Disposal of waste Submitted by: Jijishma valsan Guided by: Dr Mahamood muthedath & Dr Azeela

INDEX INTRODUCTION DEFINITION CLASSIFICATION OF HEALTH CARE WASTE TREATMENT AND DISPOSAL OPTIONS ARE :- INCINERATION CHEMICAL DINFECTION WET THERMAL TREATMENT MICRO WAVE IRRADIATION ENCAPSULATION SAFE BURYING INERTIZATION

DENTAL WASTE MANAGEMENT CLASSIFICATION OF WASTE EXTRACTED TEETH SHARPS SCRAP AMALGAM PHOTOCHEMICAL WASTE LEAD CONTAMINATION NON HAZARDOUS WASTE

BIOMEDICAL WASTE MANAGEMENT IN INDIA RULESOF BIOMEDICAL WASTE MANAGEMENT IN INDIA CATEGORIES OF BIOMEDICAL WASTE IN INDIA COLOUR CODING AND TYPES OF CONTAINER FOR DISPOSAL OF BIOMEDICAL WASTE CONCLUSION REFERENCE

INTRODUCTION The waste produced in the course of health care activities carries a higher potential for infection and injury than any other type of waste. These waste materials must be suitably disposed immediately or else it emit foul smell ,acts as a source of infection and disease and become a public health problem. Many of our hospitals neither have a satisfactory waste disposal system nor a waste management and disposal policy .The disposal of waste is exclusively entrusted to the junior most staff from the house keeping department without any supervision and even pathological waste are observed to be disposed off in the available open ground around hospitals with scant regard to aesthetic and hygeine consideration

Definition Health care waste is defined as all the waste generated by the health care establishments research facilities and laboratories. In addition it include the waste originating from minor or scattered sources such as produced in the course of health care under taken in the home (dialysis, insulin injection etc.)

Classification of health care waste Waste category Description and examples Infectious waste Waste suspected to contain pathogens e.g. laboratory cultures; waste from isolation wards; tissues (swabs), materials, or equipment that have been in contact with infected patients; excreta Pathological waste Human tissues or fluids e.g. body parts; blood and other body fluids; fetuses Sharps Sharp waste e.g. needles; infusion sets; scalpels; knives; blades; broken Glass

Waste category Eg:- Pharmaceutical waste Waste containing pharmaceuticals e.g. pharmaceuticals that are expired or no longer needed; items contaminated by or containing pharmaceuticals (bottles, boxes) Genotoxic waste Waste containing substances with genotoxic properties e.g. waste containing cytostatic drugs (often used in cancer therapy); genotoxic chemicals Chemical waste Waste containing chemical substances e.g. laboratory reagents; film developer; disinfectants that are expired or no longer needed; solvents

Waste category Eg:- Wastes with high content of heavy metals Batteries; broken thermometers; blood-pressure gauges; etc. Pressurized containers Gas cylinders; gas cartridges; aerosol cans Radioactive waste Waste containing radioactive substances e.g. unused liquids from radiotherapy or laboratory research; contaminated glassware, packages, or absorbent paper; urine and excreta from patients treated or tested with unsealed radionuclides; sealed sources

HEALTH CARE WASTE GENERATION Several surveys have provided an indication of typical health care waste generation system 80% of general health care waste which may be dealt with by the normal domestic and urban waste management. 15% pathologial and infectious waste 1% sharp waste 3%chemical and pharmacological waste

Less than 1% special waste such as radioactive or broken thermometers and used batteries A survey done in Bangalore reveals that the quantity of solid waste generated in hospitals and nursing homes generally varies from ½ to 4 kg per bed ,per day in govt.hospitals ½ to 2kg per bed per day in nursing homes . The total quantity of hospital waste generated in Bangalore is about 40 tones per day Segregation of non infectious waste from infectious waste is done only in 30% hospitals

HEALTH HAZARDS OF HEALTH CARE WASTE Exposure to hazardous health care waste can result in disease or injury due to one or more of the following characteristics 1)It contains infectious waste 2)It contains toxic or hazardous chemicals or pharmaceuticals 3)It contains sharps 4)It is genotoxic 5)It is radioactive

What is Infectious Medical Waste Infectious Medical Waste is defined as medical waste capable of producing an infectious disease. Waste is considered Infectious when it is: Contaminated by an organism that is pathogenic to healthy humans; The organism is not routinely available in the environment; and The organism is in significant quantity and virulence to transmit disease.

