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Hari Prasad Kafle

Lecturer, SHAS, FST


Pokhara University
Health Care Waste
Health care waste includes all waste generated
by health care establishment, research facilities
and laboratories etc.

It also includes waste originating from minor


or scattered sources e.g. health care undertaken
at home (dialysis, insulin injection etc.)
Health Care Waste
75-90% health care waste are non risk waste
as compared to household waste.
10-25% health care waste is regarded as
hazardous and can create varieties of health
risks.
Broadly, health care waste has been divided
into three subsets: Hospital waste, Medical
waste and potentially infectious waste.
Health Care Waste

Hospital
Waste

Medical
waste

Infectious
waste
Health Care Waste
Hospital waste: are waste generated from health
care facilities including cafeteria, office and
construction waste.
Medical waste (a subset of Hospital waste): waste
generated as a result of patient diagnosis,
treatment and immunization of human beings or
animals.
Potentially infectious waste (a sub set of medical
waste): that % of medical waste potential to
transmit infectious disease (10-25%).
Bio-medical Waste
Bio-Medical Waste" means any waste, which
is generated during the diagnosis, treatment or
immunization of human beings or animals or
in research activities pertaining thereto or in
the production or testing of biological.
Bio-medical Waste
It includes infectious and non-infectious waste.

Infectious waste includes pathological waste,


cotton, dressing, used needles, syringes,
scalpels, blades, glass etc.

Non-infectious waste includes general waste


from the kitchen/canteen, packaging material
including radioactive wastes, mercury
containing instruments, PVC plastics.
Classification of Health Care Waste
Classification of Health Care Waste
Waste Description and example
Category
Infectious Waste suspected to contain pathogens
waste e.g. laboratory cultures; waste from
isolation wards; tissue(swabs);
material or equipment that have been
contact with infected patients: excreta
etc.
Pathological Human tissue or fluids e.g. body parts;
waste blood and other body fluids; fetuses
Classification of Health Care Waste
Waste Description and example
Category
Pharmaceuti Waste containing pharmaceuticals e.g.
cal waste Pharmaceuticals that are expired or no
longer needed; items contaminated by
or containing pharmaceutical (bottles,
boxes)
Genotoxic Waste containing substances with
waste genotoxic properties e.g. waste
containing cytostatic drugs( often used
in cancer therapy); genotoxic chemicals
Classification of Health Care Waste
Waste Description and example
Category
Chemical waste Waste containing chemical
substances e.g. laboratory reagents;
film developers; disinfectants that
are expired and no longer needed;
solvents
Waste with high Batteries; broken thermometers;
contents of blood pressure gauze etc.
Heavy metals
Classification of Health Care Waste
Waste Description and example
Category
Pressurized Gas cylinders; gas cartridges; aerosol
containers cans etc.
Radio Waste containing radioactive Substances
active e.g. unused liquid form radiotherapy or
waste laboratory research; contaminated glass
wire, packages, or absorbent paper; urine
and excreta from patient treated or tested
with unsealed radionuclides; sealed
sources etc.
Classification of Health Care Waste
Waste Description and example
Category
Gases Gaseous waste generated during
waste burning of health care waste. Either
open burning or drum incinerator or
incinerator produce several gaseous
pollutants: CO2, H2O, HCL, HF, SO2,
NO etc
Classification of Health Care Waste
Waste Description and example
Category
Liquid Waste in liquid form. Waste such as
waste infected urine, expired blood, body
fluids and fluids coming from wound.
Waste water coming from different
wards and laboratories.
Incineration Could be highly toxic (both bottom ash
Ash and Fly ash). Contains high concentrated
toxic chemicals and other heavy metals
including dioxin and furans.
Sources of Health Care Waste
Government hospitals
Private hospitals
Nursing homes
Private clinics
Dentists clinic
Dispensaries
Primary Health Centers
Medical research and training institutions
Sources of Health care waste
Blood bank and collection centers
Animal houses
Slaughter houses
Laboratories
Research organizations
Vaccination centers
Bio-technology institution and product units
Composition of Health care waste
80% general health care waste (which may be
dealt with by the normal domestic and urban
waste management system).
15% pathological and infectious waste.
1% sharp waste.
3% chemical or pharmaceutical waste.
<1 % special waste, such as radio active or
cytotoxic waste , pressurized container or
broken thermometer & used batteries.
Risk Groups
Medical doctors, nurses, health care auxiliaries
and hospital maintenance personnel
Patients in health care establishments.
Visitors to health care establishments.
Workers in support services allied to health care
establishments such as laundries, waste
handling and transportation.
Risk Groups
Workers in waste disposal facilities such as
land fills or incinerators
Waste pickers (scavenger);
Waste recyclers;
Drug addicts (who scavenge for used needles
and disposed medicines); and
The entire community.
Thank You!
Health hazards from health care waste
Exposure to hazardous health-care waste can
resulting disease or injury because:
It contains infectious agents.
It is genototic.
It contains toxic chemicals or
pharmaceuticals.
It is radioactive.
It contains sharp.
It contains carcinogenic agents and gaseous
chemicals.
Health hazards from health care waste

