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Hospital Waste Management

-

By Dr. Anil Koparkar

Moderator


Prof A.M. Mehendale

Date:
-

11/08/2011

Framework
:



Introduction




Problem Statement




Evolution of felt need of HWM




BMW, 1998




Hospital Waste Management




Process




Management




Training



References


Introduction

The waste produced in the course of health
-
care activities carries a higher potential for infection and injury than any
other type of waste. Wherever it is generated, safe and reliable methods for its handling are therefore essential.
Inadequa
te and inappropriate handling of health
-
care waste may have serious public health consequences and a
significant impact on the environment. Sound management of health
-
care waste is thus a crucial component of
environmental health protection.

Improper
management of health care wastes is a public concern because of risks of infection, injury, and other health
hazards. Poor health care waste management is also a reflection of broader management deficiencies in health care
facilities. Public awareness abou
t the dangers of careless disposal, and the introduction of regulatory measures for
managing these wastes, are both relatively new in India

(The World Bank,

2003)
.


Evolution

of concept

of Biomedical Waste Management
:

The evolution of a separate category
of medical waste within the municipal waste

stream dates back to the late 1970s,
when medical wastes, including syringes and

bandages were washed up on beaches in the East Coast of the USA. The
public

outcry that followed led to the formulation of the
US M
edical Waste Tracking Act

(MWTA)
, which finally came
into force on1 November 1988.


In
India

too medical waste was considered a part of the municipal waste till the

problems associated with medical waste
were realized. There was no legislation on

Medical waste till the Ministry of Environment and Forest (MoEF) proposed
the
first

draft rules in 1995
. The rules recommended on
-
site incinerators for all hospitals

with more than 50 beds. At the
same time, in a public interest case, the
Supreme

Court of
India, in March 1996
, ordered the inclusion of alternate
technologies and

their standards in the Rules.



The
second draft rules were notified in 1997
. The
final rules were notified on

20th July 1998 and were called Bio
-
Medical Waste (Management & Handling
) or

BMW Rules 1998
.

Two other amendments have come through since.

1.

The first amendment notified

on
March 6th 2000

is referred to as Bio
-
Medical Waste (Management & Handling)

(Amendment) Rules 2000. This amendment only changed Schedule VI of the rules,

con
cerning having waste
management facilities for treatment of waste. Even when

the first deadline for eight cities with a population of
more than 3 million was over,

these cites had not been able to achieve anything significant in this direction. This

amendm
ent thus extended the deadline for implementation for the first phase.


2.

The second amendment to the rules was notified on
2 June 2000

(called BMW

Rules, 2000). Some of the major
changes made included defining the role of the

municipal body of the particula
r area, nominating Pollution
Control Boards/ Committees

as Prescribed Authorities, addition of forms for seeking authorization to operate a

facility and for filing an appeal against order passed by the prescribed authority.



The entire country now comes u
nder the umbrella of the rules as 31 December

2002 was the deadline for the last phase
of implementation of the rules covering all

the health care institutions, cities, towns and villages nationally
.

Most of the
states either nominated
State Pollution
Control Boards or the department of health as the

prescribed authority
.
However, since the work involved a lot of technical intervention

like monitoring the air emission from the incinerators,
monitoring of the waste water

effluent etc. eventually it was f
elt that pollution control departments would be

appropriate as the prescribed authority and an amendment (Second Amendments

to the Rules, June 2000) was made to
this effect.

The fact that the Ministry of Family Health and Welfare was not as actively

involv
ed in determining the BMW Rules, as
was the Ministry of Environment, explains,

to some extent, some of the difficulties in implementing the Rules at the
level of

health care facilities
i

(WHO 2003)


Few concepts

H
ealth care
wastes (HCWs)

-

Health
-
care waste includes all the waste generated by health
-
care establishments,
research facilities, and laboratories. In addition, it inclu
des the waste originating from ‘minor’

or

scattered


sources
-
such
as that produced in the course
of health care undertaken in the home (dialysis, insulin injections, etc.).



Bio
-
medical Waste


In

HCW there are sharps and wastes with infectious, hazardous, radioactive, or genotoxic
characteristics that are potentially hazardous to humans and the envi
ronment. These more dangerous HCWs

called
“biomedical wastes” (BMWs)


Infectious waste




Infectious waste is suspected to contain pathogens (bacteria, viruses, parasites, or fungi) in
sufficient concentration or quantity to cause disease in susceptible hosts.


Problem Statement

Sources of
Hospital

waste

The composition of wastes is often
characteristic of the type of source. Ex.
-

different units
within a hospital would generate waste with the following characteristics:



Medical wards
: mainly infectious waste such as dressings, bandages, sticking plaster,
gloves, disposable medical items, used hypodermic needles and intravenous sets, body
fl
uids and excreta, contaminated packaging, and meal scraps.



Operating theatres and surgical wards
: mainly anatomical waste such as tissues,
organs, fetuses, and body parts, other infectious waste, and sharps.



Other health
-
care units
: mostly general waste with a small percentage of infectious
waste.



Laboratories
: mainly pathological (including some ana
tomical), highly infectious waste
(small pieces of tissue, microbiological cultures, stocks of infectious agents, infected
animal carcasses, blood and other body
fl
uids), and sharps, plus some radioactive and chemical waste.



Pharmaceutical and chemical sto
res
: small quantities of pharmaceutical and chemical wastes, mainly packaging
(containing only residues if stores are well managed), and general waste.



Support units
: general waste only.



Health care provided by nurses
: mainly infectious waste and many shar
ps.



Physi
cians’

of
fi
ces
: mainly infectious waste and some sharps.



Dental clinics and dentists


of
fi
ces
: mainly infectious waste and sharps, and wastes with high heavy
-
metal content.


Composition
/ Classification of
Health Care Wastes

Types of Health Care
Wastes

Examples

Communal waste(
a) (solid
wastes that are not
infectious, chemical, or
radioactive)

Cardboard boxes, paper, food waste, plastic and glass
bottles

Biomedical wastes(b)



Infectious waste
(wastes
suspected of containing
pathogens)

Cultures, tissues, dressings, swabs, and other blood
-
soaked
items; waste from isolation wards

Anatomical waste

Recognizable body parts

Sharps

Needles, scalpels, knives, blades, broken glass

Pharmaceutical waste

Expired or no longer needed medicines or pharmaceuticals

Genotoxic waste

Wastes containing genotoxic drugs and chemicals (used in
cancer therapy)

Chemical waste

Laboratory reagents, film developer, solvents, expired or
no longer
needed disinfectants, and organic chemical
wastes (for example, formaldehyde,phenol
-
based cleaning
solutions)

Heavy metal waste

Batteries, broken thermometers, blood pressure gauges

Pressurized containers

Aerosol cans, gas cylinders (that is, anesthetic
gases such as
nitrous oxide,halothane, enflurane, and ethylene oxide;
oxygen, compressed air)

Radioactive waste

Unused liquids from radiotherapy; waste materials from
patients treated or tested with unsealed radionuclides

a. Also known
as “general
health care
wastes.”

b. Also known
as “hazardous
health care
wastes,”“health
care risk
wastes,” or
“special
wastes.”


