disposal of clinical wastes: tata memorial hospital experience dr rohini kelkar m.d., d.p.b....
TRANSCRIPT
Disposal of Clinical Wastes: Tata Memorial Hospital Experience
Dr Rohini Kelkar M.D., D.P.B.
Professor & Head, Dept of MicrobiologyTata Memorial Hospital, Mumbai
“No one was ever really
taught.
Each has to teach himself.”
Swami Vivekananda
The Reality• Ignorance• Commercialization of
science• Apathy
The Concerns• Occupational• Public health• Environmental
• The only documented risk of transmission of infections from waste to healthcare workers is through sharps
• There is however a potential for transmission of several microbial infections due to dumping of untreated wastes by healthcare facilities.
• Mixing of a small quantity of infectious waste with municipal garbage converts the entire waste to “ infectious”
• Segregation of wastes at source followed by appropriate treatment is the key to the success of a waste management strategy
The Science
Hospital waste
Hazardous Non-hazardous
Noninfectious Infectious
Kitchen Recyclables
Non-sharps
Patient contaminated waste
Anatomical
Equipment
Specimens
Laboratory waste
Non-plastics
Sharps: needles, scalpel blades, scalp veins, glass contaminated with blood
Radioactive
Cytotoxic drugs
Toxic Chemicals
Plastics
PVC, PE PET, PS contaminated cotton waste, gauze, linen
The Social Issue: Ragpickers
The TMH Pathway
• Closure of the incinerator
• Awareness programs for all the staff
• Refashioning the storage area
• Street play
• Posters
Incinerator circa 1994
1. CLEARLY DEFINE THE PROBLEM
Appropriate placement of Colour Coded Bins
Radioactive Waste
Segregation at source into defined categories using a simplified system.
2. FOCUS ON SEGREGATION FIRST
Sharps Disposal
3. INSTITUTE A SHARPS MANAGEMENT SYSTEM
Waste Audit
4. KEEP FOCUS ON REDUCTION
About Sharps:The only documented transmission of infection from waste to HCWs is through sharp injuries. Thus safe disposal of sharps is the first priority.
Sharp injuries: • Before or during use (17%)• After Use but before disposal (70%)• During or after disposal (13%) (Our Experience: Majority of sharp injuries occur due to improper disposal and waste handlers are the victims)
Safe Disposal of Sharps:
Do not recap needles.
If essential learn the right way to do so.
5. ENSURE WORKER SAFETY THROUGH EDUCATION, TRAINING AND PROPER PERSONAL PROTECTIVE EQUIPMENT
Collection network.
.6. PROVIDE SECURE COLLECTION AND TRANSPORTATION
Waste management Strategy:1. Reduce Risks and Liabilities: This should be detailed through written
policies and continuing training and education of hospital staff.
2. Control Costs: Audit of current practices, search for waste minimization practices is a continuing process.
3. Plan for Future: Look for alternative technologies, co-operative facilities and means of diversification.
4. Commitment towards protecting Human Health and the Environment
7. DEVELOP PLANS AND POLICIES
Infection Awareness
Week
Infection Awareness
Week
Street Play8. I
NVEST IN TRAIN
ING
9. DEVELOP THE INFRASTRUCTURE
10. Evaluation of Technologies
Evaluation of Non Burn Technologies for Medical Waste Treatment
Evaluation of Non Burn Technologies for Medical Waste Treatment
1. Demonstrated Performance1. Demonstrated Performance
Category Rating Weight Score
1.1 Stage of Development
1.2 Number of Operational Systems
1.3 Year of Successful Operations
2. Technical & Performance Criteria2. Technical & Performance Criteria
Category Rating Weight Score
2.1 Process Capacity
2.2 Waste Exclusions or Limitations
2.3 Waste Size Limitations
2.4 Weight Change
2.5 Volume Change
2.6 Recognizability / Disfigurement
2.7 Decontamination
2.8 Performance Data
2.9 Process Complexity
2.10 Operator Training
3. Vendor Qualifications 3. Vendor Qualifications
Category Rating Weight Score
3.1 Number of Vendors
3.2 Vendor Resources
3.3 Vendor Diversity and Services
4. Environmental & Permitting Issues 4. Environmental & Permitting Issues
Category Rating Weight Score
4.1 Air Emissions
4.2 Liquid Effluents
4.3 Treated Residues
4.4 Permit ability
4.5 Public Perception
5. Occupational Health & Safety Issues
5. Occupational Health & Safety Issues
Category Rating Weight Score
5.1 Routine Exposures
5.2 Maintenance and Repair Exposures
6. Facility: & Infrastructural Requirements
6. Facility: & Infrastructural Requirements
Category Rating Weight Score
6.1 Space Requirements
6.2 Construction Requirements
6.3 Utility Requirements
6.4 Space / Facility Requirements
7. Economics 7. Economics
Category Rating Weight Score
7.1 Capital Costs
7.2 Annual Costs
7.3 Life-Cycle Costs
GRAND TOTAL SCORE
On September 10, 1999, well before the first dead line set by the Ministry of Environment and Forest, 31 December 1999.
