Vegetos- An International Journal of Plant Research Supriya Shrivastava, Research Article Impacts of Biomedical Waste Management on human health and Environment Supriya Shrivastava* & Soma Roy Abstract Health care activities restore health and save lives but also generate large amounts of potentially infectious and hazardous waste. Absence of effective management of this biomedical waste pose great risk to human health and environment. Of the total waste generated, 85% is non-hazardous comparable to domestic waste. Remaining 15% is considered hazardous material that may be infectious, toxic or radioactive. Biomedical waste contains potentially harmful microorganisms which can infect hospitalized patients, health workers and the general public. In health care workers three infections are most commonly transmitted: hepatitis B virus, hepatitis C virus and human immunodeficiency virus. Other risks associated with waste and by-products include radiation burns, sharp-inflicted injuries, poisoning and pollution through the release of pharmaceutical products, poisoning and pollution through waste water and by toxic elements and compounds such as mercury and dioxins that are released during incineration. In developing countries poor waste management practices like lack of separation of health-care waste into hazardous and non-hazardous waste, unsafe injection practices and scavenging at waste disposal sites cause additional hazard. Biomedical waste management is a vital component of environmental protection process. There are rules and regulations in our country for biomedical waste disposal. There is urgent need to follow them to plan appropriate methods for segregation, packaging, labeling and treatment techniques for reduction in volume, neutralization and final disposal of the biomedical waste. The present study reviews the problems related to biomedical waste management and procedures involved in its handling and disposal and its impact on human health and environment. The other aim of this study is to create awareness amongst personnel involved in health care sector. Keywords Biomedical waste, Health hazards, Environment. INTRODUCTION Rapid expansion of health care facilities as well as the recent trend of using disposables has led to an unprecedented burden of health care related waste. For A SOCIETY FOR PLANT RESEARCH PUBLICATION last three decades, unregulated handling of biomedical waste is emerging as a serious threat to human health and safety. Biomedical waste management has recently emerged as an issue of major concern not only to hospitals, nursing home authorities but also to the environment (Mandal and Dutta, 2009). Hazards of poor management of biomedical waste have aroused the concern world over, especially in the light of its far-reaching effects on human, health and the environment ( Singh et al. 2007). Hospital waste is a potential health hazard to the health care workers, public and ecology of the area. The problems of the waste disposal in the hospitals and other health-care institutions have become issues of increasing concern (Chandra, 1999). According to Biomedical Waste (Management and Handling) Rules, 1998 of India Any waste which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining to or in the production or testing of biological samples specifies that hospital waste management is a part of hospital hygiene and maintenance activities. An important issue of environmental protection process is the solid waste management (SWM), that includes responsible planning of collecting, transporting, processing and disposing of hazardous and non-hazardous solid waste material. Within waste management, the health care waste management (HCWM) is a process that helps to ensure proper hospital hygiene and safety of health care workers and communities. HCWM concerns about planning and procurement, staff training and behavior, proper use of tools, machines and pharmaceuticals, proper methods applied for segregation, reduction in volume, treatment and disposal of biomedical waste (Rutala et al. 1989). A special concern focuses on effective management of biomedical waste incorporating an appropriate waste reduction and neutralization component (Diaz and Savage, 2003). Main purposes of waste management are to clean up the surrounding environment and to identify the appropriate methods for waste neutralization, recycling and disposal (McDougall et al. 2001). There is not a single method of biomedical waste treatment or disposal that completely eliminates all risks to humans or to environment. Corresponding author: Department of Biotechnology, Ranchi Women s College, Ranchi, India Email: bhasha_sh@yahoo.co.in Received: July 21, 2017 Revised: September 7, 2017 Published: October 10, 2017 AN APPROACH TOWARDS BIOMEDICAL WASTE Biomedical waste means any solid and/or liquid waste including its container and any intermediate product, which is generated during the diagnosis, treatment or immunization of human beings or animals or in All articles published in Vegetos: International Journal of Plant Research are the property of SPR, and is protected by copyright laws. Copyright 2017, SPR, All Rights Reserved.