Between 75% and 90%

of the waste produced
by health
-
care
providers is non
-
risk or
general
-
health
-
care
waste, comparable to
domestic waste. It
comes mostly from
the administrative and
housekeeping
functions of health
-
care establishments
and may also include
waste generated
du
ring maintenance of
health
-
care premises.
The remaining 10
-
25%
of healthcare waste is
regarded as hazardous
and may cr
eate a
variety of health risks.

Amount

of generation

Waste
generation depends on numerous factors such as established waste management methods, type of health
-
care
establishment, hospital specializations, proportion of reusable items employed in health care, and proportion of patients
treated on a day
-
care basis.
In middle
-

and low
-
income countries, health
-
care waste generation is usually lower than in
high
-
income countries.

Health
-
care waste generation according to national income
level

Total health
-
care waste
generation by region



National income level

Annual
waste generation
(kg/head of population)

Region


Daily waste
generation (kg/bed)

High
-
income countries:



North America

7





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Health
-
care waste generation according to source size



Source

Daily waste generationb
(kg/bed)



University hospital


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Health impacts of health
-
care waste

Exposure to hazardous health
-
care waste can result in disease or injury. The hazardous nature of health
-
care waste may
be due to one or more of the following characteristics:

1.

It
contains infectious agents;

2.

It is genotoxic;

3.

It contains toxic or hazardous chemicals or pharmaceuticals;

4.

It is radioactive;

5.

It contains sharps.

Persons at risk

All individuals exposed to hazardous health
-
care waste are potentially at risk, including thos
e within health
-
care
establishments that generate hazardous waste, and those outside these sources who either handle such waste or are
exposed to it as a consequence of careless management. The main groups at risk are the following:

1.

Medical doctors, nurses
, health
-
care auxiliaries, and hospital maintenance personnel;

2.

Patients in health
-
care establishments or receiving home care;

3.

Visitors to health
-
care establishments;

4.

Workers in support services allied to health
-
care establishments, such as laundries, wast
e
handling, and transportation;

5.

Workers in waste disposal facilities (such as landfills or incinerators), including scavengers.


Hazards from infectious waste and sharps

Infectious waste may contain any of a great variety of pathogenic microorganisms.
Routes of entry:

-

Through a puncture, abrasion, or cut in the skin;

-

Through the mucous membranes;

-

By inhalation

-

By ingestion.


There is particular concern about infection with human immunodeficiency virus (HIV) and hepatitis viruses B and C, for
which there

is strong evidence of transmission via health
-
care waste. These viruses are generally transmitted through
injuries from syringe needles contaminated by human blood.


Sharps may not only cause cuts and punctures but also infect these wounds if they are con
taminated with pathogens.
Because of this double risk of injury and disease transmission, sharps are considered as a very hazardous waste class.
The principal concerns are infections that may be transmitted by subcutaneous introduction of the causative age
nt, e.g.
viral blood infections. Hypodermic needles constitute an important part of the sharps waste category and are
particularly hazardous because they are often contaminated with patient’s blood.

It was estimated in 2003 that India produces
nearly
330,000 Tons

of Health care waste per
year and its increasing rapidly.

Maharashtra produced >
40,000 Kg/day BMW
in year 2009 for
20773

beds (0.193
Kg/bed/day)!
-

Annual Report
,MPCB 2009.




Hazards from chemical and pharmaceutical waste

Many of the chemicals and pharmaceuticals used in health
-
care establishments are hazardous (e.g. toxic,
genotoxic, corrosive, Inflammable, reactive, explosive, shock
-
sensitive). These substances are commonly sent in small
quantities in health
-
care waste; l
arger quantities may be found when unwanted or outdated chemicals and
pharmaceuticals are disposed of. They may cause

-

I
ntoxication, either by acute or by chronic exposure,

-

I
njuries, including burns. Intoxication can result from absorption of a chemical
or pharmaceutical through the
skin or the mucous membranes, or from inhalation or ingestion. Injuries to the skin, the eyes, or the mucous
membranes of the airways can be caused by contact with inflammable, corrosive, or reactive chemicals (e.g.
formaldehy
de and other volatile substances). The most common injuries are burns.

-

During heavy rains, leaked pesticides can seep into the ground and contaminate the groundwater. Poisoning can
occur through direct contact with the product, inhalation of vapours, drink
ing of contaminated water, or eating
of contaminated food.

-

Other hazards may include the possibility of fire and contamination as a result of inadequate disposal such as
burning or burying.


Disinfectants are particularly important members of this group:
they are used in large quantities and are often
corrosive. It should also be noted that reactive chemicals may form highly toxic secondary compounds. Obsolete
pesticides, stored in leaking drums or torn bags, can directly or indirectly affect the health of

anyone who comes into
contact with them.

Chemical residues discharged into the sewerage system may have adverse effects on the operation of biological
sewage treatment plants or toxic effects on the natural ecosystems of receiving waters. Similar problems

may be caused
by pharmaceutical residues, which may include antibiotics and other drugs, heavy metals such as mercury, phenols, and
derivatives, and disinfectants and antiseptics.


Hazards from genotoxic waste

The severity of the hazards for health
-
care
workers responsible for the

handling or disposal of genotoxic waste is
governed by a combination of

the substance toxicity itself and the extent and duration of exposure.

P
athways of exposure are
:

-

I
nhalation of dust or aerosols,

-

A
bsorption

through the sk
in,

-

I
ngestion of food accidentally contaminated with cytotoxic

drugs, chemicals, or waste, and

-

I
ngestion as a result of bad practice,

such as mouth pipetting.

-

Exposure may also occur through contact with

the bodi
ly f
uids and secretions of patients under
going
chemotherapy.



The cytotoxicity of many antineoplastic drugs is cell
-
cycle
-
speci
fi
c,

targeted on speci
fi
c intracellular processes such
as DNA synthesis and

mitosis. Other antineoplastics, such as alkylating agents, are not phase
-
speci
fi
c, but
cytotoxic
at any point in the cell cycle. Experimental studies

have shown that many antineoplastic drugs are carcinogenic and
mutagenic;

secondary neoplasia (occurring after the original cancer has been

eradicated) is known to be associated
with some forms

of chemotherapy.

