Hospital waste management

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

Category

Description and example

Infectious

waste

Waste suspected to contain pathogens

e.g. laboratory cultures; waste from

isolation wards; tissue(swabs);

material or equipment that have been

contact with infected patients: excreta

etc.

Pathological

waste

Human tissue or fluids e.g. body parts;

blood and other body fluids; fetuses

Classification of Health Care Waste

Waste

Category

Description and example

Pharmaceuti

cal waste

Waste containing pharmaceuticals e.g.

Pharmaceuticals that are expired or no

longer needed; items contaminated by

or containing pharmaceutical (bottles,

boxes)

Genotoxic

waste

Waste containing substances with

genotoxic properties e.g. waste

containing cytostatic drugs( often used

in cancer therapy); genotoxic chemicals

Classification of Health Care Waste

Waste

Category

Description and example

Chemical waste Waste containing chemical

substances e.g. laboratory reagents;

film developers; disinfectants that

are expired and no longer needed;

solvents

Waste with high

contents of

Heavy metals

Batteries; broken thermometers;

blood pressure gauze etc.

Classification of Health Care Waste

Waste

Category

Description and example

Pressurized

containers

Gas cylinders; gas cartridges; aerosol

cans etc.

Radio

active

waste

Waste containing radioactive Substances

e.g. unused liquid form radiotherapy or

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

Category

Description and example

Gases

waste

Gaseous waste generated during

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

Category

Description and example

Liquid

waste

Waste in liquid form. Waste such as

infected urine, expired blood, body

fluids and fluids coming from wound.

Waste water coming from different

wards and laboratories.

Incineration

Ash

Could be highly toxic (both bottom ash

and Fly ash). Contains high concentrated

toxic chemicals and other heavy metals

including dioxin and furans.

Sources of Health Care WasteGovernment 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 GroupsWorkers 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

infection

Causative

organism

Transmission

vehicles

Gastro enteric

infections

Entero bacteria: e.g.

salmonella, Shigella

spp., Vibrio cholera,

helminthes.

Faeces and or

vomit

Respiratory

infection

M. tuberculosis,

measles virus,

streptococcus

pneumoniae

Inhaled

secretions; saliva

Infection caused by health-care waste

Type of

infection

Causative organism Transmission

vehicles

Ocular

infections

Herpes virus Eye secretions

Genital

infections

Neisseria gonorrhoeae,

herpes virus

Genital secretions

Skin

infections

Streptococcus spp. Pus

Anthrax Bacillus anthracis Skin secretions

Infection caused by health-care waste

Type of

infection

Causative organism Transmission

vehicles

Meningitis Neisseria

meningitidis

Cerebro-spinal

fluid

AIDS Human deficiency

virus (HIV)

Blood, sexual

secretions

Hemorrhagic

fever

Junín, Lasssa, Ebola

and Marburg viruses

all body products

and secretions

Septicemia Staphylococcus spp. Blood

Infection caused by health-care waste

Type of

infection

Causative organism Transmission

vehicles

Bacteraemia Staphylococcus spp.,

enterobacter, Klebsiella

and streptococcus spp.

Blood

Candidaemia Candida albicans Blood

Viral

hepatitis A

Hepatitis A virus Faeces

Viral

hepatitis B

& C

Staphylococcus spp. Blood and

body fluids

Health care waste generation in Nepal

Studies are carried out on:

92 governmental hospitals ( 67 under MOHP, 3

community hospital, 8 teaching hospitals, 14

NGO’s 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 AsiaEstimates 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

Waste identification

Waste Segregation

Waste handling

Waste treatment & disposal

Record keeping

Training

Supervision and monitoring

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 IdentificationAn 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 ¾ 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 information’s: 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.

SecuritySecurity 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 exposureService 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

information’s, 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

managementDevelopment 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

Technology or method

Infectious

waste

Anatomical waste

Sharps

Pharmaceutical waste

Cytotoxic waste

Chemical waste

Radioactive waste

Rotary kiln Yes Yes Yes Yes Yes Yes

Low-level infectious

waste

Pyrolyticincinerator Yes Yes Yes

Small quantiti

es No

Small quantiti

es

Low-level infectious

waste

Single-chamber incinerator Yes Yes Yes No No No

Low-level infectious

waste Drum or brick incinerator Yes Yes Yes No No No No

Disposal & Treatment Methods Suitable

for Different Categories of Medical Waste

Technology or method

Infectious

waste Anatomical waste

Sharps

Pharmaceutical waste

Cytotoxic waste

Chemical waste

Radioactive 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

Encapsulation No No Yes Yes

Small quantitie

s

Small quantitie

s No

Disposal & Treatment Methods Suitable

for Different Categories of Medical Waste

Technology or method

Infectious

waste Anatomical waste

Sharps

Pharmaceutical waste

Cytotoxic waste

Chemical waste

Radioactive waste

Safe burial on hospital premises Yes Yes Yes

Small quantities No

Small quantitie

s No

Sanitary landfill Yes No No

Small quantities No No No

Discharge to sewer No No No

Small quantities No No

Low-level liquid waste

Disposal & Treatment Methods Suitable

for Different Categories of Medical Waste

Technology or method

Infectious

waste

Anatomical

waste Sharp

s

Pharmaceutical waste

Cytotoxic waste

Chemical waste

Radioactive waste

Inertization No No No Yes Yes No No

Other methods

Return expired drugs to supplier

Return expired drugs to supplier

Return unused

chemicals to supplier

Decay by 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

EncapsulateDisadvantages:

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!