HOSPITAL WASTE MANAGEMENT Dr Neha Agrawal Introduction The

HOSPITAL WASTE MANAGEMENT Dr. Neha Agrawal

Introduction � The waste produced in the course of healthcare activities carries a higher potential for infection and injury than any other types of waste. � Therefore, it is essential to have safe and reliable method for its handing. Inadequate and inappropriate handing of health –care waste may have serious public health consequences and a significant impact on the environment. � Appropriate management of health protection, and it should become an integral features of health -care services.

Definition � According to Bio-medical waste (Management and Handling) Rules, 1998 of India, “Biomedical waste” means 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 research

Between 75 to 90 per cent of the waste produced by the health –care providers is nonrisk or “general” health –care waste, comparable to domestic waste. It comes mostly from administrative and house keeping functions of the health-care establishment, and may also include waste generated during maintenance of health-care premises. The remaining 10 -25 per cent health-care waste is regarded hazardous and may create a variety of health risk.

Waste category Description and example Infectious waste Waste suspected to contain pathogens e. g. Laboratory cultures; waste from isolation wards; tissues (swabs) materials or equipment that have been in contact with infected patients; excreta Pathological waste Human tissues or fluids e. g. body part; blood and other body fluids; glass Sharp waste e. g. needles infusion sets; scalpels knives blades; broken glass Pharmaceutical waste Waste containing pharmaceuticals e. g. pharmaceuticals that are expired or no longer needed; items contaminated by or containing pharmaceuticals (bottles, boxes)

Genotoxic waste Waste containing substances with Genotoxic properties e. g. waste containing cytostatic drugs (often used in cancer therapy); genotoxic chemicals Chemical waste Waste containing chemical substances e. g. laboratory reagents; film develop; disinfectants that are expired or no longer needed solvents Waste with high content of heavy metals Batteries; broken gauges ; etc Pressurized containers Gas cylinder; gas cartridges thermometers; blood pressure Radioactive waste Waste containing radioactive substance e. g. unused liquids from radiotherapy or laboratory research; contaminated glass ware, packages or absorbent paper; urine and excreta from patients treated or tested with unsealed radionuclide sealed sources

Sources of health –care waste The institutions involved in generation of bio-medical waste are: � Government hospitals � Private hospitals � Nursing homes � Physician’s office/clinics � Dentist’s office /clinics � Dispensaries � Primary health centers � Medical research and training establishments � Mortuaries � Blood Banks and Collection Centre � Animals houses � Slaughter houses � Laboratories � Research organizations � Vaccination centre � Bio-technology institutions/ Productions Units All these health –care establishments generates waste and are therefore covered under Bio-Medical Waste (BMW) Rules.

Health –care waste generation � Waste generation depends on numerous factors such as � established waste management methods, � type of health –care establishment � hospital specialization, � proportion patients treated on a day-care basis. In middle and low income countries health – care waste generated is lower than in high income countries.

80 % general health –care waste, which may be dealt with by the normal domestic and urban waste management system. 15 % pathological and infectious waste 1 % sharps waste 3 %chemical and pharmacological waste Less than 1 % special waste, such as radio active or cytotoxin waste, pressurized containers, or broken thermometers and used batteries

A survey done in Bangalore revealed that the quantity of solid wastes generated in hospitals and nursing homes generally varies from ½ to 4 Kg per bed day in Govt, hospital, ½ to 1 kg per bed per day in nursing homes. The total quantity of hospital wastes generated in Bangalore is about 40 tones per day. Out of this nearly 45 to 50 % is infectious. Segregation of infectious wastes from non infectious wastes is done only in about 30 %of hospitals.

Health hazards of health –care waste �Exposure to hazardous health –care waste can result is disease of injury due to one or more of the following characteristics: �it contains infectious agents �it contains toxic or hazardous chemicals or pharmaceuticals �it contains sharps �it is Genotoxic �it is radioactive.

