Dr. SUMI NANDWANIAssociate Professor, Microbiology,E.S.I.C.-PGIMSR& Hospital, Basaidarapur, New Delhi

Points to be discussed …………

Overview : Definition Extent of Problem , Need, Present practices BMW Management Rules, application, duty

of occupier Segregation, categories of BMW Transport & storage Treatment & Disposal Authorization, Appeal, Reporting of

Accidents BMW Mx Committee Take Home Message

What is Biomedical Waste

Bio-medical waste is defined as waste that is generated during the diagnosis, treatment or immunization of human beings and are contaminated with patients’ body fluids (such as syringes, needles, ampoules ,organs and body parts, placenta, dressings, disposables plastics and microbiological wastes).

NEED FOR BMW MANAGEMENTThe hospital waste, in addition to the risk for patients and personnel who handle these wastes poses a threat to public health and environmentHealth hazards of BMW

Type of wasteType of waste Health hazardHealth hazardHuman / Animal Human / Animal waste/ Soiled waste/ Soiled wastewaste

HIV,HBV,HCV, Hgic fevers, HIV,HBV,HCV, Hgic fevers, cholera, salmonellosis, cholera, salmonellosis, shigellosis, rabies, shigellosis, rabies, leptospirosis, anthrax,TB, leptospirosis, anthrax,TB, pneumonia, septicemiapneumonia, septicemia

SharpsSharps HIV, HBV, HCV, InjuriesHIV, HBV, HCV, InjuriesCytotoxic/ Cytotoxic/ radioactive radioactive wastewaste

Cancer, genetic mutation, birth Cancer, genetic mutation, birth defectdefect

Chemical wasteChemical waste Poisonings, dermatitis, Poisonings, dermatitis, conjunctivitis, bronchitisconjunctivitis, bronchitis

Extent of the problemMost countries of the world, especially the developing nations, are facing

the grim situation arising out of environmental pollution due to pathological waste

In India :three million tonnes of medical wastes generated every year and the amount is expected to grow at eight per cent annually.

4.2 lakh kg of biomedical waste is generated on a daily basis,( CPCB April2011)

Only 157 facilities to treat the same.  84,809 hospitals and healthcare facilities in India only 48,183 are using either common biomedical waste treatment

facilities or have commissioned private parties to take care of the same.

Quantum of BMW Generation & Treatment in Delhi- DPCC: No. of Health Care Establishments in Delhi : About 1900 , 10.125 Tons

BMW/day (based on the annual report for the year 2010).There are 10 Incinerators (including 3 CBWTFs), 21 autoclaves(including 3CBWTFs) and 3 microwaves operating in Delhi.

Present practice within Hospitals• Around 50% of the hospitals in the

country are dumping the BMW with Municipal garbage

• Waste is not segregated at the site

• 15000 hospitals have been served notice for acting as defaulters of these rules.

• No proper treatment options

• No regulated disposal sites

Present practices within hospitals1- Mostly dumped in the open space - Rag pickers can collect contaminated syringes, cotton, plastics, etc.

2- Burnt at dumpsites in an open environment - Incomplete - Small quantities of many organic and chlorinated organic compounds as well as pathogens survives - dispersal of dangerous diseases.

3- Landfills - Designed poorly and can pollute ground-water.

BIOMEDICAL WASTE(MANAGEMENT & HANDLING) RULES by Govt. of India , 1998Amended on 2000• Authoritative order to all the hospitals to stop the indiscriminate disposal of waste and ensure that it is treated in such a manner that it does not hamper the environment and human health.

• All the BMW to be segregated at the point of generation

Application These rules apply to all persons who generate, collect, receive, store, transport, treat, dispose, or handle bio-medical waste in any form

includes a hospital, nursing home, clinic, dispensary, veterinary institutions, and animal house, pathological laboratory, blood bank e.t.c.

Duty of Occupier

 It shall be the duty of every occupier of an institution generating bio-medical waste, to take all steps to ensure that such waste is handled without any adverse effect to human health and the environment.

