Health Care WasteDefinition, ClassificationHazardsManagement

Presented by:Ujwal Gautam (for)

Group C, (Roll no. 417-431)BDS 2009, BPKIHS

Health Care WasteHealth care waste (HCW) is defined as the total waste

stream from a healthcare facility (HCF).

According to Bio-Medical Waste (Management and Handling) Rules, 1998 of India “Bio-medical waste”,

“any solid, fluid or liquid waste, including its container and any intermediate product, which is generated during

the diagnosis, treatment or immunization of human beings or animals, in research pertaining there to, or in the production or testing of biological and the animal

waste from slaughter houses or any other like establishments”.

Types of wasteAs per WHO, the biomedical wastes could be classified into eight categories on the basis of the type of waste and the risk of transmission of infectious material in them.i. General waste (domestic)ii. Pathological: recognizable body parts and contaminated animal carcasses;iii. Radioactive: such as glassware contaminated with radioactive diagnostic material or radiotherapeutic materials;iv. Chemical: for example mercury, solvents and disinfectants;v. Infectious: waste contaminated with blood and its by-products, cultures and stocks of infectious agents, waste from patients in isolation wards, discarded diagnostic samples containing blood and body fluids, infected animals from laboratories, and contaminated materials (swabs, bandages) and equipment (such as disposable medical devices);vi. Pharmaceutical wastes: expired, unused, and contaminated drugs; vaccines and sera;vii. Sharps: syringes, needles, disposable scalpels and blades, etc.; viii. Pressurised containers.

Types of hazards-

• The hazardous nature of health-care waste may be due to one or more of the following characteristics:¥ it contains infectious agents;¥ it is genotoxic;¥ it contains toxic or hazardous chemicals or pharmaceuticals;¥ it is radioactive;¥ it contains sharps

Risk group-

• medical doctors, nurses, health-care auxiliaries, and hospital maintenance personnel;

• patients in health-care establishments or receiving home care;

• visitors to health-care establishments;• workers in support services allied to health-care

establishments, such as laundries, waste handling, and transportation;

• workers in waste disposal facilities (such as landfills or incinerators), including scavengers.

Methods of Health Care Waste disposal

The management of Health Care Waste involves: Health Care Facilities (HCFs) that generates

the waste; service providers who collect the waste

from the healthcare facilities and transport it to the treatment facilities;

treatment facilities that process the waste to make it safe for final disposal.

Principles of Management:

1. Duty of care principle2. Polluter pays principle3. Precautionary principle4. Proximity principle

1. Duty of care principle

This principle stipulates that any organisation that generates waste has a duty to dispose of

the waste safely. Therefore it is the Health Care Facilities that has ultimate responsibility for how waste is containerized, handled on-site and off-

site and finally disposed of.

Principles of Management:

2. Polluter pays principleAccording to this principle all waste producers are legally and

financially responsible for the safe handling and environmentally sound disposal of the waste they produce. In case of an accidental pollution, the organisation is liable for the costs of cleaning it up.

Therefore if pollution results from poor management of health-care waste then the HCF is responsible. However, if the pollution results because of poor standards at the treatment facility then the HCF is

likely to be held jointly accountable for the pollution with the treatment facility. Likewise this could happen with the service

provider.The fact that the polluters should pay for the costs they impose on the

environment, is seen as an efficient incentive to produce less and segregate well.

Principles of Management:

3. Precautionary principle

Following this principle one must always assume that waste is hazardous until shown to be safe. This means that where it is unknown what the hazard may be, it is important to take all the

necessary precautions.

Principles of Management:

4. Proximity principle

This principle recommends that treatment and disposal of hazardous waste take place at the

closest possible location to its source in order to minimize the risks involved in its transport.

According to a similar principle, any community should recycle or dispose of the waste it produces, inside its own territorial limits.

Principles of Management:

System dynamics model for hospital waste management in a developing country

System dynamics was introduced by Jay Forrester in the

1960s at the Massachusetts

Institute of Technology as a modeling and

simulation methodology.

Causal loop diagram of hospital waste management modelThe above mentioned casual loop is the application of System

dynamics in the Hospital Waste Management

Having defined the key elements, the core elements contained in this model are mentioned below;

o Populationo Health expenditureo Health riskso Waste generationo Municipal solid Wasteo Infectious Waste treatment

Steps for a Health Care Waste Management

i. Raise awarenessii. Define a policyiii. Set up a strategyiv. Conduct an assessment of the current situationv. Draft a HCWM planvi. Consolidate the legal & regulatory frameworksvii. Standardise HCWM practicesviii. Strengthen the institutional capacitiesix. Set up waste management plans

Steps in Health Care Waste disposal:

1. Waste minimization aims at reducing as much as possible the amount of HCW that will be produced

2. HCW generationThe point at which waste is produced.

3. Segregation and containerization• clear identification of the different categories of waste

is must and the separate disposal of the waste in accordance with the categorization chosen.