. research pertaining thereto or in the production or testing there of. The physic-chemical and biological nature of these components, their toxicity and potential hazard are different, necessitating different methods and options for their treatment and/ or disposal (Ram Charitra Sah, 2007, OTA, 1990 ). The basic components of hazardous biomedical waste (Fig 1) consist of *Human anatomical waste (such as, tissues, organs, body parts etc.); *Microbiology and biotechnology waste (such as, laboratory cultures, micro-organisms, human cell cultures, toxins etc.); *Waste sharps (such as, hypodermic needles, syringes, scalps, broken glass etc.); *Discarded medicines and cyto-toxic drugs; *Solid waste (such as, dressing, bandages, plaster cats, material contaminated with blood etc.); *Solid waste (disposable items like tubes, catheters etc. excluding sharps); *Liquid waste generated from any of the infected areas; *Animal waste (generated during research or experimentation, from veterinary hospitals etc.); *Incineration ash; *Chemical waste. The healthcare waste can be subdivided into hazardous and non-hazardous categories. Since, it would not be possible for each and every health care establishment to have its own full treatment and disposal system for biomedical waste, there would be need for common treatment and disposal facilities under the coordination of medical head coordination and under the supervision and guidance of the civic authority (OTA 1990, Celikyay and Uzun 2007, Bulucea et al. 2010) World Health Organization states that 85% of hospital wastes are actually non-hazardous, whereas 10% are infectious and 5% are non-infectious but they are included in hazardous wastes. (Fig 2). About 15% to 35% of Hospital waste is regulated as infectious waste. This range is dependent on the total amount of waste generated (Glenn and Garwal 1999). Figure 1. Biomedical waste Structure Figure 2. Classification of Biomedical Waste (WHO) ENVIRONMENTAL AND HEALTH HAZARDS Biomedical waste is produced in all conventional medical units where treatment of (human or animal) patients is provided, such as hospitals, clinics, dental offices, dialysis facilities, as well as analytical laboratories, blood banks, university laboratories. Health care waste refers to all materials, biological or non-biological that are discarded in any health care facility and are not intended for any other use component (Diaz and Savage 2003). Three infections are most commonly transmitted: hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency (HIV) virus (Table 1). Among the 35 million health care workers worldwide, the estimations show (Diaz and Savage 2003, Sulmer, 1989) that each year about 3 million receive hard exposures to blood-borne pathogens, 2 million of those to HBV, 0.9 million to HCV, and 170,000 to HIV. Incineration of medical waste containing plastic with chlorine composition determines the dioxin generation. Dioxin is a known carcinogen. Once formed, dioxin is linking to organic particles that are carried by wind, deposited on land and in water. The half-life of dioxin is estimated at 25-100 years. Dioxin binds to nuclear DNA. It acts as a potential cancer promoter, weak -delete immune response and is associated with many negative effects both on human health (endometriosis, birth defects, low testosterone levels) and on environment. Also, the workers involved in the collection and treatment of the biomedical waste are exposed to a certain risk. Various communicable diseases, which spread through water, sweat, blood, body fluids and contami- 35
. nated organs, are important to be prevented. The Bio Medical Waste scattered in and around the hospitals invites flies, insects, rodents, cats and dogs that are responsible for the spread of communication disease like plague and rabies. Rag pickers in the hospital, sorting out the garbage are at a risk of getting tetanus and HIV infections. The recycling of disposable syringes, needles, other articles like glass bottles without proper sterilization are responsible for Hepatitis, HIV, and other viral diseases. It becomes primary responsibility of Health administrators to manage hospital waste in most safe and eco-friendly manner (CEET: Biomedical Waste Management-Burgeoning issue (2008) The problem of bio -medical waste disposal in the hospitals and other health care establishments has become an issue of increasing concern, prompting hospital administration to seek new ways of scientific, safe and cost effective management of the waste, and keeping their personnel informed about the advances in this area. The need of proper hospital waste management system is of prime importance and is an essential component of quality assurance in hospitals. Improper Bio-Medical waste management causes environmental pollution, unpleasant smell, growth and multiplication of vectors like insects, rodents andworms and may lead to the transmission of diseases like typhoid, cholera, hepatitis and AIDS through injuries from syringes and needles contaminated with human.