Hospital waste management

Hospital waste management

1. HOSPITAL WASTE MANAGEMENT Hari Prasad Kafle Lecturer, SHAS, FST Pokhara University

2. Health Care Waste Health care waste includes all waste generated by health care establishment, research facilities and laboratories etc. It also includes waste originating from minor or scattered sources e.g. health care undertaken at home (dialysis, insulin injection etc.)

3. Health Care Waste 75-90% health care waste are non risk waste as compared to household waste. 10-25% health care waste is regarded as hazardous and can create varieties of health risks. Broadly, health care waste has been divided into three subsets: Hospital waste, Medical waste and potentially infectious waste.

4. Health Care Waste

5. Health Care Waste Hospital waste: are waste generated from health care facilities including cafeteria, office and construction waste. Medical waste (a subset of Hospital waste): waste generated as a result of patient diagnosis, treatment and immunization of human beings or animals. Potentially infectious waste (a sub set of medical waste): that % of medical waste potential to transmit infectious disease (10-25%).

6. Bio-medical Waste “Bio-Medical Waste" means any waste, which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining thereto or in the production or testing of biological.

7. Bio-medical Waste It includes infectious and non-infectious waste. Infectious waste includes pathological waste, cotton, dressing, used needles, syringes, scalpels, blades, glass etc. Non-infectious waste includes general waste from the kitchen/canteen, packaging material including radioactive wastes, mercury containing instruments, PVC plastics.

8. Classification of Health Care Waste

9. Classification of Health Care Waste Waste Category Description and example Infectious waste Waste suspected to contain pathogens e.g. laboratory cultures; waste from isolation wards; tissue(swabs); material or equipment that have been contact with infected patients: excreta etc. Pathological waste Human tissue or fluids e.g. body parts; blood and other body fluids; fetuses

10. Classification of Health Care Waste Waste Category Description and example Pharmaceutical waste Waste containing pharmaceuticals e.g. Pharmaceuticals that are expired or no longer needed; items contaminated by or containing pharmaceutical (bottles, boxes) Genotoxic waste Waste containing substances with genotoxic properties e.g. waste containing cytostatic drugs( often used in cancer therapy); genotoxic chemicals

11. Classification of Health Care Waste Waste Category Description and example Chemical waste Waste containing chemical substances e.g. laboratory reagents; film developers; disinfectants that are expired and no longer needed; solvents Waste with high contents of Heavy metals Batteries; broken thermometers; blood pressure gauze etc.

12. Classification of Health Care Waste Waste Category Description and example Pressurized containers Gas cylinders; gas cartridges; aerosol cans etc. Radio active waste Waste containing radioactive Substances e.g. unused liquid form radiotherapy or laboratory research; contaminated glass wire, packages, or absorbent paper; urine and excreta from patient treated or tested with unsealed radionuclides; sealed sources etc.

13. Classification of Health Care Waste Waste Category Description and example Gases waste Gaseous waste generated during burning of health care waste. Either open burning or drum incinerator or incinerator produce several gaseous pollutants: CO 2 , H 2 O, HCL, HF, SO2, NO etc

14. Classification of Health Care Waste Waste Category Description and example Liquid waste Waste in liquid form. Waste such as infected urine, expired blood, body fluids and fluids coming from wound. Waste water coming from different wards and laboratories. Incineration Ash Could be highly toxic (both bottom ash and Fly ash). Contains high concentrated toxic chemicals and other heavy metals including dioxin and furans.

15. Sources of Health Care Waste Government hospitals Private hospitals Nursing homes Private clinics Dentists clinic Dispensaries Primary Health Centers Medical research and training institutions

16. Sources of Health care waste Blood bank and collection centers Animal houses Slaughter houses Laboratories Research organizations Vaccination centers Bio-technology institution and product units

17. Composition of Health care waste 80% general health care waste (which may be dealt with by the normal domestic and urban waste management system). 15% pathological and infectious waste. 1% sharp waste. 3% chemical or pharmaceutical waste. <1 % special waste, such as radio active or cytotoxic waste , pressurized container or broken thermometer & used batteries.

18. Risk Groups Medical doctors, nurses, health care auxiliaries and hospital maintenance personnel Patients in health care establishments. Visitors to health care establishments. Workers in support services allied to health care establishments such as laundries, waste handling and transportation.

