HEALTH CARE WASTE MANAGEMENT SCENARIO IN WEST BENGAL The wastes generated from health care units are generally classified as infectious and non-infectious. The infectious health care wastes are termed as bio-medical wastes and are considered to be potentially hazardous in nature. The disposal of untreated bio-medical wastes mixed with non-infectious health care wastes or other general municipal wastes poses an environmental threat and public health risk. Indiscriminate disposal of untreated bio-medical waste is often the cause for the spread of several infectious diseases. It is also responsible for the nosocomial diseases i.e. the hospital acquired diseases to the health care personnel who handle these wastes at the point of generation. Moreover, this is equally harmful to persons involved in the bio-medical waste management i.e. segregation, storage, transport, treatment and disposal. Apart from the above, a good amount of bio-medical wastes such as disposable syringes, saline bottles, I.V. fluid bottles etc. are picked up by rag pickers and are recycled back into the market without any disinfection. It is imperative, therefore, to adopt an appropriate environmentally safe method for the disposal of the hospital wastes. Sources of generation of Bio-medical wastes: Hospitals, Nursing Homes, Veterinary Hospitals, Dental Clinics, Pathological & Diagnostic Laboratories, Blood Bank etc. Type of Health Care Waste: These are of two types (i) Infectious Wastes (ii) Non-infectious Wastes INFECTIOUS HEALTH CARE WASTES (Bio-medical Waste): Human anatomical / surgical waste, Animal waste Pathological waste including tissues, organs, blood and body fluids, microbiological cultures, Cotton, Swabs etc. Used Syringes, I.V. tubes, Blood bags and other items contaminated with blood and body fluids. Items such as plaster, casts and bandages, when contaminated by blood and pus. Waste from isolation wards. The amount of infectious waste is near about 25% of the total wastes generated from a health care establishment. NON-INFECTIOUS HEALTH CARE WASTE: Non-infectious waste is broadly classified as Kitchen waste and Office wastes. It is similar to household waste. Non-infectious wastes constitutes nearly 75% of the total wastes generated from a health care unit.
In absence of proper segregation, the non-infectious waste becomes infectious and poses environmental threat to the society. Bio-medical Waste Survey The quality and the quantity of the bio-medical wastes generated from health care units depend upon a number of factors such as waste management methods, type of health care units, occupancy of healthcare units, specialization of healthcare units, ratio of reusable items in use, availability of infrastructure and resources etc. The All India Institute of Hygiene and Public Health, Kolkata conducted a study on Hospital Waste Management in W.B., sponsored by the WBPCB in the year 1996-97 and concluded that General waste containing food wastes, paper, plastics, floor sweeping, discarded glassware, earthen pot etc. constitute bulk (56-78% by weight) of the hospital waste. Waste generated in large government hospitals in Kolkata, is 1044 gms/bed/day whereas waste generated in large government hospitals in districts is comparatively low at 397 gms/bed/day. Certain salvageable items like saline bottles, surgical gloves, I.V. fluid bottles syringes etc. are disposed after use in the wards without distorting or damaging. As a result, there remains a possibility of reuse of the said items. Incinerable waste constitutes 19-30% (by weight) of the total waste generated. During the year 2002-2003, the Health & Family Welfare Department, Govt. of West Bengal conducted a waste survey at different Govt. hospitals of various categories in West Bengal under the West Bengal Health System Development Project(WBHSDP). The average generation of different types of healthcare waste for different categories of hospitals is tabulated below. Hospital Category (bed strength) Healthcare waste generation rate (gms./bed/day) General waste (%) Total BMW (%) Bio-medical waste Anatomical waste (%) Sharp Waste (%) Infectious non sharp waste (%) 251-600 702 70.12 29.88 3.70 1.21 24.97 126-250 678 64.05 35.95 5.49 2.40 28.06 51-125 658 66.08 33.92 5.26 1.82 26.84 Upto 50 782 66.48 33.52 4.98 2.33 26.23 Average 705 66.68 33.32 4.86 1.94 26.52 Source: WBHSDP report, 2002-2003.
