Healthcare Wastes

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<p>PowerPoint Presentation</p> <p>Prof. (Dr.) Prashant Mehta M.Sc, Ph.D. (Chemistry), MBA, Ph.D. (Management) National Law University, Jodhpur</p> <p>Healthcare Waste An Environmental Concern of Escalating Magnitude</p> <p>My presentation is structured on three themes namely - Emerging Prospects Challenging Problems - Waste Trail in Indian Healthcare 1ResidentialCommercialInstitutionalConstruction WasteMunicipal servicesTreatment plant sitesIndustrialAgriculturalHealthcare WasteMunicipal Solid Waste (MSW) Industrial Solid Waste Bio-Medical / Hospital Waste Agricultural Waste </p> <p>Now I come to third section of my presentation: Bio-Medical / Hospital Waste </p> <p>2Classification Bio-Medical WasteHealthcare Waste is Classified as follows3</p> <p>There is direct co-relation between population density and bio-waste generation reflected in this slide4Regulatory Framework: IndiaEnvironmental Protection Rules, 1986 - This regulations were drawn up by the government under the powers conferred on it in terms of the Environment Protection Act, 1986.The Municipal Solid Wastes (Management and Handling) Rules 1999The Hazardous Waste (Management and Handling) Rules, 1989The Plastics (Manufacture, Usage and Waste Management Rules), 2009The E-Waste (Management and Handling Rules), 2010National Rural Health Mission (NRHM) under Ministry of Health and Family Welfare, in 2007 developed and adopted an Infection Management Environment Plan (IMEP) which outlines a comprehensive framework for implementation of infection control measures and effective healthcare waste management generated by healthcare facilities. The issue of Bio-Medical Waste Management (BMWM) in India has attracted the attention of the highest judicial body at the level of Supreme Court of India. It has issued instructions regarding management of Bio-Medical Waste and Government of India was one of the first countries to frame and implement Bio-Medical Waste Management and Handling Rules, 1998 (later amended in 2000 and 2003) in the exercise of power conferred by Sections 6, 8, and 25 of the Environment (Protection) Act, 1986. Bio-Medical Waste Management and Handling RulesDefinition of biomedical waste - Any waste that is generated during the diagnosis, treatment, or immunization of human beings or animals, or in research activities pertaining to or in the production or testing of biologicals.Application of the Biomedical Waste Rules - The rules apply to all persons who generate, collect, receive, store, transport, treat, dispose, or handle BMWs in any form.Duty of occupier (operator) - of a healthcare facility (hospital, nursing home, clinic, dispensary, veterinary institution, animal house, pathological laboratory, blood bank etc) to ensure that BMWs are handled without any adverse effect to human health and the environment, and according to the prescribed treatment and disposal requirements as per the Biomedical Waste Rules.Prescribed authority - State Pollution Control Boards (SPCBs) in States and Pollution Control Committees in territories are responsible for permitting and enforcing the requirements of the Biomedical Waste Rules.Permit - Each occupier (operator) handling BMWs and providing services to 1,000 or more patients per month is required to obtain a permit from the prescribed authority.Recordkeeping - Each occupier (operator) is required to maintain records on the generation, collection, reception, storage, transportation, treatment, and disposal of BMWs. All records are subject to inspection and verification by the prescribed authority at any time.Accident reporting - Each occupier (operator) is required to report any accident related to the management of BMWs.Annual reporting - Each occupier is required to submit an annual report to the prescribed authority to provide information about categories and amounts of wastes generated and treated, and modes of treatment used.Common disposal/ Incineration sites - Local public entities are required to provide common disposal / incineration sites, and the occupiers (operators) of such sites are required to comply with the Biomedical Waste Rules.Segregation, Packaging, Transportation, and Storage - BMWs are not to be mixed with other waste. According to the Rules, BMWs are to be segregated into labelled bags/containers. Transportation of BMWs is to be conducted in authorized vehicles. No untreated waste is to be stored more than 48 hours, unless special permission is obtained from the regulatory authorities.Standards - Technology and discharge standards for incineration, autoclaving, microwaving, liquid waste discharges, and deep burial are prescribed in the Biomedical Waste Rules.Categories and Segregation of Bio-Medical Waste S. No.Bio-Medical Waste CategoriesContainer ColourTreatment and Disposal1.Human anatomical waste YellowIncineration / Deep Burial2.Animal WasteYellowIncineration / Deep Burial3.Microbiology and biotechnology waste (infectious wastes from