1. Hazards from infectious waste and sharps


HIV, hepatitis B &C, microbial resistance
2. Hazards from chemical and pharmaceutical
waste
Intoxication, burn, poisoning, shock due to
inhalation
3. Hazards from genotoxic waste
Gentoxic effects, affects genetic materials
Health hazards from health care waste

4. Hazards from radioactive waste


Headache, dizziness, vomiting,
unconsciousness and also genotoxic effects.
5. Public sensitivity
General public is very sensitive to visual
impact of health care waste particularly
anatomical waste.
Infection caused by health-care waste
Type of Causative Transmission
infection organism vehicles
Gastro enteric Entero bacteria: e.g. Faeces and or
infections salmonella, Shigella vomit
spp., Vibrio cholera,
helminthes.
Respiratory M. tuberculosis, Inhaled
infection measles virus, secretions; saliva
streptococcus
pneumoniae
Infection caused by health-care waste
Type of Causative organism Transmission
infection vehicles
Ocular Herpes virus Eye secretions
infections
Genital Neisseria gonorrhoeae, Genital secretions
infections herpes virus
Skin Streptococcus spp. Pus
infections
Anthrax Bacillus anthracis Skin secretions
Infection caused by health-care waste
Type of Causative organism Transmission
infection vehicles
Meningitis Neisseria Cerebro-spinal
meningitidis fluid
AIDS Human deficiency Blood, sexual
virus (HIV) secretions
Hemorrhagic Junn, Lasssa, Ebola all body products
fever and Marburg viruses and secretions
Septicemia Staphylococcus spp. Blood
Infection caused by health-care waste
Type of Causative organism Transmission
infection vehicles
Bacteraemia Staphylococcus spp., Blood
enterobacter, Klebsiella
and streptococcus spp.
Candidaemia Candida albicans Blood
Viral Hepatitis A virus Faeces
hepatitis A
Viral Staphylococcus spp. Blood and
hepatitis B body fluids
&C
Health care waste generation in Nepal

Studies are carried out on:


92 governmental hospitals ( 67 under MOHP, 3
community hospital, 8 teaching hospitals, 14
NGOs hospitals)
74 private health facilities/ nursing homes
16 eye hospitals
Health care waste generation in Nepal
Medical waste composition: 23% infectious,
3% sharp, 12% saline bottles and remaining
62% non infections.
Infectious waste generation rate
0.48kg/person/day.
Total medical waste generation rate
1.7kg/person/day.
Average incinarable waste: 396.77gm/day/bed.
Health care waste generation in Nepal
On an average , a 150 bed hospital have about
50-100 thermometer breakage in a months and
each thermometer contain 0.5-1 gram mercury.

On an average 1 gram mercury has been used


for dental restoration in 4 patients.