Health impacts of Bio-medical Waste(BMW) Exposure to infectious BMW can result in disease or injury. It may contain infectious agents, toxic or hazardous chemicals or pharmaceuticals, radio active wastes and waste sharps. The infectious wastes may contain any of the great variety of pathogenic microorganisms. Pathogens in infectious wastes may enter the human body through a number of routes like a puncture or cut in the skin, mucous membranes, by inhalation or ingestion. Sharps may not only cause cuts and punctures but also infect the wounds if they are contaminated with pathogens. Because of this dual risk of injury and disease transmission sharps are considered as a very hazardous waste class. Poor hospital waste management may cause the following: Hepatitis B & C HIV infection Gastro-enteric infection Respiratory infection Blood stream infection Skin infection Radioactive toxicity Health problems associated with air and water pollution. Apart from the above, there are other environmental problems associated with the disposal of untreated BMW generated from the healthcare units (HCUs). These are as follows: Decomposing waste may generate foul odour inside the hospital premises and surrounding area. Drains may be clogged with waste materials creating an unhygienic environment in the surrounding hospital premises. This phenomenon may also help in the breeding of mosquitoes/flies that might contribute to the spread of infectious diseases. Waste dump may attract stray animals and birds that might spread waste materials leading to an unaesthetic and unhygienic environment. Indiscriminate disposal of pharmaceutical products (antibiotics and cytotoxic drugs) and discharge of untreated wastewater generated from the health care units could have disastrous ecological effects. Open dump of waste may decompose to produce leachate that might contaminate ground water. Uncontrolled and open burning of wastes can generate dioxins and furans, thus polluting the air.
Rules framed for the BMW management Realizing the seriousness of the problem associated with the poor management of the bio-medical wastes, the Ministry of Environment and Forests (MoEF), Govt. of India, notified the Bio-Medical Waste (Management and Handling) Rules in July 1998 under the Environment (Protection) Act, 1986, through a Gazette notification [S.O. 630(E)]. Thereafter, the Bio-Medical Waste (Management and Handling) Rules were amended twice in the year 2000 and the last amendment was made in the year 2003. The first amendment was published on 6 th March 2000 vide S.O. 210(E), the second amendment was published on 2 nd June 2000 vide the Gazette Notification S.O. 545(E) and third Amendment was published on 17 th September 2003 vide Gazette Notification S.O. 1069(E). The main objective of the rules are to ensure proper segregation, collection, transportation and disposal of the infectious BMW in order to safe guard the public health of the society. Some of the salient features of these rules are as follows: 1) These rules are applicable to the Hospitals, Nursing Homes, Veterinary Institutions, Pathological Laboratories and Clinics, Blood Banks, etc. generating bio-medical wastes. 2) The State Pollution Control Board/Pollution Control Committee is the prescribed authority for the implementation of the Rules in the States/Union Territories. 3) Every occupier (bedded/ non-bedded) generating, collecting, receiving, storing, transporting, treating, disposing and/or handling BMW in any manner, except such occupier of clinics, dispensaries, pathological laboratories, blood banks providing treatment/service to less than 1000 (one thousand) patients per month, shall make an application in Form-I to the prescribed authority for grant of authorization. 4) The prescribed authority shall on receipt of Form-I make such enquiry as it deems fit and if it is satisfied that the applicant possesses the necessary capacity to handle the BMW in accordance with the Rules, grant or renew an authorization as the case may be. 5) The onus of the treatment of the BMW lies squarely with the occupier of the health care unit. Treatment is to be done on their own or by joining the Common Bio-medical Waste Treatment Facility available in the area. 6) The Municipal body of the area cannot pick up and transport untreated bio-medical wastes generated in the hospital and nursing homes. They can only collect and dispose duly treated BMW for disposal at municipal dump site. 7) The BMW shall not be stored beyond 48 hours without permission of the appropriate authority.