Many cytotoxic drugs are extremely irritant and have harmful local

effects after
direct contact with skin or eyes (Box 3.1). They may also

cause dizziness, nausea, headache, or dermatitis. Additional
information

on health hazards from cyt
otoxic drugs may be obtained on request from

the International Agency for
Research on Cancer (IARC).

Special care in handling genotoxic waste is absolutely essential; any

discharge of such
waste into the environment could have disastrous

ecological consequ
ences.


Hazards from radioactive waste

The type of disease caused by radioactive waste is determined by the type

and extent of exposure. It can range from
headache, dizziness, and

vomiting to much more serious problems. Because radioactive waste, like

cert
ain
pharmaceutical waste, is genotoxic, it may also affect genetic

material. Handling of highly active sources, e.g. certain
sealed sources

from diagnostic instruments, may cause much more severe injuries (such

as destruction of tissue,
necessitating amput
ation of body parts) and

should therefore be undertaken with the utmost care.

The hazards of low
-
activity waste may arise from contamination of external

surfaces of containers or improper mode or
duration of waste storage.

Health
-
care workers or waste
-
hand
ling or cleaning personnel exposed to

this radioactivity are
at risk.


Other concerns



Public sensitivity

Quite apart from fear of health hazards, the general public is very sensitive about the visual impact of
anatomical waste
, that
is recognizable human
body parts, including fetuses. In no circumstances is it acceptable to dispose of anatomical waste
inappropriately, such as on a landfill.

In some cultures, especially in Asia, religious beliefs require that human body parts be returned to a patient’s fami
ly, in tiny
coffins to be buried in cemeteries. The Muslim culture, too, generally requires that body parts are buried in cemeteries.




Public health impact of health
-
care waste

For serious virus infections such as HIV/AIDS and hepatitis B and C, health
-
car
e workers

particularly nurses

are at greatest risk
of infection through injuries from contaminated sharps (largely hypodermic needles)



BIO
-
MEDICAL WASTE (MANAGEMENT AND HANDLING) RULES, 1998


Published on 20.7.98 and amended 2000 / 2003

Includes

Rules : 1


13 (& 14)
,
Schedule : I


V
,
Forms: I


III (
Plus IV & V)
,
Annexure : I


II

Rules

1.

SHORT TITLE AND COMMENCEMENT:

These rules may be called the Bio
-
Medical Waste (Management and Handling) Rules, 1998

2.

APPLICATION(To whom):

These rules apply to all persons who generate, collect, receive, store,

transport, treat, dispose, or handle biomedical waste in any form.

3. DEFINITIONS



of terms used in this rules

4. DUTY OF OCCUPIER:

It shall be the duty of every occupier of an inst
itution generating bio
-
medical Waste
which includes a hospital, nursing home, clinic, dispensary, veterinary institution, animal house, pathological
laboratory, blood bank by whatever name called to take all steps to ensure that such waste is handled
witho
ut any adverse effect to human health and the environment.

5. TREATMENT AND DISPOSAL
:

Bio
-
medical waste shall be treated and disposed of in accordance with
Schedule I, and in compliance with the standards prescribed in Schedule V.

6. SEGREGATION, PACKAGING
, TRANSPORTATION AND STORAGE
:

Bio
-
medical waste shall not be mixed with other wastes

Bio
-
medical waste shall be segregated into containers/bags at the point of Generation in accordance with

Schedule II prior to its storage, labeled according to Schedule I
II….etc

7. PRESCRIBED AUTHORITY
:
State Pollution Control Boards in respect of States and the Pollution Control
Committees in respect of the Union Territories………….etc

8. AUTHORISATION
:
About whom n how to apply..

9. ADVISORY COMMITTEE

10. ANNUAL REPORT
:
to
the prescribed authority in Form II by 31 January every year,


11. MAINTENANCE OF RECORDS
:

records related to the generation, collection, reception, storage,
transportation, treatment, disposal and/or any form of handling of bio
-
medical waste in accordance

with
these rules and any guidelines issued.

12. ACCIDENT REPORTING


13. APPEAL
:

Any person aggrieved by an order made by the prescribed authority under these rules may,
within thirty days from the date on which the order is communicated to him

14. COMMO
N
DISPOSAL / INCINERATION SITES:

Municipal Corporations, Municipal Boards or Urban
Local Bodies, as the case may be, shall be responsible for providing suitable common disposal/incineration
sites for the biomedical wastes generated in the area under their ju
risdiction and in areas outside the
jurisdiction of any municipal body.



SCHEDULE I

-

CATEGORIES OF BIO
-
MEDICAL WASTE

Waste
category
No.

Waste Category [Type]

Treatment and Disposal
[Option+]

1

Human Anatomical Waste
(
human tissues, organs,
body parts)

I
ncineration
@
/deep burial*

2

Animal Waste
(animal tissues, organs, body parts
carcasses, bleeding parts,

fluid, blood and experimental
animals used in research, waste generated by veterinary
hospitals colleges, discharge from hospitals, animal houses)

I
ncineration
@
/deep burial*

3

Microbiology & Biotechnology Waste
(wastes from
laboratory cultures, stocks or specimens of microorganisms
live or attenuated vaccines, human and animal cell

culture
used in research and infectious agents from research and
industrial laboratories, wastes from production of
biologicals, toxins, dishes and devices used for transfer of
cultures)

Local autoclaving/microwaving/
incineration
@

4

Waste sharps
(needles, syringes, scalpels, blades, glass,
etc. that may cause puncture

and cuts. This includes both
used and unused sharps)

D
isinfection (chemical
treat
ment
@@
/auto
claving/

micro
-
waving and multilation/
shredding
##

5

Discarded Medicines and Cytotoxic Drugs
(wastes
comprising of outdated, contaminated and discarded
medicines)

I
ncineration
*
/destruction and
drugs disposal in secured
landfills

6

[Soiled] Waste
(Items contaminated with blood, and body
fluids including cotton, dressings, soiled plaster casts, lines
beddings, other material contaminated with blood)

I
ncineration
@

autoclaving/microwaving

7

Solid Waste
(wastes generated from disposable items
other than the waste 1[sharps] such as tubings, catheters,
intravenous sets etc.)

D
isinfection by chemical
treatment
@@

autoclaving/
microwaving and
mutilation/shredding
##

8

Liquid Waste
(waste generated from laboratory and
washing, cleaning, house
-
keeping and disinfecting
activities)

Disinfection

by chemical
treatment
@@

and discharge into
drains.

