Prashanth H V et al. / JPBMS, 2011, 8 (09)

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ISSN NO- 2230 - 7885

Review Article JPBMS JOURNAL OF PHARMACEUTICAL AND BIOMEDICAL SCIENCES

Biomedical Waste Management: An Update *Dr. Prashanth H.V1, Dr. . Kavyashree A N 2, Dr. Saldanha Dominic R. M 3 M.D. Associate Professor Department of Microbiology, Sri Siddhartha Medical College, Tumkur. Karnataka, India. 2 MBBS., M.D. Assistant Professor, Department of Anatomy, Sri Siddhartha Medical College, Tumkur. Karnataka, India. 3 MBBS., M.D. Associate Professor Department of Microbiology, Kasturba Medical College, Mangalore. Karnataka, India.

1 MBBS.,

Abstract: Hospital waste generation has become a prime concern due to multidimensional ramifications as a risk factor to the health of patients, hospital staff and extending beyond the boundaries of the medical establishment to the general population. Hospital waste management has been brought into focus in India recently, particularly with the notification of Bio Medical Waste (BMW) (Management and handling) Rules 1998. The following are the elements of a comprehensive waste management system. Handling, segregation, mutilation, disinfection, storage, transportation and final disposal. Lack of concern, motivation, awareness and cost factor are some problems faced in the proper waste management. Appropriate education, training and the commitment of healthcare staff, management and healthcare managers within effective policy and legislative framework is required for effective hospital waste management.

Key Words: Biomedical Waste (Management and Handling) Rules, Biomedical waste management. Introduction:

In the 1980s and 1990s concerns about exposure to the human immunodeficiency virus (HIV) and hepatitis B virus (HBV) led to question about potential risks inherent in medical wastes [1]. Hospital waste generation has become a prime concern due to multidimensional ramifications as a risk factor to the health of patients, hospital staff and extending beyond the boundaries of the medical establishment to the general population [1, 2]. The proper disposal of these waste require a dynamic waste management plan that conforms to federal, state, and local regulations and provide adequate personnel and financial resources to ensure implementation. Hospital waste management has been brought into focus in India recently, particularly with the notification of Bio Medical Waste (BMW) (Management and handling) Rules 1998 [3].This rule applies to those who generate, collect, receive, store, dispose, treat or handle biomedical waste in any manner [4]. The rule makes it mandatory for the health care establishments to segregate, disinfect and dispose their waste in an ecofriendly manner [5].

Definition:

Biomedical waste is any waste generated during the diagnosis, treatment or immunization of human beings or in research activities pertaining thereto or in the production or testing of biological and including categories mentioned in Schedule I (Table 1) [3]. It is generated in hospitals, research institutions, health care teaching institutes, clinics, laboratories, blood banks, *Corresponding Author Dr Prashanth H V., Associate Professor, Dept of Microbiology, Sri Siddhartha Medical College, Tumkur. Karnataka, India. 572107 Contact No. : 09845336354.

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animal houses, Biotechnology institutions/ production units, mortuaries, dispensaries, and veterinary institutes [4,5]. These have a moral and legal obligation to dispose of these wastes in a manner that poses minimal potential hazard to the environment or public health. Table 1: Categories of Biomedical Waste. Option Category No. 1 Category No. 2

Category No. 3

Category No.4

Category No. 5

Waste category Human anatomical waste (human tissues, organs, body parts) Animal waste (animal tissues, organ, body parts carcasses, bleeding parts, fluid, blood and experimental animals used in research, waste generated by veterinary hospital colleges, discharges from hospital, animal house.) Microbiology and biotechnology waste (waste from laboratory cultures, stocks or specimen of microorganisms live or attenuated vaccines, human and animal cell culture used in research and infectious agents from research and industrial laboratories, waste from production of biological, toxins dishes and devices used for transfer of cultures) Waste sharps (needles, syringes, scalpel, Blades, glass etc. that may cause puncture and cuts. This includes both used and unused sharps) Discarded medicines and cytotoxic drugs (waste comprising of outdated, contaminated and discarded medicines)

Treatment and Disposal Incineration */ deep burial. † Incineration*/ deep burial. †

Local autoclaving/ microwaving/incine ration*

Disinfection(chemic al treatment‡/ autoclaving/ microwaving and mutilation/ shredding §) Incineration*/ destruction and drugs disposal in secured landfills.

