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Suggested training mechanismsOur eexperiencexperience with trainingWe have dealt with a diverse audience whileconducting training sessions on waste management:from medical students to practicing professionals,and ward boys to nursing staff. Each grouprequired a different approach. It is important toconsider the background of the audience you areabout to train, and prepare the sessions inaccordance with their knowledge levels, ability tograsp concepts, language and openness to newideas.Training nursing studentsStudents respond well to a classroom situation. Aquestion answer format is ideal for such anaudience, as they enjoy the interactivity and areeager to display the knowledge that they have.Usually, a little guidance is required to channelisethem into the right direction. Students are also veryopen to fresh ideas and are naturally inquisitiveabout developments in the ‘real’ world.An effective technique is to approach the trainingas a problem-solving session.Training ward boysUsually, this group responds well when the issuesare connected to their daily routines and problems.It is a good idea to begin the session with listeningto their problems, even if they are not necessarilyrelated to waste management. A sympathetic earUnderstanding and simplifying bio-medical waste managementmakes them shed their inhibitions, and be moreopen to the session.The written word is best abandoned with thisgroup. Innovative methods such as street plays arevery effective, as this group responds well to dramaand visual forms. One will find that this groupwill make valuable suggestions that can be adoptedwhile setting up a waste management scheme.Training with doctorsDoctors require a more academic approach, whichhas well-researched data and working examplesfrom other institutions.Information about various internationalconventions, global movements and negotiationsare required to convince them about the importance of waste management.Often, they feel that the sessions are an impositionon them, therefore, their time should be respectedand the sessions should be highly professional.Training with staff nursesTraining with staff nurses is the most critical asthey form the backbone of the waste managementsystem in a hospital. Nurses are generally quiteinterested and active. However, they might be in ahurry if they are required to attend the sessionsafter their shift. The timing of the training shouldbe carefully chosen to avoid such issues. When it8

One can have nurses enact a particular procedureand dispose off waste generated during the course.Or one can have photographs of good and badpractices and ask people to point out problems inthe photograph and suggest corrections. If traineesknow that a quiz would follow the training sessionthey are generally more alert during the trainings.Suggested trainingmechanismscannot be avoided, the sessions must be madeinteresting through the use of various tools such asquizzes, placards, etc.Any training can be made more effective with agood trainer, training tools and techniques. Thusthe trainer should have good communication skillsand should be able to mould the style of thepresentation according to the target audience.Visual aids help demonstrate good practiceseffectively. Representatives from another hospitalwhich is following a sound waste managementsystem can be called for sharing their experience.9A training manual for trainers

Understanding and simplifying bio-medical waste management10

Section AAn overview of bio-medical waste management11A training manual for trainers

A1An overview of bio-medical waste managementThe public concern with medical wastedates back to the late 1980s when largequantities of syringes and needles werefound on the beaches of east coast Florida, USA.About the same time, the HIV/AIDS epidemicwas rearing its head and healthcare professionalswere waking up to its enormity. The public outcryfollowing the discovery of the needles, led to theformulation of the US Medical Waste TrackingAct (MWTA), which came into force onNovember 1, 1988.A quick-fix solution that was employed was to buyand install small on-site incinerators. Retiredincinerators were also resurrected, and in somecases more waste was added to the existingincinerators. Many of these incinerators wereunregulated. A number of them had few, if any,pollution control devices. In the early 1990s theUnited States Environment Protection Agency(USEPA) estimated that there were some 6,000hospital incinerators operating in USA.Incineration, too, was opposed by communitiesliving close to them as they were found to beseriously harming the health of people. Study afterstudy exposed the hazards of incineration, andlinked them to emissions of cancer-causing dioxinand furan. As a result, incinerators were phasedout. By 2003 the number of incinerators in USAhad come down to just about 115. [compilationby Dr. J. Emmanuel]In India, concern for medical waste was an outcomeof judicial and NGO interventions. Ministry ofEnvironment and Forests came out with the firstdraft rules on bio-medical waste in 1995. It wasthe first time that medical waste was addressed asa category separate from municipal waste.The problem with this draft was that it laid toomuch emphasis on incineration. All hospitalshaving 80 or more beds were asked to install onsite incinerators. Timely intervention by NGOs(Srishti being one of them), helped change thisdraft. The final rules had provisions for alternativetechnologies, standards for all listed technologiesand centralised facilities for bio-medical wastetreatment.Concern about the environmental and health risksof medical waste incineration has increased inrecent years as a number of studies have shownthat incinerators are a major source of extremelytoxic dioxin and other pollutants. In industrialisedas well as less-industrialised countries, growingmovements of health workers, labour andenvironmental advocates, and concerned citizenshave called for the replacement of medical wasteincinerators with cleaner, safer and less expensivealternatives.In fact, NGOs have been lobbying for zeroincineration facilities for medical waste treatment.One problem with bio-medical waste has been thatit has a complex composition, and one type of wasteUnderstanding and simplifying bio-medical waste management12

