Clinical Waste Management


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Clinical Waste Management

  2. 2. CLINICAL WASTE MANAGEMENT Page 2 ABSTRACT- The management of clinical solid waste (CSW) continues to be a major challenge, particularly in most healthcare facilities of the developing world. Poor conduct and inappropriate disposal methods exercised during handling and disposal of CSW is increasing significant health hazards and environmental pollution due to the infectious nature of the waste. Numerous researches have been conducted on the management of CSW. Although, significant steps have been taken on matters related to safe handling and disposal of the clinical waste, but improper management practice is evident from the point of initial collection to the final disposal. In most cases, the main reasons of the mismanagement of CSW are the lack of appropriate legislation, lack of specialized clinical staffs, lack of awareness and effective control. Furthermore, most of the healthcare centers of the developing world have faced financial difficulties and therefore looking for cost effective disposal methods of clinical waste. Emphasis is on the priority to inactivate the infectious micro-organisms in CSW. In that case, waste would not pose any threat to healthcare workers. This paper includes the study of clinical solid waste. The paper includes the information about the various study required for the CSW management, such as sources of waste, classification of waste, risk involved in the handling of the waste, definition of waste , generation of CSW, various disposal methods of CSW, microorganisms involved in the CSW, case study etc.
  3. 3. CLINICAL WASTE MANAGEMENT Page 3 INDEX- Sr no. Description Page no Remark 1 Introduction 4 2 Definition 5 3 Components 6 4 Sources 6 5 Classification of clinical waste 7 6 Risk involved in clinical waste 8 7 Generation of clinical waste 9 8 Handling & Transportation of clinical waste 11 9 Storage of clinical waste 13 10 Treatment of Clinical waste 15-20 11 Case study 21-27 12 References 28
  4. 4. CLINICAL WASTE MANAGEMENT Page 4 INTRODUCTION- Medical care is vital for our life, health and well being. But the waste generated from medical activities can be hazardous, toxic because of their high potential for diseases transmission. The hazardous and toxic parts of waste from health care establishments comprising infectious, bio- medical and radio-active material as well as sharps (hypodermic needles, knives, scalpels etc.) constitute a grave risk, if these are not properly treated/disposed or is allowed to get mixed with other municipal waste. Its propensity to encourage growth of various pathogen and vectors and its ability to contaminate other nonhazardous/non-toxic municipal waste jeopardises the efforts undertaken for overall municipal waste management. The rag pickers and waste workers are often worst affected, because unknowingly or unwittingly, they rummage through all kinds of poisonous material while trying to salvage items which they can sell for reuse. At the same time, this kind of illegal and unethical reuse can be extremely dangerous and even fatal. Diseases like cholera, plague, tuberculosis, hepatitis (especially HBV), AIDS (HIV), diphtheria etc. in either epidemic or even endemic form, pose grave public health risks. With a judicious planning and management, however, the risk can be considerably reduced. Studies have shown that about three fourth of the total waste generated in health care establishments is non-hazardous and non- toxic. Some estimates put the infectious waste at 15% and other hazardous waste at 5%. Therefore with a rigorous regime of segregation at source, the problem can be reduced proportionately. Similarly, with better planning and management, not only the waste generation is reduced, but overall expenditure on waste management can be controlled. Institutional/Organisational set up, training and motivation are given great importance these days. Proper training of health care establishment personnel at all levels coupled with sustained motivation can improve the situation considerable. The rules framed by the Ministry of Environment and Forests (MoEF), Govt. of India, known as ‘Bio-medical Waste (Management and Handling) Rules, 1998,’ notified on 20th July 1998, provides uniform guidelines and code of practice for the whole nation. It is clearly mentioned in this rule that the ‘occupier’ (a person who has control over the concerned institution / premises) of an institution generating bio-medical waste (e.g., hospital, nursing home, clinic, dispensary, veterinary institution, animal house, pathological laboratory, blood bank etc.) shall be responsible for taking necessary steps to ensure that such waste is handled without any adverse effect to human health and the environment. In the last few decades, human activities and changes associated with lifestyles and consumption patterns have resulted in the generation of huge volumes of different types of wastes. The wastes have threatened the survival of humans and other living things, as well as all natural resources that are necessary for human existence. Consequently, in little more than two decades public concern over the waste management and the pollution problems associated with waste generation have attracted significant attention and a great deal of research has been conducted to evaluate appropriate waste treatment options, so as to minimize environmental pollution and maximize resource recovery. In recent years, concern over the solid waste from healthcare facilities (HCFs) (i.e., hospitals, clinics, pathological laboratories, pharmacies and other supported healthcare services) has increased throughout the world. This is because waste from HCFs, arising principally from hospitals and clinics, is potentially dangerous since it can spread diseases
  5. 5. CLINICAL WASTE MANAGEMENT Page 5 because of the infectious nature of the wastes, and/or cause injury through the mismanagement of clinical solid waste. It is well known that inappropriate clinical waste management is pressing both health hazards and environmental pollution, facing many healthcare centers of this developing world. Improper clinical solid waste management practice impacts both directly and/or indirectly to healthcare staffs, patients and hospitals environment. Diseases like cholera, dysentery, skin infection, infectious hepatitis can spread epidemic way due to the mismanagement of clinical solid waste. Therefore, it is required to determine appropriate methods for the safe management of clinical solid waste. The poor management of clinical solid waste is a significant problem in most economically developing countries. However, many researchers in developing countries have investigated the existing healthcare waste management practices in selected healthcare centers within their countries. They argued that the successful clinical waste management represents a challenge in their countries due to insufficient financial investment, lack of awareness and effective control, lack of trained clinical staffs in the waste management framework. In addition, absence of healthcare waste management guideline and legislation in country level and unavailability of suitable treatment and disposal option may further obstruct in the waste management efforts. DEFINATION OF CLINICAL WASTE - The waste generated in HCFs has many definitions. There are currently several terms used to describe waste that is generated from healthcare facilities. It can lead to problems as it is important to have a specific definition of those wastes derived from healthcare premises. This is because there are practical considerations to differentiate between the wastes and waste from HCFs, and in relation to choosing the right method of waste disposal which flow from a clear understanding. The terms ‘Clinical waste’, ‘Health care waste’, ‘Infectious waste’ and ‘Medical/Hospital waste’ are typically encountered, they may have similar meanings or be subsets of one another, which substantially inhibits using and comparing data from different countries. According to the World Health Organization, 1994.  ‘Bio-medical waste’ means any solid and/or liquid waste including its container and any intermediate product, which is generated during the diagnosis, treatment or immunisation of human beings or animals or in research pertaining thereto or in the production or testing thereof. Clinical waste is defined by the Controlled Waste Regulations (1992) as (HMSO, 1992):  Any waste which consists entirely or partly of human or animal tissue, blood or other body fluids, excretions, drugs or other pharmaceutical products, swabs or dressings or syringes, needles or other sharp instruments, being waste which unless rendered safe may prove hazardous to persons coming into contact with it.