19. Risk Groups Workers in waste disposal facilities such as land fills or incinerators Waste pickers (scavenger); Waste recyclers; Drug addicts (who scavenge for used needles and disposed medicines); and The entire community.

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21. Health hazards from health care waste Exposure to hazardous health-care waste can resulting disease or injury because: It contains infectious agents. It is genototic. It contains toxic chemicals or pharmaceuticals. It is radioactive. It contains sharp. It contains carcinogenic agents and gaseous chemicals.

22. Health hazards from health care waste Hazards from infectious waste and sharps HIV, hepatitis B &C, microbial resistance Hazards from chemical and pharmaceutical waste Intoxication, burn, poisoning, shock due to inhalation Hazards from genotoxic waste Gentoxic effects, affects genetic materials

23. Health hazards from health care waste Hazards from radioactive waste Headache, dizziness, vomiting, unconsciousness and also genotoxic effects. Public sensitivity General public is very sensitive to visual impact of health care waste particularly anatomical waste.

24. Infection caused by health-care waste Type of infection Causative organism Transmission vehicles Gastro enteric infections Entero bacteria: e.g. salmonella, Shigella spp., Vibrio cholera, helminthes. Faeces and or vomit Respiratory infection M. tuberculosis, measles virus, streptococcus pneumoniae Inhaled secretions; saliva

25. Infection caused by health-care waste Type of infection Causative organism Transmission vehicles Ocular infections Herpes virus Eye secretions Genital infections Neisseria gonorrhoeae, herpes virus Genital secretions Skin infections Streptococcus spp. Pus Anthrax Bacillus anthracis Skin secretions

26. Infection caused by health-care waste Type of infection Causative organism Transmission vehicles Meningitis Neisseria meningitidis Cerebro -spinal fluid AIDS Human deficiency virus (HIV) Blood, sexual secretions Hemorrhagic fever Junín, Lasssa, Ebola and Marburg viruses all body products and secretions Septicemia Staphylococcus spp. Blood

27. Infection caused by health-care waste Type of infection Causative organism Transmission vehicles Bacteraemia Staphylococcus spp., enterobacter, Klebsiella and streptococcus spp. Blood Candidaemia Candida albicans Blood Viral hepatitis A Hepatitis A virus Faeces Viral hepatitis B & C Staphylococcus spp. Blood and body fluids

28. Health care waste generation in Nepal Studies are carried out on: 92 governmental hospitals ( 67 under MOHP, 3 community hospital, 8 teaching hospitals, 14 NGO’s hospitals) 74 private health facilities/ nursing homes 16 eye hospitals

29. Health care waste generation in Nepal Medical waste composition: 23% infectious, 3% sharp, 12% saline bottles and remaining 62% non infections. Infectious waste generation rate 0.48kg/person/day. Total medical waste generation rate 1.7kg/person/day. Average incinarable waste: 396.77gm/day/bed.

30. Health care waste generation in Nepal On an average , a 150 bed hospital have about 50-100 thermometer breakage in a months and each thermometer contain 0.5-1 gram mercury. On an average 1 gram mercury has been used for dental restoration in 4 patients. Source: MOHP 2009, Ale Devika 2005, NHRC 2002, ENPHO 2000, CEPHED 2006, 2008.

31. Composition of hospital waste in India Paper : 15 % Plastics: 10% Rags: 15% Metal including sharps: 1 Infectious waste: 1.5% Glass: 4% General waste: 53.3 % Source: National Environmental Engineering Research Institute 1997.

32. Medical Waste Generation in Asia Estimates of medical waste generation in some countries

33. Medical Waste Generation in Asia

34. Medical Waste Generation in Asia 0.33 million tons/year in India 0.25 million tons/year in Pakistan (100 ton/day from Karachi alone) 2,000 tons/day in china 60,000 tons/year in Vietnam 255 tons/day in Dhaka alone 47 tons/day in Metro Manila (11 tons/day illegally dumped) Source: Healthcare waste composition in developing Asian countries (WHO,1999)

35. Management of health care waste Effective waste management needs: National Policy, Strategy, plan, guidelines and SOP; Legislation/Rules for waste management; Political commitment; Committed manpower; Good management; Proper budgetary allocation;

36. Management of health care waste Application of local available technology and also according to resource; envelop; Involvement of NGOs; Community participation; Proper capacity development of the service providers; Development of information system in relation to MWM as a part of MIS; Supportive supervision and monitoring.

