Hospital Management Waste management

Session VIFriday, 17 February, 2011Dr. Ashfaq Ahmed Bhutto MBBS, MBA, MAS, DCPS, MRCGP, (PhD)

DEFINITION & INTRODUCTION

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Definition Healthcare waste (HCW) is defined as the total waste stream from a healthcare facility (HCF). 75-90% is similar to domestic waste. This fraction refered to as healthcare general

waste (HCGW) is made of paper, plastic packaging, food preparation, etc. that haven't been in contact with patients.

10-25% is infectious/ hazardous waste that requires special treatment. This fraction referred to as healthcare risk waste (HCRW) is the one we will focus on due to the risks that it poses both to human health and the environment.

If these two basic categories of waste aren't segregated (separated) properly, the entire volume of HCW must be considered as being infectious according to the precautionary principle, hence the importance of setting up a safe and integrated waste management system !

Exposure to HCRW can result in disease or injury. The hazardous nature of HCW may be due to one or more of the following characteristics:

it contains infectious agents; it contains sharps; it contains hazardous chemicals or pharmaceuticals; it is genotoxic; it is radioactive. 3

The 10 categories of HCRWThe 10-25% hazardous fraction of HCW are usually classified into the following waste groups.

1. Infectious wasteAre considered as infectious waste, all wastes that are susceptible to contain pathogens (or their toxins) in sufficient concentration to cause diseases to a potential host. Examples of infectious waste include discarded materials or equipment, used for the diagnosis, treatment and prevention of disease that has been in contact with body fluids (dressings, swabs, nappies, blood bags…). This category also includes liquid waste such as faeces, urine, blood or other body secretions (such as sputum or lung secretions).

2. Pathological and anatomical wastePathological waste consists in organs, tissues, body parts or fluids such as blood. Even if pathological waste may contain healthy body parts, it has to be considered as infectious waste for precautionary reasons.Anatomical waste is a sub-group of pathological waste and consists in recognisable human body parts, whether they may be infected or not. Following the precautionary principal, anatomical waste is always considered as potential infectious waste.

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The 10 categories of HCRW3. Hazardous pharmaceutical wastePharmaceutical waste includes expired, unused, spilt and contaminated pharmaceutical products, drugs and vaccines. In this category are also included discarded items used in the handling of pharmaceuticals like bottles, vials, connecting tubing.

This category also includes all the drugs and equipment used for the mixing and administration of cytotoxic drugs. Cytotoxic drugs or genotoxic drugs are drugs that have the ability to reduce/stop the growth of certain living cells and are used in chemotherapy for cancer. Cytotoxic waste is dealt with under a separate heading.

4. Hazardous chemical wasteChemical waste consists of discarded chemicals (solid, liquid or gaseous) that are generated during disinfecting procedures or cleaning processes. They may be hazardous (toxic, corrosive, flammable…) and must be used and disposed of according to the specification formulated on each container. Nevertheless non-explosive residues or small quantities of outdated products may be treated together with infectious waste.

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The 10 categories of HCRW5. Waste with a high content of heavy metalsWaste with high contents of heavy metals and derivatives are potentially highly toxic (e.g. cadmium or mercury from thermometers or manometers). They are considered as a sub-group of chemical waste but should be treated specifically.

6. Pressurized containersPressurised containers consist of full or emptied containers or aerosol cans with pressurised liquids, gas or powdered materials.

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The 10 categories of HCRWHighly hazardous and therefore require special attention.

7. SharpsSharps are items that can cause cuts or puncture wounds (needle stick injuries for instance). Whether they are infected or not, they are considered as highly dangerous and potentially infectious waste. They must be segregated, packed and handled specifically within the HCFs to ensure the safety of the medical and ancillary staff.

8. Highly infectious wasteHighly infectious waste consists in microbial cultures and stocks of highly infectious agents from Medical Analysis Laboratories. They also include body fluids of patients with highly infectious diseases.

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The 10 categories of HCRWHighly hazardous and therefore require special attention.

9. Genotoxic / cytotoxic wasteGenotoxic waste derives from drugs generally used in oncology or radiotherapy units that have a high hazardous mutagenic or cytotoxic effect. Faeces, vomit or urine from patients treated with cytotoxic drugs or chemicals should be considered as genotoxic. In specialised cancer hospitals, their proper treatment or disposal raises serious safety problems.