Infectious Wastes Specifically Are Blood and blood products in a free flowing, unabsorbed state; Contaminated sharps, Isolation Wastes, Laboratory wastes, and Unfixed pathological tissues

Diseases Caused by Blood borne Pathogens HIV / AIDS Hepatitis B Arboviral infections Brucellosis Creutzfeldt-Jakob Disease Hepatitis C Leptospirosis Malaria Rabies Syphilis Tularemia

Collection of Waste medical wastes must be collected at the point of generation in the appropriate color coded bags Orange bags for autoclaved waste, Red bags for all other treatment methods Biohazard bags must be labeled with the international biohazard symbol and appropriate wording; “biohazard,” “biomedical waste,” “infectious medical waste,” or “regulated medical waste” Waste should be collected daily &transported to the storage site

Packaging and Storage Wastes shall be collected in a lined, cardboard box or reusable plastic container that is labeled with the biohazard symbol and appropriate wording. Once the box or container is full, the bag lining it must be sealed and the container then sealed shut Boxes must be labeled with facility name, address, phone and fax numbers, and the date A full, sealed container can be stored on site for not more than 30 days and Storage area should allow easy access for staff and vehecle

Shipping and Manifests Every load of waste shipped off-site for destruction is tracked using a manifest system The manifest is a multiple copy document that accompanies the waste to the treatment facility Every individual who takes possession of the waste, including someone from your facility, must sign the manifest As the waste generator, your facility is responsible for the waste until you receive the proof-of-destruction copy of the manifest

This manifest has been signed by the treatment facility, certifying that this load has been destroyed and is no longer infectious.

Waste Disposal Options Include 21 Waste Disposal Options Include Chemical Disinfection Autoclaving Wet thermal treatment Microwave irradiation Burial Encapsulation Incineration Inertization Managed Land-fill

Chemical disinfectant In this method chemicals are added to waste to kill or to inactivate the pathogens. This method is suitable for treating liquid waste such as blood,urine,stools or hospital sewage. The effectiveness of disinfection is estimated from the survival rates of indicator organism in standard microbiologic test

Types of chemical disinfectants Formaldehydes-It has got inactivating effect on all microorganism including bacteria,viruses,and bacterial spores. Used in cases only when high level of chemical safety can be maintained. Ethylene oxide-inactivates all microorganism but due to carcinogenic property and related health hazard it is not recommended. Gluteraldehyde- It is active against bacteria and parasitic spores.It should be used as 2% aqueous solution with acetate buffer

Cont… Sodium hypochlorite- Active against most of the bacteria , virus and spores but not effective for disinfection of liquids with high organic content such as blood or stools, relatively less hazardous. Chlorine dioxide-It is a reddish yellow gas at ambient temperature, it is widely used in drinking water preparation,sanitation,and waste treatment.

Autoclaving It is a chambered device in which saturated steam is generated under high pressure(121 degree Celsius at 15 lb. pressure for 15 min is used) Used for the disinfection of dressings ,instruments and laboratory wears, culture media and pharmaceutical products Autoclaving of waste

Wet thermal treatment(steam disinfection) It is based on exposure of shredded infectious waste to high temperature ,high pressure steam. It inactivates most type of microorganism This process requires that waste be shredded before treatment to increase disinfection efficiency. Inappropriate for the treatment of anatomical waste& animal carcasses

Micro wave irradiation Most of the organisms are destroyed by the action of microwave of frequency of about 2450 MHz and a wave length of 12.24cm. The water contained within the waste is rapidly heated by the microwaves and the infectious components are destroyed by heat conduction Relatively high cost & maintenance problem So not recommended for use in developing countries

Burying Inside Hospital Premises Apply the following rules: Access to the site restricted and controlled If waste is retained on site, ensure rapid burial to isolate from animal or human contact Only hazardous HC Waste to be buried Management controls on what is dumped Each deposit covered with soil Site lined with low permeable material-concrete Groundwater pollution must be avoided Not recommended for untreated hazardous waste

Disposal to Land by Encapsulation 29 Disposal to Land by Encapsulation Fill metal or plastic containers to ¾ with waste, and add: plastic foam bituminous sand cement mortar clay material When dry, label and seal containers and landfill May be used for sharps, chemicals, drugs etc. Not recommended for non sharp infectious waste Low cost and safe method Cement encapsulated waste

Incineration Combustible waste turned to ash at temps >800 C 30 Incineration Combustible waste turned to ash at temps >800 C Reduces volume and weight Residues are transferred to final disposal site Treatment efficiency depends on incineration temperature and type of incinerator Not all wastes can be incinerated Costs vary greatly according to type of incinerator Produces combustion gases Questions for discussion: What are alternatives to incineration for disposal of infectious waste? Are any of these solutions economically viable? If not, what recommendations would you have?