. Segregation, Packing,   a. Bio-medical waste shall not be mixed with other wastes

b. Bio-medical waste shall be segregated into containers/bags at the point of generation in accordance with Schedule II

The containers shall be labeled according to Schedule III.

Health waste Characterization

Hospital waste

Non Hazardous(≈ 75-90%)

Hazardous waste(≈ 10-25%)

InfectiousOthers

(sharps, radioactive,Cytotoxic )

S.NS.N WASTE WASTE CATEGORYCATEGORY

WASTE TYPEWASTE TYPE TREATMENT TREATMENT & DISPOSAL& DISPOSAL

11 Category No.1Category No.1 Human Anatomical wasteHuman Anatomical waste (human tissues, (human tissues, organs, body partsorgans, body parts

Incineration/deep Incineration/deep burialburial

22 Category No.2Category No.2 Animal WasteAnimal Waste: Animal tissues, organs, body : Animal tissues, organs, body parts carcasses, bleeding parts, fluid, blood parts carcasses, bleeding parts, fluid, blood and experimental animals used in research, and experimental animals used in research, waste generated by veterinary hospitals, waste generated by veterinary hospitals, colleges, discharge from hospitals, animal colleges, discharge from hospitals, animal houseshouses

Incineration/deep Incineration/deep burialburial

33 Category No.3Category No.3 Microbiology & BiotechnologyMicrobiology & Biotechnology Wastes: Wastes: Wastes from laboratory cultures, stocks of Wastes from laboratory cultures, stocks of specimens of micro-organisms live or specimens of micro-organisms live or attenuated vaccines etc.attenuated vaccines etc.

Autoclave/ Autoclave/ Microwave/ Microwave/ IncinerationIncineration

44 Category No.4Category No.4 Waste SharpsWaste Sharps (needles, syringes, (needles, syringes, scalpels ,blades, glass etc.) that may causescalpels ,blades, glass etc.) that may causepuncture and cuts.puncture and cuts.

Disinfection Disinfection (chemical (chemical treatment/autoclavE/treatment/autoclavE/microwavE andmicrowavE andmutilation/shreddingmutilation/shredding

CATEGORIES OF BIO-MEDICAL WASTE

S.NS.N WASTE WASTE CATEGORYCATEGORY

WASTE TYPEWASTE TYPE TREATMENT TREATMENT AND DISPOSALAND DISPOSAL

55 Category No.5Category No.5 Discarded Medicines and Cytotoxic Discarded Medicines and Cytotoxic drugs Wastesdrugs Wastes comprising of outdated, comprising of outdated, contaminated and discarded medicinescontaminated and discarded medicines

Incineration/destructionIncineration/destructionand drugs disposal inand drugs disposal insecured landfillssecured landfills

66 Category No.6Category No.6 Soiled WasteSoiled Waste (Items contaminated with (Items contaminated withblood, and body fluids including cotton,blood, and body fluids including cotton,dressings, soiled plaster casts, linens,dressings, soiled plaster casts, linens,beddings, other material contaminatedbeddings, other material contaminatedwith blood)with blood)

IncinerationIncinerationautoclaving/ autoclaving/ microwavingmicrowaving

77 Category No.7Category No.7 Solid WasteSolid Waste (waste generated from (waste generated fromdisposable items other than the wastedisposable items other than the waste(sharps) such as tubing's, catheters,(sharps) such as tubing's, catheters,intravenous sets etc.intravenous sets etc.

Disinfection by chemicalDisinfection by chemicaltreatment/autoclaving/treatment/autoclaving/Microwaving &Microwaving &mutilation/shreddingmutilation/shredding

88 Category No.8Category No.8 Liquid Waste Liquid Waste generated from laboratory generated from laboratory and washing, cleaning, house keeping and and washing, cleaning, house keeping and disinfecting activitiesdisinfecting activities

Disinfection by chemicalDisinfection by chemicaltreatment andtreatment anddischarge into drainsdischarge into drains

S.NS.N WASTE WASTE CATEGORYCATEGORY

WASTE TYPEWASTE TYPE TREATMENT AND TREATMENT AND DISPOSALDISPOSAL

99 Category No.9Category No.9 Incineration Ash:Incineration Ash: Ash from Ash from incineration of any bio-medical incineration of any bio-medical wastewaste

Disposal in municipal landfillDisposal in municipal landfill

1010 Category No.10Category No.10 Chemical WasteChemical WasteChemicals used in production ofChemicals used in production ofbiologicals, chemicals used inbiologicals, chemicals used indisinfection as insecticides etc.disinfection as insecticides etc.