• Segregation must be done at the point of generation of the waste.

• To encourage segregation at source, (reusable) containers or baskets with colour coding is done.

• When they are 3/4 full, the liners are closed with plastic cable ties or string and placed into larger containers or liners at the intermediate storage areas.

• Suitable latex gloves must always be used when handling infectious waste.

Colour coding of polyethylene bag Type of waste material

Black Non-infectious and non-hazardous waste

Red Microbiological waste from pathological laboratory, items contaminated with blood and body fluids, and waste generated from disposable items other than sharps, etc

Yellow Human anatomical waste, microbiological waste from pathological laboratory, items contaminated with blood and body fluids, and waste generated.

Blue Waste sharps, tubing etc.

Color Coding For Segregation Of Biomedical Waste

4. Intermediate storage (in the HCF)• must be collected on a regular daily basis.• should both be close to the wards and not

accessible to unauthorized people such as patients and visitors.

5. Internal transport (in the HCF)• Transport to the central storage area is usually

performed using a wheelie bin or trolleyshould be marked with the corresponding coding color.

• The transport of general waste must be carried out separately from the collection of healthcare risk waste (HCRW) to avoid potential cross contamination or mixing of these two main categories of waste.

• The collection should follow specific routes through the HCF to reduce the passage of loaded carts through wards and other clean areas.

6. Centralized storage (in the HCF)• should be sized according to the volume of waste

generated as well as the frequency of collection. should not be situated near to food stores or food preparation areas

• its access should always be limited to authorized personnel.

• should also be easy to clean, have good lighting and ventilation, and be designed to prevent rodents, insects or birds from entering.

• should also be clearly separated to avoid cross-contamination.

• Storage time should not exceed 24-48 hours especially in countries that have a warm and humid climate.

7. External transport• should be done using dedicated vehicles, shall be

free of sharp edges, easy to load and unload by hand, easy to clean / disinfect, and fully enclosed to prevent any spillage in the hospital premises or on the road during transportation.

• transportation should always be properly documented and all vehicles should carry a consignment note from the point of collection to the treatment facility.

8. Treatment and final disposal

There are two different ways of final disposal at a facility: Burn and Non-Burn techniques.A. Non-burn techniquesB. Burn technique

A. Non-burn techniques: Burying solid medical waste: To use the burial method of waste disposal there must be enough space available to dig a burial pit and to enclose it in a fence or a wall. When burying solid medical waste, adhere to the following guidelines:

• Burial should be at least 50 meters from the nearest water source, located downhill from any wells, free of standing water, and in an area that does not flood.• Burial pit should be 1-2 meters wide and 2-5 meters deep. The bottom of the pit should be at least 1.8 meters above the water table.• Erect a fence or a wall around the site to keep out animals.• Every time solid medical waste is added to the pit, cover it with 10-30 cm of dirt.• When the level of waste reaches to within 30cm of ground level, fill the pit with dirt, seal it with concrete, and dig a new pit.

Chemical disinfection Technology: It uses chemicals to destroy pathogenic organisms from any inanimate object.

● Sharps contaminated with blood and body fluids.● Instruments, equipment that are used to cut, pierce or enter the

natural orifices like needles, syringes and endoscopes● Contaminated floors, surfaces, clothes, beds, beddings, enamel,

crockery and bed pans● Wet mopping of intensive care units, operation theatres, wards

and patient waiting areas.

B. Burn technique: Incineration of solid medical waste Incinerating is the best option for solid waste disposal, since the high temperature (1300 °C) destroys microorganisms and reduces the amount of waste. Burning in an incinerator or oil drum is recommended. Facilities that generate low levels of solid medical waste can use a small drum incinerator. A drum incinerator can be made from a 200 liter or 55 gallon oil drum.

• Burn only medical waste to minimize the amount of waste to be burned.• Use kerosene as an accelerant.• To avoid an explosion add kerosene before ignition.• Treat ash from incineration as general waste and dispose of it properly.• Liquid medical waste should be buried.

Liquid medical waste can be poured down a sink, drain, and flushable toilet. If none of these are available, in a pit. Points to be considered while disposing of liquid medical waste:

o Always wear heavy utility gloves and shoes when handling or transporting liquid medical waste.o Afterwards, wash both gloves and shoes.o Consider where the sink, drain or toilet empties.o It is hazardous to have medical waste flowing through open gutters or emptying onto the grounds of the facility.o When carrying or disposing of liquid medical waste, avoid splashing the waste on yourself, on others or on surfaces.o After disposal rinse the sink, drain, or toilet to remove residual waste, being careful to avoid splashing.o Clean the fixture with a disinfectant solution at the end of each day or more often if heavily soiled.o Decontaminate the container that held the liquid medical waste by filling it with a 0.5% chlorine solution and leaving it for 10 minutes before washing.