  6. 6. CLINICAL WASTE MANAGEMENT Page 6  Any other waste arising from medical, nursing, dental, veterinary, pharmaceutical or similar practice, investigation, treatment, care, teaching or research or the collection of blood from transfusion, being waste which may cause infection to any person coming into contact with it.  Clinical wastes include different types of wastes such as infectious waste, radioactive waste, chemical waste, pathological waste.  Non-clinical waste is defined as such waste that is not posing any risk to human health or environment. Examples of non-clinical waste include packaging materials such as cardboard, office paper, leftover food, cans etc. COMPONANTS OF CLINICAL WASTE-  Human anatomical waste (tissues, organs, body parts etc.),  Animal waste (generated during research/experimentation.  Microbiology and biotechnology waste, such as, laboratory cultures, micro-organisms.  Human and animal cell cultures, toxins etc.  Waste sharps, such as, hypodermic needles, syringes, scalpels, broken glass etc.  Discarded medicines and cyto-toxic drugs.  Soiled waste, such as dressing, bandages, and plaster casts, material contaminated with blood etc.  Solid waste (disposable items like tubes, catheters etc. excluding sharps).  Liquid waste generated from any of the infected areas.  Incineration ash.  Chemical waste. SOURCES OF CLINICAL WASTE – The sources of clinical waste are hospitals and clinics, particularly those providing acute services, i.e., offering Operating Theatres, Maternity ward, Accident & Emergency, Mortuary, Intensive Care, Isolation Wards, Pharmacy, Pathology Laboratories and other research facilities. Other sources of clinical waste are ambulance services, public health laboratories, blood donation centers and blood banks, practice center of doctors, dentists, veterinary surgeons, immunization/vaccination clinics and hospitals, clinics and nursing homes providing community care, care of the elderly and services related to mental health and learning disabilities. There has been an increase in the amount of clinical waste coming from households. This is due in part to changes in health care policies. Both medical devices and instruments are used while treating patients at home, thereby producing a variety of waste materials. Self-injecting diabetics and people changing colostomy bags at home can also generate significant quantities of clinical waste. The wastes generated from the treatment of patients suffering from infectious diseases may spread infection either through direct contact or indirectly through the environment. Waste materials originating from home health and medical care services are still included in general household waste materials, even when the wastes are infectious.
  7. 7. CLINICAL WASTE MANAGEMENT Page 7 CLASSIFICATION OF CLINICAL WASTE - Category of waste Composition Human anatomical waste Human tissues, organs, body parts. Animal waste Animal tissues, organs, body parts, blood, experimental animals used in the research. Microbiology and biotechnology waste Waste from laboratory cultures, stocks. Human & animal cell cultures used in research. Waste sharps Needles, blades, syringes. This include both used & unused sharps. Discarded medicines and drugs Waste from outdated, discarded, contaminated medicines. Solid waste Items contaminated with blood and body fluid including cotton, dressing and plasters. Liquid waste Waste generated from washing, cleaning, disinfecting activities. Incineration ash Ash from incineration of bio medical waste. Chemical waste Chemicals used for disinfectants, insecticides.
  8. 8. CLINICAL WASTE MANAGEMENT Page 8 RISK INVOLVED IN CLINICAL WASTE HANDLING - The poor management aspects are found due to the economic problem of the developing countries that prevent the government from adequately support to clinical waste management. The potential microbiological risks associated with the clinical waste are still unfamiliar to healthcare workers. This is because of the literature on the role of infectious clinical waste as reservoir of diseases is extremely limited. unfortunately scientifically substantiated evidence on the actual content of microorganisms, survival of micro-organisms in clinical waste and the infectious risks to healthcare workers and general public are extremely rare. The infectious risk posed by CSW to human health and the environment, which needs to be assessed, is the potential presence of pathogenic micro organisms. CSW may contain a great variety of pathogenic micro-organisms. Person involved in the treatment of clinical waste are exposed to infectious agents through several routes including skin penetration, skin contact, or by the aerogenic route. Recently, a study was conducted in South Korea to investigate the types of micro-organisms in various clinical wastes as well to characterize the survivals life of micro organisms in clinical waste. Study shows that a number of micro-organisms, including Pseudomonas spp., Lactobacillus spp., Staphylococcus spp., Micrococcus spp., Kocuria spp., Brevibacillus spp., Microbacterium oxydans, and Propionibacterium acnes, are available in various clinical wastes.Conducted microbiological analysis of healthcare waste to determine the quantity of infectious microorganism by colony count methods. Coliform bacteria, Escherichia coli, Enterobacter, Pseudomonas spp., Staphylococcus aureus, Bacillus cereus, Salmonella spp., Legionella and yeast and moulds were detected in healthcare waste. Microorganisms Infections Enterobacteria Gastroentic infections Mycobacterium tuberculosis Respiratory infection Streptococcus Skin infection Human immunodeficiency viruses Acquired immunodeficiency syndrome.