The different types of bio-medical waste generatedat a single medical establishment requires differentkinds of treatment technologies. It is highlyimpractical to expect each hospital to invest in thesedifferent technologies. This has led to the conceptof centralised waste treatment facilities. As per theBMW Rules 2016, the hospitals need to treat theirmicrobiological waste before giving it to CTFs.The idea was mooted years ago, and as thesefacilities were being established, the secondamendment to the Bio-medical Waste (Management and Handling) Rules came out with somenew clauses for establishment of such facilities. Asa number of these units started operating andcountr ywide experience started pouring in(regarding the problems being faced by theauthorities, operators, subscribers, NGO observations, etc.), it was realised that some standards/guidelines were required for such facilities. Thus,in addition to the national guidelines forimplementation of the rules, two new guidelines– Guidelines for Centralised Bio-medical WasteTreatment Facilities and Guidelines for Construction and Operation of Incinerators – were draftedby the Central Pollution Control Board.At the same time, NGOs were demanding theelimination of incineration as a treatment optionfor bio-medical waste. Toxics Link compiled anational survey on incineration conducted by fourmembers of HuMAN (Health and Us – MedicalWaste Action Network): Chennai based CAG(Citizen consumer and civic Action Group);MMAG (Mumbai Medical Waste ActionGroup); Thanal, Trivandrum and Toxics Link,13New Delhi.This survey was presented to the Ministry ofEnvironment and Forests and the Central Pollution Control Board (CPCB) asking for a ban onincinerators. The CPCB wrote to all its stateboards to discourage any new on-site incinerators,and later, during the course of finalisation of thedraft on guidelines for centralised facilities,incineration was limited from five to three categoriesof bio-medical waste.A2An overview of bio-medicalwaste managementcan easily contaminate another, making it difficultto manage the waste. Around 80-90 per cent ofwaste generated in a hospital is general waste, andthe remaining 10-20 per cent can be infectiousand/or hazardous (for example, cytotoxic, chemicaland radioactive waste). This breakup of waste alsodepends on the type of hospital and the facilities ithas.The new guidelines on incineration are verycomprehensive and it would be economicallyunviable now to install any new on-site incinerators. The guidelines make it clear that on-siteincinerators would not be allowed, other than inexceptional conditions where special approvalwould have to be sought from CPCB. Thus, inIndia no on site incinerators are now beingpermitted to be used at any healthcare facility. Theyare only installed in the Common Bio-MedicalWaste Treatment Facility where they have to abideby certain standards. Bio-Medical WasteManagement Rules, 2016 have made thestandards for the operation of incinerators morestringent.Slide 2: Various networksWorldwide, various organisations and networks areworking to transform the healthcare industry sothat it is not a source of harm to public health.Safe Injection Global Network (SIGN) is acoalition of several public and private partners,including WHO, UNICEF, UNAIDS, NGOs,governments, and health workers. It was formedin Geneva in October 1999 to focus on injectionsafety, of which safe disposal is an importantcomponent.Another network called Global Alliance forIncineration Alternatives, or Global Anti-Incineration Alliance (GAIA) is an internationalnetwork of NGOs working against incinerationA training manual for trainers