8) The occupier of the health care unit needs to maintain the records related to the generation, collection, reception, storage, transportation, treatment, disposal and/or any form of handling BMW. 9) Every occupier/operator shall submit an annual report to the State Pollution Control Board in Form-II by 31 st January every year. The State Pollution Control Board shall send this information in a compiled form to the CPCB by 31 st March every year. Inventorisation of the Health care units in West Bengal The WBPCB completed the inventory of the bio-medical waste in the state of West Bengal in 2005 through a project awarded by the Ministry of Environment & Forests, Govt. of India. The Board has further undertaken a project of CPCB in the year 2008 to update the inventory of the HCU in the State and also to quantify the BMW. District wise Status of Health Care Units situated within West Bengal Sl. No. Districts 1 24 Parganas (N) 2 24 Parganas (S) 3 Bankura 4 Birbhum 5 Burdwan 6 Hooghly 7 Howrah 8 Kolkata 9 Midnapore (E) 10 Midnapore (W) 11 Murshidabad 12 Nadia 13 Purulia 14 Cooch Behar 15 Jalpaiguri 16 Darjeeling 17 Malda Type of Total No. Authorization Beds HCUs of HCUs Applied Govt. 75 4399 35 Pvt. 238 4271 226 Govt. 61 1678 25 Pvt. 135 1224 134 Govt. 45 2655 13 Pvt. 42 534 42 Govt. 59 1947 55 Pvt. 40 391 40 Govt. 76 5508 30 Pvt. 172 3051 171 Govt. 43 3177 21 Pvt. 180 2506 179 Govt. 38 2763 26 Pvt. 142 1807 142 Govt. 52 15438 45 Pvt. 387 12939 372 Govt. 51 1235 29 Pvt. 106 1127 104 Govt. 74 3088 62 Pvt. 121 1136 121 Govt. 60 2795 42 Pvt. 70 782 70 Govt. 55 5044 22 Pvt. 57 860 56 Govt. 45 1507 04 Pvt. 09 483 09 Govt. 27 1282 15 Pvt. 19 438 19 Govt. 42 1659 13 Pvt. 14 251 14 Govt. 44 3102 02 Pvt. 55 1660 55 Govt. 34 1283 29 Pvt. 20 368 20
Sl. No. Districts 18 Dakshin Dinajpur 19 Uttar Dinajpur TOTAL : Type of Total No. Authorization Beds HCUs of HCUs Applied Govt. 13 645 10 Pvt. 6 103 6 Govt. 18 717 16 Pvt. 12 140 10 Govt. 912 59922 494 Pvt. 1825 34071 1790 IN-HOUSE BMW MANAGEMENT Segregation of Bio-medical Wastes As per the Bio-medical Waste (management & Handling) Rules, segregation of BMW should be as given below: Bags/Bins Type of wastes Treatment Yellow Bags Anatomical waste Incineration (for cities with population more than 5 lakhs) or Deep Burial Pit Red Bags Infectious wastes Autoclaving or Micro Waving followed by Shredding Blue/White Puncture proof containers Black bins Sharp wastes For normal MSW/ kitchen wastes Mutilating and disinfecting by Chemical treatment and then Autoclaving or Micro Waving Disposal in MSW disposal ground As the entire bio-medical waste has to be either autoclaved or incinerated/buried in deep burial pit, therefore, keeping in mind the convenience of the waste handler (staff of the health care unit and facility operator) two nos. colour-coded bags and one no. hard container have been recommended by the WBPCB: Yellow : For Incineration/deep burial Blue : For Autoclaving
Segregation of Bio-medical Waste in two(2) colour coded bags & hard container Puncture proof Container Yellow Bag (Incineration/Deep burial) Blue Bag (Autoclaving) for sharp waste (Autoclaving after chemical treatment) Human Anatomical waste (Human tissue, organs, Placenta, body parts) Syringes Urine bags Catheters Needles Cut glass Blades Specimens from laboratory/research centre Surgical Waste Blood contaminated Cotton Blood contaminated Bandages Soiled Plasters Blood contaminated Dressing Anatomical waste (Animal tissue, organs, body parts, etc.) I.V. fluid bottle Blood Bags Stents Gloves Aprons Any other tubing Scalpels Slides Lancets Discarded medicine (solid) Segregated incinerable wastes kept in Yellow coloured bag Segregated Autoclavable wastes kept in Blue coloured bag General wastes of health care unit kept in Black coloured bag
Need For The Segregation of BMW at Source The Imperative If the proper segregation of the waste is not done at source, then the bio-medical waste might get mixed up with the municipal waste of the hospital. The un-segregated BMW may jeopardize the entire process of the bio-medical waste treatment. The un-segregated BMW may endanger human and the animal lives. It is vital that all the health care units both in the Government and in the Private Sector strictly follow the recommended segregation system for bio-medical waste at source. Waste segregation is the key to waste minimization and efficient waste collection, transportation, treatment and disposal. Bio-Hazard Symbol It is mandatory for all bags used for storing and transporting BMW to be made of non-chlorinated materials and bear the Bio-Hazard Sign Symbol for bio-hazard Sharp Waste Management The sharp wastes should be handled very carefully Before disposing off syringes, these should be mutilated by needle destroyer/cutter. In case uncut/ non-mutilated syringes are kept in blue bags, this will result in prick injury, puncture of the bags and spillage of the waste Mutilation It is recommended that mutilation should be strictly practiced for disposable needles and other sharp wastes. Mutilated needles and other sharp wastes may be kept in puncture proof containers with 1% Sodium Hypochlorite solution for primary disinfection and the solution should be changed every two days.
