Disposal of Clinical Wastes: Tata Memorial Hospital Experience

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

Professor & Head, Dept of Microbiology Tata Memorial Hospital, Mumbai

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

The Reality Ignorance

Commercialization of science
Apathy Occupational Public health Environmental

The Concerns

The Science

The only documented risk of transmission of infections from waste to healthcare workers is through sharps There is however a potential for transmission of several microbial infections due to dumping of untreated wastes by healthcare facilities. Mixing of a small quantity of infectious waste with municipal garbage converts the entire waste to infectious Segregation of wastes at source followed by appropriate treatment is the key to the success of a waste management strategy

Hospital waste

Hazardous

Non-hazardous
Infectious Kitchen Recyclables

Noninfectious Cytotoxic drugs Toxic Chemicals Radioactive

Sharps: needles, scalpel blades, scalp veins, glass contaminated with blood

Non-sharps

Patient contaminated waste

Laboratory waste

Specimens

Anatomical

Plastics PVC, PE PET, PS Equipment

Non-plastics contaminated cotton waste, gauze, linen

The Social Issue: Ragpickers

The TMH Pathway

Closure of the incinerator Awareness programs for all the staff Refashioning the storage area Street play

Posters

Incinerator circa 1994

Segregation at source into defined categories using a simplified system.

2. FOCUS ON SEGREGATION FIRST

Appropriate placement of Colour Coded Bins
Radioactive Waste

Sharps Disposal

3. INSTITUTE A SHARPS MANAGEMENT SYSTEM

Waste Audit

4. KEEP FOCUS ON REDUCTION

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

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

5. ENSURE WORKER SAFETY THROUGH EDUCATION, TRAINING AND PROPER PERSONAL PROTECTIVE EQUIPMENT

Safe Disposal of Sharps: Do not recap needles. If essential learn the right way to do so.

Collection network. . 6. PROVIDE SECURE COLLECTION AND TRANSPORTATION

Waste management Strategy:

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

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

practices is a continuing process.

3. Plan for Future: Look for alternative technologies, co-operative facilities and
means of diversification.

4. Commitment towards protecting Human Health and the Environment

7. DEVELOP PLANS AND POLICIES

Infection Awareness Week

Street Play

9. DEVELOP THE INFRASTRUCTURE

10. Evaluation of Technologies

Evaluation of Non Burn Technologies for Medical Waste Treatment

1. Demonstrated Performance
Category 1.1 1.2 1.3 Stage of Development Number of Operational Systems Year of Successful Operations Rating Weight Score

2. Technical & Performance Criteria

Category 2.1 2.2 2.3 Process Capacity Waste Exclusions or Limitations Waste Size Limitations Rating Weight Score

2.4
2.5 2.6 2.7 2.8 2.9 2.10

Weight Change
Volume Change Recognizability / Disfigurement Decontamination Performance Data Process Complexity Operator Training

3. Vendor Qualifications
Category 3.1 3.2 Number of Vendors Vendor Resources Rating Weight Score

3.3

Vendor Diversity and Services

4. Environmental & Permitting Issues

Category 4.1 4.2 4.3 4.4 4.5 Air Emissions Liquid Effluents Treated Residues Permit ability Public Perception Rating Weight Score

5. Occupational Health & Safety Issues

Category
5.1 5.2 Routine Exposures Maintenance and Repair Exposures

Rating

Weight

Score

6. Facility: & Infrastructural Requirements

Category 6.1 6.2 Space Requirements Construction Requirements Rating Weight Score

6.3
6.4

Utility Requirements
Space / Facility Requirements

7. Economics
Category
7.1 7.2 7.3 Capital Costs Annual Costs Life-Cycle Costs

Rating

Weight

Score

GRAND TOTAL SCORE

Inauguration of Tata Memorial Hospital waste treatment facility

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

Selection of Technology and Implementation is not the setting sun

Evaluation is a continuous process

TMH Waste Audit Nov. 1999 to Dec. 2007

2000 Max. medical waste collected in a day Average no. of loads required/day Average medical waste treated in kgs/day Average medical waste collected in a month 341 2001 394 2002 350 2003 362 2004 396 2005 2006 530 429 2007 514

5 217

4 224

4 176

4 241

4 250

4 4 289 253

4 277

5,498

5,643

5,266

5,917

6,284

7,225 6,369

6,959

Percentage down time of the system

1.6

5.7

4.8

5.8

8.2

0 10

1.2

Total infectious waste treated 614 tonnes. 83,511 kg. in 2007. Cost of treatment = Rs. 14.86 / kg.

TMH Infectious Waste Audit 2008 - 2009

2008 Max. medical waste collected in a day 447 2009 505

Average no. of loads required/day

Average medical waste treated in kgs/day Average medical waste collected in a month

4
298

4
304

7,623

7,674

Percentage down time of the system

0.33

Total infectious waste treated 2000-2009= 800 tonnes. Cost of treatment = Rs. 14 / kg.

