JAMIA MILLIA ISLAMIA UNIVERSITY, NEW DELHI

Submission of PROJECT

Environmental law

Topic: “Management of Bio-medical wastes and their safe disposal”

SUBMITTED TO: SUBMITTED BY

Prof. Manjula Batra Nishi Jabeen

(Jamia Millia Islamia) Semester 6th

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ACKNOWLEDGEMENT

I would like to thank my teacher, Prof. Batra for providing me with such

an opportunity to work on such a challenging topic. I thank her for the

guidance and blessings and imparting me with her vast knowledge on this

subject. I extend my thanks for providing me with the platform and

means with which I could, without any difficulty complete this

assignment. I would take this opportunity to thank all my friends who

have helped me in various ways.

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Medical Waste Disposal and the Law

1. INTRODUCTION

Hospital is one of the complex institutions which are frequented by people from every walk of life in the society without any distinction between age, sex, race and religion. This is over and above the normal inhabitants of hospital i.e patients and staff. All of them produce waste which is increasing in its amount and type due to advances in scientific knowledge and is creating its impact. The hospital waste, in addition to the risk for patients and personnel who handle these wastes poses a threat to public health and environment

2. DEFINITIONAny solid waste or liquid, which may present a threat of infection to humans. The terms include, but are not limited to, non-liquid human tissue and body parts, discarded sharps, human blood, human blood products, laboratory waste that contains human disease-causing agents and body fluids. The following are also included: 

Used, absorbent material saturated with blood, body fluids, or excretions contaminated with blood and absorbent materials saturated with blood or blood

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products that have dried. Absorbent materials include items such as bandages, gauze and sponges.

Non-absorbent disposable devices that have been contaminated with blood, body fluids or blood contaminated secretions or excretions and have been sterilized or disinfected by an approved method.

Other contaminated solid waste materials which represent a significant risk of infections because they are generated in medical facilities which care for persons suffering from diseases requiring isolation criteria and listed by the U.S. Department of Health and Human Services, Centers for Disease Control, “CDC Guideline for Isolation Precautions in Hospital”, July/August 1983.

Any disposable needles (syringe and suturing types), disposable blades and glass items which have come in contact with blood in a veterinary facility. Easily shattered plastics (such as clear acrylics), which have come in contact with blood in a veterinary facility, are also included.

 Body Fluids Those fluids which have the potential to

harbor pathogens such as human

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immunodeficiency virus and hepatitis B virus and include lymph, semen, vaginal secretions, cerebrospinal synovial, pleural, pericardial and amniotic fluids. Body excretions, such as nasal discharges, saliva, sweat, tears, urine and vomitus shall not be treated as biomedical waste unless visibly contaminated with blood.

 Sharps Devices with physical characteristics capable of

puncturing, lacerating, or otherwise penetrating the skin and are contaminated. All needles whether contaminated or not are considered biomedical waste.

3. Background

Biomedical waste has become a serious health hazard in many countries, including India. Careless and indiscriminate disposal of this waste by healthcare establishments and research institutions can contribute to the spread of serious diseases such as hepatitis and AIDS (HIV) among those who handle it and also among the general public.

Biomedical waste is generated during diagnosis, treatment and immunization processes in healthcare establishments. It includes waste such as sharps, human tissue or body parts

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and other infectious materials. These wastes are potentially hazardous/infectious and their indiscriminate and unscientific management poses serious threats to human health. Hospitals and other healthcare establishments in India produce a significant quantity of waste, posing serious problems for its disposal, an issue that has received scant attention. The major problem arises when the hospital refuse is dumped in the open and is mingled with domestic waste leading to various types of hazards. The exposure to infectious and hazardous hospital waste can cause serious health problems to those who handle it, particularly to waste collectors or rag pickers and the environment. This can also become a source of many communicable diseases.

Healthcare wastes are categorized as infectious and non-infectious. Infectious waste includes human tissue, body fluids, excreta, articles such as urine containers, sharp-edged and glass pieces, many of which may be contaminated. Of major concern is the transmission of AIDS/HIV, and also hepatitis B and C, through injuries and infection of the personnel who handle these waste materials, and furthermore, there is a serious risk to public health arising from the transport of infectious and hazards waste. Non-infectious wastes are generated from laboratory work and waste from surgery and autopsies on patients with infectious diseases. A second category of clinical waste

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includes drugs that have become outdated or contaminated. The hospital refuse can also become harmful when reusable items find their way back to the hospital and ultimately to the patients.

