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Indian Journal of Forensic Medicine & Toxicology

Biomedical Waste Management - An Emerging Concern in Indian Hospitals

Author(s): Virendar Pal Singh, Gautam Biswas, Jag Jiv Sharma

Vol. 1, No. 1 (2007-07 - 2007-12)

Print-ISSN: 0973-9122; Electronic-ISSN: 0972 9130;

Virendar Pal Singh(1), Gautam Biswas(2), Jag Jiv Sharma(3)

(1)Assistant Professor, (2)Associate Professor, (3)Prof & Head
Department of Forensic Medicine, Dayanand Medical College & Hospital, Ludhiana.

ABSTRACT

The waste produced in the course of health care activities carries a higher potential for infection and injury than any other type of waste1. The present scenario of biomedical waste (BMW) management in Indian hospitals is grim. However there is an emerging concern regarding biomedical waste management, particularly as a result of notification of Bio Medical Waste (Management and Handling) Rules, 1998 which makes it mandatory for the health care establishments to ensure that such waste is handled without any adverse effect to human health and environment. This article intends to create awareness amongst the personnel involved in health care services.

KEY WORDS: Bio Medical waste (BMW), Bio Medical Waste (Management and Handling) Rules, Indian Hospitals

INTRODUCTION

WHAT IS BIO MEDICAL WASTE?

“Bio Medical waste” is any waste, which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining to or in the production or testing of biologicals and categories mentioned in schedule 1 of Bio Medical Waste (Management and Handling) Rules2.

“Biologicals” is any preparation made from organisms or micro-organisms or product of metabolism and biochemical reactions intended for use in the diagnosis, immunization or the treatment of human beings or animals or in research activities pertaining thereto2.

SOURCE OF BIO MEDICAL WASTE

Biomedical waste is generated in hospitals, nursing homes, clinics, medical laboratories, blood banks, animal houses etc. Such a waste can also be generated at home if health care is being provided there to a patient (e.g. injection, dressing material etc.)

Classification 3

Approximately 75-90% of the biomedical waste is non-hazardous and as harmless as any other municipal waste. The remaining 10-25% is hazardous and can be injurious to humans or animals and deleterious to environment. It is important to realise that if both these types are mixed together then the whole waste becomes harmful.

Table 1: Classification of Bio-Medical Waste

Classification of Bio-Medical Waste

PROVISIONS OF THE LAW

Safe disposal of biomedical waste is now a legal requirement in India. The ministry of Environment and Forests notified the Bio Medical Waste (Management and Handling) Rules, 1998 in July 1998. In accordance with these rules, it is the duty of every “occupier” i.e. a person who has the control over the institution or its premises, to take all steps to ensure that waste generated is handled without any adverse effect to human health and environment. The hospitals, nursing homes, clinics, dispensaries, pathological laboratories etc., are therefore required to set in place the biological waste treatment facilities. It is however not incumbent that every institution has to have its own waste treatment facility. The rule also envisages that common facility or any other facilities can be used for waste treatment. However it is incumbent on the occupier to ensure that the waste is treated with in a period of 48 hours. Bio Medical Waste (Management and Handling) Rules have six schedules as briefed in Table 22.

Schedule Contents
Schedule I Classification of biological waste in carious categories (Table 3)
Schedule II Color coding and types of containers to be used for each category of biomedical waste (Table 4)
Schedule III Proforma of the label to be used on container / bag
Schedule IV Proforma of the label for transport of waste container / bag
Schedule V Standards for treatment and disposal of wastes
ScheduleVI Deadline for creation of waste treatment facilities

Objectives of Bio Medical Waste Management

Objectives of BMW management are:

  • To prevent transmission of disease from patient to patient, from patient to health worker and vice versa
  • To prevent injury to the health care worker and workers and workers in support services, while handling biomedical waste
  • To prevent general exposure to the harmful effects of the cytotoxic, genotoxic and chemical biomedical waste.

BIO MEDICAL WASTE MANAGEMENT PROCESS

Handling, segregation, mutilation, disinfection, storage, transportation and final disposal are vital steps for safe and scientific management of BMW in any establishment.

WASTE COLLECTION AND SEGREGATION

Waste should be collected and segregated at the site generation itself. Its aim is to keep the harmful waste separate from the harmless and noncontagious waste. The key to minimization and effective management of biomedical waste is segregation and identification of the waste. The most appropriate way of identifying the categories of biomedical waste is by sorting the waste in to color coded plastic bags or containers in accordance with schedule II of Bio Medical Waste (Management and Handling) Rules as given in Table 3 and Table 42.

