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Disposal of Clinical Wastes: Tata Memorial Hospital Experience Dr Rohini Kelkar M.D., D.P.B. Professor & Head, Dept of Microbiology Tata Memorial Hospital,

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Presentation on theme: "Disposal of Clinical Wastes: Tata Memorial Hospital Experience Dr Rohini Kelkar M.D., D.P.B. Professor & Head, Dept of Microbiology Tata Memorial Hospital,"— Presentation transcript:

1 Disposal of Clinical Wastes: Tata Memorial Hospital Experience Dr Rohini Kelkar M.D., D.P.B. Professor & Head, Dept of Microbiology Tata Memorial Hospital, Mumbai

2 No one was ever really taught. Each has to teach himself. Swami Vivekananda The Reality Ignorance Commercialization of science Apathy The Concerns Occupational Public health Environmental

3 The only documented risk of transmission of infections from waste to healthcare workers is through sharps There is however a potential for transmission of several microbial infections due to dumping of untreated wastes by healthcare facilities. Mixing of a small quantity of infectious waste with municipal garbage converts the entire waste to infectious Segregation of wastes at source followed by appropriate treatment is the key to the success of a waste management strategy The Science

4 Hospital waste Hazardous Non-hazardous NoninfectiousInfectious KitchenRecyclables Non-sharps Patient contaminated waste Anatomical Equipment Specimens Laboratory waste Non-plastics Sharps: needles, scalpel blades, scalp veins, glass contaminated with blood Radioactive Cytotoxic drugs Toxic Chemicals Plastics PVC, PE PET, PS contaminated cotton waste, gauze, linen

5 The Social Issue: Ragpickers

6 The TMH Pathway Closure of the incinerator Awareness programs for all the staff Refashioning the storage area Street play Posters

7 Incinerator circa CLEARLY DEFINE THE PROBLEM

8 Appropriate placement of Colour Coded Bins Radioactive Waste Segregation at source into defined categories using a simplified system. 2. FOCUS ON SEGREGATION FIRST

9 Sharps Disposal 3. INSTITUTE A SHARPS MANAGEMENT SYSTEM

10 Waste Audit 4. KEEP FOCUS ON REDUCTION

11 About Sharps: The only documented transmission of infection from waste to HCWs is through sharp injuries. Thus safe disposal of sharps is the first priority. Sharp injuries: Before or during use (17%) After Use but before disposal (70%) During or after disposal (13%) (Our Experience: Majority of sharp injuries occur due to improper disposal and waste handlers are the victims) Safe Disposal of Sharps: Do not recap needles. If essential learn the right way to do so. 5. ENSURE WORKER SAFETY THROUGH EDUCATION, TRAINING AND PROPER PERSONAL PROTECTIVE EQUIPMENT

12 Collection network.. 6. PROVIDE SECURE COLLECTION AND TRANSPORTATION

13 Waste management Strategy: 1.Reduce Risks and Liabilities: This should be detailed through written policies and continuing training and education of hospital staff. 2.Control Costs: Audit of current practices, search for waste minimization practices is a continuing process. 3.Plan for Future: Look for alternative technologies, co-operative facilities and means of diversification. 4.Commitment towards protecting Human Health and the Environment 7. DEVELOP PLANS AND POLICIES

14 Infection Awareness Week Street Play 8. INVEST IN TRAINING

15 9. DEVELOP THE INFRASTRUCTURE

16 10. Evaluation of Technologies

17 Evaluation of Non Burn Technologies for Medical Waste Treatment

18 1. Demonstrated Performance CategoryRatingWeightScore 1.1Stage of Development 1.2Number of Operational Systems 1.3Year of Successful Operations

19 2. Technical & Performance Criteria CategoryRatingWeightScore 2.1Process Capacity 2.2Waste Exclusions or Limitations 2.3Waste Size Limitations 2.4Weight Change 2.5Volume Change 2.6Recognizability / Disfigurement 2.7Decontamination 2.8Performance Data 2.9Process Complexity 2.10Operator Training

20 3. Vendor Qualifications CategoryRatingWeightScore 3.1Number of Vendors 3.2Vendor Resources 3.3Vendor Diversity and Services

21 4. Environmental & Permitting Issues CategoryRatingWeightScore 4.1Air Emissions 4.2Liquid Effluents 4.3Treated Residues 4.4Permit ability 4.5Public Perception

22 5. Occupational Health & Safety Issues CategoryRatingWeightScore 5.1Routine Exposures 5.2Maintenance and Repair Exposures

