! "'~-"· "'.·.

,: '

-
15
.,
.
Hospital Waste
Management
Let the wastes of "the sick" not contaminate the lives of "the healthy"

T he waste produced in the course of health-care All these health-care establishments generate waste and
activities carries a higher potential for infection and injury are therefore, covered under Bio-Medical Waste (BMW)
than any other type of waste. Therefore, it is essential to Rules (1).
have safe and reliable method for its handling. Inadequate
and inappropriate handling of health-care waste may have Health-care waste generation
serious public health consequences and a significant impact Several surveys have provided an indication of typical
on the environment. Appropriate management of health- health-care waste generation, and it shows that this differs
care waste is thus a crucial component of environmental not only from country to country but also within the country.
health protection, and it should become an integral feature Waste generation depends on numerous factors such as
of health-care services. established waste management methods, type of health-care
establishment, hospital specializations, proportion of
Definition reusable items employed in health-care, and p roportion of
According to Bio-Medical Waste (Management and patients treated on a day-care basis.
Handling) Rules, 1998 of India, "Bio-medical waste" means In middle and low income countries, health-care waste
any waste, which is generated during the diagnosis, generated is lower than in high-income countries.
treatment or immunization of human-beings or animals, or Developing countries that have not performed their own
in research activities pertaining thereto or in the production surveys of health-care waste, find the following estimates fo r
or testing of biologicals. an average distribution of health-care wastes useful for
Between 75 to 90 per cent of the waste produced by the preliminary planning of waste management (2) :
health-care providers is non-risk or "general" health-care - 80 per cent general health-care waste, which may be
waste, comparable to domestic waste. It comes mostly from dealt with by the normal domestic, and urban waste
administrative and house keeping functions of the health- management system;
care establishments, and may also include waste generated
during maintenance of health-care premises. The remaining
- 15 per cent pathological and infectious waste;
10-25 per cent health-care waste is regarded as hazardous - 1 per cent sharps waste;
and may create a variety of health risk (2). - 3 per cent chemical and pharmacological waste;
- Less than 1 per cent special waste, such as radio-
Source_s of health-care waste active or cytotoxic waste, pressurized containers, or
The institutions involved in generation of bio-medical broken thermometers and used batteries.
waste are: Table 1 shows average composition of waste obtained
- Government hospitals; from 10 large hospitals in Mumbai, Kolkata, Delhi, and
- Private hospitals; Nagpur during the period 1993-1996.
- Nursing homes; TABLE 1
- Physician' s office/clinics; Average composition of hospital waste in India
- Dentist's office/clinics;
Percentage
- Dispensaries; Material II (wet-weight basis)
- Primary health centres;
- Medical research and training establishments; Paper 15

- Mortuaries; Plastics 10
- Blood banks and collection centres; Rags 15

- Animal houses; Metal (sharps etc.) 1

Infectious waste 1.5
- Slaughter houses;
Glass 4 .0
- Laboratories;
General waste (food waste, sweepings from 53.5
- Research organizations; hospital premises etc.)
- Vaccinating centres; and
- Bio-technology institutions/production units. Source : (National Environmental Engineering Research Institute 1997)
 5 HOSPITAL WASTE MANAGEMENT