laboratory)Yellow / RedIncineration / Autoclaving / Microwaving4.Waste sharps (for example, needles, syringe, scalpels)Blue / White / TranslucentDisinfection / Mutilation / Autoclaving / Microwaving5.Discarded medicines and cytotoxic drugsBlackIncineration/Destruction and Secure Landfilling6.Soiled waste (items contaminated with blood or body fluids such as cotton dressings, beddings)Yellow / RedIncineration / Autoclaving / Microwaving7.Solid waste (for example, tubing, catheters, intravenous sets)Blue / White / Translucent / RedDisinfection by chemical treatment / Autoclaving / Microwaving8.Liquid waste (from laboratory, washing, cleaning, housekeeping, disinfecting)-Disinfection by chemical treatment and discharge into drains9.Incineration ashBlackMunicipal Landfilling10.Chemical wastesBlackChemical treatment and discharge into drains for liquids, and secured landfills for solids.BMW Categories Draft - 2011 Amendments BMWM RULES - 2011BMWM RULES - 1998Every occupier generating BMW, irrespective of the quantum of wastes comes under the BMW Rules and requires to obtain authorization.Occupiers with more than 1000 beds required to obtain authorization.Duties of the Operator are clearly listedDuties of Operator were absentCategories of Biomedical Waste reduced to Eight. Category No. 8 (containing liquid waste generated from laboratory, cleaning, washing, and disinfection activities) and Category No. 9 (containing incineration ash) have been discarded.Biomedical waste was divided in ten categoriesTreatment and disposal of BMW made mandatory for all the Healthcare Establishments.Treatment and disposal of BMW made mandatory for all the Healthcare Establishments with more than 1000 beds. A format for annual report is appended with the Rules. Accident reporting has been made mandatory.There was no format for Annual ReportForm VI i.e. the report of the operator on HCEs not handing over the BMW added to the Rules. It empowers the operator of CBMWTF to report against the HCEs who are not carrying out proper segregation of their wastes.Form VI absentHealthcare Waste and ExamplesTypes of Healthcare WastesExamplesCommunal or General healthcare waste (solid wastes that are not infectious, chemical, or radioactive)Infectious waste (wastes suspected of containing pathogens) Anatomical waste Sharps Pharmaceutical waste Genotoxic waste Chemical waste </p> <p>Heavy metal waste Pressurized containersRadioactive waste Cardboard boxes, paper, food waste, plastic and glass bottles</p> <p>Cultures, tissues, dressings, swabs, and other blood-soaked items; waste from isolation wardsRecognizable body parts, amputated organs, placenta, aborted foetuses Needles, scalpels, knives, blades, broken glass Expired or no longer needed medicines or pharmaceuticals Wastes containing genotoxic drugs and chemicals (used in cancer therapy) Laboratory reagents, film developer, solvents, expired or no longer needed disinfectants, and organic chemical wastes (for example, formaldehyde, phenol-based cleaning solutions)Batteries, broken thermometers, blood pressure gauges Aerosol cans, gas cylinders (that is, anaesthetic gases such as nitrous oxide, halothane, enflurane, and ethylene oxide; oxygen, compressed air)Unused liquids from radiotherapy; waste materials from patients treated or tested with unsealed radionuclidesProblems With Healthcare WastesAccording to the Ministry of Environment and Forests (MoEF) gross generation of bio-medical wastes in India is 4,05,702 kg/day of which only 2,91983 kg/day is disposed, which means that almost 28 percent of the bio-medical and hospital waste is left untreated and not disposed off. Extrapolating from past figures of number of beds and average quantity of waste generation at the rate of 1 to 1.5 kg per bed per day, it is estimated that about 0.33 million tonnes of hospital waste is being generated per year which is far less than waste generated by other developed countries.Almost 53.25 percent of healthcare establishments are in operations without the adequate authorization from State Pollution Control Board (SPCB), and the waste generated from such facilities goes unaccounted / untreated and is dumped without any treatment illegally. The waste generated by healthcare establishments by the process of rendering healthcare services, can be hazardous, toxic, and even lethal due to the presence of pathogens in sufficient concentration or quantity that could result in rapid proliferation, transmission, and spreading of infectious, dangerous and fatal communicable diseases such as Hepatitis, HIV/AIDS, Cancer, and other blood borne diseases. During incineration, in most cases there is no proper filtering of emitted flue gases which pollutes the air causing illnesses to the nearby populations. Therefore institutionalizing effective healthcare waste management systems in all healthcare facilities is a key prerequisite to improving efficiency and effectiveness of healthcare of people.Genotoxic WastesGenotoxic waste is highly hazardous and may have mutagenic, teratogenic, or