05012023 1

WELCOME TO SEMINAR

05012023 2

05012023 3

Discovered during a waste audit a leg destined for disposal via the municipal system (NakarmiHECAF)

05012023 4

05012023 5

Contdhellip

One extreme case from Brazil demonstrated a carcinogenic impact on the general population from an unintended exposure to radioactive waste from a health-care facility While moving to a new site a radiotherapy institute left a sealed radioactive source in equipment at its old premises An individual who gained access to these premises removed the sealed source took it home and broke open the casing to reveal the radioactive material As a consequence 249 people were exposed of whom several died or suffered severe health problems (International Agency for Research on Cancer (IARC1988)

05012023 6

HEALTHCARE WASTE MANAGEMENT

Pabitra Sharma

05012023 7

General objective

At the end of the session the participants will be able to explain Health care waste management

05012023 8

Specific Objectives

bull define wastebull define health care wastebull state the types of health care wastebull identify sources of health care wastebull explain impact of health care wastebull state the types of infection by Health Care Wastebull list the principles of health care waste managementbull explain the steps of health care waste

management

05012023 9

Specific Objectives Cont

identify different organization in health care waste management identify the legislation regarding Health Care Waste Management in Nepal

05012023 10

Waste Definition

bull Waste (also known as rubbish trash refuse

garbage junk litter) is unwanted or useless

materials

bull ldquoSubstances or objects which are disposed of or

are intended to be disposed of or are required to

be disposed of by the provisions of the lawrdquo

(Basel Convention2003)

05012023 11

Health Care Waste (HCW)

Health-care waste includes all the waste

generated by health-care establishments research

facilities and laboratories In addition it includes

the waste originating from ldquominorrdquo or ldquoscatteredrdquo

source such as that produced in the course of

health care undertaken in the home (dialysis

insulin injections etc) (WHO1999)

05012023 12

HCW Contd

Medical waste means the hazardous waste

produced and discharged from hospitals clinics

pharmacies dispensaries blood banks pathology

laboratories veterinary institutions and health

research centers (Solid Waste Management Act

2011Nepal)

05012023 13

HCW Contd

HCW

80 general non hazardous 15 hazardous

(10 infective waste

5 non- infectious but hazardous1

is sharp

05012023 14

Classifications of waste

05012023 15

Categorization of HCW

a) Based on UNEPSBCWHO (United Nation Environment

ProgrammeSecretariat Basal Convention2004)

1 Non-risk HCW

2 HCW requiring special attention

3 Infectious and highly infectious waste

4 Other hazardous waste

5 Radioactive waste

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 2

05012023 3

Discovered during a waste audit a leg destined for disposal via the municipal system (NakarmiHECAF)

05012023 4

05012023 5

Contdhellip

One extreme case from Brazil demonstrated a carcinogenic impact on the general population from an unintended exposure to radioactive waste from a health-care facility While moving to a new site a radiotherapy institute left a sealed radioactive source in equipment at its old premises An individual who gained access to these premises removed the sealed source took it home and broke open the casing to reveal the radioactive material As a consequence 249 people were exposed of whom several died or suffered severe health problems (International Agency for Research on Cancer (IARC1988)

05012023 6

HEALTHCARE WASTE MANAGEMENT

Pabitra Sharma

05012023 7

General objective

At the end of the session the participants will be able to explain Health care waste management

05012023 8

Specific Objectives

bull define wastebull define health care wastebull state the types of health care wastebull identify sources of health care wastebull explain impact of health care wastebull state the types of infection by Health Care Wastebull list the principles of health care waste managementbull explain the steps of health care waste

management

05012023 9

Specific Objectives Cont

identify different organization in health care waste management identify the legislation regarding Health Care Waste Management in Nepal

05012023 10

Waste Definition

bull Waste (also known as rubbish trash refuse

garbage junk litter) is unwanted or useless

materials

bull ldquoSubstances or objects which are disposed of or

are intended to be disposed of or are required to

be disposed of by the provisions of the lawrdquo

(Basel Convention2003)

05012023 11

Health Care Waste (HCW)

Health-care waste includes all the waste

generated by health-care establishments research

facilities and laboratories In addition it includes

the waste originating from ldquominorrdquo or ldquoscatteredrdquo

source such as that produced in the course of

health care undertaken in the home (dialysis

insulin injections etc) (WHO1999)

05012023 12

HCW Contd

Medical waste means the hazardous waste

produced and discharged from hospitals clinics

pharmacies dispensaries blood banks pathology

laboratories veterinary institutions and health

research centers (Solid Waste Management Act

2011Nepal)

05012023 13

HCW Contd

HCW

80 general non hazardous 15 hazardous

(10 infective waste

5 non- infectious but hazardous1

is sharp

05012023 14

Classifications of waste

05012023 15

Categorization of HCW

a) Based on UNEPSBCWHO (United Nation Environment

ProgrammeSecretariat Basal Convention2004)

1 Non-risk HCW

2 HCW requiring special attention

3 Infectious and highly infectious waste

4 Other hazardous waste

5 Radioactive waste

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 3

Discovered during a waste audit a leg destined for disposal via the municipal system (NakarmiHECAF)

05012023 4

05012023 5

Contdhellip

One extreme case from Brazil demonstrated a carcinogenic impact on the general population from an unintended exposure to radioactive waste from a health-care facility While moving to a new site a radiotherapy institute left a sealed radioactive source in equipment at its old premises An individual who gained access to these premises removed the sealed source took it home and broke open the casing to reveal the radioactive material As a consequence 249 people were exposed of whom several died or suffered severe health problems (International Agency for Research on Cancer (IARC1988)

05012023 6

HEALTHCARE WASTE MANAGEMENT

Pabitra Sharma

05012023 7

General objective

At the end of the session the participants will be able to explain Health care waste management

05012023 8

Specific Objectives

bull define wastebull define health care wastebull state the types of health care wastebull identify sources of health care wastebull explain impact of health care wastebull state the types of infection by Health Care Wastebull list the principles of health care waste managementbull explain the steps of health care waste

management

05012023 9

Specific Objectives Cont

identify different organization in health care waste management identify the legislation regarding Health Care Waste Management in Nepal

05012023 10

Waste Definition

bull Waste (also known as rubbish trash refuse

garbage junk litter) is unwanted or useless

materials

bull ldquoSubstances or objects which are disposed of or

are intended to be disposed of or are required to

be disposed of by the provisions of the lawrdquo

(Basel Convention2003)

05012023 11

Health Care Waste (HCW)

Health-care waste includes all the waste

generated by health-care establishments research

facilities and laboratories In addition it includes

the waste originating from ldquominorrdquo or ldquoscatteredrdquo

source such as that produced in the course of

health care undertaken in the home (dialysis

insulin injections etc) (WHO1999)

05012023 12

HCW Contd

Medical waste means the hazardous waste

produced and discharged from hospitals clinics

pharmacies dispensaries blood banks pathology

laboratories veterinary institutions and health

research centers (Solid Waste Management Act

2011Nepal)

05012023 13

HCW Contd

HCW

80 general non hazardous 15 hazardous

(10 infective waste

5 non- infectious but hazardous1

is sharp

05012023 14

Classifications of waste

05012023 15

Categorization of HCW

a) Based on UNEPSBCWHO (United Nation Environment

ProgrammeSecretariat Basal Convention2004)

1 Non-risk HCW

2 HCW requiring special attention

3 Infectious and highly infectious waste

4 Other hazardous waste

5 Radioactive waste

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 4

05012023 5

Contdhellip

One extreme case from Brazil demonstrated a carcinogenic impact on the general population from an unintended exposure to radioactive waste from a health-care facility While moving to a new site a radiotherapy institute left a sealed radioactive source in equipment at its old premises An individual who gained access to these premises removed the sealed source took it home and broke open the casing to reveal the radioactive material As a consequence 249 people were exposed of whom several died or suffered severe health problems (International Agency for Research on Cancer (IARC1988)

05012023 6

HEALTHCARE WASTE MANAGEMENT

Pabitra Sharma

05012023 7

General objective

At the end of the session the participants will be able to explain Health care waste management

05012023 8

Specific Objectives

bull define wastebull define health care wastebull state the types of health care wastebull identify sources of health care wastebull explain impact of health care wastebull state the types of infection by Health Care Wastebull list the principles of health care waste managementbull explain the steps of health care waste

management

05012023 9

Specific Objectives Cont

identify different organization in health care waste management identify the legislation regarding Health Care Waste Management in Nepal

05012023 10

Waste Definition

bull Waste (also known as rubbish trash refuse

garbage junk litter) is unwanted or useless

materials

bull ldquoSubstances or objects which are disposed of or

are intended to be disposed of or are required to

be disposed of by the provisions of the lawrdquo

(Basel Convention2003)

05012023 11

Health Care Waste (HCW)

Health-care waste includes all the waste

generated by health-care establishments research

facilities and laboratories In addition it includes

the waste originating from ldquominorrdquo or ldquoscatteredrdquo

source such as that produced in the course of

health care undertaken in the home (dialysis

insulin injections etc) (WHO1999)

05012023 12

HCW Contd

Medical waste means the hazardous waste

produced and discharged from hospitals clinics

pharmacies dispensaries blood banks pathology

laboratories veterinary institutions and health

research centers (Solid Waste Management Act

2011Nepal)

05012023 13

HCW Contd

HCW

80 general non hazardous 15 hazardous

(10 infective waste

5 non- infectious but hazardous1

is sharp

05012023 14

Classifications of waste

05012023 15

Categorization of HCW

a) Based on UNEPSBCWHO (United Nation Environment

ProgrammeSecretariat Basal Convention2004)

1 Non-risk HCW

2 HCW requiring special attention

3 Infectious and highly infectious waste

4 Other hazardous waste

5 Radioactive waste

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 5

Contdhellip

One extreme case from Brazil demonstrated a carcinogenic impact on the general population from an unintended exposure to radioactive waste from a health-care facility While moving to a new site a radiotherapy institute left a sealed radioactive source in equipment at its old premises An individual who gained access to these premises removed the sealed source took it home and broke open the casing to reveal the radioactive material As a consequence 249 people were exposed of whom several died or suffered severe health problems (International Agency for Research on Cancer (IARC1988)

05012023 6

HEALTHCARE WASTE MANAGEMENT

Pabitra Sharma

05012023 7

General objective

At the end of the session the participants will be able to explain Health care waste management

