BIOMEDICAL WASTE MANAGEMENT.pptx

The waste produced in the course of health care activities carries a higher potential for infection & injury than any other type of waste.

Inadequate & inappropriate handling of health care waste may have serious public health consequences and it has a very significant impact on environment.

Appropriate management of health care waste is thus a crucial component of environmental health protection and it should become an integral feature of health care services.

1. BIO MEDICAL WASTE MANAGEMENT Presented by: Dr. Rohma Yusuf MDS Dept. Of Public Health Dentistry

2. CONTENTS Introduction Terminologies Historical background Classification of biomedical wastes Risks to human health & problems associated with BMW Rationale for biomedical waste disposal Salient features of BMWM rules 2016 (India)

3. Generation and sources of BMW Steps in biomedical waste Management Dental office wastes management Conclusion References 3

4. INTRODUCTION 4

5. The waste produced in the course of health care activities carries a higher potential for infection & injury than any other type of waste. Inadequate & inappropriate handling of health care waste may have serious public health consequences and it has a very significant impact on environment. Appropriate management of health care waste is thus a crucial component of environmental health protection and it should become an integral feature of health care services. 5

6. TERMINOLOGIES 6

7. WASTE That which is not or cannot be used . An unusable or unwanted substance or material. Regarded or discarded as worthless or useless. BIO-MEDICAL WASTE Any waste, which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining there to or in the production or testing of biologicals and including categories mentioned in schedule I. (Bio-medical waste – Management and Handling rules,2016, India) 7

8. Clinical waste Any waste coming out of medical care provided in hospitals or other health care establishments, but does not include waste generated at home. Hospital waste It refers to all waste, biological or non-biological that is discarded and is not intended for further use in the hospital. 8

9. Health care waste Apart from the hospital waste, it is the waste originating from ‘minor’ or ‘scattered’ sources- such as laboratories, blood banks etc, and including home care . 9 Hazardous waste Is that which has a potential threat to human health and life. E.g. In hospitals, the chemicals, cytotoxic drugs and radioactive elements constitute the hazardous waste.

10. Historical Background 10

11. The provision of potable water, disposal of odour from sewage and refuse were considered the important factors in causing epidemics. The invention of water closet by John Harrington (1561-1612) facilitated flushing away human waste and helped to keep some dwellings clean. In the late 1980s, illegally disposed medical waste begins washing ashore of the Atlantic Coast. 11

12. The U.S. Congress passed the Medical Waste Tracking Act of 1988 which set the standards for government regulation of medical waste. After the Act expired in 1991, States were given the responsibility to regulate and pass laws concerning the disposal of medical waste.  On 1st March 1996 Supreme Court of India, passed the judgement in connection with safe disposal of hospital waste. 12

13. The ministry of environment and forest, Government of India, in exercise of the powers conferred under environment (protection) act, 1986 issued draft rules called ‘bio-medical waste (management and handling) rules, 1998. The rules were further amended in the year 2011, 2015 and 2016. 13

14. CLASSIFICATION OF BIO-MEDICAL WASTES 14

15. Classification By High Power Committee On Urban Solid Waste Management In India General or non hazardous waste Hazardous waste 15

16. 16 General or non hazardous waste Constitutes 80-85% of the waste Non-risk, least infection potential Comparable to domestic waste Disposed off by municipal authorities

17. 2.Hazardous waste Constitute 10-15 % of the waste Create a variety of health risks Sub-divided into Potentially infectious waste Potentially toxic waste 17

18. Potentially infectious waste : Dressings, blood and body fluids Lab samples, cultures Instruments used for diagnosis and treatment Needles or sharps Tissues, organs, placenta Animals used for diagnosis or research purposes Potentially toxic waste: Radioactive wastes Chemical wastes Pharmaceutical wastes 18

19. 19

20. WHO CLASSIFICATION Classified into 7 categories: General waste Pathological waste Radioactive waste Chemical waste Infectious waste Sharps Pharmaceutical wastes 20

21. General waste Largely composed of domestic or household type of waste. Non- infectious Eg . Kitchen waste, packaging materials, waste water from laundries Pathological waste Infectious Eg . Tissues, organs, body parts, human foetus , blood and body fluids. Radioactive waste Waste contaminated with radio nuclides generated from in vitro analysis of body tissues and fluids, in vivo body organ imaging and tumor localization and therapeutic procedures. 21

