Biomedical waste disposal

BIOMEDICAL WASTE DISPOSAL

1. BIOMEDICAL WASTE DISPOSAL DR.S.ASWINI III YEAR POSTGRADUATE STUDENT PUBLIC HEALTH DENTISTRY 03/07/2020

2. Contents Introduction Definition History of biomedical waste management Need for biomedical waste management Sources of biomedical waste Problems related to biomedical waste(hazards) Components of health care waste management Generation Segregation Collection Storage Transportation Treatment of waste Various methods for biomedical waste treatment Biomedical Waste Management Outside India Biomedical waste management in Dentistry Guidelines for handling, treatment, and disposal of waste generated during treatment/diagnosis/ quarantine of Covid-19 patients Challenging issues in BMWM implementation Conclusion References

3. Let the waste of the “sick” not contaminate the lives of “The healthy”.

4. INTRODUCTION Medical care is vital for our life and health, but the waste generated from medical activities represents a real problem. Every day, relatively large amount of potentially hazardous waste are generated in the health care hospitals and facilities around the world.

5. INTRODUCTION.. Poor medical waste management causes environmental pollution, unpleasant smell, growth and multiplication of insects, rodents, and worms, and may lead to transmission of diseases like typhoid, cholera, HIV, and hepatitis through injuries from sharps contaminated with blood. Recently, BMWM emerged as a issue – due to the increased need and use of PPEs. The problem can be simplified and reduced if a proper management system is planned and executed.

6. DEFINITION Any waste, which is generated during the diagnosis, treatment or immunisation of human beings or animals, or in research activities pertaining thereto, or in the production or testing of biologicals or in health camps - Bio Medical Waste (Management and Handling) Rules “Biologicals” means any preparation made from organisms or micro organisms or product of metabolism and biomedical reactions intended for use in the diagnosis, treatment or immunisation

7. HISTORY OF BIOMEDICAL WASTE MANAGEMENT Harappa and Mohen -jo- ddaro – town planning skills- “Cleanliness is next to godliness” Concept of “hospices”-problems of handling and disposal of waste. They were left mostly to sweepers , staffs and supervised by some sanitary inspector.

8.  The famous British reformer, Edwin Chadwick, researched the incredibly foul conditions that could be due to waste found inside Britain’s prisons and hospitals.

9. Colonel George E. Waring, who served as an officer in the Union army during the Civil War. Waring founded the career field of sanitary engineering. American engineer and reformer

10.  Lister made the connection between modern ideas of germ theory with the concept of sanitation for medical purposes. In the 1870s, Lister discovered that inadequate sanitation and medical waste disposal practices were to blame for the rampant spread of diseases in hospitals.

11. HISTORY OF BIOMEDICAL WASTE MANAGEMENT Mid 1980s-HIV/AIDS epidemic – all hospital waste was treated as suspect, disease transmission. 1980s-In US –hospital waste floating along east coast beaches and children playing with used syringes. This led to the enactment of Biomedical Waste-Tracking Act of Nov 1988-US Environment Protection Agency.

12. HISTORY OF BIOMEDICAL WASTE MANAGEMENT However in India the seriousness about the management came into lime light only after 1990’s. The Ministry of Environment and Forest, Government of India issued a notification under the Environment protection Act in July1996 and Biomedical waste rules in 20th July 1998 . These rules apply to all persons who generate, collect, receive, store, transport, treat, dispose, or handle bio medical waste.

13. WHO- “Blue Book” 1999 & 2014

14. WHO has estimated that In 2000 -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)

15. WHO ARE AT MOST RISK? The Doctors, Nurses, technicians, laundry workers, sweepers, hospital visitors, patients, rag pickers and their relatives are exposed routinely to Bio-Medical Waste and are at more risk from the many fatal infections due to indiscriminate management

16. NEED FOR BIOMEDICAL WASTE MANAGEMENT 1. Injuries from sharps leading to infection in all categories of hospital personnel and waste handlers. 2. Nosocomial infections in patients due to poor infection control practices and poor waste management . 3. Risk of infection outside the hospital for waste handlers and scavengers and at times, for the general public living in the vicinity of hospitals. 4. Risks associated with hazardous chemicals and drugs to the persons handling wastes at all levels.

