Hospital Waste Management

A short note on Hospital Waste Management for the Public Health students at Post Graduation Level

1. Brig Gen Dr Zulfiquer Ahmed Amin M Phil, MPH, PGD (Health Economics), Advance Course HA (AIIMS, Delhi), MBBS North South University (NSU) HOSPITAL WASTE MANAGEMENT

2. Since beginning, the hospitals are known for the treatment of sick persons but we are unaware about the adverse effects of the garbage and filth generated by them on human body and environment. Now it is a well established fact that hospital waste is a potential health hazard to the health care workers, public and flora & fauna of the area.

3. Everything is made for a defined purpose. Anything which is not intended further use , termed as waste. Any waste generated as a consequence of healthcare delivery , out of hospital activities, can be termed as ‘Hospital Waste’ (HW). It is also called Bio-Medical Waste (BMW).

4. Hospital Waste Management means the management of waste produced by hospitals using such techniques that will help to check the spread of diseases through the waste. Rate of generation of HW: Developing Countries: 1-2 kg/patient/day Developed Countries: 1-5 kg/patient/day

5. • Hospitals • Nursing homes • Clinics • Medical laboratories • Blood banks • Mortuaries • Medical research & training centers • Biotechnology institution/production units • Animal houses etc. • Patients’ home, when patient is managed at home.

6. Estimated Medical Waste Generation in some countries of Asia

7. Medical Waste Generated by Different Countries Environmental Performance Index ( EPI ) 2020 measures level of environmental pollution, including hospital waste management by 180 countries . India ranked 168 th and Bangladesh 177 th in 2022.

8. Classification of Hospital Waste: Hazardous: Non-Hazardous:

9. Sources of Hospital Waste

10. Average Food Waste in a Hospital

11. Impact of Hospital Waste 1. Infection: Bacterial origin e.g. tetanus, anthrax, cholera, diarrhoea ; fungal infections e.g. candida , cryptococcus ; viral infection e.g. hepatitis, poliomyelitis. 2. Genotoxicity and Cytotoxicity : In genetics, genotoxicity describes the property of chemical agents that damages the genetic information within a cell causing mutations, which may lead to cancer. Cytotoxicity is the quality of being toxic to cells .

12. 3. Chemical Toxicity: Like benzene, carbon tetrachloride pose risk to workers handling them. 4. Radioactive Hazards: Causing cancerous growths , genetic problems. 5. Physical Injuries: Injuries and accidental cuts due to handling of sharps and needles. 6. Underground and surface water pollution. Mass scale spread of Cholera, Typhoid, Hepatitis-A, diarrhoea , dysentery, poio etc 7. Public Sensitivity: Loss of aesthetic view, fowl smelling.

13. Management of Healthcare Waste National Policy, Strategy, Plan, Guidelines and SOP Legislation/ Rules for waste management Political commitment Committed manpower Good management and supervision Proper budgetary allocation Community participation Local and appropriate technology Involvement of NGOs Development of Information System in relation to BMW Effective Waste Management needs:

14. Preferred Options of Waste Management

15. Hospital Waste Management Process

16. WHO Hospital Waste Management Cycle

17. Waste Minimization Waste minimization is characterized as the reduction of waste from the source of origin and the reuse and recycle of the waste. The basic components of waste minimization are: Improved housekeeping; • Change in process technology; • Change in products, Change in input materials; Reuse the material after proper disinfection • Recycling of chemical and raw materials; • Recovery of by-products.

18. Waste Identification Waste Identification means to determine the nature and property of the waste ; if it is solid or liquid, hazardous or non-hazardous, toxic or non-toxic etc.

19. Waste Segregation -Waste segregation means dividing or separating waste at earliest opportunity, at point of origin. Hazardous waste not to mix-up with non-hazardous waste. -An appropriate way of segregating the waste is by sorting the waste into different colour code. - Colour code is easy for identification and thereby easy for safe handling, transportation, and waste treatment. Colour code varies from country to country and even from one hospital to another in the same country. If segregation is not properly done, small quantity of hazardous waste mixes with large volume of non-hazardous waste , making a large volume of hazardous waste; costly to dispose and increase health hazards.

20. WHO Recommended Colour Code

21. Colour Code Practice in CMHs

22. Waste Handling Waste Handling means waste collection from the designated colourd bins, storage and transportation by designated individuals. Out-Fit of Waste-Handler

23. Waste Collection -Collector must wear PPE (Personal Protective Equipment). -Collection of waste only in designated coloured bag or covered coloured bins. -Content of the container should not exceed ¾ of its capacity. -If bag is used for collection, neck of bag should be strongly tied . - Avoid throwing, dragging over floor or holding the bottom of the container.

24. -No container should be used if damaged, or licked . -All bins should be covered with lid during collection and transportation of waste. -No container should be transported without leveling ‘hazard warning’ . -During collection, each container should be replaced with new one . -Collection of sharp medical waste under maximum precaution. -If there is spillage of waste from the container, gently collect the waste into bin, soak the area with 2% Lysol solution , wait for 30 minutes, then wash and wipe.

