Hello. I am Kripa Thapa Magar, Public Health Professional. This slide was prepared to train CMAs and health assistant on HCWM by compiling information from different resources.

1. Health Care Waste
Management
Kripa Thapa Magar

2. Training content
• Standard of health institution in sanitation
• Health care waste management
• General waste management
• Sanitation

3. Presentation outline
• Regulations and standard
• Organizational bodies
• Health care waste introduction
• Health care waste management
• Waste management in the context of COVID-19

4. Expected outcome
• Regulations and standard underlying HCWM
• Risks of improper HCWM to understand the
importance of proper HCWM
• Waste segregation
• Waste treatment methods according to the type
of waste in low resource setting context
• Sharps waste management

5. Regulations and Standard
• Constitution of Nepal, 2072
• National Health Policy, 2076
• Public Health Service Act, 2075
• Solid Waste Management Act,
2068
• Local Level Health Program
Implementation Guideline
• 15th Five Year Development Plan
(2019/20-2023/24)
• National Health Sector Strategy
Implementation Plan 2016-2021
• Guideline for Health Institutions
Establishment, Operation and
Upgrade Standard, 2071
• Minimum Service Standard
• Health Care Waste Management
Guideline 2014

6. नेपालको संविधान, २०७२
३०. स्वच्छ वातावरणको हकः
१. प्रत्येक नागररकलाई स्वच्छ र स्वस्थ वातावरणमा बााँच्न पाउनने हक हुनेछ ।
२. वातावरणीय प्रदूषण वा ह्रासबाट हुने क्षततबापत पीडितलाई प्रदूषकबाट कानून
बमोजिम क्षततपूतति पाउनने हक हुनेछ ।
३. राष्ट्रको ववकास सम्बन्धी कायिमा वातावरण र ववकासबीच समुचचत
सन्तुलनका लाचग आवश्यक कानूनी व्यवस्था गनि यस धाराले बाधा
पुर्याएको मातनने छैन ।

7. Contd…
३५. स्वास््य सम्बन्धी हकः
१. प्रत्येक नागररकलाई राज्यबाट आधारभूत स्वास््य सेवा तनःशुल्क प्राप्त गने
हक हुनेछ र कसैलाई पतन आकजस्मक स्वास््य सेवाबाट वजचचत गररने छैन ।
२. प्रत्येक व्यजततलाई आफ्नो स्वास््य उनपचारको सम्बन्धमा िानकारी पाउनने हक
हुनेछ ।
३. प्रत्येक नागररकलाई स्वास््य सेवामा समान पहुाँचको हक हुनेछ ।
४. प्रत्येक नागररकलार्ि स्वच्छ खानेपानी तथा सरसफार्िमा पहुाँचको हक हुनेछ ।

8. राष्ट्रिय स्िास््य नीति २०७६
६.११ सरूिा रोग, ककटजन्य रोग, पशुपन्छीजन्य रोग, जलिायु
पररिितन र अन्य रोग िथा महामारी तनयन्रण लगायि विपद्
व्यिस्थापन पूितियारी िथा प्रतिकायतको एकीकृ ि उपायहरू
अिलम्बन गररनेछ ।
६.११.४ िािािरण र स्िास््यमैरी प्रविधधलार्त प्रोत्साहन गर्दै
प्रर्देश िथा स्थानीय िहलार्त समेि ष्ट्जम्मेिार बनार्त अस्पताल
तथा अन्य स्वास््य संस्थाहरू एवं प्रयोगशालाबाट उनत्सजिित
फोहोर र औषधीिन्य फोहोरको उनचचत व्यवस्थापनको लाधग
तनयमनका साथै तनरन्िर अनुगमन गररनेछ ।

