Bio medical waste management

bio medical waste management with recent changes

1. BIO-MEDICAL WASTE MANAGEMENT By Md Asif Alam JR 3, DEPT. OF MICROBIOLOGY J.N.M.C. , A.M.U

2. LEARNING OBJECTIVES Types of BMW Sources of health care waste Health care waste management plan Biomedical waste treatment techniques Maintenance of records DIFFERENCES between BIOMEDICAL WASTE MANAGEMENT RULES of 2016 and 1998

3. WASTE : “Something that is not put into proper usage at a given time”. What comprises Biomedical Waste? Bio-medical waste is defined as any solid, liquid or fluid waste including its container and any intermediate product which is generated during the diagnosis, treatment and immunization of humans and animals or while carrying out research activities . - Biomedical Waste (Management and Handling) Rules of India, 1998.

4. Where are we looking at? GLOBALLY - Developed countries generate 1 to 5 kg/bed/day Developing countries : meager data, but figures are lower, 1-2kg/bed/day INDIA : No national level study yet. -local or regional level study shows hospitals generate roughly 1-2 kg/bed/day

5. MAGNITUDE OF PROBLEM: Indian scenario Per capita waste generation increasing by 1.3% per annum With urban population increasing between 3 – 3.5% per annum Yearly increase in waste generation is around 5% annually India produces more than 42.0 million tons of municipal solid waste annually. Per capita generation of waste varies from 200 gm to 600 gm per capita / day. Average generation rate at 0.4 kg per capita per day in 0.1 million plus towns.

6. Types of waste Infectious waste:  waste contaminated with blood and other bodily fluids (e.g. from discarded diagnostic samples),cultures and stocks of infectious agents from laboratory work (e.g. waste from autopsies and infected animals from laboratories), or waste from patients with infections (e.g. swabs, bandages and disposable medical devices); Pathological waste:  human tissues, organs or fluids, body parts and contaminated animal carcasses; Sharps waste:  syringes, needles, disposable scalpels and blades, etc.; Chemical waste:  for example solvents and reagents used for laboratory preparations, disinfectants, sterilants and heavy metals contained in medical devices (e.g. mercury in broken thermometers) and batteries;

7. Pharmaceutical waste:  expired, unused and contaminated drugs and vaccines; Cyctotoxic waste:  waste containing substances with genotoxic properties (i.e. highly hazardous substances that are, mutagenic, teratogenic or carcinogenic), such as cytotoxic drugs used in cancer treatment and their metabolites; Radioactive waste:  such as products contaminated by radionuclides including radioactive diagnostic material or radiotherapeutic materials; and Non-hazardous or general waste:  waste that does not pose any particular biological, chemical, radioactive or physical hazard.

8. ENVIRONMENTAL HAZARD Inappropriate treatment and disposal of biomedical waste leads to environmental pollution. Uncontrolled incineration cause air pollution, Dumping in nallas , tanks and along the river beds causes water pollution, Unscientific land filling causes soil pollution.

9. GENERAL CLASSIFICATION OF HOSPITAL WASTE HOSPITAL WASTE NON-HAZARDOUS(80%) HAZARDOUS(20%) Bio degradable Non biodegradable INFECTIOUS(15%) TOXIC WASTE(5%) - Non-sharps -Radioactive waste -Sharps -Discarded glass waste -Plastic disposables -Cytotoxic waste -Liquids - Incineration waste

10. Biomedical waste management (BMWM )rules According to the Ministry of Environment and Forests ( MoEF ) gross generation of BMW in India is 4,05,702 kg/day of which only 2,91,983 kg/day is disposed, which means that almost 28% of the wastes is left untreated and not disposed finding its way in dumps or water bodies and re-enters our system.

