Medical waste is now recognized as a major public health hazard. According to World Health

Organization, each year half a million people globally die due to infections such as Hepatitis B,

and C, HIV and hepatocellular cancer transmitted through unsafe healthcare practices. There is

no information as to what component of this figure comprises healthcare workers. There are also

alarming disclosures about used medical devices and other items getting recycled and repacked

by unscrupulous traders in countries such as ours. This happens when the hospitals do not take

adequate steps to disinfect and mutilate the medical waste as required under the law. Despite the

statutory provision of Biomedical Waste Management, practice in Indian Hospitals has not

achieved the desired standard even after ten years of enforcement of the law. Biomedical waste

has become a serious health hazard in many countries, including India. Careless and

indiscriminate disposal of this waste by healthcare establishments and research institutions can

contribute to the spread of serious diseases such as hepatitis and AIDS (HIV) among those who

handle it and also among the general public

1.Introduction:-

“Bio Medical Waste”:-

“Bio Medical Waste” means any waste, which is generated during the diagnosis, treatment or

immunization of human beings or animals or in research activities pertaining thereto or in the

production or testing of biological including containers.

Bio-medical waste means “any solid and/or liquid waste including its container and any

intermediate product, which is generated during the diagnosis, treatment or immunization of

human beings or animals.

Components of Bio-medical waste:-

Human anatomical waste (tissues, organs, body parts etc.).

Animal waste (as above, generated during research/experimentation, from veterinary

hospitals etc.).

Microbiology and biotechnology waste, such as, laboratory cultures, micro-organisms,

human and animal cell cultures, toxins etc.

Waste sharps, such as, hypodermic needles, syringes, scalpels, broken glass etc.

Discarded medicines and cyto-toxic drugs.

Soiled waste, such as dressing, bandages, plaster casts, material. contaminated with blood

etc.

Solid waste (disposable items like tubes, catheters etc. excluding sharps).

Liquid waste generated from any of the infected areas.

Incineration ash.

Chemical waste.

Sources of BMW:-

The major sources of health-care waste are hospitals and other health-care establishments,

laboratories and research centres, mortuary and autopsy centres, animal research and testing

laboratories, blood banks and collection services, and nursing homes for the elderly.

Quantity of BMW :-

Health-care activities - for instance, immunizations, diagnostic tests, medical treatments, and

laboratory examinations - protect and restore health and save lives. But what about the wastes

and by-products they generate?

Hospitals and other health care facilities generate lots of waste which can transmit infections,

particularly HIV, Hepatitis B & C and Tetanus, to the people who handle it or come in contact

with it. High-income countries can generate up to 6 kg of hazardous waste per person per year.

In the majority of low-income countries, health-care waste is usually not separated into

hazardous or non-hazardous waste. In these countries, the total health-care waste per person per

year is anywhere from 0.5 to 3 kg.

Segregation

Segregation refers to the basic separation of different categories of waste generated at source and

thereby reducing the risks as well as cost of handling and disposal. Segregation is the most

crucial step in bio-medical waste management. Effective segregation alone can ensure effective

bio-medical waste management. The BMWs must be segregated accordance to guidelines laid

down under schedule 1 of BMW Rules, 1998.

How does segregation help?

Segregation reduces the amount of waste needs special handling and treatment

Effective segregation process prevents the mixture of medical waste like sharps with the

general municipal waste.

Prevents illegally reuse of certain components of medical waste like used syringes,

needles and other plastics.

Provides an opportunity for recycling certain components of medical waste like plastics

after proper and thorough disinfection.

Recycled plastic material can be used for non-food grade applications.

Of the general waste, the biodegradable waste can be composted within the hospital

premises and can be used for gardening purposes.

Recycling is a good environmental practice, which can also double as a revenue

generating activity.

Reduces the cost of treatment and disposal (80 per cent of a hospital’s waste is general waste,

which does not require special treatment, provided it is not contaminated with other infectious

waste)

People at Risk:-

The main groups at risk are the following:

Doctors, nurses, ambulance staff and hospital sweepers;

Patients in health-care establishments or under home care;

Workers in support services to health-care establishments, such as laundries, waste

handling and transportation, waste disposal facilities including incinerators and other

persons separating and recovering materials from waste;

Inappropriate or inadvertent end-users such as scavengers and customers in secondary

markets for reuse (i.e. households, local medical clinics, etc.)