9. Contd…
६.२४ प्रति जैविक प्रतिरोधलार्त न्यूनीकरण गर्दै संक्रामक रोग
तनयन्रण िथा व्यिस्थापनका लाधग एकर्दार स्िास््य पध्र्दतिको
विकास िथा विस्िार गररनुका साथै िायु प्रर्दूषण, ध्ितन प्रर्दूषण,
जल प्रर्दूषण लगायिाका िाििरणीय प्रर्दूषणका साथै खाधान्न
प्रर्दूषणलार्त िैज्ञातनक ढंगले तनयमन िथा तनयन्रण गररनेछ ।
६.२४.१. िायु प्रर्दूषण, ध्ितन प्रर्दूषण, जल प्रर्दूषण, रासायतनक
प्रर्दूषण लगायिका िािािरणीय प्रर्दूषणबाट जनस्िास््यमा पनत
सक्ने असर न्यूनीकरणका लाधग सम्बष्ट्न्धि तनकायसँग सहकायत
गर्दै ठोस िैज्ञातनक योजना िथा कायतक्रमहरूको विकास गरी लागू
गररनेछ ।

10. जनस्िास््य सेिा ऐन, २०७५

11. फोहरमैला व्यिस्थापन ऐन, २०६८
४. फोहरमैला व्यिस्थापन गने र्दातयत्िः
(१) यस ऐन बमोष्ट्जम फोहरमैला व्यवस्थापन गने गराउनने दातयत्व स्थानीय तनकायको
हुनेछ ।
(२) उपर्दफा (१) मा जुनसुक
ै क
ु रा लेखखएको भए िापतन हातनकारक फोहरमैला, स्िास््य
संस्थाजन्य फोहरमैला, रासायतनक फोहरमैला िा औधोधगक फोहरमैला प्रशोधन र
व्यवस्थापन गने दातयत्व तनधािररत मापदण्िको अधीनमा रही त्यस्तो फोहरमैला उनत्पादन
गने व्यजतत वा तनकायको हुनेछ ।
(३) क
ु नै उधोग िा स्िास््य संस्थाले हातनकारक फोहरमैला, स्िास््य संस्थाजन्य
फोहरमैला, रासायतनक फोहरमैला िथा औधोधगक फोहरमैला प्रशोधन गरी बाँकी रहेको
फोहरमैला िथा अन्य फोहरमैलाको व्यिस्थापन गररदर्दन स्थानीय तनकायलार्त अनुरोध
गरेमा िा स्थानीय तनकायले तनमातण गरेको फोहरमैला व्यिस्थापन स्थल प्रयोग गनत
माग गरेमा स्थानीय तनकायले तनधातरण गरे बमोष्ट्जमको सेिा शुल्क ललर्त फोहरमैलाको
व्यिस्थापन गररदर्दन िा फोहरमैला व्यिस्थापन स्थल प्रयोग गनत दर्दन सक्नेछ ।

12. फोहोरमैला व्यवस्थापन ऐन, २०६८
दफा ३८ कसुर
फोहोरमैला व्यवस्थापन ऐन, २०६८
दफा ३९ सिाय

13. स्थानीय िहमा स्िास््य कायतक्रम सञ्चालनका
लाधग मागतर्दशतन
खण्ड गः कायतक्रम सञ्चालन प्रकक्रया
८. स्िास््य सेिा व्यिस्थापन कायतक्रम
८.१ स्वास््य चौकीस्तरमा स्िास््य संस्थाजन्य फोहरमैला व्यिस्थापनमा एिं
गुणस्िर सुधार सहयोग कायतक्रम
८.४ जिल्लास्तरका अस्पतालहरूको सेिा सुढृढीकरण
कक्रयाकलापः
३. अस्पिाल िथा अस्पिाल पररसरको सरसफार्तका लाधग ज्याला खचत
५. अस्पिालजन्य फोहर मैला व्यिस्थापन िथा संक्रमण रोकथाम
८.५ प्राथममक स्वास््य क
े न्रहरूको सेिा सुढृढीकरण
कक्रयाकलापः
३. स्िास््य संस्था जन्य फोहोर मैला व्यिस्थापन िथा संक्रमण रोकथाम

14. 15th Five Year Development Plan
Strategy 6: Management and regulation of cooperation and
collaboration between public-private and non-government
sector
Action Plan 6: Regulatory mechanism will be developed
and province and local government will be made
responsible for management of health care waste.

