Disposal of Clinical Wastes:

Tata Memorial Hospital Experience

Dr Rohini Kelkar
M.D., D.P.B.

Professor & Head, Dept of Microbiology

Tata Memorial Hospital, Mumbai

No one was
ever really
taught.
Each has to
teach himself.
Swami
Vivekananda

The Reality
Ignorance
Commercialization of science
Apathy
The Concerns
Occupational
Public health
Environmental

The Science

The only documented risk of transmission of infections from waste to

healthcare workers is through sharps

There is however a potential for transmission of several microbial

infections due to dumping of untreated wastes by healthcare facilities.

Mixing of a small quantity of infectious waste with municipal garbage

converts the entire waste to infectious

Segregation of wastes at source followed by appropriate treatment is the

key to the success of a waste management strategy

Hospital waste

Hazardous
Noninfectious

Non-hazardous
Infectious
Kitchen

Cytotoxic drugs

Recyclables

Toxic Chemicals
Radioactive

Sharps: needles, scalpel

blades, scalp veins, glass
contaminated with blood

Non-sharps

Patient
contaminated
waste

Laboratory
waste

Specimens

Plastics
PVC, PE PET, PS

Equipment

Non-plastics
contaminated cotton
waste, gauze, linen

Anatomical

The Social Issue: Ragpickers

The TMH Pathway

Closure of the incinerator

Awareness programs for all the staf
Refashioning the storage area
Street play
Posters

Incinerator circa 1994

C
1.

A
E
L

D
Y
RL

N
I
EF

E
H
T
E

O
R
P

M
E
BL

Segregation at source into defined categories

using a simplified system.

2. FOCUS ON SEGREGATION FIRST

Appropriate placement
of Colour Coded Bins

Radioactive Waste

Sharps Disposal

3. INSTITUTE A SHARPS
MANAGEMENT SYSTEM

Waste Audit

4. KEEP FOCUS ON REDUCTION

About Sharps:
The only documented transmission of infection from waste to HCWs is
through sharp injuries. Thus safe disposal of sharps is the first priority.

Sharp injuries:
Before or during use (17%)
After Use but before disposal (70%)
During or after disposal (13%)
(Our Experience: Majority of sharp injuries occur due to improper disposal
and waste handlers are the victims)

5. ENSURE WORKER SAFETY

THROUGH EDUCATION, TRAINING
AND PROPER PERSONAL
PROTECTIVE EQUIPMENT

Safe Disposal of Sharps:

Do not recap needles.
If essential learn the
right way to do so.

Collection network.
.
6. PROVIDE
SECURE COLLECTION
AND TRANSPORTATION

Waste management Strategy:

1. Reduce Risks and Liabilities: This should be detailed through written
policies and continuing training and education of hospital staf.

2. Control Costs: Audit of current practices, search for waste

minimization practices is a continuing process.

3. Plan for Future: Look for alternative technologies, co-operative

facilities and means of diversification.

4. Commitment towards protecting Human Health and the

Environment

7. DEVELOP PLANS AND POLICIES

Infection
Awareness
Week

8.

