1. Technological advances in bio-medical waste management & disposal Dr. B. N. Gokul Consultant Microbiologist & ICO Wockhardt Hospital Vivus Hospitals Mallige Medical Centre Prof of Microbiology & Infection Control In-charge SDUMC, Kolar

2. What is bio-medical waste? Biomedical waste means any waste, which is generated during the diagnosis, treatment or immunization of human beings or animals, in research activities or in the production or testing of biologicals and the animal waste from slaughter houses or any other similar establishment. All biomedical waste are hazardous. In hospital it comprises of 15% of total hospital waste.

3. Bio-medical waste

4. Categories of bio-medical waste Category No.1- Human Anatomical Waste Human tissues, organs, and body parts Category No.2 - Animal waste Animal tissues, organs, body parts, carcasses, bleeding parts, fluid, blood and experimental animals used in research; waste generated by veterinary hospitals and colleges; discharge from hospitals and animal houses

5. Categories of bio-medical waste (contd…..) Category No.3 - Microbiology & Biotechnology Waste Waste from laboratory cultures, stocks or specimens of micro-organisms, live or attenuated vaccines, human and animal cell cultures used in research, infectious agents from research and industrial laboratories, waste from production of biologicals, toxins, dishes and devices used for transfer of cultures Category No.4 - Sharps waste Needles, syringes, scalpels, blades, glass, etc. that may cause puncture and cuts, both used and unusable

6. Categories of bio-medical waste (contd…..) Category No.5 - Discarded Medicines and Cytotoxic drugs Waste comprising of outdated, contaminated and discarded medicines Category No.6 - Soiled waste Items contaminated with blood/ body fluids including cotton dressings, soiled plaster casts, linens, beddings, other material contaminated with blood

7. Classification of bio-medical waste (contd…..) Category No. 7- Solid waste Waste generated from disposable items, other than sharps, such as tubings, catheters, intravenous sets, etc Category No. 8 - Liquid waste Waste generated from laboratory, washing, cleaning, housekeeping and disinfecting activities

8. Classification of bio-medical waste (contd…..) Category No.9 - Incineration ash Ash from incineration of any bio- medical waste Category No.10 - Chemical waste Chemicals used in production of biologicals, disinfectants, insecticides, etc.

9. What is bio-medical waste (BMW) management? It is the segregation, collection, treatment, transportation and disposal of the hospital waste It is a part of hospital hygiene, infection control and maintenance activities.

10. Rationale of bio-medical waste management Only 15% of bio-medical waste is hazardous When hazardous waste is not segregated at the source of generation and mixed with non-hazardous waste, 100% waste becomes hazardous. The reasons for BMW management are: Injuries from sharps leading to infection to all categories of HCWs Healthcare associated infections in patients from poor infection control practices and poor waste management

11. Rationale of bio-medical waste management (contd…..) Risk of infection outside hospital for waste handlers and at times general public living in the vicinity of hospitals Risk associated with hazardous chemicals and drugs to persons handling wastes at all levels Disposable" being repacked and sold by unscrupulous elements without even being washed 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

12. Approach for bio-medical waste management Based on Bio-medical Waste (Management and Handling) Rules 1998, notified under the Environment Protection Act by the Ministry of Environment and Forest (Government of India), approach comprises of : 1.Segregation of waste 2.Collection of bio-medical waste 3.Storage of waste 4.Transportation 5.Treatment & disposal of hospital waste 6.Safety measures 7.Coordination between hospital and outside agencies

13. FOCUS ON SEGREGATION FIRST Should be done at the site of generation of BMW e.g. all patient care activity areas, diagnostic service areas, operation theatres, labour rooms, treatment rooms etc. The responsibility of segregation should be with the generator of bio-medical waste i.e. doctors, nurses, technicians etc. The bio-medical waste should be segregated as per categories applicable.

14. Type of container and colour for collection of bio-medical waste NoCategoryType of container Colour coding 1Human anatomical wastePlastic bagYellow 2Animal wastePlastic bagYellow 3Microbiology and Biotechnology waste Plastic bagYellow/Red 4 Waste sharp Puncture proof container Blue/ white/ translucent 5Discarded medicines and Cytotoxic waste Plastic bagsBlack 6Solid waste (Soiled)Plastic bagYellow/ Red

15. Type of container and colour for collection of bio-medical waste NoCategoryType of container Colour coding 7*Solid (plastic)Plastic bagBlue / white 8Liquid waste….. 9Incineration wastePlastic bagBlack 10Chemical waste (solid)Plastic bagBlack

16. Type of container and colour for collection of bio-medical waste Those plastics which contains liquid like blood, urine, pus, etc., should be put into red colour bag for microwaving / autoclaving and other items should be put into blue or white bag after chemical treatment and mutilation / shredding

17. Segregation of bio-medical waste

18. Collection of bio-medical waste Collection should be done as per BMW Management and Handling Rules 1998. The collection bags and the containers should be labelled as per guidelines, i.e. symbols for biohazard and cytotoxic. Labels shall be non-washable and prominently visible

19. Collection of bio-medical waste (contd….) Separate container at every point of generation for general waste to be disposed of through municipal authority Trolleys, used to collect hospital waste, be designed, there should be no leakage or spillage of BMW while transporting

20. Collection of bio-medical waste (contd…) Location of containers- All containers having different coloured plastic bags should be located at the point of generation of waste Waste bags filled up to three-fourth capacity, tied securely and removed from the site of generation to the storage area regularly The colour bags should be replaced, garbage bins, cleaned with disinfectant regularly.