15. National Health Sector Strategy
Implementation Plan 2016-2021
Outcome 2 Improved quality of care at point-of-delivery
Output 3 Improved infection prevention and health care
waste management

16. स्वास््य संस्था स्थापना, संचालन तथा स्तरोन्नतत मापदण्ड सम्बन्धी तनदेतिका, २०७०
१६. अस्पतालको पूवािधार सम्बन्धी मापदण्िहरूः (१) अस्पतालले सेवा सचचालन
गदाि देहाय बमजिमको पूवािधार सम्बन्धी मापदण्ि पूरा गरेको हुनु पनेछः
(क) अस्पताल रहने स्थान धुाँवा, धुलो, ध्वतन, िल तथा िममन प्रदुषणबाट मुतत
भएको ।
(छ) िोखखमपूणि फोहर व्यवस्थापनका लाचग उनपयुतत प्रववचधको व्यवस्था गनुिका
साथै फोहरमैला व्यवस्थापन ऐन, २०६८ र फोहरमैला व्यवस्थापन तनयमावली,
२०७० बमोजिम फोहर व्यवस्थापनका लाचग आवश्यक पूवािधार व्यवस्था
ममलाएको ।

18. (१६) फोहरमैला व्यिस्थापनका लाधग र्देहाय बमोष्ट्जमको पूिातधार मापर्दण्ड पूरा
गरेको हुनु पनेछः

19. न्यूनिम सेिा मापर्दण्ड
स्िास्थय चौकी
स्िास््यजन्य फोहोर व्यिस्थापन चेकललस्ट सरसफार्त चेकललस्ट

20. Health Care Waste Management
Guideline, 2014

21. Organizational bodies
Central level
DoHS  Management Division  Environmental
Health and Health Care Waste Management
Section
Provincial level
Provincial Health Directorate  Curative Service
and Disease Control Section

22. Health Care Waste (HCW) Introduction
The term health care waste includes
- all the waste generated within health care facilities
(HCF), research centers and laboratories
- related to medical procedures
In addition, it includes
- the same types of waste originating from minor and
scattered sources,
- including waste produced in the course of health care
undertaken in the home
- (e.g. home dialysis, self-administration of insulin)
- WHO, 2014

23. Sources of HCW
• Hospitals
• Primary Health Care Centers,
Health Post, Sub Health Post,
Immunization (EPI clinic), Primary
Health Care Outreach Clinic
(PHC/ORC)
• Clinics
• Laboratories and research centers
• Pharmacy and medical store
• Mortuary house
• Ambulance and emergency care
• Animal research
• Blood banks
• Home health care
• Quarantine and Isolation Centres

24. Categories of HCWs
Waste Categories Descriptions and Examples
Hazardous health care waste
Infectious waste
Waste contaminated with blood and other body fluids, such as
laboratory cultures, , blood bag, gauze contaminated with blood etc
Sharps waste
Used or unused sharps, e.g. needles, auto-disable syringes, syringes
with attached needles, infusion sets, scalpels, pipettes, knives, blades,
broken glass
Pathological waste Human tissues, organs, fluids, body parts, fetus, unused blood products
Pharmaceutical
waste, cytotoxic
waste
Pharmaceuticals that are expired or no longer needed, items
contaminated by or containing pharmaceuticals.
Cytotoxic waste containing substances with genotoxic properties, e.g.
waste containing cytostatic drug (often used in cancer therapy)

25. Categories of HCWs
Chemical waste
Waste containing chemical substances, e.g. laboratory reagents, film
developer, disinfectant that are expired or no longer needed, solvents,
waste with high content of heavy metals, e.g. batteries, broken
thermometer, blood pressure gauge
Radioactive waste
Waste containing radioactive substances, e.g. unused liquids from
radiotherapy or laboratory research, contaminated glassware,
packages or absorbent paper, urine and excreta from patients treated
or tested with unsealed radio nuclides, sealed sources
Non-hazardous or general health care waste
Waste that does not pose any specific biological, chemical,
radioactive or physical hazard
- WHO

26. Health Care
Waste
General Waste
Biodegrad
able
Non
biodegradable
Recyclable
Non-
recyclable
Hazardous
waste
Infectiou
s Sharps
Pathologi
cal
Pharmaceutical,
Cytotoxic
Chemical Radioacti
ve

27. Typical Waste Composition in HCFs
- WHO

28. Persons at risk
Waste
handler,
Cleaner
Health
worker
Patient &
Patient
parties
Community, rag
pickers,
Municipal
worker

29. Risk due to HCW
Harmful
characteristics of waste
Effects
Infectious agents
Disease infection such as AIDS, Hep B, Hep
C, cholera, Typhoid etc.
Sharps Injuries and infection
Chemical
Burning sensation, Headache, Poisoning,
dermatitis, conjunctivitis
Pharmaceutical Microbial drug resistance
Cytotoxic/Radioactive
chemical composition
Immediate - Headache, Vertigo, Nausea,
Vomiting
Chronic - Genetic mutation, Birth defect,
Cancer
As there is high risk of
transmission of infection due to
needle price injury, needle is the
most hazardous waste.

