Bio-Medical Waste Management

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Contents: Bio-Medical Waste Management

1. Introduction 2. Types Of Bio-medical waste Effects of Bio-medical waste


4. Collection and treatment of Bio-medical waste 5. Case Study: INHS KAYLYANI Hospital 6. Conlusion


All over the country, unsegregated and untreated biomedical waste is being indiscriminately discarded into municipal bins, dump sites, on roadsides, in water bodies or is being incompletely and improperly burnt in the open. All this is leading to rapid proliferation and spreading of infectious, dangerous and fatal communicable diseases like hepatitis, AIDS and several types of cancers. In urban and rural areas alike, incidence and prevalence of several such human diseases has increased and the per capita medical expenditure has also gone high several folds. Although, yet to be proven, morbidity or illness amongst both urban and rural dwellers has increased albeit for different reasons. The Ministry of Environment and Forests, Govt. of India has notified the Biomedical Waste (Management and Handling) rules 1998 with subsequent amendments (June 2nd 2000 and September 2003). However, only 5-10% of institutions in the country have implemented the Rules or are following them at present. Unfortunately, some western countries, in the garb of managing their biomedical wastes, are adding to our problems by exporting their wastes to poorer countries. The improper handling, treatment, storage, transport and disposal of waste can lead to serious problems like: - The entire waste from a healthcare establishment, which includes noninfectious as well as infectious waste, if unsegregated and untreated is mixed with the rest of the waste in a healthcare establishment, will convert the entire non infectious general waste (75-80%) also into infectious waste. - The indiscriminate disposal of sharps within and outside institutions leading to occupational hazards like needle stick injuries, cuts, and infections among hospital employees, municipal workers and ragpickers. -Injuries due to the sharp especially among ragpickers and hospital / municipal workers increases the incidence of Hepatitis B, C, E and HIV among these groups who transmit these diseases to others in the community and also succumb to such fatal diseases. -The problem with medical waste lies in the fact that it is not handled and treated according to its type, which leads to hazardous working conditions for

hospital personnel and exorbitant investment in technology that creates more problems. Hospital waste is generated during the diagnosis, treatment, or immunization of human beings or animals or in research activities in these fields or in the production or testing of biologicals. It may include wastes like sharps, soiled waste, disposables, anatomical waste, cultures, discarded medicines, chemical wastes, etc. These are in the form of disposable syringes, swabs, bandages, body fluids, human excreta, etc. This waste is highly infectious and can be a serious threat to human health if not managed in a scientific and discriminate manner. It has been roughly estimated that of the 4 kg of waste generated in a hospital at least 1 kg would be infected. - Undestroyed needles and syringes being circulated back to Recycling, through unscrupulous traders who employ the poor and the destitute to collect such waste for repackaging and selling in the market. - Reuse of disposable like syringes, needles, catheters, IV and dialysis sets are causing spread of infection from healthcare establishments to the general community. - Disposal of hospital waste and veterinary hospital waste in municipal dumpsite resulting in animals especially cows feeding on the blood soaked cotton and plastics, and this in turn leading to diseases like bovine tuberculosis which through milk can infect humans. - The indiscriminate dumping of untreated hospital waste in municipal bins increasing the possibility of survival, proliferation and mutation of pathogenic microbial population in the municipal waste. This leads to epidemics and increased incidence and prevalence of communicable diseases in the community. - Incidence and prevalence of diseases like AIDS, Hepatitis B&C tuberculosis and other infectious diseases increasing due to inappropriate use, storage, treatment, transport and disposal of biomedical waste. - Chances of vectors like cats, rats, mosquitoes, files and stray dogs getting infected or becoming carriers which also spread diseases in the community.