22. Chemical waste Discarded chemicals from diagnostic and experimental work, cleaning, house keeping and disinfecting procedures. E.g. Lab reagents, film developers, disinfectants 22

23. Infectious waste Wastes suspected to contain pathogens E.g. Lab cultures, waste from isolation wards, tissues, wastes from surgeries and autopsies Sharps Wastes which have the capability to injure by piercing and cutting the skin E.g. Needles, scalpels, blades, broken glass Pharmaceutical wastes Wastes containing pharmaceutical products E.g. Expired drugs, spilled drugs, boxes with drugs 23

24. Risks To Human Health

25. Genotoxicity & Cytotoxicity : Irritating to the skin & eyes May have mutagenic, or carcinogenic properties Eg . Vomit, urine or faeces from patients treated with radioactive materials, chemicals. 26

26. Public sensitivity: Apart from health hazards, general public is sensitive to visual impact of healthcare wastes. 30

27. Rationale For Bio-medical Waste Disposal 31

28. It is a part of hospital hygiene and maintenance activities. To prevent threat to life and health of not only patients and hospital staff but also to community at a larger scale. To protect the environment outside the hospital. Why should the biomedical waste be disposed off safely ? 32

29. 33

30. Improper handling, treatment and disposal of waste leads to serious problems like: The un- seggregated and untreated waste can convert the non-infectious waste into infectious waste. Disposal of hospital waste in municipal dumpsite can cause diseases in animals when they feed on them. Ineffective disinfection and sterilization during treatment can spread infection among hospital workers and the general public. 34

31. Increase in incidence and prevalence of infectious diseases like AIDS, hepatitis B and C, tuberculosis. Mosquitoes , flies, rats and stray dog menace. Risk of pollution of water, soil and air beside esthetic problems. 35

32. SALIENT FEATURES OF BMWM RULES 2016 INDIA 36

33. 37 Salient features of BMW Management Rules, 2016 The ambit of the rules has been expanded to include vaccination camps, blood donation camps, surgical camps or any other healthcare activity. Phase-out the use of chlorinated plastic bags, gloves and blood bags within two years. Pre-treatment of the laboratory waste, microbiological waste, blood samples and blood bags through disinfection or sterilisation  on-site in the manner as prescribed by WHO or NACO(National AIDS control organisation ). Provide training to all its health care workers and immunise all health workers regularly.

34. Establish a Bar-Code System for bags or containers containing bio-medical waste for disposal. Report major accidents Bio-medical waste has been classified in to 4 categories instead 10 to improve the segregation of waste at source. Procedure to get authorisation  simplified . Automatic authorisation  for bedded hospitals. One time Authorisation  for Non-bedded HCFs(healthcare facility). 38

35. The new rules prescribe more stringent standards for incinerator to reduce the emission of pollutants in environment. Inclusion of emissions limits for Dioxin and furans. State Government to provide land for setting up common bio-medical waste treatment and disposal facility. No occupier shall establish on-site treatment and disposal facility, if a service of `common bio-medical waste treatment facility is available at a distance of seventy-five kilometer. Operator must ensure the timely collection  of bio-medical waste from the HCFs (healthcare facility centre) and assist the HCFs in conduct of training . 39

36. 40

37. 41 United Kingdom In the UK, clinical waste and the way it is to be handled is closely regulated. Applicable legislation includes the Environmental Protection Act 1990 (Part II), Waste Management Licensing Regulations 1994, and the Hazardous Waste Regulations (England & Wales) 2005, as well as the Special Waste Regulations in Scotland.

38. 42 United States In addition to on-site treatment or pickup by a biomedical waste disposal firm for off-site treatment, a mail-back disposal option exists in the United States. In mail-back biomedical waste disposal, the waste is shipped through the U.S. postal service instead of transport by private hauler but it is limited to very strict postal regulations (i.e., collection and shipping containers must be approved by the postal service for use) and only available by a handful of companies.