23 6. Facility: & Infrastructural Requirements CategoryRatingWeightScore 6.1Space Requirements 6.2Construction Requirements 6.3Utility Requirements 6.4Space / Facility Requirements

24 7. Economics CategoryRatingWeightScore 7.1Capital Costs 7.2Annual Costs 7.3Life-Cycle Costs GRAND TOTAL SCORE

25 On September 10, 1999, well before the first dead line set by the Ministry of Environment and Forest, 31 December Inauguration of Tata Memorial Hospital waste treatment facility

26 Selection of Technology and Implementation is not the setting sun Evaluation is a continuous process

27 Max. medical waste collected in a day Average no. of loads required/day Average medical waste treated in kgs/day Average medical waste collected in a month 5,4985,6435,2665,9176,2847,2256,3696,959 Percentage down time of the system TMH Waste Audit Nov to Dec Total infectious waste treated – 614 tonnes. 83,511 kg. in Cost of treatment = Rs / kg.

28 Max. medical waste collected in a day Average no. of loads required/day 44 Average medical waste treated in kgs/day Average medical waste collected in a month 7,6237,674 Percentage down time of the system TMH Infectious Waste Audit Total infectious waste treated = 800 tonnes. Cost of treatment = Rs. 14 / kg.

29 TMH Waste Management Waste is Sterilized, Dehumidified, Shredded and reduced in terms of Weight and Volume by 75%. It is not recognizable as Medical Waste

30 Hazardous Waste

31 Environment News Greenpeace March 7th, 2001 KODAIKANAL, India -- Greenpeace today accused Anglo-Dutch multinational Unilever, owners of Lipton Tea and Dove soap, of double standards and shameful negligence for allowing its Indian subsidiary, Hindustan Lever, to dump several tonnes of highly toxic mercury waste in the densely populated tourist resort of Kodaikanal and the surrounding protected nature reserve of Pambar Shola, in Tamilnadu, Southern India. On 15 April, 2005, a 51 year-old asbestos laden ship, Kong Fredrick IX was on its way to Alang ship breaking yard, Gujarat for scrapping. The ship's new owners Jupiter Ship Management, a Mumbai based company, had renamed it to 'MV Riky'. Connie Hedegaard, Denmark's environment minister alerted the Indian environment minister saying, "I believe our interests are joint - and I call on you to co-operate in this case by denying the ship to be dismantled in India - and refer the ship to return to Denmark to be stripped of the hazardous waste."

32 Indias significant economic growth and rise in industrialization coupled by lax government enforcement of anti-pollution laws and regulations have had a detrimental effect on Indias natural environment. Hazardous waste from industrial processes, medical waste and Indias thriving scrap recycling businesses pollutes Indian air, soils and waterways.

33 India is a signatory to the three conventions on hazardous chemicals and waste: The Basel Convention on the Control of Trans-boundary Movement of Hazardous Waste and their Disposal, The Rotterdam Convention on the Prior Informed Consent Procedure for Certain Hazardous Chemicals and Pesticides in International Trade and The Stockholm Convention of Persistent Organic Pollutants.

34 The Hazardous Substances Management Division (HSM) of the Ministry of Environment and Forests (MoEF) has the responsibility for promoting safe management and use of hazardous substances, including hazardous waste. The HSM has established three sets of rules: The Hazardous Wastes (Management and Handling) Rules (1989, amended in 2003), The Bio-medial Wastes (Management and Handling) Rules (1998/2000), and The Batteries (Management and Handling) Rules (2001).

35 The HSM relies primarily on the The Central Pollution Control Board (CPCB), The State Pollution Control Boards (SPCBs) or State Pollution Control Committees (SPCCs), and The environmental departments in Indias 25 states to implement, monitor and prosecute.

36 Approximately 5 million tonnes of hazardous waste is produced annually in India. According to a 2003 report, Indian industries in the following five states had generated over 80% of the countrys hazardous waste: Andhra Pradesh, Gujarat, Karnataka, Maharashtra and Tamil Nadu.

