1. Bio-Medical Waste Management Satish Sinha

2. History of medical waste
Medical Waste Tracking Act in US
I Draft Rules in India–1995
Final Rules in 1998, 2 amendments and 5 guidelines
Evolution of Rules and Practices through National Experiences
National Guidelines on BMW, Guidelines on Incineration, CTFs, Immunization Waste and Mercury

3. Various networks NGOs Health Care Without Harm (HCWH)
Injection safety:
SIGN (Safe Injection Global Network)
Anti-incineration:
GAIA (Global Anti Incinerator Alliance)
Mercury
Zero Mercury
World Health Assembly
Patient safety

4. Stockholm Convention on Persistent Organic Pollutants
an international environmental treaty
aims to eliminate or restrict the production and use of persistent organic pollutants (POPs).
entered into force on 17 May 2004 with ratification by 128 and 168 signatories.

5. Basel Convention
Control of Tran boundary Movement of Hazardous Wastes and Their Disposal
Minimize hazardous waste generation and dispose it nearest to the point of generation

6. Environmental Regulations
Environment Protection Act, 1986
BMW Rules 1998
Municipal Waste (Management and Handling) Rules, 2000
Atomic Energy Act
Hazardous Wastes (Management & Handling) Rules, 1989
E-Waste Rules
Batteries (M&H) Rules 2001
Manufacture, Storage and Import of Hazardous Chemicals rules, 1989

7. Patient safety and Bio-medical waste management
In 2002 World Health assembly, passed a resolution calling member states to work for safety of Patients.
In Oct. 2004, World alliance for Patient safety was formed, who have identified certain challenges in relation to safety of patients. First Challenge is “Clean care is Safer Care” (2005)
A formal pledge committing to address health care-associated infection in the country was signed by Government of India.

8. Priority areas for Patient safety
Safe clinical practices and hand hygiene
Safe Surgical practices
Blood Safety
Safe Injections Practices
Health Care Waste Management
Rules and guidelines are available but implementation is very poor. Lack of training or poor training is also a factor. It has not been given the due priority by most of the states and dedicated budget is required. All states should focus on this.

9. Health care associated infections
Complicate between 5-10% of admissions in acute care hospitals in industrialized countries
It is estimated that this risk is up to 20 times higher in developing world
At any given time, 1.4 million people worldwide suffer from HAI, and at least 50% of HCAI are preventable.

10. Unsafe injections
India contributes to 25%-30% of the global injections (WHO, 1999)
Annual injection usage ~ 3 – 6 billion, of this nearly two-thirds (62.9%injections) unsafe India CLEN Study

11. Why Follow Universal Precautions
The prevalence rate of blood born disease- Hepatitis B 38/1000, HIV 7/1000 (NACO 1993)
Difficult to test each patient
NSI and other sharp injuries are the key Canadian health issue, affecting people per year and costing around dollar 140 million.
A safety programme at Toronto Hospital achieved 80% reduction in injuries within an year.

12. What is this concern for?
Infectious waste (solid and liquid)
Sharps waste
Cytotoxic waste
Pharmaceutical waste
Radioactive waste
Chemicals and disinfectants
Pressurised containers

13. BMW Rules and Key Actors
Notified in 1998
Concept of PPP model
Identified technologies and standards
CPCB
SPCB
Department of Health
Headline of presentation to come here (on slide master)

14. Know your waste

15. Waste Treatment & Disposal System
Category
Waste category
Treatment
Category 1
Human anatomical waste
Inc/burial
Category 2
Animal waste
Category 3
Microbiology & biotechnology waste
Inc/alternate
Category 4
Waste sharps
Disinfection & autoclaving/microwaving/shredding & mutilation
Category 5
Discarded medicines, cytotoxic drugs
Inc/landfill
Category 6 & 7
Solid waste
Autoclaving, microwaving & mutilation for category 7
Category 8
Liquid waste
Disinfection
Category 9
Incineration ash
Landfill
Category 10
Chemical waste
Drain/secured landfill after treatment
Sero conversion time for HIV- 6 months; for HBV- 2-6 months; for HCV-7 weeks
Cases of NSI & disease transmission – for my own knowledge