Table 3: Categories of biomedical wastes and methods of their disposal.2

Category Waste Type Treatment and Disposal Method
Category 1 Human Wastes (Tissues, organs, body parts Incineration @/ deep burial *
Category 2 Animal Waste Incineration @/ deep burial *
Category 3 Microbiology and Biotechnology waste Autoclave/microwave/incineration@
Category 4 Sharps Disinfection (chemical treatment)+/autoclaving/microwaving and mutilation shredding**
Category 5 Discarded Medicines and Cytotoxic Drugs Incineration@/ destruction and drugs disposal in secured landfills
Category 6 Contaminated solid waste Incineration@/autoclaving / microwaving
Category 7 Solid waste (disposable items other than sharps) Disinfection by chemical treatment+ microwaving/autoclaving & mutilation shredding*
Category 8 Liquid waste (generated from laboratory washing, cleaning, housekeeping and disiunfecting activity) Disinfection by chemical treatment+ and discharge into the drains
Category 9 Incineration ash Disposal in municipal landfill
Category 10 Chemical Wastes Chemical Treatment + and discharge in to drain for liquids and secured landfill for solids

@ There will be no chemical treatment before incineration. Chlorinated plastic shall not be incinerated.

* Deep burial shall be an option available only in towns with population less than 5 lakhs and in rural areas.

+ Chemical treatment using at least 1% hypochlorite solution or any other equivalent chemical reagent. It must be ensured that chemical treatment ensures disinfection.

** Mutilation/shredding must be such, so as to prevent unauthorized reuse.

Color Coding Type of Container Waste Category Treatment Option
Yellow Plastic Bag Cat 1,2,3,6 Incineration / deep burial
Red Disinfected container / plastic bag Cat 3,6,7 Autoclave/microwave/chemical treatment
Blue/white translucent Plastic bag/ Puncture proof Cat 4,7 Autoclave/microwave/chemical treatment and destructin shredding
Black Plastic bag Cat 5,9,10 Disposal in secure landfill

NOTES

  1. Color coding of waste management with multiple treatment options shall be selected depending on the treatment option chosen.
  2. Waste collection bags for waste types needing incineration shall not be made of chlorinated plastics.
  3. Categories 8 & 10 (liquid) do not require container/bags.
  4. Category 3 if disinfected locally need not be put in containers/bags.

PROCEDURE FOR WASTE COLLECTION3

  1. Specifically colored plastic bag should be kept in its container. Bins and bags should bear the biohazard symbol.
  2. As soon as three fourth of the bag is full of waste it should be removed from the container, tied tight with a plastic string and properly labeled.
  3. Under no circumstances, an infectious waste should be mixed with the non-infectious waste.
  4. Collection of disposable items (syringes, I/V bottles, catheters, rubber gloves etc) should be undertaken when they have been mutilated (cut) chemically disinfected (by dipping in 1% hypochlorite solution for 30min.)
  5. Syringe barrel should always be separated from the plunger before disinfection. Needles should be destroyed with needle destroyer. Manual mutilation of sharps should never be tried as it may cause injury. All other sharps must be strongly disinfected (chemically) before they are shredded or finally disposed. Sharps should be kept in puncture proof containers and properly labeled.
  6. Biomedical waste handlers should be trained in handling the waste and made aware of proper way of handling waste to avoid injury and accidents.

TRANSPORTATION AND STORAGE

The waste may be temporarily stored at the central storage area of the hospital and from there it may be sent in bulk to the site of final disposal once or twice a day depending upon the quantum of waste. During transportation following points should be taken care of:

  1. Ensure that waste bags/containers are properly sealed and labeled.
  2. Bags are picked up from the neck and placed so that bags can be picked up by the neck again for further handling. Hand should not be put under the bag. At a time only one bag should be lifted.
  3. Manual handling of waste bags should be minimized to reduce the risk of needle prick injury and infection.
  4. BMW should be kept only in a specified storage area.
  5. After removal of the bag, clean the container including the lid with an appropriate disinfectant.
  6. Waste bags and containers should be removed daily from wards / OPDs or even more frequently if needed (as in Operation Theatres, ICUs, labour rooms) Waste bags/containers should be transported in a covered wheeled containers or large bins in covered trolleys.
  7. BMW storage area should be separate from the general waste storage area.

CENTRAL STORAGE3

  • The central storage area in a hospital should be ideally situated on the ground floor near the rear entrance. This makes the transportation of waste to the site of final disposal easier.
  • The central storage area should have sufficient storage capacity to store the required number of waste bags, depending upon the quantum of waste generated in the hospital. It should have the storage capacity of at least 2 days’ waste.
  • It should have good flooring, light, ventilation, water supply and drainage system.
  • A full time storekeeper should be there to receive and dispatch the waste and to maintain proper record.
  • As per rules BMW can not be stored for more than 24 to 48 hrs.(Refrigerated storage room should be available where wastes have to be stored in bulk for over 48 hrs.)

TRANSPORT TO FINAL DISPOSAL SITE

Transportation from health care establishment to the site of final disposal in a closed motor vehicle (truck, tractor-trolley etc.) is desirable as it prevents spillage of waste on the way. Vehicles used for transport of BMW must have the “Bio-Hazard” symbol and these vehicles should not be used for any other purpose.

DISPOSAL OF BIO MEDICAL WASTE PRETREATMENT

The infected waste that can not be incinerated (e.g. Plastic and rubber items, sharps) has to be disinfected first, before it is sent for final disposal.