10. Radioactive wasteRadioactive waste includes liquids, gas and solids contaminated with radionuclides whose ionizing radiations have genotoxic effects. The ionizing radiations of interest in medicine include X- and g-rays as well as a- and b- particles. An important difference between these types of radiations is that X-rays are emitted from X-ray tubes only when generating equipment is switched on whereas g-rays, a- and b- particles emit radiations continuously.The type of radioactive material used in HCF results in low level radioactive waste. It concerns mainly therapeutic and imaging investigation activities where Cobalt 60Co, Technetium 99mTc, iodine 131I and iridium 192Ir are most commonly used.With the noticeable exception of Cobalt 60Co, their half-life is reasonably short (6 hours for 99mTc, 8 days for 131I and 74 days for 192Ir) and the concentrations used remain low. A proper storage with an appropriate retention time is sufficient to prevent radioactivity to spillage in the environment.

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The 8 steps along the waste stream1. Waste minimization This first step comes prior to the production of waste and aims at reducing as much as possible the

amount of HCW that will be produced by setting up an efficient purchasing policy and having a good stock management, for example.

2. HCW generation The point at which waste is produced.

3. Segregation and containerization The correct segregation of waste at the point of generation relies on a clear identification of the

different categories of waste 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 liners of the correct size and thickness are placed as close to the point of generation as possible. They should be properly colour-coded (yellow or red for infectious waste) and have the international infectious waste symbol clearly marked.

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.

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The 8 steps along the waste stream4. Intermediate storage (in the HCF) In order to avoid both the accumulation and decomposition of the waste, it must be collected on

a regular daily basis. This area, where the larger containers are kept before removal to the central storage area,

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 trolley.

Wheelie bins or trolley should be easy to load and unload, have no sharp edges that could damage waste bags or containers and be easy to clean. Ideally, they should 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.

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The 8 steps along the waste stream6. Centralized storage (in the HCF) The central storage area should be sized according to the volume of waste generated as well as

the frequency of collection. The facility should not be situated near to food stores or food preparation areas and its access should always be limited to authorized personnel. It should also be easy to clean, have good lighting and ventilation, and be designed to prevent rodents, insects or birds from entering. It should also be clearly separated from the central storage area used for HCGW in order 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 External transport should be done using dedicated vehicles. They 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.

The 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 a number of different treatment options to deal with infectious waste.

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Actors in the HCWM processThe main actors involved in the management of HCW are the: 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.

Each of these major actors as well as administrative authorities and the public will need to receive appropriate training to ensure appropriate measures are taken at each level for the safe management of HCW.

Generators of HCWHCW isn’t only produced in hospitals but in a number of other locations: Major sources are hospitals, clinics, laboratories, blood banks and mortuaries; Minor sources are physician’s office, dental clinics, pharmacies, etc.

Apart from producing different quantities of waste, these sources also produce different types of waste, that don’t all require the same kind of treatment and disposal as explained in the resources section under the treatment options chapter.

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Risks associated with HCW All individuals exposed to healthcare waste are potentially at risk of being

injured or infected. They include: Medical staff: doctors, nurses, sanitary staff and hospital maintenance personnel; In and out-patients receiving treatment in healthcare facilities as well as their

visitors; Workers in support services linked to healthcare facilities such as laundries,

waste handling and transportation services; Workers in waste disposal facilities, including scavengers; The general public and more specifically the children playing with the items they

can find in the waste outside the healthcare facilities when it is directly accessible to them.

Waste management and treatment options should first protect the healthcare workers and the population and minimise indirect impacts from environmental exposures to HCW.

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Risks associated with HCWOccupational and public health risks

During handling of wastes, the medical and ancillary staff as well as the sanitary labourers can be injured if the waste has not been packed safely.

In that respect, sharps are considered as one of the most dangerous category of waste. Many injuries occur because syringe needles or other sharps have not been collected in safety boxes or because these have been overfilled.

The general public can be infected by HCRW either directly or indirectly through several routes of contamination.

Dumping HCW in open areas is a practice that can have major adverse effects on the population. The «recycling» practices that have been reported, particularly, the reuse of syringes is certainly the most serious problem in a number of countries.

The WHO estimates that over 23 million infections of hepatitis B, C and HIV occur yearly due to unsafe injection practices (reuse of syringes and needles in the absence of sterilization).