Source: MOHP 2009, Ale Devika 2005, NHRC 2002, ENPHO


2000, CEPHED 2006, 2008.
Composition of hospital waste in India
Paper : 15 %
Plastics: 10%
Rags: 15%
Metal including sharps: 1
Infectious waste: 1.5%
Glass: 4%
General waste: 53.3 %
Source: National Environmental Engineering Research Institute
1997.
Medical Waste Generation in Asia
Estimates of medical waste generation in some countries
Medical Waste Generation in Asia
Medical Waste Generation in Asia
0.33 million tons/year in India
0.25 million tons/year in Pakistan
(100 ton/day from Karachi alone)
2,000 tons/day in china
60,000 tons/year in Vietnam
255 tons/day in Dhaka alone
47 tons/day in Metro Manila
(11 tons/day illegally dumped)

Source: Healthcare waste composition in developing Asian countries


(WHO,1999)
Management of health care waste
Effective waste management needs:
National Policy, Strategy, plan, guidelines and
SOP;
Legislation/Rules for waste management;
Political commitment;
Committed manpower;
Good management;
Proper budgetary allocation;
Management of health care waste
Application of local available technology and
also according to resource; envelop;
Involvement of NGOs;
Community participation;
Proper capacity development of the service
providers;
Development of information system in relation
to MWM as a part of MIS;
Supportive supervision and monitoring.
WHO Waste management Cycle
Waste
minimization

Supervision and
Waste identification
monitoring

Waste
Training Segregation

Record
Waste handling
keeping

Waste treatment &


disposal
Waste Minimization
Care full management prevents the
accumulation of large quantity of waste.
Health care service providers and institutions
administrator can play important role in
reduction of waste volume.
Waste minimization is directly proportional
with waste management cost and related risk.
Institution can adopt many policies and
practices that might reduce the waste volume.
Waste Minimization
Some policies of waste minimization are-
1. Source reduction- Purchasing and supplies
materials which are less wasteful and or
generate less medical waste.

2. Stock management- Frequent auditing; use


oldest stock first and checking the expired
date of products during receiving and supplies
of goods.
Waste Minimization
Some policies of waste minimization are-
3. Encourage use of Recyclable products- Use
materials that can be recycled both off-site or
on-site.

4. Control at institution level- Centralized


purchase and monitoring the receipt and
supply procedure of medical goods.
Waste Segregation
The key of effective waste management is the
waste segregation.

The waste should be segregated on the basis of


the category of waste.

The whole waste management depends upon


effective waste segregation, because incorrect
segregation creates lot of hassles in the down
stream of waste management.
Waste Segregation
If waste is properly segregated, small amount
are needed for disposal instead of large
quantity of waste, ultimately related manpower,
related cost, related risk lowered.

If segregation is not properly done, small


quantity of hazardous waste has a chance to
mix with large volume of non-hazardous waste
making the whole volume into hazardous
waste.
Waste Segregation
Segregation of medical waste should always be
the responsibility of waste producer and waste
should be segregated at the point just after its
generation.

Once waste is segregated, staffs should never


attempt to correct of wrong segregation by
placing/transferring items from one container
to another.
Waste Identification
An appropriate way of identifying the waste is
by sorting the waste into different COLOR
CODE.
Color code is easy for identification and
thereby easy for safe handling, transportation
and waste treatment.
The color code varies from country to country,
due to socioeconomic status, literacy rate,
availability of local resources, countries
classification of waste etc.
WHO recommended Color Code
for developing countries
Waste Handling

Waste handling means the links between


packing, storage and transportation of medical
waste from every area of the institution by
designated individual.
Waste Collection
Waste should not accumulate at the point of
birthplace.