(ceet: Table 1. Types of Infection caused by Biomedical Waste Biomedical Waste Management- Burgeoning issue, 2008). BIOMEDICAL WASTE MANAGEMENT IN INDIA Waste generation depends on various factors such as type of health care establishment, hospital specialties, proportion of reusable and disposal items, implementation of national and hospital waste management policy. In every procedure carried out in health care setting some amount of waste is generated. On an average 0.5 kg waste is generated per patient per day in Indian hospitals,whereas it may be 3 to 10 kg per patient per day in developed countries. According to western and American figures, approximately 15-20 percent ofthis total waste is hazardous including infectious wastes. However, it would be much higher (50-75 percent) in India where proper waste segregation is minimal and collection is made in mixed form. There are no national level studies on the quantity of hospital waste generated per bed per day, but studies have been carried out at local or regionallevels in various hospitals. Whatever data are available from these studies, it can be safely presumed that in most hospitals, roughly 1-2 kg/bed/dayof waste is generated. Some of the notable studies are shown in the Table 1 and 2. One study claims that the estimated quantity of the waste generated in the hospitals varies from 2-5 kg/bed/day. 36
. Biomedical Waste Management Process and responsibilities There is a big network of Health Care sectors in India. The hospital waste like bodyparts, organs, tissues, blood and body fluids alongwith soiled linen, cotton, bandage and plaster castsfrom infected and contaminated areas are veryessential to be properly collected, and segregated in a manner to prevent hospital acquired infection.(management WHO Project INDEHH 001, A Report, Gandhi Medical College and Associated, Bhopal.2001) The Biomedical waste management process includes: A) Biomedical waste generation; B) Biomedical waste segregation, collection and storage; Table 2. Quality of waste generated at various places in India C) Biomedical waste handling and transportation; D) Biomedical waste treatment and disposal. A. Biomedical waste generation According to the rule the concerned healthcare establishment should constitute a team of its experts, concerned personnel and workers: doctors,chemists, laboratory technicians, hospital engineers, nurses, cleaning inspectors & cleaning staff. From the healthcare sectors, the biomedical waste generated by all the departments has to be collected and sorted out into different categories according to the rules& regulations.health care waste is a heterogeneous mixture, which is very difficult to manage as such.but Figure 3. Responsibilities in Biomedical waste management 37
. the problem can be simplified and its dimension reduced considerably if a proper management system is planned. The liquid waste should be divided into liquid reagents/chemical discarded and the cleaning and washing water channeled into the drain. Hence, the category-wise survey of medical waste generation are human anatomical waste, animal waste, microbiology and biotechnology waste, sharps waste, medicines and cyto-toxicdrugs, soiled waste, solid waste, chemical waste, incineration ash, liquid waste. B. Biomedical Waste Segregation and Storage Each category of waste has to be kept segregated in a proper container. Such container or bag should have certain properties: it should be without any leakage; it must be able to contain the designed volume and weight of the waste without any damage; the container should have a cover, preferably operated by foot; when a bag or container is filled at 3/4th capacity it must be sealed and an appropriate label has to be attached complaint with the regulation. an adequate symbol must be pictured for all type of biomedical waste, according to their code: 1) infectious waste; 2) pathological waste; 3) sharps; 4) pharmaceutical waste; 5) genotoxic waste; 6) chemical waste; 7) waste with high content of heavy metals; 8) radioactive waste. C. Biomedical Waste Handling and Transportation This activity has three components: collection of different kinds of waste from waste storage bags and containers inside the hospital, transportation and intermediate storage of segregated waste inside the premises and transportation of the waste outside the premises towards the treatment or final disposal. D. Biomedical waste treatment and