Hospital Waste Management

of Ujjain city
Index

Chapter 1 Biomedical waste (Introduction & definitions) Page 3-9

Chapter 2 Waste generation (source/composition/type/categories) Page 10-17

Chapter 3 Materials and methods Page 18-40

Chapter 4 Standards for treatment & disposal Page 41-43

Chapter 5 Environmental management system Page 44-50

Chapter 6 Biomedical waste management system of Ujjain city Page 51-52

Chapter 7 Hypothesis Page 53-54

Chapter 8 Health care waste minimization, reuse & recycling Page 55-61

Chapter 9 Problems & recommendation Page 62-63

Chapter 10 Legislations Page 64-70
Chapter 11 Management and handling rules guidelines Page 71-77
Chapter 12 Present scenario with new rules in India Page 78-84
FAQ’s Page 85-89
Conclusion Page 89
Reference Page 90

Figure list

1 Risk of hospital waste Page 7

2 Typical waste composition in HCFs Page 11
3 Source of biomedical waste Page 11
4 Steps of waste management Page 19
5 Symbols Page 21
6 Labels Page 25
7 Sign Page 25
8 Labels Page 31
9 Simple incineration process Page 32
10 Biomedical waste flow chart Page 40
11 Waste management flow chart Page 44
12 Process flowchart of waste management of Ujjain city Page 51
13 Current status of medical waste in Ujjain city Page 54
14 Waste management hierarchy Page 55

Page | 1
Table list

1 Amount of hospital waste generated in countries Page 10

2 Hazardous and nonhazardous waste percentage Page 10
3 Composition by weight Page 10
4 Chemical waste example from health care activities Page 15
5 Categories of BMW Page 17
6 Waste segregation according to color coding Page 20
7 Comparison among different treatments Page 39
8 EPA emission limit Page 41
9 Emission standard Page 42
10 Effluent generation Page 42
11 Design and operation requirements Page 43
12 Infection caused by health care waste Page 46
13 Major difference between BMW rules of 1998 & 2016 Page 79-83

Box list

1 Common recyclable material from HCFs Page 12

2 Common genotoxic products used in health care Page14
3 Decay storage of radioactive waste Page 27
4 Cytotoxic drug hazardous to eye and skin Page 48
5 Example of practice that encourage waste Page 55
minimization
6 Example of sterilization method Page 58

Page | 2
Chapter 1 BMW

Background
From the beginning, the health care facilities or hospitals are identified as a place where the
treatment of a sick person is done but the adverse effect of the waste generated by them on humans
as well as on environment is unknown. But now we are totally understand that, this waste can be
fatal and can possess health risk too. Ministry of Environment and Forests passed an act in 1986 &
notified the Bio Medical Waste (Management and Handling) Rules in July 1998. According to these
rules, it is the duty of every “occupier” means a person who has the control over the organization or
it’s within area, to take all steps to safeguard that waste generated is handled without any adverse
effect to public health and environment.

How did BMW come into existence?

 In the late 1980’s

 A huge mass of numerous items of medical waste washed up on several east coast beaches in
New Jersey and New York.
 The generation source of this is found as incinerators and transfer stations of nearby places
 With the concern about public from dangerous diseases i.e. HIV and HBV virus infection
USA govt. lead to develop the biomedical waste management law.
 The planning of this law is to keep monitor the process of medical waste from generation to
disposal.
 However in India the seriousness about the management came into lime light only after
1990’s.

INTRODUCTION
There are many kind of waste recognizes today. Biomedical waste is a type of waste which contain
infectious materials in it. It may also include waste related with the generation of biomedical waste
that seems to be from medical or laboratory origin (e.g., packaging, unused bandages, infusion kits,
etc.), as well as research laboratory waste contains biomolecules or organisms that are prohibited to
environmental release. As described below, discarded sharps are treated as biomedical waste
whether they are contaminated or not, since with the possibility of being contaminated by blood and
their ability to cause injury when not properly disposed of. This waste is a form of bio waste. It can
be solid, liquid or semi solid. Examples include syringe, discarded blood, sharps, unwanted
microbiological cultures and stocks, identifiable body parts (including those as a result of
amputation), other human or animal tissue, used bandages and dressings, discarded gloves, other
medical supplies that may have been in contact with blood and body fluids, and laboratory waste
that exhibits the characteristics described above. Waste sharps include potentially contaminated
used (and unused discarded) needles, scalpels, lancets and other devices capable of penetrating skin.
Biomedical waste is generated by both medical and biological sources and activities, such as the
diagnosis, prevention, or treatment of diseases. Common producers of medical waste involves
hospitals, clinics, nursing homes, research laboratories, funeral homes, and home health care too. In
Health care facilities waste which contain these characteristics may be called medical waste.
Health care waste management has recently arose as a topic of major concern not only to public but
for the environment too. The bio-medical wastes generated from health care units depend upon a
number of factors such as type of health care unit, type of waste methods used by HCFs,
specialization of healthcare units, quantity of waste generated and disposal, amount of reusable
items, availability of facilities with resources, training and awareness etc.

Page | 3
The term BMW promotes a sense of extra-care in management for treatment and disposal system so
for the protection of the environment. Now it is a well understanding fact that there are many
adverse effects to the flora & fauna which are caused by the “biomedical waste”. Hospital waste is a
potential health hazard to the staff members, sanitary workers, public and flora and fauna of the
area. The problems of the waste disposing in the hospitals and other health-cares have become
issues of major concern.

The healthcare facility waste comprises all die waste created by healthcare establishments, research
facilities, and laboratories. Moreover, it involves the waste originating from scattered or minor
sources such as that produced in the course of healthcare undertaken in the home (dialysis, insulin
injections, etc.) as per the World Health Organization norms. And in Indian context, any waste
generated during die diagnosis, treatment or immunization of human beings or animals or in
research activities, pertaining there to or in the production of testing of biological component is bio-
medical waste.

However, the healthcare facilities are different in different countries and there are a lot of change in
management method of these institutions and their formulation of policy. The definition of medical
waste in Canada (as per the 1992 Canadian Council of Ministers of the Environment’s
Guidelines for the Management of Biomedical Waste in Canada) is waste generated by human
or animal health-care facilities, medical or veterinary research and teaching establishments, health
care teaching establishments and clinical testing or research laboratories, and excludes
microbiology laboratory waste, human blood and body fluid waste or waste sharps after these
wastes have been disinfected or decontaminated; also not includes the items from animal
husbandry, household in origin, controlled in accordance with the Health of Animals Act (Canada),
formerly die Animal Disease Protection Act (Canada), or generated in the food production, general
building maintenance and office administration activities of those facilities to which this definition
applies. BMW can be human anatomical waste, animal waste, microbiology laboratory waste,
human blood and body fluid waste, and waste sharps. In USA, American Society for Testing
Materials, also referred to as ASTM defines biomedical waste as any solid or liquid waste which
may present a threat of infection to humans, including non-liquid tissue, body parts, blood, blood
products, mid body fluids from humans and other primates; laboratory and veterinary wastes which
contain human disease causing agents; and discarded sharps. The following are also included: used,
absorbent materials saturated with blood, blood products, body fluids, or excretions or secretions
contaminated with visible blood; and absorbent materials saturated with blood or blood products
that have dried; non-absorbent, disposable devices that have been contaminated with blood, body
fluids or, secretions or excretions visibly contaminated with blood, but have not been treated by an
approved method; biomedical waste generator - A facility or person that produces biomedical
waste. The term includes hospitals, skilled nursing or convalescent hospitals, intermediate care
facilities, clinics, dialysis clinics, dental offices, health maintenance organizations, surgical clinics,
medical buildings, physicians’ offices, laboratories, veterinary clinics and funeral homes; mobile
health care units, such as bloodmobiles, that are part of a stationary biomedical waste generator, are
not considered individual biomedical waste generators; funeral homes that do not practice
embalming are not considered biomedical waste generators; body fluids - those fluids which have
the potential to harbor pathogens, such as human immunodeficiency virus and hepatitis B virus and
include blood, blood products, lymph, semen, vaginal secretions, cerebrospinal, synovial, pleural,
peritoneal, pericardial and amniotic fluids; contaminated - soiled by any biomedical waste;
decontamination - the process of removing pathogenic microorganisms from objects or surfaces,
thereby rendering them safe for handling; department - the Department of Health or its
representative county health department etc.

Page | 4
Healthcare institutions are little bit indispensable with our life. These institutions manage the health
issues, cure diseases and promote healthy living. But the waste generated from medical activities
are definitely hazardous, toxic, fatal and even lethal because of their nature of dealing infectious
cases who harbor the infection and are in the phase of constantly transmitting the diseases. Thus, the
healthcare organizations have a very high potential for diseases transmission through its waste. In
addition to the ordinary wastes, the hazardous and toxic components of waste from healthcare
establishments comprising infectious, bio-medical and radio-active material as well as sharps
(hypodermic needles, knives, scalpels etc.) constitute a grave risk. Diseases like cholera,
gastroenteritis, typhoid, tuberculosis, hepatitis (especially HBV), AIDS (HIV), diphtheria and many
other serious diseases can spread and posing huge public health risk.
There is no doubt that the waste need proper treatment and disposal in order to save the healthcare
places as health providers, not making them polluted and source of disease transmission. This
prioritize the correct disposal of biomedical wastes in right path. World over, the municipal solid
waste disposal has posed risks for urban governance; the fear of mixture with the biomedical wastes
can lead to the dreaded risk. The propensity of biomedical waste to encourage growth of various
type of pathogen and vectors and its habit of contaminate other nonhazardous/ non-toxic municipal
waste jeopardizes the efforts undertaken for overall municipal waste management. The sanitary
workers and rag pickers are often badly affected. At the same time, illegal and unauthorized reuse
can be highly dangerous and even very fatal. Unfortunately, in die absence of reliable and extensive
correct data, it is not possible to find out the dimension of the problem or even the extent and
variety of type of the risk involved. Some estimate infectious waste as 15 % and hazardous waste as
5 % of biomedical waste, which prompts security of medical staff, segregation of wastes at source
and right way of disposal.
This serious issue needs definite policy, rules, regulation, standards and their implementation
globally. The risks can be averted by proper disciplined judicious planning and management;
certain mandates and amendments can help to manage the disposal of BMW appropriately than
ordinary advice. The disposal has emerged as a global problem and it has drawn the attention of
medical, legal and the administrative communities as well as whole world yet.

The next component is attitude, the inclination to react in a certain way in a definite situation.
Ethics plays a great role in formation of attitude based on the knowledge available for the
individual’s mindset. Ultimately practice emergence as application of rules of knowledge and
attitude that leads to action. This bears great importance in the matter of application of ethics of bio
medical waste disposal as a matter of ‘learning together to work together for health’ ideology of
WHO Technical Report, 1988.

Definition

According to Biomedical Waste (Management and Handling) Rules, 1998 of India “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.

The Government of India (notification, 1998) emphasized that Hospital Waste Management is a
part of hospital hygiene and maintenance activities which involves management of range of
activities, which are mostly engineering functions, such as collection, segregation, storage,
transportation, treatment, and disposal of wastes. One of India’s achievements is to change the
attitudes of the operators of HCFs to incorporate good Health Care Waste management practices in
their daily operations and to purchase on-site waste management services from the private sector.

Page | 5
 Hospital waste
‘Hospital’ is a place which has given the services to the unhealthy people. Hospitals are committed
to patient good care and community health. On the one side they treat patients and at the same time
they have becomes as a generator of several diseases but we are not aware of the adverse effects
generated by them on ‘Mankind and Environment’. A modern hospital is a complicated
multidisciplinary system which uses thousand type of items for delivery of medical care. All these
items used in the hospital leave some waste leftover. This waste is a potential health hazard to the
health care workers, flora and fauna of the area. This problem has now emerging as the threat for
public as well as environmental health. Public is under a constant risk directly or indirectly due to
multifaceted problems of hospital waste.
In 2008, there were about 6 - 7 lakhs hospital beds, over 23,000 primary health care centers and
more than 15,000 small and private hospitals. During last four years rapid mushrooming of
hospitals in the public and private sector has proliferated the problem. Increase in number of
hospitals is the need of because of large amount of population. In recent scenario usage of
disposable items has increased the hospital waste. Unscientific or undisciplined disposal of hospital
waste lead to the transmission of gastro-enteric infections, respiratory problems, infections, rising
incidence of Hepatitis B, HIV, TB, transfusion transmitted diseases have compelled the authorities
to think seriously about hospital waste management programme. Emission of toxins like ‘dioxins’
and ‘Furans’, HCl produced during incineration are also generating a chain of other problems of
Environmental Hazards. Medical waste has been identified by US Environmental Agency as the
third largest known source of dioxin air emission and contributor of about 10% of mercury
emissions to the environment from human activities. Problem of improper waste management can
be decreased by creating awareness about hospital waste management practices, equipping the
readers with enough skills for effectively managing hospital waste, safe guarding themselves and
the community against adverse health impact.

The average quantity of hospital waste generated in India ranges from 1.5 to 2.2 kg/day/bed
whereas in developed countries it is 5.24 kg/day/bed. The problem of hospital waste is more of
quality as compared to quantity. It is estimated that the total amount of hospital waste in Delhi is
only 1.5% of the total municipal waste. Only a small percentage i.e. 15% to 20% of the hospital
waste is contagious and require special disposal techniques but if this 10% mixes with rest of the
waste, then 100% waste becomes contagious. Since it has the ability to contaminate the other waste
too. This issue of improper clinical Waste Management in India was first highlighted in a writ
petition in the Humble Supreme Court; and subsequently, pursuant to the directives of the court, the
Ministry of Environment and Forests, Govt. of India notified the Bio-Medical Waste (Management
and Handlings) Rules on 27th July 98; under the provisions of Environment Act 1986. The rules
have been framed to regulate the disposal of various type of Bio-Medical Waste; so as to ensure the
safety of the staff, patients, doctors, public and the environment. These rules was modified in 2011
and next modified in 2016.

Rationale of hospital waste management

Hospital waste management is a part of hospital hygiene and maintenance programme. In fact only
15% of hospital waste i.e. "Biomedical waste" is hazardous, not the whole. But when hazardous
waste is not separated at the point of generation and mixed with non-hazardous waste, then whole
100% waste becomes hazardous because of its nature.

Page | 6
The question then arises as what is the need or rationale for using so much resource in terms
of money, material, man power and machine for management of hospital waste?

The reasons are as following:

 Injuries from sharps leads to infection to all type & categories of hospital personnel and waste
handler.
 Nosocomial infections in patients from poor infection control practices and poor waste
management.
 Risk of infection outside hospital for waste handlers and scavengers and at time general
public living in the vicinity of hospitals.
 Risk associated with hazardous chemicals, drugs to persons handling wastes at all levels.
 "Disposable" being repacked and sold by unscrupulous elements without even being washed.
Drugs which have been disposed of, being repacked and sold off to unsuspecting buyers leads to
illegal trading.
 Risk of air, water soil and sound pollution directly due to waste, or due to defective
incineration emissions and ash.

Fig. 1 Risk of hospital waste

Biomedical waste Statistics

Developed countries – 1-5 kg/bed/day, with variations among countries.
In India –
 1-2 kg/bed/day with variation among Govt. And private establishments.
 Approximately 506.74 tons/ day wastes generated
 Out of which only 57% waste undergoes proper disposal.

Page | 7
 DEFINITIONS
• Hospital waste refers to mostly all type of waste general, biological or non‐ biological that is
discarded and not intended for further use. Hospital waste is “Any waste which is generated in the
diagnosis, treatment or immunization of human beings or animals or in research” in a hospital.
Hospital Waste Management means the management & handling of waste generated by hospitals
using such techniques that will help to check the spread of diseases.
• 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 and including categories mentioned in Schedule I.
• Infectious waste: The wastes which contain pathogens in sufficient concentration or amount that
could be a source of diseases. It is hazardous and fatal e.g. culture and stocks of infectious agents
from laboratories, waste from surgery, waste originating from infectious patients.
Materials containing pathogens if exposed can cause disease.
i. Human anatomical waste: waste from surgery and autopsies on patients with infectious diseases;
ii. Sharps: disposable needles, syringes, saws, blades, broken glasses, nails or any other item that
could cause a cut;
iii. Pathological: tissues, organs, body parts, human flesh, fetuses, blood and body fluids;

Non Infectious (Hazardous)

Pharmaceuticals: drugs and chemicals that are returned from wards, spilled, outdated, contaminated,
or are no longer required;
Radioactive: solids, liquids and gaseous waste contaminated with radioactive substances used in
diagnosis and treatment of diseases like toxic goiter.

Non Infectious (Non Hazardous)

Domestic waste: from the offices, kitchens, rooms, including bed linen, utensils, paper, etc.

Authorized Person
"Authorized person" means an occupier or operator authorized by the prescribed authority to
generate, collect, receive, store, transport, treat, process, dispose or handle bio-medical waste in
accordance with these rules and the guidelines issued by the Central Government or the Central
Pollution Control Board, as the case may be.

Handling
handling in relation to bio-medical waste includes the generation, sorting, segregation, collection,
use, storage, packaging, loading, transportation, unloading, processing, treatment, destruction,
conversion, or offering for sale, transfer, disposal of such waste.

Page | 8
Major Accident
Major Accident means accident occurring while handling of bio-medical waste having potential to
affect large masses of public and includes toppling of the truck carrying bio-medical waste,
accidental release of bio-medical waste in any water body but exclude accidents like needle prick
injuries, mercury spills.

Management
“Management” includes all steps required to ensure that bio- medical waste is managed in such a
manner as to protect health and environment against any adverse effects due to handling of such
waste.

Occupier
Occupier means a person having administrative control over the institution and its premises
generating medical waste, which includes a hospital, nursing home, clinic, dispensary, veterinary
institution, animal house, pathological laboratory, blood bank, health care facility and clinical
establishment, irrespective of their system of medicine and by whatever name they are called.

Page | 9
Chapter 2 Waste generation, source, composition, type & category
 BIOMEDICAL WASTE GENERATION
Estimates for an average distribution of health - care wastes useful for preliminary planning of
waste management.
• 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% - sharps waste;
• 3% - chemical and pharmacological waste;
• < 1% - special waste; such as radioactive or cytotoxic waste, pressurized containers or broken
thermometers and used batteries.

Amount and composition of hospital waste generated

(a) Table 1 Amount

Country Quantity (kg/bed/day)

U.S.A 4.5
France 2.5
Spain 3.0
U. K. 2.5
India 1.5
Source: international society of environmental botanist’s journal

(b) Hazardous/non-hazardous
Table 2

Hazardous 15%
a)Hazardous but non-
infective 5%
b) Hazardous and
infective 10%

Non-hazardous 85%

(c) Composition
Table 3

By weight
Plastic 14%
Combustible Dry Cellulosic Solid 45%
Wet Cellulosic Solid 18%
Non – Combustible 20%

Page | 10
 Infectious (hazardous
health-care waste) 10%

Chemical/radioactive
(hazardous health-care
waste) 5%

General (non-
hazardous health-care
waste) 85%

Fig. 2 typical waste compositions in health-care facilities

 SOURCES OF BIOMEDICAL WASTES

Between 75 to 90% of the waste produced by the health-care providers is non-risk or general
biomedical waste, in comparison to domestic waste. It arises mostly from administrative and
housekeeping functions of the health care establishments, and also includes waste generated during
maintenance of health-care premises. The remaining 10-25% health-care waste is described as
hazardous and that may create a variety of health risk too.

Sources of biomedical waste can be classified as major and minor sources.

Major Sources
• Govt. hospitals/private hospitals/nursing homes/dispensaries.
• Primary health centers.
• Medical colleges and research centers/paramedic services.
• Veterinary colleges and animal research centers.
• Blood banks/mortuaries/autopsy centers.
• Biotechnology institutions.
• Production units.

Page | 11
Minor Sources
• Physicians/ dentists clinics
• Animal houses/slaughter houses.
• Blood donation camps.
• Vaccination centers.
• Acupuncturists/psychiatric clinics/cosmetic piercing.
• Funeral services.
• Institutions for disabled persons.

 CLASSIFICATION OF HEALTH-CARE WASTE

General waste (Non Hazardous or Non-Risk Waste)

Non-risk waste is that, which is comparable to normal domestic garbage and presents no greater
risk, therefore, than waste from a normal home. This general waste is generated by almost
everybody in the hospital, I.e., administration, patient's risk, cafeterias rooms, cafeterias and
nursing station. Chemicals or radioactive substances and does not pose a sharps hazard. A
significant proportion (about 85%) of all waste from health-care facilities is non-hazardous waste
and is usually similar in characteristics to municipal solid waste.

Such waste may include:

1. Paper and cardboard.

2. Packaging.
3. Food waste, i.e., leftover food, fruit and vegetable peelings.
4. Aerosols.(spray)
5. Packaging materials

In many places, community or regulatory requirements encourage materials recycling. In the past,
all or most non-hazardous and municipal waste was discarded in open dumps or landfills or burnt
directly in municipal incinerators. Greater understanding of the environmental impacts of waste and
the recognition that most of the non-hazardous waste from HCFs is potentially recyclable or
compostable have changed the approaches to managing general waste.

Box lists 1. Examples of common recyclable materials found in health-care facilities.