39. 43

40. 44

41. In the year 2015 , forms VI and VII were added. Form VI was about, application for filing appeal against order passed by the prescribed authority. Form VII was about, report of the operator of the common bio-medical waste treatment and disposal facility on the health care facility or health care establishment not handing over bio-medical wastes for the dates _____ the month of ________ , the year of _______. In the year 2016 , form V is removed which was about ( authorization for operating a facility for generation, collection, reception, treatment, storage, transport and disposal of biomedical wastes.) Form VII is also removed 45

42. GENERATION AND SOURCES OF BIOMEDICAL WASTE 46

43. Major sources of health care waste Hospitals Nursing homes Dispensaries Laboratories Medical /dental colleges and research centre Veterinary colleges and animal research centre Mortuaries Autopsy centre Old age homes 47

44. Minor sources Physcian’s / Dentists’ clinics Animal houses/ slaughter houses Blood donation camps Vaccination centre Acupuncturists 48

45. WHO STATISTICS Developed countries: 1-5 kg/bed/day In india : 1-2 kg/bed/day with variation among government & private establishments. 49

46. 50 MoEF & CC: ministry of enviroment and forest & climate change TPD: tonns per day

47. 51 CBMWF: common biomedical waste treatment facilities

48. STEPS IN BIOMEDICAL WASTE MANAGEMENT 52

49. Minimize waste Collection Segregation Storage Transportation Treatment Disposal 53

50. Minimize waste By source reduction (avoiding wastage) Use of recyclables (e.g. Using sterilizable glass ware) Segregation at source (Separating biomedical plastics, glass, metal at source for autoclaving and shredding before recycling) Stock management ( replacing IV fluids, blood and drugs so that there is no wastage due to spoilage) 54

51. COLLECTION Wastes should not be allowed to accumulate at the point of production. Routine programme for collection has to be established. Collect waste daily and transport it to the central storage site. Bags should not be removed unless they are labeled. Bags or containers should be replaced when they are three quarter full . A supply of fresh collection bags should be available at the site of production. 55

52. Segregation, packaging and labeling Segregation is the key to minimization and effective waste management. Segregation reduces the amount of waste that needs special handling and treatment Effective segregation process prevents the mixture of medical waste like sharps with the general municipal waste. Prevents illegal reuse of certain components of medical waste like used syringes, needles and other plastics. 56

53. Clinical waste: recommended labeling and color coding COLOR CODING TYPE OF CONTAINER WASTE CATEGORY TREATMENT OPTIONS YELLOW Plastic bag Human anatomical waste, animal waste, microbiological & biotech. waste. Incineration / deep burial RED Disinfected container / plastic bag Microbiological & biotech waste, disposable items other than waste sharps, such as tubings , catheters, i.v sets, solid waste. Solid waste (items contaminated with blood/body fluids, eg . Cotton, soiled dressing, etc.) Autoclaving / microwaving / chemical treatment BLUE / WHITE TRANSULECT Plastic bag / puncture proof container Waste sharps, solid waste ( tubing's, catheters, intravenous sets etc.) Autoclave / microwave / chemical treatment & destruction / shredding BLACK Plastic bag Discarded medicines, cytotoxic drugs, incineration ash, chemical waste. Disposal in secured landfill.

54. Provides an opportunity for recycling certain components of medical waste like plastics after proper and thorough disinfection. Of the general waste, the biodegradable waste can be composed within the hospital premises and can be used for gardening purposes. Recycling is a good environmental practice, which can also double as a revenue generating activity. Reduces the cost of treatment and disposal (80 per cent of a hospital’s waste is general waste, which does not require special treatment, provided it is not contaminated with other infectious waste) 59

55. LABELING Why is labeling necessary? In cases of liability issues, full and correct labeling allows the origin of waste to be traced. Labeling warns hospital staff and the general public of the hazardous nature of the waste. Hazards posed by container contents can be quickly identified in case of accident, enabling emergency services to take action. 60

56. Schedule III Label for biomedical waste containers/bags Biohazard symbol Cytotoxic hazard symbol 61

57. Waste containers should be labeled with the following information: Waste category Date of collection Place in hospital where produced (e.g. wards) Waste destination 62

58. STORAGE Is the delay between production and treatment. A storage location should be designated inside the health care establishment. Storage time for health care waste should not be beyond 48 hours. Cytotoxic waste should be stored separately from other health care waste. 63

59. TRANSPORTATION Transport from the areas of generation at regular intervals. Designated staff should be aware of the hazards of the material they handle. They should be provided with adequate personal protective equipment. 64

60. On-Site transportation Wheeled trolleys, containers or carts which are not used for any other purpose are used. Specifications Easy to load and unload No sharp edges that could damage waste bags during loading or unloading Easy to clean 66