17. NEED FOR BIOMEDICAL WASTE MANAGEMENT 5. “Disposable” being repacked and sold illegally without even being washed. 6. Drugs that have been disposed of, being repacked, and sold off to unsuspecting buyers. 7. The risk of air, water, and soil pollution directly due to waste, or due to defective incineration emissions and ash .

18. SOURCES OF BIO-MEDICAL WASTE Hospitals University hospital General hospital District hospital Other health-care facilities Emergency medical care services Health-care centres and dispensaries Obstetric and maternity clinics Outpatient clinics Dialysis centres Long-term health-care establishments and hospices Transfusion centres Military medical services Prison hospitals or clinics Mortuary and autopsy centres Animal research and testing Blood banks and blood collection services Nursing homes for the elderly Related laboratories and research centres Medical and biomedical laboratories Biotechnology laboratories and institutions Medical research centres MAJOR SOURCES

19. SOURCES OF BIO-MEDICAL WASTE MINOR SOURCES Small health-care establishments First-aid posts and sick bays Physicians’ offices Dental clinics Acupuncturists Chiropractors Specialized health-care establishments and institutions with low waste generation Convalescent nursing homes Psychiatric hospitals Disabled persons’ institutions Activities involving intravenous or subcutaneous interventions Cosmetic ear-piercing and tattoo parlours Illicit drug users and needle exchanges Funeral services Ambulance services Home treatment

20. HEALTHCARE WASTE GENERATION QUANTITY/DAY/BED SOURCE ½ - 4kg Govt Hospitals ½ - 2kg Private Hospitals ½ - 1kg Nursing homes Park K. Hospital Waste Management. Park’s Textbook of Preventive and Social Medicine. 22nd edition, Jabalpur, India: M/s Banarasidas Bhanot Publishers; 2009: 795-9.

21. For example, Bangalore-40 tonnes per day 40-50% is infectious Segregation-Only 30% hospitals Park K. Hospital Waste Management. Park’s Textbook of Preventive and Social Medicine. 22nd edition, Jabalpur, India: M/s Banarasidas Bhanot Publishers; 2009: 795-9.

22. According to WHO, the Biomedical wastes are divided into

23. WHO Classification Waste Categories Description and Examples Infectious Waste Suspected to contain pathogens Lab cultures, waste from isolation wards, swabs, excreta.

24. WHO Classification.. Waste Categories Description and Examples Pathological Waste Human Tissue or fluids eg : body parts , blood , body fluids etc. Sharps eg :Needle, infusion sets, scaples , knives, blades etc.

25. WHO Classification.. Waste Categories Description and Examples Pharmaceutical waste Expired or no longer needed, contaminated. Genotoxic waste Drugs used in cancer therapy

26. WHO Classification… Waste Categories Description and Examples Chemical waste Lab reagents, film developer, expired disinfectants Wastes with high content of heavy metals Batteries, broken thermometer, BP Apparatus

27. WHO Classification.. Waste Categories Description and Examples Pressurized containers Gas cylinders, gas catridges , aerosol cans. Radioactive waste Unused liquids from radiotherapy, lab research

28. Non-hazardous or general waste:  waste that does not pose any particular biological, chemical, radioactive or physical hazard. Corrugated cardboard boxes, Newspapers and magazines plastic water bottles, soft-drink bottles Polystyrene packaging Wood (e.g. shipping pallets) Paper (e.g. white office paper, computer printer paper, coloured ledger paper) Metals (e.g. aluminium beverage cans and containers, food tin cans, other metal containers) e.g. plastic milk containers, containers for food, plastic bottles for saline solutions or sterile irrigation fluids Construction and demolition debris

29. HEALTH HAZARDS OF HEALTH CARE WASTE

30. Hazards from infectious waste and sharps Through a puncture, abrasion, or cut in the skin; Through the mucous membranes; By inhalation; By ingestion

31. CHAIN OF INFECTION

32. Hazards from infectious waste and sharps

33. Hazards from chemical and pharmaceutical waste Injuries to the skin, the eyes, or the mucous membranes of the airways can be caused by contact with flammable, corrosive, or reactive chemicals (e.g. formaldehyde and other volatile substances). The most common injuries are burns.