The designated personnel should collect the


waste containers by a routine program through
the designated route as a part of the waste
management plan.
Guidelines for waste collection
Collectors must wear protective materials.
Collection of waste in colored bag or colored
covered bins.
Content of the container should not exceed
three quarter of its capacity.
If bag is used for waste collection, tie the neck
tightly.
Avoid throwing, dragging over floor or holding
the bottom of the containers.
Guidelines for waste collection
No container should be used if damaged or
licked.
All bins should be covered with lid during
collection and transportation of waste.
Waste should not be collected more the of
containers capacity.
No container should be transported without
labeling.
Guidelines for waste collection
During collection each containers should be
replaced with a new one.
Collection of Sharp medical waste under
maximum precaution.
If there is spillage of waste from the container
(gently collect the waste into a bin, soak the
area with 2% Lysol solution, wait for 30
minutes, then wash and wipe.
Waste collection materials
Character of the materials depends upon the type
of generated medical waste.
Its better that the materials should be domestic in
origin, so that sustainability of supply could be
ensured.
The commonly used materials are Colored waste
containers or bins, puncture proof container,
heavy duty gloves, rubber service gum boots,
hand tray, Balcha, waste carrying trolley, rubber
apron etc.
Placement of color bins
Appropriate container should be placed at all
important location where particular wastes are
generated.

Instruction on waste identification should be


pasted over the containers.
Placement of color bins
General waste (Black color bin) could be
placed at landing area of the staircase, in the
straight long corridor bin could be placed at 50
meter distance, yellow colored bin could be
placed out side of the toilet in female ward for
collection of sanitary napkins.

During replacement of the bin, same colored


another bin should be placed at the site.
Labeling
Waste container should be labeled with some
basic informations: about its waste category,
weight of the waste materials, date of
collection, and site of waste production.
These information could be written on
preprinted labels with irremovable or water
resistance ink.
All waste should be labeled and marked with
international symbol especially during
transportation.
Security
Security of medical waste throughout its
lifecycle is significantly a challenge, as
because there is chance of scavenging in every
point of its lifecycle.

Scavenging of medical waste especially at the


generation site and disposal site must be
recognized as threats to institutional infection
control program, quality of patient care and
community health hazard.
Health and safety
To ensure the health and safety of the cleaner
in waste management through continuous
monitoring is important.
An appropriate health and safety program
includes
a. Training of the worker about related risk.
b. Timely issue and encourage wearing
personal protective materials.
Health and Safety
c. Immunization of the worker under
occupational safety program especially
against Hepatitis-B virus and Tetanus.
d. Ensure reporting and post exposure
prophylactic treatment.
e. Ensure periodical medical checkup system.
f. Medical surveillance.
Personal hygiene
In medical waste management personal
hygiene is very important.

The working place should be provided with


continuous water supply and soap/detergent.

Hand washing should be ensured on arrival for


work, before meal, before living the working
area and whenever is necessary.
Response to injury and exposure
Service providers should be trained to deal
with injury and exposure.
This program may include
In case of accident immediate reporting to
the designated authority.
Identify items involved in accident.
Immediate first aid measure
Giving medical attention as soon as possible.
Record keeping.
Emergency response
Should be prepare for accident and or unexpected
situation.
Should be trained to manage common emergencies,
necessary equipment should be in hand and ready
at all times.
Some common emergencies are
Accidental spillage
Equipment failure
Accidental tear or breakage of containers.
Explosion and or fire.
In-house transportation
Means transportation of waste from the site of
origin or collection to temporary storage area
within the institution.

Waste should be transported by designated


trolley, through the designated route according
to time schedule given by the institutional
authority.
In-house transportation
A consignment note should accompany the
waste during transportation.

The trolley or handcart should be easy to clean,


loading and unloading, leak proof body, should
not be used in any other case other then waste
transportation.
Temporary in-house storage
The store will be a room or area or building
within the health care facility depending upon
the quantity and quality of waste production
and frequency of waste collection.

Normally waste should not be stored more then


24 hours.
Selection criteria for Temporary in-
house storage area
Should be properly located to prevent access of
unauthorized person.
Should have an easy access for workers and
collection vehicle.
Should be away from food preparation, processing
and food store.
Provided with sufficient light and sufficient water
supply.
Should be inaccessible for scavenger, animal and
rodents.
Selection criteria for Temporary in-
house storage area
Should be sufficient space for washing and
cleaning.
Should be equipped with sand, cleaning
equipments and fire fitting equipments and
reagents.
Floor should be elevated and impervious with
proper drainage facility.
There should be weighting and recording facility.
The room should be properly ventilated.
Record keeping
Accurate record keeping is needed for effective
medical waste management.