30. Health Care Waste Management
Health care waste management is a process that
ensures proper handling and disposal of health
care waste in a safe way.
Safe HCWM covers three aspects:
1. Unnecessary waste minimization
2. General and risk waste segregation
3. Waste treatment and disposal

31. Process of HCWM
1. Waste Minimization
2. Waste Segregation
3. Waste Collection and Interim Storage
4. Waste Transportation
5. Waste Central Storage
6. Waste Treatment and Disposal

32. Waste Management Hierarchy
Minimization
Reuse
Recycle
Recover
Treatme
nt and
disposal
Most preferable
Least preferable

33. Waste Minimization
It is the most preferred method
Approaches:
▫ Source reduction
▫ Waste segregation
▫ Reverse logistics
▫ Safe reuse
▫ Recyclable products to vendor

34. Waste segregation
Segregation of waste at source is the key principle of
successful and safe waste minimization and is the most
important step for a successful management of HCW
Basic three-bin system

35. Before After
36
Segregation reduces the quantity of hazardous waste.
Waste handling, treatment and disposal methods depends upon
the types of waste. Only the proper segregation can ensure that.

36. General considerations on segregation
• Correct segregation is the responsibility of the waste
generator regardless of the position.
• Waste should be clearly identified into the different
categories with proper color and labeling
• Segregation must be done at the point of generation
of the waste
• Risk waste bin should not be placed where patient
parties can have easy access. Also the segregation
point for risk and non risk waste should be separate.
• Once general waste is mixed with risk waste, all of it
is considered as risk waste

37. Color Coding Bin System - HCWMG 2014
Waste category and
labeling
Color Code Type of waste Symbol
Non-
risk
waste
Bio-degradable Green
Leftover food stuffs, gardens,
fruits peels, flowers etc.
Recyclable
waste
Dark Blue
Plastic bottles, cans, metals,
plastics, cardboard, rubber,
saline bottle
Non-
biodegradable
and non-
recyclable waste
Light blue
Other non-risk, non-
biodegradable, non-recyclable
waste such as dust

38. Waste category
and labeling
Color
Code
Type of waste Symbol
HCW
requiring
special
attention
Pathological
waste
Red
Human body parts, organs, human tissues,
removed organs, amputated parts, bone
marrow
Sharps Red
Needles, glass syringes with fixed
needles, scalpels, blades, glass, etc. which
may cause puncture and cuts.
Pharmaceuti
cals
Red Unused and date expired drugs
Cytotoxic Red
Waste with anti-neoplastic effect such as:
alkylated substances, anti-metabolites,
antibiotics, plant alkaloids, hormones, etc.

39. Waste category and
labeling
Color
Code
Type of waste Symbol
Infectious
and
Highly
infectious
Infectious Brown
Items contaminated with blood and
body fluids from patients such as
cotton, dressing material, soiled
plaster, linen, gloves, bandages etc.
Highly
infectious
Brown
Waste generated from the
microbiological cultures, laboratory
waste, such as sputum cultures of TB
laboratories, highly concentrated
microbiological cultures
Other
hazardous
waste
Yellow
Waste with high content of heavy
metals such as batteries, pressurized
container
Radioactive
waste
Black
Waste contaminated with radionuclides
such as Cobalt, Technetium, Iodine,
Iridium

40. Color Coding Bin System - WHO 2017
Waste categories Color of bin
Infectious waste Yellow
Sharps waste Yellow
Pathological waste Yellow
Chemical and pharmaceutical waste Brown
Radioactive waste -
General HCWs Black