05012023 8

Specific Objectives

bull define wastebull define health care wastebull state the types of health care wastebull identify sources of health care wastebull explain impact of health care wastebull state the types of infection by Health Care Wastebull list the principles of health care waste managementbull explain the steps of health care waste

management

05012023 9

Specific Objectives Cont

identify different organization in health care waste management identify the legislation regarding Health Care Waste Management in Nepal

05012023 10

Waste Definition

bull Waste (also known as rubbish trash refuse

garbage junk litter) is unwanted or useless

materials

bull ldquoSubstances or objects which are disposed of or

are intended to be disposed of or are required to

be disposed of by the provisions of the lawrdquo

(Basel Convention2003)

05012023 11

Health Care Waste (HCW)

Health-care waste includes all the waste

generated by health-care establishments research

facilities and laboratories In addition it includes

the waste originating from ldquominorrdquo or ldquoscatteredrdquo

source such as that produced in the course of

health care undertaken in the home (dialysis

insulin injections etc) (WHO1999)

05012023 12

HCW Contd

Medical waste means the hazardous waste

produced and discharged from hospitals clinics

pharmacies dispensaries blood banks pathology

laboratories veterinary institutions and health

research centers (Solid Waste Management Act

2011Nepal)

05012023 13

HCW Contd

HCW

80 general non hazardous 15 hazardous

(10 infective waste

5 non- infectious but hazardous1

is sharp

05012023 14

Classifications of waste

05012023 15

Categorization of HCW

a) Based on UNEPSBCWHO (United Nation Environment

ProgrammeSecretariat Basal Convention2004)

1 Non-risk HCW

2 HCW requiring special attention

3 Infectious and highly infectious waste

4 Other hazardous waste

5 Radioactive waste

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 6

HEALTHCARE WASTE MANAGEMENT

Pabitra Sharma

05012023 7

General objective

At the end of the session the participants will be able to explain Health care waste management

05012023 8

Specific Objectives

bull define wastebull define health care wastebull state the types of health care wastebull identify sources of health care wastebull explain impact of health care wastebull state the types of infection by Health Care Wastebull list the principles of health care waste managementbull explain the steps of health care waste

management

05012023 9

Specific Objectives Cont

identify different organization in health care waste management identify the legislation regarding Health Care Waste Management in Nepal

05012023 10

Waste Definition

bull Waste (also known as rubbish trash refuse

garbage junk litter) is unwanted or useless

materials

bull ldquoSubstances or objects which are disposed of or

are intended to be disposed of or are required to

be disposed of by the provisions of the lawrdquo

(Basel Convention2003)

05012023 11

Health Care Waste (HCW)

Health-care waste includes all the waste

generated by health-care establishments research

facilities and laboratories In addition it includes

the waste originating from ldquominorrdquo or ldquoscatteredrdquo

source such as that produced in the course of

health care undertaken in the home (dialysis

insulin injections etc) (WHO1999)

05012023 12

HCW Contd

Medical waste means the hazardous waste

produced and discharged from hospitals clinics

pharmacies dispensaries blood banks pathology

laboratories veterinary institutions and health

research centers (Solid Waste Management Act

2011Nepal)

05012023 13

HCW Contd

HCW

80 general non hazardous 15 hazardous

(10 infective waste

5 non- infectious but hazardous1

is sharp

05012023 14

Classifications of waste

05012023 15

Categorization of HCW

a) Based on UNEPSBCWHO (United Nation Environment

ProgrammeSecretariat Basal Convention2004)

1 Non-risk HCW

2 HCW requiring special attention

3 Infectious and highly infectious waste

4 Other hazardous waste

5 Radioactive waste

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 7

General objective

At the end of the session the participants will be able to explain Health care waste management

05012023 8

Specific Objectives

bull define wastebull define health care wastebull state the types of health care wastebull identify sources of health care wastebull explain impact of health care wastebull state the types of infection by Health Care Wastebull list the principles of health care waste managementbull explain the steps of health care waste

management

05012023 9

Specific Objectives Cont

identify different organization in health care waste management identify the legislation regarding Health Care Waste Management in Nepal

05012023 10

Waste Definition

bull Waste (also known as rubbish trash refuse

garbage junk litter) is unwanted or useless

materials

bull ldquoSubstances or objects which are disposed of or

are intended to be disposed of or are required to

be disposed of by the provisions of the lawrdquo

(Basel Convention2003)

05012023 11

Health Care Waste (HCW)

Health-care waste includes all the waste

generated by health-care establishments research

facilities and laboratories In addition it includes

the waste originating from ldquominorrdquo or ldquoscatteredrdquo

source such as that produced in the course of

health care undertaken in the home (dialysis

insulin injections etc) (WHO1999)

05012023 12

HCW Contd

Medical waste means the hazardous waste

produced and discharged from hospitals clinics

pharmacies dispensaries blood banks pathology

laboratories veterinary institutions and health

research centers (Solid Waste Management Act

2011Nepal)

05012023 13

HCW Contd

HCW

80 general non hazardous 15 hazardous

(10 infective waste

5 non- infectious but hazardous1

is sharp

05012023 14

Classifications of waste

05012023 15

Categorization of HCW

a) Based on UNEPSBCWHO (United Nation Environment

ProgrammeSecretariat Basal Convention2004)

1 Non-risk HCW

2 HCW requiring special attention

3 Infectious and highly infectious waste

4 Other hazardous waste

5 Radioactive waste

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 8

Specific Objectives

bull define wastebull define health care wastebull state the types of health care wastebull identify sources of health care wastebull explain impact of health care wastebull state the types of infection by Health Care Wastebull list the principles of health care waste managementbull explain the steps of health care waste

management

05012023 9

Specific Objectives Cont

identify different organization in health care waste management identify the legislation regarding Health Care Waste Management in Nepal

05012023 10

Waste Definition

bull Waste (also known as rubbish trash refuse

garbage junk litter) is unwanted or useless

materials

bull ldquoSubstances or objects which are disposed of or

are intended to be disposed of or are required to

be disposed of by the provisions of the lawrdquo

(Basel Convention2003)

05012023 11

Health Care Waste (HCW)

Health-care waste includes all the waste

generated by health-care establishments research

facilities and laboratories In addition it includes

the waste originating from ldquominorrdquo or ldquoscatteredrdquo

source such as that produced in the course of

health care undertaken in the home (dialysis

insulin injections etc) (WHO1999)

05012023 12

HCW Contd

Medical waste means the hazardous waste

produced and discharged from hospitals clinics

pharmacies dispensaries blood banks pathology

laboratories veterinary institutions and health

research centers (Solid Waste Management Act

2011Nepal)

05012023 13

HCW Contd

HCW

80 general non hazardous 15 hazardous

(10 infective waste

5 non- infectious but hazardous1

is sharp

05012023 14

Classifications of waste

05012023 15

Categorization of HCW

a) Based on UNEPSBCWHO (United Nation Environment

ProgrammeSecretariat Basal Convention2004)

1 Non-risk HCW

2 HCW requiring special attention

3 Infectious and highly infectious waste

4 Other hazardous waste

5 Radioactive waste

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 9

Specific Objectives Cont

identify different organization in health care waste management identify the legislation regarding Health Care Waste Management in Nepal

05012023 10

Waste Definition

bull Waste (also known as rubbish trash refuse

garbage junk litter) is unwanted or useless

materials

bull ldquoSubstances or objects which are disposed of or

are intended to be disposed of or are required to

be disposed of by the provisions of the lawrdquo

(Basel Convention2003)

05012023 11

Health Care Waste (HCW)

Health-care waste includes all the waste

generated by health-care establishments research

facilities and laboratories In addition it includes

the waste originating from ldquominorrdquo or ldquoscatteredrdquo

source such as that produced in the course of

health care undertaken in the home (dialysis

insulin injections etc) (WHO1999)

05012023 12

HCW Contd

Medical waste means the hazardous waste

produced and discharged from hospitals clinics

pharmacies dispensaries blood banks pathology

laboratories veterinary institutions and health

research centers (Solid Waste Management Act

2011Nepal)

05012023 13

HCW Contd

HCW

80 general non hazardous 15 hazardous

(10 infective waste

5 non- infectious but hazardous1

is sharp

05012023 14

Classifications of waste

05012023 15

Categorization of HCW

a) Based on UNEPSBCWHO (United Nation Environment

ProgrammeSecretariat Basal Convention2004)

1 Non-risk HCW

2 HCW requiring special attention

3 Infectious and highly infectious waste

4 Other hazardous waste

5 Radioactive waste

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 10

Waste Definition

bull Waste (also known as rubbish trash refuse

garbage junk litter) is unwanted or useless

materials

bull ldquoSubstances or objects which are disposed of or

are intended to be disposed of or are required to

be disposed of by the provisions of the lawrdquo

(Basel Convention2003)

05012023 11

Health Care Waste (HCW)

Health-care waste includes all the waste

generated by health-care establishments research

facilities and laboratories In addition it includes

the waste originating from ldquominorrdquo or ldquoscatteredrdquo

source such as that produced in the course of

health care undertaken in the home (dialysis

insulin injections etc) (WHO1999)

05012023 12

HCW Contd

Medical waste means the hazardous waste

produced and discharged from hospitals clinics

pharmacies dispensaries blood banks pathology

laboratories veterinary institutions and health

research centers (Solid Waste Management Act

2011Nepal)

05012023 13

HCW Contd

HCW

80 general non hazardous 15 hazardous

(10 infective waste

5 non- infectious but hazardous1

is sharp

05012023 14

Classifications of waste

05012023 15

Categorization of HCW

a) Based on UNEPSBCWHO (United Nation Environment

ProgrammeSecretariat Basal Convention2004)

1 Non-risk HCW

2 HCW requiring special attention

3 Infectious and highly infectious waste

4 Other hazardous waste

5 Radioactive waste

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 11

Health Care Waste (HCW)

Health-care waste includes all the waste

generated by health-care establishments research

facilities and laboratories In addition it includes

the waste originating from ldquominorrdquo or ldquoscatteredrdquo

source such as that produced in the course of

health care undertaken in the home (dialysis

insulin injections etc) (WHO1999)

05012023 12

HCW Contd

Medical waste means the hazardous waste

produced and discharged from hospitals clinics

pharmacies dispensaries blood banks pathology

laboratories veterinary institutions and health

research centers (Solid Waste Management Act

2011Nepal)