It is important to note that not all hospital waste has the potential to transmit infection. It is estimated that 80–85% is non-infectious general waste, 10% is infectious and 5% is other hazardous waste (CPCB 2000). However, if the infectious component gets mixed with the general non-infectious waste, the entire bulk of hospital waste potentially becomes infectious. Improper disposal practices of hospital waste affects the people who come in direct contact with it. Waste piles also attract a variety of disease vectors, including mosquitoes and flies. Thus, improper waste management practices are a serious problem that involve not only to the hospital administration but society at large.

4. PRESENT PRACTICES IN HANDLING SHARPS

Each year, an estimated 16 billion injections, both preventive as well as curative, are administered worldwide. This amounts to almost 44 million injections per day out of which 95% are therapeutic in nature. For 20 therapeutic injections given, one vaccination is administered. Injections are prescribed for a wide variety of reasons. Injections are

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certainly essential to administer vaccines and for many types of treatment, but many injections are also given for questionable reasons. An immediate action to reduce the amount of sharps wastes is to reduce the number of unnecessary injections. Unsafe injections are reported to have the potency of transmitting infections from patient to patient, patient to health workers and, more rarely, from health workers to patients and to the community at large. Sharps from immunization injections are found to be unsafe with almost 30% of the sharps being either re-used or recycled as documented by WHO (WHO Bulletin, October 19992).

Realizing the problems associated with re-usables, and to ensure safety in immunization programmes, WHO, UNICEF and UNFPA issued a joint statement in 1999 on the need for use of auto-disable (AD) syringes and safety boxes to contain them in immunization campaigns3. The joint statement urged that by the end of 2003, all countries should use only auto-disable syringes for immunizations. Working towards that goal, all partners decided to finance not only the vaccine but also safe administration devices and disposal units and support related training, supervision and sensitization activities to ensure safe vaccinations.

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The major challenge associated with the use of AD syringes is the volume of waste that will be generated in the process, and its management.

The absence of a sound health care waste management system, the risks linked to re-use of waste sharps from immunization waste and the environmental impact of improper disposal are major concerns. There is thus an urgent need to find solutions.The growing use of non AD disposable syringes increases the quantity of waste generated in the rural settings and, due to their lucrative resale value in the market, the problem is magnified. With India’s growing urbanization, rural settings are becoming semi-urbanized and would soon encounter the problem faced in urban areas. The focus of the present study, accordingly, is to find solutions for urban areas.

5. SITUATION IN INDIA

Most countries of the world, especially the developing ones, are facing the grim situation arising out of environmental pollution due to pathological wastes. The origin lies in increasing population with consequent rapid growth in the number of health centres. India is no exception to this and it is estimated that there are more than 15,000 small and private hospitals and nursing homes in the country. This is apart from clinics and pathological labs which also generate

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sizeable amount of medical waste, thanks to the introduction of modern medical practices and disposable devices. India generates around three million tonnes of medical wastes every year and the amount is expected to grow at eight per cent annually. Creating large dumping grounds and incinerators is the first step and some progressive states such as Maharashtra, Karnataka and Tamil Nadu are making efforts despite opposition.

In recent time there is an increasing concern about the harmful effects of biomedical waste generated by health care facilities. General public, law enforcement agencies of the Government, the media, and also the social activists are continuously focusing on the lack of concentrated effort in management of biomedical waste in our country. Seminars, symposia and conferences are also being held by hospital administrators, clinicians and nursing professionals to update the knowledge and understanding on the issues. The waste management in the hospitals and health care establishments is being closely monitored by agencies like State Pollution Control Boards and licensing authorities of health care establishments and also by judiciary for the effective implementation of its directive.

Managing and handling bio-medical wastes is proving to be one of the most contentious issues facing health authorities in India. Negligence in medical waste disposal is creating a

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potential public health hazard and contributing to environmental and socio-economic problems. Two years have passed after the Ministry of Environment and Forests (MoE&F) drafted the Bio-Medical Waste (Management and Handling) Rules following a Supreme Court ruling. But, so far, none of the state governments have shown an inclination to strictly and effectively implement the Rules. Large corporate hospitals in many states have been proactive and have applied for authorisation with state pollution control boards. Some of these hospitals have in-house incineration facilities to dispose medical waste. However, it is the majority of state-owned hospitals which are yet to be authorised.

