aes ©) Tamil Nadu Health Systems Project Government of Tamil NaduPublished by Tamil Nadu Health Systems Project, Health & Family Welfare Department, Government of Tamil Nadu, Tamil Nadu, India website : www.tnhsp.net Hand Book on Bio-Medical Waste Management © 2008 All rights reserved. No part of this module should be reproduced, stored in a retrieval system or transmitted in any form or by any means : electronic, mechanical, photocopying, recording or otherwise without the prior on item permission from the Project, Editorial Board : Mr, PW.C. Davidar, LAS. Dr. (Capt.) M. Kamatchi Prof. Dr. K. Gajendran Dr. D. Gurusamy Dr K. Vinay Kumar Ms. V, Jaisee Suvetha Mr, Arun Senthil Ram Dr. Ranjana Dr. Ravi Babu We acknowledge the content contribution of Toxics Link to this booklet.“Thishand book has been prepared to help al health care providers in our hospitals to fully become aware about the method of disposal of bio medical waste. It is now mandated by law that specific conditions are to be observed and there arenoalternate options. Failure to fulfill the necessary obligations under the rules in force will initiate penal action and is enforceable by the law. Our appeal to you is that you read this book carefully and ensure that all the instructions are followed with utmost diligence. Special Secretary Health and Family Welfare Department & Project Director Tamil Nadu Health Systems Project. Government of Tamil Nadu.Acknowledgment The Tamil Nadu Health Systems Project, Health & Family Welfare Department, Government of Tamil Nadu Chennai has taken a major initiative to implement Bio-Medical Waste Management practices in all Government health institutions inthe state. The training of Health Care Providers and all the health staff at all levels is the key to success in this effort. This training module “Hand book on Bio-Medical Waste Management Practices” was made possible with the encouragement of the Secretary, Health & Family Welfare Department, Government of Tamil Nadu and an efficient team in the Tamil Nadu Health Systems Project. We also express our gratitude to all who contributed in making of this module,si. Contents Particulars Unit 1 Bio-Medical Waste - The Perspectives Lt Current Scenario in Health Care Institutions 12 Hospital Acquired Infections 13 Hospital Waste 14 Bio-Medical Waste (Management & Handling) Rules 1998 Unit2 Systematic Approaches for Managing Bio-Medical Waste 24 Waste in your Hospital 2.2 Segregation of Waste 23 Disinfection of Segregated Waste 24 Path Way of Colour Coded Bins for Wastes 25 Monitoring and Record Maintenance 26 Transportation and Storage 27 Treatment and Disposal Unit3 Special Situations 31 Blood, Blood Bags and Body Fluids 32 Blood Spills 33 Linens 3.4 Mercury Spills 35 Sputum Cups Unit 4 Universal Precautions 41 Hand Washing 42 Protective Gears 43 Immunization 44 Post Exposure Prephylaxis (PEP) - Needle Stick Injuries Unit Essential Practices SL Essential Practices for Sanitory Workers / Hospital Workers 52 Essential Practices for Nurses and Paramedical staff 53 Essential Practices for Doctors ‘Annexures & Chart Annexure-1&2 Annexure-3&4 Flow Chart: Page Nee 12 12 13 13 13 14 14 1S 15 16 17 18 19 20Need for the Hand Book The Government of India’s Bio-Medical Waste (Management and Handling) Rules, 1998 came into force from July, 1998, with amendments in 2000, 2003 under the Environment Protection Act, 1986. To comply with these rules, implementation of Bio-Medical Waste Management has been piloted in 2 districts of Dharmapuri and Krishnagiri since March, 2006. Based on the experience gained from the pilot, now itis planned to upscale the implementation to all the Government Hospitals in all the districts of Tamil Nadu. Itis planned in such a way that the Hospitals in all the districts are tied up with the Common Treatment Facilities which will be responsible for the final treatment and disposal of segregated Bio-Medical Waste handed cover to them by the Hospitals. Now, it is utmost important for the Hospitals to segregate the Bio- Medical Waste at the source where it is generated according to the colour coding patterns provided in the rules. Tamil Nadu Health Systems Project has now worked out this hand book meticulously in consultation with the experts in the field of Bio- Medical Waste Management such as Prof. Dr. Gajendaran, Toxics Link, TANSACS and State TB Office. This hand book provides you the basic aspects of Bio-Medical Waste, sources of generation, unified protocol for colour coding of waste, methods of final disposal at the Common Treatment Facility (CTF) and managementin special situations such as blood spills, mercury spills etc. We request you to kindly utilize this material and keep your Hospital clean from all preventable infections and also be a true citizen by obliging the law.1.1 Current Scenario in Health Care Institutions ‘The Health Care Institutions in India use approximately 80 crore: various treatment and immunization practices. jections in a year in