9

Incineration Ash
(ash from incineration of any biomedical
waste)

D
isposal in

municipal landfill

10


Chemical Waste
(chemicals used in production of
biologicals, chemicals used in disinfection, as insecticides
etc.)

Chemical treatment
@@
and
discharge into drains for liquids
and secured landfill for solids

@ Chemicals treatment
using at least 1% hypochlorite solution or any other equivalent chemical reagent. It must be
ensured that chemical treatment ensures disinfection.

## Multilation/shredding must be such so as to prevent unauthorized reuse.

@ There will be no chemical pretre
atment 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.






Color Coding : Schedule II

Colour code

Type of container

Category

Treatment options

Yellow

Plastic bag

Infectious waste

Incineration /

Cat: 1 , 2 , 6

deep burial

Red

Disinfected
container/

Disposables

Autoclaving/Microwaving/

Plastic bag

Cat: 7

Chemical Treatment

Blue

Puncture

Sharps

Autoclaving/Microwaving/

proof container +
disinfectant

Cat: 4

Chemical Treatment /

1% Sod Hypo




Needles cutting






Deep burial


Black

Plastic bag

Medicines, Incineration
ash, Chemical

Secured landfill

Cat: 5 , 9 , 10


SCHEDULE III

-

LABEL FOR TRANSPORT OF BIO
-
MEDICAL WASTE CONTAINERS BAGS



Forms



FORM
-
I
:

APPLICATION FOR AUTHORISATION/ RENEWAL OF AUTHORISATION



FORM II : ANNUAL REPORT(
To be submitted to the prescribed authority by 31 January
every year



FORM III :
-

ACCIDENT REPORTING



FORM IV (
Added by Rule 11 of the Bio
-
Medical Waste( M&H)(Second Amendment )Rules,2000
:
-

Authorization granting
format



FORM V
-

Application for filing appeal against order passed by the prescribed authority


ANNEXURE



Health
-
care waste management planning

The need for planning

Formulation of objectives and planning for their achievement are important for improving health
-
care waste management at
the national, regional, and local level.


International
recommendations for waste management

The United Nations Conference on the Environment and Development (UNCED) in 1992 led to the adoption of Agenda 21,
which recommends a set of measures for waste management. The recommendations may be summarized as follow
s:



Prevent and minimize waste production.

Chemical

waste

Radioactive

waste



Reuse or recycle the waste to the extent possible.



Treat waste by safe and environmentally sound methods.



Dispose of the final residues by landfill in confined and carefully designed sites.


Waste management plan for a health
-
care establishment




Hospital
waste management structure

This structure may be adjusted to the particular needs of each hospital.

Duties of HWM staff
-


1.

Head of Hospital

-

Forming a waste management team
.

-

Designating a Waste Management Officer (WMO) to supervise and coordinate

-

Keeping the management plan up to date.

-

Allocating suf
fi
cient
fi
nancial and personnel resources to ensure efficient operation of the plan

2.

Waste Management Officer (WMO)

The WMO is responsible for the day
-
to
-
day operation and monitoring of the waste
management system.

In the area of
waste collection
, the WMO should:

-

C
ontrol internal collection of waste containers and their transport

-

E
nsure that an appropriate

range of bags and containers for health
-
care waste, protective clothing,

and collection
trol
leys are available at all times

-

E
nsure that hospital attendants and ancillary staff immediately replace used bags and containers with the correct new
bags or containers;

-

D
irectly supervise hospital attendants and ancillary workers assigned to collect and t
ransport health
-
care waste

Concerning waste storage
-

-

Prevent all unsupervised dumping of waste

-

E
nsure the correct use of the central storage facility for health
-
care

waste

To supervise collection and disposal of the waste

-

C
oordinate and monitor all waste
disposal operations

-

M
onitor methods of transportation of wastes
-

appropriate vehicle

-

E
nsure that waste is not stored for longer than specified in the guidelines and that the transport organization

For staff training and information

-

L
iaise with the Matron (or Senior Nursing Officer) and the Hospital Manager to ensure that the nursing staff and
medical assistants are aware of their own responsibilities

-

L
iaise with Department Heads to ensure that all doctors and other qualified clinical

staff are aware of their own
responsibilities

-

E
nsure that hospital attendants and ancillary staff are not involved in waste segregation and that they handle only
waste bags and containers that have been sealed in the correct manner

For incident management

and control

-

E
nsure that written emergency procedures are available

-

I
nvestigate and review any reported incidents concerning the handling of health
-
care waste.


3.

Department Heads

Department Heads are responsible for the segregation, storage, and disposal o
f waste generated in their
departments. They should



-

E
nsure that all doctors, nurses, and clinical and non
-
clinical professional staff in their departments are aware of the
segregation and storage procedures and that all personnel comply with the highest

standards

-

C
ontinuously liaise with the WMO to monitor working practices for failures or mistakes

-

E
nsure that key staff members in their departments are given training in waste segregation and disposal procedures

The proper
management of health
-
care
waste depends largely on good
administration and organization but
also requires adequate legislation and
financing, as well as active participation
by trained and informed staff.

The head of the hospital should form a
waste manage
ment team to develop a
waste management plan. The team
should have the following members:




Head of Hospital (as
chairperson) Hospital
Manager



Heads of Hospital Departments



Hospital Engineer



Infection Control Officer



Financial Controller



Chief Pharmacist



Waste Management Officer (if
already designated).



Radiation officer



Hospital Hygienist


(o灴楯湡氩



Matron (or Senior Nursing
Officer)


-

E
ncourage medical and nursing staff to be
vigilant so as to ensure that hospital attendants and ancillary staff follow
correct procedures at all times.


4.

Matron and Hospital Manager

The Matron (or Senior Nursing Offier) and the Hospital Manager are responsible for training nursing staff, medical

assistants, hospital attendants, and ancillary staff in the correct procedures for segregation, storage, transport, and

disposal of waste. They should therefore:

-

Liaise with the WMO and the advisers (Infection Control Officer, Chief Pharmacist, and Radiat
ion Of
fi
cer) to maintain
the highest standards

-

Participate in staff introduction to, and continuous training in, the handling and disposal of health
-
care waste;

-

Liaise with Department Heads to ensure coordination of training activities, other waste managem
ent issues specific to
particular departments, etc.


5.

Infection Control Officer

-

The Infection Control Officer should liaise with the WMO on a continuous basis and provide advice concerning the
control of infection and the standards of the waste disposal sys
tem. His or her duties are to:

-

Identify training requirements according to staff grade and occupation;

-

Organize and supervise staff training courses on safe waste management;

-

Liaise with the Department Heads, the Matron, and the Hospital Manager to coordin
ate the training.