Types of incinerators:- Double- chamber pyrolytic incinerator Single chamber furnaces with static grate Rotary kilns Pyrolytic incinerators:- Most reliable & commonly used process for HCW It comprises of pyrolytic chamber & post combustion chamber Suitable for infectious pathologic ,pharmaceutical & chemical wastes. Not suitable for genotoxic and radioactive waste

Single chamber incinerator Used in cases where pyrolytic incinerator cant be afforded(used as a last resort) Treats wastes in batches Loading and de-ashing operations are performed manually A 210 litre steel drum is used Chemical & pharmaceutical waste persist if temperature do not exceed 200 degree C It will cause emission of black smoke, fly ash, and potentially toxic gases

Rotary kiln:- Comprised of rotating oven & post combustion chamber The kiln rotates 2-5 times per minute and is charged with waste at the top Ashes are evacuated at the bottom end of the kiln Can be used for infectious ,pathologic, chemical and pharmaceutical wastes including cytotoxic waste

Disadvantages of Incineration of HC Waste: 34 Disadvantages of Incineration of HC Waste: Doesn’t destroy chemical waste at lower temperature for rotary kiln Toxic air emissions if no control devices in place Maintaining temperature levels (and efficiency) in field incinerators is difficult, need to balance loads with non- hazardous materials High costs for high temperature incineration 5: Managing Medical Waste

Advantages of Incineration of HC Waste: 35 Advantages of Incineration of HC Waste: Good disinfection efficiency Drastic reduction of weight and volume Good for chemical + pharmaceutical waste 5: Managing Medical Waste

Land-fill in Municipal Landfills(safe burying) 36 Land-fill in Municipal Landfills(safe burying) If hazardous health-care waste cannot be treated or disposed elsewhere: Designate a site for hazardous HC Waste Limit access to this place Bury the waste rapidly to avoid human or animal contact Investigate more suitable treatment methods

Inertization Mixing waste with cement and other substances before disposal in order to minimize the risk of toxic substances contained in the waste migrating into surface water or ground water. Suitable for pharmaceuticals and for incineration ashes Not applicable to infectious waste Inertization plant

Dental 0ffice waste management

Classification of Waste Because dental offices use substances that may be federally, state, or locally mandated, it is important to understand the types of waste for proper disposal. OSHA regulates waste within the dental office since their primary function is to protect the employees. The EPA regulates the disposal of waste as soon as it leaves the dental office.

Classifications of Dental Office General Waste (non-regulated) Contaminated Waste (regulated) Infectious Waste Hazardous Waste Toxic Waste

Regulated Waste Defined as waste that “requires special handling, neutralization or disposal.” Includes all “sharps” such as disposable needles, scalpel blades, broken glass, burs, endodontic files and reamers. Also includes blood and blood soaked or blood-caked items, human tissue, extracted teeth, and waste from pathology procedures. Regulated waste requires special disposal in biohazard containers or bags. Dental offices should contact with licensed carriers to dispose of this waste.

Non-regulated Waste Non-regulated waste includes items such as used patient bibs, barriers used during treatment, and saliva soaked gauze. If this waste contains potentially infectious materials, even if it is considered non-regulated, it should be labeled with a biohazard label.

Sharps should be disposed of in an approved sharps container. Do not overfill Place sharps containers close to where they will be used. Do not place your fingers into the sharps container for any reason.

Scrap amalgam Scrap amalgam should be collected and stored in a air tight Container Scrap amalgam that is not recycled must be managed as hazardous waste The container of scrap amalgam i.e. recycled must be labeled with the name address and telephone number of dental office along with date on which they started collecting waste

Information about extracted teeth Since extracted teeth are potentially infectious, they are considered regulated waste. CDC regulations allow extracted teeth to be returned to the patient. To save for educational use, only teeth without amalgam may be heat sterilized. Teeth containing amalgams can be placed in biohazard containers for pickup.

Hazardous Waste Hazardous waste is defined as waste that could pose a risk to human beings or to the environment. Examples: Scrap amalgam Photochemical waste (developer and fixer) Lead foil from traditional x-ray packets Some disinfectants Batteries

Biomedical waste management In India

BIO-MEDICAL WASTE RULES 1998 Implementation of BIO-MEDICAL WASTE RULES 1998 BMW Rules have been adopted and notified with the objective to stop the indiscriminate disposal of hospital waste/ bio-medical waste and ensure that such waste is handled without any adverse effect on the human health and environment.