Inauguration of Tata Memorial Hospital waste treatment facility
Selection of Technology and Implementation is not the setting sun
Evaluation is a continuous process
2000 2001 2002 2003 2004 2005 2006 2007
Max. medical waste collected in a day
341 394 350 362 396 530 429 514
Average no. of loads required/day
5 4 4 4 4 4 4 4
Average medical waste treated in kgs/day
217 224 176 241 250 289 253 277
Average medical waste collected in a month
5,498 5,643 5,266 5,917 6,284 7,225 6,369 6,959
Percentage down time of the system
1.6 5.7 4.8 5.8 8.2 0 10 1.2
TMH Waste Audit Nov. 1999 to Dec. 2007
Total infectious waste treated – 614 tonnes.
83,511 kg. in 2007. Cost of treatment = Rs. 14.86 / kg.
2008 2009
Max. medical waste collected in a day
447 505
Average no. of loads required/day
4 4
Average medical waste treated in kgs/day
298 304
Average medical waste collected in a month
7,623 7,674
Percentage down time of the system
0 0.33
TMH Infectious Waste Audit 2008 - 2009
Total infectious waste treated 2000-2009= 800 tonnes.
Cost of treatment = Rs. 14 / kg.
TMH Waste Management
Waste is Sterilized, Dehumidified, Shredded and reduced in terms of Weight and Volume by 75%.It is not recognizable as Medical Waste
Hazardous Waste
Environment News
GreenpeaceMarch 7th, 2001
KODAIKANAL, India -- Greenpeace today accused Anglo-Dutch
multinational Unilever, owners of Lipton Tea and Dove soap, of double standards and shameful negligence
for allowing its Indian subsidiary, Hindustan Lever, to dump several
tonnes of highly toxic mercury waste in the densely populated tourist resort
of Kodaikanal and the surrounding protected nature reserve of Pambar Shola, in Tamilnadu, Southern India.
On 15 April, 2005, a 51 year-old
asbestos laden ship, Kong Fredrick IX
was on its way to Alang ship breaking
yard, Gujarat for scrapping.
The ship's new owners Jupiter Ship
Management, a Mumbai based
company, had renamed it to 'MV Riky'.
Connie Hedegaard, Denmark's
environment minister alerted the
Indian environment minister saying,
"I believe our interests are joint - and I
call on you to co-operate in this case
by denying the ship to be dismantled
in India - and refer the ship to return to
Denmark to be stripped of the
hazardous waste."
India’s significant economic growth and rise in industrialization coupled by lax government enforcement of anti-pollution laws and regulations have had a detrimental effect on India’s natural environment.
Hazardous waste from industrial processes, medical waste and India’s thriving scrap recycling businesses pollutes Indian air, soils and waterways.
India is a signatory to the three conventions on hazardous chemicals and waste:
The Basel Convention on the Control of Trans-boundary Movement of Hazardous Waste and their Disposal,
The Rotterdam Convention on the Prior Informed Consent Procedure for Certain Hazardous Chemicals and Pesticides in International Trade and
The Stockholm Convention of Persistent Organic Pollutants.