34. Hazards from chemical and pharmaceutical waste… Chemical residues discharged into the sewage system may have adverse effects on the operation of biological sewage treatment plants or toxic effects on the natural ecosystems receiving waters. Similar problems may be caused by pharmaceutical residues, which may include antibiotics and other drugs, heavy metals such as mercury, phenols, and derivatives, and disinfectants and antiseptics.

35. Hazards from genotoxic waste Experimental studies have shown that many antineoplastic drugs are carcinogenic and mutagenic; secondary neoplasia (occurring after the original cancer has been eradicated) is known to be associated with some forms of chemotherapy.

36. Hazards from genotoxic waste… Inhalation of dust or aerosols, absorption through the skin, ingestion of food accidentally contaminated with cytotoxic drugs, chemicals, or waste, and ingestion as a result of mouth pipetting. Exposure may also occur through contact with the bodily fluids and secretions of patients undergoing chemotherapy.

37. Hazards from radioactive waste Headache, dizziness, and vomiting to much more serious problems.

38. Public Sensitivity The general public is very sensitive about the visual impact of anatomical waste. In some cultures, especially in Asia, religious beliefs require that human body parts be returned to a patient’s family, in tiny “coffins,” to be buried in cemeteries.

39. BIOMEDICAL RULES 1998 The Government of India as contemplated under Section 6,8 and 25 of the Environment (Protection) Act,1986, has made the Biomedical Wastes (Management & Handling) Rules, 1998. The rules are applicable to every institution generating biomedical waste which includes hospitals, nursing homes, clinic, dispensary, veterinary institutions, animal houses, laboratory, blood bank. The rules are applicable to all persons who generate, collect, receive, store, transport, treat, dispose, or handle bio medical.

40. BIOMEDICAL RULES 2016 Schedule Purpose SCHEDULE I Biomedical wastes categories and their segregation, collection, treatment, processing and Disposal options SCHEDULE II Standards for treatment and disposal of Bio-medical wastes SCHEDULE III List of prescribed authorities and the corresponding duties SCHEDULE IV Label for bio-medical waste containers or bags Label for transporting bio-medical waste bags or containers

41. Biomedical wastes categories and their segregation, collection, treatment, processing and Disposal options

42. Components of Bio Medical Waste Management

43. 1.GENERATION Type Site of Generation Disposal By Non-Hazardous waste/General waste Office , Kitchen, Hostels, Stores, etc Municipal /Public Authority Hazardous (Infectious & toxic waste) Wards , Treatment room, Dressing room, OT, ICU, Labour room , Laboratory , Dialysis room, CT scan, Radio-imaging etc Hospital itself to BMWM Team.

44. SEGREGATION

45. ANATOMICAL WASTE (a) Human Anatomical Waste: Human tissues, organs, body parts and fetus below the viability period. (b)Animal Anatomical Waste : Experimental animal carcasses, body parts, organs, tissues, including the waste generated from animals used in experiments or testing in veterinary hospitals or colleges or animal houses Yellow coloured non-chlorinated plastic bags Incineration or Plasma Pyrolysis or deep burial

46. (c) Soiled Waste: Items contaminated with blood, body fluids like dressings, plaster casts, cotton swabs and bags containing residual or discarded blood and blood components Incineration or Plasma Pyrolysis or deep burial In absence of above facilities, autoclaving followed by shredding.

47. (d) Expired or Discarded Medicines: Pharmaceutical waste like antibiotics, cytotoxic drugs including all items contaminated with cytotoxic drugs along with glass or plastic ampoules, vials etc. Expired cytotoxic drugs and items contaminated with cytotoxic drugs to be returned back to the manufacturer or supplier for incineration at temperature >12000C or to common bio-medical waste treatment facility or hazardous waste treatment, storage and disposal facility for incineration at >12000C Or Encapsulation or Plasma Pyrolysis at >12000C. All other discarded medicines shall be either sent back to manufacturer or disposed by incineration.

48. (e) Chemical Waste: Chemicals used in production of biological and used or discarded disinfectants. Yellow coloured containers or non-chlorinated plastic bags Disposed of by incineration or Plasma Pyrolysis or Encapsulation in hazardous waste treatment, storage and disposal facility.