survey done in Bangalore revealed that the quantity of 4 . Hazards from radio-active waste
sohd wastes generated in hospitals and nursing homes
generally varies from 1/2 to 4 kg per bed per day in Govt. The type of disease caused by radio-active waste is
hospitals, 1/2 to 2 kg per bed per day in private hospitals, determined by the type and extent of exposure. It can range
and 1/2 to 1 kg per bed per day in nursing homes. The total from headache, dizziness and vomiting to much more
quantity of hospital wastes generated in Bangalore is about serious problems. Because it is genotoxic, it may also affect
40 tonnes per day. Out of this nearly 45 to 50 per cent is genetic material.
infectious. Segregation of infectious wastes from non-
infectious wastes is done only in about 30 per cent of 5. Public sensitivity
hospitals (3). Apart from health hazards, the general public is very
sensitive to visual impact of health-care waste particularly
Health hazards of health-care waste anatomical waste.
Exposure to hazardous health-care waste can result
in disease or injury due to one or more of the following Treatment and disposal technologies for health-
characteristics : care waste (2)
(a) it contains infectious agents; (b) it contains toxic or Incineration, used to be the method of choice for most
hazardous chemicals, pathological waste or pharmaceuticals; hazardous health-care wastes, and is still widely used.
(c) it contains sharps; (d) it is genotoxic; (e) it is radio-active; However, recently developed alternative treatment methods
and (f) non-hazardous or general waste. are becoming increasingly popular. The final choice of
All individuals exposed to such hazardous health-care treatment should be made on the basis of factors, many of
waste are potentially at risk, including those who generate which depend on local conditions.
the waste or those who either handle such waste or are
exposed to it as a consequence of careless management. The I. Incineration
main groups at risk are : Incineration is a high temperature dry oxidation process,
- medical doctors, nurses, health-care auxilliaries, and that reduces organic and combustible waste to inorganic
hospital maintenance personnel; incombustible matter and results in a very significant
- patients in health-care establishments; reduction of waste-volume and weight. The process is
- visitors to health-care establishments; usually selected to treat wastes that cannot be recycled,
- workers in support service allied to health-care reused or disposed off in a land fill site.
establishments such as laundries, waste handling and The flow diagram of incinerator is as shown in Fig. 1.
transportation; and Incineration requires no pre-treatment, provided that
- workers in waste disposal facilities such as land-fills or certain waste types are not included in the matter to be
incinerators including scavengers. incinerated. Characteristics of the waste suitable for
1. Hazards from infectious waste and sharps incineration are : (a) low heating volume - above
2,000 kcal/kg for single-chamber incinerators, and above
Pathogens in infectious waste may enter the human body 3 ,500 kcal/kg for pryolytic double-chamber incinerators;
through a puncture, abrasion or cut in the skin, through (b) content of combustible matter above 60 per cent;
mucous membranes by inhalation or by ingestion. There is (c) content of non-combustible solids below 5 per cent;
particular concern about infection with HIV and hepatitis (d) content of non-combustible fines below 20 per cent; and
virus B and C, for which there is a strong evidence of (e) moisture content below 30 per cent (2).
transmission uia health-care waste. Bacterias resistant to
antibiotics and chemical disinfectants, may also contribute Waste types not to be incinerated are : (a) pressurized gas
to the hazards created by poorly managed waste. containers; (b) large amount of reactive chemical wastes;
(c) silver salts and photographic or radiographic wastes;
2. Hazards from chemical and pharmaceutical waste (d) Halogenated plastics such as PVC; (e) waste with high
Many of the chemicals and pharmaceuticals used in mercury or cadmium content, such as broken thermometers,
health-care establishments are toxic, genotoxic, corrosive, used batteries, and lead-lined wooden panels; and (f) sealed
flammable, reactive, explosive or shock-sensitive. Although ampules or ampules containing heavy metals (2).
present in small quantity they may cause intoxication, either
by acute or chronic exposure, and injuries, including burns. TYPES OF INCINERATORS
Disinfectants are particularly important members of this Incinerators can range from very basic combustion unit
group. They are used in large quantities and are often that operates at much lower temperature to extremely
corrosive, reactive chemicals may form highly toxic sophisticated, high temperature operating plants. It should
secondary compounds. be carefully chosen on the basis of the available resources,
the local situation, and the risk-benefit consideration.
3 . Hazards from genotoxic waste
Three basic kinds of incineration technology are of
The severity of the hazards for health-care worker
interest for treating health-care waste :
responsible for handling or disposal of genotoxic waste is
governed by a combination of the substance toxicity itself (a) Double-chamber pyrolytic incinerators which may be
and the extent and duration of exposure. Exposure may also especially designed to burn infectious health-care waste;
occur during the preparation of or treatment with particular (b) Single-chamber furnaces with static grate, which should
drug or chemical. The main pathway of exposure is be used only if pyrolytic incinerators are not affordable; and
inhalation of dust or aerosols, absorption through the skin, (c) Rotary kilns operating at high temperatures, capable of
ingestion of food accidentally contaminated with cytotoxic causing decomposition of genotoxic substances and
drugs, chemicals or wastes etc. heat-resistant chemicals.
 HEALTH HAZARDS Or- HEALTH-CARE WASTE 1
Exhaust gas,
.,.
to atmosphere