Mechanical needle cutter Electrical needle destroyer Other important issues of in-house BMW management All the disposable items other than waste sharps, like tubings, catheters, saline bottles, I-V fluid bottles etc. shall be punctured before being sent for treatment. Waste containing mercury must not be mixed with the other waste streams. The mercury containing wastes shall be kept separately and shall not be disposed along with the bio-medical wastes or general wastes. This waste shall be treated as a hazardous waste and shall be disposed off to the Common Hazardous Waste Treatment, Storage & Disposal Facility of M/s West Bengal Waste Management Ltd. at Haldia, Dist. East Midnapore. Responsibility for proper segregation and storage of BMW shall be fixed upon the Nurses & other staff of the health care unit handling BMW. Higher authorities should supervise the management of BMW regularly. Sweepers shall collect the Bio-medical Waste kept in segregated storage in coloured plastic bags with mouths securely tied and transfer it to the central intermediate storage room located in a convenient position of the health care unit. The intermediate storage room shall be marked with the bio-hazard symbol and kept under lock & key. For Laboratory/Clinic the section in-charge shall be made responsible for supervision & strict implementation in their section. For liquid Bio-medical Waste/ leachate (category 8 & 10), the unit shall have to arrange for treatment i.e. chemical disinfection, before discharge to outside drain to meet the prescribed standard. A record of BMW generation, treatment and disposal shall be kept & maintained. This shall be made available during inspection by the WBPCB official. Records of BMW management are also required for submission of Annual Return(Form-II) to the WBPCB. Occupational Safety & Health Provisions for Bio-medical Waste Management The BMW should not be touched with bare hands
Always use good quality gloves, masks, shoes, apron etc. while handling BMW wastes The damaged or contaminated Personal Protective Equipment (PPE) must be replaced periodically Never recap used syringes, most needle pricks injuries are incidental to recapping Wash hands with soaps after handling of wastes Immunizations for Tetanus and Hepatitis-B may be administered to certain high risk workers handling bio-medical wastes Keep the common intermediate storage room for BMW neat and clean and sanitize it regularly Do not keep municipal wastes along with biomedical waste in the Common intermediate storage room. Ensure proper monitoring of the waste segregation process, use of appropriate colour coded bags for collection of wastes and storage at common storage room in order to control infection. TREATMENT AND DISPOSAL OF BMW The Bio-medical Wastes are broadly classified into incinerable wastes and autoclavable wastes. The incinerable wastes either can be treated by incinerator or through deep burial pit as per the provisions of the Rules. The waste incinerator shall have a dual chamber i.e. primary chamber & secondary chamber. The temperature of the primary chamber shall be 800 ± 50 0 C and the temperature of the secondary chamber shall be 1050 ± 50 0 C. The incinerator shall have adequate pollution control devices to control environmental pollution. No chlorinated plastic shall be incinerated in order to prevent formation of Dioxins & Furans. The autoclavable wastes(non-incinerable BMW) can be treated by Autoclave/ Microwave/ Hydroclave etc. The waste autoclave may be of two types Gravity Flow Autoclave and Vacuum Autoclave. Normally vacuum type autoclave is used for the treatment of non-incinerable wastes. The temperature, pressure & time which are required for treatment of BMW are either 121 0 C, 15 psi & 45 minutes or 135 0 C, 31 psi & 30 minutes. Currently BMW generated at different HCUs is either treated by the Common Bio-medical Waste Treatment & Disposal Facility(CBMWTDF) or by its own treatment facility. Existing Common Bio-Medical Waste Treatment and Disposal Facility run by Private Operator 1) Howrah : M/s SembRamky Environmental Management Pvt. Ltd. (capacity 30,000 beds/day) Covering Districts Howrah, Kolkata, South 24 Parganas, part of North 24 Parganas and part of Hooghly District 2) Kalyani : M/s SembRamky Environmental Management Pvt. Ltd. (capacity 30,000 beds/day) Covering Districts Nadia, Murshidabad, part of North 24 Parganas and part of Hooghly District 3) Haldia : M/s West Bengal Waste Management Ltd. (capacity 20,000 beds/day). Covering Districts East Midnapore and West Midnapore
4) Asansol : M/s SembRamky Environmental Management Pvt. Ltd. (capacity 30,000 beds/day). Covering Districts Burdwan, Bankura, Birbhum and Purulia 5) Siliguri : M/s Greenzen Bio Pvt. Ltd. (capacity 15,000 beds/day). Covering Districts Darjeeling, Jalpaiguri, Coochbehar, Uttar Dinajpur, Dakshin Dinajpur and Malda Dedicated Transport Vehicles for BMW collection & transport Waste handling at Common facility