Health Concern –hazards of Bio-medical waste:-

Biomedical waste poses hazard due to two principal reasons – the first is infectivity and other

toxicity. According to the WHO, the global life expectancy is increasing year after year.

However, deaths due to infectious disease are also increasing. A study conducted by the WHO

reveals that more than 50,000 people die everyday from infectious diseases. One of the causes

for the increase in infectious diseases is improper waste management. Blood, body fluids and

body secretions which are constituents of bio-medical waste harbour most of the viruses, bacteria

and parasites that cause infection. This passes via a number of human contacts, all of whom are

potential ‘recipients’ of the infection. Human Immunodeficiency Virus (HIV) and hepatitis

viruses spearhead an extensive list of infections and diseases documented to have spread through

bio-medical waste. Tuberculosis, pneumonia, diarrhea diseases, tetanus, whooping cough etc.,

are other common diseases spread due to improper waste management.

HEALTH IMPACTS:-

Health-care waste is a reservoir of potentially harmful micro-organisms which can infect hospital

patients, health-care workers and the general public. Other potential infectious risks include the

spread of, sometimes resistant, micro-organisms from health-care establishments into the

environment. These risks have so far been only poorly investigated. Wastes and by-products can

also cause injuries, for example radiation burns or sharps-inflicted injuries; poisoning and

pollution, whether through the release of pharmaceutical products, in particular, antibiotics and

cytotoxic drugs, through the waste water or by toxic elements or compounds such as mercury or

dioxins.Some of these are given below:-

Cytotoxic Waste:-Cytotoxic drugs have the ability to stop the growth of certain living cells and

are used as chemo-therapeutic agents. They are carcinogens and can also be mutagenic. Any

material used to handle these products and contaminated in due course would also need to be

disposed off in the same manner.Adverse health effects from both acute and chronic exposures to

cytotoxic drugs have been demonstrated in healthcare personnel.Over a long term, almost all of

these drugs have the potential of damaging cells or adversely affecting cellular growth and

reproduction. The drugs bind directly to genetic material in the cell nucleus, or affect cellular

protein synthesis. In-vivo, in-vitro and human studies have implicated anti-neoplastic drugs in

chromosomal damage, teratogenesis, and carcinogenesis.Testicular and ovarian dysfunction,

including permanent sterility, have been demonstrated in male and female patients, respectively,

who have received these drugs singly, or in combination. Studies in Finland have shown an

increased incidence of foetal loss among nurses routinely working with anti-neoplastic agents

than among those who do not. Other studies have suggested a correlation between exposure to

anti-neoplastic agents and foetal malformation in pregnant nurses. Additionally, organ damage

has been associated with exposure to some anti-neoplastic agents. Liver damage has been

reported in oncology employees, and appears to be related to the duration and the concentration

of the exposure. The risks to workers handling anti-neoplastic agents are a result of the inherent

toxicity of the drugs themselves, and the actual dose that a worker receives. The dose is

dependent on the concentration of the drug, the duration of the exposure, and the route of entry.

The adverse health effects as a result of exposure to a particular drug may depend on whether the

drug enters the body through inhalation, through the skin, or ingestion.

Sharps:-Anything that can cause a cut or a puncture wound is classified as ‘sharps’. These

include needles, hypodermic needles, scalpel and other blades, knives, infusion sets, saws,

broken glass, and nails. Whether or not they are infected, sharps are usually considered highly

hazardous healthcare waste because they have the potential to cross the passive and primary

immunology barrier of the body the skin and thus establish contact with blood. Because of this

double risk of injury and disease transmission sharps are considered very hazardous. The

principal concerns are infections that may be transmitted by subcutaneous introduction of the

causative agent, for example, viral blood infections. Hypodermic needles constitute an important

part of the sharps waste category and are particularly hazardous because they are often

contaminated with blood .Throughout the world every year an estimated 12 000 million

injections are administered. And not all needles and syringes are properly disposed of, generating

a considerable risk for injury and infection and opportunities for re-use.