49. 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. After resource recovery, the chemical liquid waste shall be pre-treated before mixing with other wastewater.

50. (g) Discarded linen, mattresses, beddings contaminated with blood or body fluid. Non-chlorinated yellow plastic bags or suitable packing material Non- chlorinated chemical disinfection followed by incineration or Plazma Pyrolysis. In absence of above facilities, shredding or mutilation or combination of sterilization and shredding. Treated waste to be sent for incineration or Plazma Pyrolysis.

51. (h) Microbiology, Biotechnology and other clinical laboratory waste: Blood bags, Laboratory cultures, stocks or specimens of microrganisms , live or attenuated vaccines, human and animal cell cultures used in research, industrial laboratories, production of biological, residual toxins, dishes and devices used for cultures. Autoclave safe plastic bags or containers Incerination , plasma pyrolosis .

52. Contaminated Waste (Recyclable) (a) Wastes generated from disposable items such as tubing, bottles, intravenous tubes and sets, catheters, urine bags, syringes (without needles and fixed needle syringes ) and vaccutainers with their needles cut) and gloves. Red coloured non-chlorinated plastic bags or containers Autoclaving followed by shredding or combination of sterilization and shredding. Treated waste to be sent to registered or authorized recyclers or for energy recovery or plastics to diesel or fuel oil or for road making, whichever is possible. Plastic waste should not be sent to landfill sites.

53. Waste sharps including Metals: Needles, syringes with fixed needles, needles from needle tip cutter or burner, scalpels, blades, or any other contaminated sharp object that may cause puncture and cuts. Puncture proof, Leak proof, tamper proof containers Autoclaving or Dry Heat Sterilization followed by shredding or encapsulation in metal container or cement concrete; combination of shredding cum autoclaving; and sent for final disposal to iron foundries (having consent to operate from the State Pollution Control Boards or Pollution Control Committees) or sanitary landfill or designated concrete waste sharp pit.

54. (a) Glassware: Broken or discarded and contaminated glass including medicine vials and ampoules except those contaminated with cytotoxic wastes. Cardboard boxes with blue colored marking Disinfection (by soaking the washed glass waste after cleaning with detergent and Sodium Hypochlorite treatment) or through autoclaving or microwaving or hydroclaving and then sent for recycling. b)Metallic Body Implants

55. 3.COLLECTION OF WASTE: Waste bags should be tightly closed or sealed when they are about 3 quarters full. Light gauge bags can be closed by tying the neck but heavier gauge bags probably require a plastic sealing tag. Waste should not be allowed to accumulate at the point of production.

56. Waste should be collected daily and transported to the storage sites. No bags should be removed unless they are labelled . The bag should be replaced immediately with new ones of the same type.

57. 4. STORAGE OF WASTE: “ The holding of Bio-Medical Waste for some period of time, at the end of which waste is treated and disposed of”. No Untreated BMW should be kept or stored >48hrs. Waste should be stored in a separate area , room or building of a size appropriate to the quantity of waste produced and frequency of collection. Storage area should have a impermeable hard standing floor with good drainage.

58. Easy access for waste collection vehicles is essential. There should be protection from the sun . It should be inaccessible for animals, insects and birds . It should have good lightning and ventilation . It should not be located close to food source.

59. 5. TRANSPORTATION: “Movement of Bio-Medical Waste from the point of generation or collection to the final disposal”. Avoid passage of waste through patient care Separate time must be marked Dedicated wheeled containers, trolley or cart used Trolley or cart thoroughly cleaned and disinfected Allow waste to be loaded secured and unloaded easily Should not have any seepage from damaged containers

60. 6. TREATMENT & DISPOSAL: 1.Incineration 2.Chemical Disinfection 3.Wet and dry thermal treatment 4.Microwave irradiation 5.Encapsulation 6.Land disposal/ Safe burying 7.Inertization

61. Incineration The term, ‘incinerate’ means, to burn something until nothing is left but sterile ash. In an incinerator, the high levels of heat are kept inside the furnace or unit so that the waste is burnt quickly and efficiently. ‘Flue gases’ are generated from this waste burning process. Ash after incineration is deep buried Process is usually used to treat waste that cannot be recycled , reused or disposed off in a landfill site.

