Bio-Medical Waste Management Satish Sinha

1. Bio-Medical Waste ManagementSatish Sinha

2. History of medical waste • Medical Waste Tracking Act in US • I Draft Rules in India–1995 • Final Rules in 1998, 2 amendments and 5 guidelines • Evolution of Rules and Practices through National Experiences • National Guidelines on BMW, Guidelines on Incineration, CTFs, Immunization Waste and Mercury

3. Various networks NGOs • Health Care Without Harm (HCWH) Injection safety: • SIGN (Safe Injection Global Network) Anti-incineration: • GAIA (Global Anti Incinerator Alliance) Mercury • Zero Mercury World Health Assembly • Patient safety

4. Stockholm Convention on Persistent Organic Pollutants • an international environmentaltreaty • aims to eliminate or restrict the production and use of persistent organic pollutants (POPs). • entered into force on 17 May 2004 with ratification by 128 and 168 signatories.

5. Basel Convention • Control of Tran boundary Movement of Hazardous Wastes and Their Disposal • Minimize hazardous waste generation and dispose it nearest to the point of generation

6. Environmental Regulations • Environment Protection Act, 1986 • BMW Rules 1998 • Municipal Waste (Management and Handling) Rules, 2000 • Atomic Energy Act • Hazardous Wastes (Management & Handling) Rules, 1989 • E-Waste Rules • Batteries (M&H) Rules 2001 • Manufacture, Storage and Import of Hazardous Chemicals rules, 1989

7. Patient safety and Bio-medical waste management • In 2002 World Health assembly, passed a resolution calling member states to work for safety of Patients. • In Oct. 2004, World alliance for Patient safety was formed, who have identified certain challenges in relation to safety of patients. First Challenge is “Clean care is Safer Care” (2005) • A formal pledge committing to address health care-associated infection in the country was signed by Government of India.

8. Priority areas for Patient safety • Safe clinical practices and hand hygiene • Safe Surgical practices • Blood Safety • Safe Injections Practices • Health Care Waste Management Rules and guidelines are available but implementation is very poor. Lack of training or poor training is also a factor. It has not been given the due priority by most of the states and dedicated budget is required. All states should focus on this.

9. Health care associated infections • Complicate between 5-10% of admissions in acute care hospitals in industrialized countries • It is estimated that this risk is up to 20 times higher in developing world • At any given time, 1.4 million people worldwide suffer from HAI, and at least 50% of HCAI are preventable.

10. Unsafe injections • India contributes to 25%-30% of the global injections (WHO, 1999) • Annual injection usage ~ 3 – 6 billion, of this nearly two-thirds (62.9%injections) unsafe India CLEN Study 2002-04

11. Why Follow Universal Precautions • The prevalence rate of blood born disease- Hepatitis B 38/1000, HIV 7/1000 (NACO 1993) • Difficult to test each patient • NSI and other sharp injuries are the key Canadian health issue, affecting 70000 people per year and costing around dollar 140 million. • A safety programme at Toronto Hospital achieved 80% reduction in injuries within an year.

12. What is this concern for? • Infectious waste (solid and liquid) • Sharps waste • Cytotoxic waste • Pharmaceutical waste • Radioactive waste • Chemicals and disinfectants • Pressurised containers

13. BMW Rules and Key Actors • Notified in 1998 • Concept of PPP model • Identified technologies and standards • CPCB • SPCB • Department of Health Headline of presentation to come here (on slide master)

14. Know your waste

15. Waste Treatment & Disposal System

16. Schedule II

17. Bio-medical waste and technology • Technology is only a fraction of the solution. • Major components of waste management are: • Segregation of waste • Waste minimisation • Reducing use of hazardous substances or processes • Waste Audit

18. Approved treatment methods • Autoclave • Chemical disinfection • Hydroclave • Microwave • Incineration • Any other technology after CPCB approval

19. In house management of waste • 1.Survey2.Meeting with the heads of all the departments3.Forming a waste management committee4.Rounds of wards to see the functioning 5.Creating a model ward6.Suggest equipment procurement7.Formal training for all the nursing staff8.Implementing the system throughout the hospital

20. Right Technology Medical waste management is 80% segregation and 20% technology • Incineration: Pathological Waste and Body Parts , no chlorinated plastics • Autoclaving: All except body parts and pathological waste • Microwaving: All except pathological waste and metals • Chemical: Mainly plastics

21. Of site management of waste-Centralized Facilities • Draft Guidelines on Common facilities- • Treatment facilities- 90% non-burn, 10% waste- burn • Limits incineration to Categories 1&2 • Atleast 1 Km from residential areas. Acceptable in industrial area • One operator allowed to cater upto 10,000 beds, situated within 150 km radius • Segregation is the role of generator; operator can report mixing of waste to the prescribed authority

23. Hurdles in Implementation • Issues of Capacity • Low priority • Resource Allocation • Fixed Mindset • Injection safety, chemical safety and waste management issues yet to find space in development planning

24. At the SPCB level • Capacity and resource • Monitoring and control • Transparency of processes • Hierarchy of control • Independent audits • Awareness of community • Increasing outreach of centralized facility to rural areas

25. At the Hospital level • Mindset issues • Involvement of senior management • Resource availability and prioritising • Government Hospitals biggest defaulters • Capacity Building • Implementation bottlenecks • Responsibility fixing • Monitoring and Accreditation • Periodic Waste audits wrt economics

26. At the CTF level • Untrained Staff • Poor maintenance of equipment • Effluent Treatment Plants • Maintenance of records • No power back ups • Closed door, non transparent • Differential charges • Flawed systems • Profit driver • Need for accreditation

27. Way Forward • Resource allocation for waste management • Maintaining a pool of trainers at block/ district levels • Stakeholders involvement • Incorporation into curricula of medical, nursing and paramedical colleges • Up gradation to latest developments in BMW management • Waste minimizations policy • Appropriate technology selection • Pro-environment procurement policy

28. Emerging Issues Mercury • First mercury documentation in healthcare in 2004: 3 kg/ hospital/year • Public notices by DPCC • Mercury phase-out committee formed by DHS • Delhi hospitals to phase out mercury • No new mercury equipment procurement in Delhi government hospitals • HCEs aiming for ISO/ NABH to phase out mercury

29. Emerging Issues Injection Safety • Increased attention by hospitals • Fines on unattended needles • No to recapping • Reporting of needle stick injury and follow up Chemical Safety • Monitored use of Glutaraldehyde, formaldehyde, benzene, cytotoxic drugs etc.

30. Thank You Toxics LinkH-2, Jungpura Ext.New Delhi 110014011-24328006, 24320711info@toxicslink.org www.toxicslink.org