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Category No. 6

Category No. 7

Category No. 8 Category No. 9

Soiled waste (items contaminated with blood, body fluids including cotton, dressing, soiled) plaster casts. Lines beddings, other material contaminated with blood. Solid waste (waste generated from disposable items other than the waste sharps such as tubings, catheters, intravenous sets etc.) Liquid waste (waste generated from laboratory and washing, cleaning, house keeping and disinfecting activities)

Incineration ash (ash from incineration of any biomedical waste) Chemical waste (chemical used in production of biologicals, chemicals used in disinfection, as insecticides etc.)

Autoclaving/ microwaving/ incineration* Disinfection (chemical treatment ‡/ Autoclaving/micro waving and mutilation/ shredding§) Disinfection by chemical treatment‡ and discharge in to drains. Disposal in municipal landfill

Chemicals treatment ‡ and Category discharge into No. 10 drains for liquids and secured landfill for solids. * There will be no chemical pretreatment before incineration. Chlorinated plastics shall not be incinerated. † Deep burial shall be an option available only in towns with population less than five lakhs and in rural areas. ‡ Chemical treatment using atleast 1% hypochlorite solution or any other equivalent chemical reagent. It must be ensured that chemical treatment ensures disinfection. § Mutilation/ shredding must be such as to prevent unauthorized reuse. Table 2: Classification of Health-Care Waste. Waste Description and examples category Waste suspected to contain pathogens e.g. laboratory cultures; waste from isolation wards; tissues Infectious (swabs), materials, or equipments that have been in waste contact with infected excreta. Pathological waste Sharps

Pharmaceutical waste Genotoxic waste Chemical waste

Waste with high content of heavy metals Pressurized containers Radioactive waste

Human tissues or fluids e.g. body parts; blood and other body fluids; fetuses Sharp waste e.g. needles; infusion sets; scalpels; knives; blades; broken glass. Waste containing pharmaceuticals e.g. pharmaceuticals that are expired or no longer needed; items contaminated by or containing pharmaceuticals (bottles, boxes). Waste containing substances with genotoxic properties e.g. waste containing cytostatic drugs (often used in cancer therapy); genotoxic chemicals. Waste containing chemical substances e,g, laboratory reagents; film developer; disinfectants that are expired or no longer needed; solvents Batteries; broken thermometers; blood-pressure gauges; etc Gas cylinders; gas cartridges

Waste containing radioactive substances e.g. unused liquids from radiotherapy or laboratory research; contaminated glassware, packages, or absorbent paper; urine and excrete a from patients, treated or tested with unsealed radio nuclides; sealed sources

Steps in Waste Management:

Medical waste should be managed at every step from acquisition to disposal according to its type and characteristics [5]. The following are the elements of a comprehensive waste management system. Handling, segregation, mutilation, disinfection, storage, transportation and final disposal [7].

Segregation:

The key to minimization and effective management of biomedical waste is segregation (separation) and identification of waste. The most appropriate way of identifying the categories of biomedical waste is by sorting the waste into colour coded plastic bags or containers [2]. Biomedical waste should be segregated into containers/bags at the point of generation in accordance with schedule II of biomedical waste (management and handling) rules 1998 as given in Table 3 [6]. It helps to reduce the bulk of infectious waste as well as treatment costs. Segregation also helps to contain the spread of infection and reduces the chance of infecting other health workers. General waste like garbage, garden refuse etc should join the stream of domestic refuse. Sharps should be collected in puncture proof containers. Bags and containers for infectious waste should be marked with Biohazard symbol (Figure 1). Cytotoxic wastes are to be collected in leak proof containers clearly labeled as cytotoxic waste [2]. Needles and syringes should be destroyed with the help of needle destroyer and syringe cutters provided at the point of generation. Infusion sets, bottles and gloves should be cut with curved scissors.

Table 3: Colour Coding and Type of Container for Disposal of Biomedical Wastes. [4] Colour Type of Waste Treatment options as per schedule I coding container category Plastic bag Cat 1, Cat 2, Incineration/deep Yellow and Cat 3, burial. Cat 6 Disinfected Cat 3, Cat 6, Autoclaving/Microwa Red container/ Cat 7 ving/ chemical plastic bag treatment Plastic bag/ Cat 4, Cat 7 Autoclaving/ Blue/wh puncture Microwaving/ ite proof Chemical treatment transluc container and Destruction/ ent Shredding Plastic bag Cat 5, and Cat Disposal in secured Black 9 and Cat 10 landfill (solid) Notes: 1. Colour coding of waste categories with multiple treatment options as defined in schedule I, shall be selected depending on the treatment option chosen, which shall be as specified in schedule I. 2. Waste collection bags for waste types needing incineration shall not be made of chlorinated plastics. 3. Categories 8 and 10 (liquid) do not require containers/ bags. 4. Categories 3 if disinfected locally need not be in containers/ bags.