Worldwide, 8-16 million hepatitis B, 2.3 to 4.7 million hepatitis C and 80 000 to 160 000

HIV infections are estimated to occur yearly from re-use of  syringe needles without

sterilization2.  Many of these infections could be avoided if syringes were disposed of

safely. The re-use of disposable syringes and needles for injections is particularly

common in certain African, Asian and Central and Eastern European countries.

Regarding injection practices, public health authorities in West Bengal, India, have

recommended a shift to re-usable glass syringes, as the disposal requirements for

disposable syringes could not be enforced.

In developing countries, additional hazards occur from scavenging on waste disposal sites

and manual sorting of the waste recuperated at the back doors of health-care

establishments. These practices are common in many regions of the world. The waste

handlers are at immediate risk of needle-stick injuries and other exposures to toxic or

infectious materials.

Mercury:- Mercury is the only heavy metal that can exist in all three states of matter: it readily

changes from solid to liquid to gaseous form and is a persistent bio-accumulative toxin. It

circulates constantly in the environment. Three major forms of chemical mercury circulate in the

atmosphere: mercury (0), mercury (II) and methyl mercury. Methyl mercury can accumulate in

muscle tissue and bio-magnify via the food chain. Mercury is a neurotoxicant and affects the

brain and the nervous system. Other vital organs like kidneys and lungs are also affected.

Mercury poisoning can be difficult to diagnose since the symptoms are common to other

afflictions. Pregnant women and children are most vulnerable to the effects of mercury. A foetus

exposed to mercury shows nervous system damage.

Vaccine waste:-In June 2000, six children were diagnosed with a mild form of smallpox

(vaccinia virus) after having played with glass ampoules containing expired smallpox vaccine at

a garbage dump in Vladivostok (Russia). Although the infections were not life-threatening, the

vaccine ampoules should have been treated before being discarded.

Pharmaceutical waste:- includes expired, unused, spilt and contaminated pharmaceutical

products, drugs, vaccines and sera that are no longer useful.

Chemicals:- are generally used in diagnostic and experimental work, and in cleaning,

housekeeping and disinfecting procedures. Many chemicals and pharmaceuticals used in

hospitals are hazardous. They are termed hazardous if they have any one of the following

properties: toxic, corrosive, flammable, reactive, genotoxic. Examples of such waste are

formaldehyde, glutaraldehyde and photographic chemicals. They may cause injuries, including

burns. Disinfectants are particularly important members of this group as they are used in large

quantities and are generally corrosive.

Hazards of Bio-medical waste:-

Injury from sharps to staff and waste handlers associated with the health care

establishment.

Hospital Acquired Infection(HAI)(Nosocomial) of patients due to spread of infection and

disease through vectors (fly, mosquito, insects etc.).

Risk of infection outside the hospital for waste handlers/scavengers and eventually

general public.

Occupational risk associated with hazardous chemicals, drugs etc. Reaction due to use of

discarded medicines

Unauthorized repackaging and sale of disposable items and unused / date expired drugs

Toxic emissions from defective/inefficient incinerators.

Indiscriminate disposal of incinerator ash / residues.

  Occupational health hazards :-

The health hazards due to improper waste management

can affect

The occupants in institutions and spread in the

vicinity of the institutions

People happened to be in contact with the

institution like laundry workers, nurses,

emergency medical personnel, and refuse workers.

Risks of infections outside hospital for waste handlers, scavengers and (eventually) the

general public

Risks associated with hazardous chemicals, drugs, being handled by persons handling

wastes at all levels 

Injuries from sharps and exposure to harmful chemical waste and radioactive waste also

cause health hazards to employees.

Hazards to the general public:-

The general public’s health can also be adversely affected by bio-medical waste.

Improper practices such as dumping of bio-medical waste in municipal dustbins, open

spaces, water bodies etc., leads to the spread of diseases.

Emissions from incinerators and open burning also lead to exposure to harmful gases

which can cause cancer and respiratory diseases.

Exposure to radioactive waste in the waste stream can also cause serious health hazards.

An often-ignored area is the increase of in-home healthcare activities. An increase in the

number of diabetics who inject themselves with insulin, home nurses taking care of

terminally ill patients etc., all generate bio-medical waste, which can cause health hazards.