61. Off-Site transportation Waste transporting organization should be registered with the waste regulation authority. Vehicles used for transportation of health care waste should not be used for any other purpose. The international hazard sign should be displaced on the vehicle. The vehicle should be steam cleaned. Protective clothing, disinfectants, cleaning equipment should be carried in a separate compartment in the vehicle. Waste container bags can be directly placed in the vehicle or they can be placed within cardboard boxes or lidded plastic or galvanized bins. 67

62. 68

63. Treatment and Disposal of Biomedical waste 69

64. TREATMENT May be defined as the process that changes the character of hazardous waste to render them less hazardous or non-hazardous. DISPOSAL Is placing the biomedical waste in it’s final resting place. 70

65. Treatment and Disposal techniques Incineration Autoclaving/steam sterilization Chemical disinfection Dry thermal treatment Microwave irradiation Hydroclaving Plasma technology Inertization Land disposal and deep burial 71

66. INCINERATION: It is a high temperature dry oxidation process that reduces Organic and combustible waste to inorganic, incombustible matter and results in a very significant reductionOf waste volume and weight. Types of incinerators: Double chamber pyrolytic incinerators Single chamber furnaces Rotary kilns

67. Wastes that should not be incinerated are Pressurized Containers: Explosion may occur and cause damage to equipment Halogenated Plastics ( Pvc ): Exhaust gases may contain toxics like hydrogen chloride and dioxins. Waste With High Content Of Heavy Metals: e.g . thermometers and batteries Waste causing emission of toxic metals (e.g. lead, cadmium and mercury) into the atmosphere. 75

68. AUTOCLAVING/WET THERMAL TREATMENT/STEAM STERILIZATION Principle : Destruction of micro-organisms by steam under pressure . Temperature of not less than 121 c and pressure 15 psi and time not less than 60 mins . OR Temperature of not less than 135 c and pressure 31 psi and time not less than 45 mins . 74

69. Vacuum type autoclave Steam is generated outside the chamber loaded with waste. Wastes treated by autoclaving All infectious wastes Plastic disposables like blood bags and urine bags. 75

70. Advantages Environmentally sound. Low investment and operating costs. Disadvantages Operation requires qualified technicians. Inadequate for pharmaceutical and chemical waste and waste that is not readily steam permeable. 76

71. CHEMICAL DISINFECTION Chemicals are added to wastes to kill or inactivate the pathogens it contains. Factors influencing the effectiveness: Type of disinfectant used Quantity and concentration Contact time with the waste Chemicals commonly used for disinfection: Formaldehyde 6-8% Gluteraldehyde , Hydrogen peroxide 6-30% Chlorine dioxide, chlorine, hypochlorites , cholramines 77

72. Advantages Relatively inexpensive . Disadvantages Highly qualified technicians are required Uses hazardous substances that require comprehensive safety measures. Ineffective for pharmaceutical and chemical waste. 78

73. DRY THERMAL TREATMENT Screw feed technology : It is the basis of a non-burn, dry thermal disinfection process in which waste is shredded and heated in a rotating auger. Reduction in 80% in volume and 25-30% by weight. Suitable for infectious wastes and sharps. Not suitable for pathological, cytotoxic and radioactive waste. 79

74. MICROWAVE IRRADIATION Microwave radiation is that portion of the electromagnetic radiation spectrum lying between the frequencies of 300 and 3,00,000 MHz. Microbial inactivation occurs due to thermal effect of the radiation. Microwaves of a frequency penetrate materials at 97 to 100 c for 25 minutes. 80

75. Suitable for treatment of most infectious waste. Not suitable for metal items, cytotoxic and radioactive waste. Advantages Good disinfection efficacy under appropriate operating conditions Drastic reduction in waste volume Environmentally sound Disadvantages High investment and operating cost Potential operation and maintenance problems 81

76. HYDROCLAVING Expansion of autoclave technology with some disinfection features added. Steam does not actually come in contact with the waste. It is indirect heating by providing steam into the outer jacket while the waste is kept inside another chamber and turned mechanically. 82

77. PLASMA TECHNOLOGY: It is based on high temperature pyrolysis process/ plasma gasification using plasma torch which allows complete destruction of wastes. The process takes place at 2000-3000 o c where the material attains a plasma state during which there is total destruction of the material. 83

78. Advantages It produces fewer exhaust gases, no hazardous residue and is an environment friendly technology. 80-85% reduction in volume and 65-70% reduction in weight is achieved. Short time is required to attain the desired temperature and reaction to take place. 84

