biomedical waste management

1. BIOMEDICAL WASTE MANAGEMENT Dr. Sayantan Mondal

2. Overview : Definition Extent of Problem , Need, Present practices BMW Management Rules and application, categories of BMW segregation,Transport & storage Treatment & Disposal Authorization, Reporting of Accidents BMW management Committee Take Home Message Points to be discussed …………

3. What is Biomedical Waste? Bio-medical waste"  means 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, and including categories mentioned in Schedule I; Biologicals"  means any preparation made from organisms or micro-organisms or product of metabolism and biochemical reactions intended for use in the diagnosis, immunisation or the treatment of human beings or animals or in research activities pertaining thereto; Specific to hospitals Bio-medical waste is defined as waste that is generated during the diagnosis, treatment or immunization of human beings and are contaminated with patient’s body fluids (such as syringes, needles, ampoules ,organs and body parts, placenta, dressings, disposables plastics and microbiological wastes).

4. Hospital waste: refers to all waste, biological or non biological, that is discarded and is not intended for further use Medical waste : refers to materials generated as a result of patient diagnoses, treatment, immunization of human beings or animals 4 Definition

5. Infectious waste: are the portion of medical waste that could transmit an ‘infectious disease’. Pathological waste : waste removed during surgery/ autopsy or other medical procedures including human tissues, organs, body parts, body fluids and specimens along their containers. 5 Definition

6. Government/private hospitals Nursing homes Physician/dentist office or clinic Dispensaries Primary health care centers Medical research and training centers animal./slaughter houses labs/research organizations Vaccinating centers Bio tech institutions/production units 6 Sources of health care waste

7. What is Biomedical Waste? Waste Sharps eg: Needles Discarded medicines Human anatomical waste Solid waste eg: cotton swabs

8. Who’s at Risk ? • Doctors and nurses • Patients • Hospital support staff • Waste collection and disposal staff • General public and • the Environment

9. Categories of Bio-Medical Wastes

10. Pharmaceutical Waste Sharp Waste 10

11. Cytotoxic drugs Lab reagents Genotoxic waste Chemical waste 11

12. Waste with high content of heavy metals Worn out batteries Blood pressure guages 12

13. 1. Infection 2. Genotoxicity Cytotoxicity    3.  Chemical toxicity   4. Radioactivity hazards.  5. Physical injuries   6. Public sensitivity. The exposure to hazardous health care waste can result in

14. Infection The infectious agents enter in the body through Puncture, Abrasion, Cut in the skin ; T hrough mucous membranes ; B y inhalation and ingestion.

15. Most Common Infections 1. Gastro enteric through faeces and/or vomit e.g. Salmonella , Vibrio Cholera, Helminthes Hepatitis A 2. Respiratory through inhaled secretions e.g. Mycobacterium tuberculosis; measles virus ; streptococcus pneumonae 3.Ocular infections through eye secretions e.g. Herpes virus , 4. Skin infection through pus e.g. Streptococcus spp , 5. Meningitis through Cerebrospinal fluid e.g. neisseria meningitides ,

16. Most Common Infection Cont. 6 . Blood borne diseases AIDS Septicaemia and  bacteraemia Viral Hepatitis B & C 7 . Hemorrhagic fevers through body fluids Lassa, Ebola and Marburg viruses

17. Genotoxicity and Cytotoxicity Chemical Toxicity Irritant to skin and eyes E.g. alkylating agent, intercalating agent Carcinogenic and Mutagenic e.g. Secondary neoplasia due to chemotherapy Many drugs are hazardous May cause intoxication , burns, poisoning on exposure

18. Radioactivity Hazards Physical Injuries R adioactive waste exposure may cause headache, dizziness, vomiting, genotoxicity and tissue damage May result from sharps, chemicals and explosive agents Public sensitivity Visual impact of the anatomical waste, recognizable body parts

19. NEED FOR BMW MANAGMENT Nosocomial infections to patients from poor infection control practices and poor waste management. Drugs which have been disposed of, being repacked and sold off to unsuspecting buyers. Risk of air, water and soil pollution directly due to waste, or due to defective incineration emissions and ash. Risk of infection outside hospital for waste handlers and scavengers, other peoples.

