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 Science
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

4. Hospital waste
Hazardous
Non-hazardous
Noninfectious
Infectious
Cytotoxic drugs
Kitchen
Recyclables
Toxic Chemicals
Radioactive
Sharps: needles, scalpel blades, scalp veins, glass contaminated with blood
Non-sharps
Patient contaminated waste
Laboratory waste
Specimens
Anatomical
Plastics
Non-plastics
PVC, PE PET, PS
Equipment
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 1994
1. CLEARLY DEFINE THE PROBLEM

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

9. Sharps Disposal
3. INSTITUTE A SHARPS MANAGEMENT SYSTEM

10. Waste Audit
4. KEEP FOCUS ON REDUCTION

11. Safe Disposal of Sharps: Do not recap needles.
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)
5. ENSURE WORKER SAFETY THROUGH EDUCATION, TRAINING AND PROPER PERSONAL PROTECTIVE EQUIPMENT
Safe Disposal of Sharps:
Do not recap needles.
If essential learn the right way to do so.

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

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

14. Infection Awareness Week
8. INVEST IN TRAINING
Street Play

15. 9. DEVELOP THE INFRASTRUCTURE

16. 10. Evaluation of Technologies

17. Evaluation of Non Burn Technologies for Medical Waste Treatment

18. 1. Demonstrated Performance
Category
Rating
Weight
Score
1.1
Stage of Development
1.2
Number of Operational Systems
1.3
Year of Successful Operations

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

20. 3. Vendor Qualifications
Category
Rating
Weight
Score
3.1
Number of Vendors
3.2
Vendor Resources
3.3
Vendor Diversity and Services

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

22. 5. Occupational Health & Safety Issues
Category
Rating
Weight
Score
5.1
Routine Exposures
5.2
Maintenance and Repair Exposures

23. 6. Facility: & Infrastructural Requirements
Category
Rating
Weight
Score
6.1
Space Requirements
6.2
Construction Requirements
6.3
Utility Requirements
6.4
Space / Facility Requirements

24. 7. Economics Category Rating Weight Score 7.1 Capital Costs 7.2
Annual Costs
7.3
Life-Cycle Costs
GRAND TOTAL SCORE

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

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

27. TMH Waste Audit Nov. 1999 to Dec. 2007
2000
2001
2002
2003
2004
2005
2006
2007
Max. medical waste collected in a day
341
394
350
362
396
530
429
514
Average no. of loads required/day 5 4
Average medical waste treated in kgs/day
217
224
176
241
250
289
253
277
Average medical waste collected in a month
5,498
5,643
5,266
5,917
6,284
7,225
6,369
6,959
Percentage down time of the system
1.6
5.7
4.8
5.8
8.2 10
1.2
Total infectious waste treated – 614 tonnes.
 83,511 kg. in  Cost of treatment = Rs / kg.

28. TMH Infectious Waste Audit 2008 - 2009
Max. medical waste collected in a day
447
505
Average no. of loads required/day 4
Average medical waste treated in kgs/day
298
304
Average medical waste collected in a month
7,623
7,674
Percentage down time of the system
0.33
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
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."
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.

32. India’s significant economic growth and rise in industrialization coupled by lax government enforcement of anti-pollution laws and regulations have had a detrimental effect on India’s natural environment.
Hazardous waste from industrial processes, medical waste and India’s 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 India’s 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 country’s hazardous waste:
Andhra Pradesh,
Gujarat,
Karnataka,
Maharashtra and
Tamil Nadu.

37. European Commission focus on waste management
Landfill
Composting
Incineration
Recycling
Transportation
Air
Emission of CH4, CO2; odours
Emission of SO2, NOx, HCl, HF, NMVOC, CO, CO2 N2O, dioxins, dibenzofurans, heavy metals(Zn, Pb, Cu, As)
Emissions of dust
Emissions of dust NOx, SO2, release of hazardous substances from accidental spills
Water
Leaching 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
Soil
Accumulation of hazardous substances in soil
Landfilling of slags, fly ash and scrap
Landfilling of final residues
Risk of soil contamination from accidental spills
Pitfalls of the currently available technologies for managing wastes

38. European Commission focus on waste management
Landfill
Composting
Incineration
Recycling
Transportation
Landscape
Soil occupancy; restriction on other land uses
Visual intrusion; restriction on other land uses
Visual intrusion
Traffic
Ecosystems
Contamination and accumulation of toxic substances in the food chain
Risk of contamination from accidental spills
Urban areas
Exposure to hazardous substances
Noise
Risk of exposure to hazardous substances from accidental spills; traffic
Pitfalls of the currently available technologies for managing wastes

39. E-waste How green is your Apple
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 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
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
Ministry of Environment & Forests:
Hazardous Wastes (Management and Handling) Amendment Rules, 2002

43. LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS
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
Ministry of Environment & Forests:
Hazardous Wastes (Management and Handling) Amendment Rules, 2002

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, 2003 1
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, 2003 12
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, 2003 23
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 2005
86,704 Kilograms
Average waste treated per month
7,225 Kilograms
Weight of sharps treated in 2005
2,917 Kilograms
Average weight of sharps treated per month
243 Kilograms
Blood & blood products
300 liters
Liquid Wastes:
Total effluent per month
164 lakh litres
Laundry effluent per month
3 lakh litres
X’ray developer per month
140 litres
Hazardous liquids consumed in labs per month
588 litres
Hazardous chemicals as solids weight per month
260 grams
Dilution factor of hazardous liquids 27,333.

50. Hazardous liquid waste / month:
Sr. No
Chemicals / Reagents
Lits. 1
10% Formalin
100 2
Xylene
190.1 3
Basic fuchsin
1.17 4
Haematoxylin stain
1.0 5
Nitric Acid
50.5 6
Anhydrous Aluminum Chloride
.005 7
Hydrochloric acid
.800 8
Diamino benzidine
20.0 9
Hydrogen peroxide
53.202 10
Glacial acetic acid
5.225 11
Gluteraldehyde 12
Ethidium bromide
.001 13
Propane / Butane
2.500 14
WD40 (Petroleum distillate)
2.00 15
Benzoin tincture
10.00 16
Lugol’s Iodine
0.42 17
Phenol (carbolic acid)
1.000 18
Ammonia solution
.050 19
Lactic acid
.045 20
Sulfuric acid
.100
Total
588.19
Hazardous liquid waste / month:

51. Hazardous solid waste / month:
Sr. No
Chemicals / Reagents
Weight (Grams) 1
Benzidine dihydrochloride
0.5 2
Naphthol phosphate
.060 3
Pararosaline hydrochloride
1.0 4
Sodium-fluoride
.200 5
Potassium dihydrogen phosphate
8.500 6
Dipotassium hydrogen phosphate 7
Benzidine G.R. 8
Zine sulphate
16.5 9
Barium chloride
13.00 10
Phenol crystals
40.00 11
Naphthylamine
16.50 12
Naphthol 13
Sodium-polyanethol sulphonat
45.00 14
Sodium hydroxide pellet 15
Sulfonilic acid 16
Trichloroacetic acid
2.1
Total
259.36

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