Chemical treatment andChemical treatment anddischargedischargeinto drains for liquids andinto drains for liquids andsecured landfill for solidssecured landfill for solids

NOTE :

1. Chemicals treatment using at least 1% hypochlorite solution or any other

equivalent chemical reagent.

2. Mutilation/shredding must be such so as to prevent unauthorized reuse.

3. There will be no chemical pretreatment before incineration. Chlorinated plastics

should not be incinerated.

4. Deep burial shall be an option available only in towns with population less than

five lakhs and in rural area.

COLOUR CODING AND TYPE OF CONTAINER FOR DISPOSAL OF BIOMEDICAL

WASTEColor Color CodingCoding

Type of Type of ContainerContainer

WasteWasteCategoryCategory

Treatment Treatment options as peroptions as perSchedule ISchedule I

YellowYellow Plastic bagPlastic bag Cat.1, 2,3,6Cat.1, 2,3,6 Incineration/deep burialIncineration/deep burial

RedRed Disinfected Disinfected container/Plastic container/Plastic bagbag

Cat 3,6,7Cat 3,6,7 Autoclave/Microwave/ Autoclave/Microwave/ Chemical TreatmentChemical Treatment

Blue/White Blue/White translucenttranslucent

Puncture proofPuncture proofcontainercontainer

Cat.4,7Cat.4,7 Autoclave/Microwave/ Autoclave/Microwave/ Chemical Treatment & Chemical Treatment & destruction/shreddingdestruction/shredding

BlackBlack Plastic bagPlastic bag Cat 5,9,10Cat 5,9,10 Disposal in secured Disposal in secured landfilllandfill

Proper labeling of bins

The bins and bags should carry the biohazard symbol indicating the nature of waste to the patients and public.

Schedule III (Rule 6) of Bio-medical Waste (Management and Handling) Rules, 1998 specifies the Label for Bio-Medical Waste Containers / Bags as:

Label shall be non-washable and prominently visible

BLACK BINKITCHEN WASTE/FOOD

PAPER

WASTE DISPOSAL

WRAPPERS

General wasteGeneral waste Paper, plasticsPaper, plastics WrappersWrappers Cardboards Cardboards Outer packagingOuter packaging Kitchen wasteKitchen waste Unsoiled plaster castUnsoiled plaster cast

YELLOW BIN

Bandages

Pathology waste

Hum

an a

nato

mic

al

was

te-p

lace

nta

Swab stick-decontaminated

WASTE DISPOSAL

SWABS

Dressing

soiled linen, contaminated gowns, drapes

Human/Animal tissue organs or body Human/Animal tissue organs or body partsparts

Animal carcassesAnimal carcasses Any non plastic soiled Any non plastic soiled waste( contaminated with blood/ body waste( contaminated with blood/ body fluids )fluids )

Cotton dressings, bandagesCotton dressings, bandages Linen beddingsLinen beddings Soiled plaster casts, Soiled paperSoiled plaster casts, Soiled paper Used/ removed suturesUsed/ removed sutures

RED BINDrains

Plastic culture plates & tubes

I/V sets

Urine bag

WASTE DISPOSAL

All infectious, non sharp plastic waste

Infectious Plastic and rubber waste such as

Gloves i. v tubings and I. V sets Catheters Urine bags, Blood bags Syringes Suction tips Infected plastic containers Rubber base materials Retraction cords