RISKS ASSOCIATED WITH WASTE DISPOSAL:-

Although treatment and disposal of health-care wastes aim at reducing risks, indirect health risks

may occur through the release of toxic pollutants into the environment through treatment or

disposal.

Landfilling can potentially result in contamination of drinking water. Occupational risks

may be associated with the operation of certain disposal facilities. Inadequate

incineration, or incineration of materials unsuitable for incineration can result in the

release of pollutants into the air. The incineration of materials containing chlorine can

generate dioxins and furanse, which are classified as possible human carcinogens and

have been associated with a range of adverse effects. Incineration of heavy metals or

materials with high metal contents (in particular lead, mercury and cadmium) can lead to

the spread of heavy metals in the environment. Dioxins, furans and metals are persistent

and accumulate in the environment. Materials containing chlorine or metal should

therefore not be incinerated.

Only modern incinerators are able to work at 800-1000 °C, with special emission-

cleaning equipment, can ensure that no dioxins and furans (or only insignificant amounts)

are produced. Smaller devices built with local materials and capable of operating at these

high temperatures are currently being field-tested and implemented in a number of

countries.

At present, there are practically no environmentally-friendly, low-cost options for safe

disposal of infectious wastes. Incineration of wastes has been widely practised, but

alternatives are becoming available, such as autoclaving, chemical treatment and

microwaving, and may be preferable under certain circumstances. Landfilling may also

be a viable solution for parts of the waste stream if practised safely. However, action is

necessary to prevent the important disease burden currently created by these wastes. In

addition, perceived risks related to health-care waste management may be significant. In

most cultures, disposal of health-care wastes is a sensitive issue and also has ethical

dimensions.

Bio-medical waste can cause health hazards to animals and birds too:-

Plastic waste can choke animals, which scavenge on open dumps.

Injuries from sharps are common feature affecting animals.

Harmful chemicals such as dioxins and furans can cause serious health hazards to

animals and birds.

Heavy metals can even affect the reproductive health of the animals

Change in microbial ecology, spread of antibiotic resistance

Situation of BMWM in India:-

Most countries of the world, especially the developing nations, are facing the grim situation

arising out of environmental pollution due to pathological waste arising from increasing

populations and the consequent rapid growth in the number of health care centres. India is no

exception to this and it is estimated that there are more than 15,000 small and private hospitals

and nursing homes in the country. This is apart from clinics and pathological labs, which also

generate sizeable amounts of medical waste.

India generates around three million tonnes of medical wastes every year and the amount is

expected to grow at eight per cent annually.

Barring a few large private hospitals in metros, none of the other smaller hospitals and nursing

homes have any effective system to safely dispose of their wastes. With no care or caution, these

health establishments have been dumping waste in local municipal bins or even worse, out in

the open. Such irresponsible dumping has been promoting unauthorized reuse of medical

waste by the rag pickers for some years now.

Legal aspect of BMWM in India:-

The Central Government, to perform its functions effectively as contemplated under sections 6,

8, and 25 of the Environment Protection Act, 1986, has made various Rules, Notifications and

Orders including the Bio-medical wastes (Management & Handling) Rules, 1998.A brief

summary of the provisions in Bio-medical wastes (Management & Handling) Rules, 1998 is

given below.

Section 3 establishes the authority of the government to undertake various steps for

protection and improvement of the environment.

Section 5 provides for issuance of directions in writing.

Section 6 empowers the government to make rules.

Section 8 permits the education of individuals dealing with hazardous wastes regarding

various safety measures.

Section 10 bestows authority to enter the premises and inspect.

Section 15 allows the government to take punitive steps against defaulters. This

involves imprisonment up to five years or penalty of upto rupees one lakh or both.

In case the default continues, it would then attract a penalty of rupees five thousand

per day up to one year and thereafter imprisonment up to seven years.

Section 17 provides for punishment in case of violations by government departments.

Even after the June, 2000 deadline most of the large hospitals have not complied with these

Rules, as there is no specified authority to monitor the implementation of these Rules. But, the

fact is that in most of the states, the pollution control boards that are connected with waste in

general do not have adequate powers or commitment to enforce the Rules.