Flue gas .. Ashes

cleaning Waste-water
(optional) (optional)
--..,.,.=---·- Steam
Flue gas 1 1- - - - - - - -t Heat recovery

Air - - - - -
Furnace
Waste - - - -
I
I
I
I
I
Water
L - -
Waste-water
- -."1 Waste-water
---- discharge
I treatment (optional) Sludges
(require
treatment)
- - - - -... Ashes
(to disposal, and possibly stabilization)

FIG. 1
Simplified flow scheme of incinerator
Source : (2)

II. Chemical disinfecti on efficiency of the microwave disinfection should be checked

routinely through bacteriological and virological tests.
Chemicals are added to waste to kill or inactivate the
pathogens it contains, this treatment usually results in V. Land disposal
disinfection rather than sterilization. Chemical disinfection is
most suitable for treating liquid waste such as blood, urine, MUNICIPAL DISPOSAL SITES : If a municipality or
stools or hospital sewage. However, solid wastes including medical authority genuinely lacks the means to treat waste
microbiological cultures, sharps etc. may also be disinfected before disposal, the use of a landfill has to be regarded as an
chemically with certain limitations. acceptable disposal route. There are two types of disposal
land- open dumps and sanitary landfills. Health-care waste
lll. Wet and dry thermal treatment should not be deposited on or around open dumps. The risk
WET THERMAL TREATMENT : Wet thermal treatment or of either people or animals coming into contact with
steam disinfection is based on exposure of shredded infectious pathogens is obvious.
infectious waste to high temperature , high pressure steam, Sanitary landfills are designed to have at least four
and is similar to the autoclave sterilization process. The advantages over open dumps : geological isolation of waste
process is inappropria te for the treatment of anatomical from the environmen t, appropriate engineering preparation
waste and animal carcassess, and will not efficiently treat before the site is ready to accept waste, staff present on site
chemical and pharmaceut ical waste. to control operations, and organized deposit and daily
SCREW-FEED TECHNOLOGY : Screw-feed technology coverage of waste.
is the basis of a non-burn, dry thermal disinfection process
in which waste is shredded and heated in a rotating auger. VI. lnertizatio n
The waste is reduced by 80 per cent in volume and by The process of "inertization" involves mixing waste with
20-35 per cent in weight. This process is suitable for treating cement and other substances before disposal, in order to
infectious waste and sharps, but it should not be used to minimize the risk of toxic substances contained in the wastes
process pathological , cytotoxic or radio-active waste. migrating into the surface water or ground water. A typical
IV. Microwav e irradiatio n proportion of the mixture is: 65 per cent pharmaceuti cal waste,
15 per cent lime, 15 per cent cement and 5 per cent water. A
Most microorganisms are destroyed by the action of homogeneo us mass is formed and cubes or pellets are
microwave of a frequency of about 2450 MHz and a wave produced on site and then transported to suitable storage sites.
length of 12.24 nm. The water contained within the waste is
rapidly heated by the microwaves and the infectious The main advantages and disadvantag es of various
components are destroyed by heat conduction. The treatment and disposal options are listed in Table 2.
 HOSPITAL WASTE MANAGEMENT