DISPOSAL OF SHARPSDestroy needle

Cut syringe tip

Decontaminate in twin bucket having 1% bleach

SHARPS including catheter guide wires

Sharp edged or pointed metallic sharpsSharp edged or pointed metallic sharps NeedlesNeedles Scalpel bladesScalpel blades Suture needleSuture needle IntracathIntracath LP needleLP needle Bone screws ( sharps), Arch bars, BursBone screws ( sharps), Arch bars, Burs LancetsLancets Glass sharps such as broken Glass sharps such as broken ampoules,injection vials ampoules,injection vials

Glass slides, coverslipGlass slides, coverslip Injection vialsInjection vials Broken test tubes/ Broken pippettesBroken test tubes/ Broken pippettes

Segregated incinerable wastes kept in Yellow bag

Segregated Autoclavable waste in Blue/ red bag

General wastes of health care unit in Black bag

Sharps in sharp container

Personnel safety devicesThe use of protective gears should be made

mandatory for all the personnel handling waste.

Storage In an area away from general traffic and accessible only to authorized personnel

DO NOT store for more than 48 hours

If for any reason it becomes necessary to store the waste beyond such period take measures to ensure that the waste does not adversely affect human health and environment

Transport Transport by wheeled trolleys/containers /carts only in vehicles authorized for the purpose

They should be Easy to load and unload No sharp edges Easy to clean

Disinfect daily Trolleys ,Wheelbarrows: covered and open, Chutes:

Transportation and Storage

c. If a container is transported from the premises where bio-medical waste is generated to any waste treatment facility outside the premises, the container shall, apart from the label prescribed in Schedule III, also carry information prescribed in Schedule IV.

Treatment and Disposal

a. Bio-medical waste shall be treated and disposal of in accordance with Schedule 1, and in compliance with the standards prescribed in Schedule V

b. Every occupier, where required, shall set up requisite bio-medical waste treatment facilities like incinerator, autoclave, microwave system for the treatment of waste, or, ensure requisite treatment of waste at a common waste treatment facility or any other waste treatment facility.

Incineration

Burning of waste material in the presence of oxygen.

Waste volume reduction, destroying some harmful constituents.

Works at temperature (~ 400–700°C).

DrawbackDrawbacktoxic products like furanes and dioxins - can cause air pollution

Non-incineration methods 1 - THERMAL PROCESSES

A - Low-Heat Thermal Processes (93°C-177°C) Wet heat (steam) disinfection - autoclave ,Dry heat (hot air) disinfection - infrared heaters.

B - Medium-Heat Thermal Processes (177°C-370°C) Chemical breakdown of organic material. Reverse polymerization using high-intensity microwave

C - High-Heat Thermal Processes (540°C-8,300°C) or higher Electrical resistance, induction, natural gas, and/or plasma energy provide the intense heat ,total destruction of the waste Significant change in the mass and volume

 

Non-incineration methods

2 - CHEMICAL PROCESSES

Dissolved chlorine dioxide, bleach (sodium hypochlorite), peracetic acid, or dry inorganic chemicals.

To enhance exposure of the waste to the chemical agent, chemical processes often involve shredding, grinding, or mixing.

3 - IRRADIATIVE PROCESSES Electron beams,Cobalt-60, or UV irradiation.

Common waste treatment facility( CWTF)

Operators auth. by Delhi Pollution Cont. Commit.

Biotic Waste Solutions Pvt. Ltd., 46, SSI Industrial Area, G.T. Karnal Road, Delhi 33

Phone (O) : 011 -47528106, 47528107

Metro Bio Care Technological Services (P). Ltd.,55, Railway Road, Samaipur Industrial Area, Delhi-42Phone No. 27898011, 27898033, 278661422.

Synergy Waste Management (P) Ltd.,Near Compost Plant, Okhla TankMathura Road New Delhi - 110020,Phone No. 26933371, 26933372

Waste Cycle

Waste Generation survey

Waste Segregation

Waste Storage

Waste transport

Waste disposal

Municipal ,sanitary landfill, drain in sewer

Waste treatment

•Return outdated

drugs/ chemicals

•Recycling/ reuse

Authorization

  Every occupier of an institution generating, handling BM W should make an application in Form 1 to the prescribed authority for grant of authorization.

Every operator of a bio-medical waste facility shall make an application in Form 1 to the prescribed authority for grant of authorization.