Bio-medical waste: “Bio-Medical Waste” is any waste,
which is generated during the diagnosis, treatment or immunization of human beings or animals. These wastes are also generated during research activities or in the production or testing of biological material. Redefining it scientifically, Biomedical waste is defined as “any solid, fluid or liquid waste, including its container and any intermediate product, which is generated during its diagnosis, treatment or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biological and the animal wastes from slaughter houses or any other like establishments.” “Any waste that is generated in the diagnosis, treatment or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals.” Infectious wastes are those biomedical wastes which contain sufficient population of infectious agents that are capable of causing and spreading infections among people, livestock and vectors. Infectious wastes include human tissues, anatomical waste, organs, body parts, placenta, animal waste (tissue / cell cultures), any pathological / surgical waste, microbiology and biotechnology waste (cultures, stocks, specimens of micro-organism, live or attenuated vaccines, etc.), cytological, pathological wastes, solid waste (swabs, bandages, mops, any item contaminated with blood or body fluids), infected syringes, needles, other sharps, glass, rubber, metal, plastic disposables and other such wastes. Cytotoxic substances, as the word suggests are toxic to cells and are often anti-neoplastic which inhibit cell growth and multiplication. These drugs when come in contact with normal cells can damage them and cause severe disability or even death of those affected. These drugs could be present in the waste generated from the treatment of cancer patients or from other work related to testing and control of cancerous cells.

Infected plastics are those biomedical plastics which have been used for administering patient care or for performing related activities and may contain blood or body fluids or are suspected to contain infectious agents in sufficient number which may lead to infections among other humans or animals. These generally include IV tubes / bottles, tubings, gloves, aprons, blood bags / urine bags, disposable drains, disposable plastic containers, endo-tracheal tubes, microbiology and biotechnology waste and other laboratory waste. As regards its type and composition, most hospital waste is similar to household waste and can be disposed of in the same way. In addition to this, however, hospitals generate certain special types of waste which should not be handled by domestic refuse collection services, because of the risk of infection, because they are hazardous in other ways, or for ethical reasons. Such waste must be collected separately at the places where it is generated, and disposed of in specially approved plants, e.g., incinerators. Hence, types of hospital waste may be classified according to the disposal methods appropriate for them, as follows:



Type A: Waste which does not require any special treatment. This is the waste produced by the hospital administration, the cleaning service, the kitchens, stores and workshops. It can be disposed of in the same way as household waste. Type B: Waste with which special precautions must be taken to prevent infection in the hospital. This is usually taken to include all waste from inpatient and casualty wards and doctors' practices, e.g. used dressings, disposable linen and packaging materials. It only constitutes a risk for patients with weakened defences while it is still inside the hospital. Once it has been removed from the wards it can be handled by the local domestic refuse collection service.

Type C: Waste which must be disposed of in a particular way to prevent infection. This is waste from isolation wards for patients with infectious diseases; from dialysis wards and laboratories, in particular those for microbiological investigations, which contains pathogens of dangerous infectious diseases, e.g. tuberculosis, hepatitis infectious diarrhoeal diseases and which constitutes a real risk of infection when disposing of this waste. It includes needles and sharp objects coated with blood, or disposable items contaminated with stool. Type D: Parts of human bodies: limbs, organs etc. This waste originates in pathology, surgical, gynecological and obstetric departments. It has to be disposed of separately, not to prevent infection but for ethical reasons. Type E: Other waste. Hospitals provide a service, and hence have infrastructures which can also generate hazardous waste products, e. 9. chemical residues from laboratories, as well as inflammable, explosible, toxic or radioactive waste, which must be disposed of in accordance with statutory provisions.

Sharps consist of needles, syringes, scalpels, blades, glass etc., which have the capability to injure by piercing the skin. As these sharps are used in patient care, there is every chance that infection can spread through this type of injury. Nurses can get a sharp injury before and after using a sharp on a patient. Further, sharps discarded without any special containment or segregation can injure and transmit disease to those who collect waste (including safai karamcharis, municipal sweepers and ragpickers). There have been reports that waste collected from the hospitals are resold, this creates an additional occupational and community health hazard.

Hospitals use plastics because they fear a spread of infection through the use of reusable medical equipment. Thus, plastic use has grown with increasing concern for infection control. However, there have been cases where even with the use of plastics there has been a spread of infection in wards. Nurses complained of nosocomial infections in wards even though disposable equipment was used — they related it to improper waste disposal of disposable equipment within the wards. PVC is a thermoplastic, with approximately 40 percent of its content being additives. Plasticisers are added to make PVC flexible and transparent.