20. In the late 1980’s I tems such as used syringes washed up on several East Coast beaches USA   HIV and HPV virus infection Lead to development of Biomedical W aste M anagement Law in USA. However in India the seriousness about the management came into lime light only after 1990’s. History

21. GLOBALLY- Developed countries generate 1 to 5 kg/bed/day Developing countries: meager data, but figures are lower. 1-2kg/pt./day WHO Report: 85% non hazardous waste : 10% infective waste : 5% non-infectious but hazardous. (Chemical, pharmaceutical and radioactive) INDIA:-No national level study - local or regional level study shows hospitals generate roughly 1-2 kg/bed/day 21 MAGNITUDE OF THE PROBLEM

22. 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) WHO has estimated that

23. >95,000 hospitals and healthcare facilities in India . 4.2 lakh kg of biomedical waste is generated on a daily basis. Three million tonnes of medical wastes generated every year. Expected to grow 8% annually. 2,91,983 kg/day BMW 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. Karnataka tops the chart with 62,241 kg/day of BMW.   Only 179 CTF to treat the BMW in the country. No. of HCF/CBWTF violated BMW rules 5472 No. of show cause notice/ Directions issued to defaulter HCE/CBWTF 3585 India : Extent of the problem CPCB,April,2011 data

24. Around 40% of the hospitals in the country are dumping the BMW with Municipal garbage Waste is not segregated at the site 3585 hospitals have been served notice for acting as defaulters of these rules. No proper treatment options No regulated disposal plan/sites Present practice within many of the Hospitals

25. Survey of waste generated. 2. Segregation of hospital waste. 3. Collection & Categorization of waste. 4. Storage of waste .( Not beyond 48 hrs. ) 5. Transportation of waste. 6. Treatment of waste. Steps in the Management of Biomedical Waste

26. 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, store, transport, treat, dispose, handle bio medical waste in receive , any form.

27. Approx. Quantity : 4 to 250 liters / bed / day Sewage from isolation wards, ICU’s toilets & urinals, Bed-bath, bathrooms and hospital’s laundry Wash waters from laboratories,OPD , Dressing rooms & Operation theaters. Liquid wastes

28. Approximate Quantity : 0.3 to 3.5 kg/bed/day 1.Garbage 55 % ( Bulk Density :330 kg/m 3 ,Cal.Value:1000 K.cal / kg, Moisture :40% ) 2.Bio-medical waste (sensu stricto) 13 % A. Wasted body remains 05% (Blood,Cultures,Anotomicals) B. Pharmaceutical & Chemical Wastes 02% C. Pathological wastes (may be infectious) 06% 3.Sharp Objects 20 % 4. Pressurized Containers & Discarded Instruments 02 % 5.Radioactive Wastes 0.3 % Solid wastes

29. WASTE CATEGORY TYPE OF WASTE Category No. 1 Human Anatomical Waste Category No. 2 Animal Waste Category No. 3 Microbiology & Biotechnology Waste Category No. 4 Waste Sharps Category No. 5 Discarded Medicine and Cytotoxic drugs Category No. 6 Soiled Waste Category No. 7 Solid Waste Category No. 8 Liquid Waste Category No. 9 Incineration Ash Category No.10 Chemical Waste TYPES OF BIOMEDICAL WASTES

30. BIOMEDICAL WASTE(MANAGEMENT & HANDLING) RULES by Govt. of India, 1998 Revised in 2011 Now known as BMW Rules, 2011 2011 1998 Every occupier generating BMW, irrespective of the quantum of wastes comes under the BMW Rules and requires to obtain authorisation Occupiers with more than 1000 beds required to obtain authorisnatio Duties of the operator listed Operator duties absent Treatment and disposal of BMW made mandatory for all the HCEs Rules restricted to HCEs with more than 1000 beds A format for annual report appended with the Rules No format for Annual Report Form VI i.e. the report of the operator on HCEs not handing over the BMW added to the Rules Form VI absent