In developed countries, legislation and good practice guidelines define medical waste and state the various possible ways for collection, transport, storage and disposal of such wastes. Furthermore, the best available technologies are used for the development of alternatives for proper disposal of medical waste with minimal risks to human health and the environment. In developing countries such as India, however, medical waste materials have not received sufficient attention.

The ‘Biomedical Waste (Management and Handling) Rules, 1998’ (The Gazette of India 1998) ratified under the

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Environmental Protection Act 1986 is a very important piece of legislation for the management of hospital waste. In accordance with ‘Biomedical Waste (Management and Handling) Rules’, biomedical waste has to be stored separately from other waste and is classified into ten different categories, each of which has a designated method of treatment. The treatment methods are incineration, autoclaving, microwaving, chemical treatment, deep burial and disposal in a secure landfill (or combinations of these methods). The occupier of the healthcare facility is responsible for segregation, collection and the proper disposal of biomedical waste.

The Ministry of Environment & Forests notified the Biomedical Waste (management & handling) Rules, 1998" (BMW Mgt) in July 1998. In accordance with the rules, every hospital generating BMW needs to set up requisite BMW treatment facilities on site or ensure requisite treatment of waste at common treatment facility. No untreated BMW shall be kept stored beyond a period of 48 hours. The cost of construction, operation and maintenance of system for managing BMW represents a significant part of overall budget of a hospital if the BMW rules have to be implemented in their true spirit. Two types of costs are required to be incurred by hospitals for BMW Mgt, internal and external. Internal cost is the cost for segregation,

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mutilation, disinfection, internal storage and transportation including hidden cost of protective equipment. External costs are off site transportation, treatment and final disposal.

6. BIOMEDICAL WASTE MANAGEMENT PROCESS

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Handling, segregation, mutilation, disinfection, storage, transportation and final disposal are vital steps for safe and scientific management of biomedial waste in any establishment. The key to minimisation and effective management of biomedical waste is segregation (separation) and identification of the waste. The most appropriate way of identifying the categories of biomedical waste is by sorting the waste into colour coded plastic bags or containers. Biomedical waste incineration, autoclave, hydroclave or microwave.7. COST OF BIOMEDICAL WASTE MANAGEMENTThe cost of construction, operation and maintenance of system for managing biomedical waste represents a significant part of overall budget of a hospital if the BMW handling rules 1998 have to be implemented in their true spirit. Govt of India in its pilot project for hospital waste management in Govt hospitals has estimated Rs.85 lakh as capital cost in 1000 bedded super speciality teaching hospital which includes on site final disposal of BMW. Two types of costs are required to be incurred by hospitals for BMW mgt, internal and external. Internal cost is the cost for segregation, mutilation, disinfection, internal storage and transportation including hidden cost of protective equipment. External cost involves off site transport of waste, treatment and final disposal.

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8. REGULATORY FRAMEWORK IN INDIAA Report on Alternative Treatment and Non-Burn Disposal Practices nominated State Pollution Control Boards or the department of health as the prescribed authority. However, since the work involved a lot of technical intervention like monitoring the air emission from the incinerators, monitoring of the waste water effluent etc. eventually it was felt that pollution control departments would be appropriate as the prescribed authority and an amendment (Second Amendments to the Rules, June 2000) was made to this effect.

The fact that the Ministry of Family Health and Welfare was not as actively involved in determining the BMW Rules, as was the Ministry of Environment, explains, to some extent, some of the difficulties in implementing the Rules at the level of health care facilities.

9. SALIENT FEATURES OF THE BIO-MEDICAL WASTE (MANAGEMENT AND HANDLING) RULES, 1998

The rules apply to all persons who generate, collect, receive, transport, treat, dispose, store, or handle bio-medical waste in any form.

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It is the duty of the occupier, where required to set up requisite bio-medical waste treatment facilities like incinerator, autoclave, microwave for treatment of waste, or ensure requisite treatment of waste at a common waste treatment facility.

Bio-medical waste is to be treated and disposed in accordance with ScheduleI

Bio-medical waste has to be segregated at the point of generation in accordance with schedule II before its storage, transportation, treatment and disposal. The containers are to be labeled as per Schedule III.No untreated bio-medical waste can be kept beyond a period of 48 hours.

9.1 Prescribed Authority:

The State Pollution Control Boards have been nominated as the Prescribed Authority for granting authorization and implementing the rules. (As per the second amendment, June 2000).