6.

Chief Pharmacist

-

Coordinate continuous monitoring of procedures for the disposal of pharmaceutical waste

7.

Radiation Officer

-

Coordinate continuous monitoring of procedures for the disposal of radiological waste

8.

Supply Officer

-

The Supply
Officer should liaise with the WMO to ensure a continuous supply of the items required for waste
management (plastic bags and containers of the right quality, spare parts for on
-
site health
-
care waste treatment
equipment, etc.)

9.

Hospital Engineer

-

I
nstalling

and maintaining waste storage facilities and handling equipment that comply with the speci
fi
cations of the
national guidelines.

-

A
ccountable for the adequate operation and maintenance of any on
-
site waste treatment equipment.

-

He/she is responsible for the
staff involved in waste treatment, ensuring that:

o

staff receive training in the principles of



waste disposal



operation and maintenance

Waste minimization

Significant reduction of the waste generated in health
-
care establishments and research facilities
may be encouraged by
the implementation of certain policies and practices, including the following:



Source reduction
: measures such as purchasing restrictions to ensure the selection of methods or supplies that are
less wasteful or generate less hazardous
waste.



Recyclable products
: use of materials that may be recycled, either on
-
site or off
-
site.



Good management and control practices
: apply particularly to the purchase and use of chemicals and
pharmaceuticals.



Waste segregation
: careful segregation
(separation) of waste matter into different categories helps to minimize the
quantities of hazardous waste.


Safe reuse and recycling

Medical and other equipment used in a health
-
care establishment may be reused provided that it is designed for the purpose

and will withstand the sterilization process.

E.g. Hand gloves

According to Annual Report of MPCB, 2009
-


a) Total Bio
-
medical waste collected & treated by HCFs in kg/day: 9445.39

b) Total recyclable bio
-
medical waste sold off by HCFs in kg/day: 1245.0
(
13.1%)


Handling, storage, and transportation of health
-
care waste

In addition to the colour coding of waste containers, the following practices are recommended:

1.

General health
-
care waste should join the stream of domestic refuse for disposal.

2.


Sharps should all be collected together, regardless of whether or not they are contaminated. Containers should be
puncture
-
proof (usually made of metal or high
-
density plastic) and
fi
tted with covers. They should be rigid and
impermeable so that they safel
y retain not only the sharps but also any residual liquids

from syringes. To

d
iscourage

abuse, containers should be tamper
-
proof (dif
fi
cult to open or break) and needles and syringes should be rendered
unusable. Where plastic or metal containers are unavai
lable or too costly, containers made of dense cardboard are
recommended (WHO, 1997); these fold for ease of transport and may be supplied with a plastic lining.

3.

Bags and containers for infectious waste should be marked with the international infectious sub
stance symbol.

4.

Highly infectious waste should, whenever possible, be sterilized immediately by autoclaving. It therefore needs to be
packaged in bags that are compatible with the proposed treatment process: red bags, suitable for autoclaving, are
recommend
ed.

5.

Cytotoxic waste, most of which is produced in major hospital or research facilities, should be collected in strong, leak
-
pro
of containers clearly labeled ‘
Cytotoxic wastes

.

6.

Large quantities of chemical waste should be packed in chemical resistant cont
ainers and sent to specialized treatment
facilities (if available). The identity of the chemicals should be clearly marked on the containers: hazardous chemical
wastes of different types should never be mixed.

7.

Waste with a high content of heavy metals (e.g
. cadmium or mercury) should be collected separately.


Aerosol containers
may be collected with general health
-
care waste once they are completely empty, provided that the waste is not
destined for incineration.

8.

Low
-
level radioactive infectious waste (e.g.

swabs, syringes for diagnostic or therapeutic use) may be collected in yellow
bags or containers for infectious

waste if these are destined for incineration.


On
-
site collection, transport, and storage of waste

Collection

-

Nursing and other clinical staff
should ensure that waste bags are tightly closed or sealed when they are about three
-
quarters full.

-

Bags should
not
be closed by stapling.

-

Wastes should not be allowed to accumulate at the point of production


Certain
recommendations

should be followed by
the ancillary workers in charge of waste collection:

-

Waste should be collected daily (or as frequently as required) and transported to the designated central storage site.

-

No bags should be removed unless they are labelled with their point of production (h
ospital and ward or department)
and contents.

-

The bags or containers should be replaced immediately with new ones of the same type.

Storage

Unless a refrigerated storage room is available, storage times for healthcare waste (i.e. the delay between
production and
treatment) should not exceed the following:

Temperate climate
: 72 hours in winter


48 hours in summer

Warm climate
: 48 hours during the cool season





24 hours during the hot season


Cytotoxic waste

should be stored
separately from other health
-
care waste in a designated secure location.

Radioactive waste

should be stored in containers that prevent dispersion, behind lead shielding. Waste that is to be stored
during radioactive decay should be labelled with the type o
f radionuclide, the date, and details of required storage conditions


On
-
site transport

Health
-
care waste should be transported within the hospital or other facility by means of wheeled trolleys, containers, or carts
that are not used for any other purpose

and meet the following specifications:

1.

Easy to load and unload;

2.

No sharp edges that could damage waste bags or containers during loading and unloading;

3.

Easy to clean.


Off
-
site transportation of waste

1.

The health
-
care waste producer is responsible for safe

packaging and

adequate labelling of waste to be transported
off
-
site and for authorization

of its destination

2.

For infectious health
-
care wastes, it is recommended that packaging should be design type
-
tested and certi
fi
ed as
approved for use.

3.

For health
-
ca
re waste, the following additional information should be marked on the label:

a.


Wa
ste category

b.


Date of collection

c.


Place in hospital where produced (e.g. ward)

d.


Waste destination.


Treatment and disposal technologies for health
-
care waste

Incineration used

to be the method of choice for most hazardous healthcare wastes and is still widely used. However, recently
developed alternative treatment methods are becoming increasingly popular. The final choice of treatment system should be
made carefully, on the ba
sis of various factors, many of which depend on local conditions:



D
isinfection efficiency;



H
ealth and environmental considerations;



V
olume and mass reduction;



O
ccupational health and safety considerations;



Q
uantity of wastes for treatment and disposal/capa
city of the system;



T
ypes of waste for treatment and disposal;



I
nfrastructure requirements;



L
ocally available treatment options and technologies;



O
ptions available for final disposal;



T
raining requirements for operation of the method;



O
peration and mainten
ance considerations;



A
vailable space;



L
ocation and surroundings of the treatment site and disposal facility;



I
nvestment and operating costs;



P
ublic acceptability;



R
egulatory requirements.