TMH Waste Management

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

Hazardous Waste

Environment News
Greenpeace March 7th, 2001 KODAIKANAL, India -- Greenpeace today accused Anglo-Dutch multinational Unilever, owners of Lipton Tea and Dove soap, of double standards and shameful negligence for allowing its Indian subsidiary, Hindustan Lever, to dump several tonnes of highly toxic mercury waste in the densely populated tourist resort of Kodaikanal and the surrounding protected nature reserve of Pambar Shola, in Tamilnadu, Southern India. On 15 April, 2005, a 51 year-old asbestos laden ship, Kong Fredrick IX was on its way to Alang ship breaking yard, Gujarat for scrapping. The ship's new owners Jupiter Ship Management, a Mumbai based company, had renamed it to 'MV Riky'. Connie Hedegaard, Denmark's environment minister alerted the Indian environment minister saying, "I believe our interests are joint - and I call on you to co-operate in this case by denying the ship to be dismantled in India - and refer the ship to return to Denmark to be stripped of the hazardous waste."

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

India is a signatory to the three conventions on hazardous chemicals and waste: The Basel Convention on the Control of Trans-boundary Movement of Hazardous Waste and their Disposal, The Rotterdam Convention on the Prior Informed Consent Procedure for Certain Hazardous Chemicals and Pesticides in International Trade and

The Stockholm Convention of Persistent Organic Pollutants.

The Hazardous Substances Management Division (HSM) of the Ministry of Environment and Forests (MoEF) has the responsibility for promoting safe management and use of hazardous substances, including hazardous waste. The HSM has established three sets of rules: The Hazardous Wastes (Management and Handling) Rules (1989, amended in 2003),

The Bio-medial Wastes (Management and Handling) Rules (1998/2000), and

The Batteries (Management and Handling) Rules (2001).

The HSM relies primarily on the

The Central Pollution Control Board (CPCB),

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

Approximately 5 million tonnes of hazardous waste is produced annually in India.

According to a 2003 report, Indian industries in the following five states had generated over 80% of the countrys hazardous waste:
Andhra Pradesh, Gujarat,

Karnataka,
Maharashtra and Tamil Nadu.

European Commission focus on waste management

Landfill Air Emission of CO2; odours CH4,

Composting Emission of CH4, CO2; odours

Incineration Emission of SO2, NOx, HCl, HF, NMVOC, CO, CO2 N2O, dioxins, dibenzofurans, heavy metals(Zn, Pb, Cu, As) Deposition of hazardous substances on surface water

Recycling Emissions dust of

Transportation Emissions of dust NOx, SO2, release of hazardous substances from accidental spills Risk of surface water and groundwater contamination from accidental spills Risk of soil contamination from accidental spills

Water

Leaching of salts, heavy metals, biodegradable and persistent organics to groundwater Accumulation of hazardous substances in soil

Waste water discharges

Soil

Landfilling of slags, fly ash and scrap

Landfilling of final residues

Pitfalls of the currently available technologies for managing wastes

European Commission focus on waste management

Landfill Landscape Soil occupancy; restriction on other land uses Contamination and accumulation of toxic substances in the food chain Exposure hazardous substances to Composting Soil occupancy; restriction on other land uses Contamination and accumulation of toxic substances in the food chain Incineration Visual intrusion; restriction on other land uses Contamination and accumulation of toxic substances in the food chain Exposure hazardous substances to Noise Recycling Visual intrusion Transportation Traffic

Ecosystems

Risk of contamination from accidental spills Risk of exposure to hazardous substances from accidental spills; traffic

Urban areas

Pitfalls of the currently available technologies for managing wastes

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

God proposes, man disposes

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

LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS

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

Class B

LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS

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

LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS

Class C Concentration limit: 20,000 mg/kg Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002

C1 Ammonia and ammonium compounds C2 Inorganic peroxides C3 Barium compounds, except barium sulphate C4 Fluorine compounds C5 Phosphorus compounds, except the phosphates of aluminum, calcium and iron C6 Bromates, (hypo)bromites C7 Chlorates, (hypo)chlorites C8 Aromatic compounds C9 Organic silicon compounds C10 Organic sulphur compounds C11 Iodates C12 Nitrates, nitrites C13 Sulphides C14 Zinc compounds C15 Salts of per-acids C16 Acid halides, acid amides C17 Acid anhydrides

LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS

Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002

Class D

Concentration limit: 50,000 mg/kg D1 Sulphur D2 Inorganic acids D3 Metal bisulphates D4 Oxides and hydroxides except those of: hydrogen, carbon, silicon, iron, aluminum, titanium, manganese, magnesium, calcium D5 Aliphatic and napthenic hydrocarbons D6 Organic oxygen compounds D7 Organic nitrogen compounds D8 Nitrides D9 Hydrides

LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS

Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002

Class E Regardless of concentration limit

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

LIST OF PROCESSES GENERATING HAZARDOUS WASTES

Ministry of Environment & Forests Hazardous Wastes (Management and Handling) Amendment Rules, 2003 1 Petrochemical processes and pyrolytic operations

2 Drilling operation for oil and gas production

3 Cleaning, emptying and maintenance of petroleum oil storage tanks including ships 4 Petroleum refining/re-refining of used oil/recycling of waste oil Industrial operations using mineral/synthetic oil as lubricant in hydraulic systems or 5 other applications 6 Secondary production and/or use of zinc Primary production of zinc/lead/copper and other non-ferrous metals except 7 aluminium 8 Secondary production of copper 9 Secondary production of lead 10 Production and/or use of cadmium and arsenic and their compounds 11 Production of primary and secondary aluminium

LIST OF PROCESSES GENERATING HAZARDOUS WASTES

Ministry of Environment & Forests Hazardous Wastes (Management and Handling) Amendment Rules, 2003 Metal surface treatment, such as etching, staining, polishing, galvanising, cleaning, 12 degreasing, plating, etc. Production of iron and steel including other ferrous alloys (electric furnaces; steel 13 rolling and finishing mills; Coke oven and by product plant)

14 Hardening of steel
15 Production of asbestos or asbestos-containing materials 16 Production of caustic soda and chlorine

17 Production of acids
18 Production of nitrogenous and complex fertilizers 19 Production of phenol 20 Production and/or industrial use of solvents Production and/or industrial use of paints, pigments, lacquers, varnishes, plastics and 21 inks 22 Production of plastic raw materials

LIST OF PROCESSES GENERATING HAZARDOUS WASTES

Ministry of Environment & Forests Hazardous Wastes (Management and Handling) Amendment Rules, 2003 23 Production and/or industrial use of glues, cements, adhesive and resins 24 Production of canvas and textiles 25 Industrial production and formulation of wood preservatives 26 Production or industrial use of synthetic dyes, dye-intermediates and pigments 27 Production or industrial use of materials made with organo-silicone compounds 28 Production/formulation of drugs/ pharmaceuticals 29 Production, use and formulation of pesticides including stock-piles

30 Leather tanneries
31 Electronic Industry 32 Pulp & Paper Industry 33 Disposal of barrels / containers used for handling of hazardous wastes / chemicals 34 Purification processes for air and water

35 Purification process for organic compounds/solvents

Waste treatment processes, e.g. incineration, distillation, separation and concentration

REPORT ON CLINICAL WASTE AUDIT 2005

Infectious waste treated from Jan-Dec 2005 Average waste treated per month Weight of sharps treated in 2005 Average weight of sharps treated per month Blood & blood products Liquid Wastes: Total effluent per month Laundry effluent per month Xray developer per month Hazardous liquids consumed in labs per month Hazardous chemicals as solids weight per month Dilution factor of hazardous liquids 27,333. 164 lakh litres 3 lakh litres 140 litres 588 litres 260 grams 86,704 Kilograms 7,225 Kilograms 2,917 Kilograms 243 Kilograms 300 liters

Sr. No 1

Chemicals / Reagents 10% Formalin

Lits. 100

2
3 4 5 6 7 8 9 10 11

Xylene
Basic fuchsin Haematoxylin stain Nitric Acid Anhydrous Aluminum Chloride Hydrochloric acid Diamino benzidine Hydrogen peroxide Glacial acetic acid Gluteraldehyde

190.1
1.17 1.0 50.5 .005 .800 20.0 53.202 5.225 150.500

Hazardous liquid waste / month:

12
13 14 15 16 17 18 19 20

Ethidium bromide
Propane / Butane WD40 (Petroleum distillate) Benzoin tincture Lugols Iodine Phenol (carbolic acid) Ammonia solution Lactic acid Sulfuric acid Total

.001
2.500 2.00 10.00 0.42 1.000 .050 .045 .100 588.19

Hazardous solid waste / month:

Sr. No 1 2 3 4 5 6 7 Chemicals / Reagents Benzidine dihydrochloride Naphthol phosphate Pararosaline hydrochloride Sodium-fluoride Potassium dihydrogen phosphate Dipotassium hydrogen phosphate Benzidine G.R. Weight (Grams) 0.5 .060 1.0 .200 8.500 8.500 1.0

8
9 10 11 12 13 14 15 16

Zine sulphate
Barium chloride Phenol crystals Naphthylamine Naphthol Sodium-polyanethol sulphonat Sodium hydroxide pellet Sulfonilic acid Trichloroacetic acid Total

16.5
13.00 40.00 16.50 16.50 45.00 45.00 45.00 2.1 259.36

In Conclusion: Key Issues

Awareness and education
Reporting systems & documentation Segregation of identified clinical infectious wastes at source Timely treatment by non-polluting technologies on-site or off-site Waste audit Waste monitoring systems Elevation of safety standards by all healthcare facilities All HCWs must have hygiene in their genes.

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

Thank You