8.2 Authorization:

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Every occupier, except those providing treatment /service to less than1000 patients a month, and every operator of a bio-medical waste facility, needs to take authorization from a prescribed authority.

8.3 Advisory Committee:

The Government of every State/Union territory has to constitute an advisory committee. The committee will include experts from medical and health fields, from the municipal department and other related departments.

8.4 Annual Report:

Every occupier /operator has to submit an annual report to the prescribed authority in Form II by January 31st every year. The report will include information about the categories and quantities of bio-medical waste handled during the preceding year.

8.5 Maintenance of Records:

Every authorized person shall maintain records related to the generation, collection, reception, storage, transportation, treatment, disposal and/or any form of handling of bio-medical waste in accordance with the Rules and any guidelines issued.

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8.6 Accident Reporting:

When any accident occurs at any institution or facility or at any other site where bio-medical waste is handled or during transportation of such waste, the authorized person has to report the accident in Form III to the prescribed authority.

8.7 Appeal: Any person aggrieved by an order made by the Prescribed Authority under these rules may, within 30 days from the date on which the order is communicated to him appeal to the Government of State/ Union territory

8.8 Schedule I:

Describes different categories of bio-medical waste and their treatment options

Option Waste category Treatment and disposal

CATEGORIES OF BIO-MEDICAL WASTE

Option Waste Category Treatment & DisposalCategory No. 1

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

incineration @/deep burial*

Category No. 2

Animal Waste(animal tissues, organs, body parts carcasses, bleeding parts, fluid, blood and experimental animals used in research, waste generated by veterinary hospitals, colleges, discharge from hospitals, animal houses)

incineration@/deep burial*

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Category No. 3

Microbiology & Biotechnology Waste(Wastes from laboratory cultures, stocks or micro-organisms live or vaccines, human and animal cell culture used in research and infectious agents from research and industrial laboratories, wastes from production of biologicals, toxins, dishes and devices used for transfer of cultures)

local autoclaving/micro-waving/incineration@

Category No. 4

Waste Sharps(needles, syringes, scalpels, blade, glass, etc. that may cause punture and cuts. This includes both used and unused sharps)

disinfection (chemical treatment @@@/auto claving/microwaving and mutilation/shredding##

Category No. 5

Discarded Medicines and Cytotoxic drugs(Waste comprising of outdated, contaminated and discarded medicines)

incineration@/destruction and drugs disposal in secured landfills

Category No. 6

Soiled Waste(items contaminated with blood, and body fluids including cotton, dressings, soiled plaster casts, lines, bedding, other material contaminated with blood)

incineration@autoclaving/microwaving

Category No. 7

Solid Waste(Waste generated from disposal items other than the sharps such a tubings, catheters, intravenous sets etc.)

disinfection by chemical treatment@@ autoclaving/microwaving and mutilation/shredding##

Category No. 8

Liquid Waste(Waste generated from laboratory and washing, cleaning, housekeeping and disinfecting activities)

disinfection by chemical treatment@@ and discharge into drains

Category No. 9

Incineration AshAsh from incineration of any bio-medical waste)

disposal in municipal landfill

Category No. 10

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

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

Note :@ There will be no chemical pretreatment before incineration. Chlorinated

plastics shall not be incinerated.* Deep burial shall be an option available only in towns with population less

than five lakhs and in rural areas.

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

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

8.9 Schedule II:

Describes color coding and type of container for disposal of Bio Medical Wastes

COLOUR CODING AND THE TYPE OF CONTAINER FOR DISPOSAL OF BIO MEDICAL WASTES

Color Coding

Type of Container Waste Category Treatment options as per Schedule-I

Yellow Plastic bag Category 1, 2 and Category 3, 6

Incineration/deep burial

Red Disinfected container/Plastic bag

Category 3, 6, 7 Autoclaving/Microwaving/ Chemical Treatment

Blue/White translucent

Plastic bag/punture proof container

Category 4, 7 Autoclaving/Microwaving Chemical Treatment and destruction/shredding

Black Plastic bag Category 5, 9 and Category 10 (solid)

Disposal in secured landfill

Note : Color coding of waste categories with multiple treatment options as defined

in Schedule-I shall be selected depending on treatment option chosen, which

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shall be as specified in Schedule-I. Waste collection bags for waste types needing incineration shall not be made

of chlorinated plastics. Categories 8 and 10 (liquid) do not require containers/bags.