  9. 9. CLINICAL WASTE MANAGEMENT Page 9 CLINICAL WASTE GENERATION - Quantities of the waste generation rate in healthcare centres depends on type of healthcare establishment, availability of instrumentation, general condition of HCFs area, ratio of disposable item in use and number of patient care. Also, the economic, social and cultural status of the patients might change the amount of waste generation. Due to higher number of day-care patients, public healthcare facilities produce larger amount of healthcare waste than private healthcare facilities. due to higher number patients care, public hospitals produce more healthcare waste than private hospitals, but total waste and the proportion of clinical waste per bed is similar in both public and private hospitals. This may happen because of mismanagement of HCW and lack of segregation of waste for shorting the clinical waste in surveyed hospitals. The healthcare waste generation rate depends on the size and the type of the medical institution, but also that it differs from country to country based on the level of economic development. The developed countries generate higher amounts of healthcare waste than that of the developing countries. Data from World Health Organization also reveal that North America produces 7–10 kg of healthcare waste per bed/day, whereas South America produces 3 kg of waste per bed/day. This difference was also found in Europe and Asia. Western Europe produces 3–6 kg, whereas Eastern Europe 1.4–2 kg of waste per bed/day. In Asia, richer countries produce 2.5 kg per bed/daily, and poorer countries 1.8–2 kg per bed/daily. From the available data it is evident that amount of healthcare waste generation rate depends on the level of economic development of the region. It is also notice that, due to higher level of economic development, the North America produce largest amount of waste. This may be due to the developed nation’s lifestyle demands consumption of a high amount of goods and services which tend to generate a higher amount of waste. Furthermore, the use of disposable instruments and packaging materials rather than the use of reusable items in healthcare centers in developed countries has increased the amount waste generation. In contrast, the proportion of clinical waste generation rate among total waste in healthcare facilities depends on several factors such as waste management plan, segregation activities at waste generation source. Waste generation source, quantity and quality of waste generation are the key issues to decide an effective clinical waste management practice. It is important to minimize waste generation rate at each generation source. On this basis, appropriate segregation and sorting of clinical waste at generation source can be an effective solution. The following table shows the generation of waste in some of the country- Country Waste generation rate South Africa 0.60 kg/patient/day Algeria 0.70 kg/bed/day
  10. 10. CLINICAL WASTE MANAGEMENT Page 10 Brazil 2.63 kg/bed/day Jordan 6.10 kg/patient/day Greece 8.4 kg/bed/day Bangladesh 1.71 kg/bed/day China 1.22 kg/bed/day The campaign for medical waste management in india began in 1996 with the supreme courts order that all hospitals with more than 50 beds should have incinerators to dispose off their BMW. It is estimated that each hospital bed in India generates about 250 gm of waste per day, which is much lower, than other countries (United States- 4.5 kg/day/bed, Netherlands-2.7 kg/day/bed and Latin America-2.63 to 3.8 kg/day/bed). In India, Delhi generates the highest BMW at about 1.5 kg /day/bed. Taking an average of 250 gm/day/bed, it can be estimated that India generates about 227 TPD of BMW. Comparison of Maharashtra with other parts of the country shows that in 1993, Maharashtra contributed the largest share of BMW among all states, which was about 19 TPD or about 13 per cent of that of India. During 1993-99, it grew almost by 60 per cent, which is more than the average increase for the country (52.3%). In 1999, Maharashtra contributed the largest amount of BMW in India at about 31.5 TPD. The data for 2001 show that Kankan division accounts for 45.40 per cent of the BMW generated in the State while Pune and Nagpur account for 18.13 per cent and 11.21 per cent, respectively. Nasik accounts for 9.65 percent, Amravati for 7.65 percent and Aurangabad for 7.95 percent of BMW. States Total no of beds Generation of biomedical waste in kg/day in 1999 Andhra Pradesh 75910 18977.5 Arunachal Pradesh 2764 619 Assam 16000 4000 Bihar 44642 11160 Goa 4741 1185 Gujarat 78664 19666 Haryana 11440 2860 Himachal Pradesh 9316 2329 Jammu & Kashmir 5515 1378 Karnataka 56558 141139 Kerala 106967 26741 Madhya Pradesh 28724 7181 Maharashtra 126378 31594
  11. 11. CLINICAL WASTE MANAGEMENT Page 11 HANDLING & TRANSPORTATION OF CLINICAL SOLID WASTE – Unless clinical waste is properly handled and disposed, it can present risks to healthcare staffs, the public and the environment. Consequently, many developed countries have devised codes of practices and guidelines for handling and disposal such waste. Although significant progress has been found, yet it still requires further modification in all aspect of clinical waste management practices. The management of clinical solid waste is considered as problematic due to its enormous volume of generation, serious threat for the human health as well as disposal cost. CSW as any solid waste that is generated in the diagnosis, treatment, or immunization of human beings or animal, in research pertaining thereto, or testing of biological, including but not limited to: soiled or blood-soaked bandages, culture dishes and other glassware. It also includes discarded surgical gloves and instruments, needles, lancets, culture, stocks and swabs used to inoculate cultures and remove body organs. Clinical solid waste may contain potential pathogenic microorganism’s .Therefore, clinical solid waste is perceived by many as hazardous or infectious. Besides, there is a possibility of the contamination of nonclinical waste with infectious agents during unsafe handling, collection, storage and transportation. Hence, effective attention must be placed during treating healthcare waste so that clinical waste cannot mix with non-clinical waste during management. Consequently, clinical solid waste should be handled, storage, transported and disposed of in a controlled manner to safeguard public health and to prevent environmental pollution. Infectious pathogenic micro-organisms may infect the human body during unsafe handling via direct conduct (puncture, abrasion or cut in the skin) or indirect conduct (mucous membranes, inhalation or ingestion). Particular concern on the handling of sharps items because it represent the most acute potential hazards to health. In developing countries, clinical solid waste has been handled and disposed together with the non-clinical waste, which is creating inevitable risks to the health care workers, publics and the environment. WHO in 2002 conducted an investigation survey on management of healthcare waste in 22 developed countries. Results showed that the proportion of healthcare facilities that do not use proper waste disposal methods ranges from 18% to 64%. Studies reported that healthcare workers are not educated enough and most of them have not had any special training on the management of clinical waste. Most of the healthcare institutions do not have appropriate colour coded bags or containers for sorting the different types of waste. Some of the healthcare centers in Nigeria and Mongolia used plastic bags, paper bags or card board boxed to collect the clinical solid waste. Besides, healthcare waste are not sorted because of the high fee of their disposal cost, therefore both clinical and non-clinical waste are mixed together and dump illegally. Even most of the hospitals have not any special place for the storage the clinical waste prior to disposal. Wastes are placed in an unsecured area until collected and is fully accessible to the animals.