21. Storage of waste Refers to holding BMW for a certain period of time at the site of generation till transit for treatment and final disposal. No untreated BMW stored beyond a period of 48 hours Requires permission of the prescribed authority if for any reason becomes necessary to store the waste beyond 48 hours

22. Transportation Transportation of waste within the hospital –Avoid passage of waste through patient care areas as far as possible –Separate time schedules for transportation of bio-medical waste and general waste –Dedicated wheeled containers, trolleys or carts with proper label –Trolleys or carts cleansed and disinfected in the event of any spillage

23. Transportation Transportation of waste for disposal outside the hospital –through desiccated vehicles specially constructed for the purpose having fully enclosed body, lined internally with stainless steel or aluminium to provide smooth and impervious surface which can be cleaned –The drivers compartment separate from the load compartment with a bulkhead –The load compartment provided with roof vents for ventilation.

25. Treatment & disposal of bio-medical waste Yellow bags- (Cat. 1, 2, 3, 6) Incineration / deep burial Red bags (Cat. 3,6) – microwave / autoclave treatment Blue/ White translucent bag (Cat. 4,7) - should be sent to shredder after autoclaving / microwaving / chemical treatment Black – Cat. 5, Cat. 9 and Cat.10 (solid) Disposal in secured landfill Liquid waste: 1 part bleach to 9 parts contaminated liquid – let stand for 20 to 30 minutes. After treating, dispose down drain with lots of H 2 O

26. Disposal of bio-medical waste General waste (non-hazardous, non-toxic, non-infectious –Through local municipal authority Bio-medical waste –Incineration: should be installed and made operational as per specification under the BMW rules 1998 regarding the incinerator and norms of combustion efficiency and emission levels The temperature of the primary chamber shall be 800 +/- 50 deg.C° secondary chamber temperature at 1050 +/- 50 deg.C° Minimum stack height shall be 30 meters above ground Note: Waste to be incinerated shall not be chemically treated with chlorinated disinfectants Chlorinated plastics shall not be incinerated

27. Disposal of bio-medical waste- Deep burial Option in towns with population less than five lakhs 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 pit with soil. Animals should not have any access to burial site On each occasion when wastes are added to the pit, layer of 10 cm of soil shall be added to cover the wastes Burial must be performed under close and dedicated supervision The deep burial site should be relatively impermeable and no shallow well should be close to the site. The pits should be distant from habitation 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 deep burial site will be authorized by the prescribed authority The institution shall maintain a record of all pits for deep burial.

28. Treatment of Bio-medical waste (Category 3,4,6,7) - Autoclave Type of autoclaveTempPressureTime (minutes) Gravity flow autoclave121° C15 psi60 135° C31 psi45 149° C52 psi30 Vacuum autoclave121° C15 psi45 135° C31 psi30

29. Treatment of Bio-medical waste- (Category 3,4,6,7) Microwaving Should not be used for cytotoxic, hazardous or radioactive waste, contaminated animal parts and large metal parts Should completely and consistently kill bacteria and other pathogenic organisms. Biological indicators of Bacillus subtilis spores be used to monitor

30. Treatment of bio-medical waste Shredding- The plastics (IV bottle, IV sets, syringes, catheters, etc.), sharps (needles, blades, glass, etc) should be shredded but only after chemical treatment / microwaving/ autoclaving, ensuring disinfection Needle destroyers can be used for disposal of needles directly without chemical treatment

31. Treatment of bio-medical waste Secured land fill: The incinerator ash, discarded medicines, cytotoxic substances and solid chemical waste should be treated by this option

32. Treatment of bio-medical waste It may be noted that there are multiple options available for certain category of waste The individual hospital can choose the best option depending upon treatment facilities available The management of radioactive waste should be undertaken as per the guidelines of BARC

33. Safety Measures Required for –Clinical workers generating waste –Workers collecting and transporting wastes -- Staff operating hospital incinerator –Staff taking waste to municipal bins –Municipal worker collecting waste at the municipal bins and transporting to dumping sites –Rag pickers Education and training programs must be developed to speak to each category in a way that will best meet the needs, build understanding and change behavior in that population

34. Coordination between hospital & outside agencies Hospital authorities should have constant interaction with the municipal authorities so that the general category of waste is regularly taken out of the hospital premises for further disposal Involvement of private sector / NGOs for creation of common facilities for treatment Coordination with NGOs and environmental groups, for public awareness & education

35. Coordination between hospital & outside agencies Sharing of facility by hospitals which do not have their own facility for treatment Hospitals having additional capacity may extend their facility to nearby smaller hospital or healthcare units Coordinated agencies required to take care of disruption of waste treatment equipment in a unit