41. Since categorization of the waste entirely depends on
the types of the waste generated, available
technology for the treatment and disposal, and the
local environmental conditions of HCFs. If possible,
HCFs should categorize and segregate the HCWs as
mentioned above. However, it is recommended that
HCFs should at least categorize and segregate the
HCWs into non-risk HCW and risk HCW.
If the container with the recommended color is not
available, any colored container can be used to
segregate wastes with proper labeling and hazardous
sign
- HCWM Guideline 2014

42. Color coding bins with proper labeling
Redesign of dressing trolley for point segregation

43. Waste Collection
• Waste must be collected regularly – at least once a day
• When waste bags/containers are 3/4th full they should
be sealed and removed.
Interim Storage
If the containers are 3/4th full before the collection time,
then it should be temporarily stored in a safe place, away
from people reach until the waste collector arrives and
transports the waste to the designated area. Such storage
practice is known as interim storage.

44. Waste Transportation
Onsite transportation
• Should take place whenever possible during less
busy times
• Hazardous and non-hazardous waste should
always be transported separately.
• All waste bags seals should be in place and intact
at the end of transportation
• Should be transported by using wheeled trolleys
or carts that are not used for any other purpose

45. Waste Storage (Central)
Different types of waste are brought for safe
retention until it is treated or collected for
transport offsite.
Capacity of store area should be three times the
daily accumulation of waste.
Storage times for infectious waste:
Temperate climate: 72 hours in winter and 48
hours in summer
Warm climate: 48 hours during the cool season
and 24 hours during the hot season

46. Waste Treatment
The purpose of treatment is to reduce the potential hazard
posed by health-care waste, while endeavoring to protect
the environment
The choice of treatment depends on:
• Waste characteristics , types and quantity
• Capability of HCF - cost, resources, area
• Available resources
• Public acceptability
• Environmental and safety factors
• Options available for final disposal
• Relevant national regulations and requirements
The method must be selected with a view to minimizing negative
impacts on health and environment.
There is no UNIVERSAL SOLUTION for waste treatment.
Local level implementation
guideline has recommended
autoclave for waste treatment

47. Waste Treatment Methods
1. Autoclaving
2. Incineration
3. Placenta pit
4. Encapsulation
5. Inertization
Less desirable
• Burning
• Deep burial
• Chemical disinfection

48. Autoclave
• Steam sterilization under pressure
• Operation – 121°C and pressure of 15 pounds per
square inch (psi) for 30 minute
• Mostly suitable for highly infectious waste,
sharps.
• Not suitable for waste containing solvents or
substances that may emit toxic flumes, bleach,
radioactive materials, combustible, flammable
or volatile liquid

49. Incineration
• High temperature (850 °C to 1100 °C) dry
oxidation process
• Following waste should never be incinerated:
▫ Pressurized gas containers
▫ Radioactive waste
▫ Halogenated plastics (PVC)
▫ Mercury or cadmium
▫ Ampoules of heavy metals
▫ Reactive chemical waste

50. Placenta pit
• Suitable for placenta and other pathological
waste
• Should be impermeable
• Should not be prone to flooding or erosion
• A safety distance of at least 1.5 m from the
bottom of the pit to the ground water level is
recommended
• Waste should not be treated with chemical
disinfectants

51. 1. Pit
2. Slab
3. Lid
4. Base or lining
5. Permeable soil
6. Drainage channel
7. Mortar layer (at least
10 mm thick)
8. Ventilation pipe
9. Tee with mosquito
netting
10. Water bottle

52. Encapsulation
• Process of filling containers with waste, adding
an immobilizing materials and sealing the
containers
• Mostly suitable for sharps and pharmaceutical
waste

53. Procedure:
• The containers or boxes should be three quarters filled with waste and then filled up
with a medium such as plastic foam, bituminous sand, cement mortar or clay
material
• The containers should be made of high-density polyethylene or metallic drums
• Drums should not have contained explosive or hazardous materials previously.

