09 biomedical waste management


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Case study of TATA Memorial Hospital

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09 biomedical waste management

  1. 1. Disposal of Clinical Wastes: Tata Memorial Hospital Experience Ankit Kumar Surana
  2. 2. “No one was ever really taught. Each has to teach himself.” Swami Vivekananda The Reality • Ignorance • Commercialization of science • Apathy The Concerns • Occupational • Public health • Environmental
  3. 3. • The only documented risk of transmission of infections from waste to healthcare workers is through sharps • There is however a potential for transmission of several microbial infections due to dumping of untreated wastes by healthcare facilities. • Mixing of a small quantity of infectious waste with municipal garbage converts the entire waste to “ infectious” • Segregation of wastes at source followed by appropriate treatment is the key to the success of a waste management strategy The Science
  4. 4. Hospital waste Hazardous Non-hazardous Noninfectious Infectious Kitchen Recyclables Non-sharps Patient contaminated waste Anatomical Equipment Specimens Laboratory waste Non-plastics Sharps: needles, scalpel blades, scalp veins, glass contaminated with blood Radioactive Cytotoxic drugs Toxic Chemicals Plastics PVC, PE PET, PS contaminated cotton waste, gauze, linen
  5. 5. The Social Issue: Ragpickers
  6. 6. The TMH Pathway • Closure of the incinerator • Awareness programs for all the staff • Refashioning the storage area • Street play • Posters
  7. 7. Incinerator circa 1994
  8. 8. Appropriate placement of Colour Coded Bins Radioactive Waste Segregation at source into defined categories using a simplified system. 2. FOCUS ON SEGREGATION FIRST
  10. 10. Waste Audit 4. KEEP FOCUS ON REDUCTION
  11. 11. About Sharps: The only documented transmission of infection from waste to HCWs is through sharp injuries. Thus safe disposal of sharps is the first priority. Sharp injuries: •Before or during use (17%) •After Use but before disposal (70%) •During or after disposal (13%) (Our Experience: Majority of sharp injuries occur due to improper disposal and waste handlers are the victims) Safe Disposal of Sharps: Do not recap needles. If essential learn the right way to do so. 5. ENSURE WORKER SAFETY THROUGH EDUCATION, TRAINING AND PROPER PERSONAL PROTECTIVE EQUIPMENT
  13. 13. Waste management Strategy: 1. Reduce Risks and Liabilities: This should be detailed through written policies and continuing training and education of hospital staff. 2. Control Costs: Audit of current practices, search for waste minimization practices is a continuing process. 3. Plan for Future: Look for alternative technologies, co-operative facilities and means of diversification. 4. Commitment towards protecting Human Health and the Environment 7. DEVELOP PLANS AND POLICIES
  14. 14. Infection Awareness Week Street Play
  16. 16. 10. Evaluation of Technologies
  17. 17. Evaluation of Non Burn Technologies for Medical Waste Treatment
  18. 18. 1. Demonstrated Performance Category Rating Weight Score 1.1 Stage of Development 1.2 Number of Operational Systems 1.3 Year of Successful Operations
  19. 19. 2. Technical & Performance Criteria Category Rating Weight Score 2.1 Process Capacity 2.2 Waste Exclusions or Limitations 2.3 Waste Size Limitations 2.4 Weight Change 2.5 Volume Change 2.6 Recognizability / Disfigurement 2.7 Decontamination 2.8 Performance Data 2.9 Process Complexity 2.10 Operator Training
  20. 20. 3. Vendor Qualifications Category Rating Weight Score 3.1 Number of Vendors 3.2 Vendor Resources 3.3 Vendor Diversity and Services
  21. 21. 4. Environmental & Permitting Issues Category Rating Weight Score 4.1 Air Emissions 4.2 Liquid Effluents 4.3 Treated Residues 4.4 Permit ability 4.5 Public Perception
  22. 22. 5. Occupational Health & Safety Issues Category Rating Weight Score 5.1 Routine Exposures 5.2 Maintenance and Repair Exposures
  23. 23. 6. Facility: & Infrastructural Requirements Category Rating Weight Score 6.1 Space Requirements 6.2 Construction Requirements 6.3 Utility Requirements 6.4 Space / Facility Requirements
  24. 24. 7. Economics Category Rating Weight Score 7.1 Capital Costs 7.2 Annual Costs 7.3 Life-Cycle Costs GRAND TOTAL SCORE
  25. 25. On September 10, 1999, well before the first dead line set by the Ministry of Environment and Forest, 31 December 1999. Inauguration of Tata Memorial Hospital waste treatment facility
  26. 26. Selection of Technology and Implementation is not the setting sun Evaluation is a continuous process
  27. 27. 2000 2001 2002 2003 2004 2005 2006 2007 Max. medical waste collected in a day 341 394 350 362 396 530 429 514 Average no. of loads required/day 5 4 4 4 4 4 4 4 Average medical waste treated in kgs/day 217 224 176 241 250 289 253 277 Average medical waste collected in a month 5,498 5,643 5,266 5,917 6,284 7,225 6,369 6,959 Percentage down time of the system 1.6 5.7 4.8 5.8 8.2 0 10 1.2 TMH Waste Audit Nov. 1999 to Dec. 2007 Total infectious waste treated – 614 tonnes.  83,511 kg. in 2007.  Cost of treatment = Rs. 14.86 / kg.