Category 3 if disinfected locally need not be put in containers/bags.

8.10 Schedule III:

Describes different Labels for bio-medical waste and their treatment options

LABEL FOR BIO-MEDICAL WASTE CONTAINERS/BAGS

BIOHAZARD SYMBOL CYTOTOXIC HAZARD SYMBOL

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BIOHAZARD CYTOTOXICHANDLE WITH CARE

Note : Lable shall be non-washable and prominently visible.

10. SPECIFIC GUIDELINES FOR HANDLING SHARPS

10.1 Definition of sharps: The rules categorize sharps in Category No 4. Sharps are defined as comprising of needles, syringes, scalpels, blades, glass, i.e. anything that may cause puncture and cuts. These include both used and unused sharps.

10.2 Segregation and storage: The types of containers prescribed for waste sharps have to be puncture-proof and can be blue, white or translucent in colour. Sharps need special attention while being segregated and stored because needles can act as a pool where pathogens may survive for a

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long time because of the presence of blood. Also the sharps can provide a direct route into the bloodstream by puncturing the skin. Syringes and needles must be damaged before they are put in containers, to prevent their re-use /resale. Sharps must always be kept in punctureresistant containers to avoid injuries and infection to those handling them.

10.3 Treatment: The rules provide for disinfection and mutilation of sharps by either chemical treatment using at least 1% hypochlorite solution or any other equivalent chemical reagent. Treatment by autoclaving/ advanced autoclaves/ microwaving is also approved. Mutilation prior to disposal is mandatory to prevent any unauthorized re-use. Mutilation can be carried out at the point of generation by using needle cutters/ destroyers or centrally in the hospital by using shredders after disinfection of sharps.

10.4 Final disposal: After disinfection and mutilation of sharps they should be disposed in secured landfills as per the rules. As secured landfills are not available everywhere alternate systems recommended include:

(a) Sharps pit:A specialized Committee constituted by the Ministry of Environment & Forests (MOEF) to formulate guidelines for

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implementation of Bio-Medical Waste (Management and Handling) Rules, 1998, prescribed the details of a sharps pit: Blades and needles waste can be disposed in a circular or rectangular pit, after disinfection. Such a rectangular or circular pit can be dug and lined with brick, masonry or concrete rings. The pit should be covered with a heavy concrete slab,

Standards for deep burial

1.A pit to trench should be dug about 2 meters deep. It should be half filled with waste, then covered with lime within 50 cm of the surface, before filling the rest of the pit with soil.

2.It must be ensured that animals do not have any access to burial sites. covers of galvanised iron/wire meshes may be used.

3.On each occasion when wastes are added to the pit, layer of 10 cm of soil shall be added to cover the wastes.

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Burial must be performed under close and dedicated supervision.

5.The deep burial site should be relatively impermeable and no shallow well should be close to the site..

6.The pits should be distant from habitation, and sited so as to ensure that no contamination occurs of any surface water or ground water. The area should not be prone to flooding or erosion.

7.The location of the deep burial site will be authorised by the prescribed authority.

8.The institution shall maintain a record of all pits for deep burial.

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10.5 ALTERNATIVE TREATMENT TECHNOLOGIES USED FOR SHARPS TREATMENT:

(a) Chemical disinfection of infectious plastics at the point of generation or at a central location was practiced by 93% of the institutions covered in the study. There was, however, no check on the quality of the chemicals used.

(b) Autoclaving of infectious plastics and sharps waste was followed in 40% of the institutions covered in the present study. This is a cost-effective treatment technology and the waste is recognizable after treatment and thus requires post- shredding.

(c) Microwaving of infectious plastics was followed in 20% of the health care institutions while due to the apprehension of sparks, no metal sharps were treated by this method. This is an expensive treatment technology and the waste is recognizable after treatment, requiring post-shredding.

(d) Hydroclaving was used in one of the health care facilities for treated infectious plastics and metal sharps. Waste was partially recognizable after treatment and preliminary shredding was carried out during the process of treatment.(e) The mutilated and treated waste from these methods has recycling potential.

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(f) Needle cutters destroyers are infectious per se. The hospitals regularly clean the destroyers with sodium hypochlorite.

