling Managing sharps

Waste minimization Source reduction Management and control measures at hospital level Stock management of chemical and pharmaceutical products

SAFE REUSE & RECYCLING Sterilization methods for reusable items: Thermal sterilization • Dry sterilization - Exposure to 160 °C for 120 minutes or 170 °C for 60 minutes in a “Poupinel” oven. • Wet sterilization - Exposure to saturated steam at 121°C for 30 minutes in an autoclave. Chemical sterilization • Ethylene oxide - Exposure to an atmosphere saturated with ethylene oxide for 3–8 hours, at 50–60°C, in a reactor tank Glutaraldehyde - Exposure to a glutaraldehyde solution for 30 minutes

Managing sharps Auto disable syringes

Disposables syringes

Glass syringes

In 2000, WHO estimation-injections with contaminated syringes caused: 21 million hepatitis B virus (HBV) infections (32% of all new infections) two million hepatitis C virus (HCV) infections (40% of all new infections) 260 000 HIV infections (5% of all new infections). One needle stick injury risks: 30% -HBV 1.8% -HCV 0.3% -HIV. 

Handling of health care waste

Waste generation globally COUNTRIES TOTAL WASTE % OF INFECTED WASTE USA 7-10 10-15 Western Europe 3-6 India 0.5-2 30-60 Source: International healthcare workers network, Patil & Shekdar 2001

Quantity of waste generation in a 30 bedded CHC Waste type Quantity Percentage 1. Infectious waste Pathological & anatomical 1.5 6 Sharps including syringes 1 4 Non-sharp wastes 7.5 30 Total 10 40 2. General waste 15 60 25

Average composition of hospital waste in India Material Percentage(wet-weight basis) Paper 15 Plastics 10 Rags Metals 1 Infectious waste 1.5 Glass 4 General waste 53.5 SOURCE: National engineering research institute

Steps of waste management

Segregation

Collection

Storage

Transport

DEEP BURIAL PIT

Name of the disinfectant Available chlorine Required Chlorine Disinfectants commonly used for disinfection of materials contaminated with blood & body fluids Name of the disinfectant Available chlorine Required Chlorine Required contact period Amount of disinfectant to be dissolved in 1 L of H2O Sodium Hypochlorite 5% 0.5% 30 min 100 ml Calcium Hypochlorite 70% 7.0 gm NaOCl powder - 8.5 gm Na dichloro Isocyanate (Na DCC) tablets 60% 4 tabs Chloramine 25% 20 gm

Infection control Hand washing Personnel protective equipment Safe handling of waste Prevention of needle stick injuries Environmental cleaning & spillage management Proper training to health care workers Immunization of health care workers

Hospital waste management structure

BMW committee – MGIMS, Sevagram Occupier - Secretary, KHS Dean, MGIMS Medical superintend Officer in charge - HOD, Community Medicine HOD, Microbiology Faculty member, community medicine Faculty Member, Microbiology CAO KHS & KH Matron Engineering Section-In-charge & civil section Sanitary Inspector Infection control Nurse

At MGIMS

GOPD

BOILER & NEEDLE CUTTER - GOPD

AUTOCLAVE

DOUBLE DOOR AUTOCLAVE

SHREDDER

DOUBLE CHAMBERED DIESEL FIRE INCINERATOR

200 kg/day

BMWM – NATIONAL PROGRAMS NVBDCP RNTCP NACO-ICWM plan BIOMEDICAL WASTE AUDIT

References Pruss A, Giroult E and Rushbrook P. (1999) Safe Management of Wastes from Health Care Activities, World Health Organization, Geneva Kishore J and Ingle G.K. (2004) Biomedical Waste Management in India, Century Publications, New Delhi Srishti - Managing Hospital Waste, A Guide for Healthcare Facilities, September 2000 Agarwal, A.G. and Singh, R. (2005) Understanding and Simplifying Bio-Medical Waste Management, Toxics Link, New Delhi Mandal S. K & Dutta J , Integrated Bio-Medical Waste Management Plan for Patna City, Institute of Town Planners, India Journal 6-2:01-25 (2009) The Bio Medical Waste(Management & Handling) Rules, (1998)& (2011) WHO - Healthcare Waste Management – www.Healthcarewaste.org NRHM-Infection management & environment plan. Policy framework march 2007. Ministry of Health & Family Welfare , Government of India. http://www.cseindia.org -Biomedical waste rules made stringent . 2012.

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