31. WASTE CATEGORY WASTE TYPE TREATMENT & DISPOSAL Category 1 Human Anatomical waste (human tissues, organs, body parts Incineration/deep burial Category 2 Animal Waste: Animal tissues, organs, body parts carcasses, bleeding parts, fluid, blood and experimental animals used in research, waste generated by veterinary hospitals, colleges, discharge from hospitals, animal houses Incineration/deep burial Category 3 Microbiology & Biotechnology Wastes: Wastes from clinical samples, pathology, biochemistry, hematology, blood bank, laboratory cultures, stocks specimens of micro-organisms, live or attenuated vaccines human and animal cell culture used in research and infectious agent from research and industrial laboratories, waste from production of biologicals , toxins, dishes and devices used for transfer of cultures Disinfection at source by chemical treatment or by Autoclaving / Microwaving / followed by Mutilation / shredding and after treatment final disposal in secured landfills or disposal of recyclable waste (plastic or glass ) through registered or authorized recycler SCHEDULE I: CATEGORIES OF BIO-MEDICAL WASTE

32. WASTE CATEGORY WASTE TYPE TREATMENT & DISPOSAL Category No. 4 Waste Sharps (needles, glass syringes or syringes with fixed needles, scalpels ,blades, glass etc.) that may cause puncture and cuts(Includes both used and unused sharps). Disinfection (chemical treatment / destruction by needle & tip cutter, autoclaving/microwave and mutilation/shredding and final disposal through CBWTF / landfills Category No. 5 Discarded Medicines & Cytotoxic drugs (Wastes comprising of outdated, contaminated and discarded medicines) Disposal in secured landfills or Incineration Category No. 6 Soiled Waste (Items contaminated with blood, & body fluids including cotton, dressings, soiled plaster casts, linens, beddings, other material contaminated with blood) Incineration

33. WASTE CATEGORY WASTE TYPE TREATMENT & DISPOSAL Category No.7 Infectious Solid Waste (waste generated from disposable items other than the waste sharps such as tubing's, hand gloves, saline bottles with IV tubes, catheters, glass, intravenous sets etc. Disinfection by chemical Treatment / autoclaving /Microwaving followed by mutilation / shredding & final disposal through registered recycler Category No.8 Chemical Waste ( Chemicals used in production of biologicals , chemicals used in disinfection as insecticides etc.) Chemical treatment and discharge into drains for liquids and secured landfill for solids

34. NOTE Chemicals treatment using at least 1% hypochlorite solution or any other equivalent chemical reagent. 2. Mutilation/shredding must be such so as to prevent unauthorized reuse. 3. There will be no chemical pretreatment before incineration. Chlorinated plastics should not be incinerated.

35. Schedule-II Colour coding and Type of Containers for Different Biomedical Wastes Colour coding Type of container Waste category Treatment / Disposal Non chlorinated Plastic Bags Incineration/ Deep Burrial Non chlorinated plastic bag / puncture proof Container for sharps Chemical Treatment / Autoclaving / Microwaving and followed by Mutilation & shredding and disposal in landfills or disposal of recyclable waste Non chlorinated Plastic Bags / Containers Chemical Treatment and discharge into drains for liquids and secured landfill for solids Non chlorinated Plastic Bags Municipal waste Disposed as per the Municipal Solid Waste Yellow Red Blue Black 1, 2, 5, 6 3, 4, 7 8

36. BIOHAZARD SYMBOL CYTOTOXIC HAZARD SYMBOL                                           BIOHAZARD                            CYTOTOXIC HANDLE WITH CARE Note : Lable shall be non-washable and prominently visible. Schedule-III LABEL FOR BIO-MEDICAL WASTE CONTAINERS/BAGS

37. Bio-medical waste shall not be mixed with other wastes Bio-medical waste shall be segregated into containers/bags at the point of generation in accordance with Schedule II The containers shall be labeled according to Schedule III. Segregation, Packing,  

38. Black Dustbin & Bags Paper waste, food waste and other non infectious wastes generated from the hospitals should be stored in black coloured bags / containers & Disposed as per MSW management rules, 2000 MANAGEMENT OF HOSPITAL WASTE