All individuals exposed to such hazardous health-care waste are potentially at risk, including those who generate the waste or those who either handle such waste or are exposed to it as a consequence of careless management. The main groups at risk are: Medical doctors, nurses, health –care auxiliaries, and hospital maintenance personnel. patients in health –care establishments: visitors to health –care establishments; workers in support service allied to health-care establishments such a laundries, waste handling and transportation; and workers in waste disposal facilities such as land fills of incinerators including scavengers.

Health hazards of health –care waste 1. Hazards from infectious waste and sharps 2. Hazards from chemical and pharmaceutical waste 3. Hazard from Genotoxic waste 4. Hazards from radioactive waste 5. Public sensitivity

Hazards from infectious waste and sharps � � � Pathogens in infectious waste may enter the human body through a puncture, abrasion or cut in the skin, through mucous membranes by inhalation or by ingestion. There is particular concern about infection with HIV and hepatitis virus B and C , for which there is a strong evidence of transmission via health –care waste. Bacteria resistant to antibiotics and chemical disinfectants, may also contribute to the hazards created by poorly managed waste.

Hazards from chemical and pharmaceutical waste � � � Many of the chemicals and pharmaceuticals used in health-care establishments are toxic, genotoxic, corrosive, flammable, reactive explosive or shock –sensitive. Although present in small quantity they may cause intoxication, either by acute or chronic exposure, and injuries including burns disinfectants are particularly important members of this group. They are used in large quantities and are often corrosive, reactive chemicals may form highly toxic secondary compounds.

Hazard from Genotoxic waste � � � The severity of the hazards for health-care worker responsible for handling or disposal of genotoxic waste is governed by a combination of the substance toxicity itself and the extent and duration of exposure, Exposure may also occur during the preparation of or treatment with particular drug or chemical. The main pathway of exposure is inhalation of dust or aerosols, absorption through the skin, ingestion of food accidentally contaminated with cytotoxic drugs, chemical or wastes etc,

Hazards from radioactive waste � � � The type of disease caused by radioactive waste is determined by the type and extent of exposure. It can range from headache, dizziness and vomiting to much more serious problems. Because it is genotoxic, it may also affect genetic material.

Public sensitivity � Apart from health hazards, the general public is very sensitive to visual impact of health-care waste particularly anatomical waste.

Treatment and disposal technologies for health-care waste

Incineration Chemical disinfection Wet and dry thermal treatment 1. Wet thermal treatment: 2. Screw-feed technology Micro wave irradiation Land disposal 1. Municipal disposal sites 2. Sanitary landfills Inertization

Incineration � Incineration is a high temperature dry oxidation process that reduces organic and combustible waste to inorganic incombustible matter and results in a very significant reduction of wastevolume and weight. The process is usually selected to treat wastes that cannot be recycled, reused or disposed off in a land fill site.

Incineration requires no pre treatment, Characteristics of the waste suitable for incineration are; a) Low heating volume-above 2000 Kcal/kg for single –chamber incinerators, and above 3500 Kcal/kg for pryolytic double –chamber incinerators: b) Content of combustible matter above 60% c) Content of noncombustible solids below 5 % d) Content of noncombustible fines below 20 % and e) Moisture content below 30 &

Waste types not be incinerated are �pressurized gas containers; �Large amount of reactive chemical wastes; �Silver salts and photographic or radiographic wastes: �Halogenated plastics such as PVC; �Waste with high mercury or cadmium content, such as broken thermometers, used batteries, and lead-lined wooden panels; and �Sealed ampoules or ampoules containing heavy metals

Types of incinerators � Three basic kinds of incineration technology are of interest for treating health-care waste. : � Double-chamber pyrolytic incinerators which may be especially designed to burn infectious health-care waste; � Single-chamber furnaces with static grate, which should be used only if pyrolytic incinerators are not affordable; � Rotary kilns operating at high temperatures, capable of causing decomposition of genotoxic substances and heat-resistant chemicals.