There is also a public health risk linked to the sale of recovered drugs in the informal sector when the elimination of expired drugs isn’t properly controlled and monitored.

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Risks associated with HCW Indirect risks via the environment

Finally, the dumping of HCW in uncontrolled areas can have a direct environmental effect by contaminating soils and underground waters.

During incineration, if no proper filtering is done, air can also be polluted causing illnesses to the nearby populations.

This has to be taken into consideration when choosing a treatment or a disposal method by carrying out a rapid environmental impact assessment (EIA).

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Reducing HCW risks Reducing the direct and indirect risks posed by HCRW is one

of the main objectives of HCWM. It is achieved through a set of measures that have to be taken in parallel at the management, training, regulatory, technical and financial levels.

Action must be taken in this respect not only within the medical sphere of HCFs, but also at regional and national political levels.

Awareness and training are certainly the first and most important means of inducing changes. A well trained person will always find solutions to the problems encountered, even if imperfect.

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Reducing HCW risksOne step after another... Considering the scope of the work, it is important to keep in mind that a phased and

progressive approach taking into account human and financial resources available will have to be taken

A small step in the right direction that can be implemented in a sustainable manner is better than trying to aim at too sophisticated systems that won't work on the long run.

Simple waste management measures, such as effective confinement of waste and safe handling, can already dramatically reduce health risks if they are consistently applied at each step along the HCW stream from the point of generation («cradle») to the point of final disposal («grave»).

A simple three bin segregation system (sharps, infectious waste and general waste) is an efficient first step that should be quite easy to implement and that enables to reduce the most important risks drastically before going into more detailed solutions taking into account all the different categories of HCW.

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Reducing HCW risksA relative risk approach At the level of waste treatment technical options, the criteria for deciding on the system

is that it protect in the best way possible healthcare workers and the community as well as minimize adverse impacts on the environment

Environmental-friendly and safe options used in high income countries may not always be affordable or possible to implement (lack of electrical supply, etc.) in less economically developed countries (LEDCs).

Health risks from environmental exposures should be weighed against the risks posed by accidental infection from poorly managed infectious waste (sharps in particular). The use of a burial pit or a small-scale incinerator, although clearly not the best solution, is much better than uncontrolled dumping.

The main criteria for the selection of a technical option should be that their implementation will offer a level of health protection which eliminates as many risks as possible. The HCWM systems can subsequently be upgraded to reach higher safety standards.

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The management of healthcare waste in emergencies Special care must be taken with refuse from a field hospital or health

centre. The main categories of waste of concern in such situations are: infectious waste; sharps and pathological waste. These wastes must be handled, stored treated and disposed of properly to reduce public health risks.

In the case of small health centres, particularly in rural areas, well-managed on-site burial may be appropriate. In larger centres producing a significant quantity of sharps and infected waste, more sophisticated technology will be required. When healthcare facilities (HCFs) operate diagnostic laboratory services, radiological diagnosis and treatment facilities, pharmacies, etc., waste management is a specialized activity requiring trained and well-equipped staff.

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The management of healthcare waste in emergenciesWaste management during triage and classification of victims Triage and classification of victims generate potentially

infectious waste. Since this is a rapid response activity, it is highly recommended that all wastes generated during this stage, without exception, are stored in containers, preferably in red bags, that are properly labelled as "bio-contaminated waste". Direct contact with such wastes must be avoided.

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The management of healthcare waste in emergenciesWaste management during medical activities Management will be similar for permanent (existing

hospitals and health centres) and provisional (field hospitals) health facilities.

Wastes should be properly segregated at the point of generation according to their type: Infectious non-sharp waste; sharps; chemical wastes (drugs, chemical solutions, etc.); non infectious, common wastes (paper, cardboard, etc.)

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The management of healthcare waste in emergencies Infectious non-sharp waste should be disposed of in washable PVC containers with

a capacity of 40–50 litres. Cardboard containers lined with a plastic bag are also an option.

Sharps must be collected in safety boxes or other puncture proof containers such as plastic bottles when no other options are available.

Non-infectious waste can be disposed of with the other general household waste by the municipal waste-collection service, if one can ensure it doesn't contain any hazardous materials.

To avoid potential confusion, colour codes should be used whenever possible: Collection should be carried out daily, especially in warm climate areas. Internal

transport should be done using a cart or trolley. The personnel assigned to handle medical waste should be properly trained and should wear protective equipment (gloves and boots are minimum requirements).