05012023 13

HCW Contd

HCW

80 general non hazardous 15 hazardous

(10 infective waste

5 non- infectious but hazardous1

is sharp

05012023 14

Classifications of waste

05012023 15

Categorization of HCW

a) Based on UNEPSBCWHO (United Nation Environment

ProgrammeSecretariat Basal Convention2004)

1 Non-risk HCW

2 HCW requiring special attention

3 Infectious and highly infectious waste

4 Other hazardous waste

5 Radioactive waste

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 12

HCW Contd

Medical waste means the hazardous waste

produced and discharged from hospitals clinics

pharmacies dispensaries blood banks pathology

laboratories veterinary institutions and health

research centers (Solid Waste Management Act

2011Nepal)

05012023 13

HCW Contd

HCW

80 general non hazardous 15 hazardous

(10 infective waste

5 non- infectious but hazardous1

is sharp

05012023 14

Classifications of waste

05012023 15

Categorization of HCW

a) Based on UNEPSBCWHO (United Nation Environment

ProgrammeSecretariat Basal Convention2004)

1 Non-risk HCW

2 HCW requiring special attention

3 Infectious and highly infectious waste

4 Other hazardous waste

5 Radioactive waste

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 13

HCW Contd

HCW

80 general non hazardous 15 hazardous

(10 infective waste

5 non- infectious but hazardous1

is sharp

05012023 14

Classifications of waste

05012023 15

Categorization of HCW

a) Based on UNEPSBCWHO (United Nation Environment

ProgrammeSecretariat Basal Convention2004)

1 Non-risk HCW

2 HCW requiring special attention

3 Infectious and highly infectious waste

4 Other hazardous waste

5 Radioactive waste

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 14

Classifications of waste

05012023 15

Categorization of HCW

a) Based on UNEPSBCWHO (United Nation Environment

ProgrammeSecretariat Basal Convention2004)

1 Non-risk HCW

2 HCW requiring special attention

3 Infectious and highly infectious waste

4 Other hazardous waste

5 Radioactive waste

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 15

Categorization of HCW

a) Based on UNEPSBCWHO (United Nation Environment

ProgrammeSecretariat Basal Convention2004)

1 Non-risk HCW

2 HCW requiring special attention

3 Infectious and highly infectious waste

4 Other hazardous waste

5 Radioactive waste

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 16

1) Non risk HCW

Non-risk health care waste (Comparable to the

domestic waste)

11 Recyclable HCW - paper card board non-

contaminated plastic or metal cans or glass

12 Biodegradable HCW ndash waste that can be

composted

13 Other non-risk HCW ndash clay equipment

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 17

HCW which needs special attention for disposal

21 Human anatomical waste -human body parts

organs and tissues

22 Sharp Waste-

23 Pharmaceutical waste

- Non- hazardous pharmacological waste- Normal

saline Dextrin or Cough syrup etc

2 Health care waste requiring special attention

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 18

HCW with special attention contd

- Potentially hazardous pharmaceutical

waste- Date expired medicine

- Hazardous pharmaceutical waste-

unidentifiable pharmaceuticals as well as heavy

metal containing disinfectants

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 19

Contdhellip

A dog finds some pathological waste on a Kathmandu street (NakarmiHECAF)

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 20

Contdhellip

In China 21 dead babies were found in a lake

some had hospital identity tags and one was

wrapped in plastic and labeled ldquomedical wasterdquo

(human right and medical waste 2011)

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 21

HCW Require Attention Contd

24 Cytotoxic pharmaceutical waste - alkylated

substances antimetabolites antibiotics plant

alkaloids hormones and others

25 Blood and body fluids waste

human or animal blood secretions and excretions

Eg dressing material s1113090wabs syringes without

needle infusion equipment

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 22

3 Infectious and highly infectious Waste

31 Infectious waste- potential of transmitting

infectious agents to humans or animals Eg isolation

wards dialysis wards or centers for patients infected

with hepatitis viruses (yellow dialysis) pathology

departments operating theatres etc

32 Highly infectious waste- All microbiological

cultures and 1113090laboratory waste

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 23

4 Other Hazardous Waste

Include chemicals heavy metals pressurized containers

discarded gaseous liquid and solid generated during diagnostic

and experimental 1113090disinfecting procedures cleaning processes

and house-keeping with features of

o Toxic

o Corrosive acids

o Flammable

o Reactive explosive shock sensitive

o Cytotoxic or genotoxic properties

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 24

5 Radioactive Waste

bull Include materials contaminated with

radio1113090nuclides which arise from the medical or

research use of radio-nuclide

bull Sealed radiation source liquid and gaseous

material contaminated 1113090with radionuclide

excreta of patients etc

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 25

WHO Classification

a) Hazardous health-care waste bull Sharps waste bull Infectious waste bull Pathological waste bull Pharmaceutical waste bull cytotoxic waste bull Chemical waste bull Radioactive waste b) Non-hazardous or general health-care waste

(WHO2014)

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 26

Categorizations According to BMW Schedule 2011

bull Category 1- Human Anatomical

bull Category 2- Animal

bull Category 3- MicrobiologyBiotechnology

bull Category 4- Sharp

bull Category 5- Discarded Medication and Cytotoxic

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 27

BMW Categorization Contd

bull Category 6- Soiled Water

bull Category 7- Solid Waste

bull Category 8- Liquid Waste

bull Category 9- Incinerator Ash

bull Category 10- Chemical Waste

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023

Categorization in Nepal

Based on UNEPSBSWHO1) Non risk HCW

bull Biodegradable

bull Non-biodegradable

28NHCWM Guideline2014

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 29

Categorization Contd

2) Risk health care wastes

bull Pathological Waste

bull Infectious waste Sharp Waste

bull Cytotoxic Waste

bull Pharmaceutical Waste

bull Other hazardous Waste

NHCWM Guideline2014

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 30

Categorization by NHRC

bull Non hazardous waste general waste

bull Hazardous contaminated waste

bull Sharp( infected or not infected)

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 31

Research

Worldwide an estimated 16 billion injections are

administered every year Not all needles and

syringes are disposed of safely creating a risk of

injury and infection and opportunities for reuse

I am Committed for Safe Injection

(BMWS2011)

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 32

Production of HCW

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 33

Production of HCW

A) Globally

bull Developed countries - 1- 5kgbedday

bull Developing countries - 1-2kgday

- The waste generation rate (kgbedday) hospital

USA - 45 Netherlands 27 and France 25

(WHO2014)

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 34

- Average HCW - 1-45 kgbedday in Latin

American countries( eg Chile Brazil Argentina

and Venezuela )

- Hazardous waste - 5 in Denmark 28 in

USA

(Monreal 1991)

Production Contdhellip

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 35

B) Production of Waste in South East Region (by 2001)

Country Waste(kgbedday) Annual wasteBangladesh 08-167 930755 tons

Bhutan 027 73 tonsIndia 10- 20 033 million tonsMaldives NA 146 tonsNepal 05 2018 tonsPakistan 163-369 025 million tonsSrilanka 036 6600 tons

WHO2001

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 36

Production Contdhellip

C) In Nepal

bull Kathmandu Metropolitan City have organized a

study on biomedical waste in hospital located

Kathmandu

- (Results- 172kg waste day patients)

- Out of which26 waste was infectious and

hazardous

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 37

Production in Nepal Contdhellip

bull Estimated at 0533 kgbed day Out of which

0256 kgbed day is general

0147 kgbedday -biodegradable waste

0120 kgbed-day- infectious waste sharps

0009 kgbed-day - hazardous

chemicalpharmaceutical waste

(UNEP 2012)

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 38

Hospital No Total bed

HCW ton

HCWR (ton)

Government teaching including MoHP

92 6601

3080 90554Government hospital under other ministry

3 1036

Private hospital 157 9207719249 211544

Private teaching hospital 14 8626

Mission hospital 8 612 246 72

Country hospital 274 26082 105119 3093

Source MoHP Poster Presentation in first HCWM International Workshop Nepal 2012

Total health care facilities with bed and corresponding waste generation

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 39

Contdhellip

Assessment study at Civil Service Hospital(CSH)

Kathmandu Waste generation

- 6458 kg per day with occupancy rate of 5565 (173

kg per bed per day)

- Pre-separation scenario (71 is risk waste and 29 is

non-risk) Post-separation scenario (25 risk and non-

risk is around 29) (CSH2011)

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023

Production in Nepal Contdhellip

Hospitals Average productions (kgd)

General (kgd)

Hazardous (kgd)

Sharp (kgd)

Patan 5940 kg 377 (635)

165 (278) 52 (88)

Koshi Zonal 44114 kg 302 (684)

125 (284) 14 (31)

National kidney center

28 kg 14 (50) 5 (17) 9 ( 33)

(JHNRCvol 112013)

Out of 24 health care institution from only 3 HCI information available

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023

bull Enayetullah et al (2011) stated average HCW

generation in Pokhara city is est - 122 kgbed

- From outdoor facility is est 034kgday

bull From all HCF facilities (Pokhara) - 28 tonday

(22 HCWs is hazardous and infectious and the

rest general waste )

(JHNRCvol 112013)

Contdhellip

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 42

Sources of HCW

a) Major sources of health-care waste

Hospitals

bull University hospital

bull General hospital

bull District hospital

(SBS2004

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 43

Sources Contd

b) Medium Sources

Medical centers OPD Mortuary Autopsy center

Hospices Abortions clinics Medical laboratories

Medical research facilities Animal hospital Blood

bank and transfusions vices etc

(SBS2004)

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 44

Sources Contd

c) Small Sources

General medical practitioners Convalescent homes

Nursing and remedial homes Medical consulting rooms

Dental practitioner Animal boarding Tattooists

Acupuncturist Veterinary practitioner Pharmacies

Cosmetic piercers etc

(SBS2004)

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 45

Possible Impact

Sanitation workerMedical paramedical staff

Patients and visitorssurroundings environment

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 46

Route of infection

Hazards

Ingestion

Inhalation

Mucous membra

nes

Skin cut injury

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 47

A study done by Adhikari et al

showed that 535 had NSI only 468 had

reported to concerned authority whereas all

students were aware of the fact that HIV and HBV

is transmitted through needle stick injuries

Contdhellip

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 48

bull One cross-sectional study in GMC-TH

showed that 7079 health care workers had

experienced Needle Stick Injury (NSI) among them

- 525 suffered from NSI with unused needles

- 475 NSI from used needles and

- 6842 of NSI sufferer of used needles reported the

incident (NHCW guideline 2014)

