1. Bio-Medical Waste Management Satish Sinha

2. History of medical waste Medical Waste Tracking Act in US I Draft Rules in India–1995 Final Rules in 1998, 2 amendments and 5 guidelines Evolution of Rules and Practices through National Experiences National Guidelines on BMW, Guidelines on Incineration, CTFs, Immunization Waste and Mercury

3. Various networks NGOs Health Care Without Harm (HCWH) Injection safety: SIGN (Safe Injection Global Network)SIGN Anti-incineration: GAIA (Global Anti Incinerator Alliance) Mercury Zero Mercury World Health Assembly Patient safety

4. Stockholm Convention on Persistent Organic Pollutants an international environmental treatyenvironmentaltreaty aims to eliminate or restrict the production and use of persistent organic pollutants (POPs).persistent organic pollutants entered into force on 17 May 2004 with ratification by 128 and 168 signatories. ratification

5. Basel Convention Control of Tran boundary Movement of Hazardous Wastes and Their Disposal Minimize hazardous waste generation and dispose it nearest to the point of generation

6. Environmental Regulations Environment Protection Act, 1986 BMW Rules 1998 Municipal Waste (Management and Handling) Rules, 2000 Atomic Energy Act Hazardous Wastes (Management & Handling) Rules, 1989 E-Waste Rules Batteries (M&H) Rules 2001 Manufacture, Storage and Import of Hazardous Chemicals rules, 1989

7. Patient safety and Bio-medical waste management In 2002 World Health assembly, passed a resolution calling member states to work for safety of Patients. In Oct. 2004, World alliance for Patient safety was formed, who have identified certain challenges in relation to safety of patients. First Challenge is “Clean care is Safer Care” (2005) A formal pledge committing to address health care-associated infection in the country was signed by Government of India.

8. Priority areas for Patient safety Safe clinical practices and hand hygiene Safe Surgical practices Blood Safety Safe Injections Practices Health Care Waste Management Rules and guidelines are available but implementation is very poor. Lack of training or poor training is also a factor. It has not been given the due priority by most of the states and dedicated budget is required. All states should focus on this.

9. Health care associated infections Complicate between 5-10% of admissions in acute care hospitals in industrialized countries It is estimated that this risk is up to 20 times higher in developing world At any given time, 1.4 million people worldwide suffer from HAI, and at least 50% of HCAI are preventable.

10. Unsafe injections India contributes to 25%-30% of the global injections (WHO, 1999) Annual injection usage ~ 3 – 6 billion, of this nearly two-thirds (62.9%injections) unsafe India CLEN Study 2002-04

11. Why Follow Universal Precautions The prevalence rate of blood born disease- Hepatitis B 38/1000, HIV 7/1000 (NACO 1993) Difficult to test each patient NSI and other sharp injuries are the key Canadian health issue, affecting 70000 people per year and costing around dollar 140 million. A safety programme at Toronto Hospital achieved 80% reduction in injuries within an year.

12. What is this concern for? Infectious waste (solid and liquid) Sharps waste Cytotoxic waste Pharmaceutical waste Radioactive waste Chemicals and disinfectants Pressurised containers

13. BMW Rules and Key Actors Notified in 1998 Concept of PPP model Identified technologies and standards CPCB SPCB Department of Health Headline of presentation to come here (on slide master)

14. Know your waste

15. Waste Treatment & Disposal System CategoryWaste categoryTreatment Category 1Human anatomical wasteInc/burial Category 2 Animal wasteInc/burial Category 3 Microbiology & biotechnology waste Inc/alternate Category 4 Waste sharps Disinfection & autoclaving/microwaving/shre dding & mutilation Category 5 Discarded medicines, cytotoxic drugs Inc/landfill Category 6 & 7 Solid waste Autoclaving, microwaving & mutilation for category 7 Category 8 Liquid wasteDisinfection Category 9 Incineration ashLandfill Category 10 Chemical wasteDrain/secured landfill after treatment