37. WHO Waste management Cycle

38. Waste Minimization Care full management prevents the accumulation of large quantity of waste. Health care service providers and institutions administrator can play important role in reduction of waste volume. Waste minimization is directly proportional with waste management cost and related risk. Institution can adopt many policies and practices that might reduce the waste volume.

39. Waste Minimization Some policies of waste minimization are- Source reduction- Purchasing and supplies materials which are less wasteful and or generate less medical waste. Stock management- Frequent auditing; use oldest stock first and checking the expired date of products during receiving and supplies of goods.

40. Waste Minimization Some policies of waste minimization are- Encourage use of Recyclable products- Use materials that can be recycled both off-site or on-site. Control at institution level- Centralized purchase and monitoring the receipt and supply procedure of medical goods.

41. Waste Segregation The key of effective waste management is the waste segregation. The waste should be segregated on the basis of the category of waste. The whole waste management depends upon effective waste segregation, because incorrect segregation creates lot of hassles in the down stream of waste management.

42. Waste Segregation If waste is properly segregated, small amount are needed for disposal instead of large quantity of waste, ultimately related manpower, related cost, related risk lowered. If segregation is not properly done, small quantity of hazardous waste has a chance to mix with large volume of non-hazardous waste making the whole volume into hazardous waste.

43. Waste Segregation Segregation of medical waste should always be the responsibility of waste producer and waste should be segregated at the point just after its generation. Once waste is segregated, staffs should never attempt to correct of wrong segregation by placing/transferring items from one container to another.

44. Waste Identification An appropriate way of identifying the waste is by sorting the waste into different COLOR CODE . Color code is easy for identification and thereby easy for safe handling, transportation and waste treatment. The color code varies from country to country , due to socioeconomic status, literacy rate, availability of local resources, countries classification of waste etc.

45. WHO recommended Color Code for developing countries

46. Waste Handling Waste handling means the links between packing, storage and transportation of medical waste from every area of the institution by designated individual.

47. Waste Collection Waste should not accumulate at the point of birthplace. The designated personnel should collect the waste containers by a routine program through the designated route as a part of the waste management plan.

48. Guidelines for waste collection Collectors must wear protective materials . Collection of waste in colored bag or colored covered bins. Content of the container should not exceed three quarter of its capacity. If bag is used for waste collection, tie the neck tightly. Avoid throwing, dragging over floor or holding the bottom of the containers.

49. Guidelines for waste collection No container should be used if damaged or licked. All bins should be covered with lid during collection and transportation of waste. Waste should not be collected more the ¾ of containers capacity. No container should be transported without labeling.

50. Guidelines for waste collection During collection each containers should be replaced with a new one . Collection of Sharp medical waste under maximum precaution. If there is spillage of waste from the container (gently collect the waste into a bin, soak the area with 2% Lysol solution, wait for 30 minutes, then wash and wipe.

51. Waste collection materials Character of the materials depends upon the type of generated medical waste . Its better that the materials should be domestic in origin , so that sustainability of supply could be ensured. The commonly used materials are Colored waste containers or bins, puncture proof container, heavy duty gloves, rubber service gum boots, hand tray, Balcha, waste carrying trolley, rubber apron etc.

52. Placement of color 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.

53. Placement of color bins General waste (Black color bin) could be placed at landing area of the staircase, in the straight long corridor bin could be placed at 50 meter distance, yellow colored bin could be placed out side of the toilet in female ward for collection of sanitary napkins. During replacement of the bin , same colored another bin should be placed at the site.

54. Labeling Waste container should be labeled with some basic information’s: about its waste category, weight of the waste materials, date of collection, and site of waste production. These information could be written on preprinted labels with irremovable or water resistance ink. All waste should be labeled and marked with international symbol especially during transportation .

55. Security Security of medical waste throughout its lifecycle is significantly a challenge , as because there is chance of scavenging in every point of its lifecycle. Scavenging of medical waste especially at the generation site and disposal site must be recognized as threats to institutional infection control program , quality of patient care and community health hazard.

56. Health and safety To ensure the health and safety of the cleaner in waste management through continuous monitoring is important. An appropriate health and safety program includes Training of the worker about related risk. Timely issue and encourage wearing personal protective materials .

57. Health and Safety Immunization of the worker under occupational safety program especially against Hepatitis-B virus and Tetanus . Ensure reporting and post exposure prophylactic treatment. Ensure periodical medical checkup system. Medical surveillance.