Incineration

Principles of incineration

Incineration is a
high
-
temperature dry oxidation process that reduces organic and combustible waste to inorganic,
incombustible matter and results in a very signi
fi
cant reduction of waste volume and weight. This process is usually selected
to treat wastes that cannot be rec
ycled, reused, or disposed of in a landfill site.

Three basic kinds of incineration technology are of interest for treating health
-
care waste:



Double
-
chamber pyrolytic incinerators, which may be especially designed to burn infectious health
-
care waste;



Sin
gle
-
chamber furnaces with static grate, which should be used only if pyrolytic incinerators are not affordable;



Rotary

kilns operating at high temperature, capable of causing decomposition of genotoxic substances and heat
-
resistant chemicals.

1.

Reduces organ
ic combustible waste to inorganic incombustible ( ash)

2.

Significant reduction of waste

3.

Efficiency: Type / temperature

4.

During operation
pollution has to be controlled
&


temperature to be regulated


Not all waste can be incinerated

5.

Pressurized
containers
,

Large amounts of reactive chemical waste

o

Radioactive / radiographic waste

o

Halogenated plastics

o

Ampules of heavy metals

6.

Cost high

7.

Types

o

Rotary kilns: 1200
-
1600 ºC

o

Double chamber : 800
-
900
º

C

o

Single chamber: 300
-
400 ºC

o

Simple field : < 300 ºC


Chemical disinfection

Simple chemical disinfection processes



Chemical disinfection, used routinely in health care to kill microorganisms on medical equipment and on
fl
oors and
walls, is now being extended to the treatment of health
-
care waste.



Chemicals a
re added to waste to kill or inactivate the pathogens it contains;



This treatment usually results in disinfection rather than sterilization.



Most suitable for treating liquid waste such as blood, urine, stools, or hospital sewage. However, solid

and even
highly
hazardous
-

health
-
care wastes, including microbiological cultures, sharps, etc., may also be disinfected chemically,
with the limitations.

Types of chemical disinfectants



The types of chemicals used for disinfection of health
-
care waste are mostly a
ldehydes, chlorine compounds,
ammonium salts, and phenolic compounds;



*The use of ethylene oxide is no longer recommended for waste treatment because of the significant hazards related
to its handling



Most of the disinfectants described here are stable for

at least 5 years and

-

with the exception of sodium

h
ypochlorite

remain effective for 6
-
12
months after opening of the container

Examples

1.

Formaldehyde (HCHO)
-
Formaldehyde is suitable for use as a chemical disinfectant only in situations in which a high
level of chemical safety can be maintained.

2.

Ethylene oxide (CH
2
OCH
2
)
-
The use of ethylene oxide is not recommended because of significant related health
hazards
.

3.

G
lutaraldehyde (CHO
-
(CH
2
)
3
-
CHO)
-
Glutaraldehyde is suitable for use as a chemical disinfectant only in
situations in

which a high level of chemical safety can be maintained.

-


Glutaraldehyde waste should never be discharged in sewers;

-


it may be neutralized through careful addition of ammonia or sodium bisulfite;

-


it may also be incinerated after mixing with a flammable solvent.

4.

sodium hypochlorite (NaOCl)



-

Aqueous solutions are corrosive to metals; usually stored in plastic
containers in well ventilated, dark, and leakage
-
proof
rooms; should be stored separately from acids.

-

Sodium hypochlorite may be widely used because of relatively mild health hazards.

-

Unused solutions should be reduced with sodium bisulfite or sodium thios
ulfate and neutralized with acids before discharge
into sewers.

-

Large quantities of concentrated solutions should be treated as hazardous chemical waste.

5.

chlorine dioxide (ClO
2
)



Wet and dry thermal treatment


Wet thermal treatment

Wet thermal
-
or steam
-
di
sinfection is based on exposure of shredded infectious waste to high
-
temperature, high
-
pressure
steam, and is similar to the autoclave sterilization process. It inactivates most types of microorganisms

-

for sporulated bacteria, a minimum temperature of 121
0
C is needed

-

99.99% inactivation of microorganisms may be expected, compared with the 99.9999% achievable with autoclave
sterilization.

-

The wet thermal process requires that waste be shredded before treatment; for sharps, milling or crushing is
recommended
to increase disinfection efficiency

-

The process is inappropriate for the treatment of anatomical waste and animal carcasses, and will not ef
fi
ciently treat
chemical or pharmaceutical wastes.

Disadvantages

1.

The shredder is liable to mechanical failure and br
eakdown;

2.

The efficiency of disinfection is very sensitive to the operational conditions.

Description of
Bacillus subtilis
and
Bacillus stearothermophilus
tests

-

Dried test spores are placed in a thermally resistant and steam
-
permeable container near the centre of the waste load and
the apparatus is operated under normal conditions.

-


At the end of the cycle, the test organisms are removed from the load; within 24
hours, test discs or strips should be
aseptically inoculated in 5.0ml soybean

casein digest broth medium and incubated for at least 48 hours, at 30
C for
Bacillus subtilis and at 55
C for Bacillus stearothermophilus.

-

The media should then be examined for

turbidity as a sign of bacterial growth; any growth should be subcultured onto
appropriate media to identify the organism either as the test microorganism or as an environmental contaminant.

Routine strip test


Expected Color change shows appropriate
temp was achived.


Wet thermal (or steam autoclave) treatment facility

Autoclaving is an efficient wet thermal disinfection process. Typically, autoclaves are used in hospitals for the sterilizati
on of
reusable medical equipment. They allow for the treatme
nt of only limited quantities of waste and are therefore commonly
used only for highly infectious waste, such as microbial cultures or sharps. It is recommended that all general hospitals, ev
en
those with limited resources, be equipped with autoclaves.


L
and disposal

If a municipality or medical authority genuinely lacks the means to treat wastes before disposal, the use of a land
fi
ll has to be
regarded as anacceptable disposal route.

There are two distinct types of waste disposal to land
-
open dumps
and
sa
nitary land
fi
lls
.


Open dumps

are characterized by the uncontrolled and scattered deposit of wastes at a site; this leads to acute pollution
problems, fires, higher risks of disease transmission, and open access to scavengers and animals.
Health
-
care waste

should
not be deposited on or around open dumps
.


Sanitary landfills

are designed to have at least four advantages over open dumps:

1.

G
eological isolation of wastes from the environment,

2.

Appropriate engineering preparations before the site is ready to acc
ept wastes,

3.