  28. 28. 2008 2009 Max. medical waste collected in a day 447 505 Average no. of loads required/day 4 4 Average medical waste treated in kgs/day 298 304 Average medical waste collected in a month 7,623 7,674 Percentage down time of the system 0 0.33 TMH Infectious Waste Audit 2008 - 2009 Total infectious waste treated 2000-2009= 800 tonnes. Cost of treatment = Rs. 14 / kg.
  29. 29. TMH Waste Management Waste is Sterilized, Dehumidified, Shredded and reduced in terms of Weight and Volume by 75%. It is not recognizable as Medical Waste
  30. 30. Hazardous Waste
  31. 31. Environment News Greenpeace March 7th, 2001 KODAIKANAL, India -- Greenpeace today accused Anglo-Dutch multinational Unilever, owners of Lipton Tea and Dove soap, of double standards and shameful negligence for allowing its Indian subsidiary, Hindustan Lever, to dump several tonnes of highly toxic mercury waste in the densely populated tourist resort of Kodaikanal and the surrounding protected nature reserve of Pambar Shola, in Tamilnadu, Southern India. On 15 April, 2005, a 51 year-old asbestos laden ship, Kong Fredrick IX was on its way to Alang ship breaking yard, Gujarat for scrapping. The ship's new owners Jupiter Ship Management, a Mumbai based company, had renamed it to 'MV Riky'. Connie Hedegaard, Denmark's environment minister alerted the Indian environment minister saying, "I believe our interests are joint - and I call on you to co-operate in this case by denying the ship to be dismantled in India - and refer the ship to return to Denmark to be stripped of the hazardous waste."
  32. 32. India’s significant economic growth and rise in industrialization coupled by lax government enforcement of anti-pollution laws and regulations have had a detrimental effect on India’s natural environment. Hazardous waste from industrial processes, medical waste and India’s thriving scrap recycling businesses pollutes Indian air, soils and waterways.
  33. 33. India is a signatory to the three conventions on hazardous chemicals and waste: The Basel Convention on the Control of Trans-boundary Movement of Hazardous Waste and their Disposal, The Rotterdam Convention on the Prior Informed Consent Procedure for Certain Hazardous Chemicals and Pesticides in International Trade and The Stockholm Convention of Persistent Organic Pollutants.
  34. 34. The Hazardous Substances Management Division (HSM) of the Ministry of Environment and Forests (MoEF) has the responsibility for promoting safe management and use of hazardous substances, including hazardous waste. The HSM has established three sets of rules: The Hazardous Wastes (Management and Handling) Rules (1989, amended in 2003), The Bio-medial Wastes (Management and Handling) Rules (1998/2000), and The Batteries (Management and Handling) Rules (2001).
  35. 35. The HSM relies primarily on the The Central Pollution Control Board (CPCB), The State Pollution Control Boards (SPCBs) or State Pollution Control Committees (SPCCs), and The environmental departments in India’s 25 states to implement, monitor and prosecute.
  36. 36. Approximately 5 million tonnes of hazardous waste is produced annually in India. According to a 2003 report, Indian industries in the following five states had generated over 80% of the country’s hazardous waste: Andhra Pradesh, Gujarat, Karnataka, Maharashtra and Tamil Nadu.
  37. 37. Landfill Composting Incineration Recycling Transportation Air Emission of CH4, CO2; odours Emission of CH4, CO2; odours Emission of SO2, NOx, HCl, HF, NMVOC, CO, CO2 N2O, dioxins, dibenzofurans, heavy metals(Zn, Pb, Cu, As) Emissions of dust Emissions of dust NOx, SO2, release of hazardous substances from accidental spills Water Leaching of salts, heavy metals, biodegradable and persistent organics to groundwater Deposition of hazardous substances on surface water Waste water discharges Risk of surface water and groundwater contamination from accidental spills Soil Accumulation of hazardous substances in soil Landfilling of slags, fly ash and scrap Landfilling of final residues Risk of soil contamination from accidental spills European Commission focus on waste management Pitfalls of the currently available technologies for managing wastes
  38. 38. Landfill Composting Incineration Recycling Transportation Landscape Soil occupancy; restriction on other land uses Soil occupancy; restriction on other land uses Visual intrusion; restriction on other land uses Visual intrusion Traffic Ecosystems Contamination and accumulation of toxic substances in the food chain Contamination and accumulation of toxic substances in the food chain Contamination and accumulation of toxic substances in the food chain Risk of contamination from accidental spills Urban areas Exposure to hazardous substances Exposure to hazardous substances Noise Risk of exposure to hazardous substances from accidental spills; traffic European Commission focus on waste management Pitfalls of the currently available technologies for managing wastes
  39. 39. E-waste How green is your Apple? Aug 25th 2006 From The Economist print edition
  40. 40. God proposes, man disposes Waste and taste Dec 11th 2006 From Economist.com The rubbish tip as cultural artefact FRESH Kills landfill in New York, until recently the biggest rubbish tip on earth, was said to be one of the very few man- made objects visible from space, along with the Great Wall of China.