An overview of bio-medicalwaste managementA3Æ 1. Safe management ofwaste from healthcare activities, A. Pruss et al, WHO,1999.and is trying to promote safer alternatives to treatbio-medical waste.Healthcare Without Harm (HCWH) is aninternational coalition of NGOs, hospitals, medicalprofessionals, community groups and labour unionsworking on ecologically sustainable healthcaresystems. Medical waste is one of their focus areas.In India, too, environmental organisations andindividuals have come together to form Health andUs - Medical Waste Action Network (HuMAN).This is a network of NGOs, academicians,practitioners, etc, lobbying for safe medical wastepractices in the country. Its aim is to take themessage of safe management of healthcare wasteto the grassroots.Slide 3: What is this concern for?Infectious waste is suspected to contain pathogens(bacteria, viruses, parasites or fungi) in sufficientconcentrations to cause disease in susceptible hosts.Æ 2. Safe management ofwaste from healthcare activities, A. Pruss et al, WHO,1999.Sharps are items that could cause cuts or puncturewounds. They include hypodermic needles,scalpels and other blades, knives, infusion sets,saws, broken glass, and nails. They are consideredhighly hazardous whether they are infected or not.Cytotoxic drugs have the ability to stop the growthof certain living cells and are used as chemotherapeutic agents. They are carcinogens and canalso be mutagenic. Any material used to handlethese products and contaminated in due coursewould also need to be disposed off in the samemanner.Pharmaceutical waste includes expired, unused,spilt and contaminated pharmaceutical products,drugs, vaccines and sera that are no longer useful.Radioactive waste includes solid, liquid, andgaseous materials contaminated with radionuclides.Radioactive healthcare waste usually containsUnderstanding and simplifying bio-medical waste managementradionuclides with short half-lives which lose theiractivity relatively quickly. Radioactive waste isgenerally produced in in-vitro analysis of bodytissue and fluid, in-vivo organ imaging and tumourlocalisation, and various investigative andtherapeutic practices.The type of disease caused by radioactive waste isdetermined by the type and extent of exposure. Itcan range from headache, dizziness and vomiting,to much more serious problems. Radioactive wasteis also genotoxic and handling of active sourcesmay have severe consequences such as thedestruction of tissue.1Chemicals are generally used in diagnostic andexperimental work, and in cleaning, housekeeping and disinfecting procedures. Many chemicalsand pharmaceuticals used in hospitals arehazardous. They are termed hazardous if they haveany one of the following properties: toxic, corrosive,flammable, reactive, genotoxic. Examples of suchwaste are formaldehyde, glutaraldehyde andphotographic chemicals.They may cause injuries, including burns.Disinfectants are particularly important membersof this group as they are used in large quantitiesand are generally corrosive.2Slide 4: Know your wasteAccording to various estimates and surveys around80-90 per cent of hospital waste is general wasteand 10-20 per cent is infectious/hazardous. Ofthis, 15-20 per cent is pathological and infectiouswaste, one per cent is sharps waste, three per centchemical/pharmaceutical and less than one per centis special waste such as radioactive, cytotoxic drugs,etc. These percentages may be higher or lowerdepending on the type of hospital (for example,teaching, research and large general hospitals willhave higher quantities of these wastes, while ruraland small speciality hospitals may have much lowerquantities).214

Slide 10: What are sharps?All individuals exposed to hazardous healthcarewaste are potentially at risk. This includes personswithin healthcare establishments and those outsidethese sources who either handle such waste or areexposed to it as a consequence of carelessmanagement. The main groups at risk includedoctors, nurses, patients, visitors to the hospital,workers in support services allied to hospitals likethe laundry, workers in waste disposal facilities,etc.Anything that can cause a cut or a puncture woundis classified as ‘sharps’. These include needles,hypodermic needles, scalpel and other blades,knives, infusion sets, saws, broken glass, and nails.Whether or not they are infected, sharps are usuallyconsidered highly hazardous healthcare wastebecause they have the potential to cross the passiveand primary immunology barrier of the body –the skin – and thus establish contact with blood.Because of this double risk of injury and diseasetransmission sharps are considered very hazardous.The hazards associated with scattered, smallsources of healthcare waste should not be overlooked; this can include waste generated by homebased healthcare.Slide7:Concernsinfectious wasteinInfectious waste may contain pathogens in sufficientconcentration to cause disease. Infectious wastewould include cultures and stocks of infectiousagents from laboratory, pathological waste (tissues,organs, body parts, human foetus, animal carcassfrom research facilities, blood and body fluids) andsharps waste.Pathogens in waste can invade the body throughvarious routes, including a puncture, abrasion or acut in the skin, through the mucous membrane orby inhalation/ingestion. Body fluids can act astransmission vehicles for various pathogens as listedin slide 17.Infectious waste from hospitals is problematicbecause laboratories harbour not just resistantstrains, but also concentrated cultures of microorganisms. Existence of bacteria resistant toantibiotics and chemical disinfectants contributesto the hazards. It has been demonstrated thatplasmids from laboratory strains contained inhealthcare waste were transferred to indigenousbacteria via the waste disposal system.215A4An overview of bio-medicalwaste managementSlide 5: Impacts of hospital wasteThe principal concerns are infections that may betransmitted by subcutaneous introduction of thecausative agent, for example, viral blood infections.Hypodermic needles constitute an important partof the sharps waste category and are particularlyhazardous because they are often contaminatedwith blood.3Æ 3. Safe management ofSlide11:Sero-conversionfollowing exposurewaste from healthcare activities, A. Pruss et al, WHO,1999.Sero-conversion means the percentage of healthcareworkers developing the infection after beingexposed to body fluids from a proven infectivesource. These rates have been documented bycarrying out a follow-up of healthcare workers withoccupational exposure to blood from a patientpositive for a particular blood-borne pathogen. Forinstance, in the case of exposure to a HIV positivepatient, the healthcare worker would be tested forHIV antibodies at the time of exposure (baselinetesting) and at periodic intervals for 12 months.(Also refer to slide 10 of the section titled Training hospital staff).Slide 14: ReuseUnsafe injection practices transmit blood-bornepathogens such as Hepatitis B, Hepatitis C andHIV. Globally, nearly two per cent of all new HIVinfections are caused by unsafe injection practicesA training manual for trainers