Contdhellip

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 49

A study on Incidence Of NSI among PCL Nursing

Students In KTM

bull 469 had NSI 447 experienced gt 1 time

bull Out of total 298 injuries- 678 during

medication 41 while drawing medicine 20

recapping the needle

(International Journal of Scientific amp Technology

Research2013)

Contdhellip

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 50

A study by Sorsa et al 1985 in Finland found an

excess of spontaneous abortions during

pregnancy and malformations in children of

females with a history of working with anticancer

agents (WHO2014)

Contdhellip

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 51

Waste Hazards (eg)

Infectious waste and sharps Infection like HIV hepatitis resistant to antibiotic

Chemical and pharmaceutical Burn injury intoxication even death

Genotoxic Secondary neoplasma skin eye irritation

Radioactive Headache dizziness vomiting

Public sensitivity Public is very sensitive to visual impacts of health care waste specially anatomical waste

Effects of HCW

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 52

Infection By HCW Contdhellip

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 53

Infection By HCW Contdhellip

(WHO1999)

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 54

Samples taken from different areas of Bir Hospital

bull The mercury level was found to be highest in the

Dental OPDMedical ward (378 μgm3)

bull The mercury in water highest in the floor wash

sample of the Dental Ward (0045 mgl)

bull The mercury concentration in soil sample (area

near maintenance) - (272mgkg)

Interim report on HCWMBir Hospital 2068

Contdhellip

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 55

Survival of pathogenic microorganisms in the environment

The hepatitis B virusbull Is very persistent in dry airbull can survive for up to 1 week - in discarded

needle antiseptics like 70 ethanolbull Viable for 10 hours at 60 degC

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 56

Survival of microorganism Contd

HIV Virus

- Survives for no more than 15 min if exposed to

70 ethanol and only three to seven days at

ambient(20degC) temperature

- It is inactivated at 56 degC

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 57

Overview

In 2010 unsafe injections were still responsible for

33 800 new HIV infections 17 million hepatitis B

infections and 315000 hepatitis C infections

(WHO2014)

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 58

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 59

Need Health care waste management

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 60

Guiding Principles of HCWM

bull The ldquoPolluer Paysrdquo Principle

bull The ldquoPrecautionaryrdquo Principle

- (adopted under the Rio Declaration on

Environment and Development (UNEP 1972) )

bull The ldquoDuty of Carerdquo Principle

bull The ldquoProximityrdquo Principle

bull The ldquoPrior Informed Consent Principlerdquo

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 61

Steps for the Waste Management

bull Waste Minimization

bull Waste Segregation

bull Waste Collection and Storage

bull Waste Transportation

bull Waste Treatment and Disposal

(Solid Waste Management Act 2011 )

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 62

Waste Minimization

bull Waste minimization is defined as the prevention

of waste production and or its reduction at a

source

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 63

Waste Minimization ContdWaste minimization can be achieved through

bull Avoidence

bull Reduction

- Product Substitution

- Product Changes

- Procedural Changes

bull Re-Use

bull Recycling

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 64

Waste Segregation

bull Waste segregation refers to the process of separation

of waste at the point of generation and keeping them

apart during handling collection interim storage and

transportation

bull Segregation of the waste at source is the key principle

of successful and safe waste minimization and is the

most important step for a successful management of

HCW

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 65

Color Coding in Segregation Types of Waste WHO HCWG 2014 Symbol Non-risk waste Biodegradables

Black Green

Non-risk waste Recyclable Dark blue

Other non-risk HCW Light blue

Pathological waste (Danger Pathological waste

Yellow with biohazard symbol

Red

Hazardous Sharps Danger contaminated sharps Do not open

yellow with sharp

Red

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 66

Types of Waste WHO HCWG 2014

Symbol

Pharmaceuticals (cytotoxic) Danger Hazardous Infectious waste

Brown With symbol

Red

Danger Hazardous Infectious waste

Brown

Danger Highly infectious waste

Yellow Brown

Other hazardous waste Danger To be discarded by au- thorized staff only

Color Coding contd

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 67

Segregation contdhellip

Types of waste

WHO HCWG 2014 Symbol

Radioactive Waste (Danger Radioactive waste )

radiation symbol

Black

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 68

Color Coding (BMW)

Colour Category

Yellow 1255

Red 347 ( earlier soiled water are in red)

Blue 8

Black Municipal waste

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 69

bull The study conducted by MoHP help from WHO

concluded that HCWM is poor and 387

hospitals adopted correct segregation of HCWs

HCW were disposed at Okharpauwa dumping

site without any pre-treatment (MoHP2012)

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 70

Waste Collection and Storage

bull In order to avoid accumulation of the waste it

must be collected and transported to a central

storage area within the HCF on a regular basis

before being treated or removed

bull This area must be marked with warning sign

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 71

Collection Contd

bull Bags should be fill not more than 34th

bull Label of ward

bull Types of waste

bull Symbol properly

bull Weight

bull Record register

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 72

Storage Contdhellip

bull Waste security and restriction of access to authorized

persons

bull Easy access for waste collection vehicle water

bull Protection from sun rain strong winds and floods

bull Temperature

- ( Cold area)ndash max- 72 hour(winter) 48 hour

(summer)

- Hot area max-48 hr(winter) 24 hr(summer)

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 73

Storage Contd

bull Anatomical Waste - 3deg C to 8deg C

bull Infectious waste (if store gt week) 3deg C to 8deg C

bull Cytotoxic waste store separately

bull Radioactive waste should be stored in

containers (lead shielding) with labeling bull Chemical waste

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 74

Waste Transport

bull Suggested collection frequency on room to room

basis is once every shift

bull No bags should be removed unless they are

labeled with their point of production

bull The bags or containers should be replaced

immediately with new ones of the same type

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 75

Transportation Contd

Follow the guideline strictly in bothbull On-site transport bull Off-site transport

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 76

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 77

Treatment and Disposal

HCW can be treated and disposed through the

following techniques

i) Biological procedure

ii) Autoclave

iii) Chemical disinfection

iv) Encapsulation

HCWMGuideline 2014

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 78

Treatment and Disposal Contd

v) Sanitary landfill

vi) Burial

vii) Septicconcrete vault

viii) Incineration

ix) Inertization

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 79

Biological Procedure

bull Biological process uses an enzyme mixture to decontaminate HCW

bull The technology requires regulation of temperature pH enzyme level and other variables

bull Composting falls in this category

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 80

Vermicomposting

The possible option is the vermicomposting In this

process the earthworm of species Eisnia foetida

is used for the composting process

Biological Procedure Contdhellip

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 81

Biological Procedure Contd

bull The Chainpur sub health post has been generating bio-gas from placentas

bull In Bir Hospital Infected gauze and cotton waste

are disinfected using autoclaved then adopt the process of vermicomposting

Health care Foundation Nepal(HECAF)2071)

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 82

Autoclave

bull Autoclave is a process of steam sterilization under pressure

bull Autoclaves are commonly used for the treatment of highly infectious waste such as microbial cultures or sharps Large volume of blood

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 83

Autoclave Contdhellip

For effective inactivation of vegetative micro-

organisms most bacterial spores in a small

amount of waste 1113090about 5-8 kg1113090 - 60 minute

cycle at 121degC (minimum) and 1 bar (100kpa)

(WHO 1999)

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 84

Autoclave Contdhellip

The effectiveness depends on time temperature

pressure load size stacking configuration and

packing density types and integrity of bags or

containers used physical properties of the

materials amount of residual air and the

moisture content in the waste (UNEP 2012)

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 85

Chemical Disinfection

bull Chemical disinfections are usually applied for the

treatment of infectious and highly infectious HCW

bull Aldehydes chlorine compounds phenolic

compounds are added to HCW to kill or inactivate

pathogens

bull Preferred treatment for liquid infectious wastes

but can also be used in treating solid waste too

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 86

Chemical Disinfection Contd

bull Useful in treating blood urine stools and sewage

bull Chemical systems use heated alkali to destroy

tissues organs body parts and other anatomical

waste

bull Chemotherapy waste including bulk cytotoxic

agents can be treated by chemical decomposition

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 87

Chemical Disinfection Contdhellip

bull Sodium Hypochlorite (5) ndash 100mllit- for 24 hour (for Cytotoxic Waste)

bull Calcium Hypochlorite (70 chlorine) 7glit-bull Alkaline hydrolysis -process that converts animal

carcasses human body parts and tissues into a decontaminated aqueous solution

- (Later the contents are heated to between 110 degC and 127 degC for 6-8 hours)

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 88

Chemical Disinfection Contdhellip

bull Lime milk (calcium oxide) used in liquid wastes with high organic content (eg stool or vomit during a cholera outbreak)

bull lime milk in a ratio of 12for 6 hours Urine - 11 for 2 hours(Robert Koch Institute 2003)

bull Formaldehyde and ethylene oxide are no longer recommended for waste treatment due to significant hazards related to their use

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 89

Encapsulation

bull Involves the filling of the containers with waste

adding an immobilizing material and sealing the

container

bull When containers are three quarters filled with

sharps pharmaceuticals and chemical waste an

immobilizing agent poured on it

bull It is particularly suitable for sharps and

pharmaceutical waste

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 90

Encapsulation Contdhellip

The following are typical proportions (by weight) for

the mixture for encapsulation

bull 65 pharmaceutical waste

bull 15 lime

bull 15 cement

bull 5 water (WHO2014)