62. INCINERATORS-TYPES Double chamber pyrolytic incinerators (for infectious waste) Single chamber (if double chamber not affordable) Rotatory Kilns (for genotoxic waste)

63. Double chamber pyrolytic incinerators (for infectious waste) In a double chamber incinerator, these flue gases are also incinerated in the second chamber before being sent to the air pollution control device (900 &1200 C) Excess of air is used to minimize smoke and odors. The flue gases are cleaned of pollutants before they are dispersed in the atmosphere.

64. Suitable for : sharps and pathological waste. Pharmaceutical and chemical residues. Inadequate for: Genotoxic waste Radioactive waste Drawbacks: Relatively expensive equipment Expensive to operate and maintain. Well trained personnel are required

65. Single chamber incinerator Used for health care waste if pyrolytic chamber cannot be affordable Treats waste in batches. Loading and de- ashing done manually. The combustion is initiated by addition of fuel and should then continue unaided. A drum or field incinerator – simplest form Used as last resort - becoz its difficult to burn the waste completely without generating potentially harmful smoke. Chemical and pharmaceutical residues will persist sometimes.

66. Rotary Kiln A rotary kiln, which comprises a rotating oven and a post-combustion chamber The axis of a rotary kiln is inclined at a slight angle to the vertical (3–5% slope). The kiln rotates 2 to 5 times per minute and is charged with waste at the top. The gases produced in the kiln are heated to high temperatures to burn off gaseous organic compounds in the post-combustion chamber and typically have a residence time of 2 seconds. Adequate for the following waste categories: • Infectious waste (including sharps) and pathological waste. • All chemical and pharmaceutical wastes, including cytotoxic waste.

67. 2. CHEMICAL DISINFECTION: Commonly used for treatment of liquid infectious waste eg. Blood , urine , stool and hospital sewage Chemicals are added to waste to kill the pathogen it contains. Recently, commercial, self‑contained and fully automatic systems have been introduced which are more reliable than the manual methods.

68. 3. WET AND DRY THERMAL TREATMENT: Wet thermal treatment/steam disinfection is based on exposure if infectious waste to high temperature and high pressure steam similar to process of autoclaving , inappropriate for treating anatomical waste, chemical and pharmaceutical waste. Screw feed technology : Dry thermal treatment in which waste is shredded and heated in rotating auger 80% volume and 20-35% weight is reduced, suitable for infectious waste and sharps.

69. 4. MICROWAVE IRRADIATION: Microwave of frequency 2450MHZ and wave length 12.24cm used to destroy the microorganism. Water contained in the waste is rapidly heated by microwave and infectious components are destroyed by heat conduction. Disadvantage : High cost and maintenance problems.

70. Involves filling containers made of high dentistry polythene or metal drums with waste. Then, these containers are filled with a medium of immobilizing material such as plastic foams, sand, cement mortar or clay and sealing the containers . After the medium has dried , the containers are sealed and disposed off in landfill sites. It is a simple low coast and safe method . Not recommended for non sharp infectious waste. 5. ENCAPSULATION :

71. 6. LAND DISPOSAL:(Safe burying) A. Open Dumps : risk for public health B. Sanitary landfills: designed and constructed to prevent contamination of soil surface, ground water and direct contact with public.

72. Other emerging technologies for destruction of BMW include Ozone Promession Gas‑phase chemical reduction, Base‑ catalysed decomposition, Supercritical water oxidation, Sodium reduction, Superheated steam reforming, Fe‑ tamyl /peroxide treatment (pharmaceutical waste), Biodegradation (using mealworm or bacteria to eat plastics), Mechanochemical treatment, Sonic technology, Nanotechnology Electrochemical technologies, Solvated electron technology and phytotechnology.

73. Common Biomedical Waste Treatment Facilities/Service Provider All the hospitals should made agreement with the Common Biomedical Waste Treatment Facilities (CBMWTF) for the disposal of the biomedical waste. The CBMWTF consists of autoclave, shredder, incinerator and secured land fill facilities. At present 11 CBMWTF for treatment of soiled biomedical waste are in operation in Tamil Nadu.