It is estimated that about 60% of it is infectious and often disposed improperly, which makes a path for transmission of infections such as HIV, HBV, etc to health care providers unknowingly. The Health Care Waste generation ranges between 0.5 to 2,0 kg per bed per day. At present, the bio-medical waste is being collected in mixed state and disposed along with municipal waste, Poorly managed bio-medical waste not only poses a potential danger to patients and the community butalso a great risk to health care providers themselves, 1.2 Hospital Acquired Infections Hepatitis ABEC HIV - AIDS Cholera, Typhoid, Tiyoaniens Tuberculosis Staphylococcal Candida infections infections Fig No. 1 1.3 Hospital Waste Waste generated in health care units including hospitals, laboratories and blood banks/camps etc., includes bio-medical waste and general waste. 4‘Source : Hospital Staff, Patients, Attenders, Public, etc. Staying and Waiting places or rooms. Type: General Waste 85% Wastes : Food Waste, Plastic bag, etc. ipoules, lancets, etc. TV tubes, placenta, 1.4 Bio-Medical Waste (Management & Handling) Rules, 1998, According to the Bio-Medical Waste (Management & Handling) Rules 1998, Bio-Medical Waste is defined as “any waste which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities there to or in the Production or testing of biologicals and including categories mentioned in Schedule - 1" The Government of India notified the Rules in 1998 and itis applicable across the country toall Health Care establishments. The Rules recognize that there are different kinds of waste generated from any health care institution. It identifies different categories of Bio Medical Waste and specifies the kind of waste treatment / disposal for each category. 2Salient Features of the Rules : a, Waste Categories Schedule 1 : Categories of Bio-Medical Waste ‘Human Anatomical Waste = human tissues, body parts, etc. il Animal Waste - animal tissues, organs, ‘body parts, etc. and Biotechnology Waste - ym laboratory cultures, stocks, of micro-organisms, etc. 9.4 Waste Sharps - needles, syringes, scalpels, blades, glass, etc. which may be used and unused. Category No.5 Discarded Medicines and Cytotoxic Drugs - Incineration / wastes comprising of outdated, ‘Secured Land Fill, contaminated and discarded medicine. wastes from disposable in the waste sharps like ; intravenous sets, Category No. 8 Liquid Waste - waste generated from Disinfection by chemical laboratory and washing, cleaning, treatment & discharge disinfection activities, etc, into drains. Category No.9 Incineration Ash - ash from incineration Disposal in municipal of any bio-medical waste. Landfill. Category No. 10 Chemical Waste - chemicals used in Chemical treatment and disinfection, production of biologicals, etc. _ discharge into drains for liquids and secured landfills for solids,Duty of the Occupier It shall be the duty of every occupier of a Hospital / Health care Unit generating Bio Medical Waste to ensure that such waste Is handled without adverse effect to human health and the environment. Segregation The Bio-Medical Waste should not be mixed with other waste, It should be segregated at the point of generation in accordance to the colour codes prescribed in the rules and should be properly labeled. Storage Untreated Bio-Medical Waste shall not be stored more than 48 hrs, but in case of emergency, prior approval must be sought from prescribed authority. Transportation Bio-Medical waste shall be transported only in such vehicles authorised by the competent authority. Authorization It means the permission granted by the prescribed authority for the generation, collection, reception, storage, transportation, treatment, disposal or any other form of handling of Bio-Medical Waste in accordance with the Rules. The prescribed authority is the Tamil Nadu Pollution Control Board for the state or the District Environmental Engineer for districts. Maintenance of records Every occupier shall maintain records on generation, collection, reception, storage, treatment, disposal or any other form of handling Bio-Medical Waste and itis subjected toinspection and verification atany time. Non-Compliance Failure to comply with any provision of this Actis punishable with imprisonment for up tofive years or witha fine of Rs. 1,00,000 or bath.Unit 2. Systematic Approaches for Managing Bio-Medical Waste 2.1 Waste in your Hospital In any Hospital, only 10-15% of the waste contributes to Bio Medical Waste and the rest 85% is General Waste. + Qut of the 15% Bio-Medical Waste, 10% is infectious waste and 5% is hazardous waste, + Mixing of 15% Bio-Medical Waste with 85% General waste [© : leads to not only converting the General Waste into Bio-Medical Waste but also makes it more infectious, - — Bio Medical Waste (10% infections 5% hazardous) ‘Improper segregation practices increase the cost of treatment General Waste and disposal up to 500% * Proper segregation practice reduces the chances of spreading infection and the investment in waste disposal. 