TABLE 2
Main advantages and disadvantag es of treatment and disposal options
Treatment /
Advantages
--- - ---- -- ------ ~
~posal method Disadvantages
-
Rotary kiln Adequate for all infectious waste. most chemical High investment and operating costs.
waste and pharmaceutical waste.
Pyrolytic Very high disinfection efficiency. Adequate for all infectious Incomplete destruction of cytotoxics.
incineration waste and most pharmaceutical and chemical waste. Relatively high investment and operating costs.
Single-chamber Good disinfection efficiency. Significant emissions of atmospheric pollutants.
incineration Drastic reduction of weight and volume of waste. Need for periodic removal of slag and soot.
The residues may be disposed off in landfills. Inefficiency in destroying thermally resistant
No need for highly trained operators. chemicals and drugs such as cytotoxics.
Relatively low investment and operating costs.
Drum or brick Drastic reduction of weight and volume of the Destroys only 99% of microorganisms. No destruction
incinerator waste. Very low investment and operating costs. of many chemicals and pharmaceuticals. Massive
emission of black smoke, fly ash, toxic flue gas,
and odours.
Chemical Highly efficient disinfection under good operating Requires highly qualified technicians for operation
disinfection conditions. of the process.
Some chemical disinfectants are relatively Uses hazardous substances that require comprehensive
inexpensive. safety measures.
Inadequate for pharmaceutical, chemical and some
types of infectious waste.
Wet thermal Environmentally sound . Shredders are subject to frequent breakdowns and
treatment• poor functioning.
Relatively low investment and operating costs. Operation requires qualified technicians.
Inadequate for anatomical, pharmaceutical,
chemical waste and waste that is not
readily steam-permeable.
Mircowave Good disinfection efficiency under appropriate Relatively high investment and operating costs.
irradiation operating conditions.
Drastic reduction in waste volume. Potential operation and maintenance problems.
Environmentally sound.
Encapsulation Simple, low-cost, and safe. Not recommended for non-sharp infectious waste.
May also be applied to pharmaceuticals.
Safe burying Low costs. Safe only if access to site is limited and certain
Relatively safe if access to site is restricted and precautions are taken .
where natural infiltration is limited.
lnertization Relatively inexpensive. Not applicable to infectious waste.
r
• May not apply to more sophisticated , self-contained , commercial methods.
Source : (2)

National legislation is the basis for improving health-care (d) Dispose off the final residue by landfill in confined and
waste disposal practices in any country. It establishes legal carefully designed sites.
control, and permits the national agency responsible for the
disposal of health-care waste, usually the Ministry of Health, Bio-Medic al Waste Managem ent in India (1, 4, 5)
to apply pressure for their implementa tion. The Ministry of
Environmen t may also be involved. There should be a clear Bio-Medical Waste (Manageme nt and Handling) Rule
designation of responsibilit ies before the law is enacted. 1998, prescribed by the Ministry of Environmen t and
Forests, Governmen t of India, came into force on 28th July
The United Nations Conference on the Environmen t and 1998. This rule applies to those who generate, collect,
Developmen t (UNCED) in 1992 recommend ed the following
receive, store, dispose, treat or handle bio-medical waste in
measures :
any manner. The Act is now superceded by Bio-Medical
(a) Prevent and minimize waste production; Waste Managemen t Rules, 2016, which came into force
(b) Reuse or recycle the waste to the extent possible; from 28th March 2016. Table 3 shows the categories of bio-
(c) Treat waste by safe and environmen tally sound medical waste, types of waste and treatment and disposal
methods; and options under Rule 2016.
 HEALTH HAZARDS OF HEALTH-CARE WASTE

TABLE 3
I
Schedule I, Part I !
Biomedical wastes, categories and their segregation, collection, treatment , processing and disposal options
Type of bag or
Category Type of waste container to Treatment and disposal options