The Hazardous Substances Management Division (HSM) of the Ministry of Environment and Forests (MoEF) has the responsibility for promoting safe management and use of hazardous substances, including hazardous waste.
The HSM has established three sets of rules:
The Hazardous Wastes (Management and Handling) Rules (1989, amended in 2003),
The Bio-medial Wastes (Management and Handling) Rules (1998/2000), and
The Batteries (Management and Handling) Rules (2001).
The HSM relies primarily on the
The Central Pollution Control Board (CPCB),
The State Pollution Control Boards (SPCBs) or State Pollution Control Committees (SPCCs), and
The environmental departments in India’s 25 states
to implement, monitor and prosecute.
Approximately 5 million tonnes of hazardous waste is produced annually in India.
According to a 2003 report, Indian industries in the following five states had generated over 80% of the country’s hazardous waste:
Andhra Pradesh,
Gujarat,
Karnataka,
Maharashtra and
Tamil Nadu.
Landfill Composting Incineration Recycling Transportation
Air Emission of CH4, CO2; odours
Emission of CH4, CO2; odours
Emission of SO2, NOx, HCl, HF, NMVOC, CO, CO2 N2O, dioxins, dibenzofurans, heavy metals(Zn, Pb, Cu, As)
Emissions of dust
Emissions of dust NOx, SO2, release of hazardous substances from accidental spills
Water Leaching of salts, heavy metals, biodegradable and persistent organics to groundwater
Deposition of hazardous substances on surface water
Waste water discharges
Risk of surface water and groundwater contamination from accidental spills
Soil Accumulation of hazardous substances in soil
Landfilling of slags, fly ash and scrap
Landfilling of final residues
Risk of soil contamination from accidental spills
European Commission focus on waste management
Pitfalls of the currently available technologies for managing wastes
Landfill Composting Incineration Recycling Transportation
Landscape Soil occupancy; restriction on other land uses
Soil occupancy; restriction on other land uses
Visual intrusion; restriction on other land uses
Visual intrusion
Traffic
Ecosystems Contamination and accumulation of toxic substances in the food chain
Contamination and accumulation of toxic substances in the food chain
Contamination and accumulation of toxic substances in the food chain
Risk of contamination from accidental spills
Urban areas Exposure to hazardous substances
Exposure to hazardous substances
Noise Risk of exposure to hazardous substances from accidental spills; traffic
European Commission focus on waste management
Pitfalls of the currently available technologies for managing wastes
E-wasteHow green is your Apple?
Aug 25th 2006From The Economist print edition
God proposes, man disposes Waste and taste
Dec 11th 2006
From Economist.com
The rubbish tip as cultural artefact
FRESH Kills landfill in New York, until
recently the biggest rubbish tip on earth,
was said to be one of the very few man-
made objects visible from space, along
with the Great Wall of China.
LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS
Class AConcentration limit: 50 mg/kgA1 Antimony and antimony compoundsA2 Arsenic and arsenic compoundsA3 beryllium and cadmium compoundsA4 Cadmium and beryllium compoundsA5 Chromium (VI) compoundsA6 Mercury and mercury compoundsA7 Selenium and selenium compoundsA8 Tellurium and tellurium compoundsA9 Thallium and thallium compoundsA10 Inorganic cyanide compounds (cyanides)A11 Metal carbonylsA12 NapthaleneA13 AnthraceneA14 PhenanthreneA15 Chrysene, benzo(a) anthracene, fluoranthene, benzo(a) pyrene, benzo(K)fluoranthene, indeno(1, 2, 3-ed) pyrene and benzo(ghi)peryleneA16 Halogenated fused aromatic rings, e.g. polychlorobiphenyls plus derivativesA17 Halogenated aromatic compoundsA18 BenzeneA19 Dieldrin, aldrin, and endrinA20 Organotin compounds
Ministry of Environment & Forests:Hazardous Wastes (Management and Handling) Amendment Rules, 2002
LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS
Ministry of Environment & Forests:Hazardous Wastes (Management and Handling) Amendment Rules, 2002
Class B
Concentration limit: 5,000 mg/kgB1 Chromium (III) compoundsB2 Cobalt compoundsB3 Copper compoundsB4 Lead and lead compoundsB5 Molybdenum compoundsB6 Nickel compoundsB7 Tin compoundsB8 Vanadium compoundsB9 Tungsten compoundsB10 Silver compoundsB11 Organic halogen compoundsB12 Organic phosphorus compoundsB13 Organic peroxidesB14 Organic nitro-and nitroso-compoundsB15 Organic azo-and azo-oxy compoundsB16 NitrilesB17 AminesB18 (Iso-and thio-) cyanatesB19 Phenol and phenolic compoundsB20 MerceptansB21 AsbestosB22 Drilling, cutting, grinding and rolling oil or emulsions thereofB23 Halogen-silanesB24 Hydrazine(s)B25 FluorineB26 ChlorineB27 BromineB28 White phosphorusB29 Ferro-silicon and alloysB30 Manganese-siliconB31 Halogen-containing substances which produce acidic vapours on contact with damp air or water, e.g. silicon tetrachloride, aluminum chloride, titanium tetrachloride
LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS
Ministry of Environment & Forests:Hazardous Wastes (Management and Handling) Amendment Rules, 2002
Class C Concentration limit: 20,000 mg/kg
C1 Ammonia and ammonium compoundsC2 Inorganic peroxidesC3 Barium compounds, except barium sulphateC4 Fluorine compoundsC5 Phosphorus compounds, except the phosphates of aluminum, calcium and ironC6 Bromates, (hypo)bromitesC7 Chlorates, (hypo)chloritesC8 Aromatic compoundsC9 Organic silicon compoundsC10 Organic sulphur compoundsC11 IodatesC12 Nitrates, nitritesC13 SulphidesC14 Zinc compoundsC15 Salts of per-acidsC16 Acid halides, acid amidesC17 Acid anhydrides
LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS
Ministry of Environment & Forests:Hazardous Wastes (Management and Handling) Amendment Rules, 2002
Class D
Concentration limit: 50,000 mg/kgD1 SulphurD2 Inorganic acidsD3 Metal bisulphatesD4 Oxides and hydroxides except those of: hydrogen, carbon, silicon, iron, aluminum, titanium, manganese, magnesium, calciumD5 Aliphatic and napthenic hydrocarbonsD6 Organic oxygen compoundsD7 Organic nitrogen compoundsD8 NitridesD9 Hydrides
LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS
Ministry of Environment & Forests:Hazardous Wastes (Management and Handling) Amendment Rules, 2002Class E
Regardless of concentration limit
E.1 Highly flammable substancesE.2 Substances which generate dangerous quantities of highly flammbale gases on contact with water or damp air.
LIST OF PROCESSES GENERATING HAZARDOUS WASTES
Ministry of Environment & ForestsHazardous Wastes (Management and Handling) Amendment Rules, 2003
1 Petrochemical processes and pyrolytic operations
2 Drilling operation for oil and gas production
3 Cleaning, emptying and maintenance of petroleum oil storage tanks including ships
4 Petroleum refining/re-refining of used oil/recycling of waste oil
5Industrial operations using mineral/synthetic oil as lubricant in hydraulic systems or other applications
6 Secondary production and/or use of zinc
7Primary production of zinc/lead/copper and other non-ferrous metals except aluminium
8 Secondary production of copper
9 Secondary production of lead
10 Production and/or use of cadmium and arsenic and their compounds
11 Production of primary and secondary aluminium
LIST OF PROCESSES GENERATING HAZARDOUS WASTES
Ministry of Environment & ForestsHazardous Wastes (Management and Handling) Amendment Rules, 2003
12Metal surface treatment, such as etching, staining, polishing, galvanising, cleaning, degreasing, plating, etc.