Medical equipment made from PVC:
Blood bags Feeding tubes Catheters IV Containers IV Components Inhalation masks Breathing tubes Pressure monitor tubes Drip chamber Parts of a syringe Labware Dialysis tubes

Incineration is a complex technology that is used to burn waste. The problem of medical waste is one of disinfecting the waste and not of destroying it. With the increased use of disposables in medicine, the amount of plastic going for incineration has increased manifold. The burning of plastics, especially in unregulated incinerators, creates a new set of chemical toxins, some of which, are super toxins even in extremely small quantities. Incineration thus converts a biological problem into a chemical one.

Sources of Mercury in hospitals:
1. Thermometers 2. Blood pressure cuffs

3. Feeding tubes 4. Dilators and batteries 5. Dental amalgam 6. Used in laboratory chemicals like Zenkers solution and histological fixatives.

Glutaraldehyde is a colourless, oily liquid, which is also commonly available as a clear, colourless, aqueous solution. It is a powerful, cold disinfectant, used widely in the health services for high-level disinfection of medical instruments and supplies and available with trade names such as: Cidex, Totacide, and Asep. Glutaraldehyde is a widely used disinfectant and a sterilizing agent (commonly available in 1 percent and 2 percent solutions) in medical and dental settings. It is used in embalming (25% solution), as an intermediate and fixative for tissue-fixing in electron microscopy (20 percent, 50 percent and 99 percent solutions) and in X-ray films.

Radiations are used for wide variety applications in research, industry, medicine, manufacturing, agriculture, consumer goods and services. The common concern is that in all these uses, care must be taken to ensure that everyone is protected from the potential hazards of radiation.

Sharps consist of needles, syringes, scalpels, blades, glass etc., which have the capability to injure by piercing the skin. As these sharps are used in patient care, there is every chance that infection can spread through this type of injury. Nurses can get a sharp injury before and after using a sharp on a patient. Further, sharps discarded without any special containment or segregation can injure and transmit disease to those who collect waste (including safai karamcharis, municipal sweepers and ragpickers). There have been reports that waste collected from the hospitals are resold, this creates an additional occupational and community health hazard.


Acid gases include nitrogen oxide, which has been shown to cause acid rain formation and affect the respiratory and cardiovascular system. As large amounts of plastic are incinerated hydrochloric acid is produced. This acid attacks the respiratory system, skin, eyes and lungs with side effects such as coughing, nausea and vomiting. Heavy metals are released during incineration of medical waste. Mercury, when incinerated, vaporizes and spreads easily in the environment. Lead and cadmium present in the plastics also accumulates in the ash. Acute and chronic exposure to lead can cause metabolic, neurological and neuro-psychological disorders. It has been associated with decreased intelligence and impaired neurobehavioral development in children. Cadmium has been identified as a carcinogen and is linked to toxic effects on reproduction, development, liver and nervous system.

Disposal of PVC via incineration leads to the formation of dioxin and furans. Dioxin and furans are nwanted by-products of incineration with carcinogenic and endocrine-disrupting properties. They are toxic at levels as low as 0.006 picograms per Kg of body weight.

When products containing mercury are incinerated, the mercury becomes airborne and eventually settles in waterbodies from, where via biomagnification in the food chain and bioaccumulation, it reaches humans. If it is flushed, it enters waterbodies directly, and if it is thrown in bins it could enter the body of animals via skin or inhalation, or permeate into the ground causing soil and groundwater poisoning. This metal accumulates in the muscle tissues. Three major types of mercury are found in the environment – methyl mercury, mercury (zero), mercury (two). Out of these, methyl mercury is the most toxic; it bio accumulates and has the capability to interfere with cell division and cross the placental barrier. It also binds to DNA and interferes with the copying of chromosomes and production of proteins. Pregnant women and children are most vulnerable to the effects of mercury. The

Minamata disaster in Japan is an example of mercury-poisoning via biomagnification and bioaccumulation. Mercury exposure can lead to pneumonitis, bronchitis, muscle tremors, irritability, personality changes, gingivitis and forms of nerve damage

Aqueous solution is not flammable. However, after the water evaporates the remaining material will burn. During a fire, toxic decomposition products such as carbon monoxide and carbon dioxide can be generated.