ADA Best Management Practices for Amalgam WasteDOs Do use precapsulated alloys

and stock a variety of capsule sizes

Do recycle used disposable amalgam capsules

Do salvage, store and recycle non-contact amalgam (scrap amalgam)

Do salvage (contact) amalgam pieces from

restorations after removal and recycle the amalgam waste Do use chair-side traps,

vacuum pump filters and amalgam separators to retain amalgam and recycle their contents.

Do recycle teeth that contain amalgam restorations.

Do manage amalgam waste through recycling as much as possible

DON’T Don’t use bulk mercury Don’t put used disposable amalgam capsules in biohazard containers, ninfectious waste container (red bags) or regular garbage. Don’t put non-contact amalgam

waste in biohazard containers, infectious waste containers (red bags) or regular garbage

Don’t put contact amalgam waste in biohazard containers,

infectious waste containers (red bags) or regular garbage Don’t rinse devices containing amalgam over drains or sinks Don’t dispose of extracted teeth

that contain amalgam restorations in biohazard containers, infectious waste containers (red bags), sharps containers or regular garbage Don’t flush amalgam waste down

the drain or toilet

WHO recommendations:

duty of careall associated with financing and

supporting health-care activities should provide for the costs of managing health-

care waste

Governments should:• allocate a budget to cover the costs of establishment and maintenance of sound health-care waste management systems• request donors, partners and other sources of external financing to include an adequate contribution towards the management of waste associated with their interventions• implement and monitor sound health-care waste management systems, support capacity building, and ensure worker and community health.

Donors and partners should:• include a provision in their health program assistance to cover the costs of sound healthcare waste management systems.

Non-governmental organizations should:• include the promotion of sound health-care waste management in their advocacy• undertake programs and activities that contribute to sound health-care waste management.

The private sector should:• take responsibility for the sound management

of health-care waste associated with the products and services they provide, including the design of products and packaging.

All concerned institutions and organizations should:

• promote sound health care waste management• develop innovative solutions to reduce the volume and toxicity of the waste they produce and associated with their products• ensure that global health strategies and programs take into account health-care waste management.

..International agreements

1. The Basel ConventionThis convention is a global agreement, ratified by some 178 member countries to address the problems and challenges posed by hazardous waste.The key objectives of the Basel Convention are:

• to minimize the generation of hazardous wastes in terms of quantity and hazardousness;• to dispose of them as close to the source of generation as possible;• to reduce the movement of hazardous wastes.

A central goal of the Basel Convention is “environmentally sound management” (ESM), the aim of which is to protect human health and the environment by minimizing hazardous waste production whenever possible.

2. The Stockholm Convention on Persistent Organic PollutantsThis Convention is a global treaty to protect human health and the environment from persistent organic pollutants (POPs).

References

M. Tsakona, E. Anagnostopoulou, E. Gidarakos, Hospital waste management and toxicity evaluation: A case study, Waste Management, Volume 27, Issue 7, 2007, Pages 912-920, ISSN 0956-053X, 10.1016/j.wasman.2006.04.019.(http://www.sciencedirect.com/science/article/pii/S0956053X06001541)

Mochammad Chaerul, Masaru Tanaka, Ashok V. Shekdar, A system dynamics approach for hospital waste management, Waste Management, Volume 28, Issue 2, 2008, Pages 442-449, ISSN 0956-053X, 10.1016/j.wasman.2007.01.007.(http://www.sciencedirect.com/science/article/pii/S0956053X07000360)

M Manzurul Hassan, Shafiul Azam Ahmed, K Anisur Rahman, and Tarit Kanti Biswas, Pattern of medical waste management: existing scenario in Dhaka City, Bangladesh, BMC Public Health. 2008; 8: 36.Published online 2008 January 26. doi: 10.1186/1471-2458-8-36(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2254398/?tool=pmcentrez)

K. Park, Park’s Textbook of Preventive and Social Medicine, 20th Ed., M/s Banarsidas Bhanot Publishers- Jabalpur (India), 2009

World Health Organization, WHO core principles for achieving safe and sustainable management of health-care waste, International Health Care Waste meeting, June 20 - 22, 2007, Geneva

A. Prues, E. Giroult, P. Rushbrook (Eds.), Safe Management of Wastes from Health-Care Activities, World Health Organization, Geneva (1999)

http://www.who.int/topics/medical_waste/en

http://www.healthcarewaste.org/

“Infection Control & Management of Hazardous Materials for Dental Team” Chris H.Miller,Charles John Palenik.

American Dental Council Guidelines

….References