16. Treatment options as per Schedule I
Schedule II
Colour coding
Type of Container I
Waste Category
Treatment options as per Schedule I
Yellow
Plastic bag
Human, animal, microbiology, soiled waste
Incineration/deep burial
Red
Disinfected container/ plastic bag
Microbiology, solid & soiled waste
Autoclaving/Microwaving/Chemical Treatment
Blue/White translucent
Plastic bag/puncture proof container/Sharps Blaster
Waste sharps & solid waste
Autoclaving/Microwaving/Chemical Treatment & destruction/shredding
Black
Discarded medicine, cytotoxic drugs, incineration ash & Chemical waste
Disposal in secured landfill

17. Bio-medical waste and technology
Technology is only a fraction of the solution.
Major components of waste management are:
Segregation of waste
Waste minimisation
Reducing use of hazardous substances or processes
Waste Audit

18. Approved treatment methods
Autoclave
Chemical disinfection
Hydroclave
Microwave
Incineration
Any other technology after CPCB approval

19. In house management of waste
1.Survey 2.Meeting with the heads of all the departments 3.Forming a waste management committee 4.Rounds of wards to see the functioning 5.Creating a model ward 6.Suggest equipment procurement 7.Formal training for all the nursing staff 8.Implementing the system throughout the hospital

20. Right Technology
Medical waste management is 80% segregation and 20% technology
Incineration: Pathological Waste and Body Parts , no chlorinated plastics
Autoclaving: All except body parts and pathological waste
Microwaving: All except pathological waste and metals
Chemical: Mainly plastics

21. Of site management of waste-Centralized Facilities
Draft Guidelines on Common facilities-
Treatment facilities- 90% non-burn, 10% waste- burn
Limits incineration to Categories 1&2
Atleast 1 Km from residential areas. Acceptable in industrial area
One operator allowed to cater upto 10,000 beds, situated within 150 km radius
Segregation is the role of generator; operator can report mixing of waste to the prescribed authority

22. Medical waste in India: 2006-2009
2008
2009
HCF
Total Number of Healthcare facilities
73975
129511
Number of HCFs linked to CTFs / own facility
34001
116080
Number of facilities where waste is not being treated
39974
13431
Percentage of total facilities with no type of treatment mechanism
54%
10%
Waste
Bio-medical waste generated /day
kgs
413500#
414956#
Bio-medical waste treated /day
kgs
295270
291983
Bio-medical waste not treated /day-
kgs
113719
Percentage of Bio-medical waste untreated /day
55%
28%
Incinerator
Total incinerators in the country
436
547
Incinerators with APCDs
207
250
Incinerators without APCDs
229
297
Total Number of Violations
24,412
13037
HCF issued Show cause notices
14898

23. Hurdles in Implementation
Issues of Capacity
Low priority
Resource Allocation
Fixed Mindset
Injection safety, chemical safety and waste management issues yet to find space in development planning

24. At the SPCB level Capacity and resource Monitoring and control
Transparency of processes
Hierarchy of control
Independent audits
Awareness of community
Increasing outreach of centralized facility to rural areas

25. At the Hospital level Mindset issues Involvement of senior management
Resource availability and prioritising
Government Hospitals biggest defaulters
Capacity Building
Implementation bottlenecks
Responsibility fixing
Monitoring and Accreditation
Periodic Waste audits wrt economics

26. At the CTF level Untrained Staff Poor maintenance of equipment
Effluent Treatment Plants
Maintenance of records
No power back ups
Closed door, non transparent
Differential charges
Flawed systems
Profit driver
Need for accreditation

27. Way Forward Resource allocation for waste management
Maintaining a pool of trainers at block/ district levels
Stakeholders involvement
Incorporation into curricula of medical, nursing and paramedical colleges
Up gradation to latest developments in BMW management
Waste minimizations policy
Appropriate technology selection
Pro-environment procurement policy

28. Emerging Issues Mercury
First mercury documentation in healthcare in 2004: 3 kg/ hospital/year
Public notices by DPCC
Mercury phase-out committee formed by DHS
Delhi hospitals to phase out mercury
No new mercury equipment procurement in Delhi government hospitals
HCEs aiming for ISO/ NABH to phase out mercury

29. Emerging Issues Injection Safety Chemical Safety
Increased attention by hospitals
Fines on unattended needles
No to recapping
Reporting of needle stick injury and follow up
Chemical Safety
Monitored use of Glutaraldehyde, formaldehyde, benzene, cytotoxic drugs etc.

30. Thank You
Toxics Link H-2, Jungpura Ext. New Delhi ,