  41. 41. LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS Class A Concentration limit: 50 mg/kg A1 Antimony and antimony compounds A2 Arsenic and arsenic compounds A3 beryllium and cadmium compounds A4 Cadmium and beryllium compounds A5 Chromium (VI) compounds A6 Mercury and mercury compounds A7 Selenium and selenium compounds A8 Tellurium and tellurium compounds A9 Thallium and thallium compounds A10 Inorganic cyanide compounds (cyanides) A11 Metal carbonyls A12 Napthalene A13 Anthracene A14 Phenanthrene A15 Chrysene, benzo(a) anthracene, fluoranthene, benzo(a) pyrene, benzo(K)fluoranthene, indeno(1, 2, 3-ed) pyrene and benzo(ghi)perylene A16 Halogenated fused aromatic rings, e.g. polychlorobiphenyls plus derivatives A17 Halogenated aromatic compounds A18 Benzene A19 Dieldrin, aldrin, and endrin A20 Organotin compounds Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002
  42. 42. LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002 Class B Concentration limit: 5,000 mg/kg B1 Chromium (III) compounds B2 Cobalt compounds B3 Copper compounds B4 Lead and lead compounds B5 Molybdenum compounds B6 Nickel compounds B7 Tin compounds B8 Vanadium compounds B9 Tungsten compounds B10 Silver compounds B11 Organic halogen compounds B12 Organic phosphorus compounds B13 Organic peroxides B14 Organic nitro-and nitroso-compounds B15 Organic azo-and azo-oxy compounds B16 Nitriles B17 Amines B18 (Iso-and thio-) cyanates B19 Phenol and phenolic compounds B20 Merceptans B21 Asbestos B22 Drilling, cutting, grinding and rolling oil or emulsions thereof B23 Halogen-silanes B24 Hydrazine(s) B25 Fluorine B26 Chlorine B27 Bromine B28 White phosphorus B29 Ferro-silicon and alloys B30 Manganese-silicon B31 Halogen-containing substances which produce acidic vapours on contact with damp air or water, e.g. silicon tetrachloride,
  43. 43. LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002 Class C Concentration limit: 20,000 mg/kg C1 Ammonia and ammonium compounds C2 Inorganic peroxides C3 Barium compounds, except barium sulphate C4 Fluorine compounds C5 Phosphorus compounds, except the phosphates of aluminum, calcium and iron C6 Bromates, (hypo)bromites C7 Chlorates, (hypo)chlorites C8 Aromatic compounds C9 Organic silicon compounds C10 Organic sulphur compounds C11 Iodates C12 Nitrates, nitrites C13 Sulphides C14 Zinc compounds C15 Salts of per-acids C16 Acid halides, acid amides C17 Acid anhydrides
  44. 44. LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002 Class D Concentration limit: 50,000 mg/kg D1 Sulphur D2 Inorganic acids D3 Metal bisulphates D4 Oxides and hydroxides except those of: hydrogen, carbon, silicon, iron, aluminum, titanium, manganese, magnesium, calcium D5 Aliphatic and napthenic hydrocarbons D6 Organic oxygen compounds D7 Organic nitrogen compounds D8 Nitrides D9 Hydrides
  45. 45. LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002Class E Regardless of concentration limit E.1 Highly flammable substances E.2 Substances which generate dangerous quantities of highly flammbale gases on contact with water or damp air.