Yellow
-----------·----- ---·-----------------------
be used
Yellow coloured
(a) Human anatomical waste: Human tissues, Incineration or plasma pyrolysis or deep burial• ~
organs. body parts and foetus below the non-chlorinated
viability period. plastic bags.
(b) Animal anatomical waste: Experimental
animal carcasses, body parts, organs, tissues,
including the waste generated from animals
used in experiments or testing in veterinary
hospitals or colleges or animal houses.
(c ) Soiled waste: Items contaminated with blood, Incineration or plasma pyrolysis or deep burial•.
body fluids like dressings, plaster casts, In absence of above facilities, autoclaving or micro-waving/
cotton swabs and bags containing residual hydroclaving followed by shredding or mutilation or
or discarded blood and blood components. combination of sterilization and shredding. Treated waste
to be sent for energy recovery.
(d) Expired or discarded medicines : Yellow coloured Expired cytotoxic drugs and items contaminated with
Pharmaceutical waste like antibiotics, non-chlorinated cytotoxic drugs to be returned back to the manufacturer
cytotoxic drugs including all items plastic bags or or supplier for incineration at temperature > 1200° C
contaminated with cytotoxic drugs along containers. or to a common bio-medical waste treatment facility
with glass or plastic ampoules, vials etc. or hazardous waste treatment, storage and disposal
facility for incineration at > 1200° C or Encapsulation
or Plasma Pyrolysis at > 1200° C.
All other discarded medicines shall be either sent back
to manufacturer or disposed by incineration.
(e ) Chemical was te: Chemicals used in Yellow coloured Disposed of by incineration or Plasma Pyrolysis or
production of biological and used or containers or Encapsulation in hazardous waste treatment, storage
discarded disinfectants. non-chlorinated and disposal facility.
plastic bags.
(f) Chemical liquid was te: Liquid waste generated Separate After resource recovery, the chemical liquid waste shall
due to use of chemicals in production of collection be pre-treated before mixing with other wastewater.
biological and used or discarded disinfectants, system leading The combined discharge shall conform to the
Silver X-ray film developing liquid, discarded to effluent discharge norms given in Schedule-III.
formalin, infected secretions, aspirated body treatment
fluids, liquid from laboratories and floor system.
washings, cleaning, house-keeping and
disinfecting activities etc.
(g) Discarded linen. mattresses, beddings Non-chlorinated Non-chlorinated chemical disinfection followed by
contaminated with blood or body fluid. yellow plastic incineration or Plazma Pyrolysis or for energy recovery.
bags or suitable In absence of above facilities, shredding or
packing material. mutilation or combination of sterilization and
shredding. Treated waste to be sent for energy
recovery or incineration or Plazma Pyrolysis.
(h) Microbiology, biotechnology and other Autoclave safe Pre-treat to sterilize with non-chlorinated chemicals
clinical laboratory waste: Blood bags. plastic bags on-site as per National AIDS Control Organisation or
laboratory cultures, stocks or specimens of or containers. World Health Organisation guidelines thereafter for
micro-organisms, live or attenuated vaccines, Incineration.
human and animal cell cultures used in research.
industrial laboratories, production of biological,
residual toxins, dishes and devices used for
cultures.
Red Contaminate d waste (Recyclable) : Red coloured Autoclaving or micro-waving/hydroclaving followed by
Wastes generated from disposable items such as non-chlorinated shredding or mutilation or combination of sterilization
tubing, bottles, intravenous tubes and sets, catheters, plastic bags or and shredding. Treated waste to be sent to registered or
urine bags, syringes (without needles and fixed containers. authorized recyclers or for energy recovery or plastics to
needle syringes) and vaccutainers with their diesel or fuel oil, or for road making, whichever is possible.
needles cut) and gloves. Plastic waste should not be sent to landfill sites.
White Waste sharps Includi ng metals: Needles. syringes Puncture proof, Autoclaving or Dry Heat Sterilization followed by shredding
(Trans- with fixed needles, needles from needle tip cutter Leak proof. or mutilation or encapsulation in metal container or
lucent) or burner, scalpels, blades or any other tamper proof cement concrete; combinations of shredding cum
contaminated sharp object that may cause containers. autoclaving; and sent for final disposal to iron foundries
puncture and cuts. This includes both used, {having consent to operate from the State Pollution
discarded and contaminated metal sharps. Control Boards or Pollution Control Committees)
or sanitary landfill or designated concrete waste sharp pit.
Blue (a) Glassware: Broken or discarded and Cardboard boxes Disinfection {by soaking the washed glass waste after
contaminated glass including medicine vials with blue coloured cleaning with detergent and Sodium Hypochlorite
and ampoules except those contaminated marking. treatment) or through autoclaving or microwaving or
with cytotoxic wastes. hydroclaving and then sent for recycling.
(b) Me tallic body implants Cardboard boxes
with blue coloured
marking.
• Disposal by deep burial is permitted only in rural or remote areas where there is no access to common bio-medical waste treatment facility. This will
be carried out with prior approval from the prescribed authority and as per the standards specified in Schedule-Ill. The deep burial facility shall be
located as per the provisions and guidelines issued by Central Pollution Control Board from time to time.
Source: (4)
 HOSPITAL WASTE MANAGEMENT