Applicability of BMW Rules, 1998

The BMW Rules are applicable to every occupier of an institution generating biomedical waste

which includes a hospital, nursing homes, clinic, dispensary, veterinary institutions, animal

houses, pathological lab, blood bank by whatever name called, the rules are applicable to even

handlers.

Common Biomedical wastes treatment facility [CBWTFs]

The Common Biomedical wastes treatment facility, (see rules 14, amended in June 2000, which

cast the responsibilities on municipal bodies to collect biomedical wastes/treated biomedical

wastes and also provide sites for setting up of incinerator.) The owner of CBWTFs are service

providers, who are providing services to health care units for collection of BMWs for its final

disposal to their site.

CATEGORIES OF BIOMEDICAL WASTE SCHEDULE – I

WASTE

CATEGORY TYPE OF WASTE

TREATMENT AND

DISPOSAL OPTION

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 and colleges, discharge from

hospitals, animal houses)

Incineration@ / deep burial*

Category No. 3

Microbiology & Biotechnology Waste (Wastes from laboratory

cultures, stocks or specimen of live micro organisms or

attenuated vaccines, human and animal cell cultures used in

research and infectious agents from research and industrial

laboratories, wastes from production of biologicals, toxins and

devices used for transfer of cultures)

Local autoclaving/

microwaving /

incineration@

Category No. 4

Waste Sharps (Needles, syringes, scalpels, blades, glass, etc. that

may cause puncture and cuts. This includes both used and

unused sharps)

Disinfecting (chemical

treatment@@ / autoclaving /

microwaving and

mutilation / shredding##

Category No. 5Discarded Medicine and Cytotoxic drugs (Wastes comprising of

outdated, contaminated and discarded medicines)

Incineration@ / destruction

and drugs disposal in

secured landfills

Category No. 6

Soiled Waste (Items contaminated with body fluids including

cotton, dressings, soiled plaster casts, lines, bedding and other

materials contaminated with blood.)

Incineration@ / autoclaving /

microwaving

Category No. 7 Solid Waste (Waste generated from disposable items other than

the waste sharps such as tubing, catheters, intravenous sets, etc.)

Disinfecting by chemical

treatment@@ / autoclaving /

microwaving and

mutilation / shredding# #

Category No. 8Liquid Waste (Waste generated from the laboratory and

washing, cleaning, house keeping and disinfecting activities)

Disinfecting by chemical

treatment@@ and discharge

into drains

Category No. 9Incineration Ash (Ash from incineration of any biomedical

waste)

Disposal in municipal

landfill

Category No.10Chemical Waste (Chemicals used in production of biologicals,

chemicals used in disinfecting, as insecticides, etc.)

Chemical treatment @@ and

discharge into drains for

liquids and secured landfill

for solids.

@@  Chemical treatment using at least 1% hypochlorite solution or any other equivalent chemical reagent. It

must be ensured that chemical treatment ensures disinfection.

** Mutilations / Shredding must be such as to prevent unauthorized reuse.

@ There will be no chemical pre-treatment before incineration. Chlorinated plastics shall not be incinerated.

*      Deep burial shall be an option available only in towns with population less than five lakh and in rural areas.

COLOUR CODING AND TYPE OF CONTAINER SCHEDULE II

Colour Coding Type of Container Waste Category Treatment options as per Schedule I

Yellow Plastic bagCat.1,Cat.2, Cat.3

and Cat.6Incineration/ deep burial

Red Disinfected container/ Cat.3, Cat.6, and Autoclaving/Micro waving/ Chemical

plastic bag Cat.7 Treatment

Blue/ White

Translucent

Plastic Bag/ puncture

proof containerCat.4 and Cat.7

Autoclaving/Micro waving/ Chemical

Treatment and destruction/ shredding

Black Plastic bagCat.5, Cat.9, and

Cat.10 (solid)Disposal in secured landfill

Notes:

Colour coding of waste categories with multiple treatment options as defined in Schedule I, shall be

selected depending on treatment option chosen, which shall be specified in Schedule I.

Waste collection bags for waste types needing incineration shall not be made of chlorinated plastics.

Categories 8 and 10 (liquid) do not require containers/bags.

Category 3 if disinfected locally need not be put in containers/bags.