BIO-MEDICAL WASTE RULES 1998 Implementation of BIO-MEDICAL WASTE RULES 1998 Health care waste includes Waste generated by the health care facilities Research facilities Laboratories Biomedical waste in hospitals 85% are non-infectious 10% are infectious 5% are hazardous 49

Basic Principles Bio-medical waste shall not be mixed with other wastes. Segregation at source – both at ward and unit level Color coding to support segregation at source Bio-medical waste shall be segregated into containers/ bags at the point of generation in accordance with Schedule II (BMW Rules 1998) prior to its storage, transportation, treatment and disposal. 50

Basic Principles The containers shall be labeled according to Schedule III (BMW Rules 1998) Transport waste safely to pick up site Identify destination for each type of waste and ensure safe disposal Keep track of usage 51

Use/Reuse of equipment Biomedical Waste Management - Issues Use/Reuse of equipment Unsafe collection Unsafe disposal 52

CATEGORIES OF BIO-MEDICAL WASTE Schedule-I CATEGORIES OF BIO-MEDICAL WASTE Option Waste Category Treatment & Disposal Category No. 1 Human Anatomical Waste (human tissues, organs, body parts) incineration @/deep burial* 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, colleges, discharge from hospitals, animal houses) incineration@/deep burial* Category No. 3 Microbiology & Biotechnology Waste (Wastes from laboratory cultures, stocks or micro-organisms live or vaccines, human and animal cell culture used in research and infectious agents from research and industrial laboratories, wastes from production of biologicals, toxins, dishes and devices used for transfer of cultures) local autoclaving/micro-waving/incineration@ Category No. 4 Waste Sharps (needles, syringes, scalpels, blade, glass, etc. that may cause punture and cuts. This includes both used and unused sharps) disinfection (chemical treatment @@@/auto claving/microwaving and mutilation/shredding## Category No. 5 Discarded Medicines and Cytotoxic drugs (Waste comprising of outdated, contaminated and discarded medicines) incineration@/destruction and drugs disposal in secured landfills

CATEGORIES OF BIO-MEDICAL WASTE (continued) Schedule-I CATEGORIES OF BIO-MEDICAL WASTE (continued) Category No. 6 Soiled Waste (items contaminated with blood, and body fluids including cotton, dressings, soiled plaster casts, lines, bedding, other material contaminated with blood) incineration@autoclaving/microwaving Category No. 7 Solid Waste (Waste generated from disposal items other than the sharps such a tubings, catheters, intravenous sets etc.) disinfection by chemical treatment@@ autoclaving/microwaving and mutilation/shredding## Category No. 8 Liquid Waste (Waste generated from laboratory and washing, cleaning, housekeeping and disinfecting activities) disinfection by chemical treatment@@ and discharge into drains Category No. 9 Incineration Ash Ash from incineration of any bio-medical waste) disposal in municipal landfill Category No. 10 Chemical Waste (Chemicals used in production of biologicals, chemicals used in production of biologicals, chemicals used in  disinfection, as insecticides, etc.) chemical treatment@@ and discharge into drains for liquids and secured landfill for solids

CATEGORIES OF BIO-MEDICAL WASTE (continue) Schedule-I CATEGORIES OF BIO-MEDICAL WASTE (continue) Note : @ There will be no chemical pretreatment before incineration. Chlorinated plastics shall not be incinerated. * Deep burial shall be an option available only in towns with population less than five lakhs and in rural areas. @@ Chemicals treatment using at least 1% hypochlorite solution or any other equivalent chemical reagent. It musts be ensured that chemical treatment ensures disinfection. ## Multilation/shredding must be such so as to prevent unauthorised reuse.

Schedule-II COLOUR CODING AND THE TYPE OF CONTAINER FOR DISPOSAL OF BIO MEDICAL WASTES Colour Coding Type of Container Waste Category Treatment options Yellow Plastic Bag Categories 1, 2, 3 & 6. Incineration/ deep burial  Red Disinfected container/Plastic bag Categories 3, 6, 7 Autoclaving/Micro-waving/Chemical Treatment Blue/White Translucent Plastic Bag /puncture proof containers Cat. 4, Cat. 7 Autoclaving/Micro-waving/ Chemical Treatment & Destruction / shredding Black Categories 5, 9, 10 Disposal in secured landfill. Notes: 1. Colour coding of waste categories with multiple treatment options as defined in schedule 1, shall be selected depending on treatment option chosen, which shall be as specified in Schedule I. 2. Waste collection bags for waste types needing incineration shall not be made of chlorinated plastics. 3. Categories 8 and 10 (liquid) do not require containers/bags.

Conclusion Because no disposal method is easy or completely 58 Conclusion Because no disposal method is easy or completely safe prevention is best!................... Eliminate purchase by buying safer alternatives Recycle Use smallest quantities possible, use with engineering controls and Personal Protective Equipment Segregate hazards into separate waste streams at source Supervise disposal using best available ecologic option

Reference Parks preventive & social medicine(17 th edition) Essentials of preventive and community dentistry(4 th edition) Modern dental assisting(8 th edition)-Doni .l bird&Debbi.s.Robinson Dental office administration Hospital administration &planning- Dr A .G Chandorkar Internet sources-IMW program website

Thank you…………….