Disposal of Clinical Wastes: Tata Memorial Hospital Experience Dr Rohini Kelkar M.D., D.P.B....

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


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


3.1 Number of Vendors

3.2 Vendor Resources

3.3 Vendor Diversity and Services

4. Environmental & Permitting Issues 4. Environmental & Permitting Issues


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


5.1 Routine Exposures

5.2 Maintenance and Repair Exposures

6. Facility: & Infrastructural Requirements

6. Facility: & Infrastructural Requirements


6.1 Space Requirements

6.2 Construction Requirements

6.3 Utility Requirements

6.4 Space / Facility Requirements

7. Economics 7. Economics


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."

http://www.indiatogether.org/support/home.php?img=regular

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



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



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



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


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



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



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

Disposal of Clinical Wastes: Tata Memorial Hospital Experience Dr Rohini Kelkar M.D., D.P.B....

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