Accidents due to improper disposal of nuclear therapeutic material from unsafe operation of x-ray apparatus, improper handling of radioisotopic solutions like spills and left over doses, or inadequate control of radiotherapy have been reported world over with a large number of persons suffering from the results of exposure. In Brazil while moving, a radiotherapy institute a left over sealed radiotherapy source resulted in an exposure to 249 people of whom several either died or suffered severe health problems International atomic Energy Agency, 1988). In a similar incidence four people died from acute radiation syndrome and 28 suffered serious radiation burns (Brazil, 1988)

Collection and Treatment of Bio-

Medical Waste

The fight against hospital infection demands the cooperation of all those employed in the hospital: doctors, technicians, nursing and cleaning staff. This is why one of the most urgent tasks is to convince, train and monitor the personnel responsible for refuse disposal. Unless they are convinced of the need, trained and monitored, all efforts to improve the situation will be doomed to failure. Hospital waste should always be collected in disposable containers which satisfy the following requirements: they must be moisture-resistant and nontransparent; sellable in such a way as to prevent egress of micro-organisms; safe to transport; and colour-coded to distinguish them from household refuse bags. The waste must be collected in such containers at the point where it is generated, and removed from the wards daily without being sorted or transferred to other containers. The containers must be carefully sealed. Generally, plastic bags are used for Type B and C waste, and plastic buckets for Type D waste. The material these disposable containers are made of must be appropriate for the next treatment stage. If the waste is subsequently incinerated, for example, combustible materials with a low level of toxicity must be used; if it is heat-disinfected the materials must be steam-permeable. This requirement also applies, incidentalIy, to all disposable items purchased by hospitals.

The waste must be transported to a central incineration plant outside the hospital in specially designed vehicles which do not compress it. The interior of the vehicle body must be easy to clean and it must be adequately ventilated. Generally speaking, hospital waste should be burnt in appropriate incinerators: this is a recognized, proven method for disposing of all hospital waste. There are many different incineration systems available on the market today. Basically, an incineration plant should satisfy the following requirements: • it should burn dry, wet and organic waste completely. • glass, plastics and metals contained in the waste should not impair the function of the plant in any way.

The combustion process should be fully automated, and exhaust gases should be within the statutory limits even if there are considerable differences in the calorific values of the waste. It should have an automatically closing charging sluice to prevent operating personnel from coming into contact with the combustion chamber. Plants which satisfy these requirements are now available in all sizes. Alternatively, Type C waste can be disinfected and subsequently disposed of as household refuse, or, in special cases, removed to guarded sanitary landfills and immediately covered. Type D waste can be interred in an appropriate manner in cemeteries. A variety of methods, chemical and physical, can be used for disinfection. To disinfect waste, however, only thermal systems in which the waste is steamtreated at temperatures above 105°C have so far proved successful. Disinfection in pressure-resistant installations involves approximately the same amount of work as incineration, but has the disadvantage that it is not possible to check visually whether the treatment has been a complete success. With incineration this is of course possible. For this reason incineration is to be preferred in countries which have no trained inspection personnel. There are also devices on the market which shred waste and then disinfect it with liquid chemicals. These devices are only suitable for small quantities,

mostly prone to breakdowns, and there is no guarantee that the disinfectant fluid will reach all the waste. They are not suitable for handling all the waste generated by a hospital.

-Make needle reuse impossible: Auto disable syringes, like Solo Shot device, cannot be used more than once and therefore cannot carry infection from one patient to another.

the sharp out of sharps waste: Needle removers “de-fang”

syringes, immediately removing the needles after injection and isolating them in secure containers. The syringe cannot be reused, and there’s no risk of accidental needle sticks.

needles away from vulnerable hands: Special stickproof

containers capture used needles and other medical waste until they can be destroyed. PATH is working to increase access to these “safety boxes,” identifying low-cost options and making them available for all types of injections.