  12. 12. CLINICAL WASTE MANAGEMENT Page 12 This activity has three components: collection of different kinds of waste (from waste storage bags/containers) inside the hospital, transportation and intermediate storage of segregated waste inside the premises and transportation of the waste outside the premises (to the treatment/disposal facility).  Collection of Waste Inside the Hospital/Health Care Establishment- The collection containers for bio-medical waste have to be sturdy, leak proof, of adequate size and wheeled. Two wheeled bins of 120-330 litre capacity and four wheeled bins of 500-1000 litre capacity may be used. The 4 wheeled containers have two fixed wheels and two castors and they are fitted with wheel locking devices to prevent unwanted rolling. There should be no sharp edges or corners, especially in metallic bins. For convenience as well as for avoiding any confusion, the colour code applicable for the bags / containers should also be used for the bins. Collection timings and duty chart should be put in a prominent place with copies given to the concerned waste collectors and supervisors. For general waste from the office, kitchen, garden etc., normal wheel-barrows may be used.  Transportation of Segregated Waste inside the Premises- All attempts should be made to provide separate service corridors for taking waste matter from the storage area to the collection room. Preferably these corridors should not cross the paths used by patients and visitors. The waste has to be taken to the common storage area first, from where it is to be taken to the treatment/disposal facility, either within or outside the premises as the case maybe.  Collection and Transportation of Waste for Small Units- Smaller units, such as, nursing homes, pathological laboratories etc. do not have many departments/divisions and the generation of waste is small and normally they do not have treatment facility for the bio-medical waste. In their case, intermediate storage area is not required. They should install a needle cutter and a small device for cutting plastic tubing, gloves etc. In case, highly infectious bio-medical waste is expected to be generated, they may consider installing a separate steam autoclave of suitable size exclusively for this purpose. Adequate precaution must be taken to ward off any occupational hazard or environmental problem. This particular autoclave should never be used for sterilising medical supplies or surgical equipment. Such establishments require provision for segregated storage (according to the rules) which can be packed in sealed containers/sturdy bags and handed over to the agency carrying them to the common treatment/disposal facility.  Transportation of Waste Outside - In case of off-site treatment, the waste has to be transported to the treatment/disposal facility site in a safe manner. The vehicle, which may be a specially designed van, should have the following specifications - · It should be covered and secured against accidental opening of door, Leakage/spillage etc.
  13. 13. CLINICAL WASTE MANAGEMENT Page 13 · The interior of the container should be lined with smooth finish of Aluminium or stainless steel, without sharp edges/corners or dead spaces, this can be conveniently washed and disinfected. · There should be adequate arrangement for drainage and collection of any run off/leachate, which may accidentally come out of the waste bags/containers. The floor should have suitable gradient, flow trap and collection container. · The size of the van would depend on the waste to be carried per trip. · In case, the waste quantity per trip is small, covered container of 1-2 cu.m. mounted on 3 wheeled chassis and fitted with a tipping arrangement can be used. STORAGE OF CLINICAL WASTE - Storage of waste is necessary at two points: (i) At the point of generation. (ii) Common storage for the total waste inside a health care organisation. For smaller units, however, the common storage area may not be possible. Systematic segregated storage is the most important step in the waste control programme of the health care establishment. For ease of identification and handling it is necessary to use colour coding, i.e., use of specific coloured container with liner / sealed container (for sharps) for particular wastes. It must be remembered that according to the Rules, untreated waste should not be stored beyond a period of 48 hours. Recommended Labelling and Colour Coding – A simple and clear notice, describing which waste should go to which container and how frequently it has to be routinely removed and to where, is to be pasted on the wall or at a conspicuous place nearest to the container. The notice should be in English, Hindi and the predominant local language. Preferably, it should have drawings correlating the container in appropriate colour with the kind of waste it should contain. Segregated Storage in Separate Containers (at the Point of Generation)- Each category of waste has to be kept segregated in a proper container or bag as the case may be. Such container / bag should have the following property: · It must be sturdy enough to contain the designed maximum volume and weight of the waste without any damage. · It should be without any puncture/leakage.  
  14. 14. CLINICAL WASTE MANAGEMENT Page 14 The container should have a cover, preferably operated by foot. If plastic bags are to be used, they have to be securely fitted within a container in such a manner that they stay in place during opening and closing of the lid and can also be removed without difficulty. . The sharps must be stored in puncture proof sharps containers. But before putting them in the containers, they must be mutilated by a needle cutter, placed in the department/ward itself. . The bags/containers should not be filled more than 3/4th capacity. Attempts should be made to designate fixed places for each container so that it becomes a part of regular scenario and practice for the concerned medical as well as nursing staff. Certification- When a bag or container is sealed, appropriate label (s) clearly indicating the following information has to be attached. A water-proof marker pen should be used for writing. They should be labelled with the ‘Biohazard’ or ‘cyto-toxic’ symbol. · The containers should bear the name of the department/laboratory from where the waste has been generated so that in case of a problem or accident, the nature of the waste can be traced back quickly and correctly for proper remediation and if necessary, the responsibility can be fixed. · The containers should also be labelled with the date, name and signature of the person responsible. This would generate greater accountability. · The label should contain the name, address, phone/fax nos. of the sender as well as the receiver. It should also contain name, address and phone/fax nos. of the person who is to be contacted in case of an emergency. Common/Intermediate Storage Area- Collection room(s)/intermediate storage area where the waste packets/bags are collected before they are finally taken/transported to the treatment/disposal site are necessary for large hospitals having a number of departments, laboratories, OTs, wards etc. This is all the more important when the waste is to be taken outside the premises. Two rooms - one for the general and the other for the hazardous waste are preferable. In case of shortage of rooms, the general waste (non-hazardous) can be directly stored outside in dumper containers with lids of suitable size. Arrangement for separate receptacles in the storage area with prominent display of colour code on the wall nearest to the receptacles has to be made. When waste carrying carts/containers arrive at this area, they have to be systematically put in the relevant receptacle/designated area.