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 91

Sanitary landfill

bull Sanitary landfill is an engineered method

designed and constructed to keep the waste

isolated from the environment

bull It shouldnt contaminate the soil surface and

ground water and should limit air pollution

smells and direct contact with public

05012023 92

Sanitary landfill Contd

bull Disposing of certain types of HCW (infectious

waste and small quantities of pharmaceutical

waste) is acceptable

bull 1113090Should be at least 50 m away from water

sources

05012023 93

Burial

bull Hazardous waste can be buried in a special pit

bull Especially in remote locations in temporary

refugee encampments

bull Pit should be 11130902-5m deep and 1-21113090m wide

bull The bottom of the pit should be at least 2 m

above the water level

05012023 94

Burial Contdhellip

bull In outbreak of an especially virulent infection (as

Ebola virus)lime and soil cover may be added bull About 50m 11130901113090meters a1113090way from any 1113090water

body such as rivers or lakes1113090 bull After each waste load it should be covered 1113090with

a 11130901113090111309011130901113090 10-30 cm thick soil layer1113090

05012023 95

Burial Contd

bull 1113090large quantities 1113090higher than 11130901 kg1113090 of

chemical 1113090pharmaceutical waste should not be

buried

bull When the level of the waste reaches 11130901113090 to 30-50

11130901113090 cm to the surface of the ground fill the pit

1113090with dirt seal 1113090with concrete and dig another

pit

05012023 96

Septic concrete vault

bull This method can be used for the disposal of

used sharps and syringes

bull Dig a pit 111130901113090m x 11113090m x 11130901113090111309018m depth1113090

bull The site must be isolated and at least 111309011130901113090500

feet aw1113090ay from the ground water sources

bull Deposit the collected safety boxes filled with

used sharps and needles inside the

septicconcrete vault

05012023 97

Incineration

bull Incineration converts combustible materials into

non-combustible residue or ash

bull Incinerators can be oil1113090fired or electrically

powered or a combination of both

05012023 98

Incineration Contdhellip

bull Gases are ventilated through the incinerator

stacks and the residue or ash is disposed in a

sanitary landfill

bull In case of cytotoxic drug- 1200 degC ( but prefer

Autoclave)

05012023 99

Incineration contd

bull When 1113090incinerated at lo1113090w temperatures or

w1113090hen plastics that contain polyvinyl chloride

1113090PVC1113090 are incinerated dioxins furans and

toxic gases may be produced

bull This happens if 1113090waste are incinerated at

temperatures lt 800degC or wastes are not

completely incinerated1113090

05012023 100

Wastes that Should Never be Incinerated

bull Pressurized gas containers bull 1113090large amounts of reactive chemical 1113090waste bull 1113090Radioactive waste bull 1113090Silver salts or radiographic waste bull 1113090Halogenated plastics 1113090e1113090g1113090 PVC1113090 bull 1113090Mercury or cadmium bull 1113090Ampoules of heavy metals

05012023 101

Inertization

bull Inertization is usually suitable disposal method for

the pharmaceuticals and incinerated ash 1113088with

heavy metal content (1113090WHO1999) 11130901113090111309011130901113090

bull HCW is mixed with cement111309011130901113090 lime cement

and 11130901113090water1113090

bull The formed mixture is allowed to set into cubes or

pellets the waste must be grinded

05012023 102

Treatment for Radioactive waste

bull ldquoDecay in storagerdquo which is the safe storage of

waste a general rule is to store the waste for at

least 10 times the half-life of the longest lived

radionuclide in the waste

bull Return to supplier

bull long-term storage at an authorized radioactive

waste disposal site

05012023 103

Treatment of liquid wastewater

bull Liquid wastes including hazardous chemicals and

laboratory wastes have not been addressed in

almost all institutions1113090

bull HCFs like Western Regional Hospital Bir Hospital

Civil Service Hospital Manipal Teaching Hospital

Shahid Gangalal National Heart Centre and some

other HCFs are practicing HCWM system

05012023 104

Contdhellip

A study (Center for Public Health and Environmental Development

(CEPHED) 2012) showed bull 9032 hospitals - not practice environment sound

waste treatmentbull 6129 hospitals have very poor source separation bull 8065 hospitals not practise separate waste

collectionbull 6742 hospitals have very poor transportation ( NHCWMG2014)

05012023 105

HCWM in Chitwan

bull Effective segregation of waste at sourcebull Used to transport and disposed by contractorbull Most hospital are using Incinerators burial

method for needlesharp waste managementbull Planning to produce biogas from placenta and

leftover food( Already started in Pithuwa hospital)

bull Planning under construction of waste water treatment plant

05012023 106

HCWM Team

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 93

Burial

bull Hazardous waste can be buried in a special pit

bull Especially in remote locations in temporary

refugee encampments

bull Pit should be 11130902-5m deep and 1-21113090m wide

bull The bottom of the pit should be at least 2 m

above the water level

05012023 94

Burial Contdhellip

bull In outbreak of an especially virulent infection (as

Ebola virus)lime and soil cover may be added bull About 50m 11130901113090meters a1113090way from any 1113090water

body such as rivers or lakes1113090 bull After each waste load it should be covered 1113090with

a 11130901113090111309011130901113090 10-30 cm thick soil layer1113090

05012023 95

Burial Contd

bull 1113090large quantities 1113090higher than 11130901 kg1113090 of

chemical 1113090pharmaceutical waste should not be

buried

bull When the level of the waste reaches 11130901113090 to 30-50

11130901113090 cm to the surface of the ground fill the pit

1113090with dirt seal 1113090with concrete and dig another

pit

05012023 96

Septic concrete vault

bull This method can be used for the disposal of

used sharps and syringes

bull Dig a pit 111130901113090m x 11113090m x 11130901113090111309018m depth1113090

bull The site must be isolated and at least 111309011130901113090500

feet aw1113090ay from the ground water sources

bull Deposit the collected safety boxes filled with

used sharps and needles inside the

septicconcrete vault

05012023 97

Incineration

bull Incineration converts combustible materials into

non-combustible residue or ash

bull Incinerators can be oil1113090fired or electrically

powered or a combination of both

05012023 98

Incineration Contdhellip

bull Gases are ventilated through the incinerator

stacks and the residue or ash is disposed in a

sanitary landfill

bull In case of cytotoxic drug- 1200 degC ( but prefer

Autoclave)

05012023 99

Incineration contd

bull When 1113090incinerated at lo1113090w temperatures or

w1113090hen plastics that contain polyvinyl chloride

1113090PVC1113090 are incinerated dioxins furans and

toxic gases may be produced

bull This happens if 1113090waste are incinerated at

temperatures lt 800degC or wastes are not

completely incinerated1113090

05012023 100

Wastes that Should Never be Incinerated

bull Pressurized gas containers bull 1113090large amounts of reactive chemical 1113090waste bull 1113090Radioactive waste bull 1113090Silver salts or radiographic waste bull 1113090Halogenated plastics 1113090e1113090g1113090 PVC1113090 bull 1113090Mercury or cadmium bull 1113090Ampoules of heavy metals

05012023 101

Inertization

bull Inertization is usually suitable disposal method for

the pharmaceuticals and incinerated ash 1113088with

heavy metal content (1113090WHO1999) 11130901113090111309011130901113090

bull HCW is mixed with cement111309011130901113090 lime cement

and 11130901113090water1113090

bull The formed mixture is allowed to set into cubes or

pellets the waste must be grinded

05012023 102

Treatment for Radioactive waste

bull ldquoDecay in storagerdquo which is the safe storage of

waste a general rule is to store the waste for at

least 10 times the half-life of the longest lived

radionuclide in the waste

bull Return to supplier

bull long-term storage at an authorized radioactive

waste disposal site

05012023 103

Treatment of liquid wastewater

bull Liquid wastes including hazardous chemicals and

laboratory wastes have not been addressed in

almost all institutions1113090

bull HCFs like Western Regional Hospital Bir Hospital

Civil Service Hospital Manipal Teaching Hospital

Shahid Gangalal National Heart Centre and some

other HCFs are practicing HCWM system

05012023 104

Contdhellip

A study (Center for Public Health and Environmental Development

(CEPHED) 2012) showed bull 9032 hospitals - not practice environment sound

waste treatmentbull 6129 hospitals have very poor source separation bull 8065 hospitals not practise separate waste

collectionbull 6742 hospitals have very poor transportation ( NHCWMG2014)

05012023 105

HCWM in Chitwan

bull Effective segregation of waste at sourcebull Used to transport and disposed by contractorbull Most hospital are using Incinerators burial

method for needlesharp waste managementbull Planning to produce biogas from placenta and

leftover food( Already started in Pithuwa hospital)

bull Planning under construction of waste water treatment plant

05012023 106

HCWM Team

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 94

Burial Contdhellip

bull In outbreak of an especially virulent infection (as

Ebola virus)lime and soil cover may be added bull About 50m 11130901113090meters a1113090way from any 1113090water

body such as rivers or lakes1113090 bull After each waste load it should be covered 1113090with

a 11130901113090111309011130901113090 10-30 cm thick soil layer1113090

05012023 95

Burial Contd

bull 1113090large quantities 1113090higher than 11130901 kg1113090 of

chemical 1113090pharmaceutical waste should not be

buried

bull When the level of the waste reaches 11130901113090 to 30-50

11130901113090 cm to the surface of the ground fill the pit

1113090with dirt seal 1113090with concrete and dig another

pit

05012023 96

Septic concrete vault

bull This method can be used for the disposal of

used sharps and syringes

bull Dig a pit 111130901113090m x 11113090m x 11130901113090111309018m depth1113090

bull The site must be isolated and at least 111309011130901113090500

feet aw1113090ay from the ground water sources

bull Deposit the collected safety boxes filled with

used sharps and needles inside the

septicconcrete vault

05012023 97

Incineration

bull Incineration converts combustible materials into

non-combustible residue or ash

bull Incinerators can be oil1113090fired or electrically

powered or a combination of both

05012023 98

Incineration Contdhellip

bull Gases are ventilated through the incinerator

stacks and the residue or ash is disposed in a

sanitary landfill

bull In case of cytotoxic drug- 1200 degC ( but prefer

Autoclave)

05012023 99

Incineration contd

bull When 1113090incinerated at lo1113090w temperatures or

w1113090hen plastics that contain polyvinyl chloride

1113090PVC1113090 are incinerated dioxins furans and

toxic gases may be produced

bull This happens if 1113090waste are incinerated at

temperatures lt 800degC or wastes are not

completely incinerated1113090

05012023 100

Wastes that Should Never be Incinerated

bull Pressurized gas containers bull 1113090large amounts of reactive chemical 1113090waste bull 1113090Radioactive waste bull 1113090Silver salts or radiographic waste bull 1113090Halogenated plastics 1113090e1113090g1113090 PVC1113090 bull 1113090Mercury or cadmium bull 1113090Ampoules of heavy metals