Treatment should be done according to the type of waste. Infectious non-sharp waste as well as sharps should either be disposed of in protected pits or incinerated. Existing functioning nearby waste treatment facilities (autoclaves / incinerators) should be used but only if safe means of transport can be ensured.

For the rehabilitation and reconstruction phases after the emergency, long term environmentally friendly options should be selected. In general, non-burn technologies such as autoclaving should be preferred to incineration technologies. 22

General procedures in case of spillagesThe actions listed below provide an example of typical measures that could/should be taken in case of accidental spillages of HCW.1. Evacuate the contaminated area.2. Decontaminate the eyes and skin of exposed personnel immediately.3. Inform the designated person who should coordinate the necessary actions.4. Determine the nature of the spill.5. Evacuate all the people not involved in cleaning up.6. Provide first aid and medical care to injured individuals.7. Secure the area to prevent exposure of additional individuals.8. Provide adequate protective clothing to personnel involved in cleaning-up.9. Limit the spread of the spill.10. Neutralize or disinfect the spilled or contaminated material if indicated.11. Collect all spilled and contaminated material. [Sharps should never be picked up by hand; brushes

and pans or other suitable tools should be used]. Spilled material and disposable contaminated items used for cleaning should be placed in the appropriate waste bags or containers.

12. Decontaminate or disinfect the area, wiping up with absorbent cloth. The cloth (or other absorbent material) should never be turned during this process, because this will spread the contamination. The decontamination should be carried out by working from the least to the most contaminated part, with a change of cloth at each stage. Dry cloths should be used in the case of liquid spillage; for spillages of solids, cloth impregnated with water (acidic, basic, or neutral as appropriate) should be used.

13. Rinse the area, and wipe dry with absorbent cloths.14. Decontaminate or disinfect any tools that were used.15. Remove protective clothing and decontaminate or disinfect it if necessary.16. Seek medical attention if exposure to hazardous material has occurred during the operation.

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Two International Agreements on HCW

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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 Secretariat, based in Geneva (Switzerland) is administered by UNEP. It facilitates the implementation of the Convention and related agreements. It also provides assistance and guidelines on legal and technical issues and conducts training on the proper management of 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. HCRW is one of the categories of hazardous wastes covered by the Convention.

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Four principles1. 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 HCF that has ultimate responsibility for how waste is containerized, handled on-site and off-site and finally disposed of.

2. Polluter pays principle According 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.

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Four principles3. 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.

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.

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Costing estimation of HCW Calculating the costs of setting up a HCWM system isn't easy if

one wants to take into account all the components (management, training, regulatory and technical).

This approach called system costing requires that a full description of the national HCWM system be drawn. Such a description would also include knowing for each HCF, the services offered, number of beds and occupancy rates, number of outpatients; quantity and composition of HCW produced; treatment systems used; transport requirements; etc.

This is not easy. Alternate way is to use WHO’s HCWM Costing Analysis Tool (CAT).

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LEGISLATION

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Legislation

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Responsibilities of wards

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Waste Management Team of the Hospital/ Clinic/Lab. shall be responsible to ensure proper management of the waste generated in the Hospital/ Clinic/ Lab.

Responsibility for Waste Management

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WASTE CLASSIFICATION

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Option Waste Category Treatment & DisposalCategory No. 1 Human Anatomical Waste

(human tissues, organs, body parts)incineration @/deep burial*

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

incineration@/deep burial*

Category No. 3 Microbiology & Biotechnology Waste(Wastes from laboratory cultures, stocks or micro-organisms live or vaccines, human and animal cell culture used in research and infectious agents from research and industrial laboratories, wastes from production of biologicals, toxins, dishes and devices used for transfer of cultures)

local autoclaving/micro-waving/incineration@

Category No. 4 Waste Sharps(needles, syringes, scalpels, blade, glass, etc. that may cause punture and cuts. This includes both used and unused sharps)

disinfection (chemical treatment @@@/auto claving/microwaving and mutilation/shredding##

Category No. 5 Discarded Medicines and Cytotoxic drugs(Waste comprising of outdated, contaminated and discarded medicines)

incineration@/destruction and drugs disposal in secured landfills

CATEGORIES OF BIO-MEDICAL WASTE

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Option Waste Category Treatment & Disposal

