1. Health Care Waste Definition, Classification Hazards Management Presented by: Ujwal Gautam (for) Group C, (Roll no. 417-431) BDS 2009, BPKIHS
2. Health Care Waste Health 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, inresearch pertaining there to, or in the production or testing of biological and the animal waste from slaughter houses or any other like establishments”.
3. Types of wasteAs per WHO, the biomedical wastes could be classified into eight categorieson the basis of the type of waste and the risk of transmission of infectiousmaterial 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.
4. 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
5. 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.
6. Methods of Health Care Waste disposalThe 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.
7. Principles of Management:1. Duty of care principle2. Polluter pays principle3. Precautionary principle4. Proximity principle
8. Principles of Management: 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 CareFacilities that has ultimate responsibility for how waste is containerized, handled on-site and off- site and finally disposed of.
9. Principles of Management: 2. Polluter pays principleAccording to this principle all waste producers are legally and financially responsible for the safe handling andenvironmentally sound disposal of the waste they produce. In case of an accidental pollution, the organisation is liable forthe costs of cleaning it up. Therefore if pollution results from poor management of health-care waste then the HCF isresponsible. However, if the pollution results because of poorstandards 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.
10. Principles of Management: 3. Precautionary principleFollowing 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.
11. Principles of Management: 4. Proximity principle This principle recommends that treatment and disposal of hazardous waste take place at theclosest 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.
12. System dynamics model for hospital waste management in a developing countrySystem dynamicswas introduced by Jay Forrester in the 1960s at the Massachusetts Institute of Technology as a modeling and simulation methodology.
13. Causal loop diagram of hospital waste management modelThe above mentioned casual loop is the application of System dynamics in the Hospital Waste Management
14. Having defined the key elements, the coreelements contained in this model are mentionedbelow; o Population o Health expenditure o Health risks o Waste generation o Municipal solid Waste o Infectious Waste treatment
15. Steps for a Health Care Waste Managementi. 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
16. Steps in Health Care Waste disposal:1. Waste minimizationaims at reducing as much as possible the amount ofHCW that will be produced2. HCW generationThe point at which waste is produced.
17. 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.
18. Color Coding For Segregation Of Biomedical WasteColour 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.
19. 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.
20. 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.
21. 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.
22. 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.
23. 8. Treatment and final disposalThere are two different ways of final disposal at afacility: Burn and Non-Burn techniques.A. Non-burn techniquesB. Burn technique
24. 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.
25. Chemical disinfection Technology: It uses chemicals to destroypathogenic 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.
26. B. Burn technique: Incineration of solid medicalwaste Incinerating is the best option for solid wastedisposal, since the high temperature (1300 °C)destroys microorganisms and reduces the amountof waste. Burning in an incinerator or oil drum isrecommended. Facilities that generate low levels ofsolid medical waste can use a small drumincinerator. A drum incinerator can be made from a200 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.
27. Liquid medical waste can be poured down a sink, drain, andflushable toilet. If none of these are available, in a pit. Pointsto 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.
28. ADA Best Management Practices for Amalgam Waste DON’TDOs Don’t use bulk mercury Do use precapsulated alloys Don’t put used disposable and stock a variety of capsule amalgam capsules in biohazard sizes containers, ninfectious waste Do recycle used disposable container (red bags) or regular amalgam capsules garbage. Do salvage, store and recycle Don’t put non-contact amalgam non-contact amalgam waste in biohazard containers, (scrap amalgam) infectious waste containers (red Do salvage (contact) amalgam bags) or regular garbage pieces from Don’t put contact amalgam waste in restorations after removal biohazard containers, and recycle the amalgam infectious waste containers (red waste bags) or regular garbage Do use chair-side traps, Don’t rinse devices containing vacuum pump filters and amalgam over drains or sinks amalgam separators to retain Don’t dispose of extracted teeth amalgam and recycle their that contain amalgam contents. restorations in biohazard Do recycle teeth that contain containers, infectious waste amalgam restorations. containers (red bags), sharps Do manage amalgam waste containers or regular garbage through recycling as much as Don’t flush amalgam waste down possible the drain or toilet
29. WHO recommendations: duty of care all associated with financing and supporting health-care activities shouldprovide for the costs of managing health- care waste
30. 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.
31. Donors and partners should: • include a provision in their health program assistance to cover the costs of sound healthcare waste management systems.
32. 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.
33. 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.
34. All concerned institutions and organizationsshould: • 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.
35. ..International agreements1. The Basel ConventionThis convention is a global agreement, ratified by some 178member countries to address the problems and challenges posedby 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 soundmanagement” (ESM), the aim of which is to protect humanhealth and the environment by minimizing hazardous wasteproduction whenever possible.2. The Stockholm Convention on Persistent Organic PollutantsThis Convention is a global treaty to protect human health andthe environment from persistent organic pollutants (POPs).
36. ReferencesM. Tsakona, E. Anagnostopoulou, E. Gidarakos, Hospital waste management andtoxicity 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 systemdynamics 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 TaritKanti Biswas, Pattern of medical waste management: existing scenario inDhaka 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)
37. ….ReferencesK. Park, Park’s Textbook of Preventive and Social Medicine, 20th Ed., M/sBanarsidas Bhanot Publishers- Jabalpur (India), 2009World Health Organization, WHO core principles for achieving safe andsustainable management of health-care waste, International Health CareWaste meeting, June 20 - 22, 2007, GenevaA. Prues, E. Giroult, P. Rushbrook (Eds.), Safe Management of Wastes fromHealth-Care Activities, World Health Organization, Geneva (1999)http://www.who.int/topics/medical_waste/enhttp://www.healthcarewaste.org/“Infection Control & Management of Hazardous Materials for Dental Team”Chris H.Miller,Charles John Palenik.American Dental Council Guidelines