58. Personal hygiene In medical waste management personal hygiene is very important. The working place should be provided with continuous water supply and soap/detergent. Hand washing should be ensured on arrival for work, before meal, before living the working area and whenever is necessary.

59. Response to injury and exposure Service providers should be trained to deal with injury and exposure. This program may include In case of accident immediate reporting to the designated authority. Identify items involved in accident. Immediate first aid measure Giving medical attention as soon as possible. Record keeping .

60. Emergency response Should be prepare for accident and or unexpected situation. Should be trained to manage common emergencies, necessary equipment should be in hand and ready at all times. Some common emergencies are Accidental spillage Equipment failure Accidental tear or breakage of containers. Explosion and or fire.

61. 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.

62. In-house transportation A consignment note should accompany the waste during transportation. The trolley or handcart should be easy to clean , loading and unloading, leak proof body, should not be used in any other case other then waste transportation.

63. Temporary in-house storage The store will be a room or area or building within the health care facility depending upon the quantity and quality of waste production and frequency of waste collection. Normally waste should not be stored more then 24 hours .

64. Selection criteria for Temporary in-house storage area Should be properly located to prevent access of unauthorized person. Should have an easy access for workers and collection vehicle. Should be away from food preparation, processing and food store. Provided with sufficient light and sufficient water supply. Should be inaccessible for scavenger, animal and rodents.

65. Selection criteria for Temporary in-house storage area Should be sufficient space for washing and cleaning. Should be equipped with sand, cleaning equipments and fire fitting equipments and reagents. Floor should be elevated and impervious with proper drainage facility. There should be weighting and recording facility . The room should be properly ventilated.

66. Record keeping Accurate record keeping is needed for effective medical waste management. Record keeping might give some important information’s, which are needed for: Assess the recurrent expenditure Assess the quality and quantity of generated waste

67. Record keeping Assess the cost directly related with the man and materials Assess the cost related with waste treatment and disposal method Assess the risk involved with generated waste , amount and nature of accident, amount of damage, measure taken against accident etc. Assess the failures, problem and obstacle in waste management for better compliance of the program.

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69. Transportation for out house management Means collection of stored waste from the health care facilities to the final disposal site. Collection of waste from different institute should be in a covered Van. The driver area should be totally separated from waste carrying area.

70. Strategy of medical waste management Development of awareness among the service providers by sensitization; Proper capacity development of the service providers by providing training; Development of in-house management of waste; Development and adoption of option for the final disposal of waste depending upon the situation, type of hospital, amount of waste production;

71. Strategy of medical waste management Supply of logistics like different color bin, needle crusher, service gloves, boot, mask etc; Establishment of accountability framework; Formation of “Local waste management committee” and plan for implementation; Refresher training program for service providers; Effective Monitoring and supervision .

72. Key consideration for the better management of medical waste Strongly believes the need of alternative approach of MWM. Hospitals will bear the responsibility of safe management of its generated waste. Need for attitude change of service providers, patients and community people. Service providers can contribute positively in reducing waste volume and segregation.

73. Key consideration for the better management of medical waste Committed and well motivated hospital staff can adopts an effective strategy for proper MWM. Government should take positive steps in making guideline Legislation and policy on HWM with ensuring monitoring and supervision.

74. Disposal & Treatment Methods Suitable for Different Categories of Medical Waste Technology or method Infectious waste Anatomical waste Sharps Pharmaceutical waste Cytotoxic waste Chemical waste Radioactive waste Rotary kiln Yes Yes Yes Yes Yes Yes Low-level infectious waste Pyrolytic incinerator Yes Yes Yes Small quantities No Small quantities Low-level infectious waste Single-chamber incinerator Yes Yes Yes No No No Low-level infectious waste Drum or brick incinerator Yes Yes Yes No No No No

75. Disposal & Treatment Methods Suitable for Different Categories of Medical Waste Technology or method Infectious waste Anatomical waste Sharps Pharmaceutical waste Cytotoxic waste Chemical waste Radioactive waste Chemical disinfection Yes No Yes No No No No Wet thermal treatment Yes No Yes No No No No Microwave irradiation Yes No Yes No No No No Encapsulation No No Yes Yes Small quantities Small quantities No