37 LandfillCompostingIncinerationRecyclingTransportation AirEmission of CH 4, CO 2 ; odours Emission of SO 2, NO x, HCl, HF, NMVOC, CO, CO 2 N 2 O, dioxins, dibenzofurans, heavy metals(Zn, Pb, Cu, As) Emissions of dust Emissions of dust NO x, SO 2, release of hazardous substances from accidental spills WaterLeaching of salts, heavy metals, biodegradable and persistent organics to groundwater Deposition of hazardous substances on surface water Waste water discharges Risk of surface water and groundwater contamination from accidental spills SoilAccumulation of hazardous substances in soil Landfilling of slags, fly ash and scrap Landfilling of final residues Risk of soil contamination from accidental spills European Commission focus on waste management Pitfalls of the currently available technologies for managing wastes

38 LandfillCompostingIncinerationRecyclingTransportation LandscapeSoil occupancy; restriction on other land uses Visual intrusion; restriction on other land uses Visual intrusion Traffic EcosystemsContamination and accumulation of toxic substances in the food chain Risk of contamination from accidental spills Urban areasExposure to hazardous substances NoiseRisk of exposure to hazardous substances from accidental spills; traffic European Commission focus on waste management Pitfalls of the currently available technologies for managing wastes

39 E-waste How green is your Apple? Aug 25th 2006 From The Economist print edition

40 God proposes, man disposes Waste and taste Dec 11th 2006 From Economist.com The rubbish tip as cultural artefact FRESH Kills landfill in New York, until recently the biggest rubbish tip on earth, was said to be one of the very few man- made objects visible from space, along with the Great Wall of China.

41 LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS Class A Concentration limit: 50 mg/kg A1 Antimony and antimony compounds A2 Arsenic and arsenic compounds A3 beryllium and cadmium compounds A4 Cadmium and beryllium compounds A5 Chromium (VI) compounds A6 Mercury and mercury compounds A7 Selenium and selenium compounds A8 Tellurium and tellurium compounds A9 Thallium and thallium compounds A10 Inorganic cyanide compounds (cyanides) A11 Metal carbonyls A12 Napthalene A13 Anthracene A14 Phenanthrene A15 Chrysene, benzo(a) anthracene, fluoranthene, benzo(a) pyrene, benzo(K)fluoranthene, indeno(1, 2, 3-ed) pyrene and benzo(ghi)perylene A16 Halogenated fused aromatic rings, e.g. polychlorobiphenyls plus derivatives A17 Halogenated aromatic compounds A18 Benzene A19 Dieldrin, aldrin, and endrin A20 Organotin compounds Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002

42 LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002 Class B Concentration limit: 5,000 mg/kg B1 Chromium (III) compounds B2 Cobalt compounds B3 Copper compounds B4 Lead and lead compounds B5 Molybdenum compounds B6 Nickel compounds B7 Tin compounds B8 Vanadium compounds B9 Tungsten compounds B10 Silver compounds B11 Organic halogen compounds B12 Organic phosphorus compounds B13 Organic peroxides B14 Organic nitro-and nitroso-compounds B15 Organic azo-and azo-oxy compounds B16 Nitriles B17 Amines B18 (Iso-and thio-) cyanates B19 Phenol and phenolic compounds B20 Merceptans B21 Asbestos B22 Drilling, cutting, grinding and rolling oil or emulsions thereof B23 Halogen-silanes B24 Hydrazine(s) B25 Fluorine B26 Chlorine B27 Bromine B28 White phosphorus B29 Ferro-silicon and alloys B30 Manganese-silicon B31 Halogen-containing substances which produce acidic vapours on contact with damp air or water, e.g. silicon tetrachloride, aluminum chloride, titanium tetrachloride

43 LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002 Class C Concentration limit: 20,000 mg/kg C1 Ammonia and ammonium compounds C2 Inorganic peroxides C3 Barium compounds, except barium sulphate C4 Fluorine compounds C5 Phosphorus compounds, except the phosphates of aluminum, calcium and iron C6 Bromates, (hypo)bromites C7 Chlorates, (hypo)chlorites C8 Aromatic compounds C9 Organic silicon compounds C10 Organic sulphur compounds C11 Iodates C12 Nitrates, nitrites C13 Sulphides C14 Zinc compounds C15 Salts of per-acids C16 Acid halides, acid amides C17 Acid anhydrides

44 LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002 Class D Concentration limit: 50,000 mg/kg D1 Sulphur D2 Inorganic acids D3 Metal bisulphates D4 Oxides and hydroxides except those of: hydrogen, carbon, silicon, iron, aluminum, titanium, manganese, magnesium, calcium D5 Aliphatic and napthenic hydrocarbons D6 Organic oxygen compounds D7 Organic nitrogen compounds D8 Nitrides D9 Hydrides

45 LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002 Class E Regardless of concentration limit E.1 Highly flammable substances E.2 Substances which generate dangerous quantities of highly flammbale gases on contact with water or damp air.