Box 1 Common recyclable materials from health-care facilities

Corrugated cardboard boxes Newspapers and magazines
Polyethylene terephthalate (PET or PETE) (e.g. plastic water bottles, soft-drink bottles) Polystyrene
packaging
Wood (e.g. shipping pallets)
Paper (e.g. white office paper, computer printer paper, colored ledger paper)
Metals (e.g. aluminum beverage cans and containers, food tin cans, other metal containers)
High-density polyethylene (HDPE) (e.g. plastic milk containers, containers for food, plastic bottles for saline
solutions or sterile irrigation fluids)
Clear, colored or mixed glass Construction and demolition debris

Page | 12
In addition, durable goods such as used furniture, bed frames, carpets, curtains and dishware, as well
as computer equipment, printer cartridges and photocopying toners, are also reusable. Flowers, food
waste from kitchen services and plant waste from grounds maintenance are examples of compostable
waste.
• Infectious waste: Waste which contain pathogens; e.g. laboratory cultures; waste from isolation
wards; tissues (swabs), materials, or equipment that have been in contact with infected patients.

This waste contaminated by any type of bacterium, virus, parasites or fungi, which includes:

1. Cultures (the growing of microorganisms in a nutrient medium (such as gelatin (Proteins from
bone & skin) or agar) from laboratory work.
2. Waste from surgery and autopsies (post-mortem).
3. Waste from infected patients.
4. Waste from infected hemodialysis patients
5. Infected animals from laboratories.
6. Any material having been in contact with infected patients.

 Pathological waste: Human tissues or fluids e.g. amputate body parts; blood and other body
fluids; fetuses. This waste includes:

1. Tissues
2. Organs
3. Body parts
4. Fetuses (Unborn Vertebrates)
5. Blood and body fluids

• Pharmaceutical waste: Waste containing pharmaceuticals; e.g. pharmaceuticals that are expired
or no longer needed; contaminated pharmaceuticals. These include

1. Expired or unused pharmaceutical products.

2. Spilled or contaminated pharmaceutical products.
3. Surplus drugs, vaccines or sera.
4. Discarded items used in handling pharmaceutical, for example bottles, gloves, masks, and
tubes.

• Genotoxic waste: They are the type of drugs used in oncology or radiotherapy that contain a high
hazard or cytotoxic effects. These wastes include:

1. Cytotoxic drugs and outdated material.

2. Vomiting, feces or urine from patients treated with cytotoxic drugs (mainly use in cancer
therapy) or chemicals.
3. Contaminated materials from the preparation and administration of the drugs such as syringes,
vials (A bottle that contains a drug (especially a sealed sterile container for injection by needle) etc.

Page | 13
Box lists 2. Examples of common Genotoxic materials found in health-care facilities.

Box Common Genotoxic products used in health care

Classified as carcinogenic
Chemicals:
1. benzene
Cytotoxic and other drugs:
• azathioprine, Chlorambucil, Chlornaphazine, cyclosporine, cyclophosphamide,
melphalan, semustine, tamoxifen, thiotepa, treosulfan
Classified as possibly or probably carcinogenic
Cytotoxic and other drugs:
azacitidine, bleomycin, carmustine, chloramphenicol, chlorozotocin, cisplatin,
dacarbazine, daunorubicin, dihydroxymethylfuratrizine (e.g. Pan furan S – no longer in
use), doxorubicin, limousine, methylthiouracil, metronidazole, mitomycin, nafenopin,
niridazole, oxazepam, phenacetin, phenobarbital, phenytoin, procarbazine hydrochloride,
progesterone, sarcolysin, streptozocin, trichlormethine
Classified by working groups of the International Agency for Research on Cancer (IARC)

• Chemical waste: Waste containing chemicals e.g. laboratory reagents; film developer;
disinfectants and solvents that are expired or no longer in need.

Chemical waste can include the following;

1. Chemicals from diagnostic and experiment work

2. Cleaning processes
3. Housekeeping and disinfecting procedures.
4. Mercury waste such as from broken clinical equipment spillage.
5. Cadmium waste, mainly from discarded batteries.

Page | 14
 Table 4. Chemical waste from health care facilities

Chemical waste Examples

Halogenated solvents Chloroform, methylene chloride, perchloroethylene, refrigerants,
Trichloroethylene
Non-halogenated Acetone, acetonitrile, ethanol, ethyl acetate, formaldehyde, isopropanol,
Solvents methanol, toluene, xylenes
Halogenated Calcium hypochlorite, chlorine dioxide, iodine solutions, iodophors, sodium
Disinfectants dichloroisocyanurate, sodium hypochlorite (bleach)
Aldehydes Formaldehyde, glutaraldehydes, ortho-phthalaldehyde
Alcohols Ethanol, isopropanol, phenols
Other disinfectants Hydrogen peroxide, peroxyacetic acid, quarternary amines
Metals Arsenic, cadmium, chromium, lead, mercury, silver
Acids Acetic, chromic, hydrochloric, nitric, sulfuric
Bases Ammonium hydroxide, potassium hydroxide, sodium hydroxide
Oxidizers Bleach, hydrogen peroxide, potassium dichromate, potassium
Permanganate
Reducers Sodium bisulfate, sodium sulfite
Miscellaneous Anesthetic gases, asbestos, ethylene oxide, herbicides, paints, pesticides,
waste oils

Wastes contain high amount of heavy metals: Batteries, gas cylinders, broken thermometers,
Pressurized containers, blood pressure gauges, gas cartridges, aerosol cans.
• Radioactive waste: Radioactive wastes are the substances contaminated with radionuclide. They
come into existence as a result of procedures such as in vitro analysis of body tissue and fluid, in
vivo organ imaging and tumor localization, and various investigative and therapeutic practices.

Radionuclides used in health care are either in sealed sources or unsealed (or open) sources.
Unsealed sources are mainly liquids that are applied directly, while sealed sources are radioactive
materials contained in parts of equipment or encapsulated in unbreakable or impervious objects,
such as pins, “seeds” or needles.

Page | 15
Radioactive health-care waste often contains radionuclide having short half-lives (half of the
radionuclide content decays in hours or a few days); consequently, the waste loses its radioactivity
relatively quickly. However, certain specialized therapeutic procedures use radionuclide with
longer half-lives; these are usually in the form of small objects placed on or in the body and may be
reused on other patients after sterilization. Waste in the form of sealed sources may have a
relatively high radioactivity, but is only generated in low volumes from larger medical and research
laboratories. Sealed sources are generally returned to the supplier and should not enter the waste
stream.

The waste produced by health-care and research activities involving radionuclide and related
equipment maintenance and storage can be classified as follows:

 sealed sources;
 spent radionuclide generators;
 low-level solid waste (e.g. absorbent paper, swabs, glassware, syringes, vials);
 excreta from patients treated or tested with unsealed radionuclide;
 residues from shipments of radioactive material and unwanted solutions of radionuclide
intended for diagnostic or therapeutic use;
 Gases and exhausts from stores and fume cupboards.
 liquid immiscible with water, such as liquid scintillation counting;
 residues used in radioimmunoassay, and contaminated pump oil;
 waste from spills and from decontamination of radioactive spills;
 low-level liquid waste (e.g. from washing apparatus);

Sharps:
Sharps are items that could cause cuts or puncture wounds, including needles, cutter, scalpels and
other blades, knives, infusion sets, saws, broken glass and pipettes. Whether or not they are
infected, they are usually taken as highly hazardous health-care waste and should be treated as if
they were potentially infected.

Sharps include the following whether infected or not:

 Needles
 Syringes
 Scalpels (A thin straight surgical knife used in dissection and surgery)
 Infusion sets
 Saws and knives
 Surgical blades
 Broken glass
 Any other items that can cut and puncture

Page | 16
Categories of Biomedical waste
Table 5. Category of BMW

Page | 17
Chapter 3 Material and Methods
HOW BIOMEDICAL WASTE MANAGEMENT IS BENEFICIAL?

• Leads to some cleaner and healthier surroundings.

• Decreased incidence of nosocomial infections.

• Reduction in the cost of infection control within the hospital.

• Disease and death due to reuse and repackaging of infectious disposables is eliminated.

• Segregation and appropriate treatment of medical waste reduces cost of waste management and
generous revenue.

Need of biomedical waste management in hospitals

Medical care is a part of our life and health, but the waste generated from medical activities shows
a real problem for livings and human world. Improper management of waste generated in health
care facilities creates direct and indirect health impact on the community, the health care workers
and on the environment every day, relatively large amount of potentially infectious and hazardous
waste are generated in the health care hospitals and facilities around the world.
Indiscriminate disposal of BMW or hospital waste and exposure to such waste possess serious
threat to environment and to human health that requires specific treatment and management prior to
its final disposal.
The reasons due to which there is great need of management of hospitals waste such as:
1. Injuries from sharps leading to infection to all categories of hospital personnel and waste
handler.
2. Nosocomial infections in patients from poor infection control practices and poor waste
management.
3. Risk of infection outside hospital for waste handlers and scavengers and at time general public
living in the vicinity of hospitals.
4. Risk associated with hazardous chemicals, drugs to persons handling wastes at all levels.
5. “Disposable” being repacked and sold by unscrupulous elements without even being washed.
6. Drugs which have been disposed of, being repacked and sold off to unsuspecting
7. Buyers. Risk of air, water and soil pollution directly due to waste, or due to defective
incineration emissions and ash.

Management & Steps

Management

Biomedical waste need to be properly managed and disposed for protection of the environment,
general public and workers, especially healthcare and sanitation workers who are at risk of
exposure to biomedical waste as an occupational hazard. Steps in the management of biomedical
waste include generation, accumulation, handling, storage, treatment, transport and disposal.

Page | 18
 On-site versus off-site

Off-site disposal occurs, at a location which is different from the site of generation. Treatment may
occur either on-site or off-site. On-site treatment of large quantities of biomedical waste usually
requires the use of relatively expensive equipment, and is generally cost effective for very large
hospitals and major universities who have the space, labor and budget to operate such equipment.
Off-site treatment and disposal involves hiring of a biomedical waste disposal service (also called a
truck service) whose employees are well trained and aware to collect and haul away biomedical
waste in special containers (usually cardboard boxes, or reusable plastic bins) for treatment at a
facility designed to handle biomedical waste.

Steps for waste management

Figure 4: Steps for waste management

 Segregation

In the treatment method of waste management the segregation of wastes is the first and most
important prerequisite. Segregation allows special attention to be given to the relatively small
quantities of infectious wastes and thereby reducing the risks as well as cost of handling and
disposal of the otherwise 100% infectious waste. Segregation at the source of generation itself is
compulsory. Each and every person who generate and handle, waste should be trained in handling
different type and categories of it. The segregation and collection of sharps needs more attention
because pathogens can survive for long periods in articles such as needles because of presence of
blood. Any cuts in the skins of handlers make a direct path for pathogens to enter in the blood.
Organizations, which generate hazardous substances such as radioactive waste, demands special
training. Every person in the institute should have the understanding of the waste quantity
generated and the type of waste generated. Waste quantification is also a part of segregation.

Page | 19
The correct type of segregation of waste is the responsibility of the person who generates each waste
item, whatever their position in the organization. The HCFs management is responsible for
monitoring that there is a suitable segregation, transport and storage system is running or not, and
that all staff adheres to the correct procedures or not. Segregation should be carried out by the
producer of the waste as close as possible to its place of generation, which means segregation should
take place in a medical area, at a bedside, in an operating theatre or laboratory by nurses, physicians
and technicians. If classification of a waste item is uncertain, it should be placed into a container
which is used for hazardous medical waste as a precaution.

The simplest and easiest waste-segregation method is to separate all hazardous & nonhazardous
waste. However, for providing a minimum level of safety for staff and patients, the hazardous waste
portion is commonly separated into two parts: potentially infectious items and used sharps. In the
latter, the largest components are typically tubing, bandages, disposable medical items, swabs and
tissues. Consequently, the segregation of general, non-hazardous waste, potentially infectious waste
and used sharps into separate containers is often referred to as the “three-bin system”. Further types
of containers can be used for other categories of wastes, such as chemical and pharmaceutical wastes,
or to separate out pathological waste, where it is to be handled and disposed of in different ways from
the other portions of the waste flow.

Table 6. Segregation should be done as per categories.

Category Type of Container Color coding

1. Human anatomical waste Plastic bag Yellow

2. Animal waste Plastic bag Yellow

3. Microbiology and Plastic bag yellow/red

Biotechnology waste

4. Waste sharp Container Puncture proof Blue/white

and cytotoxic waste

5. Discarded Medicines Plastic bag Black

6. Solid soiled waste plastic bag yellow/red

7. Solid waste plastic bag Blue (all disposable

plastics)

8. Liquid waste – –

9. Incineration ash plastic bag Black

10. Chemical waste (solid) plastic bag Black

Labeling of waste containers helps to identify the source, type and quantities of waste produced in
each area, and allow problems with waste segregation to be traced back to a medical area. A simple
approach is to fix a label to each container with the details of the medical area, date and time of
closure of the container, and the name of the person filling out the label. Using an international
hazard symbol on each waste container is also recommended. Several symbols are present to the
different kinds of hazardous waste produced and these are shown in Figure 5

Page | 20
 New radiation symbol
Biohazard symbol Old radiation symbol

Fig. 5 Biohazard, radiation and chemical hazard symbols

Beyond basic segregation

Non-hazardous waste
With each major category (e.g. non-hazardous, potentially infectious, used sharps), further
segregation may be more advantageous. For example, general waste can be broken down into
recyclables, reusable, biodegradable waste and non-recyclable portions. If these are mixed at the
point of generation, it may prevent recyclables from being recovered.

Food wastes can be collected from medical areas and can returned directly to the kitchens. Because
kitchen wastes can be composted or, where regulations allow, sterilized and used for animal feed.

Hazardous waste
Highly infectious waste, such as diagnostic laboratory samples, operation theatres left and waste from
infectious patients in isolation have to be collected separately and autoclaved at the point of
generation.

Anatomical waste, mostly recognizable parts of body or fetal material, must be handled according to
prevailing cultural and religious preferences (most commonly, authorized burial or cremation). In
low-resource areas, placentas and other non-recognizable anatomical waste can be disposed of in a
pit where it can biodegrade naturally.

Sharps waste (needle and syringe) should be placed directly into a sharps container. In some places, it
is necessary for syringes to have their needles removed or destroyed before placing the syringe in a
waste bin. Any removed needles are placed in a puncture-proof container and dealt with accordingly.
This approach is not universally accepted as best practice.

Policies regarding the use of needle cutters (means hub cutters) or needle pullers, and destroyers vary
from place to place. A needle puller is a type of pliers which removes the needle from the syringe – a
process called defanging. In some countries, needle cutters or pullers, or destroyers are mandatory
for vaccination programs. A WHO study investigated the advantages and risks of needle cutters
(Ahmed, 2010); the study group used needle cutters or destroyers, and the comparison group used
usual practice.

Page | 21
 There was no statistically difference in the number of needle-stick injuries among the waste handlers
and injection providers, or blood exposures among the injection providers; however, injuries and
exposures were slightly lower in the group using the needle cutters/needle pullers. The use of hub
cutters/needle pullers did not increase the amount of time required to give the vaccinations. The
overall amount of waste produced during the study was slightly less in the group that used the hub
cutters/needle pullers, but less than 0.2% of it was sharps waste. Table 7.2 summaries the advantages
and disadvantages of needle cutters/destroyers.

Various chemical and pharmaceutical wastes should be segregated and collected separately:
subcategories include mercury, batteries, cadmium-containing wastes, photochemical, stains and
laboratory reagents, cytotoxic drugs and other pharmaceuticals. All should be clearly labeled with the
type of waste and the name of the major chemicals, with any necessary hazard labels attached to
corrosive, flammable, explosive or toxic chemicals. Liquid chemical wastes should never be mixed
or disposed of down the drain, but should be stored in strong leak-proof containers. It may be
possible to recover silver from photochemical at a profit, and return of chemicals to suppliers should
be practiced where possible. Silver is increasingly being used in medical products, but is rarely
segregated due to a lack of dedicated disposal or metals recovery facilities. Low-energy light bulbs
(compact fluorescents) contain small amounts of mercury. Both these and batteries should be
segregated and treated by recycling processes, where suitable facilities exist. Mercury use is being
reduced in health care and other applications around the world because of its toxicity and pollution
potential. Since it is volatile, spilled mercury can be inhaled by staff and patients if it is not cleaned
up properly, but a simple spill kit can be cheap and effective. Where mercury thermometers and
sphygmomanometers are still in use, medical staff should be supplied with a spill kit and trained in
how to use it. Any spill larger than a thermometer should be dealt with in consultation with the local
health and safety authority. Brushes and vacuum cleaners should never be used for spilled mercury.
Mercury can be cleaned up easily from wood, linoleum, tile and similar smooth surfaces. It cannot be
completely removed from carpets, curtains, upholstery or other absorbent materials. The affected
portion should be isolated and disposed of in accordance with official guidelines. For more
information on spill clean-up, see section 11.3.2.

Unused pharmaceuticals should go back to the pharmacy for return to the manufacturers or
dispatched to specialist waste-treatment contractors. Pharmaceuticals should be kept in their original
packaging to aid identification and prevent reaction between incompatible chemicals. Spilt and
contaminated chemicals and pharmaceuticals should not be returned to the pharmacy but should go
directly from the point of production to a waste store. Typically, they are stored and transported
within a health-care facility in brown cardboard boxes and must be kept dry.

Where specialist disposal services exist, they should collect and handle radioactive wastes.
Otherwise, waste may be stored in secure, radiation-proof repositories (leak-proof, lead-lined and
clearly labeled with the name of the radionuclide and date of deposition) where it should be left to
decay naturally.

Page | 22
Collection within the health-care facility
Collection times should be fixed and appropriate to the quantity of waste produced in each area of the
health-care facility. General waste should not be collected at the same time or in the same trolley as
infectious or other hazardous wastes.

Waste bags and sharps containers should be filled to no more than three quarters full. Once this level
is reached, they should be sealed ready for collection. Plastic bags should never be stapled but may
be tied or sealed with a plastic bag or tie. Replacement bags or containers should be available at each
waste-collection location so that full ones can immediately be replaced.

Waste bags and containers should be labeled with the date, type of waste and point of generation to
allow them to be tracked through to disposal. Where possible, weight should also be routinely
recorded. Anomalies between departments with similar medical services or over time at one location
can show up differences in recycling opportunities, or problems such as poor segregation and
diversion of waste for unauthorized reuse.

Collection should be daily for most wastes, with collection timed to match the pattern of waste
generation during the day. For example, in a medical area where the morning routine begins with the
changing of dressings, infectious waste could be collected mid-morning to prevent soiled bandages
remaining in the medical area for longer than necessary. Visitors arriving later in the day will bring
with them an increase in general waste, such as newspapers and food wrappings; therefore, the
optimum time for general and recyclable waste collection would be after visitors have departed.

In comparison with this general type of medical area, a theatre would generate a high proportion of
potentially infectious waste and could have several collections during the day to fit in with the
schedule of operations. A child and maternal health clinic might generate primarily sharps waste
from injections, which would be collected at the end of each working day.

Storage:
Different categories of segregated wastes need to be collected in Color-coded containers as
prescribed in the Bio-Medical Waste (Management and Handling) Rules. 2000. Sharps must always
be kept in puncture-proof containers to avoid injuries and infection to the workers handling them.
Plastic bags for storing the waste must be suspended inside a frame or be placed inside a sturdy
container. A lid should be provided to cover the opening of the bag. Laboratories and other
functional areas should have containers/bags for the wastes generated there. In all rooms of a
hospital, there should be a container for general waste. All wastes from isolation wards should be
regarded as infectious and treated as such. Each container must be clearly labeled to show where it
comes from because it may be necessary to trace the waste back to its source. For example, if a
waste collector is injured by a syringe or blade put into the wrong container, it is possible to
determine the origin of the waste and identify the staff member responsible. It may also help in
determining the type of infection that may have been transmitted. The storage time for each
category of waste generated should be determined; wastes such as placenta which cannot be stored
for long durations should be collected early. Ideally, waste should be collected at least twice a day.

Page | 23
Interim storage in medical departments

Where possible, hazardous waste generated in medical areas should be stored in utility rooms, which
are designated for cleaning equipment, dirty linen and waste. From here, the waste can be kept away
from patients before removal, then collected conveniently and transported to a central storage facility.
This is known as interim or short-term storage.

If utility rooms are not available, waste can be stored at another designated location near to a medical
area but away from patients and public access. Another possibility for interim storage is a closed
container stationed indoors, within or close to a medical area. A storage container used for infectious
waste should be clearly labeled and preferably lockable

Central storage inside health-care facilities

Central storage areas are places within a facility where different types of waste should be kept for
safe retention until it is treated or send for offsite transport. The general requirements are relevant to
most types of health-care facilities where sufficient waste is generated and needs to be stored
centrally or separately. Some types of waste storage for particular items (e.g. blood, radioactive
substances, chemical) are only likely to be required at large and specialized medical centers.

General requirements

A storage location for health-care waste should be designated inside the organization. Space for
storing wastes should be incorporated into a building design when new construction is undertaken;
for an example, see the Guidelines for design and construction of hospitals and health care facilities
(Facility Guidelines Institute, 2010). These storage areas size should be selected according to the
quantities of waste produced and the collection. The areas must be completely enclosed and separate
from another rooms or food preparation areas. Loading docks, space for compactors and balers for
cardboard, staging areas for sharps boxes, recycling containers and secure storage (e.g. for batteries)
should all be provided.