Annual Report

 Every occupier/operator submit an annual report to the prescribed authority in Form II by 31 January every year, to include information about the categories and quantities of bio-medical wastes handled during the preceding year. The prescribed authority shall send this information in a compiled form to the Central Pollution Control Board by 31 March every year.

Maintenance of Records& . Accident Reporting a. Every authorized person shall maintain records related to BMW.

b. All records shall be subjected to inspection and verification by the prescribed authority at any time.

c. When any accidents the authorized person shall report the accident in Form III to the prescribed authority forth with

Dos and Don’tsDo’s The used product should be segregated The used product should be mutilated.

The used product is treated prior to disposal.

Use protective gear when handling waste

Collect waste when the bin is 3/4 the full

Clean spills with disinfectant Use trolleys & do not drag waste bagsDo not Reuse plastic equipment. Mix plastic equipment with other

wastes. Burn plastic waste. Avoid needle stick injuries Avoid using common lift to move waste Avoid spillage

BMW management committee

Head of the hospital : chairman Waste Mx officer (dev. and implementation plan)

Members: HOD’s of all department Nursing superintendent, Head nurse, Sanitary inspector Chief pharmacist, Radiation officer Supply officer, financial officer

Responsibility of WMO Responsibility of WMO

Day to day control of segregation, transport & disposal of BMW

Co-ordinate with the store officer for continuous supply of basic items for BMWM

Prepare guidelines for BMWM & distribute to all department

Prepare BMW posters to raise awareness

Responsibility of WMO (Contd…..) Responsibility of WMO (Contd…..)

Arrange training programmes on BMWM & safety measures for all categories of HCW

Co-ordinate with HOD/In-charge of Deptt. where deficiencies are pointed out

Co-ordinate with CPWD Deptt. (Civil & Electrical)

Send monthly & annual report to DPCC

• Check Segregation• Monitoring disinfection of waste on site• Availability of basic items for BMWM• Monitoring compliance of usage of facilities by HCW• Monitor level of awareness• Prepare waste audit• Liason between HOD’s, CNO’s & WMO

• Check segregation• Check labeling• Weigh the waste• Monitor final disposal of the waste• Ensure the working of incinerator• Provide monthly data of waste generated by both Hospitals

Feedback to WMOAssist in training programme

Proper spill handling: Notify people in the area Don appropriate PPE Place absorbent material on spill Apply appropriate disinfectant – allow sufficient contact time (30 min)

Pick up material (watch for glass – use tongs or dust pan); dispose of material into biomedical waste

Reapply disinfectant and wipe For large/high hazard spills use 10% hypochlorite

For routine disinfection of surfaces where BMW is handled, use a 1:10 solution of freshly diluted bleach or 1% hypochlorite (ethanol evaporates too quickly!)

BMW Spills & Surface Disinfection

Handwashing is the single most effective way to stop the spread of disease.

Make certain that jewelry is limited to wedding rings, certain areas such as OR< C-section,Cath Lab and NBN allow no jewelry. Nails should be kept short and clean.

Gloves do not replace handwashing. Hand sanitizer may be used if no visible soiling is present and the sinks cannot be readily accessed. This is in every patient room. It can also be used when the water is out of service.

Inspect your hands each time they are washed. Only use hospital approved soaps and lotions, do not bring in any from home

Alcohol based hand rubs at point of care Sinks and clean running water

Training Compliance

Hand Washing

Steps to Effective Handwashing

Use soap & warm water. Scrub 10-15 seconds

Rinse well with fingers pointed downward.

After drying hands, turn off water using a paper towel. Discard towel in trash.

It is TIME to ACT, to prevent an epidemic waiting to happen.

Bio-medical waste programme cannot be successfully implemented without the willingness, self-motivation, and co-operation from all sections of employees of any health care setting.

Conclusion

If we want to protect our environment and health of community we must sensitize our selves to this important issue not only in the interest of health managers but also in the interest of community.

THANK YOU

Presented ByDr Sumi Nandwani

MD,DNB, PGCHM,MNAMSAssociate Professor

Department of Microbiology