Category No. 6 Soiled Waste(items contaminated with blood, and body fluids including cotton, dressings, soiled plaster casts, lines, bedding, other material contaminated with blood)

incineration@autoclaving/microwaving

Category No. 7 Solid Waste(Waste generated from disposal items other than the sharps such a tubings, catheters, intravenous sets etc.)

disinfection by chemical treatment@@ autoclaving/microwaving and mutilation/shredding##

Category No. 8 Liquid Waste(Waste generated from laboratory and washing, cleaning, housekeeping and disinfecting activities)

disinfection by chemical treatment@@ and discharge into drains

Category No. 9 Incineration AshAsh from incineration of any bio-medical waste)

disposal in municipal landfill

Category No. 10 Chemical Waste(Chemicals used in production of biologicals, chemicals used in production of biologicals, chemicals used in  disinfection, as insectricides, etc.)

chemical treatment@@ and discharge into drains for liquids and secured landfill for solids

CATEGORIES OF BIO-MEDICAL WASTE (continued)

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Note :

@ There will be no chemical pretreatment before incineration. Chlorinated plastics shall not be incinerated.

* Deep burial shall be an option available only in towns with population less than five lakhs and in rural areas.

@@ Chemicals treatment using at least 1% hypochlorite solution or any other equivalent chemical reagent. It musts be ensured that chemical treatment ensures disinfection.

## Multilation/shredding must be such so as to prevent unauthorised reuse.

CATEGORIES OF BIO-MEDICAL WASTE (continue)

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COLOUR CODING AND THE TYPE OF CONTAINER FOR DISPOSAL OF BIO MEDICAL WASTES

Colour Coding Type of Container Waste

Category Treatment options

Yellow Plastic Bag Categories 1, 2, 3 & 6. Incineration/ deep burial

 Red Disinfected container/Plastic bag

Categories 3, 6, 7

Autoclaving/Micro-waving/Chemical Treatment

Blue/White Translucent

Plastic Bag /puncture proof containers

Cat. 4, Cat. 7

Autoclaving/Micro-waving/ Chemical Treatment & Destruction / shredding

Black Plastic Bag Categories 5, 9, 10 Disposal in secured landfill.

Notes:1. Colour coding of waste categories with multiple treatment options as defined in schedule, shall be selected depending on treatment option chosen, which shall be as specified.

2. Waste collection bags for waste types needing incineration shall not be made of chlorinated plastics.

3. Categories 8 and 10 (liquid) do not require containers/bags.

ISSUES

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Studies in Pakistan show that large hospital’s generate 2.0 kg of waste, per bed per day. Of this, 0.5 kg can be categorized as biomedical risk waste.

There are many small hospitals and clinics which also generate risk waste in significant quantities.

Facts

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Daily Medical Waste Generation (from both public & private sector hospitals): Approximately 0.8 million tons (Source: UN & HSA, MoH)

Improper disposal practices results in reuse of discarded syringes, IV tubes, blood bags and other equipment which is not designed for either sterilization or reuse.

If hospital waste is not properly managed and disposed of, it can result in injury by contaminated sharps and infection with Hepatitis B, C, and HIV.

Facts

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In Pakistan there are about 92,000 beds in public sector hospitals

Pakistan –Population 180 million will rise to 250 million by year 2025

Amount of Hospital Waste generated will increase to alarming rates due to growth of population and healthcare facilities

No well established segregation system Frequent dumping of hospital waste with municipal

waste

Situational Analysis

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Major sources of water table pollutions Lapses in Landfill designs Maintenance and monitoring issues of incinerator

technology Issues related to behaviors change Need proper integrated management, priority

setting & infrastructure development

Situational Analysis

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WASTE GENERATION

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Waste Generation by Country(Global Waste Survey Final Report Published by IMO 1995)*

Countries Amount /year

Japan 395 M tonnes/year

Germany 104 M tonnes/year

Netherlands 6.1 M tonnes/year

Hungary 102 M tonnes/year

Poland 130 M tonnes/year

Romania 607 M tonnes/year

Bahrain 92,000 tonnes/year

China 6 B tonnes/year

Philippines 1.3 M tonnes/year

*from primary and secondary industry sectors

Country Waste Generation (Kg/bed/day)

Total Waste Generation(tons/year)

Bangladesh 0.8-1.67 93,075 (255 tons/day) (only in Dhaka)

Bhutan 0.27 73

India 1-2 330,000

Maldives NA 146

Nepal NA 365

Sri Lanka 0.36 6600(only in Colombo)