54. Inertization
• Involves mixing waste with cement and other
substances before disposal
• Applicable for pharmaceuticals and incinerated
ash with heavy metal content
• Waste is mixed with cement and other
substances in a composition of 65% waste, 15%
lime, 15% cement and 5% water

55. Interim treatment approaches and
emergency situations
Burning
1. Small medical waste incinerators, such as single
chamber, drum and brick incinerators
2. Burning of HCW in a pit (followed by covering
with a layer of soil)
These are less desirable, but it is genuinely the only
realistic option in an emergency and in low
resource settings.
As far as possible, the burning of PVC plastics and
other chlorinated waste should be avoided to
prevent the generation of dioxins and furans.

56. Dioxins and furans are generated by the combustion of health-
care waste which contains chlorine. Dioxins and furans are bio-
accumulative and are highly toxic. They can cause reproductive
and developmental problems, damage the immune system,
interfere with hormones and also cause cancer. One source of
chlorine in health-care waste is the plastic polyvinylchloride
(PVC) in medical devices. For example, gloves or blood bags
can consist of PVC. Therefore, the purchase of PVC-free
devices is recommended.
- WHO, 2017

57. Deep Burial
• Not advisable. Only recommended in the conditions
when other methods are not applicable
• Area should not be prone to flooding or erosion
• Should be relatively impermeable and no shallow well
should be close to the site
• The bottom of the pit should be at least 2 m above the
ground water
• Inside the pit, alternating layers of waste, covered with
10 cm of soil should be placed
• When the pit is within about 50 cm of the ground
surface, the waste should be covered with lime before
filling the rest of the pit with soil and sealed permanently
• An earth mound around the mouth of the pit should be
constructed to prevent water from entering

59. Chemical disinfection
• Mostly applicable for infectious waste
• Local level implementation guideline has
recommended chlorine solution, phenyl
• Chlorine use – 0.5% chlorine solution for at least
30 minutes

60. Treatment methods based on type of waste
Waste
category
Two
chambers
incineratio
n
Single
chamber
incineratio
n
Autoc
lave
Chemical
disinfectio
n
Sanitary landfill
Infectious Yes Yes Yes Yes
Yes (pretreatment
for highly
infectious)
Pathologic
al
Yes
Yes No No No
Sharps Yes Yes Yes Yes
Yes for small
quantities with
encapsulation
Pharmace
utical
Small amount
only
No No No
Yes for small
quantities with
encapsulation
/inertization

61. Sharp Waste Management
Do’s Don’ts
Use needle cutter Don’t recap sharps
Separate sharps from
other waste
Don’t bend or
manipulate needles
Use rigid puncture
proof disposal bin
Don’t remove needle
from disposable
syringes
Empty sharps bin when
they are 3/4th full
Don’t press down
sharps to make room in
sharp bin Locate needle cutter near
the point of generation

62. स्थानीय िहमा स्िास््य कायतक्रम सञ्चालनका
लाधग मागतर्दशतन

63. Waste Management in Context of
COVID-19

64. Waste Type
Treatment/Dispos
al
General Non-
biodegradable
waste
Paper, Clothes,
Material
Autoclave/Burial/7 days
storage/Incineration
Plastic
Autoclave/Burial/7 days
storage
Biodegradable
waste
Burial
Pathological
waste
Placenta, tumour Placenta pit

65. Sharp waste
Needle
Autoclave/0.5% chlorine then
encapsulation (Needle cut
compulsory)
Scapel, glasses
Autoclave/0.5% chlorine then
encapsulation
Infectious
waste
Cotton, gauge,
blood bag,
Autoclave/Burial
PPE
Reusable
Cleaning with soap and water then
autoclave/0.5% chlorine for 10
min then cleaning with water &
sun dry
Disposable
Autoclave/0.5% chlorine for 10
min then cleaning with water &
sun dry
Waste Type Treatment/Disposal

66. References
• Solid Waste Management Act 2068, GoN
• Health Care Waste Management Guideline 2014, DoHS, MoHP, GoN
• Local Level Health Program Implementation Guideline 2074/75, MoHP,
GoN
• Health Care Waste Management in the context of COVID-19 Emergency
(Interim Guidance) 2020, MoHP, GoN
• Safe Management of Wastes from Health Care Activities 2014, WHO
• Safe Management of Wastes from Health Care Activities 2017, WHO
• Medical Waste Management 2011, ICRC

67. Our Waste, Our Responsibility
हाम्रो फोहोर, हाम्रो जिम्मेवारी
THANK YOU