39. KITCHEN WASTE/FOOD PAPER/plastic WASTE DISPOSAL WRAPPERS Outer packing/ Cardboard General/Kitchen waste BLACK BIN For Noninfectious Solid waste

40. Bandages Human anatomical waste-placenta Swab stick-decontaminated WASTE DISPOSAL SWABS Dressing soiled l inen, contaminated gowns, drapes Animal waste Discarded medicine/cytotoxic drugs YELLOW BIN Category 1,2, 5,6

41. RED BIN Drains Plastic culture plates & tubes I/V sets Urine bag WASTE DISPOSAL All infectious waste sharp, non sharp & sharps plastic waste Category 3, 4, 7 Pathology waste

42. In Blue Nonchlorinated bags Chemical waste Chemical Treatment and discharge into drains for liquids and secured landfill for solids

43. Segregated incinerable wastes kept in Yellow bag

44. Sharps in sharp container

45. Personnel safety devices The use of protective gears should be made mandatory for all the personnel handling waste.

46. In an area away from general traffic and accessible only to authorized personnel DO NOT store for more tha n 48 hours If for any reason it becomes necessary to store the waste beyond such period take measures to ensure that the waste does not adversely affect human health and environment Storage

47. Transportation and Storage If a container is transported from the premises where bio-medical waste is generated to any waste treatment facility outside the premises, the container shall, apart from the label prescribed in Schedule III, also carry information prescribed in Schedule IV.

48. Waste category No. Day -------- Month -------- Waste class Year -------- Waste description Date of generation----------- Sender's Name & Address Receiver's Name & Address Phone No. ........................... Phone No. ........................... Telex No. ............................ Telex No. ............................ Fax No. ............................... Fax No. ............................... Contact Person ................... Contact Person ................... In Case of Emergency, Please Contact: Name & Address Phone No. Schedule-IV Label for Transportation of Bio-Medical Waste Containers / Bags

49. 1.Incineration 2.Chemical Disinfection 3.Wet and dry thermal treatment 4.Microwave irradiation 5.Land disposal 6.Inertization Treatment & Disposal Technologies

50. Incineration Combustion efficiency (CE) shall be at least 99.00%. The Combustion efficiency is computed as follows: %C0 2 C.E. = ------------ X 100 %C0 2 + % CO The temperature of the primary chamber shall be 800 +/-50 C The secondary chamber gas residence time shall be at least 1 (one) second at 1050 +/- 50 C Drawback toxic products like furanes and dioxins - can cause air pollution

51. Bio Medical Wastes Destruction by Double Chambered Incinerator

52. Details of Double Chambered Incinerator

53. Incinerator Ash Disposal

54. Emission Standards Parameters Concentration mg/Nm 3 at (12%CO 2 correction) Particulate matters 150 Nitrogen Oxide 450 HCl 50 Minimum stack height shall be 30 metres above ground Volatile organic compounds in ash shall not be more than 0.01%

55. Schedule -V DEEP BURIAL PIT for BMW

56. Autoclave A temperature of not less than 121 C and pressure of 15 pounds per square inch (psi)for an autoclave residence time of not less than 60 minutes Validation test : Spot testing by Bacillus stearo-thermophilus spores on a spores strip with at least 1 x 10 4 Spores/ml. Routine test : Chemical indicator strip/tape

57. STANDARD FOR MICROWAVING SHOULD KILL BACTERIA AND OTHER PATHOGENIC ORGANISM BIOLOGICAL INDICATOR Bacillus Subtilis CHEMICAL PROCESSES Dissolved chlorine dioxide, bleach (sodium hypochlorite), peracetic acid, or dry inorganic chemicals. To enhance exposure of the waste to the chemical agent, chemical processes often involve shredding, grinding, or mixing.

