Understanding and simplifyingbio-medical waste managementA training manual for trainersToxics Link, Revised May 2016AuthorsAuthors: Anu G. Agrawal

About Toxics LinkToxics Link is an environmental NGO, dedicated to bringing toxics related information into the publicdomain, both relating to struggles and problems at the grassroots as well as global information to thelocal levels. We work with other groups around the country as well as internationally in an understandingthat this will help bring the experience of the ground to the fore, and lead to a more meaningful articulationof issues. Toxics Link also engages in on-the ground work especially in areas of municipal, hazardousand medical waste management and food safety among others. We are also involved in a wider range ofenvironmental issues in Delhi and outside as part of a coalition of non-governmental organisations.Understanding and simplifying bio-medical waste management

ContentsAcknowledgements . 4An introduction to the manual . 5How to use this resource . 7Suggested training mechanisms . 8Section A: An overview of bio-medical waste management . 11Section B: Bio medical waste management: An environment and health paradigm 19Section C: Implementing waste management in hospital. 25Section D: Reducing Carbon Footprint of a Health care Facility . 33Section E: Training Hospital Staff . 41Section F: Aspects of waste management . 51Section G: Rules and Policies . 61Section H: Treatment technologies and Common Bio-medical Waste Treatment . 69Section I: Annexures . 79A training manual for trainers

AcknowledgementsWe would like to thank the various hospitals and state governments which provided us thewonderful opportunity to conduct training programmes around the country; this manualis a result of the experience and skills gathered and honed during these training programmes.Our special thanks to Dr. Glenn Mc Rae and Dr. Jorge Emmanuel of Healthcare Without Harm forreviewing specific text of this manual. And foremost to all the trainees who brought several practicalissues to our notice and helped us improve the manual through their suggestions. Not to forget the entireToxics Link family which was always supportive.Understanding and simplifying bio-medical waste management4

An introduction to this manualThe issue of medical waste managementwas first taken up in India around 1995.A lot has changed since then in the waymedical waste is handled, stored, treated anddisposed.An important catalyst to this change have beenthe Bio-medical Waste (Management &Handling) Rules 1998, now Bio-Medical Wastetraining has gradually become one of our focalareas. We have learnt from each training session;every hospital has its unique problems andchallenges. As we attempted to resolve particularproblems, and respond to the queries of the hospitalstaff, we enhanced our understanding of thepractical problems and the unique needs ofhealthcare institutions. This helped us evolve ourtraining methodology as well as its content.The main aim of themanual is to ensure thatevery healthcare workerand other stakeholdersare aware of the hazardsassociated with improperbio-medical wastemanagement.Management Rules, 2016.Framing the rules was one important aspect ofwaste management, but implementing the rulesrequired that the medical fraternity understood therules and adopted them into their professionalenvironments. This was possible only throughlarge-scale training of medical staff. Consideringthe geographical spread of India, and the size ofits medical sector, this has been, and continues tobe, a challenging task.Toxics Link, has played its part in traininghealthcare professionals regarding medical wastemanagement and the implementation ofmanagement systems in hospitals and other medicalinstitutions. Srishti emphasises the importance ofmanagerial interventions and staff dedication tobring about efficient waste management practices.It works towards dispelling the belief thattechnology is the only solution for medical wastemanagement.As our work with various hospitals has progressed,the training needs have also increased. As a result,5Apart from training hospital staff, we have alsoconducted various Training of Trainers (ToT)programmes all around the country, in associationwith various hospitals and Pollution ControlBoards/ Committees. These programmes create abrigade of trainers who act as ambassadors andtake the message of waste management forward.By the end of such sessions, trainees are exposedto a lot of information, but they do not have enoughtime to assimilate everything. Once they return totheir workplaces, they have expressed the need fora comprehensive resource on training. This manualhas been compiled to fulfill their requirement.The main aim of the manual is to ensure that everyhealthcare worker and other stakeholders are awareof the hazards associated with improper biomedical waste management.The manual has been produced to provide aconvenient, up-to-date training resource that willallow interested people and trainers to increaseawareness on waste management and related issuesA training manual for trainers

An introductionto this manualat every level in their organisation.The Training manual has eight sections and eachsection has slides on a particular topic. Most ofthe points in the slides are self explanatory, butsome of them, which may need explanations, havedescriptive notes.This manual would keep evolving to address newerissues as experience in this field grows. Yoursuggestions and comments on the manual wouldtherefore be highly appreciated.Understanding and simplifying bio-medical waste management6

How to use this resourceThe manual has been divided into logical sections.Beginning with an overview that introduces the audienceto history of Bio-medical waste and its management, themanual moves on to talk about the environmental and healthimpacts of mismanagement of Bio medical waste. This sectionintroduces the audience to all the relevant conventions.The next section deals with the implementation of bio-medicalwaste management system in a hospital. This section deals withsegregation of waste, its transportation, management policies athospitals and techniques that a hospital could follow to have asuccessful bio-medical waste management programme.The section that now follows provides a step by step guide to thehospital in reducing its carbon footprint.The Training of Staff section that follows focuses on specific kindsof bio-medical waste, such as sharps, gultaraldehyde and cytotoxicdrugs. Each kind of waste is discussed, and the hazards associatedwith it are elaborated.The next section, Aspects of Waste Management deals withmanaging each kind of bio-medical waste. This includes theprocesses to be followed and the precautions to be taken for differentwaste categories.After this, the manual spells out the Rules and Policies that applyto medical institutions. This section is appropriate while trainingsenior managerial staff at hospitals.Each of the above mentioned sections consists of slides that areprovided as print-outs in this manual. The latest version of thepresentations for this manual can be found at the following -m/index.htmEach of the above mentioned training modules are provided asPowerPoint presentations in the accompanying CD. The slides ofthe presentations also have hyperlinks to relevant pictures thatvisually depict a point. Depending on the resources available,trainers can either print out the slides and pictures or use a computerto make the presentations.The manual also provides supporting material to key slides ofeach section. The trainer should study the section for which s/hewants to conduct a training session and familiarise herself/himselfwith the issues concerned. The level of elaboration of each slideand discussions around the topics will obviously depend on thekind of audience, its needs, knowledge-base and the purpose ofthe training. The trainer is expected to exercise discretion in makingsuch decisions.The trainer should be able to select a set of slides appropriate fora particular session. Some seminars, lecture series, discussionforums may need discussion on a particular issue. The specificsections can be in such sessions.A few miscellaneous slides have also been provided. These slidescan be used if a discussion starts to build around these topics in atraining session.The last section entails the treatment technologies available fortreatment of Bio medical waste and the role of a Common Biomedical waste treatment facility in the same.7A training manual for trainers

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.