Figures 6 and 7 show typical signs advising the hazard posed by waste. In general, there are four
different variety of waste-storage areas:

Non-hazardous or general waste

hazardous waste

infectious and sharps waste

chemical and pharmaceutical waste

Radioactive waste.

Page | 24
 Figure 6. Example labels outside the storage facility

No entry for Toxic sign for

unauthorized Biohazard sign for infectious chemical and
persons for all storage hazardous
areas and sharps waste pharmaceutical waste

Figure 7. Illustrates the signs that should be displayed inside the storage facilities.

No eating or drinking No smoking

Hazardous waste storage

Further specifications should be taken for the storage of hazardous waste, within the general
requirements.

Infectious waste storage

The storage place should be considered as an infectious waste area by using the biohazard sign.
Floors and walls must be sealed or tiled to allow easy disinfection. If available, the storage room
should be connected to a sewage system for infectious hospital liquid waste. The compacting of
untreated infectious waste or waste with a high amount of blood or other body fluids destined for
offsite disposal (for which there is a risk of spilling) is not permitted. Sharps can be stored without
difficulty, but other infectious waste should be kept cool or refrigerated at a temperature preferably
no higher than 3°C to 8°C if stored for more than a week. Unless a refrigerated storage room is
available, storage times for infectious waste (e.g. the time gap between generation and treatment)
should not exceed the following periods:

Page | 25
• temperate climate • warm climate
48 hours during the cool
-- 72 hours in winter -- season
24 hours during the hot
-- 48 hours in summer -- season.

Pathological waste storage

Pathological waste and the growth of pathogens it may contain biologically active waste, and gas
formation during storage should be expected. For reducing these possibilities, the storage places
should have the same conditions as those for infectious and sharps wastes.

In some rituals, body parts are passed to the family for cultural procedures or are buried in designated
places. They should be kept in sealed covered bags to minimize infection risks before handover to the
public.

Pharmaceutical waste storage

Pharmaceutical waste must be segregated from other wastes and regulations should be followed for
final disposal. In general, this type of wastes can be hazardous or non-hazardous, and liquid or solid
in nature, and each should be handled differently. The classification should be carried out by a
pharmacist or other expert on pharmaceuticals. The pharmaceutical waste streams that are listed
below can be distinguished (WHO, 1999):

Pharmaceutical waste with non-hazardous characteristics that can be stored in a non-hazardous

storage area -- ampoules with non-hazardous content (e.g. vitamins);
 Fluids with non-hazardous contents, such as vitamins, salts (sodium chloride), amino salts;
 Solids or semi-solids, such as tablets, capsules, granules, powders for injection, mixtures,
creams, lotions, gels and suppositories;
 Aerosol cans, including propellant-driven sprays and inhalers.

Hazardous waste that should be stored in accordance with their chemical characteristics (e.g.
genotoxic drugs) or specific requirements for disposal (e.g. controlled drugs or antibiotics)

 Controlled drugs (should be stored under government supervision);disinfectants and

antiseptics;
 Anti-infective drugs (e.g. antibiotics); -- geotaxis drugs (genotoxic waste);
 Ampoules with, for example, antibiotics.

Genotoxic waste is highly toxic and should be identified and stored carefully away from other
health-care waste in a designated secure location. It can be stored in the same manner as toxic
chemical waste, although some cytotoxic waste may also carry a risk of infection.

Page | 26
Chemical waste storage
When planning storage places for hazardous chemical waste, the characteristics of the different
chemicals to be stored and disposed of must be considered (inflammable, corrosive, explosive). The
storage place should be an enclosed area and separated from other waste storage areas (Figure 7.11).
When storing liquid chemicals, the storage should be equipped with a liquid- and chemical-proof
sump. If no sump is present, catch-containers to collect leaked liquids should be placed under the
storage containers. Spillage kits, protective equipment and first-aid equipment (e.g. eye showers)
should be available in the central storage area. The storage area itself should have adequate lighting
and good ventilation to prevent the accumulation of toxic fumes.

To ensure the safe storage of chemical wastes, the following separate storage zones should be
available to prevent dangerous chemical reactions. The storage zones should be labeled according to
their hazard class. If more than one hazard class is defined for a specific waste, use the most
hazardous classification:

Explosive waste

Corrosive acid waste

Corrosive alkali waste (bases)

toxic waste

flammable waste

oxidative waste

halogenated solvents (containing chlorine, bromine, iodine or fluorine)

Non-halogenated solvents.

Liquid and solid waste should be stored separately. If possible, the original packaging should be
taken for storage too. The packaging used to store and transport chemical wastes offsite should also
be labeled. This label should have the following information: hazard symbol(s), waste classification,
date, and point of generation (if applicable).

The storage area for explosive or highly flammable materials must be suitably ventilated above and
below, with a bonded floor and constructed of materials suitable to withstand explosion or leakage.

Radioactive waste
Radioactive waste should be stored in containers that prevent dispersion of radiation, and stored
behind lead shielding. Waste that is to be stored during radioactive decay should be labeled with the
type of radionuclide, date, period of time before full decay and details of required storage conditions.

Page | 27
The decay storage time for radioactive waste differs from other waste storage, because the main
target will be to store the waste until the radioactivity is substantially reduced and the waste can be
safely disposed of as normal waste. A minimum storage time of 10 half-life times for radioisotopes in
wastes with a half-life of less than 90 days is a common practice. Infectious radioactive waste should
be decontaminated before disposal. Sharp objects such as needles, Pasteur pipettes and broken glass
should be placed into a sharps container. Liquids associated with solid materials, such as assay tube
contents, should be decanted or removed by decay time. All radioactive labeling should be removed
on any items to be disposed of. Box 7.2 gives a sample calculation of decay storage time.

Box 3 Decay storage of radioactive waste – a sample calculation of decay storage time
Decay storage
Cr-51, Ga-67, I-125, I-131, In-111, P-32, Rb-86, Rd-222, S-35, Tc-99m and so on
Example
I-125
Half-life: 60.2 days (<90 days)
60.2 days × 10 = 602 days of decay storage Sources: IAEA (2005); FIU (2005)

Radioactive waste with a half-life of more than 90 days must be collected and stored externally in
accordance with national regulations. In many countries, this type of waste would be taken to a
national disposal site by a government agency or its specialist contractor.

Storage places must be equipped with sufficient shielding material, either in the walls or as movable
shielding screens. The storage must be clearly marked with “RADIOACTIVE WASTE”, and the
international hazard label should be placed on the door. The storage place should be constructed in a
manner that renders it flame-proof and should have such surfaces on floors, benches and walls that
allow proper decontamination. An air-extraction system and radioactive monitoring system should be
put in place. The International Atomic Energy Agency provides comprehensive guidance on all
aspects of the safety of radioactive waste management in the Safety Standards Series.

Type of storage devices

Dustbins:
It is important to assess the amount of waste generated at each point. Dustbins should be of such
capacity that they do not overflow between each cycle of waste collection process. Dustbins must
be cleaned after every cycle of clearance of waste and with disinfectants. Dustbins can be lined
with plastic bags, which are chlorine-free, and color coded as per the law and standards.
Trolleys
The use of trolleys will help in the removal of infectious waste at the point of source itself, instead
of adding a new category of waste.

Page | 28
 Handling devices
Wheel barrows:
These are used to transfer the waste from the generation source to the collection centers. There are
two types of wheelbarrow – one is covered and another is open. Wheelbarrows are made of steel
and having two wheels and a handle. Only packed waste (in plastic bags) should be carried. It is
important not to directly dump waste into it. Care should be taken not to allow liquid waste from
spilling into the wheelbarrow, otherwise it will corrode. These are ideal only for transferring debris
within the organizations. These are also available in various sizes depending on the utility.
Chutes:
Chutes are vertical conduits provided for easy transportation of refuse vertically in case of
institutions with more than two floors. Chutes should be fabricated from stainless steel. It should
have a self-closing lid. These chutes should be fumigated everyday with formaldehyde vapors. The
contaminated linen (contaminated with blood and or other body fluids) from each floor should be
bundled in soiled linen or in plastic bags before ejecting into the chute.
Alternately, elevators with mechanical winches or electrical winches can be provided to bring down
waste containers from each floor. Chutes are necessary to avoid horizontal transport of waste thereby
minimizing the routing of the waste within the premises and hence reducing the risk of secondary
contamination.

Selection of treatment methods

The choice of treatment process involves consideration of waste characteristics, quantity generated,
technology capabilities and requirements, environmental safety factors, and economics.
Factors to consider include:
• Waste characteristics
• Amount of wastes for treatment and disposal
• How health-care facility to handle the quantity of waste
• Types of waste treatment and disposal method
• Technology availability and requirements
• Availability of treatment options and technologies locally
• Treatment efficiency
• Volume and mass reduction
• Installation requirements and available space for equipment
• Infrastructure requirements
• Operation and maintenance requirements
• Skills needed for operation for the technology
• Environmental and safety factors
• Occupational health and safety considerations
• Location and surroundings of the treatment site and disposal facility
• Public acceptability and sensitivity
• Options available for final disposal
• Regulatory requirements
• Cost considerations
• Shipping fees and customs duties
• Installation and commissioning costs
• Cost of transport and disposal of treated waste
• Decommissioning costs.
• Consideration of rules, regulations and Standards

Page | 29
There are five basic processes for the treatment of hazardous components in health-care waste, in
particular, sharps, infectious and pathological wastes: thermal, chemical, irradiation, biological and
mechanical.

 Pre-treatment:
Some pre-treatment should be carried out at the point of waste generation. Syringes and needles
should be broke or damaged before putting into the waste containers so that rag-pickers are
dissuaded from collecting them for resale. This helps in the needles from recycling at after stage.
Sharps must be disinfected at source with chemical disinfectants. Highly infectious waste and
laboratory waste such as body parts with ganger or HIV-infected blood need to be pretreat and
disposed immediately. For liquid bio-medical waste, pre-treatment is necessary.

 Recycling: Recycling of waste is a very important process which needs to be looked at the pre-
treatment stage or wherever possible, and should be considered. Recycling of organic waste
originated form kitchens and food department is good. This could be done at a very low cost within
the premises itself. Other substances that could be recycled are paper, plastics, glass and metals.
Mostly, the economics of recycling of wastes works only with large quantities according to which
waste should be stored for a longer duration. The hazards or the benefits of recycling should also be
count. The possibility of common collection system from all the HCFs generating it could be
established for recycling waste.

TRANSPORTATION AND STORAGE PROCESS

The transportation of bio-medical waste is an important factor and must be taken as it moves to
storage facilities, pre-treatment post-treatment or onsite disposal facilities.The waste can be
temporarily stored at the central storage area of the HCFs or can be sent in bulk to the site of final
disposal depending upon the quantum of waste from there.
During transportation of waste following points should be consider:

 No untreated bio‐medical waste shall be kept stored beyond a period of 48 hours.

 All type of medical waste, except general and non-hazardous waste, must be kept
separate at all stages from municipal waste.
 The segregated waste need always be collected and transported separately
 Bags should not be filled completely, it should filled ¾ of the size.
 Ensure that waste bags/containers are properly sealed with labelling.
 Mixing of segregated waste should be prohibited.
 Hand should not be put under the bag.
 Manual handling of waste bags should be decreased to reduce the risk of needle from
injury and infection.
 Bio Medical Waste should be kept only in a specified storage area.
 After removal of the bag, cleaning of the container with an appropriate disinfectant is
needed.
 Waste bags and containers should be removed daily from each generating area. Waste
bags should be transported in a wheeled containers or large bins in covered trolleys.
 The waste receptacles and equipment used for carting the waste should be used
exclusively.

Page | 30
  This equipment should be cleaned and disinfected timely. minimum way for routing
the waste within the health care should be taken to minimize the spread of another
infections
 Special vehicles could be used to prevent access and direct contact with the waste by
people.
 The containers should be properly closed during transportation and waste tracking
practiced mandatory.
 It should be possible to wash the interior surface of the containers thoroughly.
 Accidents should be taken into account and the driver should be trained in the
procedures to be followed in case of an accidental spillage.

TRANSPORT TO FINAL DISPOSAL SITE

The waste which is transported to the collection point, ready to be transported to another place for
final treatment. An autoclave or microwave technology could be used to treat the infected waste.
An incinerator could also be set up to treat certain waste. Pre-treated waste could be shredded or
macerated to help reduce its volume. For liquid bio-medical waste post- treatment is a must.
• Transportation from health care facilities to the final disposal site in a closed vehicle (truck,
tractor‐trolley etc.) is desirable as it prevents spillage of waste on the route.
• Vehicles used for transport of BMW must have the “Bio‐Hazard” symbol and these vehicles
should not be used for any other purpose.

Note: Label shall be non‐washable & prominently

Fig 8. Labels

j) Final Disposal:
Before waste is finally disposed, as much as possible care should be taken to minimize the waste.
Only hazardous substances such as treated incinerator ash should be disposed of after retrieving the
recyclable portion. The liquid waste should be disposed of in sewers or septic tanks and the solid
waste into sanitary landfills.

k) Disposal methods
Different methods can be used for the disposal of bio medical waste and are described as below:
Shredder: Shredding is a process by which waste are reshaped or cut into smaller pieces so as to
make the wastes unrecognizable. It helps in prevention of reuse of bio-medical waste and also acts
as identifier that the wastes have been disinfected and are safe to dispose of. A shredder is to be
used for shredding in bio-medical waste with minimum requirements.

Page | 31
  The plastic (I.V. bottles, I.V. sets, syringes, catheters etc.), sharps (needles, blades, glass etc.)
should be shredded but only after their chemical treatment, microwaving or autoclaving.

 Needle destroyers can be taken in use for disposal of needles directly without chemical
treatment.

Incineration:
It is a controlled combustion process where harmful microorganisms present in it are destroyed under
high temperature and waste is completely oxidized. An article regarding plasma pyrolysis of medical
waste was reported by Neema and Gareshprasad (2002). The authors elaborted that the operating cost
of the system would be Indian Rupees 13 per kilogram (kg), and the energy recovered would cost
Indian Rupees 8 per kg; thus the net cost would be Rs 7 per kg. Quantity and composition of hospital
waste generated are in Table 5. Incineration is mostly popular in countries such as Japan where land
is a scarce resource, as they do not consume as much area as a landfill. Sweden has been a leader in
using the energy generated from incineration over the past 20 years. Denmark also extensively uses
waste-to-energy incineration in localized combined heat and power facilities supporting district
heating schemes.

 A high temperature dry oxidation process, which reduces organic and combustible waste
to inorganic incombustible matter.
 Usually used for the waste that cannot be reused, recycled or disposed of in landfill site.
 The incinerator should be installed and made operational as per specification under the
BMW rules 1998
 Certificate may be taken from CPCB or State Pollution Control Board
 Category 1, 2, 3, 5, and 6 waste can be incinerated.

Fig 9. Simple Incineration process

Characteristics of waste suitable for incineration are:

 Low heating volume
 above 2000 Kcal/Kg for single chamber incinerators and
 Above 3500 Kcal/Kg for pyrolysis double chamber incinerators.
 Content of combustible matter above 60%.
 Content of noncombustible matter below 50%.
 Content of noncombustible fines below 20%.
 Moisture content below 30%.

Page | 32
Waste types not to be incinerated are:

 Pressurized gas containers.

 Large amount of reactive chemical wastes.
 Silver salts and photographic or radiographic wastes.
 Halogenated plastics such as PVC.
 Waste with high mercury or cadmium content such as broken thermometers, used
batteries.
 Sealed ampoules or ampoules containing heavy metals.

Non-Incineration Technology
Non-incineration treatment includes four basic processes: thermal, chemical, irradiative, and
biological. The majority of non-incineration technologies employ the thermal and chemical
processes. The main purpose of the treatment technology is to decontaminate waste by
destroying pathogens.

 Chemical Methods
́ hemical treatment involves use of disinfectants such as dissolved chlorine dioxide, bleach
C
(sodium hypochlorite), peracetic acid, or dry inorganic chemicals. These disinfectants are used to
treat liquid waste that was drained to separate disinfection canals in the hospital campus. Addition
of these chemicals kills the entire native and transient microbial flora. After disinfection the liquid
waste will be released to sewers. To enhance exposure of the waste to the chemical agent, chemical
processes involve shredding, grinding, or mixing. In liquid systems, the waste may go through a
dewatering section to remove and recycle the disinfectant. Besides chemical disinfectants, there are
also encapsulating compounds that can solidify sharps, blood, or other body fluids within a solid
matrix prior to disposal (HCWH, 2001). Press et al. (1999) described that chemical disinfection is
usually carried out on hospital premises. Recently, commercial, self-contained, and fully automatic
systems have been developed for health care waste treatment and are being operated in industrial
zones. The disinfected waste may be disposed of as non-risk health care waste, but the chemical
disinfectants may create serious environmental problems in case of leakage or after disposal.
Chemical disinfection, used routinely in health care to kill microorganisms on medical equipment
and on floors and walls, is now being extended to the treatment of health care waste.

Chemicals are added to waste to kill or inactivate the pathogens it contains; this treatment usually
results in disinfection rather than sterilization. Chemical disinfection is most suitable for treating
liquid waste such as blood, urine, stools, or hospital sewage. Several self-contained waste treatment
systems, based on chemical disinfection, have been developed specifically for health care waste and
are available commercially.

Biological processes

These processes can be seen in natural living organisms but refer mainly to the degradation of
organic matter when applied to health-care waste treatment. Some biological systems use enzymes
to enhance the speed for the destruction of organic waste containing pathogens. Composting and
vermiculture are biological processes and have been used to decompose hospital kitchen waste, as
well as other organic digestible waste (Mathur, Verma & Srivastava, 2006) and placenta waste.
Another example is the natural decomposition of pathological waste through burial.

Page | 33
Mechanical processes

Mechanical treatment processes include several shredding, grinding, mixing and compaction
technologies that can reduce waste mass and volume, although they cannot destroy pathogens. In
most cases, mechanical processes are not stand-alone health-care waste-treatment processes, but
supplement for other treatments. Mechanical destruction can render a waste unrecognizable and can
be used to destroy needles and syringes (depending on the type of shredding). In the case of thermal
or chemical treatment processes, mechanical devices such as shredders and mixers can also improve
the rate of heat transfer or expose more surface area of waste to waste treatment. Mechanical devices
used to prepare wastes before other forms of waste destruction add significantly to the level of
management and maintenance required to treat health-care waste safely and efficiently.

Unless shredders, mixers and other mechanical devices are an integral part of a closed treatment
system, they should not be used before the incoming health-care waste is disinfected. If they are
used, workers are at an increased risk of being exposed to pathogens in aerosols released into the
environment by mechanical destruction of untreated waste bags. If mechanical processes are part of a
closed system, the technology should be designed in such a way that the air in and from the
mechanical process is disinfected before being released to the surroundings.

 Thermal Treatment

These type of processes depend on heat (thermal energy) to destroy pathogens in the waste. This
category can be subdivided into low-heat and high-heat designs. This classification is useful because
of the differences in the thermo chemical reactions and physical changes taking place in the wastes
during their treatment in the different types of equipment. These differences produce different
atmospheric emissions characteristics.

Low-heat thermal treatment are those that use thermal energy at elevated temperatures high enough
to kill microorganisms but not enough to cause combustion or pyrolysis of the waste. Pyrolysis is the
thermal degradation of a substance through the application of heat in the absence of oxygen.
Pyrolysis is a special case of thermolysis, and is most commonly used for organic materials. It take
place at high temperatures but does not involve reactions with oxygen. In practice, it is difficult to
have a completely oxygen-free atmosphere, so some oxidation takes place. In general, low-heat
thermal process operate between 100 °C and 180 °C. This processes take place in either moist or dry-
heat environments. Moist (wet) thermal treatment includes the use of steam to disinfect waste and is
normally performed in an autoclave or steam-based treatment system. Microwave treatment is a
moist thermal process, because disinfection occurs through the action of moist heat (hot water and
steam) produced by the microwave energy. Dry-heat processes use hot air without the addition of
water/steam. In dry-heat systems, the waste is heated by conduction, convection or radiation.

Page | 34
Steam treatment technologies

Autoclaves

 Category 3, 4, 6 and 7 can be treated by these techniques.

Autoclaves are used for treating a range of infectious waste, including cultures and stocks, sharps,
materials contaminated with blood and limited amounts of fluids, isolation and surgery waste,
laboratory waste (excluding chemical waste) and “soft” waste (including gauze, bandages, drapes,
gowns and bedding) from health care. With sufficient time and temperature, it is technically possible
to treat small quantities of human tissue, but ethical, legal, cultural, religious and other considerations
may preclude their treatment. Autoclaves are generally not used for large anatomical remains (body
parts), because it is difficult to determine the time and temperature parameters needed to allow full
penetration of heat to the center of the body part.

An autoclave consists of a metal vessel designed to withstand high pressures, with a sealed door and
an arrangement of pipes and valves through which steam is injected into and removed from the
vessel. Some autoclaves are designed with a steam jacket surrounding the vessel; steam is introduced
into both the outside jacket and the inside chamber. Heating the outside jacket minimizes the
condensation on the inside chamber wall and allows the use of steam at lower temperatures. An
autoclave without a steam jacket, sometimes called a “retort”, is commonly used in large-scale
applications and is cheaper to construct.