Using a needle cutter/destroyer:
1. Place used needle in the cutter/destroyer. 2. Cut/destroy the needle and the nozzle of syringe in the destroyer/cutter. 3. Separate syringe’s barrel and plunger and put in liquid disinfectant. 4. After every shift empty the contents of needle container/destroyer into liquid disinfectant, remove through pouring out contents through a sieve.

Due to poor operation and maintenance, these incinerators do not destroy the waste, need a lot of fuel to run, and are often out of order. There is a lot of difference between the theory and practice of incinerator operation. This is true around the world. The problem of medical waste needs a systematic approach, with investments in training of staff, segregation, waste minimisation and safe technologies, as also centralised facilities. Merely investing in unsafe incinerators cannot solve it.

Do’s and Don’ts:
1. That the used product is mutilated. 2. That the used product is treated prior to disposal. 3. Segregation

Do not
1. Reuse plastic equipment. 2. Mix plastic equipment with other waste. 3. Burn plastic waste.

Alternatives to mercury based instruments
Digital instruments are available as substitutes to the mercury containing instruments. Costs: The cost of the blood pressure instruments ranges from Rs 2000 to 7000 and the cost of thermometers ranges from Rs 200 to 300

Why are the alternative technologies better ?
These less harmful, non-toxic substitutes pose no environmental or health hazards and last for a longer duration. The life span of the mercury instruments, on the other hand, is short because of their fragility. Even though the initial investment cost of the alternative technologies is high, the assets associated with them are lifelong.

Identify All Usage Locations: All departments that use glutaraldehyde must
be identified and included in the safety program. Eliminate as many usage locations as possible and centralize usage to minimize the number of employees involved with the handling of glutaraldehyde

Monitor Exposure Levels: Measurement of glutaraldehyde exposure levels
must be conducted in all usage locations.

Training: An in-depth education and training program should be conducted
for all employees who work with hazardous chemicals.

Use Personal Protective Equipment: All employees who work with
glutaraldehyde must be provided appropriate personal protective equipment. This equipment includes proper eye/face protection, chemical protective gloves, and protective clothing.

Engineering controls: Rooms in which glutaraldehyde is used should have a
minimum of 10 air exchange rates per hour. General room ventilation: A neutralizing agent will, over time, chemically inactivate the glutaraldehyde

A chain is as strong as the weakest link in it, thus, not even one person in the hospital should be missed while training is given. The entire staff is involved in waste management at some point or the other, including administrators, stores personnel and other, seemingly uninvolved, departments. To ensure that the waste is carried responsibly from cradle to grave, and to see that all the material required for waste management is available to the staff, it is important to involve everyone, including: • Doctors • Administrators • Nurses • Technicians • Ward Boys and safai karamcharis

1. Universal Precautions: All the healthcare workers being exposed directly
or indirectly to infectious diseases must take Universal Precautions to reduce the chance of spread of infection.

2. Sterilization and cleaning: Ensure that the hospital has adequate
procedures for the routine, cleaning, and disinfection of environmental surfaces, beds, bed rails, bedside equipment, and other frequently touched surfaces, and ensure that these procedures are being followed. Routine microbiology tests for air and water contamination should be carried out in all parts of the hospital. Sterilize and disinfect instruments that enter tissue, or through which blood flows, before and after use. Sterilize devices or items that touch intact mucus membranes. In all the autoclave cycles, spore strips need to be placed to check the efficacy of the machine. Recommended chemical disinfectants should be used for the storage of instruments and fumigation of rooms. All the rooms must have proper ventilation.

3. Managing Body Fluid Spillages: Urine, Vomit & Faeces : All spillages of
body fluids (urine, vomit or faeces) should be dealt with immediately. Gloves (ideally disposable) should be worn, spillage should be mopped up with absorbent toilet tissue or paper towels: this should be disposed of into the waste bin meant for soiled waste. Pour 10 percent hypochlorite solution and leave it for 15 min. Clean the area with a swab. For spillages outside (e.g. in the playground) sluice the area with water. Do not forget to wash the gloves and then wash your hands after you have taken the gloves off.