Categories of Biomedical Waste:

Ten categories of biomedical waste have been described in schedule I of BMW rules 1998 (Table 1) [3].

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Disinfection of sharps, soiled linen, and plastic and rubber goods is to be achieved at point of generation by usage of sodium hypochlorite with minimum contact of 1 hour. Fresh solution should be made in each shift. The medical waste should be completely free of pathogenic bacteria before disposal. This would ensure maximum public hygiene quality [5]. On site collection requires staff to close the waste bags by tying the neck or by sealing the bags. Kerb side storage area needs to be impermeable and hard standing with good drainage. It should provide an easy access to waste collection vehicle [2].

Waste Accumulation and Storage:

Waste accumulation and storage can occur between the point of waste generation and the site of waste treatment or disposal. Accumulation refers to the temporary holding of small quantities of waste near the point of generation. Storage of waste is characterized by longer holding periods and larger waste quantities. The storage area is usually located near where waste is treated, loaded for transport or disposed of. The Storage area requires special ventilation features such as use of high efficiency particulate air (HEPA) filters. It should not have floor drains, floors and walls should be impervious to liquids and easy to clean [1]. They should be disinfected regularly. Refrigeration may be required for prolonged storage of putrifiable and other wastes. Storage area should be posted with ‘Explicit signs’ [5]. No untreated biomedical waste shall be kept stored beyond a period of 48 hours.

Waste Transportation and Disposal:

When medical waste is not treated on site, untreated waste must be transported from the generating facility to another site for treatment and /or disposal [1]. Biomedical waste should be transported within the hospital by means of wheeled trolleys, containers or carts that are not used for any other purpose. The trolleys have to be cleansed daily. Off side transportation vehicle should be marked with the name and address of carrier. Biohazard symbol should be painted. Suitable system for securing the load during transport should be ensured. Such a vehicle should be easily cleanable with rounded corners. Final treatment of biomedical waste can be done by technologies like incineration, autoclave, microwave or hydroclave. Biomedical waste disposal methods are tabulate in Table I [4]. Every hospital generating, collecting, receiving, storing, transporting, treating, disposing and handling biomedical waste has to make an application accompanied by prescribed fee to the state pollution control board or authority prescribed by them for grant of authorization. Every occupier/operator has to submit an annual report to the prescribed authority every year, to include information about the categories and quantification of biomedical waste handled during the preceding year. Every hospital should maintain records related to handling of biomedical waste. When any accident involving biomedical waste occurs at any institution or facility or any other site where biomedical waste is handled or during transportation of such waste, the authorized person shall report the accident to the prescribed authority forthwith [8].

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Disposal by burning is the most satisfactory method of disposal of solid waste which is recommended for disposal of all hospital waste. In thermal treatment, the principle mechanism of waste destruction is the use of high temperature and/ excess air. Thermal incineration is also preferable for disposal of hazardous wastes because of its high efficiency in destroying organic materials. Various kinds of thermal equipments which are used for treatment of hospital waste are the autoclave, the microwave system and the incinerator. The process of autoclaving of sterilization by steam under high pressure is now also available for final treatment of hospital biomedical waste. The important point to note that proper temperature, pressure and holding time have to be matched to achieve desired level of sterilization. Autoclaving reduces the volume of waste by a small amount, with plastic material melted and disfigured. Addition of equipment like shredder, grinder and compactor helps in shredding, pulverizing and compacting the waste. This helps in volume reduction. Microwaves are electromagnetic waves which enter into or penetrate materials. When exposed to microwave energy, molecules of a mass are put to vibration which produces heat resulting in disinfection. Maintenance of temperature of 95oC to 100oC for a holding time of 25 minutes ensures that all microorganisms are killed. Unlike autoclaving microwave process is a more automated process. It results in volume reduction of waste upto about 80% of its original mass. However one major disadvantage is that it is not able to penetrate large objects like amputated limbs and similar anatomical waste. It capital cost and operational cost are quite high besides requiring skilled operators [8]. Incineration is a process by which combustible material is burned at high temperature under controlled condition to convert waste into harmless mineral residue and gases. Characteristics of waste suitable for incineration are: 1) Low heating volume – above 2000 Kcal/Kg for single chamber incinerators and above 3500 Kcal/Kg for pyrolytic double chamber incinerators. 2) Content of combustible matter above 60%. 3) Content of non combustible matter below 50%. 4) Content of non combustible fines below 20%. 5) Moisture content below 30%. Waste types not to be incinerated are: 1) Pressurized gas containers. 2) Large amount of reactive chemical wastes. 1) Silver salts and photographic or radiographic wastes. 2) Halogenated plastics such as PVC. 3) Waste with high mercury or cadmium content such as broken thermometers, used batteries. 4) Sealed ampoules or ampoules containing heavy metals.