Air is an effective insulator and a principal factor in determining the efficiency of steam treatment.
Removal of air from the autoclave is necessary to ensure penetration of heat into the waste. Unlike
instrument sterilization autoclaves, waste-treatment autoclaves must treat the air that is removed at
the start of the process to prevent the release of pathogenic aerosols. This is usually done by treating
the air with steam or passing it through a high-efficiency particulate air filter before it is released.

Therefore, autoclaves can be sub divided according to the method of air removal. The three common
types are:

 gravity-displacement autoclaves

 pre-vacuum or high-vacuum autoclaves

 Pressure pulse autoclaves.

A gravity-displacement autoclave have advantage that the steam is lighter than air. Hence, steam is
introduced under pressure into the chamber, forcing the air downwards into an outlet port of the
chamber.

Page | 35
 Microwaving,
Microbial inactivation take place as a result of the thermal effect of electromagnetic radiation
spectrum lying between the frequencies 300 to 300,000 MHz Microwave heating is an inter-
molecular heating process. The heating occurs inside the waste material in the presence of steam.

 Category 3, 4, 6 and 7 can be treated by these techniques.

Irradiative Treatment

Irradiation treatment encompasses designs using irradiation from electron beams, cobalt-60 or
ultraviolet sources. These technologies demanded shielding to prevent elevated occupational
exposures to electromagnetic radiation. The pathogen destruction efficacy depends upon the dose
absorbed by the mass of waste. Electron beams are powerful enough to penetrate waste
bags/containers.
 Germicidal ultraviolet radiation has been used to destroy airborne microorganisms as a
supplement to other treatment technologies, but is not able to penetrate closed waste bags.
 Gamma irradiation has been used from many years as a means of inactivating
potential pathogens on the surfaces of many different medical products.

Since the appropriate dose of radiation can be precisely calculated, it has been found to be an
extremely reliable treatment system. A newer form of irradiation system employs an electron
beam generated by an accelerator to sterilize medical products and potentially, clinical waste.
Irradiation systems require extensive shielding to protect the workers and can only treat
relatively small quantities of waste and do not change the physical appearance of the material
(EA, 2003). HCWH (2001) recorded that these technologies require shielding to prevent
occupational exposures.

Microwave Irradiation

The microwave is based on the principle of generation of high frequency waves. These waves cause
the particles within the waste material to vibrate, and generating heat. This heat generated from
within destroys all pathogens.
Most microorganisms are destroyed by the action of microwaves of a frequency of about 2450
MHz and a wavelength of 12.24 cm. The microwaves rapidly heat the water molecules contained
within the waves and the infectious components are destroyed by heat conduction. In the USA, a
routine bacteriological test using Bacillus subtitles is recommended to demonstrate a 99.99%
reduction of viable spores (Press et al., 1999). Hoffman and Hanley (1994) assessed a clinical waste
decontamination unit that used microwave-generated heat for operator safety and efficacy. Tests
with loads artificially contaminated with aerosol-forming particles showed that no particles were
detected outside provided the seals and covers were correctly sealed. Thermometric measurement
of a self- generated steam decontamination cycle was used to determine the parameters needed to
ensure heat disinfection of the waste reception hopper, prior to entry for maintenance or repair.
Bacterial and thermometric test pieces were passed through the machine within a full load of
clinical waste. These test pieces, designed to represent a worst-case situation, were enclosed in
aluminum foil to shield them from direct microwave energy. None of the 100 bacterial test pieces
yielded growth on culture and all 100 thermal test pieces achieved temperatures in excess of 99 °C
during their passage through the decontamination unit. It was concluded that this method might be
used to render safe the bulk of ward generated clinical waste.

Page | 36
Hydroclaving is similar to that of autoclaving except that the waste is subjected to indirect heating
by applying steam in the outer jacket. The waste is continuously tumbled in the chamber during the
process.
Advanced Treatment Technologies: Pyrolysis Treatment and Plasma Technology
Plasma Pyrolysis is a technology for safe disposal of medical waste. It is an eco-friendly, which
converts organic waste into commercially useful by-products. The intense heat generated by the
plasma enables it to dispose all types of waste including municipal solid waste, biomedical waste
and hazardous waste in a safe and reliable manner. Pyrolysis involves the high temperature (545 to
1000 0C) combustion of waste in the absence of oxygen. In generating these high temperatures, the
systems treat, destroy, and reduce the volume of clinical waste (EA, 2003). Medical waste is
pyrolysed into CO, H2, and hydrocarbons when it comes in contact with the plasma-arc.
These gases are burned and produce a high temperature (around 1200°C). In the plasma pyrolysis
process, the hot gases are quenched from 500°C to70°C to avoid recombination reactions of
gaseous molecules that inhibit the formation of dioxin and furans. The gas analysis results reveal
that toxic gases found after the combustion are well within the limit of the Central Pollution
Control Board emission standards. The plasma pyrolysis technology has been indigenously
developed at the Facilitation Centre for Industrial Plasma Technologies, Institute for Plasma
Research, Gandhinagar (Nema and Ganesh Prasad, 2002).

Plasma Technology
In plasma system, an electric current is discharged through an inert gas (e.g., argon) to ionize it and
in turn cause an electric arc to create temperatures as high as 6000 0C. The clinical waste within the
system is brought to temperatures between 1300 to 17000C, destroying potentially pathogenic
microbes and converting the waste into a glassy rock or slag, ferrous metal, and inert gases (EA,
2003). In a plasma torch, an arc is established between two electrodes. A carrier gas, which may be
inert or have some heating value passes between the electrodes and transfers the energy to the
waste material. In a non-transferred system, the, anode and cathode are both part of the plasma
torch. Another design is to use a DC (Direct Current) plasma arc, wherein the arc forms between a
graphite electrode directly to the metal in a molten bath formed from the waste in the treatment
chamber (HCWH, 2001).

Residue Treatment
The leftover byproducts after incineration are called residues (i.e. fly ash, grate sifting, bottom ash,
heat recovery ash, and air pollution control residue). These residues are generated at different
points in waste incineration treatment. Chemical analyses of solid waste residue, air pollution
control residue, bottom ash, and combined ash are mostly reported.
Lombardi et al. (1998) informed that a fly ash produced from a health care solid waste incineration
plant was solidified in cementations matrices. The high sulphate, chloride and alkali content and the
low Al, Fe, and Si values this fly ash cannot be used in the blended cement formulation. The ash
generated from a HCFs waste incinerator is treated with a high temperature melting process at
about 1200°C. The XRD (X-ray diffraction), leaching tests, XRF (X-ray fluorescence), and
sequential chemical extraction of metals can be used for knowing the quality of the produced slag.
The slag contained huge amount of Al2O3 , B, Cu, CaO, Ni, Ba, Sn, and SO2.

Page | 37
 Effluent Treatment
Health care effluents are the most risky waste for contaminating our environment that why before
released into the drains these are treated to detoxify.
A lot of scientists researched on the ill effects generated by the effluents. For example Giuliani et
al., (1996) evaluated the genotoxic potential of the wastewater of a hospital. Within 2 years over
800 native wastewater samples were analyzed. Genotoxic activity was found in 13% of the
samples. The highest genotoxic activity occurred in the morning hours, but the genotoxic samples
were detected also during the day and night. Nearly 96% of the genotoxic wastewater samples
revealed a genotoxic potential without growth inhibition of test bacteria monitored as OD-600, in
the same way as antineoplastic drugs like mitomycin C or cisplatin. 4% of the genotoxic
wastewater samples showed combined cytotoxic and genotoxic activities as seen in control
experiments using glutaraldehyde containing disinfectants and certain antibiotics. The sludge from
health care waste treatment facilities is also a source of infectious organisms. Therefore, the
treatment of such sludge to reduce pathogenic microorganisms should be in need.In the treatment
of hospital waste sludge, which contains high concentrations of organic components, the amount of
hypochlorite has a pseudo-first-order relationship to the formation of organic halides. Ethanol is a
safe and common solvent that is used for the extraction of organic halides from sludge. However,
the high partitioning coefficient of sludge for Microorganisms retard the extraction effectiveness of
ethanol.

Kiffmeyer et al. (1998) informed a trace analytical procedure for the cisplatin, cytostatic drugs
vinblastine, carmustine, chlorambucil, cytarabine, etoposide, 5- fluorouracil, melphalan,
methotrexate, and cyclophosphamide, was developed to evaluate the environmental hazards of
drugs in clinical wastewater and sewage treatment plants. The analysis was performed using solid
phase extraction with subsequent HPLC separation and quantitative determination by gradient
elution techniques with DAD and fluorescence detection. Detection limits after the clean-up and
enrichment procedure vary from 0.002 to 0.2 mg/L.
Maurya et al. (2002, 2003a, 2003b) have optimized a best-suited condition by considering the
concentration of substrate, reaction time, amount of catalyst, oxidant and solvent for maximum
transformation of phenol. All encapsulated complexes serve as catalyst for the decomposition of
H2O2 and for the oxidation of phenol to a mixture of catechol and hydroquinone using H2O2 as an
oxidant. However, selectivity towards the formation of catechol and hydroquinone vary from
catalyst to catalyst.
Rai et al. (2007) investigated in a laboratory scale the decolonization of a simulated dye waste
containing three different triphenylmethane dyes using two-stage anaerobic high rate reactor. It has
been shown that the influent dye concentration had little effect on overall COD and color removal.

Deep burial:

 Category 1 and 2 only

 In cities having less than 5 lakh population & rural area.

 A pit or trench should be dug about 2 m deep. It should be half filled with waste, and then
covered with lime within 50 cm of the surface, before filling the rest of the pit with soil.
 It must be ensured that animals do not have access to burial sites.
 Covers of galvanized iron/wire meshes may be used.
 On each occasion, when wastes are added to the pit, a layer of 10cm of soil be added to cover
the wastes.
 Burial must be performed under close and dedicated supervision.
 The site should be relatively impermeable and no shallow well should be close to the site.
 The pits should be distant from habitation, and sited so as to ensure that no contamination
occurs of any surface water or ground water.
Page | 38
  The area should not be prone to flooding or erosion.
 The location of the site will be authorized by the prescribed authority.
 The institution shall maintain a record of all pits for deep burial.

Land disposal:

 Open dumps

 Secured/Sanitary landfill: advantages.

 The incinerator ash, discarded medicines, cytotoxic substances and solid chemical waste should
be treated by this option.

Table 7. Comparison of treatment technologies for medical wastes

Treatment Autoclave Hydroclave Microwave Incinerator Chemical

Systems
Description sterilization Steam Microwave High Mixing pre
Steam (Direct sterilization, heating of temperature ground
simultaneous heating) (indirect pre shredded waste Waste with
heating) waste incineration chemical,
shredding and such as
dehydration chlorine
Sterilization Medium Medium Medium High (total Dependent
efficacy destruction of on chlorine
microorganism) strength
and
dispersment
through the
waste
Capital cost Low Low High High Moderate
Operating cost Low Low High High Low
Operator Low skill Low skill Automated, High level High level
maintenance level level but highly operator and required for
skills required required complex maintenance chemical
and high skills required control
level and grinder
maintenance
skill required

Air Odorous Somewhat Somewhat Can be highly Some

emissions but odorous odorous but toxic chlorine
non-toxic but non-toxic nontoxic Emissions
Water Odorous, Odorous but Negligible None None
Emissions may contain sterile
live micro
organism
Treated waste Wet waste, Dehydrated, Shredded but Mostly ash, Shredded wet
characteristics all shredded wet may waste,
material waste, waste contain toxic containing
recognizable unrecognizable substances chemicals
material used as
disinfectant

Page | 39
Fig 10.

Page | 40
Chapter 4 Standards for treatment and disposal of bio-medical wastes
Standards for incinerators
All incinerators should meet the following operating and emission standards
A. Operating Standards
Combustion efficiency (CE) shall be at least 99.00%.
The Combustion efficiency is computed as follows:

% 𝐶𝑂2
𝐶. 𝐸 = %𝐶𝑂 𝑋 100
2 + %𝐶𝑂

 The temperature of the primary chamber shall be 800o ± 50o C.

 The secondary chamber gas residence time shall be at least I (one) second at 1050o ±
o
50 C, with minimum 3% Oxygen in the stack gas.
B. Emission Standards
The emission standards are given in Table 8.
Table 8. EPA Emission limits for new hospital/medical/infectious waste incinerators
POLLUTANT EMISSION LIMITS

Small Medium Large

Particulate Matter

69 mg/dscm 34 mg/dscm 34 mg/dscm

Carbon Monoxide 40 ppmv 40 ppmv 40 ppmv
Dioxins/Furans 125 ng/dscm total or 25 ng/dscm total or 25 ng/dscm total or
2.3 ng/dscm TEQ 0.6 ng/dscm TEQ 0.6 ng/dscm TEQ\
Hydrogen Chloride or
99% reduction 15 ppmv or 99% 15 ppmv or 99% 15 ppmv or 99%
or 99% reduction Reduction reduction Reduction
Sulphur Dioxide 55 ppmv 55 ppmv 55 ppmv
Nitrogen Oxides 250 ppmv 250 ppmv 250 ppmv
Lead 1.2 mg/dscm or 70% 0.07 mg/dscm or 0.07 mg/dscm or
Reduction 98% reduction 98% reduction
Cadmium 0.16 mg/dscm or 0.04 mg/dscm or 0.04 mg/dscm or
65% reduction 90% reduction 90 % reduction
Mercury 0.55 mg/dscm or 0.55 mg/dscm or 0.55 mg/dscm or
85% reduction 85% reduction 85% reduction

Mg = milligrams, dscm = dry standard cubic meter, ppmv = parts per million by volume ng =
nanograms, TEQ = toxic equivalent; Capacities: small=less than or equal to 200 lbs/hr;
medium=greater than 200 lbs/hr to 500 lbs/hr; large=greater than 500 lbs/hr.

Page | 41
Standard for liquid waste:
Table 9. Shows the effluent generated from the hospital should conform to the following limits
Table 9. Emission standards waste incinerators
S. No. Contaminant Limit
1 Total Particulate 20 mg/m3
2 Carbon Monoxide 55 mg/m3
3 Sulphur Dioxide 180 mg/m3
4 Nitrogen Oxides (NOx as NO2) 380 mg/m3
5 Hydrogen Chloride 50 mg/m3or 90% removal
6 Hydrogen Fluoride 4 mg/m3
7 Total Hydrocarbons (as Methane CH4) 32 mg/m3
8 Arsenic 4 µg/m3
9 Cadmium 100 µg/m3
10 Chromium 10 µg/m3
11 Lead 50 µg/m3
12 Mercury 200 µg/m3
13 Chlorophenols 1 µg/m3
14 Chlorobenzenes 1 µg/m3
15 Poly cyclic aromatic Hydrocarbons 5 µg/m3
16 Polychlorinated Biphenyls 1 µg/m3
17 Total PCDDs &PCDFs Opacity 0.5 ng/m35%

Common Biomedical Treatment Facilities

Tables 10 and 11show the machinery requirements for Common Waste Treatment Facility
Table 10. Effluent generated from hospital

Parameters Permissible limits

pH 6.3-9.0
Suspended solids 100 mg/L

Oil and grease 10 mg/L

BOD 30 mg/L

COD 250 mg/L

Page | 42
Table 11. Design and Operation Requirements for Biomedical Waste Incinerators and Emission
Control Systems
Incinerator Type Modular(Excess
S. No. Parameter Air and Starved Air) Incinerator Type Mass Burn

1 Incinerator

Minimum Incineration 1000 degrees C at fully mixed 1000 degrees C determined by an

2 Temperature Height overall design review

1 second calculated from the point

3 Minimum Residence Time
4 Primary Air (Underfire)
1 second after final secondary air
injection ports
Utilize multi-port injection to
minimize waste distribution
Difficulties
where most of the combustion has
been completed and the
incineration temperature fully
developed
Use multiple plenums with
individual air flow control

5 Secondary Air (Overfire) Up to 80% of total air required (1) At least 40% of total air required

Overfire Air Injector
6 Design
7 Auxiliary Burner Capacity
That required for penetration and
coverage of furnace cross-section
Secondary burner 60% of total rated
heat capacity, and that required to
meet start-up and part- load
temperatures
That required for penetration and
coverage of furnace cross-section
60% of total output, and that
required to meet start-up and part-
load Temperatures

Oxygen Level at the

8 Incinerator Outlet 6 to 12% 6 to 12%
9 Turndown Restrictions 80 to 110% of designed capacity 80 to 110% of designed capacity
55 mg/m3@ 11% (4-h rolling 55 mg/m3@ 11% (4-h rolling
10 Maximum CO Level average) average)

11 Combustion Efficiency 99.9% (8-h rolling average) 99.9% (8-h rolling average)
12 Emission Control Systems

Flue Gas Temperature at

Inlet or Outlet of Emission
13 Control Device Not to exceed 140 degrees C Not to exceed 140 degrees C
14 Opacity Less than 5% Less than 5%

Page | 43
Chapter 5
Environmental management systems

An EMS (environmental management system) is a type of formal approach in different countries

with strict environmental laws for managing organizations impact on the environment. Health care
facilities of any size must derive benefit from introducing and implementing an EMS. These benefits
involves cost reductions through reduced energy consumption, reduced quantities of waste, increased
recycling, and minimized negative impacts on the environment from waste handling and treatment,
and an improved public image.

An EMS framework formulates the environmental aspects of waste management, includes 3 R’s
(reduction, reuse and recycling). It also has considerable relevance to environmentally preferable
purchasing. This is because a health-care facility usually has a choice in the purchase of products or
services. It is becoming increasingly common to require suppliers to have an EMS in place as a
condition of awarding contracts. An EMS need to be an integral part of an organization’s approach
for better management. It is used for developing and implementing its environmental policy and to
manage its continuing environmental impacts.
Key elements of an EMS should include the following:
Process or mechanism for screening project plans and proposals for potential environmental risks; for
example, using screening tools, checklists and expert review;
Development and use of environmental management plans that clearly define which environmental
mitigation measures should be taken, by whom, and at which point in the project’s implementation;
Monitoring and reporting activities to verify that relevant environmental management actions are
being taken and that they are generating the intended results;
Evaluation of the overall environmental performance of projects and activities to inform
organizational learning and future environmental mitigation actions.

Most of the organizations including hospitals formulates an EMS with the goal of obtaining ISO
14001 certification as stipulated by the International Standards Organization. ISO 14001 provides all
the specific requirements for an EMS and is a part of the ISO 14000 series that relates more generally
to environmental management. As an example, a hospital in the United Kingdom introduced an EMS
and worked with local authorities & waste contractors to change waste-management methods and
introduce recycling schemes. They noticed that using an environmental procurement policy reduced
health-care waste quantities by 4.1% (78 tones), energy consumption by 3.6% and water usage by
9.6%.

Environmental management system for BMW

The EMS is a framework which aimed at providing effective paths for institutions in response to
change the external and internal factors. Waste procedure of the hospital can be studied by (Das et al,
2001; CPHEE 1998; Kelkar, 1998; Kela et al, 2000). Figure 11 describes the waste management flow
chart and process chart of indicated the proper sequence from generation of waste to its final
disposal. Figure 3 shows the interference of the points and data (Jaswal & Jaswal 2000). Color
coding and type of container for disposal of biomedical wastes is given in Table 4 Biomedical waste
solutions specialize are in three categories namely:

Page | 44
 Fig 11 waste management flow chart

Effects of biomedical waste

The improper management of bio-medical waste can causes serious environmental problems that
causes to air, water and soil pollution. The pollutants that cause damage can be classified into
biological, chemical and radioactive. There are many legislations and guidelines around the world
concerning environmental problems, which can be addressed.

Air Pollution
Air pollution can be take place in both indoors as well as in outdoors atmosphere. Health care waste
that generated by air pollution are been classified in 3 categories namely as -Biological, Chemical
and radioactive.

In-door air pollution

Pathogens present in the waste can enter and remain in the air for a long period of toime in the form
of spores. Waste Segregation, pre-treatment etc. can also reduce this problem to a great extent.
Sterilizing the rooms will also help in checking the indoor air pollution due to biological. The
indoor air pollution caused due to the poor ventilation and can cause diseases like SBS (Sick
Building Syndrome). Proper building design and well-maintained air conditioners can reduce the
SBS. Chemicals need to be utilized as per prescribed norms. Excess use of chemicals should be
restricted.

Page | 45
Out-door air pollution
Outdoor air pollution can be caused by pathogens. The biomedical waste without doing pre-
treatment if transported outside the organizations, or if it is dumped in open areas, pathogens then
enter into the atmosphere. Chemical pollutants that can creat outdoor air pollution have two major
sources-open burning and incinerators. Open burning of bio-medical waste is the most harmful.
When inhaled can cause respiratory diseases. Certain organic gases such as dioxins and furans are
carcinogenic. The design parameters and maintenance of such treatment and disposal technology
should be as per the standards.

Radioactive emissions
Research and radio-immunoassay activities may generate small quantities of radioactive gas.
Gaseous radioactive material should be evacuated directly to the outside. The use of such device
requires maintenance of the trap and monitoring of the off-gas.

Radioactive effluent
Radioactive waste in liquid form can arise from body organ imaging, from chemical or biological
research, from decontamination of radioactive spills, from patient’s urine and from scintillation
liquids used in radioimmunoassay. Under normal conditions, urine and feces can be handled as no
radioactive waste so long as the patient’s room is routinely monitored.

Water Pollution
The liquid waste generated from HCFs when enter into sewers can lead to water pollution if treated
improperly. Water pollution may alter parameters such as pH, BOD, DO, COD, color etc.