- - - -- __.____ - -----
P·, rt-2
1. All plastic bags shall be as per BIS standards as and when
- - -
disposal facility of TSDFs or plasma pyrolysis at temperature
published, till then the prevailing plastic waste management > 1200° C.
rules shall be applicable. 8. Residual or discarded chemical wastes, used or discarded
2. Chemical Treatment using at least 10% Sodium disinfectants and chemical sludge can be disposed at
Hypochlorite having 30% residual chlorine for twenty hazardous waste treatment, storage and disposal facility. In
minutes or any other equivalent chemical reagent that such case, the waste should be sent to hazardous waste
should demonstrate Log 104 reduction efficiency for micro- treatment, storage and disposal facility through operator of
organisms. common bio-medical waste treatment and disposal facility
3. Mutilation or shredding must be to an extent to prevent only.
unauthorized reuse. 9. On-site pre-treatment of laboratory waste, microbiological
4. There will be no chemical pretreatment before incineration, waste, blood samples, blood bags should be disinfected or
except for microbiological. lab and highly infectious waste. s terilized as per the guidelines of World Health Organisation
5. Incineration ash (ash from incineration of any bio-medical or National AIDS Control Organisation and then given to
waste) shall be d isposed through hazardous waste the common bio-medical waste treatment and d isposal
facility.
treatment, storage and disposal facility, if toxic or hazardous
constituents are present beyond the prescribed limits as 10. Installation of in-house incinerator is allowed. However in
given in the Hazardous Waste (management, handling and case there is no common biomedical facility nearby, the
transboundary movement) Rules, 2008, or as revised from same may be installed by the occupier after taking
time to time. authorization from the State Pollution Control Board.
11. Syringes should be either mutilated or needles should be cut
6. Dead foetus below the viability period (as per the Medical and or stored in tamper proof, leak proof and puncture
Termination of Pregnancy Act 1971 , amended from time to proof containers for sharp storage. Wherever the occupier is
time) can be considered as human anatomical waste. Such not linked to a disposal facility it shall be the responsibility
waste should be handed over to the operator of common of the occupier to sterilize and dispose in the manner
bio- medical waste treatment and disposal facility in yellow prescribed.
bag with a copy of the official medical terminatio n of 12. Bio-medical waste generated in households during
pregnancy certificate from the obstetrician or the medical healthcare activities shall be segregated as per these rules
superintendent of hospital or healthcare establishment. and handed over in separate bags or containers to
(7) Cytotoxic drug vials shall not be handed o ver to mun icipal waste collectors. Urban Local Bodies shall have
unauthorized person under any circumstances. These shall tie up with the common bio-medical waste treatment and
be sent back to the manufacturers for necessary disposal at d isposal facility to pickup this waste from the Material
a single point. As a second option, these may be sent for Recovery Facility (MRF) or from the house hold directly, for
incineration at common bio-medical waste treatment and final disposal in the manner as prescribed in this schedule .

The bio-medical waste should be segregated into waste are as shown in Fig. 2 shows the label for
containers/bags at the point of generation of the waste. The bio-hazards symbol and cytotoxic hazard symbol which
colour coding and the type of containers used for disposal of should be prominently visible and non-washable .

Bio-hazard Symbol Cytotoxic Hazard Symbol

Bio-hazard Cytotoxic

HANDLE WITH CARE

FIG. 2
Schedule Ill
Label for bio-medical waste conta iners/bags
No te : Label sha ll be non-washable and prominently visible.

References 3. Rao, H.V.N. (1995). Disposal of Hospital Wastes in Bangalore and

The ir Impact on Environment, Appropriate Waste Management
1. S harma, A.K. (1998). B io-Medical Waste (Man agem ent & Techno logies for Developing Countries, 3rd International
Handling) Rules, 1998, Suvidha Law House, Bhopal. Conference 25- 26 Feb 1995, Nagpur, Technical Papers Vol. II.
2. Pruss, A., Circ uit, E., a nd Rushbrook, P. (1999) Safe 4 . Govt. of India (2016). Ministry of Environment, Forest and
Managem ent of Wastes from Health -Care A ctivities, WHO, Climate Change , Notification published in the Gazette of India ,
1999. Bio-Medical Waste Ma nagem ent Rule 201 6 .