76. Disposal & Treatment Methods Suitable for Different Categories of Medical Waste Technology or method Infectious waste Anatomical waste Sharps Pharmaceutical waste Cytotoxic waste Chemical waste Radioactive waste Safe burial on hospital premises Yes Yes Yes Small quantities No Small quantities No Sanitary landfill Yes No No Small quantities No No No Discharge to sewer No No No Small quantities No No Low-level liquid waste

77. Disposal & Treatment Methods Suitable for Different Categories of Medical Waste Technology or method Infectious waste Anatomical waste Sharps Pharmaceutical waste Cytotoxic waste Chemical waste Radioactive waste Inertization No No No Yes Yes No No Other methods       Return expired drugs to supplier Return expired drugs to supplier Return unused chemicals to supplier Decay by storage

78. Technologies for Treatment and Final Disposal Incineration Chemical disinfection Render inert

79. Incineration Description: A high temperature dry oxidation process that reduces organic and combustible waste to inorganic matter . Many different types of incinerator ranging from the sophisticated to the basic; however, basic incinerators often cause serious emissions problems. Advantages: Requires no pre-treatment. Good disinfection efficiency.

80. Incineration Disadvantages: If not operated effectively may pollute atmosphere High capital and operational costs. Low cost incineration is possible by using a drum or brick incinerator, however, these present large emission problems and are not as effective in the destruction of hazards. Suitable condition: >60% combustible Moisture content < 30%. Not suitable for pressurized gas canisters, reactive chemical waste, PVC, wastes with high heavy metal content, photographic or radiography wastes.

81. Chemical disinfection Description: Chemicals added to the waste to kill/inactivate the pathogens . Shredding is usually necessary before disinfection, as only the surface of intact solid waste will be treated. The waste is then disposed of in a conventional way, e.g. landfill. Advantages: Efficient disinfection when operated well. Some chemical disinfectants are low cost . Shredding reduces volume of waste.

82. Chemical disinfection Disadvantages: Disinfectants may themselves be hazardous to operators & pose risks in the case of leakage and subsequent disposal. Needs highly trained operators . Shredder liable to mechanical failure. Suitable condition: Best for liquid or sewage Inadequate for pharmaceutical, chemical and some types of infectious waste.

83. Render inert Description: Mixing the waste with cement in order to prevent migration of toxic substances from waste into ground water etc. Advantages: Relatively low cost. Low-technology

84. Render inert Disadvantages: Bulky and heavy final waste product to be disposed of. Especially suitable for pharmaceuticals. Suitable condition Not suitable for infectious waste.

85. Wet thermal treatment (including autoclaving) Description: Exposure of shredded waste to high temperature, high-pressure steam. If temperature and contact time is sufficient, most micro-organisms are inactivated. Waste can subsequently be disposed of as municipal waste. Advantages: Relatively low capital and operating costs. Low environmental impact.

86. Wet thermal treatment (including autoclaving) Disadvantages: Shredder liable to mechanical failure. Efficiency of disinfection very sensitive to operational conditions. Suitable condition Not suitable for anatomical, pharmaceutical or chemical wastes.

87. Microwave irradiation Description: Waste shredded, humidified and then irradiated by microwaves. The heat generated destroys micro-organisms. Advantages: Very efficient disinfection when operated well. Environmentally sound. Reduction in volume of waste.

88. Microwave irradiation Disadvantages: Relatively high capital and operating costs. Potential operation and maintenance problems. Suitable condition Not suitable for pharmaceutical or chemical wastes Not suitable for large metal objects.

89. Landfill (Sanitary) Description: Landfill isolates waste from the environment; it requires appropriate engineering preparation, staff to control operations, organized deposition and covering of waste. Waste may be pre-treated (see above). Ideally, healthcare waste is separated from municipal waste. Advantages: Simple, low cost & safe when operated properly.

90. Landfill (Sanitary) Disadvantages: If not operated properly scavengers may access the waste and it may cause pollution of environment etc. Suitable condition Generally suitable

91. Encapsulate Description: Pre-treatment involving filling containers with waste, adding an immobilizing material and sealing the container e.g. bituminous sand, cement mortar. Advantages: Preventing access to HC waste by scavengers. Relatively simple, low cost & safe

92. Encapsulate Disadvantages: Not recommended as sole method for non-sharp infectious waste. Bulky and heavy final waste product to be disposed of. Suitable condition Appropriate for establishments using minimal programs for disposal of sharps, chemical or pharmaceutical residue. Source: WHO, 1999

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