  15. 15. CLINICAL WASTE MANAGEMENT Page 15 Parking Lot for Collection Vehicles- A shed with fencing should be provided for the carts, trolleys, covered vehicles etc. used for collecting or moving the waste material. Care has to be taken to provide separate sheds for the hazardous and non-hazardous waste so that there is no chance of cross contamination. Both the sheds should have a wash area provided with adequate water jets, drains, raised platform, protection walls to contain splash of water and proper drainage system. TREATMENT OF CLINICAL WASTE - The selection of clinical waste disposal methods must be cost effective, easily implemented and environmental friendly. A waste disposable method must have (i) minimal risk assessments for proposed waste management facilities, (ii) minimal human health impacts (iii) minimal environmental impacts, and (iv) cost effective. The waste disposable method must have the capability of inactivating infectious micro- organisms so that the waste does not pose any hazard of infectious diseases for anyone exposed to it. Relatively, several technologies have been conducted to treat clinical waste for the inactivation of potentially pathogenic micro-organisms so that the waste no longer poses a danger to public health and safety. But none of these practices are able to adequately inactivate the micro-organisms, since each practice has its own weakness and disadvantage, thereby the urgency to find an efficient method to preserve human health and environment. It is found form literatures that the most common disposal methods of clinical solid waste, particularly in developing countries, are open dumping, landfill or incineration. Some other disposal methods are utilized in the management of clinical wastes are steam sterilization or autoclaving, chemical sterilization, microwaving, etc. The most common methods utilized in healthcare centers to dispose clinical waste in different countries are shown in Table. Country Disposal methods South Africa Land filing, open burning, incineration. Bangladesh Dumping Brazil Land filling, incineration, autoclave. Nigeria Burning, dumping, incineration. Grease Recycling, reuse. Egypt Incineration, dumping. India Incineration, land filling..
  16. 16. CLINICAL WASTE MANAGEMENT Page 16 OPEN DUMP & OPEN BURNING – Open dump is the most common method of clinical waste disposal in developing countries. This is probably less expensive and no other alternative methods are available at this reasonable cost. Though, this method also is the least cost option, but open dumping has long been recognized as a potential infection source of public health and environmental pollution. It is uncontrolled and inadequate disposal option of clinical waste. Therefore, clinical waste should not be deposited on or around open dumps. This is because this uncontrolled clinical waste transmits infectious pathogenic micro-organisms to the environment either via direct contact through wounds, inhalation, or ingestion, or indirect contact through the food chain or a pathogenic host species. Also wind easily blows over the dumped waste, dispersing air pollutants to nearby communities. Burning is aimed to reduce the volume of waste and stopping the spread of papers. The burning itself is a potential source of generating toxic emissions. This is more likely since wastes such as plastics, syringes and paper are burned together. There is high chance that toxic chemicals like dioxins and furans are generated and separating air pollutants. AUTOCLAVING - Autoclaves have been used for the sterilization of various kinds of infectious hospital waste. Autoclaves are generally used to treat sharps, items contaminated with blood, residues from surgery and from isolation wards, bandages, gauze, linen, gowns, and other similar materials and non-chemical laboratory wastes. The autoclaves have a temperature range of 50– 250 C, but they are operated at 160 C as the optimum temperature to kill bacteria. Autoclave of clinical waste is considered as an alternative technology of the incinerator, but it is viewed as a more costly method than incineration. This is because, autoclaving is the double treatment option of clinical solid waste, and since autoclaving wastes require another treatment method for final disposal. It cannot handle large quantities of hazardous waste. Besides, autoclave cannot treat a variety of chemical and hazardous substances such as wastes from chemotherapy treatment, mercury, volatile and semi-volatile organic compounds, radioactive wastes. It is not suitable to treat large body parts, animal carcasses, or other large items that, because of their mass and other characteristics, which make it difficult or time consuming for the entire material to reach the prescribed temperatures.
  17. 17. CLINICAL WASTE MANAGEMENT Page 17 MICROWAVE - Microwaves are electromagnetic waves with frequencies between radio and infrared waves. It is important that the waste is wet, either as a result of naturally occurring moisture or by the addition of steam, in order to create the thermal process. Some treatment processes utilise microwaves to heat water to form steam, which is then applied to the clinical waste stream. Some systems apply low frequency radio waves to inactivate microorganisms contained within the waste. The microwaves heat the clinical waste from the inside of the materials to their external surfaces. However, microwaving clinical waste might be economically competitive compared to the incinerator. Nevertheless microwave technology is not suitable for large scale treatment. The treatment cost is also expensive and is not affordable for the developing countries. INCENERATION - Incinerations have led to its worldwide use as the preferred means of treating and disposing clinical solid waste. Incineration is a high-temperature dry oxidation process that converts the waste into residual ash and gases. It is particularly useful in the treatment of pathological waste and sharps, as these components of the waste stream are rendered unrecognizable. This process is usually selected to treat wastes that cannot be recycled, reused, or disposed of in a landfill site. Incineration emits lots of harmful pollutants including particular concern carbon monoxide (as a result incomplete combustion), hydrogen chloride, metals (e.g. mercury lead, arsenic, cadmium) dioxin and furan. Many of these pollutants, dioxins in particular, can be carried long distance from their emissions source and accumulate in soil, water, and food source, and pollute them. The successful incineration of clinical solid waste within a safe waste management program depends on the form of collection containers, maintenance support, acceptable energy sources, and understandable operational instructions. A properly designed incinerator can completely burn waste and leave minimum residual in the form of ashes, whilst minimizing the exposure risks to emissions through the correct placement of the units in relation to the clinic and the
  18. 18. CLINICAL WASTE MANAGEMENT Page 18 surrounding communities. In developing country’s hospitals, most of the incinerators are in poor design and have operational problems. The incinerators are local made and it is constructed from burned bricks and cement. Waste is burned using coal as fuel, which cannot produce require temperature to properly burn the waste. Therefore, high amount of ash is generated because of incomplete burning of waste. Incineration is an inappropriate technology for most developing countries due to high financial start-up cost and occupational capital required to implement incineration facilities. Another distinct concern on the risk of infectious micro-organisms, many people still believe that if infectious clinical waste is incinerated, the emission from stack gas and the ash may have infectious micro-organisms even if the most modern incineration plant is used. Many developed countries of the world are bringing an end to waste incineration and are turning to alternative technology of incinerator due high maintain cost and serious negative environmental impact. LANDFILING - Landfill is an easy and low cost waste disposal method. But, if a landfill is not properly managed, it raises human health risk and environmental pollution concern. Landfill is considered an unsophisticated disposal method, which requires careful segregation of waste so that it does not pose significant health effects on public health and environment. In developing countries, landfills are operated like an open dump. The clinical waste is dumped in the landfill mixed with non-clinical wastes, and later burned. Landfill produces waste products in three phases during the waste degradation process. These are solid (i.e., degraded waste), liquid (i.e., leachate, which is water polluted with waste), and gas (usually referred as landfill gas). Further, these three waste products may pollute the three principle media of environment. Therefore, landfill is not a safe solution to treatment of the clinical waste. This is because landfills can produce gas and contaminated water, as well as wind-blown litter and dust, and attract vermin. Besides, land disposal of clinical solid waste is often done in low lying areas of an open land, which may prone to flooding, increasing the possibility of surface water contamination during the rainy season. The main potential impacts on health arise from inhaled landfill gas and exposure to groundwater