11. Applicable to Whom ??? T o a l l p ers o ns w ho g e n e r a t e , c ol l e c t , r e c e i v e , s t o r e , t r ans p o r t , t r ea t , dispose or handle BMW in any form including: - Ayush hospitals - Clinical establishments Health camps Medical or surgical camps Vaccination camps Blood donation camps First aid rooms of schools Hospitals Nursing homes Clinics Research or Educational Institutions Dispensaries Veterinary institutions Animal houses Pathological laboratories, Blood banks Forensic laboratories and research labs

12. Salient Features of BMW Rules, 2016 12 Chapters; 4 Schedules & 5 Forms Schedules Schedule I – Bio-medical Wastes categories and their segregation, collection, treatment, processing and disposal Schedule II – Standards for treatment and disposal of bio-medical wastes Schedule III – List of Prescribed Authorities and Corresponding duties Schedule IV – Label for Bio-medical Waste Containers or Bags Forms Form I – Accident Reporting Form II – Application for Authorisation or Renewal of Authorisation Form III – Authorisation Form IV – Annual Report Form V – Application for filing appeal against order passed by the Prescribed Authority

13. DIFFERENCES between BIOMEDICAL WASTE MANAGEMENT RULES of 2016 and 1998

14. BMW CATEGORIES

15. APPLICATION

16. EPA – ENVIRONMENTAL PROTECTION ACT Infectious or potentially infectious biomedical waste is a contaminant and must be managed as a hazardous waste. The objective of guidelines are: To provide uniform standards for the segregation, management and disposal of infectious or potentially infectious biomedical waste. To reduce the incidence of health care worker and the public from contacting a disease or injury from biomedical waste. To waste minimization and the reduction of air contamination from incineration of biomedical waste.

17. INFECTIOUS WASTE MANAGEMENT PLAN 1. Designation of the waste that should be managed as infectious 2. Segregation of infectious waste from the noninfectious waste 3. Packaging 4. Storage 5. Treatment 6. Disposal 7. Contingency measures for emergency situations 8. Staff training

18. 1 . Segregation of wastes Key to successful Biomedical waste management. Done at point of Generation of waste and put in separate coloured bags. The responsibility lies mainly with the generator, i.e., doctors, nurses and the technicians. BMW should not be mixed with any other kind of waste. Mixing of waste will make entire waste potentially hazardous. If coloured bag is not available, then a clearly visible label of appropriate colour is acceptable

19. How to segregate waste .... in Non Chlorinated Bags W A S TE PLA S T I C NON PLA S T I C BMW S HA R P GENERAL PUNCTURE PROOF Infectious plastic waste Infectious non plastic waste Glassware and metal waste Sharp waste

20. CYTOTOXIC HAZARD SYMBOL Logos used for segregation of BMW

21. BMW Category BM W categories & Type of waste Treatment Options Treatment Options Yellow In b ags / c o ntainers Human anatomical; animal anatomical waste; soiled waste; Expired or discarded medicines; and Chemical waste Incineration Plasma Pyrolysis Expired cytotoxic drugs to be returned back to manufacturer Chemical Liquid waste Chemical liquid waste shall be pretreated and then conform to Schedule III Discarded linen, mattresses, beddings contaminated with blood or body fluid Non-chlorinated chemical disinfection followed by incineration or plasma pyrolysis or for energy recovery Microbiology, biotechnology and other clinical lab waste Pre-treat to sterilize with non-chlorinated chemicals on-site thereafter for incineration Red In bags Contaminated Waste (Recyclable) Autoclaving or microwaving/hydroclaving followed by shredding or mutilation or combination of sterilization and shredding Treated waste to be sent to recyclers f or energy recovery Plastic waste should not be sent to landfill

22. BM W categories & Treatment Options BMW Category Type of waste Treatment Options White In container / bags Waste sharps including metals Autoclaving Dry Heat Sterilisation followed by shredding or mutilation or encapsulation in metal container or cement concrete Combination of shredding cum autoclaving and sent for final disposal to iron foundaries or sanitary landfill Blue B o x es Glassware and Metallic body implants Disinfection - b y soak i n g the washed glass watse after cl e aning with d ete r g ent and Sodium Hy p oc h lorite t r e a tm e n t/ A u tocl a v ing / m i c r o w a v ing / h y d r ocl a v ing and then sent f o r r ecycling