11. POLICY ON IMMUNIZATION WASTE MANAGEMENT

Presently, there is no waste management policy formulated by the Ministry of Environment and Forest specific to immunization waste as this category is considered as a part of the bio-medical waste and is covered under the existing rules.Within the existing framework, some guidelines should be laid down to ensure that immunization camps and routine immunizations do not leave unmanaged waste.There should be policy for providing training to medical para staff on biomedical waste and it will be updated yearly. Employee training material covered will include:

Identification Transport Segregation of waste Handling of biomedical waste (onsite) Treatment of biomedical waste Using of protective clothing Storage of biomedical waste

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12. COMMON REGIONAL FACILITY FOR FINAL DISPOSAL OF INFECTIOUS BMW

Hospitals, private practitioners, emergency care centers though aware of the rules do not have the time or resources to arrange satisfactory disposal of biomedical waste. Self contained on site treatment methods may be desirable and feasible for large healthcare facilities. They will not be practical or economical for smaller institutes. An acceptable common system should be in place which will provide free supply of colour coded bags, daily collection of infectious waste, safe transportation of waste to off site treatment facility and final disposal with suitable technology.

General waste like garbage, garden refuse etc. should join the stream of domestic refuse. Sharps should be collected in puncture proof containers. Bags and containers for infectious waste should be marked with Biohazard symbol. Highly infectious waste should be sterilised by autoclaving. Cytotoxic wastes are to be collected in leak proof containers clearly labelled as cytotoxic waste. Needles and syringes should be destroyed with the help of needle destroyer and syringe cutters provided at the point of generation. Infusion sets, bottles and gloves should be cut with curved scissors. Disinfection of sharps, soiled linen, plastic and rubber goods

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is to be achieved at point of generation by usage of sodium hypochlorite with minimum contact of 1 hour.

Fresh solution should be made in each shift. On site collection requires staff to close the waste bags when they are three quarters full either by tying the neck or by sealing the bag. Kerb side storage area needs to be impermeable and hard standing with good drainage. It should provide an easy access to waste collection vehicle .

Biomedical waste should be transported within the hospital by means of wheeled trolleys, Containers or carts that are not used for any other purpose. The trolleys have to be cleaned daily. Off site transportation vehicle should be marked with the name and address of carrier.

Biohazard symbol should be painted. Suitable system for securing the load during transport should be ensured.

Such a vehicle should be easily cleanable with rounded corners. All disposable plastic should be subjected to shredding before disposing off to vendor. Final treatment of biomedical waste can be done by technologies like etc.

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12.1 COMMON REGIONAL FACILITY IN DELHI/NCR

Synergy Waste Management (P) Ltd.Near Composite Plant,Okhla Tank, Mathura Road,New Delhi-110020 (INDIA)

The First ISO 9001 & 14001 Certified Common Biomedical Waste Treatment Facility (CBWTF) in Delhi to provide services for the disposal of biomedical waste as per the CPCB Guidelines.

The First Organization in Delhi with our own infrastructure for the collection, transportation and disposal of Bio-medical waste as per the Bio-medical Waste (Management & Handling) Rules, 1998, amended up to the year 2000, and authorized by the DPCC, Govt. of NCT of Delhi.

The First private Organization in Delhi in collaboration with Directorate Health Services, Govt. of NCT of Delhi, operational at Okhla, near STP & Composite Plant, Okhla Tank, Mathura Road, New Delhi for Biomedical waste treatment and disposal.

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Also authorized by the UP State Pollution Control Board as well as Haryana State Pollution Control Board for the disposal of Biomedical Waste, for which we are running one facility at Meerut, Bareilly, Lucknow, (U.P.) and one at Hisar (Haryana). One more Common Treatment Facility is being set-up in Gorakhpur (U.P) as per the NOC issued for setting up the plant at Gorakhpur by U.P. State Govt. Also signed up an agreement with UPHSDP (U.P. State Health System Dev. Project) for supplies as well as Biomeidcal waste management services in the State of U.P.

Presently, catering to more than 3200 healthcare establishments including private and Government Hospitals.

13. SOME REPORTS/STUDIES OF CONCERN ON DISPOSAL OF BIO MEDICAL WASTE

13.1 Treating biomedical waste still a dream

Times Of India 20 Mar 2004NEW DELHI: Ever stopped to think what happens to all the medical waste which comes out of hospitals, clinics, research institutions and colleges?

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Well, the latest assessment is that about five per cent of nearly 1.4 million tonnes of hazardous biomedical waste is treated in some form, the rest careering down the dangerous route of open dumps, lakes, rivers - or finding its way back into the market. It could be coming to you and me. Safai karamcharis can’t handle it. The authorities have framed rules but acknowledge "a very big problem", with the Central Pollution Control Board now set to begin a stock-taking exercise on how even the limited treatment facilities are doing.