05012023 101

Inertization

bull Inertization is usually suitable disposal method for

the pharmaceuticals and incinerated ash 1113088with

heavy metal content (1113090WHO1999) 11130901113090111309011130901113090

bull HCW is mixed with cement111309011130901113090 lime cement

and 11130901113090water1113090

bull The formed mixture is allowed to set into cubes or

pellets the waste must be grinded

05012023 102

Treatment for Radioactive waste

bull ldquoDecay in storagerdquo which is the safe storage of

waste a general rule is to store the waste for at

least 10 times the half-life of the longest lived

radionuclide in the waste

bull Return to supplier

bull long-term storage at an authorized radioactive

waste disposal site

05012023 103

Treatment of liquid wastewater

bull Liquid wastes including hazardous chemicals and

laboratory wastes have not been addressed in

almost all institutions1113090

bull HCFs like Western Regional Hospital Bir Hospital

Civil Service Hospital Manipal Teaching Hospital

Shahid Gangalal National Heart Centre and some

other HCFs are practicing HCWM system

05012023 104

Contdhellip

A study (Center for Public Health and Environmental Development

(CEPHED) 2012) showed bull 9032 hospitals - not practice environment sound

waste treatmentbull 6129 hospitals have very poor source separation bull 8065 hospitals not practise separate waste

collectionbull 6742 hospitals have very poor transportation ( NHCWMG2014)

05012023 105

HCWM in Chitwan

bull Effective segregation of waste at sourcebull Used to transport and disposed by contractorbull Most hospital are using Incinerators burial

method for needlesharp waste managementbull Planning to produce biogas from placenta and

leftover food( Already started in Pithuwa hospital)

bull Planning under construction of waste water treatment plant

05012023 106

HCWM Team

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 95

Burial Contd

bull 1113090large quantities 1113090higher than 11130901 kg1113090 of

chemical 1113090pharmaceutical waste should not be

buried

bull When the level of the waste reaches 11130901113090 to 30-50

11130901113090 cm to the surface of the ground fill the pit

1113090with dirt seal 1113090with concrete and dig another

pit

05012023 96

Septic concrete vault

bull This method can be used for the disposal of

used sharps and syringes

bull Dig a pit 111130901113090m x 11113090m x 11130901113090111309018m depth1113090

bull The site must be isolated and at least 111309011130901113090500

feet aw1113090ay from the ground water sources

bull Deposit the collected safety boxes filled with

used sharps and needles inside the

septicconcrete vault

05012023 97

Incineration

bull Incineration converts combustible materials into

non-combustible residue or ash

bull Incinerators can be oil1113090fired or electrically

powered or a combination of both

05012023 98

Incineration Contdhellip

bull Gases are ventilated through the incinerator

stacks and the residue or ash is disposed in a

sanitary landfill

bull In case of cytotoxic drug- 1200 degC ( but prefer

Autoclave)

05012023 99

Incineration contd

bull When 1113090incinerated at lo1113090w temperatures or

w1113090hen plastics that contain polyvinyl chloride

1113090PVC1113090 are incinerated dioxins furans and

toxic gases may be produced

bull This happens if 1113090waste are incinerated at

temperatures lt 800degC or wastes are not

completely incinerated1113090

05012023 100

Wastes that Should Never be Incinerated

bull Pressurized gas containers bull 1113090large amounts of reactive chemical 1113090waste bull 1113090Radioactive waste bull 1113090Silver salts or radiographic waste bull 1113090Halogenated plastics 1113090e1113090g1113090 PVC1113090 bull 1113090Mercury or cadmium bull 1113090Ampoules of heavy metals

05012023 101

Inertization

bull Inertization is usually suitable disposal method for

the pharmaceuticals and incinerated ash 1113088with

heavy metal content (1113090WHO1999) 11130901113090111309011130901113090

bull HCW is mixed with cement111309011130901113090 lime cement

and 11130901113090water1113090

bull The formed mixture is allowed to set into cubes or

pellets the waste must be grinded

05012023 102

Treatment for Radioactive waste

bull ldquoDecay in storagerdquo which is the safe storage of

waste a general rule is to store the waste for at

least 10 times the half-life of the longest lived

radionuclide in the waste

bull Return to supplier

bull long-term storage at an authorized radioactive

waste disposal site

05012023 103

Treatment of liquid wastewater

bull Liquid wastes including hazardous chemicals and

laboratory wastes have not been addressed in

almost all institutions1113090

bull HCFs like Western Regional Hospital Bir Hospital

Civil Service Hospital Manipal Teaching Hospital

Shahid Gangalal National Heart Centre and some

other HCFs are practicing HCWM system

05012023 104

Contdhellip

A study (Center for Public Health and Environmental Development

(CEPHED) 2012) showed bull 9032 hospitals - not practice environment sound

waste treatmentbull 6129 hospitals have very poor source separation bull 8065 hospitals not practise separate waste

collectionbull 6742 hospitals have very poor transportation ( NHCWMG2014)

05012023 105

HCWM in Chitwan

bull Effective segregation of waste at sourcebull Used to transport and disposed by contractorbull Most hospital are using Incinerators burial

method for needlesharp waste managementbull Planning to produce biogas from placenta and

leftover food( Already started in Pithuwa hospital)

bull Planning under construction of waste water treatment plant

05012023 106

HCWM Team

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 96

Septic concrete vault

bull This method can be used for the disposal of

used sharps and syringes

bull Dig a pit 111130901113090m x 11113090m x 11130901113090111309018m depth1113090

bull The site must be isolated and at least 111309011130901113090500

feet aw1113090ay from the ground water sources

bull Deposit the collected safety boxes filled with

used sharps and needles inside the

septicconcrete vault

05012023 97

Incineration

bull Incineration converts combustible materials into

non-combustible residue or ash

bull Incinerators can be oil1113090fired or electrically

powered or a combination of both

05012023 98

Incineration Contdhellip

bull Gases are ventilated through the incinerator

stacks and the residue or ash is disposed in a

sanitary landfill

bull In case of cytotoxic drug- 1200 degC ( but prefer

Autoclave)

05012023 99

Incineration contd

bull When 1113090incinerated at lo1113090w temperatures or

w1113090hen plastics that contain polyvinyl chloride

1113090PVC1113090 are incinerated dioxins furans and

toxic gases may be produced

bull This happens if 1113090waste are incinerated at

temperatures lt 800degC or wastes are not

completely incinerated1113090

05012023 100

Wastes that Should Never be Incinerated

bull Pressurized gas containers bull 1113090large amounts of reactive chemical 1113090waste bull 1113090Radioactive waste bull 1113090Silver salts or radiographic waste bull 1113090Halogenated plastics 1113090e1113090g1113090 PVC1113090 bull 1113090Mercury or cadmium bull 1113090Ampoules of heavy metals

05012023 101

Inertization

bull Inertization is usually suitable disposal method for

the pharmaceuticals and incinerated ash 1113088with

heavy metal content (1113090WHO1999) 11130901113090111309011130901113090

bull HCW is mixed with cement111309011130901113090 lime cement

and 11130901113090water1113090

bull The formed mixture is allowed to set into cubes or

pellets the waste must be grinded

05012023 102

Treatment for Radioactive waste

bull ldquoDecay in storagerdquo which is the safe storage of

waste a general rule is to store the waste for at

least 10 times the half-life of the longest lived

radionuclide in the waste

bull Return to supplier

bull long-term storage at an authorized radioactive

waste disposal site

05012023 103

Treatment of liquid wastewater

bull Liquid wastes including hazardous chemicals and

laboratory wastes have not been addressed in

almost all institutions1113090

bull HCFs like Western Regional Hospital Bir Hospital

Civil Service Hospital Manipal Teaching Hospital

Shahid Gangalal National Heart Centre and some

other HCFs are practicing HCWM system

05012023 104

Contdhellip

A study (Center for Public Health and Environmental Development

(CEPHED) 2012) showed bull 9032 hospitals - not practice environment sound

waste treatmentbull 6129 hospitals have very poor source separation bull 8065 hospitals not practise separate waste

collectionbull 6742 hospitals have very poor transportation ( NHCWMG2014)

05012023 105

HCWM in Chitwan

bull Effective segregation of waste at sourcebull Used to transport and disposed by contractorbull Most hospital are using Incinerators burial

method for needlesharp waste managementbull Planning to produce biogas from placenta and

leftover food( Already started in Pithuwa hospital)

bull Planning under construction of waste water treatment plant

05012023 106

HCWM Team

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 97

Incineration

bull Incineration converts combustible materials into

non-combustible residue or ash

bull Incinerators can be oil1113090fired or electrically

powered or a combination of both

05012023 98

Incineration Contdhellip

bull Gases are ventilated through the incinerator

stacks and the residue or ash is disposed in a

sanitary landfill

bull In case of cytotoxic drug- 1200 degC ( but prefer

Autoclave)

05012023 99

Incineration contd

bull When 1113090incinerated at lo1113090w temperatures or

w1113090hen plastics that contain polyvinyl chloride

1113090PVC1113090 are incinerated dioxins furans and

toxic gases may be produced

bull This happens if 1113090waste are incinerated at

temperatures lt 800degC or wastes are not

completely incinerated1113090

05012023 100

Wastes that Should Never be Incinerated

bull Pressurized gas containers bull 1113090large amounts of reactive chemical 1113090waste bull 1113090Radioactive waste bull 1113090Silver salts or radiographic waste bull 1113090Halogenated plastics 1113090e1113090g1113090 PVC1113090 bull 1113090Mercury or cadmium bull 1113090Ampoules of heavy metals

05012023 101

Inertization

bull Inertization is usually suitable disposal method for

the pharmaceuticals and incinerated ash 1113088with

heavy metal content (1113090WHO1999) 11130901113090111309011130901113090

bull HCW is mixed with cement111309011130901113090 lime cement

and 11130901113090water1113090

bull The formed mixture is allowed to set into cubes or

pellets the waste must be grinded

05012023 102

Treatment for Radioactive waste

bull ldquoDecay in storagerdquo which is the safe storage of

waste a general rule is to store the waste for at

least 10 times the half-life of the longest lived

radionuclide in the waste

bull Return to supplier

bull long-term storage at an authorized radioactive

waste disposal site

05012023 103

Treatment of liquid wastewater

bull Liquid wastes including hazardous chemicals and

laboratory wastes have not been addressed in

almost all institutions1113090

bull HCFs like Western Regional Hospital Bir Hospital

Civil Service Hospital Manipal Teaching Hospital

Shahid Gangalal National Heart Centre and some

other HCFs are practicing HCWM system

05012023 104

Contdhellip

A study (Center for Public Health and Environmental Development

(CEPHED) 2012) showed bull 9032 hospitals - not practice environment sound

waste treatmentbull 6129 hospitals have very poor source separation bull 8065 hospitals not practise separate waste

collectionbull 6742 hospitals have very poor transportation ( NHCWMG2014)