Exhaust gas to atmosphere ashes Flue gas cleaning Waste water ashes Flue gas air steam Heat recovery furnace waste ashes Waste water treatment Water discharge sludges

II. Chemical disinfection � Chemical are added to waste kill or inactivate the pathogens it contains, this treatment usually results in disinfection rather than sterilization. Chemical disinfection is most suitable for treating liquid waste such as blood, urine, stools or hospital sewage. However, solid wastes including microbiological cultures, sharps etc, may also be disinfected chemically with certain limitations.

III. Wet and dry thermal treatment � Wet thermal treatment: Wet thermal treatment or steam disinfection is based on exposure of shredded infectious waste to high temperature, high pressure steam, and is similar to the autoclave sterilization process. The process is inappropriate for the treatment of anatomical waste and animal carcassess, and will not efficiently treat chemical and pharmaceutical waste.

III. Wet and dry thermal treatment Screw-feed technology: � Screw –feed technology is the basis of a nonburn, dry thermal disinfection process in which waste is shredded and heated in a rotating auger. The waste is reduced by 80 % in volume and by 20 -35 % in weight. This process is suitable for treating infectious waste and sharps, but it should not be used to process pathological, cytotoxic or radioactive waste.

IV. Micro wave irradiation � Most microorganisms are destroyed by the action of microwave of a frequency of about 2450 MHZ and a wave length of 12. 24 cm. The water contained within the waste is rapidly heated by the microwaves and the infectious components are destroyed by heat conduction. The efficiency of the microwave disinfection should be checked routinely through bacteriological and virological tests.

V. Land disposal Municipal disposal sites: � There are two types of disposal land open dumps and sanitary landfills. Health-care waste should not be deposited on or around open dumps. The risk of either people or animals coming into contact with infectious pathogens is obvious.

V. Land disposal � Sanitary landfills are designed to have at least four advantages over pen dumps: � geological isolation of waste from the environment, � appropriate engineering preparation before the site is ready to accept waste, � staff present on site to control operations, � organized deposit and daily coverage of waste.

VI. Inertization � The process of “Inertization” involves mixing waste with cement and other substances before disposal, in order to minimize the risk of toxic substances contained in the wastes migrating into the surfaces water or ground water. � A typical proportion of the mixture is 65% pharmaceutical waste. 15 %lime, 15% cement and 5 % water. A homogeneous mass is formed an cubes or pellets are produced on site and then transported to suitable storage sites.

National legislation is the basis for improving health-care waste disposal practices in any country. It establishes legal control, and permits the national agency responsible for the disposal of health-care waste, Usually the ministry of Health, to apply pressure for their implementation. There should be a clear designation of responsibilities before the law is enacted.

The United Nations Conference on the Environment and Development (UNCED) in 1992 recommended the following measures: Prevent and minimize waste production Reuse or recycle the waste to the extent possible. Treat waste by safe and environmentally sound methods and Dispose off the final residue by landfill in confined and carefully designed sites.

Treatment disposal method Advantages Disadvantages Rotary kiln Adequate for all infectious waste, most chemical waste and pharmaceutical waste High investment and operating costs Pyrolytic Incineration Very high disinfection efficient. Adequate for all infectious waste and most pharmaceutical and chemical waste Significant emissions at of atmospheric pollutants need for periodic removal of slag and soot. Inefficiency in destroying thermally resistant chemicals and drugs such as cytotoxics Drum or brick incinerator Drastic reduction of weight and volume of the waste. Very low investment and operating costs Destroys only 99% of microorganisms no destruction of many chemicals and pharmaceuticals. Massive emission of black smoke, fly ash, toxic flue gas, an odours Chemical disinfection Highly efficient disinfection under good operating conditions Some chemical disinfectants are relatively Requires highly qualified technicians for operation of the process Uses hazardous substances that require comprehensive safety measures Inadequate for pharmaceutical, chemical and some types of infectious waste Wet Environmentally sound Relatively low investment and operating costs Shredders are subject to frequent breakdowns and poor functioning Operation requires qualified techniques. Inadequate for anatomical, pharmaceutical chemical waste and waste that is no readily steam permeable thermal treatment