23. CHEMICAL/LIQUID WASTE liquid waste: To be treated with 1 to 2 % Hypochlorite or to have an ETP. Floor washing etc should be pre-treated onsite using 1 - 2% Sodium Hypochlorite or connected to ETP

24. Handling of Wastes Disposable items like gloves, syringes, IV bottles, catheters etc. have to be shredded, cut or mutilated. For instance, the fingers of the gloves should be cut, IV bottles can be punctured and the same can be done for other disposable items. Extreme care has to be taken while handling the SHARPS (needles and syringes) & blood bags with proper protection.

25. SHARPS All the health workers employed in/outside the hospital must be vaccinated against Hepatitis B, tetanus and typhoid.

26. Policy for Handling Sharps User responsible for disposal of sharps Must dispose of sharps after each test Must place sharps in sharps boxes Do not drop sharps on the floor or in the office waste bin Place sharps container near your workspace Seal and remove when box is ¾ full Incinerate all waste

27. Sharp container All sharp containers should have: A lid Puncture-proof or thick walls A large enough hole for lancets and needles Leakproof sides and bottom A label or color code indicating bio-hazard material Sufficient quantity available at each testing site Not all sharps containers need be purchased commercially. An empty bleach container will sufficient. This type container meets all previously mentioned specification.

28. WASTE

29. Sharps Containers Must Be: Placed near workspace Closed when not in use Sealed when ¾ full

30. Do NOT recap Do NOT bend Do NOT remove Do NOT transport Do NOT re-use

31. NEEDLE CUTTER MANUAL NEEDLE DESTROYING MACHINE

32. Shredder Used for shredding needles,syringes.i.v.bottles,etc. to prevent its reuse.

33. 3. Collection of waste: - Sanitation staff should collect waste under the supervision of nursing staff and sanitation supervisor; - Documentation

34. -Polythene bags to be changed with each shift or when they are 3/4 th full and they have to be sealed whenever the waste is being transported within or outside the hospital. - Bins with lids.

35. 4. Storage of Waste: Not to be stored for longer than 4-6 hours. Presence of an impermeable, hard-standing floor with good drainage which should be easy to clean and disinfect. Good lightning and at least passive ventilation. Availability of water supply for cleaning purposes. Easy access for staff and collection services. Inaccessible for animals, insects, and birds. Away from fresh food stores or food preparation areas.

36. 5. Transportation The bio-medical waste collected in designated coloured containers shall be transported to the CBWTF in a fully covered vehicle. Such vehicle shall be dedicated for transportation of bio-medical waste only.

37. What we see --

38. 6. Treatment & Disposal: General waste should be dumped at municipal dumping site . Sanitation officer should be responsible for proper coordination between municipal and hospital. OUT HOUSE MANAGEMENT Role of Common Facilitator: *To collect Bio Medical Waste from Individual Hospital every day.

39. Treatment & Disposal Technologies Chemical Disinfection Wet and dry thermal treatment Microwave irradiation Incineration Land disposal Inertization Newer methods

40. i ) Chemical disinfection Chemicals are added to waste to kill or inactivate the pathogen it contains. Disinfection prior to disposal is required for the following categories of waste-: Sharp waste Disposable infectious plastics Infectious glassware Blood and body fluids

41. HYPOCHLORITE — Most economical and effective disinfectant. Sodium Hypochlorite available as 4% solution Floor washing etc should be pre-treated onsite using 1 - 2% Sodium Hypochlorite Available as Sodium hypochlorite sol. and calcium hypochlorite sol. Should be allowed to act for 30 mins. Changed frequently: atleast once a day. There will be no chemical pre-treatment before incineration. PVC shall not be incinerated.