2.2 Segregation of Waste Segregation of waste means Separating and placing the Hospital Waste / Bio-Medical Waste and General waste in the different colour coded bins as per rules (given below). Different Colour Coded Bins Red Bin | F ‘Yellow Bin Bue Bin Black Bin Green Bin_ Instructions for Good Segregation Practices ‘Segregation should be done immediately without delay at the point of generation itself: “+ Colour bins should be kept at appropriate places like wards, OP, etc. Based only on its _ need. + Bins should be covered with a lid and properly labeled. "+ Bins should be cleaned at regular intervals. "+ Place the appropriate poster against the appropriate colour bins. 2.3 Disinfection of Segregated Waste Disinfection is a process of destroying micro-organisms that can cause potential danger by transmitting infections. Itis an essential part in Bio-Medical Waste Management. Mode of Disinfection « Disinfection can be done in two ways i.e, Chemical and Mechanical wherever essential, « In the Chemical disinfection process, generally chlorine based chemical disinfectants like Sodium Hypochlorite Solution, bleach, etc. are used. « Inthe Mechanical disinfection process, devices like autoclave or microwave are used. Instructions for accurate disinfection = Disinfection process should begin after segregation at the point of waste generation (nursing stations, wards, etc.), itself. Freshly prepared 1% Sodium Hypochlorite Solution from stock should be used. ‘Incase of heavily soaked material or spill, 10% bleach solution may beused. Waste material has to be completely soaked / covered for a minimum contact time of 30 minutes should be allowed. “= Container should be closed to prevent chlorine escape. 2.4 Path Way of Colour Bins for Wastes Twin Bin (for plastic waste disinfection) after 30 minutes of disinfection, put 25 Liters Red Bin (big) with 15 Liters Red Bin (small)with the plastic wastes in Red Bin (big) Red Bag for Plastic Wastes Red Bag for non-Plastic Wastes 6There are three types of Red Bins - Twin Bin, 25 Liters Red Bin (big), and 15 Liters Red Bin (small) Clearly demarcate plastic and non-plastic wastes. + Put the plastic waste such as syringes, LV. Tubes, ryles tube, catheters, etc. In the Twin bin provided which has 1% freshly prepared Sodium Hypochlorite Solution in it. ‘The plastic waste should be immersed at least for 30 minutes in the Twin Bin for disinfection process, ‘After disinfecting the plastic waste, shift it to the specially designed pictured Red colour bag with big bio-hazard symbol inside the red bin (25 liters - big). Non-plastic waste (used cotton, gauze, soiled bandages) should be placed in red bag with ‘small bio-hazard symbol inside the small red bin (15 liters - small), Twin Bin System of Disinfection , + Bio-Medical Waste such as sharps including ampoules, vials, broken glasses, suture, slides, etc. should be placed in the Blue Bin, + Needles and suture lancets should be managed by using needle destroyer.Needle Management with Needle Destroyer HIV & HBV transmission can be largely minimized by adhering strict needle management plan by using the Needle Destroyer Instrument. When the needle is inserted in the hole provided in the needle destroyer, a high temperature electric arc is passed which burns the needle. + The used needles should be destroyed immediately to reduce minimum handling of sharps. All the nursing stations should have a needle destroyer and it should be used regularly. + Theremnants should be handed over to the CTF in separate container. + Thesyringes should be placed in the red bin intended for plastic waste. Instructions for Safe Handling of Sharps + Personal protective gear must be worn while managing sharps. = Needles should never be recapped. + Needles should be destroyed immediately after use. * Syringes should be cut and disinfected in a Twin bin. + Other sharps like lancets, blades, scalpels, ete. can be directly put in disinfecting solution (Red colour twin bin). * Sharps related accidents must be reported immediately to the administration. + Bio-Medical Waste such as anatomical waste, placenta, tissues, body parts, etc. should be placed in the Yellow Bins.! (4. Black Bin + Inthe Black Bin, all expired drugs and cytotoxic drugs, etc, should be placed. + General waste such as food items, plastic covers, needle covers and non infected plaster of paris, etc should be placed in the Green bins. 2.5 Monitoring and Record Maintenance Health Care Units and Hospitals should maintain the records for the Bio-Medical Waste generated and disposed from their premises. Bio- Medical Waste Management Registers includes four types. 1. Registers for Daily Collection of Bio-Medical Waste at the source. . Register of Source wise collection of Bio-Medical Waste for the day. . Monthly consofidation register for collection of Bio-Medical Waste. 