Types of Incinerators: 1)

Single chamber furnaces with static grate. These should be used only if pyrolytic incinerators are not affordable. 2) Double Chamber Pyrolytic Incinerators. These are the most commonly used incinerators. In the first (pyrolytic) chamber, waste is destroyed through an oxygen deficient, medium temperature combustion process (800°C).This produces solid ashes and gases. In the second chamber gases are burnt at a high temperature (900-1200° C) using an excess of air to Journal of Pharmaceutical and Biomedical Sciences (JPBMS), Vol. 08, Issue 08

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minimize smoke and odor. This type of incinerator is somewhat expensive and requires trained personnel to handle it. 3) Rotary Kilns. It comprises of rotating oven and a post combustion chamber. They are used to burn chemical wastes (chemicals, pharmaceuticals including cytotoxic drugs) [9].

Landfill Disposal:

It is another method of final disposal of BMW. If a municipality or medical authority genuinely lacks the means to treat the waste before disposal, sanitary landfill observing certain standards can be as an acceptable choice especially in developing countries. Standards for deep burial: 1. A pit or trench should be dug about 2 meters deep. It should be half filled with waste, and then covered with lime within 50 cm of the surface, before filling the rest of the soil with soil. 2. It must be ensured that animals do not have any access to burial site. 3. On each occasion, when wastes are added to the pit, a layer of 10 cm of soil shall be added to cover the wastes. 4. Deep burial site should be relatively impermeable and no shallow well should be close to the site. The site should be away from the residential area and the vicinity of drinking water so as to avoid the risk of pollution. 5. The location of deep burial site will be authorized by the prescribed authority. 6. The institution shall maintain a record of all pits for deep burial [3].

On Site versus off Site Treatment of Medical Waste:

Onsite treatment is favoured by generators who produce small volumes of medical waste and by those who want more control over the treatment and disposal of their wastes and their associated liabilities. It is the choice of institutions that are distant from a commercial service area. It has the burden and costs of operation. Off site medical treatment is in states and urban location where medical waste is subject to greater scrutiny and community concern. It entails the use of either a commercial or a co operative owned facility [1].

Plastic in Health Care:

Disposable syringes, bottles, bottles, blood and urobags, catheters, surgical gloves etc are some of the examples of plastic usage in healthcare. Plastic has been associated with decline in sperm count, genital abnormalities and a rise in the incidence of breast cancer. Burning of plastics releases carcinogens like dioxin and furan. Once hailed as wonder material plastic is now a serious environmental and health concern, essentially due to its nonbiodegradable nature. The options for plastic waste disposal are environmentally, compatible long term land filling or recycling. All disposable plastic should be subjected to shredding before disposing off to vendor. Designing ecofriendly, biodegradable plastic are the need of the hour. Minimizing the generation of plastic waste is also very important [5].

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Waste Minimization:

Waste minimization is an important aspect of medical waste management. It is best implemented through a waste management program that emphasizes source reduction and recycling of wastes. Source reduction means reducing the quantities of waste generated. It can be done by 5) Strict definition of waste types accompanied by source separation of the different waste streams. 6) Substitution of products that generate less waste [1]. Recycling reduces the quantities of waste generated by reusing certain materials with or without prior reprocessing, rather than discarding them. The cost for disposal of infectious waste may be ten times the cost for disposal of ordinary solid waste. Any measures that decrease the amount of infectious waste generated will simultaneously decrease the cost of infectious waste disposal [5]. Proper management is essential for implementation of a waste minimization program. The good management includes an employee awareness program, employee training, purchasing strategies and inventory control [1].