16. Schedule II Colour coding Type of Container IWaste CategoryTreatment options as per Schedule I YellowPlastic bagHuman, animal, microbiology, soiled waste Incineration/deep burial RedDisinfected container/ plastic bag Microbiology, solid & soiled waste Autoclaving/Microwa ving/Chemical Treatment Blue/White translucent Plastic bag/puncture proof container/Sharps Blaster Waste sharps & solid waste Autoclaving/Microwa ving/Chemical Treatment & destruction/shreddin g BlackPlastic bagDiscarded medicine, cytotoxic drugs, incineration ash & Chemical waste Disposal in secured landfill

17. Bio-medical waste and technology Technology is only a fraction of the solution. Major components of waste management are: oSegregation of waste oWaste minimisation oReducing use of hazardous substances or processes oWaste Audit

18. Approved treatment methods Autoclave Chemical disinfection Hydroclave Microwave Incineration Any other technology after CPCB approval

19. In house management of waste 1.Survey 2.Meeting with the heads of all the departments 3.Forming a waste management committee 4.Rounds of wards to see the functioning 5.Creating a model ward 6.Suggest equipment procurement 7.Formal training for all the nursing staff 8.Implementing the system throughout the hospital

20. Right Technology Medical waste management is 80% segregation and 20% technology Incineration: Pathological Waste and Body Parts, no chlorinated plastics Autoclaving: All except body parts and pathological waste Microwaving: All except pathological waste and metals Chemical: Mainly plastics

21. Of site management of waste- Centralized Facilities Draft Guidelines on Common facilities- Treatment facilities- 90% non-burn, 10% waste- burn Limits incineration to Categories 1&2 Atleast 1 Km from residential areas. Acceptable in industrial area One operator allowed to cater upto 10,000 beds, situated within 150 km radius Segregation is the role of generator; operator can report mixing of waste to the prescribed authority

22. 200620082009 HCFTotal Number of Healthcare facilities73975129511 Number of HCFs linked to CTFs / own facility34001 116080 Number of facilities where waste is not being treated 3997413431 Percentage of total facilities with no type of treatment mechanism 54%10% WasteBio-medical waste generated /day319453 kgs413500 # 414956 # Bio-medical waste treated /day143952 kgs295270291983 Bio-medical waste not treated /day-175501 kgs113719 Percentage of Bio-medical waste untreated /day 55%28% IncineratorTotal incinerators in the country436547 Incinerators with APCDs207250 Incinerators without APCDs229297 Total Number of Violations24,41213037 HCF issued Show cause notices14898 Medical waste in India: 2006-2009

23. Hurdles in Implementation  Issues of Capacity  Low priority  Resource Allocation  Fixed Mindset  Injection safety, chemical safety and waste management issues yet to find space in development planning

24. At the SPCB level  Capacity and resource  Monitoring and control  Transparency of processes  Hierarchy of control  Independent audits  Awareness of community  Increasing outreach of centralized facility to rural areas

25. At the Hospital level  Mindset issues  Involvement of senior management  Resource availability and prioritising  Government Hospitals biggest defaulters  Capacity Building  Implementation bottlenecks  Responsibility fixing  Monitoring and Accreditation  Periodic Waste audits wrt economics

26. At the CTF level  Untrained Staff  Poor maintenance of equipment  Effluent Treatment Plants  Maintenance of records  No power back ups  Closed door, non transparent  Differential charges  Flawed systems  Profit driver  Need for accreditation

27. Way Forward  Resource allocation for waste management  Maintaining a pool of trainers at block/ district levels  Stakeholders involvement  Incorporation into curricula of medical, nursing and paramedical colleges  Up gradation to latest developments in BMW management  Waste minimizations policy  Appropriate technology selection  Pro-environment procurement policy

28. Emerging Issues Mercury  First mercury documentation in healthcare in 2004: 3 kg/ hospital/year  Public notices by DPCC  Mercury phase-out committee formed by DHS  Delhi hospitals to phase out mercury  No new mercury equipment procurement in Delhi government hospitals  HCEs aiming for ISO/ NABH to phase out mercury

29. Emerging Issues Injection Safety  Increased attention by hospitals  Fines on unattended needles  No to recapping  Reporting of needle stick injury and follow up Chemical Safety  Monitored use of Glutaraldehyde, formaldehyde, benzene, cytotoxic drugs etc.

30. Thank You Toxics Link H-2, Jungpura Ext. New Delhi 110014 011-24328006, 24320711 info@toxicslink.org www.toxicslink.org