An overview of bio-medicalwaste managementA5Æ 4. www.injectionsafety.orgwith a total of 96,000 people infected annually.4section.Reuse of syringes and needles, without theirsterilisation, exposes millions of people to the riskof these infections.Case StudiesThe problem of unsafe injection practices can beovercome only by bringing about a change in thebehavior of healthcare workers and patients, byensuring availability of equipments and suppliesand by managing the waste generated appropriatelyand safely.4For more information visit the Safe Injection GlobalNetwork website: www.injectionsafety.orgSlide 18: Exposure hazardsThe use of radiation sources in medical and otherapplications is widespread throughout the world.Occasionally, the public is exposed to radioactivewaste (usually originating from radiotherapytreatments) that has been disposed off improperly.Serious accidents have been documented inGoiânia, Brazil in 1988 where four people diedfrom acute radiation syndrome and 28 sufferedserious radiation burns. Similar accidentshappened in Mexico City in 1962; Algeria in1978; Morocco in 1983 and Ciudad Juárez,Mexico in 1983.5Slide 21: MercuryÆ 5. WHO Information FactSheet No. 253, October2000.Mercury is used in medical equipment and indental amalgams. It is a neuro- and nephro-toxicsubstance. It affects the nervous system and canimpair the way we talk, hear, see, walk, feel andthink. Humans are exposed to mercury throughcontaminated air, water or food, or directly throughthe skin.In the case of mercury spills, personnel get exposedand they do not have the capacity to handle eitherthe spill or the exposure. World over, there is ashift to products which do not use mercury. Fordetails refer to the slides on mercury in the TrainingUnderstanding and simplifying bio-medical waste managementThree children, ranging from 20 months to sixyears, were exposed to mercury from a thermometer spilt on the carpet. They developed symptomsof sensitivity to light, weight loss, sweating andscaling palms, eczema and itching. The two moreseverely affected required four months of therapyfor a complete recovery.In another instance, 1.1 gram of mercury collectedfrom a broken thermometer was collected in a panand placed over a hot stove. Two elderly patients,who were exposed to the resulting mercury vapours,developed severe pulmonary edema, confusion,tremors and coma and died after seven and 17days of hospitalisation, respectively.Slide 22: GlutaraldehydeGlutaraldehyde is a potent skin irritant andsensitiser. Exposure to it is a recognised cause ofoccupational asthma. People may be needlesslyexposed to glutaraldehyde vapours in a patient’sroom. Glutaraldehyde, along with many otherdisinfectants and chemicals, needs to be handledcarefully to minimise health hazard.Slides 23 to 25: Salient features ofthe rules and associated rulesThe section on Rules gives a detailed account ofthe Indian legislation on this issue. However, theseslides touch on some salient features of the rules.The last slide highlights the fact that a hospitalgenerates many different types of waste. Foreffective waste management the hospital would haveto follow several legislations and guidelines,including the Solid Waste Rule, Atomic EnergyAct and Hazardous Waste Rules and E-wasteRules.The other Acts that a hospital would need to16

17A6An overview of bio-medicalwaste managementadhere to include the Water and th

he issue of medical waste management was first taken up in India around 1995. A lot has changed since then in the way medical waste is handled, stored, treated and disposed. An important catalyst to this change have been the Bio-medical Waste (Management & Handling) Rules 1998, now Bio-Medical Waste Management Rules, 2016.