4, Register for needle stick injuries. - Separate Registers should be maintained in each ward, OP, theaters, laboratories, etc. and the respective Staff in-charge (Staff Nurse / Paramedical staff) should fill the details daily as per Annexure-1. - Sanitary Workers / Hospital Workers should maintain source (wards, OP, etc.) Ward wise Bio-Medical Waste collection register as per Annexure-2 duly attested by Staff Nurse in-charge. - The Hospital Superintendent / Chief Medical Officer is responsible to maintain consolidated Monthly register on Bio- Medical Waste Management as per Annexure-3 and the Register for Needle Stick Injuries as per Annexure-4, = The Hospital Infection Control Officer is responsible for overall monitoring, payment to ‘Common Treatment Facility and record maintenance of Bio-Medical Waste Management. 92.6 Transportation and Storage + After weighing the segregated Bio-Medical Waste and registering its details in the wards / OP / Lab / Theaters, etc, it should be transported to the respective Colour Bins kept in the Trolleys. The waste collected in the trolleys should be transported and stored in the Health Care Waste Storage Room in the Hospital for the disposal to the Common Treatment Facility. Care should be taken that no Bio-Medical Waste should be spilled during transportation. 2.7 Treatment and Disposal The segregated Bio-Medical Waste collected from the Hospital should be transported to the Common Treatment Facility for further final disposal. What isa Common Treatment Facility? ‘Common Treatment Facility (CTF) ot Common Bio-Medical Waste Treatment Facility is referred to a place or establishment where the Bio-Medical Waste collected from the Hospitals is treated and disposed in accordance to the Bio-Medical Waste (Management & Handling) Rules. Technology used for Treatment and Disposal of Waste Based on the kind of segregated waste various treatment technologies are used for final disposal. + Autoclave + Incineration + Sharp Pits + Secured Land Fill Autoclave + Autoclave is the process in which the waste is treated under high pressure and temperature of about 120° centigrade fora minimum periodof 30 minutes thereby destroying all forms of fungus, bacteriaand micro-organism including virus. + The disinfected Bio-Medical Waste collected in Red bag is autoclaved. « Theautoclaved waste is safe and sterile.Incineration + It is a process of burning the anatomical waste such as human tissues, organs, placenta and the waste collected in yellow bag without disinfection, body parts in high temperature to destroy the waste. + Thefinal residueisash. Secured Land Fill + Secured Land Fill is one which has containment measures such as liners and a leach ate collection system so that materials placed in the landfill will not migrate into the surrounding sol, air and water. + The ash from the incinerators and the waste from black bags which includes cytotoxic ‘drugs and expired drugs will be disposedtoa secured landfill, Deep Burial + Deep Burial is an alternate technology opted for disposing small quantities of Bio Medical Waste. + A separate pit is dug and used to dispose Bio-Medical Waste which can decompose naturally. + The pits should be relatively distant (1 - 2 meters wide and 2 - 5 meters deep) and covered from human habitation. Security fence around the pit Embedded Wire Mesh When the contents reach $0 om of the surface the hole is filed in wth ima and then soi arth mound to keep surface water out of the pit. 2- Sms Bio-Medical Waste : 10cm layer of soi 1-2Mes Design for Deep Burial Pit Layer of time Sharp Pits = The sharps like disinfected needles which is stored in the puncture proof container in the Hospitals and the wastes in blue bags are disposedto the sharp pitsatthe CTF. "‘Special Situations in Health Care Units Some special situations may occur in any hospital such as HIV positive infected blood bag / blood spills / linens / mercury spills and infected sputum cups, which needs a specific and different Bio-Medical Waste Treatment methodology in the Hospital. Such treatment cases aregiven below. 3.1 Blood / Blood Bags & Body Fluid Source : Laboratories, etc. ‘Treatment : + Ensure the gloves are fitted on before Handling. + The Bag containing the discarded blood / body fluids should be emptied in a 5% Sodium Hypochlorite Solution for 30 minutes. The emptied bag also should be immersed inthe same solution for 30 minutes. After disinfecting the discarded blood or body fluid, can be drained to the main drainage and the disinfected bag should be transferred to the Red plastic bag (big). 3.2 Blood Spills Source : Wards / Laboratories, etc. ‘Treatment : + Ensure thatthe gloves are used before Handling. + Coverthe Spill with absorbent cotton orclath. =. + Discard this cloth in the small red bin intended for non plastic waste. Disinfect the surface with 5% Sodium Hypochlorite Solution/5% Phenol/10% Bleach for 10-15 minutes or use phenolic disinfectants. 