13.2 Knowledge, Attitude and Practices of Bio-Medical Waste Management Amongst Staff of a Tertiary Level Hospital in India

Author(s): S. Saini, S.S. Nagarajan, R.K. Sarma

Despite the statutory provision of Biomedical Waste Management, practice in Indian Hospitals has not achieved the desired standard even after seven years of enforcement of the law. In view of this, the present study on Knowledge, Attitude and Practice (KAP) on the subject was carried out in a tertiary level teaching hospital. The hospital under scrutiny for KAP is a 1600 bedded super specialty teaching hospital and research centre with latest facilities. The Institute has a work force of 800 doctors, 1600 nurses and 6000 other support staff. The study is based on a questionnaire

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designed to understand the KAP of the staff involved in direct patient care facility regarding the Biomedical waste management practices. The KAP study enrolled 156 respondents, representing doctors and nurses from selected patient care areas; Here, a significant gap was observed in the knowledge, attitude and practice of the consultants, residents and scientists with regard to biomedical waste disposal, to their knowledge/understanding on the subject.

The definite apathy of intellectuals towards the operational aspects of the BMW management system can be attributed to the tubular vision of the professionals that is mainly focused on the curative aspects of the patient care services, with lack of understanding towards the role of support services in the overall context of comprehensive health care delivery. Nursing professionals on the other hand, had an edge over the clinicians as far as attitude and practice of BMW mgmt. is concerned although their knowledge on the subject was relatively low. This can be attributed to their accountability and commitment in ward management and the predominance of female workforce, which is by and large more disciplined. The para-medical staff including laboratory and housekeeping staff had least understanding on the subject, but had higher positive attitude with more practical habits, which may be attributed to strict instructions by authorities and fear for any punitive action.

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14. COURTS VIEWS ON BIOMEDICAL WASTE

MANAGEMENT

10 January 2001: Four years ago, a Delhi lawyer, B.L.Wadhera, filed a case in the Delhi high court saying that incinerators were incapable of burning Indian solid municipal wastes. His argument was that this waste was much less calorific than Western waste and that the pollution caused by incinerators neutralised any advantage of incinerating waste. He did not take up the issue of bio-medical waste. It was left to such NGOs as Srishti and Chintan to campaign against use of incinerators even for bio-medical waste. Bio-medical waste includes amputated diseased limbs and other anatomical parts, infected plasters, bandages and syringes, leftovers from microbiology and biotechnology laboratories, and contaminated blood and body fluids.

Wadhera was provoked to file a public interest litigation (PIL) since a Rs 2 crore Danish incinerator-cum-power plant installed at Timarpur in north Delhi had been lying idle since 1985. It also did not work during its demonstration. At that time, the polluting quality of incineration technology was not well-known. Also, the concept of bio-medical waste as being different from municipal waste did not exist. Both were being mixed and disposed off together. The country was thus

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hugely vulnerable to the spread of diseases and the contamination of the ground water system. But no one knew.

The Delhi high court took a series of actions. It instructed the Central Pollution Control Board (CPCB), the nodal agency for all pollution-related matters, to review medical waste disposal and suggest new methods. It demanded why the then Delhi Government had approved an incinerator that did not function from start. And, it turned the screws on major government and private hospital for not following medical disposal norms.

The hospital wastes attracted the attention of the Supreme Court as early as in 1994 when a writ petition was filed under Article 32 of the Constitution against the concerned authorities to provide clean and health environment. Issue of improper hospital waste management was the crux of the case in B.L. Wadhera v. Union of India, AIR 1996 SC 2969.

 The court gave series of directions. The most important among them are: 1. All hospitals with 50 beds and above should install incinerators or any of effective alternative method under their own administrative control. 

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2. The incinerator or alternative methods should be fitted with necessary pollution control mechanism, approved and confirming to the standards laid down by the Central Pollution control Board.