Emphasis on Recycling:

Recycling of disinfected waste need to be emphasized and the new amendments in BMW is this regard is expected shortly. The autoclavable plastics, glass tubes and petri plates after disinfection can be washed and reused. The disinfected plastic waste could be shredded and then passed on for plastic recycling. For the fear of use of the duplicated supplies or unauthorized usage, the mutilation or shredding of glass is also suggested in the BMW rules [10].

Specific Guidelines for Handling Sharps:

Sharps are defined as comprising of needles, syringes, scalpels, blades, glass, i.e. anything that may cause puncture and cuts. These include both used and unused sharps. The rules provide for disinfection and mutilation of sharps by either chemical treatment using at least 1% hypochlorite solution or any other equivalent chemical agent. Mutilation prior to disposal is mandatory. Mutilation can be carried out at point of generation by using needle cutters/ destroyers or centrally in the hospital by using shredders. After this they should be disposed in secured landfills.

Safe pit for Sharps:

To avoid recycling of sharps, their burial in safe pit is an effective and economical disposal method. It can be constructed by 5 feet deep circular concrete ring of 3’ diameter. A slab is used on top in which GIC pipe with 5” or 6” diameter is used which is fitted lock and key arrangements. Size of the pit may vary as per the quantum of sharp waste to be disposed of. The pit is plastered inside at bottom and around. When it is filled up, cement slurry can be used to close it and second pit is constructed [9].

Cost of Biomedical Waste Management:

Cost is often the decisive factors in decisions pertaining to medical waste management. The cost of construction,

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operation and maintenance of system for managing waste represents a significant part of overall budget of a hospital if the BMW handling rules have to be implemented. Self contained on site treatment methods may be desirable and feasible for large healthcare facilities. They will not be practical or economical for smaller institutes. An acceptable common system should be in place which will provide regular supply of colour coded bags, daily collection of infectious waste, safe transportation of waste to off site treatment facility and final disposal with suitable technology [2]. Safe and effective management of waste is not only a legal necessity but also a social responsibility. Lack of concern,

motivation, awareness and cost factor are some problems faced in the proper waste management [5]. The biomedical waste management should go beyond data compilation, enforcement of regulations and acquisition of better equipment. An effective communication strategy is imperative keeping in view the low awareness level among different category of staff in the health care establishments regarding biochemical waste management [7]. It should be supported through appropriate education, training and the commitment of healthcare staff, management and healthcare managers within effective policy and legislative framework. Such a system provides benefits of risk minimization regulatory compliance, cost containment, liability reduction and promotion of good community relations.

1. Gordon JG, Reinhardt PA, Denys GA., Medical waste management. In: Mayhall, CG, editor. Hospital Epidemiology and Infection Control. 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 2004. p. 1773-85. 2. Rao SKM, Ranyal RK, Bhatia SS, Sharma VR. Biomedical waste management: An Infra structural Survey of hospitals. MJAFI. 2004; 60(4): 371-82. 3. Biomedical Waste (management and Handling) Rules (1998). Mininstry of Environment and Forests Notification, Government of India July 27; 1998. 4. Park K. Hospital Waste Management. In: Park K editor. Park’s Textbook of Preventive and Social Medicine.20th ed. Jabalpur: M/s Banarasidas Bhanot Publications; 2009. p. 694-699. 5. Hedge V, Kulakarni RD, Ajantha GS. Biomedical Waste Management. JOMFP. 2007; 11(1): 5-9.

6. Radha KV, Kalaivani K, Lavanya R.. A Case Study of Biomedical Waste Management in Hospitals. Global Journal of Health Science. 2009; 1(1): 82-88. 7. Acharya DB, Singh Meeta. The book of Hospital Waste Management. New Delhi: Minerva press; 2000: 15-47. 8. Sakharkar BM, editor. Salient points of biomedical waste rules. In: Principles of Hospital Administration and Planning. 2nd ed. New Delhi: Jaypee Brothers; 2009. p. 367-369. 9. Singh VP, Biswas G, Sharma JJ. Biomedical waste management –An Emerging Concern in Indian Hospitals. Indian Journal of Forensic Medicine and Toxicology. 2007; 1(1): 7-12. 10. Chitnis V, Vaidya K, Chitins DS. Biomedical waste in laboratory medicine: Audit and Management. Indian Journal of Medical Microbiology.2005; 23:6-13.

Conclusion:

Reference:

Conflict of Interest: - None Source of funding: - None

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