E
V
IN

T
S

IN

A
R
T

I
IN

G
N

Street
Play

9. DEVELOP THE INFRASTRUCTURE

10. Evaluation of Technologies

Evaluation of Non Burn

Technologies for
Medical Waste
Treatment

1. Demonstrated
Performance
Category
1.1

Stage of Development

1.2

Number of Operational Systems

1.3

Year of Successful Operations

Rating

Weight

Score

2. Technical &
Performance Criteria
Category
2.1

Process Capacity

2.2

Waste Exclusions or Limitations

2.3

Waste Size Limitations

2.4

Weight Change

2.5

Volume Change

2.6

Recognizability / Disfigurement

2.7

Decontamination

2.8

Performance Data

Rating

Weight

Score

3. Vendor
Qualifications
Category
3.1

Number of Vendors

3.2

Vendor Resources

3.3

Vendor Diversity and Services

Rating

Weight

Score

4. Environmental &
Permitting Issues
Category
4.1

Air Emissions

4.2

Liquid Effluents

4.3

Treated Residues

4.4

Permit ability

4.5

Public Perception

Rating

Weight

Score

5. Occupational
Health & Safety
Issues
Category
5.1

Routine Exposures

5.2

Maintenance and Repair Exposures

Rating

Weight

Score

6. Facility: &
Infrastructural
Requirements
Category
6.1

Space Requirements

6.2

Construction Requirements

6.3

Utility Requirements

6.4

Space / Facility Requirements

Rating

Weight

Score

7. Economics
Category
7.1

Capital Costs

7.2

Annual Costs

7.3

Life-Cycle Costs
GRAND TOTAL SCORE

Rating

Weight

Score

Inauguration of Tata Memorial Hospital waste treatment facility

On September 10, 1999, well before the first dead line set by
the Ministry of Environment and Forest, 31 December 1999.

Selection of Technology and

Implementation is not the setting sun

Evaluation is a continuous process

TMH Waste Audit Nov. 1999 to Dec. 2007

2000

2001

2002

2003

2004

2005 2006

2007

Max. medical
waste collected in
a day

341

394

350

362

396

530 429

514

Average no. of
loads required/day

217

224

176

241

250

Average medical
waste collected in
a month

5,498

5,643

5,266

5,917

6,284

Percentage down
time of the system

1.6

5.7

4.8

5.8

8.2

Average medical
waste treated in
kgs/day

4 4
289 253

7,225 6,369

0 10

Total infectious waste treated 614 tonnes.

83,511 kg. in 2007. Cost of treatment = Rs.
14.86 / kg.

4
277

6,959

1.2

TMH Infectious Waste Audit 2008 - 2009

2008

2009

Max. medical
waste collected in
a day

447

505

Average no. of
loads required/day

Average medical
waste treated in
kgs/day

298

304

Average medical
waste collected in
a month

7,623

7,674

Percentage down
time of the system

0.33

Total infectious waste treated 2000-2009= 800

tonnes.
Cost of treatment = Rs. 14 / kg.

TMH Waste Management

Waste is Sterilized, Dehumidified, Shredded and

reduced in terms of Weight and Volume by 75%.
It is not recognizable as Medical Waste

Hazardous Waste

Environment News
Greenpeace
March 7th, 2001
KODAIKANAL, India -- Greenpeace
today accused Anglo-Dutch
multinational Unilever, owners of
Lipton Tea and Dove soap, of double
standards and shameful negligence
for allowing its Indian subsidiary,
Hindustan Lever, to dump several
tonnes of highly toxic mercury waste
in the densely populated tourist resort
of Kodaikanal and the surrounding
protected nature reserve of Pambar
Shola, in Tamilnadu, Southern India.

On 15 April, 2005, a 51 year-old

asbestos laden ship, Kong Fredrick IX
was on its way to Alang ship breaking
yard, Gujarat for scrapping.
The ship's new owners Jupiter Ship
Management, a Mumbai based
company, had renamed it to 'MV Riky'.
Connie Hedegaard, Denmark's
environment minister alerted the
Indian environment minister saying,
"I believe our interests are joint - and I
call on you to co-operate in this case
by denying the ship to be dismantled
in India - and refer the ship to return to
Denmark to be stripped of the
hazardous waste."

Indias significant economic growth and

rise in industrialization coupled by lax
government enforcement of anti-pollution
laws and regulations have had a
detrimental effect on Indias natural
environment.
Hazardous
waste
from
industrial
processes, medical waste and Indias
thriving scrap recycling businesses pollutes
Indian air, soils and waterways.

India is a signatory to the three

conventions on hazardous chemicals and
waste:
The Basel Convention on the Control of
Trans-boundary Movement of Hazardous
Waste and their Disposal,
The Rotterdam Convention on the Prior
Informed Consent Procedure for Certain
Hazardous Chemicals and Pesticides in
International Trade and
The Stockholm Convention of Persistent
Organic Pollutants.

The Hazardous Substances Management Division (HSM)

of the Ministry of Environment and Forests (MoEF) has
the responsibility for promoting safe management and
use of hazardous substances, including hazardous waste.
The HSM has established three sets of rules:
The Hazardous Wastes (Management and Handling)
Rules (1989, amended in 2003),
The Bio-medial Wastes (Management and Handling)
Rules (1998/2000), and
The Batteries (Management and Handling) Rules (2001).