Pakistan 1.06 250,000

Estimates of medical waste generation in South Asia

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WASTE TREATMENT

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International recommendations for waste managementUN Conference on Environment and Development

Agenda 21 Waste Hierarchy Prevent or Minimize Re-use or recycle Incinerate with heat recovery Use alternative to incineration Landfill the residues

Waste hierarchy The waste hierarchy refers to the 3Rs of reduce, reuse, and recycle, which

classify waste management strategies according to their desirability. The 3Rs are meant to be a hierarchy, in order of importance. However in Europe the waste hierarchy has 5 steps: reduce, reuse, recycle, recovery, and disposal.

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Reuse

Materials should only be reused if they aredesigned for re-use

Plastic syringes and catheters should bediscarded after use

There may be numerous opportunities forreuse of commonly used objects which areusually discarded after use

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RecyclingPackaging materials can be recycled:• Paper and cardboard• Glass• Metal containers• Plastic wrappings

Consideration should be given to segregation of materials that could be recycled, considering the market opportunities.

Slide 51

Recycle Products When Possible

Slide 52

PRECAUTION

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Employers must:

Ensure that Universal Precautions are observed Provide free Hepatitis-B vaccination series Provide all necessary PPE and ensure that is it used Provide BBP training at hire, and annually thereafter Maintain records of all training Maintain an Exposure Control Plan, update annually Record exposure incidents and follow-up activities

Preventing Disease Transmission

The single most effective measure to control the transmission of Bloodborne Pathogens is:

Universal Precautions Treat all human blood and other potentially

infectious materials like they are infectious for Hepatitis B and HIV

Blood and Fluid Borne Pathogen Exposures

Exposures to blood and fluid borne pathogens in the medical setting typically occur by one of the following ways:

Puncture from contaminated needles, broken glass, or other sharps

Contact between non-intact (cut, abraded, acne, or sunburned) skin and infectious body fluids

Direct contact between mucous membranes and infectious body fluids

Example: A splash in the eyes, nose, or mouth

Transmission of Blood and Fluid Borne Pathogens

An exposure incident does not guarantee disease transmission. Several factors affect transmission:

Infected Source – the disease stage of the source Means of Entry - severity or depth of the: puncture wound,

broken skin, or direct contact with mucus membrane Infective Dose - the amount and type of fluid, as well as the

amount of infectious agent in the fluid Blood is the fluid of greatest concern

Susceptible Host - immunocompromised

Prevention of ExposureGuidelines to reduce the risk of exposure:

Frequent hand washing Use of standard barrier precautions Regular cleaning and decontamination of work surfaces with

a cleaning agent labeled as effective against Mycobacterium/TB

Vaccination against Hepatitis-B Proper infectious waste disposal

Exposure Incident Response

Wash exposed area with soap and water Flush splashes to nose, mouth or skin with water Irrigate eyes with water or saline Report the exposure to supervisor Follow your facility’s exposure response plan Report all exposures, regardless of severity, for your safety

WASTE MANAGEMENT

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Health-care waste managementin a hospital

Good waste management depends on: A dedicated Waste Management Team Good administration Careful planning Sound organization Underpinning legislation Adequate financing Full participation by trained staff

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The Waste Management Plan

1. Assess present situation and carry out a waste survey

2. Identify opportunities for minimization, reuse and recycling

3. Identify handling, treatment and disposal options4. Evaluate options5. Prepare a management plan6. Establish a record keeping system7. Estimate related costs8. Prepare training programme9. Prepare implementation strategy

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Implementation of the Plan

The implementation is the responsibility of the Head of the establishment Phased introduction Opportunities for expansion Identify key personnel network Arrange training Implement Review the plan annually Prepare annual report for national government

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Waste segregation

Key to waste minimization Essential for effective waste management Improves public health protection Should be done according to specific treatment and

disposal requirements Should be carried out by waste producer Should be harmonized all over the country Same segregation from production until disposal

Why Bother Segregate Wastes?In USA costs for waste disposal: About $0.01 per pound to haul regular waste

to a landfill.

From $0.28, and increases to over $4.00 per pound to haul and treat as infectious waste.

A Real Life Example During an inspection of one southern West Virginia facility it

was noted that the ER, ICU, Lab, OB, and OR departments were not segregating any waste.