05012023 105

HCWM in Chitwan

bull Effective segregation of waste at sourcebull Used to transport and disposed by contractorbull Most hospital are using Incinerators burial

method for needlesharp waste managementbull Planning to produce biogas from placenta and

leftover food( Already started in Pithuwa hospital)

bull Planning under construction of waste water treatment plant

05012023 106

HCWM Team

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 98

Incineration Contdhellip

bull Gases are ventilated through the incinerator

stacks and the residue or ash is disposed in a

sanitary landfill

bull In case of cytotoxic drug- 1200 degC ( but prefer

Autoclave)

05012023 99

Incineration contd

bull When 1113090incinerated at lo1113090w temperatures or

w1113090hen plastics that contain polyvinyl chloride

1113090PVC1113090 are incinerated dioxins furans and

toxic gases may be produced

bull This happens if 1113090waste are incinerated at

temperatures lt 800degC or wastes are not

completely incinerated1113090

05012023 100

Wastes that Should Never be Incinerated

bull Pressurized gas containers bull 1113090large amounts of reactive chemical 1113090waste bull 1113090Radioactive waste bull 1113090Silver salts or radiographic waste bull 1113090Halogenated plastics 1113090e1113090g1113090 PVC1113090 bull 1113090Mercury or cadmium bull 1113090Ampoules of heavy metals

05012023 101

Inertization

bull Inertization is usually suitable disposal method for

the pharmaceuticals and incinerated ash 1113088with

heavy metal content (1113090WHO1999) 11130901113090111309011130901113090

bull HCW is mixed with cement111309011130901113090 lime cement

and 11130901113090water1113090

bull The formed mixture is allowed to set into cubes or

pellets the waste must be grinded

05012023 102

Treatment for Radioactive waste

bull ldquoDecay in storagerdquo which is the safe storage of

waste a general rule is to store the waste for at

least 10 times the half-life of the longest lived

radionuclide in the waste

bull Return to supplier

bull long-term storage at an authorized radioactive

waste disposal site

05012023 103

Treatment of liquid wastewater

bull Liquid wastes including hazardous chemicals and

laboratory wastes have not been addressed in

almost all institutions1113090

bull HCFs like Western Regional Hospital Bir Hospital

Civil Service Hospital Manipal Teaching Hospital

Shahid Gangalal National Heart Centre and some

other HCFs are practicing HCWM system

05012023 104

Contdhellip

A study (Center for Public Health and Environmental Development

(CEPHED) 2012) showed bull 9032 hospitals - not practice environment sound

waste treatmentbull 6129 hospitals have very poor source separation bull 8065 hospitals not practise separate waste

collectionbull 6742 hospitals have very poor transportation ( NHCWMG2014)

05012023 105

HCWM in Chitwan

bull Effective segregation of waste at sourcebull Used to transport and disposed by contractorbull Most hospital are using Incinerators burial

method for needlesharp waste managementbull Planning to produce biogas from placenta and

leftover food( Already started in Pithuwa hospital)

bull Planning under construction of waste water treatment plant

05012023 106

HCWM Team

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 99

Incineration contd

bull When 1113090incinerated at lo1113090w temperatures or

w1113090hen plastics that contain polyvinyl chloride

1113090PVC1113090 are incinerated dioxins furans and

toxic gases may be produced

bull This happens if 1113090waste are incinerated at

temperatures lt 800degC or wastes are not

completely incinerated1113090

05012023 100

Wastes that Should Never be Incinerated

bull Pressurized gas containers bull 1113090large amounts of reactive chemical 1113090waste bull 1113090Radioactive waste bull 1113090Silver salts or radiographic waste bull 1113090Halogenated plastics 1113090e1113090g1113090 PVC1113090 bull 1113090Mercury or cadmium bull 1113090Ampoules of heavy metals

05012023 101

Inertization

bull Inertization is usually suitable disposal method for

the pharmaceuticals and incinerated ash 1113088with

heavy metal content (1113090WHO1999) 11130901113090111309011130901113090

bull HCW is mixed with cement111309011130901113090 lime cement

and 11130901113090water1113090

bull The formed mixture is allowed to set into cubes or

pellets the waste must be grinded

05012023 102

Treatment for Radioactive waste

bull ldquoDecay in storagerdquo which is the safe storage of

waste a general rule is to store the waste for at

least 10 times the half-life of the longest lived

radionuclide in the waste

bull Return to supplier

bull long-term storage at an authorized radioactive

waste disposal site

05012023 103

Treatment of liquid wastewater

bull Liquid wastes including hazardous chemicals and

laboratory wastes have not been addressed in

almost all institutions1113090

bull HCFs like Western Regional Hospital Bir Hospital

Civil Service Hospital Manipal Teaching Hospital

Shahid Gangalal National Heart Centre and some

other HCFs are practicing HCWM system

05012023 104

Contdhellip

A study (Center for Public Health and Environmental Development

(CEPHED) 2012) showed bull 9032 hospitals - not practice environment sound

waste treatmentbull 6129 hospitals have very poor source separation bull 8065 hospitals not practise separate waste

collectionbull 6742 hospitals have very poor transportation ( NHCWMG2014)

05012023 105

HCWM in Chitwan

bull Effective segregation of waste at sourcebull Used to transport and disposed by contractorbull Most hospital are using Incinerators burial

method for needlesharp waste managementbull Planning to produce biogas from placenta and

leftover food( Already started in Pithuwa hospital)

bull Planning under construction of waste water treatment plant

05012023 106

HCWM Team

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 100

Wastes that Should Never be Incinerated

bull Pressurized gas containers bull 1113090large amounts of reactive chemical 1113090waste bull 1113090Radioactive waste bull 1113090Silver salts or radiographic waste bull 1113090Halogenated plastics 1113090e1113090g1113090 PVC1113090 bull 1113090Mercury or cadmium bull 1113090Ampoules of heavy metals

05012023 101

Inertization

bull Inertization is usually suitable disposal method for

the pharmaceuticals and incinerated ash 1113088with

heavy metal content (1113090WHO1999) 11130901113090111309011130901113090

bull HCW is mixed with cement111309011130901113090 lime cement

and 11130901113090water1113090

bull The formed mixture is allowed to set into cubes or

pellets the waste must be grinded

05012023 102

Treatment for Radioactive waste

bull ldquoDecay in storagerdquo which is the safe storage of

waste a general rule is to store the waste for at

least 10 times the half-life of the longest lived

radionuclide in the waste

bull Return to supplier

bull long-term storage at an authorized radioactive

waste disposal site

05012023 103

Treatment of liquid wastewater

bull Liquid wastes including hazardous chemicals and

laboratory wastes have not been addressed in

almost all institutions1113090

bull HCFs like Western Regional Hospital Bir Hospital

Civil Service Hospital Manipal Teaching Hospital

Shahid Gangalal National Heart Centre and some

other HCFs are practicing HCWM system

05012023 104

Contdhellip

A study (Center for Public Health and Environmental Development

(CEPHED) 2012) showed bull 9032 hospitals - not practice environment sound

waste treatmentbull 6129 hospitals have very poor source separation bull 8065 hospitals not practise separate waste

collectionbull 6742 hospitals have very poor transportation ( NHCWMG2014)

05012023 105

HCWM in Chitwan

bull Effective segregation of waste at sourcebull Used to transport and disposed by contractorbull Most hospital are using Incinerators burial

method for needlesharp waste managementbull Planning to produce biogas from placenta and

leftover food( Already started in Pithuwa hospital)

bull Planning under construction of waste water treatment plant

05012023 106

HCWM Team

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 101

Inertization

bull Inertization is usually suitable disposal method for

the pharmaceuticals and incinerated ash 1113088with

heavy metal content (1113090WHO1999) 11130901113090111309011130901113090

bull HCW is mixed with cement111309011130901113090 lime cement

and 11130901113090water1113090

bull The formed mixture is allowed to set into cubes or

pellets the waste must be grinded

05012023 102

Treatment for Radioactive waste

bull ldquoDecay in storagerdquo which is the safe storage of

waste a general rule is to store the waste for at

least 10 times the half-life of the longest lived

radionuclide in the waste

bull Return to supplier

bull long-term storage at an authorized radioactive

waste disposal site

05012023 103

Treatment of liquid wastewater

bull Liquid wastes including hazardous chemicals and

laboratory wastes have not been addressed in

almost all institutions1113090

bull HCFs like Western Regional Hospital Bir Hospital

Civil Service Hospital Manipal Teaching Hospital

Shahid Gangalal National Heart Centre and some

other HCFs are practicing HCWM system

05012023 104

Contdhellip

A study (Center for Public Health and Environmental Development

(CEPHED) 2012) showed bull 9032 hospitals - not practice environment sound

waste treatmentbull 6129 hospitals have very poor source separation bull 8065 hospitals not practise separate waste

collectionbull 6742 hospitals have very poor transportation ( NHCWMG2014)

05012023 105

HCWM in Chitwan

bull Effective segregation of waste at sourcebull Used to transport and disposed by contractorbull Most hospital are using Incinerators burial

method for needlesharp waste managementbull Planning to produce biogas from placenta and

leftover food( Already started in Pithuwa hospital)

bull Planning under construction of waste water treatment plant

05012023 106

HCWM Team

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 102

Treatment for Radioactive waste

bull ldquoDecay in storagerdquo which is the safe storage of

waste a general rule is to store the waste for at

least 10 times the half-life of the longest lived

radionuclide in the waste

bull Return to supplier

bull long-term storage at an authorized radioactive

waste disposal site

05012023 103

Treatment of liquid wastewater

bull Liquid wastes including hazardous chemicals and

laboratory wastes have not been addressed in

almost all institutions1113090

bull HCFs like Western Regional Hospital Bir Hospital

Civil Service Hospital Manipal Teaching Hospital

Shahid Gangalal National Heart Centre and some

other HCFs are practicing HCWM system

05012023 104

Contdhellip

A study (Center for Public Health and Environmental Development

(CEPHED) 2012) showed bull 9032 hospitals - not practice environment sound

waste treatmentbull 6129 hospitals have very poor source separation bull 8065 hospitals not practise separate waste

collectionbull 6742 hospitals have very poor transportation ( NHCWMG2014)