The HSM relies primarily on the

The Central Pollution Control Board (CPCB),
The State Pollution Control Boards (SPCBs) or State
Pollution Control Committees (SPCCs), and
The environmental departments in Indias 25 states
to implement, monitor and prosecute.

Approximately 5 million tonnes of hazardous waste is

produced annually in India.
According to a 2003 report, Indian industries in the
following five states had generated over 80% of the
countrys hazardous waste:
Andhra Pradesh,
Gujarat,
Karnataka,
Maharashtra and
Tamil Nadu.

European Commission focus on waste management

Landfill
CH4,

Composting

Incineration

Recycling

Transportation

Emission
of
CH4,
CO2;
odours

Emission of SO2, NOx,

HCl, HF, NMVOC,
CO, CO2 N2O, dioxins,
dibenzofurans, heavy
metals(Zn, Pb, Cu, As)

Emissions
dust

of

Emissions of dust
NOx, SO2, release of
hazardous
substances
from
accidental spills

Air

Emission of
CO2; odours

Water

Leaching of salts,
heavy
metals,
biodegradable and
persistent organics
to groundwater

Deposition
of
hazardous substances
on surface water

Waste water
discharges

Risk of surface water

and
groundwater
contamination from
accidental spills

Soil

Accumulation
of
hazardous
substances in soil

Landfilling of slags,
fly ash and scrap

Landfilling of
final residues

Risk
of
soil
contamination from
accidental spills

Pitfalls of the currently available technologies for managing wastes

European Commission focus on waste management

Landfill

Composting

Incineration

Recycling

Transportation

Landscape

Soil occupancy;
restriction
on
other land uses

Soil occupancy;
restriction
on
other land uses

Visual intrusion;
restriction
on
other land uses

Visual
intrusion

Traffic

Ecosystems

Contamination
and
accumulation of
toxic substances
in the food chain

Contamination
and
accumulation of
toxic substances
in the food chain

Contamination
and accumulation
of
toxic
substances in the
food chain

Urban areas

Exposure
hazardous
substances

to

Exposure
hazardous
substances

to

Risk
of
contamination
from accidental
spills
Noise

Risk
of
exposure
to
hazardous
substances from
accidental
spills; traffic

Pitfalls of the currently available technologies for managing wastes

E-waste
How green is your Apple?
Aug 25th 2006
From The Economist print edition

God proposes,
man disposes

Waste and taste

Dec 11th 2006
From Economist.com
The rubbish tip as cultural artefact
FRESH Kills landfill in New York, until
recently the biggest rubbish tip on earth,
was said to be one of the very few manmade objects visible from space, along
with the Great Wall of China.

LIST OF WASTE SUBSTANCES WITH CONCENTRATION

LIMITS
Class A
Ministry of Environment &
Concentration limit: 50 mg/kg
Forests:
A1 Antimony and antimony compounds
A2 Arsenic and arsenic compounds
Hazardous Wastes
A3 beryllium and cadmium compounds
(Management and Handling)
A4 Cadmium and beryllium compounds
Amendment Rules, 2002
A5 Chromium (VI) compounds
A6 Mercury and mercury compounds
A7 Selenium and selenium compounds
A8 Tellurium and tellurium compounds
A9 Thallium and thallium compounds
A10 Inorganic cyanide compounds (cyanides)
A11 Metal carbonyls
A12 Napthalene
A13 Anthracene
A14 Phenanthrene
A15 Chrysene, benzo(a) anthracene, fluoranthene, benzo(a) pyrene,
benzo(K)fluoranthene, indeno(1, 2, 3-ed) pyrene and benzo(ghi)perylene
A16 Halogenated fused aromatic rings, e.g. polychlorobiphenyls plus derivatives
A17 Halogenated aromatic compounds
A18 Benzene
A19 Dieldrin, aldrin, and endrin
A20 Organotin compounds