  19. 19. CLINICAL WASTE MANAGEMENT Page 19 contaminated by landfill leachate. Although landfill gas consists mainly of methane and carbon dioxide, it can contain a large number of other gases at low concentrations, some of which are toxic. The major components of landfill gas, methane and carbon dioxide, are ‘greenhouse gases (GHGs). Both gases are major constituents of the world’s problem GHGs; however while carbon dioxide is readily absorbed for use in photosynthesis, methane is less easily broken down, and it is considered 20 times more potent as a GHG. Leachate, on the other hand, poses a threat to surface and ground water systems. Leachate from landfill sites tends to have highly variable concentrations of wide range of salts, halogenated organic compounds, trace metals and organic acids, which may contaminate with surrounding soil and water. It has also been reported that leachate from solid waste landfill site may be mutagenic and carcinogenic. Landfills of clinical waste are a potential threat to the human health and the quality of the environment, although the full extent of this threat has not been scientifically evaluated. In many countries, clinical wastes are restricted to dispose in landfill, unless it is disinfected from infectious micro-organisms as to pose any risk to human health. For instance, clinical waste has come to European landfills under strictly control because of infectious nature of the waste and public abhorrence. Several studies in the literature have reported on risk assessment that is related to environmental issue especially regarding the environmental pollution by landfill leachate and gas. But, very few studies in the literature have reported on infectious risk of human health and the pathway of infection through clinical waste landfill. staphylococcus aureus, Enterococcus spp., Salmonella spp. and other enterobacteriaceae are found in landfill leachate many weeks after clinical waste deposit in landfill. Therefore, landfill can be considered as a prolonged survival and dispersal of pathogen micro-organisms from clinical waste. In another study, it is determined 43 different species of bacteria and yeast in landfill leachate and bulk material during an engineering aerobic bio reduction process. Among the bacteria species, some of them are associated with human infections. Landfill is the common option for the general waste disposal methods. Besides, it also takes part as a secondary option for other waste disposal methods. Furthermore, landfill continues to be a common method of waste disposal despite the high potential to pollute the environment and human health infection. Therefore, it is bearing the importance to think about proper engineered landfill to minimize the risk assessment of the landfill hazards to preserve the environment and the human health.
  20. 20. CLINICAL WASTE MANAGEMENT Page 20 CHEMICAL DISINFECTING - This treatment is recommended for waste sharps, solid and liquid wastes as well as chemical wastes. Chemical treatment involves use of at least 1% hypochlorite solution with a minimum contact period of 30 minutes or other equivalent chemical reagents such as phenolic compounds, iodine, hexachlorophene, iodine-alcohol or formaldehyde-alcohol combination etc. Pre- shredding of the waste is desirable for better contact with the waste material. In the USA, chemical treatment facility is also available in mobile vans. In one version, the waste is shredded, passed through 10% hypochlorite solution (dixichlor) followed by a finer shredding and drying. The treated material is landfilled. HYDROCLAVE TREATMENT - Hydroclave is innovative equipment for steam sterilisation process (like autoclave). It is a double walled container, in which the steam is injected into the outer jacket to heat the inner chamber containing the waste. Moisture contained in the waste evaporates as steam and builds up the requisite steam pressure (35-36 psi). Sturdy paddles slowly rotated by a strong shaft inside the chamber tumble the waste continuously against the hot wall thus mixing as well as fragmenting the same. In the absence of enough moisture, additional steam is injected. The system operates at 132 deg.C. and 36 psi steam pressure for sterilisation time of 20 minutes. The total time for a cycle is about 50 minutes, which includes start-up, heat-up, sterilisation, venting and depressurisation and dehydration. The treated material can further be shredded before disposal. The expected volume and weight reductions are up to 85% and 70% respectively. The hydroclave can treat the same waste as the autoclave plus the waste sharps. The sharps are also fragmented. This technology has certain benefits, such as, absence of harmful air emissions, absence of liquid discharges, non-requirement of chemicals, reduced volume and weight of waste etc. Tata Memorial Hospital in Mumbai has installed the first hydroclave in India in September 1999.
  21. 21. CLINICAL WASTE MANAGEMENT Page 21 CASE STUDY - The objectives of this study were: (i) to assess the waste handling and treatment system of hospital bio-medical solid waste and its mandatory compliance with Regulatory Notifications for Bio-medical Waste (Management and Handling) Rules, 1998, under the Environment (Protection Act 1986), Ministry of Environment and Forestry, Govt. of India, at the chosen KLE Society’s J. N. Hospital and Medical Research Centre, Belgaum, India and (ii) to quantitatively estimate the amount of non-infectious and infectious waste generated in different wards/sections. During the study, it was observed that: (i) the personnel working under the occupier (who has control over the institution to take all steps to ensure biomedical waste is handled without any adverse effects to human health and the environment) were trained to take adequate precautionary measures in handling these bio-hazardous waste materials, (ii) the process of segregation, collection, transport, storage and final disposal of infectious waste was done in compliance with the Standard Procedures, (iii) the final disposal was by incineration in accordance to EPA Rules 1998 (iv) the non-infectious waste was collected separately in different containers and treated as general waste, and (v) on an average about 520 kg of non-infectious and 101 kg of infectious waste is generated per day (about 2.31 kg per day per bed, gross weight comprising both infectious and non-infectious waste). This hospital also extends its facility to the neighbouring clinics and hospitals by treating their produced waste for incineration. Hospital study center profile - The KLE Society s 1000-bed Hospital and Medical Research Center, Belgaum, sprawled over 16 acres of land situated on the Pune–Bangalore highway, is the only hospital in this region of Karnataka State that has all basic specialities. Including General Medicine, General Surgery, Orthopedics, ENT, Obstetrics & Gynecology, Ophthalmology, Pediatrics and Psychiatry. In addition, this hospital offers super-speciality services in Cardiology, Cardiovascular and Thoracic Surgery, Urology, Nephrology, Neurology, Neuro-Surgery, Laparoscopic Surgery, Pediatric Surgery, Neonatology and Gastroenterology. These clinical services are comprehensively supported by diagnostic and support facilities like CT scan, _C_ Arm with Image Intensifier 800 MA X-ray machine with Image Intensifier, 500 MA mobile X-ray, various endoscopes, Ultra-sonography, Gamma Camera for thyroid, brain, bone and others.