79. INERTIZATION The process involves mixing waste with cement and other substances before disposal in order to minimize the risk of toxic substance contained in the wastes migrating into the surface water or ground water. A typical proportion of the mixture is : 65% pharmaceutical waste 15% lime 15% cement 5% water 85

80. A homogenous mass is formed and cubes or pellets are produced on site and transported to storage sites. Advantage Relatively inexpensive Disadvantage Not applicable to infectious waste 86

81. DISPOSAL OF SHARPS                                Blades and needle waste after disinfection should be disposed in circular or rectangular pits. Such pits can be dug and lined with brick , or concrete rings. The pit should be covered with a heavy concrete slab, which is penetrated by a galvanized steel pipe projecting about 1.5 m above the slab, within internal diameter of up to 20 mm. When the pipe is full it can be sealed completely after another has been prepared. 87

82. Grinding and shredding This is a mechanical destruction method which is used to convert biomedical waste into more homogenous form for easy handling. The waste is physically broken down into smaller particles. Advantages Increases the extent of contact between waste and disinfection by increasing the surface area. Renders any body parts unrecognizable and avoids any adverse visual impact on disposal. Reduces the volume of the waste. 89

83. LAND DISPOSAL The use of a land fill has to be regarded as an acceptable disposal route when the municipal or medical authorities genuinely lack the means to treat waste before disposal. Two types of disposal land: Open dumps Sanitary land fills A land fill does not provide an environment conducive to survival of human pathogens because of : High temperature Oxygen depletion 90

84. A pit of 1 cubic meter is sufficient for disposal of waste for a period of 1 month for every 10 beds. When fresh waste is added to the pit, a layer of 10 cm soil is added to cover it. A new pit is dug when the waste comes within 50 cm of the ground surface. The pit should be impermeable, distant from any habitation or source of water 91

85. A pit or trench should be dug about 2 m deep. It should be half filled with waste, and then covered with lime within 50 cm of the surface, before filling the rest of the pit with soil. It must be ensured that animals do not have access to burial sites. Covers of galvanized iron/wire meshes may be used. On each occasion, when wastes are added to the pit, a layer of 10cm of soil be added to cover the wastes. Burial must be performed under close and dedicated supervision. DEEP BURIAL 92

86. The site should be relatively impermeable and no shallow well should be close to the site. The pits should be distant from habitation, and sited so as to ensure that no contamination occurs of any surface water or ground water. The area should not be prone to flooding or erosion. The location of the site will be authorized by the prescribed authority. The institution shall maintain a record of all pits for deep burial. 93

87. 94 DENTAL OFFICE WASTES MANAGEMENT

88. Dental wastes: Any waste product generated by a dental office, clinic or laboratory including amalgams, saliva, rinse water. They are potentially harmful to the enviroment and require special storage and disposal. 95

89. 96

90. 97 Dental waste items Does it contain metals?( other than sharps) Is it a used chemical? Is it a biowaste ? Chromium containers x ray system cleaners: Dispose off as hazardous wastes. Lead foils and sheilds : Action metal, BFI Silver, fixer, scrap films: Silver recovery system, BFI Mercury/ Amalgam : Sybertech waste reduction Ltd., BFI Used chemiclave : Discharge to sanitary sewer Disinfectants: Discharge to sewer Blood: Discard as infectious wastes, garbage Sharps and other wastes: Dispose as per local bylaws N N N Y Y Y

91. 98

92. CONCLUSION The Bio-medical Waste generated from the hospitals and all other sources should be treated without polluting the environment. The new rules are elaborate, stringent and new provisions have been added. New rules have definitely cleared certain ambiguity of the previous ones but still lacks on many fronts. 99

93. LET THE WASTES OF ‘THE SICK’ NOT CONTAMINATE THE LIVES OF ‘THE HEALTHY’. 100

94. References Park’s text book of preventive and social medicine. K Park 18 th edition, 2005. WHO : Wastes from health-care activities: October 2000 A textbook of preventive and community dentistry- 4 th edition, Soben Peter Bio-Medical Waste (Management & Handling) Rules, 1998 Bio-Medical Waste (Management & Handling) Rules, 2016 Hospital waste management. Dr. AG Chandorkar and Dr. BS Nagoba : 1 st edition, 2003, Paras publishing 101

95. 102 7 . Dr. K. Pushpanjali , Dr. KH Shaik Hyder Ali, Dr. BK Srivastava . Safe management of dental health care waste – a practical approach IDA 2003, Vol. 74; 29-33 . 8. Google.com

96. 103