42. ii) Wet and Dry thermal treatment

43. STANDARDS FOR AUTOCLAVING OF BIO- MEDICAL WASTE (Pre- treatment..at source) Chemical indicator strip …. is to be used with each batch of waste and note change in color as an indication of temperature and pressure achieved. Frequency : To use more than one strip with every batch and bag,record the same. Spore testing at least once in every week PROCEDURE : The autoclave should be dedicated for the purposes of disinfecting and treating bio-medical waste. When operating a gravity flow autoclave, medical waste shall be subjected to: A temperature of not less than 121° C and pressure of 15 pounds per square inch (psi) for an autoclave residence time of at least 20 minutes.

44. Screw feed technology: It is a Dry thermal treatment in which waste is shredded and heated in rotating auger. There is a decrease in 80% by volume and 20-35% by weight. Hydroclaving Newer method Indirect heating without any direct contact with the waste. Steam is introduced into the outer jacket while the waste is kept inside another chamber .

45. Turned mechanically with the help of a series of large rotating rods which spin continuously, rupturing the waste bags & ensuring complete exposure to heat. Moisture content in the waste turns to steam & builds pressure inside the vessel which sterilizes the waste: 80-85% reduction in volume & 65-70% reduction in weight. Waste is shredded followed by recycling or disposed by secured land filling .

46. iii)Microwave irradiation Treatment of most infectious wastes except body parts and large metal cytotoxic wastes. Microwaves of frequency 2450MHz and wave length 12.24nm is used to destroy the microorganisms. Water contained in the waste is rapidly heated by microwave and infectious components are destroyed by heat conduction. Hazardous wastes cannot be treated by microwaving.

47. Microwaving

48. Innovation in microwaving techniques: Sanitec Microwave Waste is processed at relatively low (95-100°C) temperatures. There are no chemicals used in any part of the process, and there are no liquid discharges of any kind. Ecosteryl ( two stage microwave decontamination) Waste is first reduced in a shredder into particles smaller than 20mm. These are brought to temperatures close to 100°C for one hour so as to destroy all micro-organisms. The end result is an unrecognisable decontaminated pulp which can join the household waste chain.

49. iv) Incineration: It is a High temperature dry oxidation process that reduces organic and combustible waste into inorganic and incombustible matter , resulting in significant reduction in waste volume and weight. waste that *cannot be recycled , reused or can be disposed in land. * have a low heating value, and containing - combustible matter above 60%. non-combustible solids below 5%. non-combustible fines below 20%. moisture content below 30%.

50. At JNMC

51. Types of Incinerators Double chambered (for infectious waste) Temp. of primary combustion chamber (PCC) – 750-850 deg C Temp. of secondary chamber (SCC) - 1000-1100 deg C Single chambered (if double chambered incinerator is not affordable) Rotatory Kilns 1200- 1600 deg (for genotoxic waste)

52. Double Chambered/ Pyrolytic Incinerator

53. WASTES NOT TO BE INCINERATED Pressurized gas containers. Reactive chemical wastes. Silver salts and photographic and radiographic wastes. Halogenated plastics such as polyvinyl chloride (PVC). Waste with high mercury or cadmium content, such as broken thermometers, used batteries, and lead-lined wooden panels. Sealed ampoules or ampoules containing heavy metals. Red bags must not be incinerated as red colour contains cadmium which causes toxic emissions.

54. Advantages Good disinfection efficiency. Drastic reduction of waste volume and weight. No requirement for highly qualified operators. Relatively low investment and operation costs. Disadvantages Generation of significant emissions containing atmospheric pollutants , including gases and ash; May produce odours (which can be limited by not incinerating halogenated plastics). Periodic removal of slag and soot necessary.

55. Incinerator Ash Disposal

56. v)Land Disposal: - Open Dumps : risk for public health - Sanitary landfills : designed and constructed to prevent contamination of soil,surface,ground water and direct contact with public.

57. Sanitary Landfills They have atleast four advantages over open dumps Geological isolation of waste from the environment. Appropriate engineering preparations before the site is ready to accept wastes. Staff present on site to control operations. Organized deposit and daily coverage of waste.