LIST OF WASTE SUBSTANCES WITH CONCENTRATION

Class B
LIMITS
Concentration limit: 5,000 mg/kg
B1 Chromium (III) compounds
B2 Cobalt compounds
Ministry of Environment &
B3 Copper compounds
Forests:
B4 Lead and lead compounds
B5 Molybdenum compounds
Hazardous Wastes
B6 Nickel compounds
(Management and Handling)
B7 Tin compounds
B8 Vanadium compounds
Amendment Rules, 2002
B9 Tungsten compounds
B10 Silver compounds
B11 Organic halogen compounds
B12 Organic phosphorus compounds
B13 Organic peroxides
B14 Organic nitro-and nitroso-compounds
B15 Organic azo-and azo-oxy compounds
B16 Nitriles
B17 Amines
B18 (Iso-and thio-) cyanates
B19 Phenol and phenolic compounds
B20 Merceptans
B21 Asbestos
B22 Drilling, cutting, grinding and rolling oil or emulsions thereof
B23 Halogen-silanes
B24 Hydrazine(s)
B25 Fluorine
B26 Chlorine
B27 Bromine
B28 White phosphorus
B29 Ferro-silicon and alloys
B30 Manganese-silicon
B31 Halogen-containing substances which produce acidic vapours on contact with damp air or water, e.g. silicon tetrachloride,

LIST OF WASTE SUBSTANCES WITH CONCENTRATION

LIMITS
Class C
Concentration limit: 20,000 mg/kg

Ministry of Environment &

Forests:
Hazardous Wastes
(Management and Handling)
Amendment Rules, 2002

C1 Ammonia and ammonium compounds

C2 Inorganic peroxides
C3 Barium compounds, except barium sulphate
C4 Fluorine compounds
C5 Phosphorus compounds, except the phosphates of aluminum, calcium and iron
C6 Bromates, (hypo)bromites
C7 Chlorates, (hypo)chlorites
C8 Aromatic compounds
C9 Organic silicon compounds
C10 Organic sulphur compounds
C11 Iodates
C12 Nitrates, nitrites
C13 Sulphides
C14 Zinc compounds
C15 Salts of per-acids
C16 Acid halides, acid amides
C17 Acid anhydrides

LIST OF WASTE SUBSTANCES WITH CONCENTRATION

LIMITS

Class D

Ministry of Environment &

Forests:
Hazardous Wastes
(Management and Handling)
Amendment Rules, 2002

Concentration limit: 50,000 mg/kg

D1 Sulphur
D2 Inorganic acids
D3 Metal bisulphates
D4 Oxides and hydroxides except those of: hydrogen, carbon, silicon,
iron, aluminum, titanium, manganese, magnesium, calcium
D5 Aliphatic and napthenic hydrocarbons
D6 Organic oxygen compounds
D7 Organic nitrogen compounds
D8 Nitrides
D9 Hydrides

LIST OF WASTE SUBSTANCES WITH CONCENTRATION

LIMITS

Class E

Ministry of Environment &

Forests:
Hazardous Wastes
(Management and Handling)
Amendment Rules, 2002

Regardless of concentration limit

E.1 Highly flammable substances
E.2 Substances which generate dangerous quantities of
highly flammbale gases on contact with water or damp air.

LIST OF PROCESSES GENERATING HAZARDOUS

WASTES
Ministry of Environment & Forests
Hazardous Wastes (Management and Handling) Amendment Rules, 2003
1 Petrochemical processes and pyrolytic operations
2 Drilling operation for oil and gas production
3 Cleaning, emptying and maintenance of petroleum oil storage tanks including ships
4 Petroleum refining/re-refining of used oil/recycling of waste oil
Industrial operations using mineral/synthetic oil as lubricant in hydraulic systems or
5 other applications
6 Secondary production and/or use of zinc
Primary production of zinc/lead/copper and other non-ferrous metals except
7 aluminium
8 Secondary production of copper
9 Secondary production of lead
10 Production and/or use of cadmium and arsenic and their compounds
11 Production of primary and secondary aluminium