Land Pollution
Soil pollution from bio-medical waste is caused because of discarded medicines, infectious waste,
chemicals used in treatment and ash and other waste generated during treatment. Heavy metals
such as cadmium, lead, mercury etc. which are present in the waste will get absorbed by plants and
then enter the food chain. Nitrates and phosphates present in leachates from landfills are also
pollutants. Excessive amounts of trace nutrient and other elements including heavy metals in soil
are very harmful to crops, animals and human beings. Reducing the waste and proper treatment
before disposal on land are the only ways of reducing this kind of pollution.

The Health Impacts of Bio-Medical Waste

a. Persons at risk – All individual exposed to health care waste are potentially at some risk
including those within the 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
i.e. medical doctors, nurses, health-care auxiliaries and hospital maintenance personnel
ii. Patients in health-care establishments or receiving home care
iii. Visitors to health-care establishments.
iv. Workers in support services allied to health care establishments such as laundries, waste
handling and transportation.
v. workers in waste disposal facilities (such as landfills or incinerators), including scavengers The
hazards associated with scattered, small sources of health care waste should not be over looked;
waste from these sources includes that generated by home-based health- care, such as dialysis and
that generated by illicit drug use.

Page | 46
 B. Hazards from Infectious Waste & Sharps – Infectious waste may contain a great variety of
pathogen micro-organisms. Pathogens in infectious waste can enter into the human body by a
number of ways:
I. through a puncture, abrasion or in the skin
ii. through the mucous membranes
iii. by inhalation
iv. by ingestion

Examples of infections that might be caused by exposure to health-care waste are listed in Table 12,
together with the body fluids that are the usual vehicles of transmission and that contaminate waste
items. Concentrated cultures of pathogens and contaminated sharps (particularly hypodermic needles)
are the waste items that pose the most acute potential hazards to health.

Table 12. Potential infections caused by exposure to health-care wastes, causative organisms
and transmission vehicles
Type of infection Examples of causative Organisms Transmission vehicles

Enterobacteria, e.g. Salmonella, Shigella spp., Vibrio

Gastroenteric infections cholerae, Clostridium difficile, helminths Faeces and/or vomit

Mycobacterium tuberculosis, measles virus,

Streptococcus pneumoniae, severe acute respiratory Inhaled secretions,
Respiratory infections syndrome (SARS) saliva

Ocular infection Herpesvirus Eye secretions

Genital infections Neisseria gonorrhoeae, Herpesvirus Genital secretions

Skin infections Streptococcus spp. Pus

Anthrax Bacillus anthracis Skin secretions

Neisseria meningitides Cerebrospinal fluid

Meningitis Acquired Blood, sexual secretions,
immunodeficiency Human immunodeficiency virus body

syndrome (AIDS) (HIV) Fluids

Haemorrhagic fevers Junin, Lassa, Ebola and Marburg Viruses All bloody products and

Secretions

Septicemia Staphylococcus spp. Blood

Coagulase-negative Staphylococcus spp. (including

methicillian-resistant S. aureus), Enterobacter, Nasal secretion, skin
Bacteraemia Enterococcus, Klebsiella and Streptococcus spp. contact

Candidaemia Candida albicans Blood

Viral hepatitis A Hepatitis A virus Faeces

Viral hepatitis B and C Hepatitis B and C viruses Blood and body fluids

Avian influenza H5N1 virus Blood, faeces

Page | 47
 There should be particularly more concern about infection with human immunodeficiency virus
(HIV) and hepatitis viruses B and C, for which there is strong evidence of transmission from injury
by syringe needles contaminated by human blood, which can occur when sharps waste is poorly
managed. Although theoretically any needle-stick injury can lead to the transmission of blood
borne infections, there is some evidence that hollow needles are associated with a higher risk of
transmission than solid needles, such as suture needles. They may not only cause physical injury
but also infect wounds if they are contaminated with pathogens. The main concern is that infection
may be transmitted by subcutaneous introduction of the causative agent.

The existence in health-care facilities of bacteria resistant to antibiotics and chemical disinfectants
may contribute to the hazards created by improper management. It has been demonstrated that
plasmids from laboratory strains contained in health-care waste were transferred to indigenous
bacteria via the waste disposal system (Novais et al., 2005). Moreover, antibiotic-resistant
Escherichia coli have been shown to survive in an activated sludge plant, although there does not
seem to be significant transfer of this organism under normal conditions of wastewater disposal and
treatment.

c. Hazards from chemical and pharmaceutical waste

Many kind of the chemicals and pharmaceuticals are used in health care are hazardous. They are
usually present in small amounts in waste, whereas larger quantities may be found when unwanted or
outdated chemicals are sent for disposal. Chemical wastes can cause intoxication,. Intoxication can
result from absorption of a chemical 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 occur by
contact with flammable, corrosive or reactive chemicals.

Laboratory and HCFs staffs are regularly exposed to many chemicals during their work, especially in
specialist and research department.

The hazardous properties most relevant to wastes from health care are as follows:
Toxic. Almost all chemicals are fatal at some level of exposure. Fumes, dusts and vapors from
toxic materials can be harmful because they can be inhaled and quickly pass from the lungs into the
blood, permitting rapid circulation into the whole body.

Corrosive. Strong acids and alkali bases can corrode completely through other substances,
including clothing. If splashed on the skin or eyes, they can cause serious chemical burns and
permanent injury. Some of these also break down into poisonous gases, which further increase
hazardousness.

Explosive. Some materials can explode when exposed to heat or flame, especially flammable
liquids when ignited in confined spaces, and the uncontrolled release of compressed gases.

Flammable. Compounds with this property can catch fire very easily, burn rapidly, spread quickly
and give off intense heat. Many materials used and stored in medical areas, laboratories and
maintenance workshops are flammable, including solvents, fuels and lubricants.

Page | 48
Chemically reactive. These materials should be used with extreme caution and stored in special
containers. Some can burn when exposed to air or water, some when mixed with other substances.
It is important to note that reactive materials do not have to be near heat or flames to burn. They
may burn spontaneously in the presence of air and also give off vapors that may be harmful if
inhaled.

d. Hazards from genotoxic waste

Special care must take in handling this kind of waste is essential. Exposure to genotoxic substances
in health care may occur during the preparation of, or treatment with, particular drugs or chemicals.
The main path of exposure are inhalation, absorption through the skin, ingestion of food
accidentally contaminated with cytotoxic drugs, ingestion as a result of bad practice, such as mouth
pipetting, or from waste items. Exposure may also occur through contact with body fluids and
secretions of patients undergoing chemotherapy.

The cytotoxicity of many antineoplastic drugs is cell-cycle specific, targeted on specific

intracellular processes such as DNA synthesis and mitosis. Other antineoplastics, such as alkylation
agents, are not phase specific but are 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. Any discharge of genotoxic waste into the environment could have disastrous
ecological consequence.

Box 4. Cytotoxic drugs hazardous to eyes and skin

Alkylating agents

Vesicant (blistering) drugs: aclarubicin, chloromethane, cisplatin, mitomycin

Irritant drugs: carmustine, cyclophosphamide, dacarbazine, ifosfamide, melphalan, streptozocin, thiotepa

Intercalating agents

Vesicant drugs: amsacrine, dactinomycin, daunorubicin, doxorubicin, epirubicin, pirarubicin, zorubicin

Irritant drugs: mitoxantrone

Vinca alkaloids and derivatives

Vesicant drugs: vinblastine, vincristine, vindesine, vinorelbine

Epipodophyllotoxins

Irritant drugs: teniposide

Page | 49
 e. Hazards from radioactive waste

The nature of illness caused by radioactive waste is determined by the type and extent of exposure.
It can be headache, dizziness and vomiting to many serious problems. Radioactive waste is
genotoxic, and a sufficiently high radiation dose may affect genetic material. Handling highly
active sources, such as those used in diagnostic instruments (e.g. gallium sealed sources) may cause
severe injuries, including tissue destruction, necessitating the amputation of body parts. Extreme
cases can be fatal.

The hazards of low-activity radioactive waste may arise from contamination of external surfaces of
containers or improper mode or duration of waste storage. Health-care workers, and waste-handling
and cleaning personnel exposed to radioactivity are most at risk.

f. Public sensitivity

Apart from fear of health hazards, the general public is sensitive about the visual impact of
anatomical waste, particularly human body parts which can be recognizable, including fetuses. There
are no normal circumstances where it is acceptable to dispose of anatomical waste inappropriately. In
Muslim and some other cultures, especially in Asia, religious beliefs require human body parts to be
returned to a patient’s family and buried in cemeteries.

Page | 50
Chapter 6 Biomedical waste in Ujjain, India

Figure 12. A process flow chart of the existing waste system of the hospital management of the infectious waste is
crucial in today’s health care area

With increasing awareness in general populations regarding hazards of hospital waste, public
interest, litigations were filed against erring officials. Some landmark decisions to streamline
hospital waste management.
All health care institutions are required to handle biomedical waste in a specified proper manner.
Ujjain is generating approximately 235 metric tons of waste per day out of which 65 tons are
Biomedical Waste. The Government hospitals and some major private hospitals have their own
arrangement for treatment of biomedical waste.

Page | 51
Fig 13. current status of medical waste disposal in Ujjain

Health Impacts of BMW on Community of Ujjain City

Exposure to hazardous health-care waste can result in severe disease/injury. The fatal nature of
health-care waste may be because of the following characteristics:

It contains infectious agents

It is genotoxic
it contains toxic or hazardous chemicals or pharmaceuticals
it contains sharps

In spite of high sickness rate among the HCFs staff dealing with medical waste, the awareness
regarding the protection of their health and manual handling was found to be little missing. The
perception is that "everybody else is doing the same so there lays danger in doing it myself. Most of
the staff was found wearing protective gears, spectacles, shoes and hand gloves even. Besides they
complained that the same are not provided by their employers like hospitals and municipalities. The
sanitation staff do understand the relation of waste and diseases but they replied that they have been
doing the same from a very long time so they have become immune to many health problems. The
sanitation staffs working in health care facilities get free medication from their place of work/from
municipal clinics.

Page | 52
Chapter 7 Hypothesis

The survey of HCFs in the Ujjain District envisages the formulation of various hypotheses.

Eleven hypotheses have been stipulated relating to waste management practices to the type of
hospitals, category of hospitals, bed capacity, and bed occupancy, quantity of waste generated and
waste handling human resources. The eleven hypotheses can also be classified into four groups of
waste management practices as segregation practices, treatment and disposal practices, waste
handling safety measures and waste administration.

H1: There is no significant association between the type of hospital and Waste Management
Practices

H2: There is no significant association between the category of hospital and Waste Management
Practices

H3: There is no significant association between the bed capacity and Waste Management Practices

H4: There is no significant association between the bed occupancy and Waste Management
Practices

H5: There is no significant association between the amount of waste generated and Waste
Management Practices

H6: There is no significant association between the numbers of waste handling workers and Waste
Management Practices

H7: There is no significant impact of the type of hospital on Waste Management Practices

H8: There is no significant impact of bed capacity on Waste Management Practices

H9: There is no significant impact of bed occupancy on Waste Management Practices

H10: There is no significant impact of amount of waste generated on Waste Management Practices

H11: There is a significant impact of number of waste handling workers on Waste Management
Practices

Page | 53
Figure 13. Formulated Research Hypothesis

Page | 54
Chapter 8 Health – care waste minimization, reuse and recycling
The waste-management hierarchy

Protecting public health through the management of wastes can be achieved by a variety of methods.
These can be summarized in an order of preference called the ‘waste hierarchy’, with the most
desirable method at the top to the least desirable at the base (Figure 6.1). ‘Desirability’ is defined in
terms of the overall benefit of each method from their particular impacts on the environment,
protection of public health, financial affordability and social acceptability.

Most preferable

Prevent
Reduce
Reuse
Recycle
Recover
Treat
Dispose

Least preferable

Figure 14 the waste-management hierarchy

The waste-management hierarchy is largely based on the concept of the “3Rs”, namely reduces,
reuse and recycle, and broadly relates to the sustainable use of resources. Best practice waste
management will aim to avoid or recover as much of the waste as possible in or around a health-care
facility, rather than disposing of it by burning or burial. This is sometimes described as tackling
waste “at source” rather than adopting “end-of-pipe” solutions.

The most preferable approach, if locally achievable, is to avoid producing waste as far as possible
and thus minimize the quantity entering the waste stream. Where practicable, recovering waste items
for secondary use is the next most preferable method. Waste that cannot be recovered must then be
dealt with by the least preferable options, such as treatment or land disposal, to reduce its health and
environmental impacts.

Page | 55
Waste minimization

The preferred management solution is quite simply not to produce the waste, by avoiding wasteful
ways of working. To achieve lasting waste reduction (or minimization), the focus should be on
working with medical staff to change clinical practices to ones that use less materials. Although
waste minimization is most commonly applied at the point of its generation, health-care managers
can also take measures to reduce the production of waste through adapting their purchasing and stock
control strategies. Examples of policies and practices found to minimize quantities of waste are
summarized in Box 5.

Box 5 Examples of practices that encourage waste minimization

Source reduction
Purchasing reductions: selecting supplies that are less wasteful where smaller quantities can
be used, or that produce a less hazardous waste product.
Use of physical rather than chemical cleaning methods (e.g. steam disinfection instead of
chemical disinfection).
Prevention of wastage of products (e.g. in nursing and cleaning activities).
Management and control measures at hospital level
Centralized purchasing of hazardous chemicals.
Monitoring of chemical use within the health centre from delivery to disposal as hazardous
wastes.
Stock management of chemical and pharmaceutical products
More frequent ordering of relatively small quantities rather than large amounts at one time,
to reduce the quantities used (applicable in particular to unstable products).
Use of the oldest batch of a product first.
Use of all the contents of each container.
Checking of the expiry date of all products at the time of delivery, and refusal to accept
short-dated items from a supplier.
Waste minimization usually benefits the waste producer: costs for both the purchase of goods
and for waste treatment and disposal is reduced, and the liabilities associated with the disposal
of hazardous waste are also lower.
All employees have a role to play in this process and should be trained in waste minimization.
This is particularly important for the staff of departments that generate large quantities of
hazardous health-care waste.
Suppliers of chemicals and pharmaceuticals can also become responsible partners in waste-
minimization programmes. The health centre can encourage this by ordering only from
suppliers who provide rapid delivery of small orders, who accept the return of unopened stock,
and who offer offsite waste-management facilities for hazardous wastes.

Page | 56
Environmentally preferable purchasing

Environmentally preferable purchasing (EPP) refers to the purchase of the least damaging products
and services, in terms of environmental impact. At its simplest, EPP may lead to the purchase of
recycled paper, through to more sophisticated measures such as the selection of medical equipment
based on an assessment of the environmental impact of the equipment from manufacture to final
disposal – known as “life-cycle thinking”. The Department of Sanitation New York City has
produced a useful EPP guide; another example of EPP is from a study undertaken in South Africa for
public health clinics, which included consideration of green purchasing. A health-care centre with an
EPP policy in place may have a requirement that purchases can only be made from suppliers with an
environmental management system (see section 6.7).

The application of EPP can help health-care centers to reduce their overall impact on the
environment, provide healthier conditions for patients and staff by switching to less hazardous
materials (e.g. solvents, cleaning fluids), and lower the costs related subsequently to waste disposal.
A widely cited example is the purchase of mercury versus a mercury-free thermometer. When
mercury thermometers break, there are costs associated with cleaning up a hazardous material and
then preventing mercury from entering the environment at the final disposal stage (CDHS, 2000;
Karliner, 2010; Practice Greenhealth, 2012).

Managing stores carefully will prevent the accumulation of large quantities of outdated chemicals or
pharmaceuticals and limit the waste to the packaging (boxes, bottles) plus residues of the products
remaining in the containers. These small amounts of chemical or pharmaceutical waste can be
disposed of easily and relatively cheaply, whereas disposing of larger amounts requires costly and
specialized treatment, which underlines the importance of waste minimization.

Life-cycle management considers benefits, costs and risks over the full life cycle of a product or
service – including waste management. Life-cycle management applies approaches to product design
and development that minimize environmental impacts of products throughout all life stages of a
product, starting with the extraction of resources for raw material inputs, and continuing through
processing and manufacturing of all feed stocks and final products, distribution, use and, ultimately,
disposal. Life-cycle analysis is a tool used for life-cycle management, to quantify the life-cycle
impacts of a product (Kaiser, Eagan & Shaner, 2001).7

Green procurement

Reducing the toxicity of waste is also beneficial, by reducing the problems associated with its
treatment or disposal (Kaiser, Eagan & Shaner, 2001). For example, the purchasing manager at a
health-care facility could investigate the possibility of purchasing plastics that may be easily
recycled, or order goods supplied without excessive packaging.

Globally, the most easily recyclable plastics are polyethylene, polypropylene and polyethylene
terephthalate (PET). Conversely, polyvinyl chloride (PVC) is the most difficult, partly because its
products come in a variety of forms containing different additives. Packaging of mixed materials,
such as paper or card covered in plastic or aluminum foil, is rarely recyclable.

Page | 57
PVC is also of concern because of the toxicity of some of its additives and should be avoided
wherever possible. Similarly, polycarbonate is made from biphenyl A, which is an endocrine
disruptor. Latex or nitrile gloves are the most common replacements for PVC gloves. Latex or
silicone tubing can replace PVC tubing, polyethylene IV bags can replace PVC bags, and ethylene
vinyl acetate bags can replace PVC bags for saline and blood. Ethylene oxide is used to sterilize
medical devices, but it is carcinogenic and so should be avoided where alternatives exist.

Recycling symbols for plastics

An international classification system to identify different types of plastic is available. Common

types in health-care settings are:

low-density polyethylene – LDPE, 4

high-density polyethylene – HDPE, 2

polypropylene – PP, 5

polyethylene terephthalate – PET or PETE, 1

Polycarbonate – PC, which has no designated number but may be labeled 7 (a miscellaneous
category for low-volume plastics).
Where items are not labeled, procurement staff should contact the manufacturer for further
information or change to a product that is clearly labeled as being made from a material known to be
recyclable.

Safe reuse

The reuse of materials in a health-care facility has provoked much debate, with particular concern
over the reuse of single-use (medical) devices. In general, the use of non-disposable items for
medical procedures should be encouraged where their reuse after cleaning can be demonstrated to
minimize infection transmission to acceptably low probabilities. When considering reuse, it is
important to make a distinction between different types of products:

non-medical supplies, disposable items (which should be avoided)

medical devices that pose no cross-infection risk (e.g. blood-pressure meters)

Medical devices specifically designed for reuse (e.g. surgical instruments).

Page | 58
Syringes and hypodermic needles should not be reused because of the significant chance of spreading
disease. Proper steps should be taken to make sure that they are disposed of safely. Where syringes
are in short supply, nurses may replace the needle, but the chance of infection remains. A syringe that
has been rinsed but not sterilized can still have a 1.8% chance of passing on human
immunodeficiency virus if used for intravenous injection and 0.8% for intramuscular injection (Reid
& Juma, 2009). Research is limited and the risk is probably underestimated. Anecdotal reports of
syringes being repackaged are common, and a survey in Dhaka, Bangladesh (Hassan et al., 2008),
confirms that some hospital cleaners salvaged sharps and other materials for reuse. An outbreak of
hepatitis in Gujarat, India, in 2009, involving at least 240 cases and 60 deaths, was traced back to the
illegal trade in medical waste, as well as direct reuse of single-use items (Solberg, 2009).

Reuse may involve a combination or all of the following steps: cleaning, decontamination,
reconditioning, disinfection and sterilization. Common sterilization methods are listed in Box 6.3.

Plastic syringes and catheters should not be reused. However, they may be recycled after sterilization.
There are also certain devices (e.g. patient self-administered intermittent urinary catheters, face
masks for oxygen administration) that are intended for limited reuse by the individual and only
require washing with mild detergents.

Long-term radionuclide conditioned as pins, needles or seeds and used for radiotherapy may be
reused after sterilization.

Special measures must be applied in the case of potential or proven contamination with the causative
agents of transmissible spongiform encephalopathy (also known as prion diseases). These measures,
which are capable of reducing or eliminating infectivity, are described in detail in the World Health
Organization (WHO) Report of a consultation on public health issues related to animal and human
encephalopathy’s (WHO, 1992).

Box 6 Examples of sterilization methods for reusable items

Thermal sterilization
Dry sterilization:
Exposure to 160 °C for 120 minutes or 170 °C for 60 minutes in a “Pauline” oven. Wet sterilization:
Exposure to saturated steam at 121 °C for 30 minutes in an autoclave.
Chemical sterilization
Hydrogen peroxide:
A 7.5% solution can produce high-level disinfection in 30 minutes at 20 °C. Alternatively,
equipment exists that can generate a hydrogen peroxide plasma from a 58% hydrogen peroxide
solution. The equipment has a 45-minute process time. Hydrogen peroxide can also be used in
combination with per acetic acid.
Per acetic acid:
Can produce sterilization in 12 minutes at 50–55 °C, with instruments ready to use in 30 minutes.
Per acetic acid can also be used in combination with hydrogen peroxide.
OPA (ortho-phthaldehyde):
High-level disinfection in 12 minutes at 20 °C. Hypochlorous acid/hypochlorite:

Page | 59
 400–450 ppm active free chlorine, contact conditions established by simulated use testing with
endoscopes.
NOTE: ethylene oxide and glutaraldehyde are widely used but are being replaced in an increasing
number of health-care facilities because of their health effects. Ethylene oxide is a human carcinogen,
and glutaraldehyde can cause asthma and skin irritation.
Source: USEPA (2002); United States Food and Drug Administration list of approved sterilants
(March 2009)

Certain types of containers may be reused, provided they are carefully washed and disinfected.
Containers for pressurized gas should be sent to specialized centers to be refilled. Containers that
once held detergent or other liquids may be reused as containers for sharps waste (if purpose-made
containers are not affordable), provided they are puncture-proof and clearly marked on all sides for
used sharps.