74. BAR CODE Based Software system All the CBWTFs are implementing Real Time collection system using this software for more efficient collection of Bio-Medical Waste. Accurate data available.

75. Mixing of Bio-Medical Waste with General Waste. Commonly observed violations:

76. Mismatch Coloured Bags/Containers

77. Poor Segregation

78. Improper Transportation of BMW

79. Open Burning of Waste which may lead to Dioxins and Furans

80. Non-Obtaining/Expired Authorization, Consents from PCB(Pollution Control Board). Untreated human anatomical waste, animal anatomical waste, soiled waste and, biotechnology waste stored beyond a period of 48 hours. Bar-Code Stickers not pasted on the Color Coded bags/Puncture proof Sharp Container. Chlorinated Yellow & Red Color coded bags used for disposal of waste. Not Submitting Annual Report under Bio-Medical Waste

81. Violations of Rules: As per law, it is mandatory for all types of medical services provider to ensure proper implementation of Bio-Medical Waste Rules 2016. punishable ‘to imprisonment for a term which may extend to 5 years or with fine which may extend to one lakh rupees, or with both and in case of failure or contravention continues, with additional fine which may extend to five thousand rupees for every day

82. BIOMEDICAL WASTE MANAGEMENT IN DENTISTRY

83. Mercury-containing wastes (1) Stored unused elemental mercury in a sealed containers: using disposable suction tips and amalgam separators on dental suction units, the traps should be changed weekly to prevent amalgam accumulation, (2) mixing only required amalgam amount or using premeasured amalgam capsules, (3) Not throwing extracted teeth with amalgam fillings in the regular garbage, (4) using a mercury container to store all scrap /old amalgam, which is passed on to the CWC

84. DO NOT sweep with a broom or vacuum. Remove all metallic jewelry. Use protective gloves (nitrile or latex), goggles, lab coat and disposable shoe coverings. The preferred way to collect mercury is to dust the spill area with absorbent powder . The powder binds with mercury to create a mercury-metal amalgam that is much safer and easier to handle than elemental mercury. Follow the instructions on the powder to form and collect the amalgam using a “mercury spill kit” in case of a spill of mercury,

85. Silver containing wastes (A) The fixer with a recovery unit, can be mixed with developer and water and disposed down the sewer or septic system . Spent developer is permitted to be discharged in the above systems after dilution with water . Using a digital X-ray unit and an X-ray cleaner without chromium are other suggested safety measures. (B) Undeveloped X-ray films contain a high level of silver and must be treated as hazardous waste. It is advisable to collect any unused film that needs disposing in a recommended container for recycling by the disposal company. Using a digital X-ray unit minimizes purchase of new X-ray films.

86. Lead-containing wastes The lead foil inside X-ray packets and lead aprons contain leachable toxins which can contaminate soil and groundwater in landfill sites after disposal. These should only be handed over to CWC. High doses of lead intake lead to reproductive toxicity, neurotoxicity, carcinogenicity, hypertension, renal function, immunology, toxicokinetics , etc

87. Needles, scalpels, burs, acid etch tips, files, blades and other sharp objects: Their waste management includes collection in white puncture resistant container with a lid that cannot be removed. The container should be properly labeled with biohazard symbol and once full, the CWC should be contacted for disposal.

88. Paper, cardboard, aluminum, plastics, etc.: Their use should be minimized and recycled. Containers or packaging made of PVC plastic should be avoided where feasible, as this is difficult to recycle and can produce acid gases if incinerated.

89. From cleaning and washing water channeled into the drain Hospitals should set up their own effluent treatment plants ( etps ), for treating the waste water that can eventually be reused. In hospitals that do not have etps , the water can be chemically treated and released into the common sewage pipeline, provided it is connected to the local municipal water treatment facilities .