  46. 46. LIST OF PROCESSES GENERATING HAZARDOUS WASTES Ministry of Environment & Forests Hazardous Wastes (Management and Handling) Amendment Rules, 2003 1 Petrochemical processes and pyrolytic operations 2 Drilling operation for oil and gas production 3 Cleaning, emptying and maintenance of petroleum oil storage tanks including ships 4 Petroleum refining/re-refining of used oil/recycling of waste oil 5 Industrial operations using mineral/synthetic oil as lubricant in hydraulic systems or other applications 6 Secondary production and/or use of zinc 7 Primary production of zinc/lead/copper and other non-ferrous metals except aluminium 8 Secondary production of copper 9 Secondary production of lead 10 Production and/or use of cadmium and arsenic and their compounds 11 Production of primary and secondary aluminium
  47. 47. LIST OF PROCESSES GENERATING HAZARDOUS WASTES Ministry of Environment & Forests Hazardous Wastes (Management and Handling) Amendment Rules, 2003 12 Metal surface treatment, such as etching, staining, polishing, galvanising, cleaning, degreasing, plating, etc. 13 Production of iron and steel including other ferrous alloys (electric furnaces; steel rolling and finishing mills; Coke oven and by product plant) 14 Hardening of steel 15 Production of asbestos or asbestos-containing materials 16 Production of caustic soda and chlorine 17 Production of acids 18 Production of nitrogenous and complex fertilizers 19 Production of phenol 20 Production and/or industrial use of solvents 21 Production and/or industrial use of paints, pigments, lacquers, varnishes, plastics and inks 22 Production of plastic raw materials
  48. 48. LIST OF PROCESSES GENERATING HAZARDOUS WASTES Ministry of Environment & Forests Hazardous Wastes (Management and Handling) Amendment Rules, 2003 23 Production and/or industrial use of glues, cements, adhesive and resins 24 Production of canvas and textiles 25 Industrial production and formulation of wood preservatives 26 Production or industrial use of synthetic dyes, dye-intermediates and pigments 27 Production or industrial use of materials made with organo-silicone compounds 28 Production/formulation of drugs/ pharmaceuticals 29 Production, use and formulation of pesticides including stock-piles 30 Leather tanneries 31 Electronic Industry 32 Pulp & Paper Industry 33 Disposal of barrels / containers used for handling of hazardous wastes / chemicals 34 Purification processes for air and water 35 Purification process for organic compounds/solvents Waste treatment processes, e.g. incineration, distillation, separation and concentration
  49. 49. REPORT ON CLINICAL WASTE AUDIT 2005 Infectious waste treated from Jan-Dec 2005 86,704 Kilograms Average waste treated per month 7,225 Kilograms Weight of sharps treated in 2005 2,917 Kilograms Average weight of sharps treated per month 243 Kilograms Blood & blood products 300 liters Liquid Wastes: Total effluent per month 164 lakh litres Laundry effluent per month 3 lakh litres X’ray developer per month 140 litres Hazardous liquids consumed in labs per month 588 litres Hazardous chemicals as solids weight per month 260 grams Dilution factor of hazardous liquids 27,333.
  50. 50. Hazardous liquid waste / month: Sr. No Chemicals / Reagents Lits. 1 10% Formalin 100 2 Xylene 190.1 3 Basic fuchsin 1.17 4 Haematoxylin stain 1.0 5 Nitric Acid 50.5 6 Anhydrous Aluminum Chloride .005 7 Hydrochloric acid .800 8 Diamino benzidine 20.0 9 Hydrogen peroxide 53.202 10 Glacial acetic acid 5.225 11 Gluteraldehyde 150.500 12 Ethidium bromide .001 13 Propane / Butane 2.500 14 WD40 (Petroleum distillate) 2.00 15 Benzoin tincture 10.00 16 Lugol’s Iodine 0.42 17 Phenol (carbolic acid) 1.000 18 Ammonia solution .050 19 Lactic acid .045 20 Sulfuric acid .100 Total 588.19
  51. 51. Hazardous solid waste / month: Sr. No Chemicals / Reagents Weight (Grams) 1 Benzidine dihydrochloride 0.5 2 Naphthol phosphate .060 3 Pararosaline hydrochloride 1.0 4 Sodium-fluoride .200 5 Potassium dihydrogen phosphate 8.500 6 Dipotassium hydrogen phosphate 8.500 7 Benzidine G.R. 1.0 8 Zine sulphate 16.5 9 Barium chloride 13.00 10 Phenol crystals 40.00 11 Naphthylamine 16.50 12 Naphthol 16.50 13 Sodium-polyanethol sulphonat 45.00 14 Sodium hydroxide pellet 45.00 15 Sulfonilic acid 45.00 16 Trichloroacetic acid 2.1 Total 259.36
  52. 52. In Conclusion: Key Issues • Awareness and education • Reporting systems & documentation • Segregation of identified clinical infectious wastes at source • Timely treatment by non-polluting technologies on-site or off-site • Waste audit • Waste monitoring systems • Elevation of safety standards by all healthcare facilities • All HCWs must have “hygiene in their genes”.
  53. 53. “ Men occasionally stumble over the truth but most of them pick themselves up and hurry off as if nothing has happened.” - Sir Winston Churchill.
  54. 54. Thank You