carcinogenic properties. It raises serious safety problems, both inside hospitals and after disposal, and should be given special attention. Genotoxic waste may include certain cytostatic drugs (see below), vomit, urine, or faeces from patients treated with cytostatic drugs, chemicals, and radioactive material. Cytotoxic (or antineoplastic) drugs, the principal substances in this category, have the ability to kill or stop the growth of certain living cells and are used in chemotherapy of cancer. They play an important role in the therapy of various neo-plastic conditions but are also finding wider application as immunosuppressive agents in organ transplantation and in treating various diseases with an immunological basis. Cytotoxic drugs are most often used in specialized departments such as oncology and radiotherapy units, whose main role is cancer treatment; however, their use in other hospital departments is increasing and they may also be used outside the hospital setting.Most Common Genotoxic WastesClassified as carcinogenic </p> <p>Chemicals: benzene </p> <p>Cytotoxic and other drugs: azathioprine, chlorambucil, chlornaphazine, ciclosporin, cyclophosphamide, melphalan, semustine, tamoxifen, thiotepa, treosulfan </p> <p>Radioactive substances: (radioactive substances are treated as a separate category in this handbook) </p> <p>Classified as possibly or probably carcinogenic </p> <p>Cytotoxic and other drugs: azacitidine, bleomycin, carmustine, chloramphenicol, chlorozotocin, cisplatin, dacarbazine, daunorubicin, dihydroxymethylfuratrizine (e.g. Panfuran Sno longer in use), doxorubicin, lomustine, methylthiouracil, metronidazole, mitomycin, nafenopin, niridazole, oxazepam, phenacetin, phenobarbital, phenytoin, procarbazine hydrochloride, progesterone, sarcolysin, streptozocin, trichlormethine a </p> <p>Classified by working groups of the International Agency for Research on Cancer (IARC).Categories of Harmful Cytotoxic DrugsAlkylating agents: cause alkylation of DNA nucleotides, which leads to cross-linking and miscoding of the genetic stock; Antimetabolites: inhibit the biosynthesis of nucleic acids in the cell; Mitotic inhibitors: prevent cell replication. Cytotoxic wastes are generated from several sources and can include the following: Contaminated materials from drug preparation and administration, such as syringes, needles, gauges, vials, packaging; Outdated drugs, excess (leftover) solutions, drugs returned from the wards; Urine, faeces, and vomit from patients, which may contain potentially hazardous amounts of the administered cytostatic drugs or of their metabolites and which should be considered genotoxic for at least 48 hours and sometimes up to 1 week after drug administration. In specialized oncological hospitals, genotoxic waste (containing cytostatic or radioactive substances) may constitute as much as 1% of the total healthcare wastes.Chemical WastesFormaldehyde is a significant source of chemical waste in hospitals. It is used to clean and disinfect equipment (e.g. haemodialysis or surgical equipment), to preserve specimens, to disinfect liquid infectious waste, and in pathology, autopsy, dialysis, embalming, and nursing units. Photographic chemicals Photographic fixing and developing solutions are used in X-ray departments. The fixer usually contains 510% hydroquinone, 15% potassium hydroxide, and less than 1% silver. The developer contains approximately 45% glutaraldehyde. Acetic acid is used in both stop baths and fixer solutions. Solvents Wastes containing solvents are generated in various departments of a hospital, including pathology and histology laboratories, and engineering departments. Solvents used in hospitals include halogenated compounds, such as methylene chloride, chloroform, trichloroethylene, and refrigerants, and non-halogenated compounds such as xylene, methanol, acetone, isopropanol, toluene, ethyl acetate, and acetonitrile. Organic chemicals Waste generated in health-care facilities include: disinfecting and cleaning solutions such as phenol-based chemicals used for scrubbing floors, perchlorethylene used in workshops and laundries; oils such as vacuum-pump oils, used engine oil from vehicles (particularly if there is a vehicle service station on the hospital premises); insecticides, rodenticides. Inorganic chemicals Waste inorganic chemicals consist mainly of acids and alkalis (e.g. sulfuric, hydrochloric, nitric, and chromic acids, sodium hydroxide and ammonia solutions). They also include oxidants, such as potassium permanganate (KMnO4) and potassium dichromate (K2Cr2O7), and reducing agents, such as sodium bisulfite (NaHSO3) and sodium sulfite (Na2SO3).Wastes with High Content of Heavy MetalsWastes with a high heavy-metal content represent a subcategory of hazardous chemical waste, and are usually highly toxic. </p> <p>Mercury wastes are typically generated by spillage from broken clinical equipment but their volume is decreasing with the substitution of solid-state electronic s...</p>