58. Every occupier of an institution generating, collecting, receiving, storing, transporting, treating and /or handling Biomedical Waste shall apply on Form 1 for Authorization to the Board. The State Pollution Control Board are declared as prescribed Authority for grant of Authorization. The Board grants authorizations after satisfying itself. Authorization

59. APPLICATION FOR AUTHORISATION (To be submitted in duplicate.) To The Prescribed Authority (Name of the State Govt/UT Administration) Address. 1. Particulars of Applicant (i) Name of the Applicant (In block letters & in full) (ii) Name of the Institution: Address: Tele No., Fax No. Telex No. 2. Activity for which authorisation is sought: (i) Generation (ii) Collection (iii) Reception (iv) Storage (v) Transportation (vi) Treatment (vii) Disposal (viii) Any other form of handling 3. Please state whether applying for resh authorisation or for renewal: (In case of renewal previous authorisation-number and date)

60. Form 1- Continued 4. (i) Address of the institution handling bio-medical wastes: (ii) Address of the place of the treatment facility: (iii) Address of the place of disposal of the waste: 5. (i) Mode of transportation (in any) of bio-medical waste: (ii) Mode(s) of treatment: 6. Brief description of method of treatment and disposal (attach details): 7. (i) Category (see Schedule 1) of waste to be handled (ii) Quantity of waste (category-wise) to be handled per month 8. Declaration I do hereby declare that the statements made and information given above are true to the best of my knowledge and belief and that I have not concealed any information. I do also hereby undertake to provide any further information sought by the prescribed authority in relation to these rules and to fulfill any conditions stipulated by the prescribed authority. Date : Signature of the Applicant   Place : Designation of the Applicant

61.   Every occupier/operator submit an annual report to the prescribed authority in Form II by 31 January every year, to include information about the categories and quantities of bio-medical wastes handled during the preceding year. The prescribed authority shall send this information in a compiled form to the Central Pollution Control Board by 31 March every year. Annual Report

62.  a. Every authorized person shall maintain records related to BMW. b. All records shall be subjected to inspection and verification by the prescribed authority at any time. c. In any accidents, the authorized person shall report the accident in Form III along with the remedial action taken to the prescribed authority forth with Maintenance of Records & Accident Reporting

63. Setting up a CELL or UNIT for BMW management . The BMW 2011, Rules have also made mandatory for all the HCEs with 30 or more beds to set up a cell or unit to deal with the BMW management. The cell has to meet every six months and minutes of the meeting have to be submitted along with the Annual Report to the prescribed authority

64. Head of the hospital : chairman Waste Mx officer (dev. and implementation plan) Members: HOD ’ s of all department Nursing superintendent, Head nurse, Sanitary inspector Chief pharmacist, Radiation officer Supply officer, financial officer BMW management committee

65. Day to day control of segregation, transport & disposal of BMW Co-ordinate with the store officer for continuous supply of basic items for BMWM Prepare guidelines for BMWM & distribute to all department Prepare BMW posters to raise awareness Arrange training programmes on BMWM & safety measures for all categories of HCW Co-ordinate with HOD/In-charge of Deptt. where deficiencies are pointed out Co-ordinate with Chhattisgarh Environment Conservation Board ) Responsibility of WMC

66. Dos and Don ’ ts Do ’ s The used product should be segregated The used product should be mutilated. The used product is treated prior to disposal. Use protective gear when handling waste Collect waste when the bin is 3/4 the full Clean spills with disinfectant Use trolleys & do not drag waste bags Do not Reuse plastic equipment. Mix plastic equipment with other wastes. Burn plastic waste. Avoid needle stick injuries Avoid using common lift to move waste Avoid spillage

67. Waste minimization & recycling of waste Identification of points of generation of waste Waste segregation at source Compiling the inventory of waste Waste treatment (disinfection etc.) at the site Waste collection and transportation, on-site and off-site Waste treatment , on-site & off the site Final disposal of waste Occupational safety Continuous monitoring of the system Training of the staff. 70 in conclusion

68. Conclusion Bio-medical waste programme cannot be successfully implemented without the willingness, self-motivation, and co-operation from all sections of employees of any health care setting. If we want to protect our environment and health of community we must sensitize our selves to this important issue not only in the interest of health managers but also in the interest of community .