S
taff present on site to control operations, and

4.

Organized deposit and daily coverage of waste.


Encapsulation



One option for pretreatment is encapsulation, which involves filling containers with waste, adding an immobilizing
material, and sealing the containers.



The process uses either cubic boxes made of high
-
density polyethylene or metallic drums, which are thr
ee
-
quarters
filled with sharps and chemical or pharmaceutical residues.



The containers or boxes are then filled up with a medium such as plastic foam, bituminous sand, cement mortar, or
clay material.



After the medium has dried, the containers are sealed a
nd disposed of in landfill sites.



Advantages:
-

-

This process is relatively cheap, safe, and particularly appropriate for establishments that practise
minimal
programmes
for the disposal of sharps and chemical or pharmaceutical residues.

-

Very effective in re
ducing the risk of scavengers gaining access to the hazardous health
-
care waste


Safe burial on hospital premises

In health
-
care establishments that use minimal programmes, for healthcare waste management, particularly in remote
locations, in temporary ref
ugee encampments, or in areas experiencing exceptional hardship, the safe burial of waste on
hospital premises may be the only viable option available at the time. However, certain basic rules should still be establish
ed
by the hospital management:

-

Access
to the disposal site should be restricted to authorized personnel only.

-

The burial site should be lined with a material of low permeability, such as clay, if available, to prevent pollution of
any shallow groundwater that may subsequently reach nearby well
s.

-

Only hazardous health
-
care waste should be buried. If general hospital

waste were also buried on the premises,
available space would be

quickly
fi
lled up.

-

Large quantities (
>
1kg) of chemical wastes should not be buried at one

time. Burying smaller quant
ities avoids serious
problems of environmental

pollution.

-

The burial site should be managed as a land
fi
ll, with each layer of

waste being covered with a layer of earth to
prevent odours, as well as

to prevent rodents and insects proliferating.


Inertization

The process of inertization involves mixing waste with cement and other substances before disposal in order to minimize the
risk of toxic substances contained in the waste migrating into surface water or groundwater. It is especially suitable,

for
pharmaceuticals and for incineration ashes with a high metal content (in this case the process is also called ‘stabilization’
).


Collection and disposal of wastewater

Characteristics and hazards of wastewater from health
-
care establishments

Wastewater

from health
-
care establishments may also contain various potentially hazardous components.

Microbiological pathogens

-

The principal area of concern is wastewater with a high content of enteric pathogens,
including bacteria, viruses, and helminths, which
are easily transmitted through water.

Hazardous chemicals

-

Small amounts of chemicals from cleaning and disinfection operations are regularly discharged into
sewers. If the recommendations are not followed, larger quantities of chemicals may be present in

wastewater.

Pharmaceuticals
-

Small quantities of pharmaceuticals are usually discharged to the sewers from hospital pharmacies and
from the various wards. If the recommendations are not followed, more important quantities of pharmaceuticals including
ant
ibiotics and genotoxic drugs may also be discharged.

Radioactive isotopes
-

Small amounts of radioactive isotopes will be discharged into sewers by oncology departments but
should not pose any risk to health if the recommendations are followed.

Related haz
ards
-

In some developing and industrializing countries, outbreaks of cholera are periodically reported.

-

In developing countries, where there may be no connection to municipal sewage networks, discharge of untreated or
inadequately treated sewage to the en
vironment will inevitably pose major health risks.

-

The toxic effects of any chemical pollutants contained in wastewater on the active bacteria of the sewage purification
process may give rise to additional hazards.


Wastewater management

1.

Connection to a m
unicipal sewage treatment plant


useful where
the municipal sewers are connected to
efficiently operated sewage treatment plants that ensure at least 95% removal of bacteria;

2.

On
-
site treatment or pretreatment of wastewater
-

hospital sewage should include
the following operations:

a.

Primary treatment

b.

Secondary biological puri
fi
cation
. Most helminths will settle in the sludge resulting from secondary
puri
fi
cation, together with 90
-
95% of bacteria and a signi
fi
cant percentage of viruses; the secondary effluent
will thus be almost free of helminths, but will still include infective concentrations of bacteria and viruses.

c.

Tertiary treatment
. The secondary ef
fl
uent will probably contain at least 20 mg/litre suspended organic
matter, which is too high for efficient
chlorine disinfection. It should therefore be subjected to a tertiary
treatment, such as lagooning; if no space is available for creating a lagoon, rapid sand filtration may be
substituted to produce a tertiary effluent with a much reduced content of suspe
nded organic matter
(
<
10mg/litre).

d.

Chlorine disinfection
.

To achieve pathogen concentrations comparable to those found in natural waters, the
tertiary ef
fl
uent will be subjected to chlorine disinfection to the breakpoint. This may be done with chlorine
dio
xide (which is the most efficient), sodium hypochlorite, or chlorine gas. Another option is ultraviolet light
disinfection.


*
Disinfection of the effl
uents is particularly important if they are discharged into coastal waters close to shellfish
habitats,
especially if local people are in the habit of eating raw shellfish.

Sludge treatment

The sludge from the sewage treatment plant requires anaerobic digestion to ensure thermal elimination of most pathogens.
Alternatively, it may be dried in natural drying
beds and then incinerated together with solid infectious health
-
care waste. On
-
site treatment of hospital sewage will produce a sludge that contains high concentrations of helminths and other pathogens.


Reuse of wastewater and sludges in agriculture and a
quaculture

According to the relevant WHO guidelines (Mara & Cairncross, 1989), the treated wastewater should contain

-

no more than one helminth egg per litre and

-

no more than 1000 faecal coliforms per 100 ml

-

if it is to be used for unrestricted irrigatio
n.

-

It is essential that the treated sludge contains no more than one helminth egg per kilogram and no more than 1000
faecal coliforms per 100 g.

-

The sludge should be applied to
fi
elds in trenches and then covered with soil

Minimal safety requirements

For

health
-
care establishments that apply minimal programmes and are unable to afford any sewage treatment, the following
measures should be implemented to minimize health risks:



Patients with enteric diseases should be isolated in wards where their excreta c
an be collected in buckets for chemical
disinfection; this is of utmost importance in case of cholera outbreaks, for example, and strong disinfectants will be
needed.



No chemicals or pharmaceuticals should be discharged into the sewer.



Sludges from hospit
al cesspools should be dehydrated on natural drying beds and disinfected chemically (e.g. with
sodium hypochlorite, chlorine gas, or preferably chlorine dioxide).



Sewage from health
-
care establishments should never be used for agricultural or aquacultural
purposes.