Recycling and recovery

Recycling is practiced by a wide range of institutions, including municipalities, private companies,

households, and public institutions such as schools and hospitals. From an environmental
perspective, recycling is less desirable than reusing a waste item, because it frequently requires
substantial energy input and transport to offsite recycling centers.

The recovery of waste is defined in one of two main ways. Most simply, “recovery” commonly refers
to energy recovery whereby waste is converted to fuel for generating electricity or for direct heating.
In temperate climates, the heat generated by onsite incinerators may be an attractive and cost-
effective option for heating hospitals, public buildings and residential districts. Alternatively, “waste
recovery” is a term used to encompass recycling of waste items to be converted into new products,
and composting of organic waste matter to produce compost or soil conditioner for use in agriculture
or similar purposes.

Recycling is increasingly popular in some health-care facilities, especially for the large, non-
hazardous portion of waste. It can reduce costs considerably, either through reduced disposal costs or
through payments made by a recycling company for the recovered materials (Box 6.4).

Minimum approach to waste minimization

The waste-minimization hierarchy should feature in the waste-management policy of all health-care
facilities, with a broad aim to move current practices upwards in the hierarchy from predominantly
disposal to an emphasis on recycling or even prevention.

The first practical steps are to pay more attention to the quantity and type of materials purchased
regularly, establish a system to gather waste-management ideas from staff, evaluate these ideas, and
put the good ideas into practice. Often, there will be obvious opportunities to reduce the amount and
toxicity of materials purchased, and hence the amount and toxicity of waste generated. Targets could
be both quantitative (e.g. consumption of paper will be reduced by 10%) and qualitative (e.g.
hazardous solvents will be substituted by more environmentally friendly products). Educating staff to
use medical materials carefully to avoid generating unnecessary waste is a further simple measure
that can be undertaken. Reuse is another option to minimize waste, but it is not without
complications and requires a realistic assessment of which reuse practices are considered safe and
which to avoid because the risk of infection transmission to patients and staff is unacceptable.
Page | 60
It is sensible for health-care managers to periodically review their purchasing practices and available
choices, and to remind their staff to avoid excessive waste production wherever possible.

Desirable improvements to the minimum approach

The initial approach envisages a health-care centre that has attempted some reduction in the waste it
produces. Several opportunities allow health-care centers to go beyond this, including by expanding
the effort in reducing waste and extending the activities to more items. Encouraging staff to extend
waste minimization requires the adoption of more rigorous methods and disciplines. Waste-
minimization targets can be established for each area of medical or support activities, and people can
be made more personally responsible for waste minimization – possibly by providing incentives for
those people and departments who are successful in achieving their targets. A significant step in
improving waste minimization is to adopt life-cycle management for items used in large quantities
and for frequently used services. Further techniques can involve working with suppliers to make
available products from materials that degrade more easily or that can be used again for secondary
purposes. Collectively, these improvements can further reduce the physical quantity of waste, and
environmental impacts from the remaining health-care waste requiring treatment and disposal.

Page | 61
Chapter 9
Problems faced by the Health Care Institutions
The problems faced by the HCFs in the public and private organizations are almost the same but
there are a lots of differences. The problems faced by health care are as:
a. Inadequate space – In many cases during the establishment of institutions there was no
consideration on the waste management. Mainly the health care institutions are constructed and
operate in places where there is no scope for any future expansion. So now days the health care
institutions are finding it very difficult to find suitable and adequate space within their hospitals to
accommodate the waste treatment and disposal facilities.
b. Lack of funds – In general public felt that there is no scarcity of funds in the private health care
institutions. However adequate priority is not given for the biomedical waste management. All are
having a notion to install some type of incinerator and incinerate all waste irrespective of its
category or type. There is a notion that incineration of waste is the one and only option of waste
management. The segregation procedures suggested, which are mandatory, in the rules are mostly
not taken into account. However in the case of government hospitals. Finance is the vital problem.
At present there is no budgeted allocation of funds. And hence these health care institutions are
facing of problem for purchasing biomedical waste containers/bags, making facilities for storage of
waste, establishing treatment facilities, disposal of treated waste, etc. Lack of fund allocation
specifically for these purposes prevents institutions for going for the management of biomedical
waste. Most of the hospitals in the Govt. sector are finding it difficult to mobilize adequate
resources for establishing waste treatment and disposal facilities.
g. Awareness –The waste management techniques suggested in the Rule is quite new to all and
different from which was followed by the institutions till 1998. Health care institutions as per the
information available were doing the waste management by dumping in the backyard and in most
cases adequate attention was not given to waste management. All institutions try to some or other to
avoid the waste. The Rules suggests highly scientific and best biomedical waste management
methods so as to avoid all types of environmental as well as health effects due to mismanagement of
waste. The management specifications and suggestions try to avoid all sorts of occupational health
problems to workers as well as to the general public. The environmental and health effects of
techniques like mixing of waste with other wastes and incineration of waste are also addressed. The
true and correct awareness of the scope of the Rule as well as the biomedical waste management is to
be imparted to all health workers irrespective of their type of work.
h. Inadequacy of waste management system – At present the waste management system is
lacking in most health care institutions particularly so in most of the public health care institutions.
The lowest level of staff is supposed to manage the waste as per their will and pleasure. This has to
be changed and altered drastically. Modern techniques like formation of committees comprising of
members representing all category of staff can improve the situation.
i. Lack of monitoring facilities – At present there is no monitoring system to assess the waste
management facilities available are carried out effectively and as expected. Periodical meeting of
waste management committees can improve the system.
j. Responsibility is not fixed –The responsibility of waste management and connected matters are
not made mandatory to any officer of health care institutions. It is true that the head of institutions
is responsible. However the head of institutions has to find out suitable officer under him and give
responsibility on these matters along with powers for carrying out the works.
g. Non-availability of equipments – There is a problem regarding the non-availability of required
instruments, waste containers/bag Etc. of required specification.

Page | 62
Recommendations
1. For the use of incinerator training and awareness should be given to staff members.
2. Specific fund should be allocated for the use of incinerator.
3. Every hospital should have special boxes to use as dustbin.
4. Medical wastes should not be mixed with other waste.
5. Private hospitals should allowed to use incinerator which is installed in goverment hospital. For
this purpose they can charge a specific fee.
6. Special vehicle should be started to collect waste from private hospitals as well as clinics
7. As mentioned by biomedical waste rules, the whole waste should be fragmented into colors
because of their hazardous nature.
8. Bio-medical waste Management Board can be established in each District.
9. Judicial powers should be given to either the management board or special court which should be
established in the matters of environment pollution for imposing fines
10. Housekeeping staff wear protective devices such as gloves, face masks, gowned, while
handling the waste.
11. There should be label on waste carrying bags and trolleys and also poster must put on the wall
near to the bins (waste) giving details about the waste type that has to dispose.

Page | 63
Chapter 10
Legislative, Regulatory and Policy aspect of health care waste
Importance of a national policy
It is possible for enhancements in waste management to begin in preparing local health-care facilities.
Though, to have a sway more widely across a country usually needs active government involvement.
The most common first step by a government ministry is to define the changes desired in a national
biomedical waste management plan. This would be seen as a significant step in forming a fruitful and
supportable management system, which all health-care facilities can work on the way to. A policy
can be observed as a draft that drives choice making at a political level and should rally on
government effort and resources to create the conditions to make changes in HCFs.

A national policy must recognize the needs and difficulties in the country, as well as in view of the
relevant international pacts and treaties adopted nationally that govern public health, sustainable
expansion, the environment and safe management of risky waste.

Once a national policy has been formulated, usually rule and supporting regulations governing
medical management, if required, should be established. To be utmost effective, regulations should
designate what is likely from health-care team and explain the ways for their enforcement. It is
possible that specialized organizations or influential foundations will supplement official regulations
with practical guidelines & manuals, codes of good proficient practice and guidance shared between
skilful managers. A national policy ought to make allowances for local differences, and variations in
regional capacity and socio economic conditions. Additionally, there are useful available guidance
documents produced; for instance, by the WHO (World Health Organization), United Nations
Environment Programme.

Guiding principles

Five principles are broadly documented as underlying the effective and well-ordered management of
wastes. These principles have been used by many countries while developing their policies,
legislation and guidance:

The “polluter pays” principle indicates that all producers of waste are legitimately and fiscally
responsible for the safe and environmentally disposal of the waste. This also attempts to assign
responsibility to the party that causes damage.

The “precautionary” principle is a influential principle governing health & safety

protection. It was well-defined and accepted under the Rio Declaration on Environment and
Development (UNEP, 1972) as Principle 15: “Where there are threats of serious or
irreversible damage to the environment, lack of full scientific certainty should not be used as
a reason for postponing cost-effective measures to prevent environmental degradation”.

The “duty of care” principle specifies that any person handling/managing toxic substances
or wastes or related equipment is morally responsible for using the paramount care in that
task. This principle is best attained when all parties involved in the production, storage,
treatment, transport, and disposal of wastes (including HCFs waste) are suitably registered or
licensed to produce, receive and handle named classes of waste.

Page | 64
 The “proximity” principle mentions that treatment and disposal of dangerous waste take
place at the closest possible place to its source to decrease the risks involved in its
transportation. Likewise, every community must be cheered to recycle or dispose of the
waste it produces, inside its own territorial limits, except it is insecure to do so.

The “prior informed consent principle” as embodied in various global pacts is designed to
secure public health and environment from hazardous waste. It necessitates that affected
societies and other shareholders be apprised of the hazards and risks, and that their accord be
obtained. In the context of medical waste, the principle could relate to the transport of waste
and operation of waste treatment and disposal facilities.

International agreements and conventions

The following international agreements and conventions are relevant to the management of wastes
from health-care organizations, the security of the environment and sustainable development should
be taken account of when preparing waste management policy and standards.

The Basel Convention

The Basel Convention on the Control of Trans-Boundary Movements of Hazardous Wastes and their
Disposal (the Basel Convention) is the peak widespread global environmental treaty on hazardous &
other wastes. It includes 170 member countries and purposes to protect human health and
environment alongside the adverse effects resulting from the generation, management, transboundary
actions and disposal of wastes.

The Basel Convention controls the transboundary movements of wastes by relating the “prior
informed consent” principle. Shipments without consent to and from non-parties are illegal untill
there is a special treaty that contains provisions no less environmentally sound than the convention.
Each party is mandatory to introduce appropriate legislation to avoid and punish illegal traffic in
hazardous & other wastes. In addition, the contract assists its parties to ensure that hazardous and
other wastes are managed and disposed of in an environmentally safe manner. To this end, parties are
suggested to decrease the quantities that are moved across rims, to treat and dispose of wastes as
close as possible to the place of generation, and to prevent the generation of wastes at source. Strong
controls need to be applied from the point of the generation of a fatal waste to its storage, treatment,
reuse, transport, recovery, recycling and its final disposal.

The Basel Conention specifically talk about to:

Y1 – Clinical wastes from medical care in hospitals, medical centers and clinics

Y3 – Waste pharmaceuticals, drugs and medicines.

The convention also has a category of hazardous characteristics defined as “H 6.2 – Infectious
substances – substances or wastes containing viable microorganisms or their toxins which are known
or suspected to cause disease in animals or humans.”

The Basel Convention is reformed at times through decisions made at the regular Conference of the
Parties to the Basel Convention. Remarkably, the conference agreed (Decision III/1) to prohibit
hazardous waste shipments from one countries to another countries.

Page | 65
Available guidance

World Health Organization Guidance

The WHO policy paper, Safe health-care waste management (WHO, 2004), acclaims that countries
conduct assessments before choosing health-care management methods. WHO advises that
government organizations should adopt the strategies outlined below

Short-term strategies

 Manufacture of all syringe components using the same plastic to facilitate recycling
 Choice of polyvinyl chloride–free medical devices.
 Reorganizations and development of recycling options wherever possible.
 Research into, and promotion of, new technology or alternative to small-scale
incineration.

Medium-term strategies

 More efforts to decrease the number of needless injections, to reduce the volume of
hazardous health-care waste that requirements to be treated.
 Exploration into the health effects of chronic exposure to low levels of dioxin and
furan.
 Risk calculation to compare the health risks associated with incineration, and exposure
to waste.

Long-term strategies

 Effective, scaled-up advertising of non-incineration technologies for the final disposal

of medical waste to stop the disease burden from unsafe health-care waste management and
exposure to dioxins and furans.
 Support to countries in formulating a national guidance guidebook for sound
management of health-care waste.
 Maximum support to countries in developing and implementing a national plan,
policies, rules & regulations on health-care waste.
 Promotion of the principles of environmental management of health-care waste as set
out in the Basel Convention.
 Give support to allocate human and financial resources for safe management of
health-care waste in countries.
WHO also advocates the Core principles for achieving safe and sustainable management of
health-care waste (WHO, 2007). These principles require that each & everyone associated with
health-care activities should provide for the costs of managing health-care waste.

Page | 66
In particular:
Governments should
 Assign a budget to cover all the costs of establishment and maintenance of health-
care waste management systems
 Requested to donors, partners and other external financing source to include an
adequate contribution towards the management of waste associated with their intrusions;
 Implementing and monitoring health-care waste management systems, and ensure
worker and community health.
Donors and partners should
 Include a provision in their health programme support to cover the costs of health-care
waste-management systems.
NGOs should
 Include the advancement of sound waste management in their advocacy
 Accept programmes and activities that contribute to sound health-care waste
management.

The private sector should

 Take charge for the management of health-care waste linked with the products and
services it provides, plus the design of products and packaging.
All concerned institutions and organizations should
 promote health-care waste management;
 develop advanced solutions to reduce the volume and toxicity of the waste
 Ensuring that global health strategies and programmes take into account health-care
waste management.

The International Solid Waste Association

The International Solid Waste Association (ISWA) is familiar as an international, sovereign and non-
profit-making association, functioning in the public interest to promote and grow sustainable waste
management worldwide. ISWA has national and individual members from around the globe and
promotes sustainable and professional waste management.

ISWA policy document on health-care waste management

ISWA advocates that appropriate attention is given to the safe and sustainable management of health-
care waste and supports the sustainable management of biomedical waste by the segregation, storage,
transport, treatment and final disposal of waste.

It has given the following principles to its member countries:

 Proper consideration is given to sustainable development in the acquirement and use

of resources, reducing resource use where ever possible, reusing items, maximizing the
recycling of materials, and taking account of sustainable development concerns in the
management of wastes.

Page | 67
  Each HCF should have a waste management plan, which is reviewed regularly, in
addition to a responsible, properly trained and competence assessed waste manager. In
addition, all staff is trained and aware in the management of waste within a facility.
 Hazardous waste is properly segregated from the other waste that can be seems as
municipal solid waste. Health care waste is collected and transported within the facility in
suitable containers, and stored at suitable sites not exceeding the duration of 48 hours or less.

Full explanation is taken of the guidance confined in Safe management of wastes from health-care
activities (WHO, 1999) and the Technical guidelines on the environmentally sound management
of biomedical and healthcare wastes (Y1; Y3) (UNEP, 2003). Full account is also taken of the
implications of the Stockholm Convention.

ISWA also supports the opinion that, due to the extensive practice of drug abuse and the growth in
the amount of health care treatment being carried out in the home, proper provisions should be made
to ensure that waste from minor sources is caught and treated correctly.

National legislation

A national policy certificate should form the basis for developing the law and should be
complemented by technical guidelines developed for enactment of the law. This legal “package”
should specify guidelines on the treatment of different waste categories, segregation, collection,
storage, treatment methods, disposal and transport of waste; and duties and training requirements.
The national policy should take into account the resources and facilities available in the country
concerned and any cultural aspects of waste handling.

A national law on health care waste management may stand alone, or constitute part of more
comprehensive legislation, such as:

 a law on managing all forms of toxic wastes, where the application to medical waste is
stated explicitly;
 A law on hospital hygiene & infection control, where a specific section should be
devoted to health care waste.

A national law should include the following elements:

 a clear meaning of hazardous health care waste and its categories;
 a precise sign of the legal obligations of the biomedical waste producer regarding safe
handling and disposal;
 specifications for record keeping and reporting;
 establishment of permit or licensing procedures for systems of treatment and waste
handling;

specifications for an inspection system and regular audit procedures to ensure enforcement of the
law and for penalties to be imposed for contravention;

Designation of courts responsible for handling disputes arising from enforcement of, or non-
compliance with, the law.
Gradual implementation of the law is recommended in preference to any attempt to introduce all
measures simultaneously, particularly where existing practices are inadequate.

Page | 68
Technical guidelines

Technical guidelines intended to aid the implementation of legislation should be practical and
directly applicable to local managers and staff. They should contain sufficient detail to ensure that
safe practices and appropriate standards can be achieved. They should outline the legal framework to
be met for the safe management of health-care waste and how the guidance improves hospital
hygiene, and occupational health and safety. Technical guidelines can be prepared by various
organizations, both public and nongovernmental, and collectively address a broad of range of
relevant topics:

responsibilities of public health authorities

safe practices for waste minimization

separation, handling, storage and transport of health-care waste

treatment and disposal methods for each category of health-care waste and for wastewater

Limits of emission of atmospheric pollutants and measures for protection of water resources.

An example of national technical guidelines is contained in Health technical memorandum 07-01:

safe management of health care waste (UK DoH, 2006).

Minimum approach to developing health-care waste-management policy

Where there is no national policy, legislation or guidelines, this should not prevent a hospital or
health-care facility from commencing a modest programme of health-care waste management. A
short document could be prepared that states the problems, sets out simple actions, identify the
stakeholders, and mobilizes them to carry out the actions. Initially, this is all that may be necessary.
A number of publications can assist in preparing a health-care waste-management system and
training programme for staff. The following two example publications can be downloaded from the
internet:

The success of a practical health-care waste-management plan in one hospital will often influence
other hospitals. It may also encourage national governments subsequently to devise the necessary
national policy and framework.

Page | 69
Desirable improvements to the minimum approach

A number of desirable improvements should be considered when setting policy and legislation.
These are to:

set a national budget to ensure that the regulations are fully complied with, and require that
individual establishments do the same;

continually improve the mandatory standards of health-care waste management;

create an organized system of enforcement of the legislation;

create a national system of training and assessment of technical competence in the management of
health-care waste;

Create a system of awareness raising, training and regular assessment of sustainable development
in the management of all wastes produced in health-care facilities.

Page | 70
Chapter 11
BIOMEDICAL WASTE MANAGEMANT AND HANDLING RULES

 Notifications and Amendments

 On 20th July 1998 Ministry of Environment and Forest (MoEF), Govt. of India, set up a rule
known as ‘ Biomedical waste (Management & Handling) rules
 1st Amendment Dated 06/03/2000
 2nd Amendment Dated 17/09/2003
 The Moe, F&CC has notified the new BMW rules,2016 on 28th March, under the
Environment (Protection) Act, 1998 and the amendments there of.
 Published in the Gazette of India, Extraordinary, Part II,Section3,sub section(i)
Biomedical Waste Management Rules
Harmless disposal of biomedical waste is now an authorized requirement in India. The Biomedical
Waste Management & Handling) Rules, 1998 came into existence on 1998. In accord with these
rules, it is the duty of every “occupier” i.e. a person who has the control over the institution or its
premises, to take all steps to ensure that waste generated is handled without any adverse effect to
human health and environment. It consists of six schedules.
 Schedule I
 Schedule II
 Schedule III
 Schedule IV
 Schedule V
 Schedule VI

Guidelines
i. Non-infectious wastes need to be segregated as a separate category and these wastes should not
be mixed with other categories of waste.
ii. Each ward of health care facilities should have at least two colored containers and other colored
container can be placed at centralized places.
iii. All the objects should be made non-reusable before they taken out of the hospital.
iv. For defacement of needles and syringes, all hospitals should provide adequate number of needle
destroyers and syringes cutters at appropriate place.
v. The needles after disinfections or destruction shall be collected in a puncture proof container
vi. A detailed study should be carried for the treatment of liquid effluent generated in the hospital.
vii. An inventory of various kind of hazardous chemicals used in medical treatment shall be
arranged. The possibilities of recycling of such hazardous chemicals should also be looked into.
viii. Infectious waste must kept separately in bins lined with polyethylene bags wherever needed.
ix. Under no conditions should the infections waste be mixed with non-infectious bags.
x. The bag lining the bin should be only 3/4th filled to ensure that the waste does not spill out.
xi. While carrying the bag containing infectious waste it has to be sealed.
xii. Bags containing transmittable waste have to be disposed of through incineration, autoclaving,
or micro waving as per recommendations.