LIST OF PROCESSES GENERATING HAZARDOUS

WASTES
Ministry of Environment & Forests
Hazardous Wastes (Management and Handling) Amendment Rules, 2003
Metal surface treatment, such as etching, staining, polishing, galvanising, cleaning,
12 degreasing, plating, etc.
Production of iron and steel including other ferrous alloys (electric furnaces; steel
13 rolling and finishing mills; Coke oven and by product plant)
14 Hardening of steel
15 Production of asbestos or asbestos-containing materials
16 Production of caustic soda and chlorine
17 Production of acids
18 Production of nitrogenous and complex fertilizers
19 Production of phenol
20 Production and/or industrial use of solvents
Production and/or industrial use of paints, pigments, lacquers, varnishes, plastics and
21 inks
22 Production of plastic raw materials

LIST OF PROCESSES GENERATING HAZARDOUS

WASTES
Ministry of Environment & Forests
Hazardous Wastes (Management and Handling) Amendment Rules, 2003
23 Production and/or industrial use of glues, cements, adhesive and resins
24 Production of canvas and textiles
25 Industrial production and formulation of wood preservatives
26 Production or industrial use of synthetic dyes, dye-intermediates and pigments
27 Production or industrial use of materials made with organo-silicone compounds
28 Production/formulation of drugs/ pharmaceuticals
29 Production, use and formulation of pesticides including stock-piles
30 Leather tanneries
31 Electronic Industry
32 Pulp & Paper Industry
33 Disposal of barrels / containers used for handling of hazardous wastes / chemicals
34 Purification processes for air and water
35 Purification process for organic compounds/solvents
Waste treatment processes, e.g. incineration, distillation, separation and concentration
techniques

REPORT ON CLINICAL WASTE AUDIT 2005

Infectious waste treated from Jan-Dec 2005

86,704 Kilograms

Average waste treated per month

7,225 Kilograms

Weight of sharps treated in 2005

2,917 Kilograms

Average weight of sharps treated per month

Blood & blood products

243 Kilograms
300 liters

Liquid Wastes:
Total effluent per month

164 lakh litres

Laundry effluent per month

3 lakh litres

Xray developer per month

140 litres

Hazardous liquids consumed in labs per month

588 litres

Hazardous chemicals as solids weight per month

260 grams

Dilution factor of hazardous liquids 27,333.

Sr. No

Chemicals / Reagents

10% Formalin

Xylene

Basic fuchsin

Haematoxylin stain

Nitric Acid

50.5

Anhydrous Aluminum
Chloride

.005

Hydrochloric acid

.800

Diamino benzidine

20.0

Hydrogen peroxide

53.202

10

Glacial acetic acid

5.225

11

Gluteraldehyde

12

Ethidium bromide

.001

13

Propane / Butane

2.500

14

WD40 (Petroleum distillate)

15

Benzoin tincture

16

Lugols Iodine

17

Phenol (carbolic acid)

18

Ammonia solution

.050

19

Lactic acid

.045

20

Sulfuric acid

.100

Total

Lits.
100
190.1
1.17
1.0

150.500

2.00
10.00
0.42
1.000

588.19

Hazardous liquid
waste / month:

Hazardous solid waste / month:

Sr. No

Chemicals / Reagents

Benzidine dihydrochloride

Naphthol phosphate

Pararosaline hydrochloride

Sodium-fluoride

Potassium dihydrogen phosphate

8.500

Dipotassium hydrogen phosphate

8.500

Benzidine G.R.

Zine sulphate

Barium chloride

13.00

10

Phenol crystals

40.00

11

Naphthylamine

16.50

12

Naphthol

16.50

13

Sodium-polyanethol sulphonat

45.00

14

Sodium hydroxide pellet

45.00

15

Sulfonilic acid

45.00

16

Trichloroacetic acid
Total

Weight (Grams)
0.5
.060
1.0
.200

1.0
16.5

2.1
259.36

In Conclusion: Key Issues

Awareness and education

Reporting systems & documentation
Segregation of identified clinical infectious wastes at
source

Timely treatment by non-polluting technologies on-site

or of-site

Waste audit
Waste monitoring systems
Elevation of safety standards by all healthcare facilities
All HCWs must have hygiene in their genes.

 Men occasionally stumble over the

truth but most of them pick
themselves up and hurry off as if
nothing has happened.
- Sir Winston Churchill.

Thank You