13Production of iron and steel including other ferrous alloys (electric furnaces; steel rolling and finishing mills; Coke oven and by product plant)
14 Hardening of steel
15 Production of asbestos or asbestos-containing materials
16 Production of caustic soda and chlorine
17 Production of acids
18 Production of nitrogenous and complex fertilizers
19 Production of phenol
20 Production and/or industrial use of solvents
21Production and/or industrial use of paints, pigments, lacquers, varnishes, plastics and inks
22 Production of plastic raw materials
LIST OF PROCESSES GENERATING HAZARDOUS WASTES
Ministry of Environment & ForestsHazardous Wastes (Management and Handling) Amendment Rules, 2003
23 Production and/or industrial use of glues, cements, adhesive and resins
24 Production of canvas and textiles
25 Industrial production and formulation of wood preservatives
26 Production or industrial use of synthetic dyes, dye-intermediates and pigments
27 Production or industrial use of materials made with organo-silicone compounds
28 Production/formulation of drugs/ pharmaceuticals
29 Production, use and formulation of pesticides including stock-piles
30 Leather tanneries
31 Electronic Industry
32 Pulp & Paper Industry
33 Disposal of barrels / containers used for handling of hazardous wastes / chemicals
34 Purification processes for air and water
35 Purification process for organic compounds/solvents
36Waste treatment processes, e.g. incineration, distillation, separation and concentration techniques
REPORT ON CLINICAL WASTE AUDIT 2005
Infectious waste treated from Jan-Dec 2005 86,704 Kilograms
Average waste treated per month 7,225 Kilograms
Weight of sharps treated in 2005 2,917 Kilograms
Average weight of sharps treated per month 243 Kilograms
Blood & blood products 300 liters
Liquid Wastes:
Total effluent per month 164 lakh litres
Laundry effluent per month 3 lakh litres
X’ray developer per month 140 litres
Hazardous liquids consumed in labs per month 588 litres
Hazardous chemicals as solids weight per month 260 grams
Dilution factor of hazardous liquids 27,333.
Hazardous liquid waste / month:
Sr. No Chemicals / Reagents Lits.
1 10% Formalin 100
2 Xylene 190.1
3 Basic fuchsin 1.17
4 Haematoxylin stain 1.0
5 Nitric Acid 50.5
6 Anhydrous Aluminum Chloride
.005
7 Hydrochloric acid .800
8 Diamino benzidine 20.0
9 Hydrogen peroxide 53.202
10 Glacial acetic acid 5.225
11 Gluteraldehyde 150.500
12 Ethidium bromide .001
13 Propane / Butane 2.500
14 WD40 (Petroleum distillate) 2.00
15 Benzoin tincture 10.00
16 Lugol’s Iodine 0.42
17 Phenol (carbolic acid) 1.000
18 Ammonia solution .050
19 Lactic acid .045
20 Sulfuric acid .100
Total 588.19
Hazardous solid waste / month:
Sr. No Chemicals / Reagents Weight (Grams)
1 Benzidine dihydrochloride 0.5
2 Naphthol phosphate .060
3 Pararosaline hydrochloride 1.0
4 Sodium-fluoride .200
5 Potassium dihydrogen phosphate 8.500
6 Dipotassium hydrogen phosphate 8.500
7 Benzidine G.R. 1.0
8 Zine sulphate 16.5
9 Barium chloride 13.00
10 Phenol crystals 40.00
11 Naphthylamine 16.50
12 Naphthol 16.50
13 Sodium-polyanethol sulphonat 45.00
14 Sodium hydroxide pellet 45.00
15 Sulfonilic acid 45.00
16 Trichloroacetic acid 2.1
Total 259.36
In Conclusion: Key Issues
• Awareness and education
• Reporting systems & documentation
• Segregation of identified clinical infectious wastes at source
• Timely treatment by non-polluting technologies on-site or off-site
• Waste audit
• Waste monitoring systems
• Elevation of safety standards by all healthcare facilities
• All HCWs must have “hygiene in their genes”.
“ Men occasionally stumble over the truth but most of them pick themselves up and hurry off as if nothing has happened.”
- Sir Winston Churchill.
Thank You