4. Patient Placement: A separate room is important to prevent
direct/indirect contact transmission when the patient is with highly transmissible microorganisms, or the patient has poor hygienic habits.

5. Immunization programmes: Since hospital personnel are at risk of
exposure to preventable diseases, maintenance of immunity is an essential. Optimal use of immunizing agents will not only safeguard the health of personnel but also protect patients from becoming infected by personnel. The most efficient use of vaccines withhigh risk groups is to immunize personnel before they enter high-risk situations.



Facilities and procedures described in the rules:
(a) Collection: It is mandatory to mention the facilities available e.g.
polythene lined waste bins for collection of solid wastes, and corrosion resistant cardboards or delay tanks for collection of liquid wastes.

(b) Transfer: it is important to state the type of container employed during
transfer of waste/sources e.g. cardboards, sturdy polythene bags, radio-graphy camera

(d) Disposal: Identify the disposal methods for solid, liquid and gaseous
wastes briefly such as for: i). Solids: Burial pits, municipal dumping site or waste management agency e.g. BRIT etc. ii). Liquids: Sanitary sewerage system, soak-pit, waste management agency etc. iii). Gaseous wastes: Incineration facility, fume hood etc.

Safety Clothing: A set of safety clothing and equipment for waste handlers
was identified and provided. It included cap, eye protection goggles, mask, apron, gloves and boots. Disposable caps and masks were used. Gloves and aprons selected were of nonpermeable material to prevent contact with blood & body fluids. However gloves selected were malleable enough to permit finger movement. Handling, segregation, mutilation, disinfection, storage, transportation and final disposal are vital steps for safeand scientific management of biomedial

waste in any establishment. The key to minimisation and effective management of biomedical waste is segregation (separation) and identification of the waste. The most appropriate way of identifying the categories of biomedical waste is by sorting the waste into colour coded plastic bags or containers.


1. Already existing bins were used. 2. Hard plastic bins were purchased instead of cheap alternatives or pedal bins, as the hospital, going by their experience, wanted to go in for bins which would last longer. 3. Initially, changing of bags was done on a regular basis. In case of infectious and plastic waste, bags were changed once a day, and for general waste, bags were changed twice daily. The cost of this exercise was coming to almost Rs. 100 daily. The hospital has now decided to experiment with plastic reduction in its waste stream. Thus, only the infectious waste bags are replaced daily, the bags meant for disinfected plastics and general waste are retained till the bag remains intact and clean. 4. The plastic bags purchased by the hospital are cheaper alternatives to the expensive bags available. 5. The hospital purchased extra stock in addition to its present needs, as done for other items, to prevent any slack in the system. 6. To minimize the use of chemical disinfectant in the wards, two bins have been provided, one for disinfection of plastics and one for disinfected plastics. After each shift, or when the bin with disinfectant is full, the contents are transferred to the other bin (min. residence period of any item in disinfectant is 2hrs)

Strategy adopted:
1. To reduce the load of plastics, the hospital is planning to go in for cloth lining. This would cost them 1-2 Rs. / bag. 2. Microbiological studies in the hospital’s laboratory have shown that 10% bleach is effective for two days, thus a new solution is prepared every alternate day.


Inadequate waste collection, handling and disposal promotes the spread of infection in hospitals is and can thus undermine doctors' efforts to heal their patients. Moreover, it can cause infection outside the hospital. So proper disposal of hospital waste is in everyone's interest. To achieve this, clear guidelines must be issued; organizational measures are necessary; hospital personnel must be trained, convinced of the need for appropriate disposal method and monitored, waste must be collected in disposable containers at the place where it is generated and transported without being transferred or compacted. Special waste must be burned in incinerators which are technologically up to date. Health workers shouldn’t have to be afraid that saving another’s life will endanger their own. Nor should communities pay for better health care with medical waste they aren’t yet able to manage. Hospital waste management should be with a view to minimize risk to healthcare workers, and cause minimum damage to the environment

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