3. The Central Pollution control Board and the State Pollution Control Boards should regularity send its inspection teams in different areas to ascertain that the collection, transportation and disposal garbage/wastes is carried out satisfactorily. Under the Indian Penal Code, 1860 a polluter of the environment can also be punished if he does an act which causes any common injury, danger of annoyance to the public or to the people in general then the act may be treated as public as defined under Section 268 and the offender may be treated punished under Section 290 or 291 of the Code, There are also penal provision under a situation which either causes, or destroys, or diminishes the value or utility of any property, of affects the property injuriously as provided under the Section 426, 230, 231, and 432 of the Indian Penal Code. This otherwise means that if any person who generates, collects, receives, stores, transport, treated, disposes or handles bio-medical wastes in any form shall be treated as a contravener of the above penal provisions. Raghunath Patnaik, “Bio-medical Waste Management and the Process of Environmental Governance” 322 Central India Law Quarterly 24 (2001)

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Four years on, much of Wadhera’s efforts, and a considerable part of the high court’s exertions, have come to nought. Incinerators are being run even though medical waste is still not adequately calorific. Incinerators have been determined as active polluters but no action has followed. And even while there is a greater felt need for such clean technologies as autoclaving and microwaving, the rot persists.

15. SOME SUGGESTIONS WHICH WOULD ACT AS REMEDIAL MEASURES INCLUDE

15.1 AWARENESS AND EDUCATION

In India hospitals and other health care establishments are not well equipped to handle the enormous amount of biomedical waste. There is an urgent need to raise the awareness amongst all concerned. Information can be disseminated through organizing seminars, workshops, practical demonstrations, group discussions, lectures etc. It is vital to formulate an effective education and training programs specific for different target groups involved in biomedical waste handling and management.

Intensive training programs at regular time interval for all the staff with special importance to the new comers.

Need for orientation programs for newcomers to understand the hospital function.

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The entire waste management practices should be a part of total hygiene practice of the society rather than confining to hospital and health facility.

The scenario of bio-medical waste demands the better management. The present rules are ineffective to manage the bio-medical waste. The law relating to bio-medical waste management should play an important play in curbing the menace. It sad to note that the surveys itself reveals poor implementation of the bio-medical rules. .. Law has stumbled in performing its duty; much of attribute from the lack of proper implementation mechanism Though the law relating to bio-medical is in infant stage; the time has come to act seriously and implement the rules effectively. Greater commitment is required on the part of the Government looking into the magnitude of the problem. The regulatory body should be strengthened. There is a need for re look at the rules. The Rules must drop the plan of imposition of setting up of a treatment plant in every hospital. The Rules should devote its attention towards establishment of common treatment sites which includes incinerator or autoclave, shredder and an engineered pit despite the fact that the occupier/operator has means potential to handle the same. The Rules must be strictly enforced with Proper segregation is the secret of

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proper regulation bio-medical waste. Training of these personnel will lay road in that direction. Since the hospitals have become the source of huge profits. They owe a duty to protect the interest and the safety of its workers and the public. Hospitals may face an excessive burden because of regulation of medical waste. But they should realize that law will no longer tolerate.

16. CONCLUSION / SUMMARY

In the field of medical practice statutory public health guidelines for Biomedical waste Management and close monitoring of its compliance alone cannot achieve the ultimate goal, if it is not accompanied with social science approach of mass education motivation and change of mind set in all strata of medical practice. Continuous logistic support and user friendly approach is equally important while implementing in the process of any rules, regulations concerning the medical practice other than the core mandate they area are assigned to.

The study has shown a definite apathy of intellectuals towards the operational aspects of the system. The medical professionals have tubular vision on patient care services and pay very little heeds to support services in the overall context of comprehensive patient welfare. Nursing

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professional are found to have had on edge in the attitude and understanding in the subject and it is found that they are practicing the guidelines in more responsible manner may be due to their accountability and commitment in the patient welfare. Paramedical staff including laboratory staff and housekeeping staff have relatively less understanding on the subject, but has high attitude and more practical habits which may be because of strict instructions by authorities and fear for punitive action.

"There is a need to bring change from the top, " says Dr T.K.Joshi, consultant and project director at the Lok Nayak Jayaprakash Narayan Hospital’s Centre for Occupational and Environmental Health. "We need an attitude change."

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The hospital waste, in addition to the posing risk to the patients and personnel who handle these wastes, is also a threat to the public health and environment. It is emerging as a health hazard to the community at large. Keeping in view, inappropriate management of biomedical wastes, the Ministry of Environment and Forests notified the “Bio Medical Waste (Management and Handling) Rules 1998.” These rules are meant to protect the society, patients and health care workers. The most imperative component of the waste management plans is to develop a system and culture

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through education, training and persistent motivation of the health care staff.

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THANK YOU

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