12+ Now use cloth or cotton to absorb the spill and discard it in the red small bag intended for non plastic waste, + Finally, use the normal mop. 3.3 Linens Source : Wards / Casualty / Theaters / Labor Rooms, etc. Treatment : + Ensure that the gloves are fitted on before Handling. + Used Linens soiled with blood / body fluids should be transported very carefully with the tag tied on it making ‘minimal handling only’. + They should be unloaded directly into the washing chamber (laundry) after disinfecting with 10% Sodium Hypochlorite Solution for 30 minutes, After which it can be mixed with regular linens. 3.4 Mercury Spills Source : Wards / Dental OP, etc. be % ° Treatment : ata + Open all the windows immediately. : e °0 + Remove all the jewels and watches. ° + Ensure that the gloves are fitted on before handling. + Spilled mercury should be collected with the cardboard sucked with the syringes. + Empty the syringes with mercury in a container with water. + It should be labeled as mercury waste and handed over to CTF. 3.5 Sputum Cups Source : Laboratory, etc. Treatment : + Ensure that the gloves are fitted on before Handling. * Remove the lid from the sputum cups. = Place the sputum cup with its lid opened into a_ inner sieve container of a twin bin which contains 5% Sodium Hypochlorite Solution and keep it for 12 hours. © After 12 hours, lift the disinfected sputum cups from the inner sieve container of twin bin and transit to Red bins intended for plastic waste. = Solution is drained into the main drain.Unit 4 Universal Precautions Universal Precautions for Health Providers Universal Precautions are a series of recommendations for health care providers to protect themselves, their patients and other health care workers from the spread of infectious diseases. Methods of Universal Precautions 4.1 Hand Washing + Ibis the single most essential practice, which reduces the risk of transmission of infection. + Hand washing with soap water in an effective manner is essential. + Hand washing is necessary even gloves wear used. 4.2 Protective Gears + Health Care Providers should use the Protective Gears like Apron, Gloves and Mask wherever essential to reduce the cross contamination and the risk of transmitting infection from person to person in Hospital.4.3 Immunization + Health Care Staff are exposed to high risk of infections like HBV, HIV and Tetanus. recommended that all the Health Care Staff should be vaccinated. However, no vaccine exists to prevent HIV infection. 4.4 Post Exposure Prophylaxis (PEP) - Needle Stick Injuries Place the injured part under running water and allow the bleeding from the site of injury. Wash the wounds with soap. * Apply antiseptic cream and cover the wound with the dressing. * Report the incident immediately to the doctor / nurse concemed toreceivethe PEP drugs. + Needle Stick Injuries should be registered in the prescribed Annexure-4, h ™ 5Unit_5 Essential Practices for Health Care Providers It is sensed, Bio-Medical Waste Practices lead to some injuries and infections when handled without necessary precautions, The Health Care Staff such as Sanitary Workers / Hospital Workers, Nurse / Para Medical Staff & Doctors are to be sensitized for effective management of Bio-Medical Waste. 5.1 Essential Practices for Sanitary Workers / Hospital Workers. + Wear Protective Gears such as apron, gloves and mask before handling Bio-Medical Waste. Do not mix the segregated waste. * Collect and store the Bio-Medical Waste in Health Care Waste Storage Rooms. + Use trolley for collection and transportation of Bio Medical Waste in the Hospital premises + Avoid dragging of waste bags to prevent spillage + Weigh the Bio-Medical Waste at the point of collection at each Health Care Units and record the quantitative details in the prescribed Register on daily basis. 5.2 Essential Practices for Nurse / Para Medical Staff + Segregate the waste as per colour code. Disinfect the segregated waste wherever essential. Avoid transferring sharp instruments directly from person to person. + Do not recap the needles. + Record the quantity of weighed Bio-Medical waste in the prescribed register on daily basis.5.3 Essential Practices for Doctors Conduct regular visit in and around the Hospital and monitor the entire conditions of Bio Medical Waste Management and rectify the drawbacks or violations immediately as per guidelines prescribed. Monitor and maintain the Registers for Bio-Medical Waste Management dully filled by the respective staff / officers in the Hospital. Create awareness amongst the Hospital Staff, patients & public and build their attitude towards handling Bio-Medical Waste and General Waste meticulously. Convene monthly meetings with all the Staff and discuss the issues and best practices in managing Bio-Medical Waste, Recognize and encourage the persons who handle Bio Medical Waste effectively. Promote ownership among the staff and publicto sustain the proper practice of handling Bio-Medical Waste and also to keep the entire hospital atmosphere as hygienic, uncontaminated and safe in the long run. 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