FINAL DISPOSAL

Incineration is a high temperature dry oxidation process, which reduces organic and combustible waste to inorganic incombustible matter. This method is usually used for the waste that can not be reused, recycled or disposed of in landfill site.

Characteristics of waste1 suitable for incineration are:

  1. Low heating volume – above 2000 Kcal/Kg for single chamber incinerators and above 3500 Kcal/Kg for pyrolytic double chamber incinerators.
  2. Content of combustible matter above 60%.
  3. Content of non combustible matter below 50%.
  4. Content of non combustible fines below 20%.
  5. Moisture content below 30%.

Waste types1 not to be incinerated are:

  1. Pressurized gas containers.
  2. Large amount of reactive chemical wastes.
  3. Silver salts and photographic or radiographic wastes.
  4. Halogenated plastics such as PVC.
  5. Waste with high mercury or cadmium content such as broken thermometers, used batteries.
  6. Sealed ampoules or ampoules containing heavy metals.

TYPES OF INCINERATORS1

  1. Single chamber furnaces with static grate. These should be used only if pyrolytic incinerators are not affordable.
  2. Double Chamber Pyrolytic Incinerators. These are the most commonly used incinerators. In the first (pyrolytic) chamber, waste is destroyed through an oxygen deficient, medium temperature combustion process (800° C).This produces solid ashes and gases. In the second chamber gases are burnt at a high temp.(900-1200° C) using an excess of air to minimize smoke and odor. This type of incinerator is somewhat expensive and requires trained personnel to handle it.
  3. Rotary Kilns. It comprises of rotating oven and a post combustion chamber. They are used to burn chemical wastes (chemicals, pharmaceuticals including cytotoxic drugs).

SAFE PIT FOR SHARPS

Sharps (needles and blades etc) are being used in a day to day practice in all health care establishments. To avoid recycling of sharps, their burial in safe pit is an effective and economical disposal method. It can be constructed by 5 feet deep circular concrete ring of 3’ diameter. A slab is used on top in which GIC pipe with 5” or 6” diameter is used which is fitted lock and key arrangements. Size of the pit may vary as per the quantum of sharp waste to be disposed of. The pit is plastered inside at bottom and around. When it is filled up, cement slurry can be used to close it and second pit is constructed.

LANDFILL DISPOSAL

It is another method of final disposal of BMW. If a municipality or medical authority genuinely lacks the means to treat the waste before disposal, sanitary landfill observing certain standards can be as an acceptable choice especially in developing countries.

Standards for deep burial2

  1. A pit or trench should be dug about 2 meters deep. It should be half filled with waste, then covered with lime within 50 cm of the surface, before filling the rest of the soil with soil.
  2. It must be ensured that animals do not have any access to burial site.
  3. On each occasion, when wastes are added to the pit, a layer of 10 cm of soil shall be added to cover the wastes.
  4. Deep burial site should be relatively impermeable and no shallow well should be close to the site. The site should be away from the residential area and the vicinity of drinking water so as to avoid the risk of pollution.
  5. The location of deep burial site will be authorized by the prescribed authority.
  6. The institution shall maintain a record of all pits for deep burial.

AWARENESS AND EDUCATION

In India hospitals and other health care establishments are not well equipped to handle the enormous amount of biomedical waste. There is an urgent need to raise the awareness amongst all concerned. Information can be disseminated through organizing seminars, workshops, practical demonstrations, group discussions, lectures etc. It is vital to formulate an effective education and training programs specific for different target groups involved in biomedical waste handling and management.

CONCLUSION

The hospital waste, in addition to the posing risk to the patients and personnel who handle these wastes, is also a threat to the public health and environment4,5. It is emerging as a health hazard to the community at large. Keeping in view, inappropriate management of biomedical wastes, the Ministry of Environment and Forests notified the “Bio Medical Waste (Management and Handling) Rules 1998.” These rules are meant to protect the society, patients and health care workers. The most imperative component of the waste management plans is to develop a system and culture through education, training and persistent motivation of the health care staff.

REFERENCES:

  1. Park K. Hospital Waste Management. Park’s Textbook of Preventive and Social Medicine. M/s Banarasidas Bhanot Publications, New elhi. 18th Edn, 2005: 595-598.
  2. Bio Medical Waste (Management and Handling) Rules, 1998.
  3. Sharma M. Hospital Waste Management and its Monitoring. Jaypee Brothers, New Delhi.1st Edn, 2002.
  4. Rao SKM, Ranyal RK, Bhatia SS, Sharma VR. Bio Medical Waste Management: an Infrastructural Survey of Hospitals. MJAFI, 2004; 60(4): 379-382.
  5. Singh IB, Sharma RK. Hospital Waste Disposal System and Technology. Journal of Academy of Hospital Administration. July 1996; 8(2): 44-48.

Corresponding Author: Dr.Virendar Pal Singh
215 – A, Sewak Colony, Patiala, Punjab
email: singhvp(at)gmail.com

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