All waste was being disposed of as infectious. Management said the staff was too busy to segregate

garbage.

In 1996 this facility generated 245,060 lbs. of infectious waste.

They paid $0.29 cents per pound to have their infectious waste hauled away and treated.

The Cost of Over Classification The inspection revealed 90 - 95%

over classification. The total cost for disposal of

infectious waste for 1996 was $71,067.40

Cost savings potential of $64,000 to $68,000

Teamwork Made it PossibleThis same facility two years later:

In 1998 they generated 114,000 pounds. A reduction of about 50%.

In 2001 they generated 58,838 pounds. A total reduction of more than 76%

This facility realized a $54,004 cost savings

Source Separation is the Key! Everyone needs to consider which waste stream an item

goes in every time wastes are disposed We realize that you are busy, but it only takes a few seconds

to separate waste items into the proper waste stream By properly segregating medical wastes, the weight of

infectious waste can be drastically reduced in every facility

Handling Medical waste should be handled as little as possible before

disposal. It should not be collected from patient-care areas by emptying into open carts; this may lead to contamination of the surroundings and to scavenging of waste as well as to an increased risk of injury to staff, clients and visitors.

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Bag filling Waste and sharps containers should be discarded when they

become three quarters full and at least once daily or after each shift. The reason for this is to reduce the risk of plastic bags splitting open and of an injury from a protruding sharp item in sharps containers.

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To be done by Sanitary staff and transferred to Central Waste storage facility of the Institute. Establish a routine programme for collection Collect ward waste daily Waste bags should be sealed All containers and bags should be labeled Full containers should be immediately

replaced with empty containers or bags

Waste Collection

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Interim Storage Waste should be transported to interim storage at the end of every

shift. To reduce the risk of infection and of injury, minimize the amount of time waste is stored at the facility.

Waste should be stored in an area of controlled access that is minimally trafficked by staff, clients, and visitors.

Interim storage time should not exceed two days. It is preferable to have a room to store waste on each floor of the

facility, but, if this is difficult, one central storage room should be designated.

The storage area should also be included in a cleaning schedule.

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Transporting Solid Medical Waste Transporting solid medical waste is an option for final disposal if a

facility is unable to use burn or non-burn techniques. It is the least desirable option for disposal because it is likely that nonmedical personnel will put themselves at risk by being involved in the disposal process. If this option is used, facility staff must educate the waste transport and disposal personnel to the risks involved in the disposal process and must teach them how to dispose of solid medical waste safely.

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On-Site: All waste bags except yellow ones, should be transferred to W.

Storage room on daily basis by the sanitary workers by Four –wheeled trolleys ( three wheeled are quite uncomfortable).

Different colored bags have to be segregated in the storage room.

Off – site: Should be arranged by concerned municipal / local authority. The

waste should be transferred to the vehicle by sanitary worker under the supervision of WMO.

Transportation

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WASTE DISPOSAL

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Treatment and disposal optionsfor waste

Treatment Incineration Chemical disinfection Autoclaving Encapsulation Microwave irradiation

Final disposal Municipal landfill Burying inside premises Discharge into sewer

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Disposal to landNot recommended for untreated hazardous

waste

Minimum requirements for land disposal:• No deposit on open dumps• A degree of management control is exercised• Engineered avoid leaching to water bodies and

retain waste on site• Rapid burial of HCW on site to isolate from animal or human contact

Burying solid medical waste 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 30-cm of ground level, fill

the pit with dirt, seal it with concrete, and dig a new pit.

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Land fill

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Land fill

Sharps Must be collected at the point of generation, in a

leak-proof and puncture-resistant container

Containers must bear the international biohazard symbol and appropriate wording

Containers should never be completely filled, nor filled above the full line indicated on box.

Liquid Infectious Medical Wastes

Placed directly in the Biohazardous waste,

Poured down a sanitary sewer,

Solidified using an approved disinfectant solidifier and discarded in the solid waste

Liquid Infectious Medical Waste, i.e., the contents of suction canisters, may be disposed of in several ways:

Disposal of radioactive

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Radioactive waste which has to be stored to allow decay to back ground level, shall be placed in a waste bag, in a large yellow container or drum. The container or drum shall be labeled, “RADIOACTIVE WASTE”, with radiation symbol.

Non-infectious radioactive waste which has decayed to background level, shall be placed in white waste bag.

Infectious radioactive waste which has decayed to background level, shall be placed in yellow waste bag.