05012023 105

HCWM in Chitwan

bull Effective segregation of waste at sourcebull Used to transport and disposed by contractorbull Most hospital are using Incinerators burial

method for needlesharp waste managementbull Planning to produce biogas from placenta and

leftover food( Already started in Pithuwa hospital)

bull Planning under construction of waste water treatment plant

05012023 106

HCWM Team

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 103

Treatment of liquid wastewater

bull Liquid wastes including hazardous chemicals and

laboratory wastes have not been addressed in

almost all institutions1113090

bull HCFs like Western Regional Hospital Bir Hospital

Civil Service Hospital Manipal Teaching Hospital

Shahid Gangalal National Heart Centre and some

other HCFs are practicing HCWM system

05012023 104

Contdhellip

A study (Center for Public Health and Environmental Development

(CEPHED) 2012) showed bull 9032 hospitals - not practice environment sound

waste treatmentbull 6129 hospitals have very poor source separation bull 8065 hospitals not practise separate waste

collectionbull 6742 hospitals have very poor transportation ( NHCWMG2014)

05012023 105

HCWM in Chitwan

bull Effective segregation of waste at sourcebull Used to transport and disposed by contractorbull Most hospital are using Incinerators burial

method for needlesharp waste managementbull Planning to produce biogas from placenta and

leftover food( Already started in Pithuwa hospital)

bull Planning under construction of waste water treatment plant

05012023 106

HCWM Team

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 104

Contdhellip

A study (Center for Public Health and Environmental Development

(CEPHED) 2012) showed bull 9032 hospitals - not practice environment sound

waste treatmentbull 6129 hospitals have very poor source separation bull 8065 hospitals not practise separate waste

collectionbull 6742 hospitals have very poor transportation ( NHCWMG2014)

05012023 105

HCWM in Chitwan

bull Effective segregation of waste at sourcebull Used to transport and disposed by contractorbull Most hospital are using Incinerators burial

method for needlesharp waste managementbull Planning to produce biogas from placenta and

leftover food( Already started in Pithuwa hospital)

bull Planning under construction of waste water treatment plant

05012023 106

HCWM Team

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 105

HCWM in Chitwan

bull Effective segregation of waste at sourcebull Used to transport and disposed by contractorbull Most hospital are using Incinerators burial

method for needlesharp waste managementbull Planning to produce biogas from placenta and

leftover food( Already started in Pithuwa hospital)

bull Planning under construction of waste water treatment plant

05012023 106

HCWM Team

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 106

HCWM Team

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 107

Past to Current Legislation for addressing Health Care Waste Management

- The Constitution of Kingdom of Nepal

1990

The state shall give priority to protection

of the environment and also to the

prevention of its further damage

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 108

Past to Current Legislation for addressing Health Care Waste Management

bull Solid Waste Management and Resource Mobilization Act 1987

bull The Town Development Act 1988

bull The Labor Act 1991

bull Industrial Enterprise Act 1992

bull The Environment Protection Act 1997

bull The Local Self- Governance Act 1999

(fine anyone up to Rs 1500000 for haphazard dumping of solid

waste)

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 109

Past to Current Legislation for addressing Health Care Waste Management

bull The three year Interim Plan of Nepal Government

(206465- 206667) - mentioned the programs for

Health Care Waste Management

bull Interim Constitution of Nepal (2063) 2007 (with

amendment) right of healthy environment for all

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 110

Past to Current Legislation for addressing Health Care Waste Management

bull Health Care Waste Management Guidelines (20089

DoHS)

bull Urban Environmental Management Guidelines (2011)

bull Second Long Term Health Plan 2054-74 (1997- 2017)

bull Solid Waste Management Act (2011)

(Fine of Rs 50 000 to 100 000 for the first time and the

penalty will be double for the repetition

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 111

Organization in HCWM

bull Center for Public Health and Environmental Development

bull Epidemiology and disease Control Division bull Ministry of Environmentbull Ministry of Health and Populationbull Ministry of Science Technology and Environmentbull United Nations Development Programme

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 112

Organization in HCWM Contd

bull United Nations Environment Programme bull Ministry of Urban Developmentbull Private Hospital Associationbull WHObull UNbull Health Care Foundation Nepal

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 113

Bir hospital in HCWM

bull Health Care Foundation Nepal (HECAF) has been

working in the field of health care waste

management since 1999

bull when it installed the first non-burn medical waste

management system in the National Kidney Centre

bull Waste is segregated at source and infectious

materials are disinfected in an autoclave

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 114

Health and Safety Practices in HCWM

bull Infection Prevention bull Personal hygiene and hand hygiene bull Workerrsquos Protectiontraining bull Protective clothing bull Immunization bull Injection safety awaeness bull Response to injury and exposure

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 115

Conclusion

Everyday large amount of HCW generate having different characteristic To overcome from this need to proper manage of HCW as well as treatment of waste

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 116

Reference

Ananth P Prashanthini A and Visvanathan VC (2010) Healthcare waste management in Asia

Bir Hospital (2011) Interim Report of Health Care Waste Management System In Bir Hospital Kathmandu WHOCEPHED (2012) Waste Management Environmental Health Condition of

Hospitals in Nepal CDC (1988) Guideline for Handwashinng and Environmental ControlCSH (2013) Health Care Waste Management Policy Civil Service Hospital Minbhawan Kathmandu Enayetullah et al (2011) Feasibility Study for the Establishment and

Operation of CommonCentral Treatment Facility (CTF) for Hospital in Pokhara City JoshiHD (2013) Health Care Waste Management Practice in NepalJNHRC

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 117

Reference

MoE (2004) 1113090Final Report on Hazardous Waste Policy Study 1113090Nepal1113090 Ministry of EnvironmentMoH (2003) Health Care Waste Management in Nepal MoHP 1113090111309011130901113090a Revised Health Care Waste Management Guideline( 2014) Ministry of Health and Population Department of Health Services MoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCMoHP (2005) Infection Prevention Reference Manual for Clinical Service NHTCNHRC (2002) 1113090111309011130901113090B National Health Care Waste Management

Training Manual Nepal Health Research Council

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 118

Reference

MoHPWHONRCS (2013) Biosafety and Waste Management Blood Transfusion Services Nepal

National Planning Commission (2010) The Three Year Interim Plan of Nepal Government (206465- 206667) Retrieve on 15th Jan 2016 from httpwwwnpcgovnp Nepal Health Research Council (2007) Health Care Waste Management in Selected Health Care Institutions in Nepal Kathmandu Nepal Nepal Health Research Council Park K (2015) Parkrsquos Textbook of Preventive and Social Medicine (23rd ed) India MS Banarsids Bhanot

Poudel et al (Sep 2013) Incidence Of Needle Stick Injury Among Proficiency Certificate Level Nursing Students Kathmandu International Journal of Scientific amp Technology Research

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 119

Reference

MOHP (2011) Solid Waste Management Act MOHPUNEPSBCWHO (2004) Preparation of National Health- Care Waste Management Plans in Sub-Saharan Countries Guidance Manual Secretariat of the Basel Convention and World Health Organization Basel ConventionUNEP (2003) Technical Guidelines on the Environmentally Sound Management of Biomedical and Healthcare Wastes (Y1Y3) Secretariat of the Basel Convention WHO (2014) Safe Management of Wastes from Health- Care Activities ( 2nd ed) WHO WHO (2008) Policy Paper on Mercury in Health Care Department

of Protection of the Human Environment Water Sanitation and Health

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120

05012023 120

THANK YOU

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Contdhellip
• Slide 6
• General objective
• Specific Objectives
• Specific Objectives Cont
• Waste Definition
• Health Care Waste (HCW)
• HCW Contd
• HCW Contd
• Slide 14
• Categorization of HCW
• 1) Non risk HCW
• Slide 17
• HCW with special attention
• Contdhellip
• Contdhellip
• HCW Require Attention
• 3 Infectious and highly infectious Waste
• 4 Other Hazardous Waste
• 5 Radioactive Waste
• WHO Classification
• Categorizations According to BMW Schedule 2011
• BMW Categorization
• Categorization in Nepal
• Categorization Contd
• Categorization by NHRC
• Research
• Slide 32
• Production of HCW
• Slide 34
• B) Production of Waste in South East Region (by 2001)
• Production Cont
• Production in Nepal
• Slide 38
• Contdhellip (2)
• Production in Nepal (2)
• Slide 41
• Sources of HCW
• Sources Con
• Sources Contd
• Possible Impact
• Route of infection
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Survival of pathogenic microorganisms in the environment
• Survival of microorganism
• Overview
• Slide 58
• Slide 59
• Guiding Principles of HCWM
• Steps for the Waste Management
• Waste Minimization
• Waste Minimization Contd
• Waste Segregation
• Color Coding in Segregation
• Slide 66
• Segregation contdhellip
• Color Coding (BMW)
• Slide 69
• Waste Collection and Storage
• Collection Contd
• Storage Contdhellip
• Storage Contd
• Waste Transport
• Transportation
• Slide 76
• Treatment and Disposal
• Treatment and Disposal Contd
• Biological Procedure
• Slide 80
• Biological Procedure
• Autoclave
• Autoclave
• Autoclave Contdhellip
• Chemical Disinfection
• Chemical Disinfection
• Chemical Disinfection (2)
• Chemical Disinfection (3)
• Encapsulation
• Encapsulation Contdhellip
• Sanitary landfill
• Sanitary landfill
• Burial
• Burial Contdhellip
• Burial Cont
• Septic concrete vault
• Incineration
• Incineration C
• Incineration contd
• Wastes that Should Never be Incinerated
• Inertization
• Treatment for Radioactive waste
• Treatment of liquid wastewater
• Contdhellip
• HCWM in Chitwan
• Slide 106
• Past to Current Legislation for addressing Health Care Waste Ma
• Past to Current Legislation for addressing Health Care Waste Ma (2)
• Past to Current Legislation for addressing Health Care Waste Ma (3)
• Past to Current Legislation for addressing Health Care Waste Ma (4)
• Organization in HCWM
• Organization in HCWM
• Bir hospital in HCWM
• Health and Safety Practices in HCWM
• Conclusion
• Reference
• Reference (2)
• Reference (3)
• Reference (4)
• Slide 120