  22. 22. CLINICAL WASTE MANAGEMENT Page 22 Method - Assessment of operating procedures- A general survey of the operating procedures practiced in handling and treatment of solid waste was performed to assess its compliance with Standard Legal Norms and Procedures as per the Bio-Medical Waste Management Rules 1998. Quantitative determination of waste - The following steps were involved in the determination of the bio-medical waste generated from different places in the study center: (i) The supporting staffs of each ward/laboratory/department were briefed over the nature of assistance and support that was needed in determining the quantity of wastes during the study period. (ii) The staffs was given coded stickers to paste on all of the color-coded, high-density, polyethylene bags used for collection of the waste to facilitate in tracing the source of waste generation for the data collection. (iii) The quantities of infectious and non-infectious solid waste were recorded in two places: inside the incinerator room and outside the incinerator room for infectious and non-infectious wastes, respectively. (iv) Solid waste of both types (infectious and non-infectious) was weighed individually on a suspension spring scale (±100 g) with the assistance of the staff and the weight was recorded by department. Final disposal of waste- Non-infectious waste- The separately collected and transported non-infectious waste is put in the large municipal bins to be removed by the city municipal authorities. Treatment of infectious biomedical solid waste- The final disposal of infectious bio-medical waste is carried out by incineration. Destromat Pyrolytic Incinerator Model PY-300 equipped with a 30-m high chimney with a load capacity of 1000 kg and 150-kg/h incineration rates, operates using an oil-blast technique. The minimum operating temperature maintained in the incinerator is 800C over an 12-h incinerating cycle (from 8 AM to 8 PM), having a break period of 12 h for cooling and emptying the accumulated ash, before a fresh load of bio-medical waste is inserted. During incineration, the door of the incinerator is periodically opened and the waste material is turned upside down for complete incineration of the waste matter. The last load of bio-medical waste that is charged in the incinerator in a particular day is fed at least 2 h prior to start of the cooling cycle so that no part
  23. 23. CLINICAL WASTE MANAGEMENT Page 23 of the bio-medical waste is left unburned. The ash generated in the incinerator is removed from the incinerator every day and stored outside the incinerator room. Periodically, after accumulation of a sufficient quantity of ash, the material is transported to be dumped in pits, away from the populated area. RESULTS- Assessment of operating procedures - Observations were made during the waste handling process and questions were asked to the staff in charge regarding the care taken in handling wastes. The explanation given by staff was that they were handling bio-hazardous materials and that if they were careless it could be injurious to them and to others, and also could cause the spread of infection or disease. Staff further added that there could be serious ramifications on the human health in the community, which might spread to a larger area. Segregation- The waste was segregated separately, according to its characteristics, at the point of generation, mainly from the patient care areas. The hospital used colour-coded, high-density polyethylene bags for easy identification and segregation of bio-medical solid waste. Non-infectious and domestic type of waste was collected in black polyethylene bags, placed in bins while the infectious wastes was collected in red, yellow and blue colour-coded polyethylene bags placed within blue high-density polyethylene bags labelled with a bio-hazardous infectious materials symbol in specific bins. Both types of waste were collected twice a day, once in the morning before 8 am and once in the evening before 6 pm. However, the waste from the Operation Theatres (OT) and Intensive Care Units (ICU) was collected more often, depending on the number of operations and cases attended in any particular day. All containers kept for collection of hazardous wastes were labelled with biohazard/cytotoxic symbols while other containers for non-hazardous wastes were not labelled. Colour coding of polyethylene bag Type of waste material Black Non infectious and non hazardous waste Red Microbiological waste from pathological laboratory, items contaminated with blood and body fluids, and waste generated from disposable items other than sharps, etc Yellow Human anatomical waste, microbiological waste from pathological laboratory, items contaminated with blood and body fluids, and waste generated. Blue Waste sharps, tubing etc.
  24. 24. CLINICAL WASTE MANAGEMENT Page 24 Packaging- Infectious waste was packaged to: (i) protect waste handlers and the public from possible injury and disease that could result from exposure to the waste and (ii) avoid attraction to rodents and vermin. The integrity of packaging was preserved during handling, storage, transportation and treatment.Objects that are capable of puncturing or cutting including syringes with needles, scalpels, blades, pipettes and broken glass, were put in puncture-proof containers. The needle tips were first destroyed by shredding. Later, these materials were disinfected prior to incineration by soaking them for a period of at least 30 min in a freshly prepared 1% hypochlorite solution before discarding them in the bins. Storage- The bio-medical solid wastes were not stored for more than 18 h off-site. The bins in the wards were strictly placed away from patients and from the nursing station. Collection, replacement of empty colour-coded bags and transportation - The collection of infectious and non-infectious wastes was undertaken by two teams of two members each, one for pulling the cart and distributing empty polyethylene bags and the other member for sealing the bags, putting the bags into the cart and replacing the bins with polyethylene bags. The staffs were aware of the potential hazards of the material they were handling and were found to take requisite protective measures. They wore impervious gloves and masks during collection of infectious waste, segregation of various colour-coded containers and transporting waste in the designated cart, taking adequate precaution to prevent any spillage from the plastic bags. Final disposal- A simple dictum was followed in the final disposal of hospital waste: ‘‘infectious waste is subjected to treatment with either heat or chemicals and non-infectious waste need not be treated.’’ Bio-medical solid waste comprising: (i) human anatomical waste, (ii) microbial and biotechnology waste, (iii) sharps, (iv) soiled waste, (v) solid waste and (vi) discarded medicines and cytotoxic drugs were collected in red, yellow and blue colour- coded high-density polyethylene bags and disposed of in an incinerator. The local municipal authorities transported the segregated non-hazardous general waste collected in black bags every other day for suitable disposal. Quantitative estimation of medical solid waste- Records were maintained over a period of three months of the number of beds in different wards and in various wings, as well as the amount of waste generated each day. The Sagar wing, which is mainly concerned with Gynecology, is the biggest wing with 131 beds, generates approximately 62.54 kg/day. Sagar wing and Sharavati wing (95 beds) jointly contribute about 45% of the total waste.