25. Placement of Colour Bins -Appropriate container should be placed at all important location where particular wastes are generated . -Instruction on waste identification should be pasted over the containers. -Waste containers should be labeled with some basic information about category of waste, weight of the material, date of collection, and site of waste production (In irremovable or water resistant ink). -General Waste (Black Bin) could be placed at landing area of the staircase , in the straight long corridor bin could be placed at 50 meter distance , yellow coloured bin could be placed outside of the toilet in female ward for collection of sanitary napkins.

26. Transportation In-house transportation In-house transportation means transportation of waste from the site of origin or collection to temporary storage area within the institution. Waste should be transported by designated trolley , through the designated route according to time schedule given by the institutional authority.

27. Temporary in-house storage The store will be a room or area or building within the healthcare facility depending upon the quantity and quality of waste production and frequency of waste collection . Characteristics of In-House Storage -Waste should not be stored more than 24 hours. -Prevent access of unauthorized person. -Easy access for workers and collection vehicles. -Away from food preparation, processing, and food store. -Sufficient light and water supply. -Inaccessible for scavengers, animals and rodents. -Away from water sources.

28. Record Keeping Accurate record keeping is needed for effective medical waste management. Record keeping might give some important information, which will help: -To assess the quality and quantity of generated waste. -To assess the cost directly related with the man and materials. -To assess the cost related with waste treatment and disposal method. -To assess the recurrent expenditure . -To assess the risk involved with generated waste, amount and nature of accident, amount of damage, measures taken for accidents etc. -To assess the failure, problems and obstacle in waste management for better compliance of the program.

29. Treatment and Final Disposal of Hospital Waste Treatment of Waste : -Incineration: Burning at high temp with O 2 . -Autoclave: Sterilization of microbiological waste by subjecting them to high pressure (15 psi), high temperature (121 C) in moisture for around 30-60 minutes . -Chemical Disinfection: -Render Inert: Neutralizing waste by radioactive chemicals . Incineration Incineration involves burning waste at high temperatures ranging between 750°C and 1100°C  in the presence of oxygen . This method is capable of reducing waste mass by almost 70% and volume by up to 90% and produce heat and energy.

30. Incineration Characteristics of waste suitable for incineration are: -Content of combustible matter above 60%. -Content of non combustible matter below 50%. - Moisture content below 30%. -Higher heating value of waste (Average 5100 BTU/Lb of waste). Waste types not to be incinerated are: -Pressurized gas containers. -Large amount of reactive chemical wastes. -Silver salts and photographic or radiographic wastes. -Halogenated plastics such as PVC. -Waste with high mercury or cadmium content such as broken thermometers, used batteries. -Sealed ampoules or ampoules containing heavy metals.

31. Chemical Disinfection -Disposal of chemical waste is the responsibility of the unit generating/using it. -Chemicals should be neutralized by disinfectants and then drained into the sewerage system. -Liquid chlorine, sodium hypochlorite, chlorine dioxide, ozone, phenolic compounds, iodine and iodine compounds are commonly used as chemical disinfectants

32. F/b = Followed By

33. (Effluent Treatment Plant)

34. There are only three NGOs in Bangladesh that are actively working in the field of hospital waste management . These NGOs are ‘PRISM’ (Project in Agriculture , Rural Industry, Science and Medicine ) Bangladesh in Dhaka city, ‘BASA’ (Bangladesh Association for Social Advancement) in Tongi and ‘ Shawpno ’ in Bagura . They are collecting the waste from the designated hospitals with a nominal service charge. Among the three NGOs, PRISM Bangladesh along with DCCs (Dhaka City Corporation) are collecting and treating the hospital waste up to final disposal . There are only 1121 hospitals , clinics and diagnostic centres under PRISM management program. Recently, PRISM has expanded their program in Narayanganj , Savar , Sylhet , Rangpur , Rajshahi and Jashore district. Rest of the healthcare institutions follow their own or old system of disposal by burn and burial . Hospital Waste Management- Practices in Bangladesh

35. Hospital Waste Management in Bangladesh

36. The hospital waste management practices somehow has not been given due attention and importance in Bangladesh . Other problems include : - Lack of implementation of guideline. - Existing gaps within the Waste Management Rule 2008. - Problem in Environmental Act 1995. - Lack of interest and unity. - Economic constrains. -Inefficient management . - Corruption. - Hazardous waste management is not high in the political agenda . -Inadequate enforcement of existing pollution control laws. - Lack of supervision of final disposal of waste by responsible agency. Challenges of Hospital Waste Management in Bangladesh

37. To remedy the situation, the MOH&FW recently sent a proposal to the Planning Ministry on setting up of Waste Management Systems at 15 government hospitals by 2024 at a cost of around Tk 214 crore .

38. Prospects of BMW Management Industry in Future Hospital Waste Management sector is an untapped market globally . In future, it will be a prospective avenue both for hospitals and business entities.

39. Conclusion hospital waste management increases safety of employees, patients and community by reducing the potential to sustain a sharps injury, exposure to blood-borne pathogens and reduces hospital-acquired infections (HAIs).  Not far in time, Hospital Waste used to be disposed in the stream.