High level and relatively long half-life radionuclide shall be packed and stored in accordance with the instruction of the original supplier under supervision of Radiology officer and sent to the supplier for disposal.

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Simple chemical disinfectionTreatment by contact to commonly usedproducts for surface disinfection

Requires shredding of waste May introduce strong chemicals into the environment Efficiency depends on operational conditions Only the surface is disinfected Human tissue should usually not be disinfected Special disposal required to avoid pollution of the

environment

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Wet thermal treatment systemsMethod that exposes waste to steam underpressureExamples:

autoclaving, larger off-site treatment facilitiesCharacteristics:• Low investment and operating costs for simple

apparatus• Environmentally friendly• Not appropriate for tissue or carcasses• Trained operatives required

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Microwave irradiation Waste is shredded Waste is humidified for homogeneous

heating Microwaves rapidly heat the waste Microbiological inactivation by heat

conduction and radiation Routine microbiological testing required Waste is compacted for landfill

INCINERATION

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Incineration Technology

Burn pile Burn barrel Moving grate Fixed grate Rotary-kiln Fluidized bed

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Incineration Reduces organic and combustible waste to inorganic

incombustible waste (ashes) Reduces significantly waste volume and weight Residues are transferred to final disposal site Treatment efficiency depends on incineration

temperature and type of incinerator Not all wastes can be incinerated Investment and operation costs vary greatly according to

type of incinerator Produces combustion gases

Pressurized gas containers Large amounts of reactive chemical waste Radioactive waste Silver salts or radiographic waste Halogenated plastics (e.g. PVC) Mercury or cadmium Ampoules of heavy metals

Waste not to be Incinerated

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INCINERATOR

Incinerator

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INCINERATOR

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Incineration- Boston’s W-T-E Plant Saugus Plant built in 1975

based on Swiss grate system.

First modern waste-to-energy plant

Used European system that needed major modification because of the difference between European and U.S. waste streams.

1500 tons/day

40 Megawatts power generated

Incineration

SYSAV incineration plant in Malmö, Sweden capable of handling 25 metric tons per hour household waste.

To the left of the main stack, a new identical oven line is under construction (March 2007).

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Incineration

The Spittelau incineration plant in Vienna, designed by Friedensreich Hundertwasser.

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Incineration Pollution Before the flue gas cleaning system, the flue gases may

contain significant amounts of: Particulate matter Heavy metals Dioxins Furans Sulfur dioxide Hydrochloric acid.

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Luke Hospital incinerator

Gaseous emissions Dioxin and furans

According to the United States Environmental Protection Agency, incineration plants are no longer significant sources of dioxins and furans.

In 1987, before the governmental regulations required the use of emission controls, there was a total of 10,000 grams (350 oz) of dioxin emissions from US incinerators.

Today, the total emissions from the 87 plants are 10 grams (0.35 oz) annually, a reduction of 99.9 %.

Backyard barrel burning of household and garden wastes, still allowed in some rural areas, generates 580 grams (20 oz) of dioxins annually

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Dioxins-Health effects in humans Exposure to high levels of dioxins in humans causes a severe form of

persistent acne, known as chloracne. A case-control study has shown an elevated risk of sarcoma (a type of

cancer) associated with low-level exposure (4.2 fg/m3) to dioxins from incineration plants.

High levels of exposures to dioxins have been shown by epidemiological studies to lead to an increased risk of tumors at all sites.

Other effects in humans may include: Developmental abnormalities in the enamel of children's teeth. Central and peripheral nervous system pathology Thyroid disorders Damage to the immune systems Endometriosis Diabetes

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Dioxin poisoning- chloracne. The President of Ukraine's face showed an impressive recovery from the

disfigurement and scarring caused by dioxin poisoning in 2004. Doctors found levels of dioxin 1,000 times higher than the norm.

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Dioxin cracking methods The breakdown of dioxin requires

exposure of the molecular ring to a sufficiently high temperature so as to trigger thermal breakdown of the strong molecular bonds holding it together.

Modern incinerator designs include a high temperature zone, where the flue gas is ensured to sustain a temperature above 850 °C (1,560 °F) for at least 2 seconds before it is cooled down. They are equipped with auxiliary heaters to ensure this at all times. These are often fueled by oil, and normally only active for a very small fraction of the time.

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THANK YOU Request for safe waste management

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