  25. 25. CLINICAL WASTE MANAGEMENT Page 25 The ratio of non-infectious to infectious wastes in various sections in the study center was estimated. The data indicates that wards generate about 327 kg/day of non-infectious waste. This is about five times the quantity of infectious waste (63 kg/day) generated by the wards. The data also show the amount of non-infectious waste generated by the wards is about 74% of the total non-infectious waste generated by the entire hospital. The remaining 26% is generated in the OT/delivery room, OPD, Service Sector, Hospital Laboratory & Blood Bank and administrative block. The least amount of non-infectious waste is generated in the Hospital Laboratory & Blood Bank (BB) with approximately 1%, which is about 10 times less than the total infectious waste generated in the same block. Infectious wastes are not generated in OPD, Service Sector and the Administrative Block, because there is only paper movement and any instruments used for diagnosis are reused after sterilizing. However, approximately 54% of the total quantity of infectious waste is generated in the OT/ Delivery Room.It was found that about two-thirds of the total quantity of the waste is generated in the Wards, about 18% in OT, 7% OPD, 6% from the Service Sector and 6% from the Hospital Laboratory, Blood Bank and the Administrative Block combined. Approximately 521 kg/day of non-infectious and 102 kg/day of infectious waste with an approximate ratio of 5:1 is generated. About 622 kg/day of both non-infectious and infectious wastes are generated. From the records of in-patient register monitored over the study period, it was found that about 375 beds are occupied at any one time, with an average admission, discharge and death rate of about 47.04%, 48.16% and 1.45% respectively. The amount of waste generated per bed would be 2.31 kg/day. Ward No of beds Waste generated in kg For 1 day For 3 months Sharavati wing- semi private, private, cardiology, dialysis. Etc 95 66 5971 Sagar wing-female room, casualty, labour room, LG private room etc. 131 62.54 5628 Krishna wing- male surgical, semi private, private, ICU etc. 92 55 4958 Ghataprabha wing- MICU, SICU, private 100 51 4598 Cauvery wing- male medical, semi- private, private etc 78 36 3272 Malaprabha wing- Urology, neurology etc. 78 15 1733
  26. 26. CLINICAL WASTE MANAGEMENT Page 26 Total 574 289 25981 DISCUSSION- Waste management procedures- The personnel engaged in the process of segregation, handling and transport of waste were found to be skilled for the type of job they were doing and took adequate safety measures to protect them and prevent spillage, as they were aware of the potential hazards involved in this process. It was a general observation that the bin size was sufficient and the bins were always emptied before it was filled to the brim. Incineration room and its operating procedures- The incinerator room was located at the rear of the hospital, separated from the main building with sufficient space for easy movement of the trolleys and vans carrying the waste directly into the room where the segregated solid biomedical waste could be unloaded for incineration. It was observed that the hospital was extending its incineration facility at a very nominal price to the clinics and nursing homes in the city and in nearby areas with a dedicated team of staff for transport and collection of biomedical wastes for incineration at its site, once a day, every day. The operating conditions were found to be well monitored with periodic checks of the temperature of incineration. This institution has been rendering its services since June 1996 and until the date of the study period, no complaints had been made. However, a method has not been adopted to determine if the incineration process is complete except that the last load is fed two hours prior to the end of the burning cycle of the day and that the temperature is automatically and constantly maintained at 800C during incineration. This observation was very positive compared to a study undertaken in Delhi, India which reported that the low quality incinerators that have been installed in many hospitals are causing more harm than good because they operate at temperatures below 300C and discharge toxic emissions polluting the environment and causing a major public health hazard, and do not meet the standards set forth by the Bio-medical Waste Rules which states that the combustion efficiency must be at least 99% with zero emission standards of dioxins, furans, heavy metal vapours, harmful particles, by Bio-medical Rules. OBSERVATIONS & SUGGESTIONS-- In general, the management and treatment of biomedical solid waste in the study center conformed to the Bio-medical Solid Waste Rules (Management and Handling), 1998. At present, the hospital has a capacity of 574 beds, but is commissioned for 1000 beds. The total amount of non-infectious and infectious waste generated is approximately 2310 and 385 kg/day, respectively, which is well within the capacity of the installed incinerator. About 16.4%, the waste generated in this center is infectious. The hospital administration extends its incineration facilities to the clinics and nursing homes operating in the area by charging them very nominal fees. The facility’s records indicated that an average of 200 kg of waste is being handled from outside facilities. Some suggestions were made to the hospital staffs, which were well taken and
  27. 27. CLINICAL WASTE MANAGEMENT Page 27 appreciated. It was told to the authors that the suggestions would be taken to the hospital administration for discussion. The suggestions were as follows:  In order to achieve aesthetic appeal for the entire process of waste management, the collection of the non-infectious and infectious waste should start at the patient/visitor area so that a less full trolley moves along these areas. It was advised that the infectious wastes should be collected separately from the Laboratory and OT and should go directly to the incinerator and should not be transported through the patient area.  Rather replacing the polyethylene bags in the respective bins (with periodic disinfections of the bins), the bins should be collected each time and replaced with clean bins with the polyethylene bags already in them. The collected bins should be carried in separate trolleys to minimize the possibility of spillage.  Periodic meetings should be conducted involving administrative and maintenance staff that are directly or indirectly involved with waste management in order to share and discuss the technical or practical difficulties and provide suggestions that may be specific to a particular hospital and region.  A compulsory inducting training programme should be conducted for all new staff in the hospital to familiarize them with the operating procedures practiced in the hospital.  A Diploma Course in Hospital Waste Management should be initiated, keeping the needs of developing nations in mind.
  28. 28. CLINICAL WASTE MANAGEMENT Page 28 REFERECES-  Clinical solid waste management practices and its impact on human health and environment – A review. Md. Sohrab Hossain, Amutha Santhanam, N.A. Nik Norulaini, A.K. Mohd Omar. Received 15 July 2010, Accepted 5 November 2010. Journal-Waste management.  Biomedical solid waste management in an Indian hospital: a case study- Gayathri V. Patil, Kamala Pokhrel. Accepted 28 July 2004, Published 30 September 2004. Journal- Waste management  CPHEEO manual on solid waste management 2000.  State Environment report- Maharashtra. Prepared by-Indira Gandhi Institute of Development Research, Mumbai. Sponsored by- Maharashtra state pollution control board and Ministry of Environment & forest.    Management-MS-22-.html  