Record keeping might give some important


informations, which are needed for:
a. Assess the recurrent expenditure
b. Assess the quality and quantity of generated
waste
Record keeping
c. Assess the cost directly related with the man
and materials
d. Assess the cost related with waste treatment
and disposal method
e. Assess the risk involved with generated waste,
amount and nature of accident, amount of
damage, measure taken against accident etc.
f. Assess the failures, problem and obstacle in
waste management for better compliance of
the program.
Thank you!
Transportation for out house
management
Means collection of stored waste from the
health care facilities to the final disposal site.

Collection of waste from different institute


should be in a covered Van.

The driver area should be totally separated


from waste carrying area.
Strategy of medical waste
management
Development of awareness among the service
providers by sensitization;
Proper capacity development of the service
providers by providing training;
Development of in-house management of
waste;
Development and adoption of option for the
final disposal of waste depending upon the
situation, type of hospital, amount of waste
production;
Strategy of medical waste
management
Supply of logistics like different color bin,
needle crusher, service gloves, boot, mask etc;
Establishment of accountability framework;
Formation of Local waste management
committee and plan for implementation;
Refresher training program for service
providers;
Effective Monitoring and supervision.
Key consideration for the better
management of medical waste
Strongly believes the need of alternative
approach of MWM.
Hospitals will bear the responsibility of safe
management of its generated waste.
Need for attitude change of service providers,
patients and community people.
Service providers can contribute positively in
reducing waste volume and segregation.
Key consideration for the better
management of medical waste
Committed and well motivated hospital staff
can adopts an effective strategy for proper
MWM.

Government should take positive steps in


making guideline Legislation and policy on
HWM with ensuring monitoring and
supervision.
Disposal & Treatment Methods Suitable
for Different Categories of Medical Waste
Infecti Anato Pharma
Technology or ous mical Shar ceutical Cytotoxi Chemica Radioactive
method waste waste ps waste c waste l waste waste
Low-level
infectious
Rotary kiln Yes Yes Yes Yes Yes Yes waste
Small Small Low-level
Pyrolytic quantiti quantiti infectious
incinerator Yes Yes Yes es No es waste
Low-level
Single-chamber infectious
incinerator Yes Yes Yes No No No waste
Drum or brick
incinerator Yes Yes Yes No No No No
Disposal & Treatment Methods Suitable
for Different Categories of Medical Waste
Infectio
Technology us Anatomi Sharp Pharmaceu Cytotoxic Chemical Radioactiv
or method waste cal waste s tical waste waste waste e waste
Chemical
disinfection Yes No Yes No No No No
Wet
thermal
treatment Yes No Yes No No No No
Microwave
irradiation Yes No Yes No No No No
Small Small
Encapsulati quantitie quantitie
on No No Yes Yes s s No
Disposal & Treatment Methods Suitable
for Different Categories of Medical Waste
Infectio
Technology us Anatomi Sharp Pharmaceu Cytotoxic Chemical Radioactiv
or method waste cal waste s tical waste waste waste e waste
Safe burial Small
on hospital Small quantitie
premises Yes Yes Yes quantities No s No
Sanitary Small
landfill Yes No No quantities No No No
Low-level
Discharge Small liquid
to sewer No No No quantities No No waste
Disposal & Treatment Methods Suitable
for Different Categories of Medical Waste

Infecti Anatom Pharmace


Technology ous ical Sharp utical Cytotoxi Chemical Radioactive
or method waste waste s waste c waste waste waste

Inertization No No No Yes Yes No No

Return Return Return


expired expired unused
Other drugs to drugs to chemicals Decay by
methods supplier supplier to supplier storage
Technologies for Treatment and
Final Disposal
Incineration
Chemical disinfection
Render inert
Incineration
Description: A high temperature dry oxidation
process that reduces organic and combustible
waste to inorganic matter. Many different types
of incinerator ranging from the sophisticated to
the basic; however, basic incinerators often
cause serious emissions problems.