90. Discharged waste water contains organic or inorganic solids and microbial contaminants which can be measured by the BOD and COD tests . BOD – Biochemical oxygen demand is the amount of dissolved oxygen needed by aerobic biological organisms in a body of water to break down organic material present in a given water sample at certain temperature over a specific time period; COD – Chemical oxygen demand is used to indirectly measure the amount of organic compounds in water. It is a useful measure of water quality

91. Biswal S. Liquid biomedical waste management: An emerging concern for physicians. Muller J Med Sci Res 2013;4:99-106

92. Green Dentistry It is a high‑tech approach, which reduces the environmental impact of dental practices in moving toward an ecologically sustainable health care system. Components: Reduce dental waste Conservation of water, energy, and money Hi‑tech dentistry. Rathakrishnan M, Priyadarhini A. Green dentistry: The future. J Int Clin Dent Res Organ 2017;9:59-61.

93. Biomedical Waste Management Outside India In 2012, WHO conducted a survey on the BMWM status of 24 countries of West Pacific area, which included countries such as Japan, China, Australia, New Zealand, Philippines, Malaysia, Vietnam, Cambodia, Republic of Korea. The status in each country was assessed on five main areas of BMW, namely, management, training, policy and regulatory framework, technologies implemented, and financial resources. Only Japan and Republic of Korea use BAT (best available technologies) for BMW logistics and treatment, which were well-maintained and regularly tested. Most of the countries had no or very less financial resources for BMWM.

94. Challenging issues in health care waste management Lack of Segregation Practices Poor Regulative Measures Lack of Green Procurement Policy Waste-picking and Reusing Financial Constraints Inadequate Awareness and Training Programs Reluctance to Change and Adoption

95. Guidelines for Handling, Treatment, and Disposal of Waste Generated during Treatment/Diagnosis/ Quarantine of COVID-19 Patients

96. /

97. (a) COVID-19 Isolation wards: Keep separate color coded bins/bags/containers in wards as per BMWM Rules, Management Rules. As precaution double layered bags (using 2 bags) should be used Collect and store biomedical waste separately prior to handing over the same CBWTF. bags/containers should be labelled as “COVID-19 Waste”. The (inner and outer) surface of containers/trolleys should be disinfected with 1% sodium hypochlorite solution daily.

98. (b) Responsibilities of persons operating Quarantine Camps/Homes or Home-Care facilities General solid waste (household waste) generated from quarantine centers or camps should be handed over to waste collector identified by Urban Local Bodies Biomedical waste if any generated from quarantine centers/camps should be collected separately in yellow colored bags (suitable for biomedical waste collection) provided by ULBs.

99. CONCLUSION In developing Countries like India, the proper disposal of infectious waste is a growing problem and if it is not managed in a sustained way, it will make the situation worse. There is considerable variation in the knowledge, facilities, handling and disposal of BMW among Medical and Dental practitioners.

100. There is an urgent need to update the curriculum, regular orientation training programs and strict implementation of guidelines for BMW management & upgrade the disposal facilities at healthcare facilities. The monitoring agencies needs to supervise the strict implementation of BMW regulations at private sector establishments.

101. REFERENCES 1. Ministry of Environment and Forests, Notification N. S.O.630 (E). Biomedical Waste (Management and Handling) Rules, 1998. The Gazette of India, Extraordinary, Part II, Section 3(ii), Dated 27th July,1998. p. 10‑20, 460. 2. Singh IB, Sarma RK. Hospital waste disposal system & technology. J Acad Hosp Adm 1996‑1997;8‑9:33‑9. 3. Chitnis V, Vaidya K, Chitnis DS. Biomedical waste in laboratory medicine: Audit and management. Indian J Med Microbiol 2005;23:6‑13. 4. Acharya DB, Meeta S. The Book of Hospital Waste Management. New Delhi: Minerva Press; 2000. p. 15, 47. 5. Ministry of Environment, Forest and Climate Change, Notification. The Gazette of India, Extraordinary, Part II, Section 3( i ). Available from: http://www.iwma.in/BMW%20Rules,%202016.pdf. [Last accessed on 2016 Mar 28]. 6. Zhu YG, Zhao Y, Li B, Huang CL, Zhang SY, Yu S, et al. Continental‑scale pollution of estuaries with antibiotic resistance genes. Nat Microbiol 2017;2:16270. 7. Park K (2015). Park’s Text book of Preventive and Social Medicine. 23RD ed. M/s Banarasidas Bhanot publishers. Jabalpur .

102. THANK YOU