Standby Autoclave Autoclave with automatic feeding system Waste Autoclave Incinerator with Air Pollution Control Device Chimney for Incinerator Existing Common Bio-Medical Waste Treatment and Disposal Facility run under the WBHSDP, Health Deptt., Govt. of West Bengal 1) Kalyani : J.N.M. Hospital, Kalyani (Autoclave: capacity 50 kgs./cycle) covering 998 beds within Kalyani Municipal areas 2) Diamond Harbour : Diamond Harbour Sub Divisional Hospital (Microwave) covering 200 beds within Diamond Harbour Municipal areas
Autoclaves installed under the WBHSDP, Health Deptt., Govt. of West Bengal for treatment of non-anatomical BMW 1) Howrah : Howrah Dist. Hospital 2) Siliguri : Siliguri Sub Divisional Hospital 3) Jalpaiguri : Jalpaiguri District Hospital 4) Coochbehar: Coochbehar M. J. N. Hospital 5) Malda : Malda District Hospital 6) Murshidabad : Murshidabad District Hospital 7) Birbhum : Suri Sadar Hospital 8) Nadia: Nadia District Hospital, Krishnanagar 9) Bardhaman: Bardhaman Med. College & Hospital 10) Bankura : Bankura Med. College & Hospital 11) Purulia : Purulia District Hospital 12) Hooghly : Hooghly District Hospital 13) North 24 Parganas. : Barasat District Hospital Microwave installed for treatment of non-anatomical BMW 1) Midnapore District Hospital under WBHSDP, Govt. of W.B. 2) Kolkata Medical College & Hospital procured by the hospital authority Service charges taken by the CBMWTDF operator a) For Govt. HCUs (bedded) Rs. 2.45/- per bed/day on the basis of sanctioned bed Rs. 4.95/- per bed/day on the basis bed occupancy Rs. 4.05/- per bed/day on the basis bed occupancy for incinerable waste only b) For Private HCUs (bedded) Rs. 2.70/- per bed/day on the basis of sanctioned bed Rs. 3.00/- per bed/day on the basis of sanctioned bed for the CBMWTDF at North Bengal Status of the HCUs regarding the treatment of their BMW It is reported that 201 nos. Govt. HCUs have already ensured the treatment of their BMW either by its own treatment facility or by joining the CBMWTDF. Similarly 1368 nos. private HCUs have already ensured the treatment of their BMW by joining the CBMWTDF.
Recently, the Govt. of W.B. has approved a budgetary provision for the treatment cost of BMW generated from all the State Govt. Health Care Establishments. The Department of Health & Family Welfare, Govt. of W.B. has issued an order in this regard on 28.05.2009. Action against the defaulting Health Care Units : The West Bengal Pollution Control Board directed 2 (two) nos. State Govt. hospitals namely i) Satyabala Devi I. D Hospital and ii) Uluberia S. D Hospital and 7 (seven) nos. private Health Care Units namely i) Kasturi Medical Research Centre (P) Ltd. ii) Ekbalpur Nusing Home Pvt. Ltd. iii) Anandalok iv) Charnock Hospital & Research Centre Pvt. Ltd. v) Restorative Clinic & Research Centre (P) Ltd. vi) Health Point & vii) Dreamland Nursing Home to close down for non-submission of BMW Authorisation application, not ensuring the treatment of BMW and mismanagement of BMW. Later the closure order was withdrawn as all the Health Care Units complied with the provisions of the BMW Rules. In some of the cases, pollution costs were imposed against the units. Besides the above, the WBPCB arranges regular hearings of the defaulting Govt. & Pvt. HCUs. Hearing of i) SSKM Medical College & Hospital, ii) R. G. Kar Medical College & Hospital iii) Kolkata Medical College & Hospital iv) Calcutta National Medical College & Hospital and v) Burdwan Medical College & Hospital were conducted in 2008. Improvement of in-house management of BMW was observed during further inspection at the defaulting HCUs. Initiative has been taken by the WBPCB for improvement of the compliance of Rules The WBPCB is pursuing individual health care units as well units under the Health & Family Welfare Department, Govt. of WB. for submission of application for Bio-medical Waste Authorization, Consent to Operate and Annual Report. A monitoring committee to oversee the implementation of the Bio-medical Waste Management & Handling Rules in the State Govt. Hospitals has been formed involving the Joint Director (PH & CD), Health & Family Welfare Deptt., Govt. of WB, representatives of WBPCB, Kolkata Municipal Corporation & Environment Deptt., Govt. of WB. A number of meetings have been conducted by the Board with the H&FW Deptt., Govt. of WB and Chief Medical Officers of Health of various districts to improve compliance status with respect to the submission of the BMW Authorisation application, segregation at source and ensuring treatment of BMW. Regular monitoring is conducted by the WBPCB at different HCUs to verify their compliance status. ***