Advantages:
Requires no pre-treatment.
Good disinfection efficiency.
Incineration
Disadvantages:
If not operated effectively may pollute atmosphere
High capital and operational costs. Low cost incineration is
possible by using a drum or brick incinerator, however,
these present large emission problems and are not as
effective in the destruction of hazards.
Suitable condition:
>60% combustible
Moisture content < 30%.
Not suitable for pressurized gas canisters, reactive chemical
waste, PVC, wastes with high heavy metal content,
photographic or radiography wastes.
Chemical disinfection
Description: Chemicals added to the waste to
kill/inactivate the pathogens. Shredding is
usually necessary before disinfection, as only
the surface of intact solid waste will be treated.
The waste is then disposed of in a conventional
way, e.g. landfill.
Advantages:
Efficient disinfection when operated well.
Some chemical disinfectants are low cost.
Shredding reduces volume of waste.
Chemical disinfection
Disadvantages:
Disinfectants may themselves be hazardous to
operators & pose risks in the case of leakage and
subsequent disposal.
Needs highly trained operators.
Shredder liable to mechanical failure.
Suitable condition:
Best for liquid or sewage
Inadequate for pharmaceutical, chemical and some
types of infectious waste.
Render inert
Description:
Mixing the waste with cement in order to
prevent migration of toxic substances from
waste into ground water etc.

Advantages:
Relatively low cost.
Low-technology
Render inert
Disadvantages:
Bulky and heavy final waste product to be
disposed of.
Especially suitable for pharmaceuticals.

Suitable condition
Not suitable for infectious waste.
Wet thermal treatment
(including autoclaving)
Description: Exposure of shredded waste to
high temperature, high-pressure steam. If
temperature and contact time is sufficient, most
micro-organisms are inactivated. Waste can
subsequently be disposed of as municipal
waste.
Advantages:
Relatively low capital and operating costs.
Low environmental impact.
Wet thermal treatment
(including autoclaving)
Disadvantages:
Shredder liable to mechanical failure.
Efficiency of disinfection very sensitive to
operational conditions.
Suitable condition
Not suitable for anatomical, pharmaceutical
or chemical wastes.
Microwave irradiation
Description: Waste shredded, humidified and
then irradiated by microwaves. The heat
generated destroys micro-organisms.

Advantages:
Very efficient disinfection when operated
well. Environmentally sound. Reduction in
volume of waste.
Microwave irradiation
Disadvantages:
Relatively high capital and operating costs.
Potential operation and maintenance
problems.

Suitable condition
Not suitable for pharmaceutical or chemical
wastes
Not suitable for large metal objects.
Landfill (Sanitary)
Description: Landfill isolates waste from the
environment; it requires appropriate
engineering preparation, staff to control
operations, organized deposition and covering
of waste. Waste may be pre-treated (see above).
Ideally, healthcare waste is separated from
municipal waste.
Advantages:
Simple, low cost & safe when operated
properly.
Landfill (Sanitary)
Disadvantages:
If not operated properly scavengers may
access the waste and it may cause pollution
of environment etc.

Suitable condition
Generally suitable
Encapsulate
Description: Pre-treatment involving filling
containers with waste, adding an immobilizing
material and sealing the container e.g.
bituminous sand, cement mortar.

Advantages:
Preventing access to HC waste by
scavengers.
Relatively simple, low cost & safe
Encapsulate
Disadvantages:
Not recommended as sole method for non-
sharp infectious waste.
Bulky and heavy final waste product to be
disposed of.
Suitable condition
Appropriate for establishments using
minimal programs for disposal of sharps,
chemical or pharmaceutical residue.
Source: WHO, 1999
Thank You!