46 LIST OF PROCESSES GENERATING HAZARDOUS WASTES Ministry of Environment & Forests Hazardous Wastes (Management and Handling) Amendment Rules, Petrochemical processes and pyrolytic operations 2 Drilling operation for oil and gas production 3 Cleaning, emptying and maintenance of petroleum oil storage tanks including ships 4 Petroleum refining/re-refining of used oil/recycling of waste oil 5 Industrial operations using mineral/synthetic oil as lubricant in hydraulic systems or other applications 6 Secondary production and/or use of zinc 7 Primary production of zinc/lead/copper and other non-ferrous metals except aluminium 8 Secondary production of copper 9 Secondary production of lead 10 Production and/or use of cadmium and arsenic and their compounds 11 Production of primary and secondary aluminium

47 LIST OF PROCESSES GENERATING HAZARDOUS WASTES Ministry of Environment & Forests Hazardous Wastes (Management and Handling) Amendment Rules, Metal surface treatment, such as etching, staining, polishing, galvanising, cleaning, degreasing, plating, etc. 13 Production of iron and steel including other ferrous alloys (electric furnaces; steel rolling and finishing mills; Coke oven and by product plant) 14 Hardening of steel 15 Production of asbestos or asbestos-containing materials 16 Production of caustic soda and chlorine 17 Production of acids 18 Production of nitrogenous and complex fertilizers 19 Production of phenol 20 Production and/or industrial use of solvents 21 Production and/or industrial use of paints, pigments, lacquers, varnishes, plastics and inks 22 Production of plastic raw materials

48 LIST OF PROCESSES GENERATING HAZARDOUS WASTES Ministry of Environment & Forests Hazardous Wastes (Management and Handling) Amendment Rules, Production and/or industrial use of glues, cements, adhesive and resins 24 Production of canvas and textiles 25 Industrial production and formulation of wood preservatives 26 Production or industrial use of synthetic dyes, dye-intermediates and pigments 27 Production or industrial use of materials made with organo-silicone compounds 28 Production/formulation of drugs/ pharmaceuticals 29 Production, use and formulation of pesticides including stock-piles 30 Leather tanneries 31 Electronic Industry 32 Pulp & Paper Industry 33 Disposal of barrels / containers used for handling of hazardous wastes / chemicals 34 Purification processes for air and water 35 Purification process for organic compounds/solvents 36 Waste treatment processes, e.g. incineration, distillation, separation and concentration techniques

49 REPORT ON CLINICAL WASTE AUDIT 2005 Infectious waste treated from Jan-Dec ,704 Kilograms Average waste treated per month7,225 Kilograms Weight of sharps treated in 20052,917 Kilograms Average weight of sharps treated per month243 Kilograms Blood & blood products300 liters Liquid Wastes: Total effluent per month164 lakh litres Laundry effluent per month 3 lakh litres Xray developer per month140 litres Hazardous liquids consumed in labs per month588 litres Hazardous chemicals as solids weight per month260 grams Dilution factor of hazardous liquids 27,333.

50 Hazardous liquid waste / month: Sr. NoChemicals / Reagents Lits. 110% Formalin 100 2Xylene Basic fuchsin Haematoxylin stain 1.0 5Nitric Acid Anhydrous Aluminum Chloride.005 7Hydrochloric acid.800 8Diamino benzidine Hydrogen peroxide Glacial acetic acid Gluteraldehyde Ethidium bromide Propane / Butane WD40 (Petroleum distillate) Benzoin tincture Lugols Iodine Phenol (carbolic acid) Ammonia solution Lactic acid Sulfuric acid.100 Total

51 Hazardous solid waste / month: Sr. NoChemicals / ReagentsWeight (Grams) 1Benzidine dihydrochloride0.5 2Naphthol phosphate.060 3Pararosaline hydrochloride1.0 4Sodium-fluoride.200 5Potassium dihydrogen phosphate Dipotassium hydrogen phosphate Benzidine G.R.1.0 8Zine sulphate Barium chloride Phenol crystals Naphthylamine Naphthol Sodium-polyanethol sulphonat Sodium hydroxide pellet Sulfonilic acid Trichloroacetic acid2.1 Total

52 In Conclusion: Key Issues Awareness and education Reporting systems & documentation Segregation of identified clinical infectious wastes at source Timely treatment by non-polluting technologies on-site or off-site Waste audit Waste monitoring systems Elevation of safety standards by all healthcare facilities All HCWs must have hygiene in their genes.

53 Men occasionally stumble over the truth but most of them pick themselves up and hurry off as if nothing has happened. - Sir Winston Churchill.

54 Thank You


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