Page | 71
 xiii. Properly labeled waste containers minimize confusion in handling and disposal of waste.
Therefore, all containers should be have prescribed color and label.
xiv. Sharps Blood bags, syringes and should be handled with utmost care. The doctor manager
should ensure that such objects are either out or mutilated before removing them from the OT or
nursing desk.
xv. Before disinfection always separate the syringes barrel from its plunger.
xvi. All the workers working in the hospital waste must be vaccinated against hepatitis B.
xvii. All the employees should put on gloves while dealing with infectious waste.
xviii. Sharps should not be left carelessly counter tops, on beds, food trays, or on the floor as
critical injuries can outcome.
xix. Separation of hospital waste is the key to ensure that 90% of the waste which is
noncontaminated is treated simply. At no step should infectious waste come in interaction with-
non-infectious waste. If mixed, non-infectious waste has to be treated as infectious waste.

 Safety measures
• All the generators of medical waste should accept precautions and suitable safety measures while
handling the biomedical waste.
• It should be confirmed that:
 Drivers, collectors and handlers are awake of the nature and risk of the medical waste.
 written instructions should provide about the procedures to be adopted in the event of
accidents.
 Protective gears must provided and instructions regarding their uses are also given.
 Workers are secure by vaccination against tetanus and hepatitis B.

 Training

 Every hospital must have a well-planned awareness and training programme for all.
• Training should be lead in appropriate language and in an acceptable manner.
• All the medical professionals must be aware of medical Waste (Management and Handling) Rules
1998
Duties of the Occupier - It shall be the duty of every occupier to-
(a) Take all required steps to ensure that biomedical waste is handled without any adverse effect to
the environment and in accord with these rules;
(b) make a provision within the premises for a secure and ventilated location for storage of
segregated waste in colored bags/containers in the manner as stated in Schedule I, to confirm that
there shall be no secondary handling, pilferage of recyclables or inadvertent spillage by animals
and the waste from such place shall be directly conveyed in the manner as prescribed in these rules
to the common bio-medical waste treatment facility as the case may be, in the manner as prescribed
in Schedule I;

Page | 72
(c) pre-treat of the blood samples, laboratory waste, microbiological waste, and blood bags through
sterilization/ disinfection on-site in the way as prescribed by the WHO or National AIDs Control
Organization (NACO) guidelines and afterwards then sent to the common bio-medical waste
treatment facility for disposal;
(d) Phase out use of gloves, blood bags and chlorinated plastic bags within two years from the date
of notification of these rules;
(e) Dispose of solid waste other than bio-medical waste in accordance with the provisions of
respective waste management rules made under the relevant laws and amended from time to time;
(f) Not to give treated bio-medical waste with municipal solid waste;
(g) provide training to all its health care workers and others, involved in handling of bio medical
waste at the time of induction and thereafter at least once every year and the details of training
programmes conducted, number of personnel trained and number of personnel not undergone any
training shall be provided in the Annual Report;
(h) Immunize all its health care workers and others, involved in handling of bio-medical waste for
protection against diseases including Hepatitis B and Tetanus that are likely to be transmitted by
handling of bio-medical waste, in the manner as prescribed in the National Immunization Policy or
the guidelines of the Ministry of Health and Family Welfare issued from time to time;
(i) Establish a Bar- Code System for bags or containers containing bio-medical waste to be sent out
of the premises or place for any purpose within one year from the date of the notification of these
rules;
(j) Ensure segregation of liquid chemical waste at source and ensure pre-treatment or neutralization
prior to mixing with other effluent generated from health care facilities;
(k) Ensure treatment and disposal of liquid waste in accordance with the Water (Prevention and
Control of Pollution) Act, 1974 (6 of 1974);
(l) Ensure occupational safety of all its health care workers and others involved in handling of
biomedical waste by providing appropriate and adequate personal protective equipment;
(m) conduct health check up at the time of induction and at least once in a year for all its health
care workers and others involved in handling of bio- medical waste and maintain the records for the
same;
(n) maintain and update on day to day basis the bio-medical waste management register and display
the monthly record on its website according to the bio-medical waste generated in terms of
category and color coding as specified in Schedule I;
(o) report major accidents including accidents caused by fire hazards, blasts during handling of
biomedical waste and the remedial action taken and the records relevant thereto, (including nil
report) in Form I to the prescribed authority and also along with the annual report;
(p) Make available the annual report on its web-site and all the health care facilities shall make own
website within two years from the date of notification of these rules;
(q) Inform the prescribed authority immediately in case the operator of a facility does not collect
the bio-medical waste within the intended time or as per the agreed time;

Page | 73
(r) Establish a system to review and monitor the activities related to bio-medical waste
management, either through an existing committee or by forming a new committee and the
Committee shall meet once in every six months and the record of the minutes of the meetings of
this committee shall be submitted along with the annual report to the prescribed authority and the
healthcare establishments having less than thirty beds shall designate a qualified person to review
and monitor the activities relating to bio-medical waste management within that establishment and
submit the annual report;
(s) Maintain all record for operation of incineration, hydro or autoclaving etc., for a period of five
years;
(t) Existing incinerators to achieve the standards for treatment and disposal of bio-medical waste as
specified in Schedule II for retention time in secondary chamber and Dioxin and Furans within two
years from the date of this notification.
5. Duties of the operator of a common bio-medical waste treatment and disposal facility. -It
shall be the duty of every operator to -
(a) take all necessary steps to ensure that the bio-medical waste collected from the occupier is
transported, handled, stored, treated and disposed of, without any adverse effect to the human
health and the environment, in accordance with these rules and guidelines issued by the Central
Government or, as the case may be, the central pollution control board from time to time;
(b) Ensure timely collection of bio-medical waste from the occupier as prescribed under these rules;
(c) Establish bar coding and global positioning system for handling of bio- medical waste within
one year;
(d) Inform the prescribed authority immediately regarding the occupiers which are not handing
over the segregated bio-medical waste in accordance with these rules;
(e) Provide training for all its workers involved in handling of bio-medical waste at the time of
induction and at least once a year thereafter;
(f) Assist the occupier in training conducted by them for bio-medical waste management;
(g) Undertake appropriate medical examination at the time of induction and at least once in a year
and immunize all its workers involved in handling of bio-medical waste for protection against
diseases, including Hepatitis B and Tetanus, that are likely to be transmitted while handling bio-
medical waste and maintain the records for the same;
(h) Ensure occupational safety of all its workers involved in handling of bio-medical waste by
providing appropriate and adequate personal protective equipment;
(i) report major accidents including accidents caused by fire hazards, blasts during handling of
biomedical waste and the remedial action taken and the records relevant thereto, (including nil
report) in Form I to the prescribed authority and also along with the annual report;
(j) Maintain a log book for each of its treatment equipment according to weight of batch; categories
of waste treated; time, date and duration of treatment cycle and total hours of operation;
(k) Allow occupier, who are giving waste for treatment to the operator, to see whether the treatment
is carried out as per the rules;
(l) Shall display details of authorization, treatment, and annual report etc. on its web-site;

Page | 74
 (m) after ensuring treatment by autoclaving or microwaving followed by mutilation or shredding,
whichever is applicable, the recyclables from the treated bio-medical wastes such as plastics and
glass, shall be given to recyclers having valid consent or authorization or registration from the
respective State Pollution Control Board or Pollution Control Committee;
(n) Supply non-chlorinated plastic colored bags to the occupier on chargeable basis, if required;
(o) Common bio-medical waste treatment facility shall ensure collection of biomedical waste on
holidays also;
(p) Maintain all record for operation of incineration, hydro or autoclaving for a period of five years;
(q) Upgrade existing incinerators to achieve the standards for retention time in secondary chamber
and Dioxin and Furans within two years from the date of this notification.
4. Duties of authorities.-The Authority specified in column (2) of Schedule-III shall perform the
duties as specified in column (3) thereof in accordance with the provisions of these rules.
5. Prescribed authority.-(1) the prescribed authority for implementation of the provisions of these
rules shall be the State Pollution Control Boards in respect of States and Pollution Control
Committees in respect of Union territories.
(2) The prescribed authority for enforcement of the provisions of these rules in respect of all health
care establishments including hospitals, nursing homes, clinics, dispensaries, veterinary institutions,
animal houses, pathological laboratories and blood banks of the Armed Forces under the Ministry
of Defense shall be the Director General, Armed Forces Medical Services, who shall function under
the supervision and control of the Ministry of Defense.
(3) The prescribed authorities shall comply with the responsibilities as stipulated in Schedule III of
these rules.
Procedure for authorization.-Every occupier or operator handling bio-medical waste, irrespective
of the quantity shall make an application in Form II to the prescribed authority i.e. State Pollution
Control Board and Pollution Control Committee, as the case may be, for grant of authorization and
the prescribed authority shall grant the provisional authorization in Form III and the validity of
such authorization for bedded health care facility and operator of a common facility shall be
synchronized with the validity of the consents.
(1) The authorization shall be one time for non-bedded occupiers and the authorization in such
cases shall be deemed to have been granted, if not objected by the prescribed authority within a
period of ninety days from the date of receipt of duly completed application along with such
necessary documents.
(2) In case of refusal of renewal, cancellation or suspension of the authorization by the prescribed
authority, the reasons shall be recorded in writing: Provided that the prescribed authority shall give
an opportunity of being heard to the applicant before such refusal of the authorization.
(3) Every application for authorization shall be disposed of by the prescribed authority within a
period of ninety days from the date of receipt of duly completed application along with such
necessary documents, failing which it shall be deemed that the authorization is granted under these
rules.
(4) In case of any change in the bio-medical waste generation, handling, treatment and disposal for
which authorization was earlier granted, the occupier or operator shall intimate to the prescribed
authority about the change or variation in the activity and shall submit a fresh application in Form
II for modification of the conditions of authorization.

Page | 75
Advisory Committee.-
(1) Each & every State Government or Union territory Administration should establish an Advisory
Committee for the State or Union territory under the chairmanship of the respective health secretary
to oversee the execution of the rules in the state and to instruct any improvements and the Advisory
Committee should include representatives from the Departments of Health, Environment,
Veterinary Sciences and Animal Husbandry, Urban Development of that State Government or
Union territory Administration, urban local bodies or local bodies or Municipal Corporation, State
Pollution Control Board or Pollution Control Committee, representatives from Indian Medical
Association, common bio-medical waste treatment facility and non-governmental institutions.
(2) Notwithstanding anything contained in sub-rule (1), the Ministry of Defense shall constitute the
Advisory Committee (Defense) under the chairmanship of Director General of Health Services of
Armed Forces consisting of representatives from the Ministry of Defense, Ministry of
Environment, Forest and Climate Change, Central Pollution Control Board, Ministry of Health and
Family Welfare, Armed Forces Medical College or Command Hospital.
(3) The Advisory Committee constituted under sub-rule (1) and (2) shall meet at least once in six
months and review all matters related to implementation of the provisions of these rules in the State
and Armed Forces Health Care Facilities, as the case may be.
(4) The Ministry of Health and Defense may co-opt representatives from the other Governmental
and non-governmental organizations having expertise in the field of bio-medical waste
management.
12. Monitoring of implementation of the rules in health care facilities.
(1) The Ministry of Environment, Forest and Climate Change shall review the implementation of
the rules in the country once in a year through the State Health Secretaries and Chairmen or
Member Secretary of State Pollution Control Boards and Central Pollution Control Board and the
Ministry may also invite experts in the field of bio-medical waste management, if required.
(2) The Central Pollution Control Board shall monitor the implementation of these rules in respect
of all the Armed Forces health care establishments under the Ministry of Defense.
(3) Every State Government or Union territory Administration shall constitute District Level
Monitoring Committee in the districts under the chairmanship of District Collector or District
Magistrate or Deputy Commissioner or Additional District Magistrate to monitor the compliance of
the provisions of these rules in the health care facilities generating bio-medical waste and in the
common bio-medical waste treatment and disposal facilities, where the bio-medical waste is treated
and disposed of.
(4) The Central Pollution Control Board along with one or more representatives of the Advisory
Committee constituted under sub-rule (2) of rule 11 may inspect any Armed Forces health care
establishments after prior intimation to the Director General Armed Forces Medical Services.
(5) The District Level Monitoring Committee constituted under sub-rule (4) shall submit its report
once in six months to the State Advisory Committee and a copy thereof shall also be forwarded to
State Pollution Control Board or Pollution Control Committee concerned for taking further necessary
action.

Page | 76
 (6) The District Level Monitoring Committee shall comprise of District Medical Officer or District
Health Officer, representatives from State Pollution Control Board or Pollution Control Committee,
Public Health Engineering Department, local bodies or municipal corporation, Indian Medical
Association, common bio-medical waste treatment facility and registered nongovernmental
organizations working in the field of bio-medical waste management and the Committee may co-
opt other members and experts, if necessary and the District Medical Officer shall be the Member
Secretary of this Committee.
Annual report.-
(1) Every operator or occupier of common biomedical waste treatment facility should submit an
annual report in Form-IV to the prescribed authority, on or before the 30th June of every year.
(2) The prescribed authority should review, compile and analyses the information received and
send this information to the Central Pollution Control Board on or before the 31st July of every
year.
(3) The Central Pollution Control Board shall compile, review and analyses the information
received and send this information, along with its suggestions or comments or observations to the
MoEF(Ministry of Environment, Forest) and Climate Change on or before 31st August every year.
(4) The Annual Reports should also available online on the websites of Occupiers, State Pollution
Control Boards as well as Central Pollution Control Board.
Maintenance of records.-
(1) Every authorized person should maintain records regarding to the generation, collection,
storage, transportation, treatment, disposal or any other handling of bio-medical waste, for a period
of 5-6 years, in accordance with these rule & guidelines issued by the Central Government/Central
Pollution Control Board or the prescribed authority as according to the case may be.
(2) All records should be subject to verification and examination by the prescribed authority or the
Ministry of Environment, Forest and Climate Change at any time.
Accident reporting.-
(1) In case of any major fatality at any organization or any other site while handling medical waste,
the authorized person shall intimate instantly to the prescribed authority about accident and should
forward a report within 24 hours in writing about the remedial steps taken in Form I.
(2) Information concerning all other accidents and curative steps taken shall be provided in the
annual report in accord with rule by the occupier.

 Penalties as per rules

 The Penalties are as specified in Environment (Protection) act 1986.
 Imprisonment for upto five years with fine upto one lakh rupees, or both.
 In case the failure additional fine upto five thousand rupees for every day.

Page | 77
Chapter 11
Present Scenario
According to MoE, F&CC
 Gross generation of BMW in India is 484TPD from 1,68,869 HCFs, out of which 447TPD is
treated
 Almost 38 TPD of the wastes is left untouched and not disposed finding its routes in dumps or
water bodies and re-enters our systems.
 There are 198 CBMWF are in operation and 28 are in under construction.
 21,870 HCFs have their own treatment facilities and 1, 31,837 HCFs are using the CBMWFs.

‘New Bio-Medical Waste Management Rules will Change the way Country Used to Manage
Waste Earlier; Make a Big Difference to Clean India Mission’
Under this new regime, the coverage has improved and also delivers for pre-treatment of lab waste,
blood samples, etc. It mandates bar code system for suitable control. It has easy categorization and
authorization. Thus, it will create a huge difference to clean India Mission,
The major features of BMW Management Rules, 2016 contain the following:-
(a)The ambit of the guidelines has been extended to include surgical camps, vaccination camps,
blood donation camps or any other health care activity;
(b)Phase-out the usage of chlorinated plastic bags blood bags and gloves within two years;
(c)Pre-treatment of the microbiological waste, laboratory waste, blood bags and blood samples
through disinfection/sterilization on-site in the manner as prescribed by WHO or NACO;
(d)Provide training to all health care workers and immunize workers regularly;
(e)Establishment of a Bar-Code System for bags/containers containing medical waste for disposal;
(f)Report major accidents in a sequence;
(g)Existing incinerators have to achieve the standards for retention time in secondary chamber and
Dioxin and Furans in two years;
(h)Medical waste need to be sub divided in to 4 categories instead 10 for improvement the
segregation of waste at source;
(i)Procedure for getting authorization is to be simple.
(j)The new rules should define more stringent standards for incinerator for miimizing the emission
of pollutants;
(k)Inclusion of emissions limits for Dioxin and furans;
(l)State Government should provide land for setting up common waste treatment and disposal
facility;
(m)No occupier should established on-site treatment and disposal facility, if a service of common
waste treatment facility is available it should be at a distance of 75 *kilometer.
(n)Operator of a common bio-medical waste treatment and disposal facility to ensure the timely
collection of bio-medical waste from the HCFs and assist the HCFs in conduct of training.

Page | 78
 Bio-medical waste
Biomedical waste includes human & animal anatomical waste, treatment apparatus like needles,
syringes and other materials used in health care in the process of treatment and research. This waste
is generated during diagnosis, treatment or immunization in hospitals, clinics, nursing homes,
pathological laboratories, blood bank, etc. Total bio-medical waste generation in the country is 484
TPD from 1, 68,869 healthcare facilities (HCF)

Proper Bio-medical waste management

Methodical disposal of medical Waste via segregation, collection and treatment in an
environmentally sound manner reducing the adverse impact on health workers and on the
environment. The hospitals are required to put in place the mechanisms for effective disposal either
directly or through common biomedical waste treatment and disposal facilities. The hospitals
servicing 1000 patients or more per month are required to obtain authorization and segregate
biomedical waste in to 10 categories, pack five color backs for disposal. There are 198 common bio-
medical waste treatment facilities (CBMWF) are in operation and 28 are under construction. 21,870
HCFs have their own treatment facilities and 1, 31,837 HCFs are using the CBMWFs.

Problems of unscientific Bio-medical waste disposal

 The quantum of waste generated in India is estimated to be 1-2 kg per bed per day in a
hospital and 600 gm. per day per bed in a clinic. 85% of the hospital waste is non-hazardous, 15%
is infectious/hazardous. Mixing of hazardous results in to contamination and makes the entire waste
hazardous. Hence there is necessity to segregate and treat. Improper disposal increases risk of
infection; encourages recycling of prohibited disposables and disposed drugs; and develops
resistant microorganisms -
Consultation process for new Bio-medical Waste Management Rules, 2016
 The draft Bio-medical Waste Rules were published in June, 2015 inviting public objections
and suggestions. Stakeholders consultation meets were organized in New Delhi, Mumbai and
Kolkata .Consultative meetings with relevant Central Ministries, State Governments, State
Pollution Control Boards and major Hospitals were also held. The suggestions / objections (about
50) received were examined by the Working Group in Ministry. Based on the recommendations of
the Working Group, the Ministry has published the Bio- medical Waste Management Rules, 2016.