58. Deep burial site should be relatively impermeable and distant from habitats. There should be no well, lake, river etc. close to the site to avoid contamination of surface water or ground water. DEEP BURIAL PIT for BMW

59. Encapsulation It is a method involving filling container with waste, adding immobilizing material and sealing the containers, to prevent the access to unscrupulous activities. The process uses cubic boxes made up of metallic drum which are three quarters filled with sharps or chemicals or pharmaceutical waste and then filled with a medium such as plastic foam, cement mortar or clay materials

60. vi) Inertization Process of mixing waste with cement and other substances before disposal in order to minimize the risk of toxic substance migrating into surface water or ground water and to prevent scavenging. The proportion of the materials used in inertization are as follows 65% pharmaceutical waste 15% lime 15% cement 5% water

61. vii) Newer methods Plasma pyrolysis Utilises rapid heating – 5000 deg Celsius that can be achieved in milliseconds. It consumes small quantity of gas. generation of heat is independent of chemistry of material used. The high ultraviolet radiation flux destroys pathogens and waste to be treated. Advantage : No segregation of waste is needed.

62. Sharps Blaster Sharps Blaster consists of a computerised sterilisation unit and disposable, four litre metal canisters for sharps or clinical waste. The unit treats the waste canister for up to two and a half hours at temperatures reaching 185°C, sterilising the infectious waste and sealing the canister for safe disposal. Bio-Oxidizer Model #100 The principle of operation is the electro-pyrolysis of organics followed by two phases of electro-oxidation. The Bio-Oxidizer® system electrically heats the organic solids and liquids, turning them into vapor, and then oxidizes the vapors in two oxidizers. The remaining residue, which is typically less than 5% of the original weight and volume, is sterile, inert, and may be discarded as municipal waste in most instances or possibly recycled .

63. Ecolotec The patented Ecolotec system consists basically of a jacketed pressure/vacuum vessel into which infectious waste is loaded. The vessel is fitted with internal knife hammers which rotate at up to 3500 revolutions per minute to break up and shred the waste while live steam is being injected to raise the temperature to about 132°C. The violent knife action brings every waste particle in immediate contact with the steam atmosphere and eliminates cold spots, while drastically shortening the time needed for reliable sterilization .

64. Suggested validation test for treatment of bio-medical waste

65. Handle waste as per norms Arrange safe storage of waste Follow onsite pre-treatment of infective waste Replace chlorinated plastic bags,gloves and bood bags with non chlorinated Dispose of solid waste separate from bio medical waste other than bio-medical waste in accordance. DUTIES OF OCCUPIER- Healthcare facility

66. DUTIES OF OCCUPIER- Healthcare facility Handle waste as per norms Arrange safe storage of waste Follow onsite pre-treatment of infective waste Replace chlorinated plastic bags,gloves and bood bags with non chlorinated Dispose of solid waste separate from bio medical waste other than bio-medical waste in accordance.

67. Provide training to all its health care workers at the time of induction and thereafter at least once every year and the details of training programmes conducted, number of personneltrained and number of personnel not undergone any training shall be provided in the Annual Report Immunise all its health care workers against Hepatitis B and Tetanus as per protocol Establish a Bar- Code System for bags or containers containing bio-medical waste Ensure segregation of liquid chemical waste at source and ensure pre- treatment or neutralisation

68. Provide PPE to healthcare workers Report major accidents Make available the annual report on its web-site Inform the prescribed authority immediately if waste is not picked or retained for more than 48 hrs Establish a committee to review and meet once in every six months and the record of the minutes of the meetings of this committee and incorporate in annual report Maintain all records for a period of 05 yrs Conduct health check up at the time of induction and at least once in a year for all its health care workers Maintain daily register and upload monthly records on website

69. Occup ier Han d le/Seg regation storage/disposal Pre-treatment Non ch lorin at ed bags Health check Immunisation T r ai n ing R egi s t er Monthly r e p o rt / An nu al report Committee

70. Thank you