Hospital sewage should not be discharged into natural water bodies that are used to irrigate fruit or vegetable crops,
to produce drinking water, or for recreational purposes.


Recommendations for cost reductions

in HCW management

Cost reductions

can be achieved by taking particular measures at different stages in the management of wastes:

On
-
site management



Comprehensive management of chemicals and pharmaceuticals stores.



Substitution of disposable medical care items by recyclable items.



Adequate

segregation of waste to avoid costly or inadequate treatment of waste that does not require it.



Improved waste identification to simplify segregation, treatment, and recycling.

Comprehensive planning



Development and implementation of a comprehensive heal
th
-
care waste management strategy, within the
framework of the hospital waste management plan, which includes the above recommendations.



Planning collection and transport in such a way that all operations are safe and cost
-
efficient.



Possible cooperative
use of regional incineration facilities, including private sector facilities where appropriate.



Establishment of a wastewater disposal plan.

Documentation



Waste management and cost documentation: assessment of the true costs makes it easier to identify pr
iorities for
cost reduction and to monitor progress in the achievement of objectives.
Choice of adequate treatment or
disposal
method



Selection of a treatment and disposal option that is appropriate for waste type and local circumstances.



Use of treatment
equipment of appropriate type and capacity.
Measures at personnel level



Establishment of training programmes for workers to improve the quality and quantity of work.



Protection of workers against occupational risks.


Safety

practices for health
-
care person
nel
&

waste workers

Principles

Health
-
care waste management policies or plans should include provision for the continuous monitoring of workers health
and safety to ensure that correct handling, treatment, storage, and disposal procedures are being
followed

Essential occupational health and safety measures include




Proper training of workers;



provision of equipment and clothing for personal protection;



Establishment of an effective occupational health programme that includes immunization,
post
-
exposure prophylactic
treatment, and medical surveillance.



One must understand the value of immunization against viral hepatitis B, and the importance of consistent use of
personal protection equipment.




These measures should be designed to prevent ex
posure to hazardous materials or other risks, or at least to keep
exposure within safe limits.

Who among waste worker are at risk?

Workers at risk include health
-
care providers, hospital cleaners, maintenance workers, operators of waste treatment
equipment
, and all operators involved in waste handling and disposal within and outside health
-
care establishments.

Protective clothing

The type of protective clothing used will depend to an extent upon the risk associated with the health
-
care waste, but the
following should be made available to all personnel who collect or handle health
-
care waste:

1.

Helmets, with or without visors depending on the operation.

2.

Face masks depending on operation.

3.

Eye protectors (safety goggles) depending on operation.

4.

Overalls (co
veralls)
obligatory
.

5.

Industrial aprons
obligatory.

6.

Leg protectors and/or industrial boots
obligatory
.

7.

Disposable gloves (medical staff) or

heavy
-
duty gloves (waste workers)
obligatory
.

Personal hygiene

It is important for reducing the risks from handling health
-
care waste,

and convenient washing facilities (with warm water

and soap) should

be available for personnel involved in the task.

This is

of particular importance at storage and incineration
facilities.

Immunization

Viral hepatitis B

infections have been reported among health
-
care

Personnel and waste handlers, and immunization against the disease is

therefore recommended.
Tetanus immunization

is also recommended for

all personnel handling was
te.


Management practices

1.

Waste segregation
: careful separation of different types of waste into different and distinct containers or bags defines
the risk linked to each waste package.

2.

Appropriate packaging
: prevents spillage of waste and protects workers

from contact with waste.

3.

Waste identification

(through distinct packaging and labelling): allows for easy recognition of the class of waste and of
its source.


4.

Appropriate waste storage
: limits the access to authorized individuals only, protects against in
festation by insects and
rodents, and prevents contamination of surrounding areas.

5.

Appropriate transportation
: reduces risks of workers being exposed to waste.


Training

Public education on hazards linked to health
-
care waste

The objectives of public
education on health
-
care waste are the following:



To prevent exposure

to health
-
care waste and related health hazards; this exposure may be voluntary, in the case of
scavengers, or accidental, as a consequence of unsafe disposal methods.



To create awarenes
s

and foster responsibility
among hospital patients and visitors to health
-
care establishments
regarding hygiene and health
-
care waste management.



To inform the public

about the risks linked to health
-
care waste, focusing on people living or working in clo
se
proximity to, or visiting, health
-
care establishments, families of patients treated at home, and scavengers on waste
dumps.

Methods can be considered for public education



Poster exhibitions on health
-
care waste issues



Explanation by the staff of health
-
care establishments to incoming patients and visitors on waste management policy



Information poster exhibitions in hospitals, at strategic points such as waste bin locations, giving instructions on
waste segregation


Education and training of health
-
care
personnel



All health
-
care
-
personnel should be trained for waste handling. The instructors should have experience in teaching
and training, and be familiar with the hazards and practices of health
-
care waste management; ideally, they should
also have experi
ence in waste handling.



Periodic repetition of courses will provide refreshment training as well as orientation for new employees and for
existing employees with new responsibilities; it will also update knowledge in line with policy changes.



The Infection

Control Of
fi
cer (ICO) should be given responsibility for all training related to the segregation, collection,
storage, and disposal of health
-
care waste.


References

1.

WHO.

Safe Management of Bio
-
medical Sharps Waste in India
:4
-
8.

A
vailable at URL:

-

http://www.searo.who.int/LinkFiles/SDE_SDE_mgmt
-
bio
-
medical
-
framework.pdf

2.

Pru
ss, A., E. Giroult, and P. Rushbrook. 1999.
Safe Management of Wastes from Health
-
Care Acti
vities.
Geneva:World Health Organization.

3.

The U.S. Government, U.S. Environmental Protection Agency Medical Waste Tracking Act and the Standards for
the Tracking and Management of Medical Wastes. November 1988

4.

Sakharkar BM. Principles of Hospital Administ
ration and Planning, Jaypee Brothers Medical Buplishers(P) Ltd,
New Delhi,1999.

5.

Khan MF. Hospital waste management

Principles and guidelines. Kanishka publisher, Distributers, New Delhi.
2004.

6.

Ministry of environment & forests notification, Government of

India. Bio
-
medical waste (management and
handling) rules, 1998. July, 1998
.

7.

Personal communication with Department of Microbiology, MGIMS, Sewagram

8.

mpcb.gov.in

-

3rd & 4th Floor Kalpataru Point, Sion, Mumbai

-

022 24010437



Shredder




Autoclave




Incinerator










Sharp Disposal pit




i

(WHO 2003)

WHO. "Safe Management of Bio
-
medical Sharps Waste in India." 2003: 4
-
8.