Microwave irradiation Good disinfection efficiency under appropriate operating condition Drastic reduction in waste volume, Environmentally sound Encapsulat Simple low-cost and safe. ion May also be applied to pharmaceuticals Safe burying Relatively high investment and operating costs Potential operation and maintenance problems Not recommended for sharp infectious waste non- Low costs. Safe only if access to site is Relatively safe if access to limited and certain precautions site is restricted and where are taken natural infiltration is limited Inertization Relatively inexpensive Not applicable waste to infectious

Bio-Medical Waste Management in India � Bio-Medical Waste (Management and Handling) Rule 1998, prescribed by the Ministry of Environment and Forests, Government of India, came into force on 28 th July 1998. � This rule applies to those who generate, collect, receive, store, dispose, treat or handle bio-Medical Waste in any manner.

Option Waste category Treatment disposal and Category No-1 Human Anatomical Waste (human tissues organs, body parts) Incineration 2 burial /deep Category No 2 Animal Waste (animal tissues, organs, body parts carcasses, bleeding parts, fluids, blood and experimental animals used in research, Waste generated by veterinary hospitals colleges discharges from hospital animal house. / Incineration 2 / deep burial Category No-3 Microbiology and Biotechnology Waste (Waste from laboratory cultures, stocks or specimens of micro-organism. Live or attenuated vaccines, human and animals cell culture used in research and infectious agent from research and industrial laboratories waste from production of biological toxins dishes and devices and for transfer of cultures Local autoclaving / microwaving / incineration 2 Category No-4 Waste sharps (needle, syringes, scalpels, blades, glass etc that may cause puncture and cuts, this includes both used and unused sharps. Disinfection (chemical treatment/@ autoclaving /microwaving and mutilation/ shredding

Category No-5 Discarded medicines and Cytotoxic drugs (Waste comprising of outdated contaminated and discarded medicines) Incineration @ destruction and drugs disposal in secured landfills Category No-6 Solid waste (items contaminated with blood, and fluids including cotton dressings solid plaster casts, linen, bedding other material contaminated with blood) Incineration autoclaving microwaving Category No-7 Solid waste (waste generated from disposal items other then the waste sharps such as tubing’s catheters intravenous sets etc Disinfection by chemical treatment @ autoclaving /microwaving and mutilation/ shedding ## Category No-8 Liquid waste (waste generated from laboratory and was Disinfection by the chemical treatment @@ and discharge into drains Category No-9 Incineration ash (ash from incineration of any bio medical waste) Disposal in municipal landfill Category. No 10 Chemicals used in production of biological chemicals used disinfection a insecticides, etc. Chemical treatment @@ and discharge into drains for liquids and secured landfill for solids @

Color coding and type of container for disposal of bio-medical wastes The bio-medical waste should be segregated into containers/bags at the point of generation of the waste Colour coding Types of Waste category container Yellow Plastic bag Red Disinfected Cat. 3, Cat. 6, Cat. 7 container/ plastic bag Cat. 1, Cat. 2, and Incineration/ Cat. 3, Cat. 6 burial Blue/White Plastic bag/ Cat. 4, Cat. 7, transluc puncture ent Black Plastic bag Treatment options as per Schedule 1 deep Autoclaving/ microwaving / chemical treatment Autoclaving / microwaving / chemical treatment and Destruction / Shredding Cat. 5 and Cat. 9 and Disposal in secured Cat. 10 (solid landfill

References �Park K. Park’s Textbook of Preventive and social medicine. 17 th ed. , Jabbalpur, M/s Banarsidas Bhanot, 2002 �Park K. Park’s Textbook of Preventive and social medicine. 18 th ed. , Jabbalpur, M/s Banarsidas Bhanot, 2002 �B. K. Mahajan, M. C. Gupta. Textbook of preventive and social medicine. Jaypee Brothers Medical Publishers Pvt. Ltd. , New Delhi, 3 rd ed. , 2003

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