Table 13. Major difference between BMW Rules

Major difference between BMW Rules 1998 & 2016

1998 2016
1. Occupiers with more than 1000 beds Every occupier generating BMW, including
required to obtain authorization health camp or ayush requires to obtain
authorization
2. Operator duties absent Duties of the operator listed
3. Biomedical waste divided in ten Biomedical waste divided in 4 categories
categories
4. Rules restricted to HCEs with more Treatment and disposal of BMW made
than 1000 beds mandatory for all the HCEs
5. No format for annual report A format for annual report appended with the
rules
6. Schedule I,II,III,IV,V Change of Schedule I,II,III,IV

Page | 79
 Schedules

7. Sch1. Cat. Of waste or type of waste Sch1. Cat. According to color code & type of
(10 cat.) waste with treatment/disposal option
8. Sch2. Color code, type of container, Sch2.Standard for treatment & disposal of
waste cat. & treatment options BMW(including plasma pyrolysis & dry heat
sterilization)
9. Sch3. Label for BMW containers/ Sch3.list of prescribed authorities and the
bags corresponding duties.
10. Sch4. Label for transportation of Sch4. Part A label for BMW
BMW Part B label for transporting
11. Sch5. Standard for treatment &
disposal of BMW
12. Sch6. List of authorities and
corresponding
duties

Major changes proposed in the Bio- Medical Waste Management Rules, 2016 and its likely
implication

Bio- Medical Waste Bio- Medical Waste Reasons and likely

(Management and
Handling)
Rules, 2011
Title
Bio- Medical Waste
(Management
and Handling) Rules, 2011
These rules apply to all
persons
who generate, collect, receive,
Store, transport, treat, dispose,
or handle bio medical waste in
any form.
Duties of the Health care facilities
Every occupier of an
institution
Generating bio-medical waste
which includes a hospital,
nursing home, clinic,
dispensary, veterinary
institution, animal house,
pathological laboratory, blood
bank to take all steps to ensure
Management Rules, 2016
Bio- Medical Waste
Management Rules, 2016
Application
These rules shall apply to all
persons who generate, collect,
receive, store, transport, treat,
dispose, or handle bio-medical
waste in any form and shall
not apply to:
• radioactive wastes,
• wastes covered under the
MSW Rules, 2000,
• lead acid batteries,
• hazardous wastes,
• E- waste,
• Hazardous microorganisms.
Additions:
Health care facilities (HCF)
shall make a provision within
the premises for a safe,
ventilated and secured
location for storage of
segregated biomedical waste
pre-treat the laboratory waste,
microbiological waste, blood
implications
The word ‘Management’
includes
Handling
Modified to bring more clarity
in the
Application.
Clarified that vaccination
camps, blood
donation camps, surgical
camps or any
other healthcare activity
undertaken
outside the healthcare facility,
will be
Covered.
To ensure that there shall be
no
secondary handling, pilferage
of recyclables or inadvertent
scattering or spillage by
animals and the bio-medical
waste from such place or
premises can be directly
transported in to the common
Page | 80
that such waste is handled
without any adverse effect to
human health and the
environment.
Duties of the operator of a common bio-medical waste treatment and disposal facility
..Nil...
Every HCFs, where required,
samples and blood bags bio-medical waste treatment
through disinfection or Facility.
sterilization on-site in the This is to prevent the possible
manner as prescribed by the microbial contamination.
World Health Organization Will eliminate the emission of
(WHO) or National dioxin and furans from
AIDs Control Organisation burning of such wastes.
(NACO) guidelines and then Will improve the management
sent to the common bio- of BMW including collection,
medical waste treatment segregation.
facility for final disposal. To protect the health of
phase out use of chlorinated workers Will improve the
plastic bags, gloves and blood segregation, transportation
bags within two years from and disposal system.
the date of notification of Also will eliminate pilferage
these rules provide training to on the way of BMW to
all its health care workers and disposal facility.
others involved in handling of Help to monitor and improve
bio medical waste at the time the management
of induction and thereafter at Will improve the environment
least once every year in the vicinity treatment
immunise all its health care facility.
workers and others involved
in handling of bio-medical
waste for protection against
diseases including Hepatitis B
and Tetanus that are likely to
be transmitted by handling
of bio-medical waste,
establish a Bar- Code System
for bags or containers
containing bio-medical waste
to be sent out of the premises
report major accidents
including accidents caused by
fire hazards, blasts during
handling of bio-medical
waste and the remedial action
taken to SPCB existing
incinerators shall achieve the
standards for retention time in
secondary chamber and
Dioxin and Furans within two
years from the date of this
notification
Same as the duties of HCFs Specific responsibility on the
and additionally they shall operator of a common bio-
ensure timely collection of medical waste treatment and
bio-medical waste from the disposal facility will be make
HCFs, assist the HCFs in them clear to their duties
conduct of training
Treatment and disposal
No occupier shall establish This is to make the installation
Page | 81
shall set requisite bio-medical
waste treatment facilities like
incinerator, autoclave,
microwave system for the
treatment of waste, or, ensure
requisite treatment of waste at
a common waste treatment
facility or any other waste
treatment facility
Segregation, packaging, transportation and storage
Bio-medical waste classified
in to 10 categories based on
treatment options.
No untreated bio-medical
waste shall be kept stored
beyond a period of 48 hours
Provided that if for any reason
it becomes necessary to store
the waste beyond such period,
the authorised person must
take permission of the
prescribed authority and take
measures to ensure that the
waste does not adversely
affect human health and the
environment.
Hospitals treating 1000 or
more patients per month to
obtain authorization from
SPCBs/PCCs
The Government of every
on-site treatment and disposal and operation of common
facility, if a service of ` treatment facility a viable one.
common biomedical waste
treatment facility is available
at a distance of seventy-five
kilometer. In cases where
service of the common bio-
medical waste treatment
facility is not available, the
Occupiers shall set up
requisite biomedical waste
treatment equipment like
incinerator, autoclave or
microwave, shredder prior to
commencement of its
operation, as per the
authorisation given by the
prescribed authority.
Bio-medical waste classified Will improve the segregation
in to 4 categories based on of waste at source channelize
treatment options. proper treatment and disposal
Untreated human anatomical Will eliminate obtaining
waste, animal anatomical permission within 48 hours
waste, soiled waste and, which is not practically
biotechnology waste shall not Feasible.
be stored beyond a period of
forty – eight hours:
In case for any reason it
becomes necessary to store
such waste beyond such a
period, the occupier shall take
appropriate measures to
ensure that the waste does not
adversely affect human health
and the environment and
inform the SPCB along with
the reasons.
Authorisation
One time Authorisation for HCFs can make application
Non-bedded HCFs. The along with consent and hence
validity of authorization shall getting authorisation will not
be synchronised with validity be additional burden for
of consent orders for Bedded HCFs. and operator of
HCFs treatment facility.
It will also help to SPCB in
making single inspection /
monitoring to consider both
the consent and authorisation.
Advisory Committee
No change in the concept Advisory Committee has
Page | 82
State/Union Territory shall
constitute an advisory
committee with the experts in
the field of medical and
health, animal husbandry and
veterinary sciences,
environmental management,
municipal administration, and
any other related department
or organisation including
nongovernmental
organisations.
Ministry of Defence shall
constitute, an Advisory
Committee under Additional
Director General of Armed
Forces Medical Services with
representative of Ministry of
Defence, MoEFCC, for HCFs
under Armed forces under the
Ministry of Defence.
Standards for emission from incinerators
SPM in the Incinerator’s
Emission 150 mg/nm3
Residence Time in Secondary
chamber of incinerators is 1
second
...Nil..
Site for common bio-medical waste treatment and disposal facility
--Nil..
..Nil..
except additional members.
Shall meet once in Six
Months.
50 mg/nm3
2 second
Standards for Dioxin and
furans prescribed.
The department dealing the
allocation of land shall be
responsible for providing
suitable site for setting up of Management facility. Making
common biomedical waste
treatment and disposal
facility in the State
Government
Monitoring of implementation
Ministry of Environment,
Forest and Climate Change
shall review the
implementation of the rules in of implementation through the
the country once in a year
through the State Health
strengthened suitably with
additional members
The proposed stringent
standards for emission from
Incinerator (reduction of
permissible limit for
particulate matter,
Introduction of standards for
Dioxin and Furans and
increasing the residence time
in the Incinerator Chambers)
will improve the operation of
incinerator and reduce the
emission of pollutants in
environment.
Getting suitable land is the
problem in many States for
establishment of waste
the responsibility to provide
land by the Department
dealing the allotment of land
would eliminate the issue of
getting land for the waste
management
Facility.
The monitoring of the
implementation was earlier
only with SPCBs and review
District Committee is likely to
improve the implementations.
Page | 83
 Secretaries and CPCB.SPCBs
State Government shall
constitute District Level
Monitoring Committee under
the chairmanship of District
Collector or District
Magistrate or Deputy
Commissioner or Additional
District Magistrate to monitor
the compliance of the
provisions of these rules in the
health care facilities.
The District Level Monitoring
Committee shall submit its
report once in six months to
the State Advisory
Committee, State Pollution
Control Board for taking
further necessary action.
The District Level Monitoring
Committee shall comprise of
District Medical Officer or
District Health Officer,
representatives from SPCB,
Public Health Engineering
Department, local bodies or
municipal corporation,
Indian Medical Association,
Common bio-medical waste
treatment facility registered
NGO working in the field of
bio-medical waste
management.
District Medical Officer shall
be the Member Secretary of
this
Committee.

Various communicable diseases, which spread through water, sweat, blood, body fluids and
contaminated organs, are important to be prevented. The Bio Medical Waste scattered in and
around the hospitals invites flies, insects, rodents, cats and dogs that are responsible for the spread
of communication disease like plague and rabies. Rag pickers in the hospital, sorting out the
garbage are at a risk of getting tetanus and HIV infections. The recycling of disposable syringes,
needles, IV sets and other article like glass bottles without proper sterilization are responsible for
Hepatitis, HIV, and other viral diseases. It becomes primary responsibility of Health administrators
to manage hospital waste in most safe and eco-friendly manner.
The problem of bio-medical waste disposal in the hospitals and other healthcare establishments has
become an issue of increasing concern, prompting hospital administration to seek new ways of
scientific, safe and cost effective management of the waste, and keeping their personnel informed
about the advances in this area. The need of proper hospital waste management system is of prime
importance and is an essential component of quality assurance in hospitals.

Page | 84
Chapter 12
FAQ’s
1) Can I handover the General waste of the hospital to the Municipal authorities?
Yes, we can but only if we have separated it at point of source and it is not contaminated. We
should remember that even food waste can be contaminated. So, if we suspect that any type of
waste is contaminated or infectious, first treat it appropriately – not just routinely but make sure the
waste is actually decontaminated and no longer be a health hazard. Thereafter handover to the
municipal authorities. Normally infectious waste cannot be easily decontaminated within the
healthcare establishment and that is the reason the common facility operator picks up your
infectious waste and transports it in a safe way to an offsite facility and treats and decontaminates
the waste. However, if HCE has on-site facility/facilities to properly decontaminate and treat the
different kinds of wastes generated in HCE, then handover the ‘treated’ hospital waste to the
municipal authorities for secured land filling.

2) Why one has to be concerned about Biomedical Waste?

Hospital waste management is part of hospital sanitation and maintenance activities. General
Hospital hygiene is a prerequisite for good medical waste management. A part of the
Hospital waste is hazardous and may cause a danger to health and life not only to patients and
Staff but also to the community. Hospital personnel and patients within the hospital, the impact on
human health and Environment outside the hospital is also very important.

3) Is it a serious issue?
Yes, the improper handling, treatment and disposal of medical waste lead to serious problems
Like:
the unsegregated and untreated infectious waste (15-20%) will convert the entire non
Infectious general waste (70-80%) into infectious waste.
the disposal of hospital waste in municipal dumpsite leads to cows feeding on the blood
Soaked cotton.
 ineffective disinfection or sterilization during treatment can also cause spread of
Infection amongst hospital, municipal workers and the general public.
increase in incidence and prevalence of diseases like AIDS, Hepatitis B&C,
Tuberculosis and other infectious diseases is due to inappropriate use, storage,
Treatment, transport and disposal of biomedical waste
cats, rats, mosquitoes, flies and stray dog menace

4) Why so much hue and cry about hospital waste? /

The Ministry of Environment and Forests, Govt. of India, has notified the Biomedical
Waste (Management and Handling) Rules 1998 with subsequent amendments (March
6th and June 2nd 2000)

5) Who all come under the purview of the BMW Rules?

Every occupier of an institution generating, collecting, receiving, treating, disposing
And handling biomedical waste, should comply with the rules within the stipulated time.
This includes all clinics, dispensaries, laboratories, blood banks treating more than
1000 patients per month.

Page | 85
6) What are the benefits of waste management?
Waste management leads to cleaner and healthier surroundings
Incidence of nosocomial infections reduces
Cost of infection control within the hospital reduces
Disease and death due to reuse and repackaging of infectious disposables is eliminated
Low incidence of Occupational health hazards
Segregation and appropriate treatment of medical waste reduces cost of waste management and
generates revenue

7) Where should I dispose the segregated and treated waste?

The segregated waste should be treated on site (if the hospital has the provisions) or it has to be
given to a common biomedical waste treatment facility provider.

8) What are the hazards to health care personnel?

Needle stick injuries, cuts and bruises from blades and other sharp instruments in healthcare
establishments can lead to severe infection and death among healthcare personnel.
Infections can also be contracted due to contact with patients, blood, sputum, urine, stools and
other body fluids.
Allergy due to fumes and particulate matter and hazards while administering radioactive and
cytotoxic treatment can also cause disability and death among healthcare workers.

9) What is Needle Stick injury?

Injuries caused by needles are generally known as Needle stick injuries

10) What are Infectious Plastics?

IV tubes / bottles, tubings, gloves, aprons, blood bags / urine bags, drains in disposable plastic
containers, endo-tracheal tubes, microbiology and biotechnology waste and other laboratory waste
in disposable plastics

11) What is cytotoxic waste?

This is the waste generated from the treatment of cancerous cells.

12) How do I minimize waste?

By Source reduction (avoiding wastage), Use of recyclables (e.g. using sterilizable glass ware),
Purchasing policy (purchasing non-PVC healthcare equipment), Segregation at source (separating
biomedical plastics, glass, metal at source for autoclaving & shredding each category separately
before recycling), Stock management (inventorying regularly and replacing IV fluids, blood and
drugs so that there is no wastage due to spoilage)

13) How do I treat the Wastes with Multiple characteristics?

There are some wastes with multiple characteristics that fall into more than one category e.g.
‘Radioactive sharps’, ‘plastic IV tubes with cytotoxics’. They need to be managed with caution.
These wastes should be treated first for the hazardous waste component, and once the hazard is
removed, then it can be treated as infectious metal sharps, glass, plastic, pathological etc., and
treated accordingly.

14) What happens if Plastics are dumped in an Incinerator?

Plastics, especially chlorinated plastics, when incinerated at low temperature release toxic
carcinogenic gases like Dioxins and Furans.

Page | 86
15) Apart from the segregating and disposing aspects, do I have to maintain any Records?
1. An Annual Report has to be submitted to the State Pollution control board by 31st Jan every
year, to include the categories of waste and their quantification. So this involves daily
quantification of waste. The Air and Water Consent forms should also be filed.
2. Every authorized person has to maintain records related to generation, collection, reception,
storage, transportation, treatment, disposal and/or any form of handling of biomedical waste, and be
subject to inspection and verification at any time.
3. If any accident occurs at any institution or the site, the authorized person shall forthwith record
in the stipulated form.
4. Payment of Authorization fee

16) What is Authorisation fee?

This is for grant of authorization for generating waste, which has to be treated later.
The Authorisation is granted for a period of 3 years, or the case may be, including an initial trial
period of one year from the date of issue by the State Pollution Control boards.

17) Who is prescribed Authority?

The State Pollution Control Board is the Prescribed Authority (in case of states) and Pollution
Control Committee (in case of Union territory).

18) Should I use a plastic liner?

Yes, if it is infectious waste, the general waste could be disposed in cardboard boxes.

19) How do I dispose Sharps?

Sharps should be contained in a Sharps pit, or could be encapsulated in Plaster of Paris, Concrete
etc.

20) Hospital waste management - who’s responsibility is it anyway - doctors? Nurses?

cleaning staff?
It is a collective initiative and shared responsibility of all viz., doctors, and nurses, cleaning staff,
all employees and administrators.

21) what about Radioactive waste?

Radioactive waste from medical establishments may be stored under carefully controlled conditions
until the level of radioactivity is so low that they may be treated as other waste. Special care is
needed when old equipment containing radioactive source is being discarded. An expert advice
should be taken into account.

22) What about mercury control in Health care facilities?

The solid wastes containing Mercury due to breakage of thermometer, pressure and other
measuring equipment in HCUs need to be given proper attention not only in respect of the
collection of the spilled mercury, its storage and sending of the same back to the manufacturers, but
also taking of all measures to ensure that the spilled mercury does not become part of biomedical
wastes or other solid wastes generated from HCUs. As per Schedule -2 of Hazardous Waste
(management & Handling)Rules, 2003, any waste containing equal to or more than 50 ppm of
mercury is a hazardous waste and the concerned generators of the wastes including the HCUs are
required to dispose the waste as per the HW Rules.
23) The importance of medical waste bins in hospitals
A lot has been said over the years regarding the health and hygiene in hospitals, but one thing that
is over looked time and again is hospital-acquired infections. As such, one of the most important
tools in hospital hygiene is hospital bins.

Page | 87
Medical waste is unwanted biological products that are highly infectious in nature. It has to be
disposed properly otherwise it poses a health and environmental danger. Medical waste is found in
hospitals, laboratories, research centers, tattoo parlors, etc. Medical waste is broadly classified as
infectious waste and bio hazardous waste, and can easily spread any disease virally and can even
pose a danger to life.
Hospital bins are a great source of dirt that gets accumulated over a period of time if not emptied
timeously. They house a great deal of waste that can contain bacteria, which may further reduce the
levels of hygiene in patients. They also contain bodily fluids and other waste products that, if
stringent measures are not followed, will cause numerous problems for staff and patients.
The management of medical waste in developing countries poses a major health problem, inviting
serious health implications. When visiting health care facilities, patients should not become more ill
then they already are, hence it is vitally important to ensure patient safety by keeping the health
Centre clean and environmentally sound. Waste collection service providers also have to be looked
at meticulously.
Illegal disposal
In many instances of illegal disposal, medical waste is mixed with the municipal waste and a
percentage is buried without any measure or burned with no proper regulation. Public awareness of
health care waste has grown in recent years, especially with the emergence of Aids. In addition, the
possibility that health care wastes could transmit HIV, hepatitis B virus (HBV) and other agents
associated with blood-borne diseases is also a major concern. Therefore, the disposal of health care
waste and its potential health impact are an important public health issue.
Waste threats and disposal
Effective medical waste disposal is the first and foremost way to prevent unwanted disease and
prevent untoward infection from medical wastes. All staff in any hospital or laboratory is equally
responsible in housekeeping. Good housekeeping can reduce the infection to a great extent. It also
cuts down on the spreading of microorganisms and bacteria. The advantages of proper medical
waste disposal include the creation of a healthy atmosphere that is free from microbes, thus
minimizing the risk of infection to staff, visitors and other people, cutting off unpleasant sights and
bad odors, and the reduction of fleas and insects.
Most staff is not aware of the risks involved when handling medical waste and the related
infections. Sharp objects, such as used needles, pose serious risk of infections like HIV, HBV, etc.
If medical waste is not properly disposed by staff, then infection may easily spread to patients and
other clients who visit hospital and laboratories. Moreover, while disposing of medical waste, it
must be done cautiously without polluting the environment. In an ideal world, staff disposing of
medical waste must be well-trained and must be observed by a supervisor. In addition, every
hospital must follow the segregation guidelines.
Bin varieties
Some hospitals have installed fire retardant bins in many places that are required by the rules of
safety and hygiene. The safety of the patients is crucial to hospitals, making these bins very
important in areas where patients’ health and safety is at risk. Hygiene should be a top focus in
places where health care is of primary importance. These bins are not only retarding the fire, but
also have antibacterial and microbial properties, which help ensure that the bin is not responsible
for spreading any kind of disease or infection.
There are many medical waste bins, community waste bins and waste collection bins in hospitals
that are colour-coded and are available in different areas throughout the health care facility. This
helps prevent any kind of contaminated diseases making its way to a conventional landfilling
during the collection process. There are also simple sack holder bins that have pedals or even
sensors to prevent mishandling of the bin. Mishandling of bins is a serious issue as this is where
most transfer of infections occurs.

Page | 88
 When installing the medical waste bins, litterbins and waste collection bins, another important
factor to consider is size. All bins should ideally be roughly the same size. If one type of bin is
filled before another, then there is an increased chance that people will fill the wrong bins with the
wrong products – and may lead to improper disposal methods thereof. The hospital bin is a very
important tool that helps ensure that health care facilities remain hygienic for a long period, and it
is ultimately the responsibility of the authorities in question to take care of this fact.
24) Difference between anatomical and non-anatomical waste?
(1) human anatomical waste consisting of body parts or organs, but excluding teeth, hair, nails, blood
and biological liquids;
(2) animal anatomical waste consisting of carcasses, body parts or organs, but excluding teeth, hair,
claws, feathers, blood and biological liquids;
(3) Non-anatomical waste consisting of any of the following:
(a) a sharp or breakable object having been in contact with blood or with a biological liquid or tissue
and having been used in medical, dental or veterinary care or in a medical or veterinary biology
laboratory, or such an object used in embalming;
(b) Biological tissue, cell culture, microbial culture, or material in contact with such tissue or culture,
used in a medical or veterinary biology laboratory;
(c) Live vaccine;
(d) A blood container or material that has been saturated with blood and used in medical care, in a
medical biology laboratory or in embalming;

CONCLUSION
Medical wastes should be classified according to their source, typology and risk factors associated
with their handling, storage and ultimate disposal. The segregation of waste at source is the key
step and reduction, reuse and recycling should be considered in proper perspectives. We need to
consider innovative and radical measures to clean up the distressing picture of lack of civic concern
on the part of hospitals and slackness in government implementation of bare minimum of rules, as
waste generation particularly biomedical waste imposes increasing direct and indirect costs on
society. The challenge before us, therefore, is to scientifically manage growing quantities of
biomedical waste that go beyond past practices. If we want to protect our environment and health
of community we must sensitize ourselves to this important issue not only in the interest of health
managers but also in the interest of community.

Page | 89
References
 Govt. of India, "Bio-medical waste (management and handling) rules". The gazette of India.
Ministry of Environment and Forest. 1998.
 National guidelines on Hospital waste management. Biomedical waste regulations. 1998.
 J. Int. Environmental Application & Science, Vol. 4 (1): 65-78 (2009) Management of
Biomedical Waste in India and Other Countries: A Review By B. Ramesh Babu, A.K. Parande, R.
Rajalakshmi, P. Suriyakala, M. Volga Central Electrochemical Research Institute, Karaikudi–
630006, Tamilnadu, India
 Parag Dalai, International Journal of Advanced Researeh,2013, Volume 1, Issue 2, 52-58, Guest
Faculty Ujjain Engineering College, Ujjain.
 Biomedical Waste Management A Step Towards A Healthy Future KAMLESH TEWARY,
VIJAY KUMAR, PAMIT TIWARY
 BIOMEDICAL WASTE MANAGEMENT by Facilitator: Dr. NAVPREET Assistant
Professor, Department of Community Medicine Govt. Medical College & Hospital, Chandigarh
 Need of Biomedical Waste Management System in Hospitals - An Emerging issue - A
Review Vol. 7(1), 117-124 (2012) PRAVEEN MATHUR, SANGEETA PATAN* and ANAND
S. SHOBHAWAT Department of Environmental Science, MDS University Ajmer - 305 009
(India).
 Press Information Bureau Government of India Ministry of Environment and Forests
 The importance of medical waste bins in hospitals posted by SMedia on July 12, 2012 in
Medical waste, News, Waste
 Need of Biomedical Waste Management System in Hospitals – An Emerging issue – A Review
PRAVEEN MATHUR, SANGEETA PATAN and ANAND S. SHOBHAWAT Department of
Environmental Science, MDS University Ajmer.
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3430187/
 8 See http://www.corporatecitizen.nhs.uk/casestudies.php/15/cardiff-and-vale-nhs-trust-
environmental-management-system

Page | 90
Page | 91
Page | 92