disposal. Different methods and treatment technologies have been developed starting from the chemical composition and hazardous traits of biomedical waste: (1) Incineration; (2) Autoclave treatment; (3) Hydroclave treatment; (4) Microwave treatment; (5) Chemical disinfecting; (6) Sanitary and secured land filling; (7) General Waste. The biomedical waste has to be transported to the treatment or disposal facility site in a safe manner. The vehicle should have certain specifications: it should be covered and secured against accidental opening of door, leakage etc.; the interior of the container without sharp edges or corners in the aim to be easily washed and disinfected; there should be adequate arrangement for drainage and collection of any leakage. Biomedical Waste Management Rules Safe disposal of biomedical waste is nowa legal requirement in India. The Biomedical Waste Management & Handling) Rules, 1998 came into force on 1998. In accordance with these rules, it is the duty of every occupier i.e. a person who has the control over the institution or its premises to take all steps to ensure that waste generated is handled without any adverse effect to human health and environment. It consists of six schedules Chemicals treatment using at least 1% hypochlorite solution or any other equivalent chemical reagent. It must be ensured that chemical treatment ensures disinfection. Mutilation/shredding must be such so as to prevent unauthorised reuse. There will be no chemical pretreatment before incineration. Chlorinated plastics shall not be incinerated. Deep burial shall be an option available only in towns with population less than five lakhs and in rural areas. Options given above are based on available technologies. Occupier/operator wishing to use other State-of-the-art technologies shall approach the Central Pollution Control Board to get the standards laid down to enable the prescribed authority to consider grant of authorization. Table 3. Average composition of hospital waste in India 38
. SCHEDULE I CATEGORIES OF BIO-MEDICAL WASTE Option Waste Category Treatment & Disposal Category No. I Human Anatomical Waste Incineration @/deep burial* Category No. 2 (human tissues, organs, body parts) Animal Waste Incineration @ / deep burial* (animal tissues, organs, body parts carcasses, bleeding parts, fluid, blood and experimental animals used in research, waste generated Category No 3 by veterinary hospitals colleges, discharge from hospitals, animal) houses) Microbiology & Biotechnology Waste local autoclaving / micro-waving / incineration@ Category No 4 Category No 5 Category No 6 (wastes from laboratory cultures, stocks or specimens of micro-organisms live or attenuated vaccines, human and animal cell culture used in research and infectious agents from research and industrial laboratories, wastes from production of biologicals, toxins, dishes and devices used for transfer of cultures) Waste sharps (needles, syringes, scalpels, blades, glass, etc. that may cause puncture and cuts. This includes both used and unused sharps) Discarded Medicines and Cytotoxic drugs (wastes comprising of outdated, contaminated and discarded medicines) Solid Waste disinfection (chemical treatment @ 01/auto claving / micro- waving and mutilation/ shredding" Incineration @/destruct ion and drugs disposal in secured landfills drugs disposal in secured Incineration @ autoclaving / micro-waving (Items contaminated with blood, and body fluids including cotton dressings, soiled plaster casts, lines, beddings, other material Category No. 7 contaminated with blood) Solid Waste disinfection by chemical (wastes generated from disposable items other than the waste shaprs such as tubings, catheters, intravenous sets etc). treatment @ @ autoclaving/micro-waving and mutilation/ shredding## Category No. 8 Liquid Waste (waste generated from laboratory and washing, cleaning, house- disinfection by chemical treatment@@ and discharge into drains. Category No. 9 keeping and disinfecting activities) Incineration Ash disposal in municipal landfill Category No. 10 (ash from incineration of any bio-medical waste) Chemical Waste (chemicals used in production of biologicals, chemicals used in disinfection, as insecticides, etc.) chemical treatment and discharge into drains for liquids and secured landfill for solids 39
. SCHEDULE II COLOUR CODING AND TYPE OF CONTAINER FOR DISPOSAL OF BIO-MEDICAL WASTES Colour Conding Type of Container -I Waste Category Treatment options as per Schedule I Yellow Plastic bag Cat. 1, Cat. 2, and Cat. 3, Cat. 6. Incineration/deep burial Red Disinfected container/ plastic bag Cat. 3, Cat. 6, Cat.7. Autoclaving/Microwaving/ Chemical Treatment Blue/White translucent Plastic bag/puncture proof Container Cat. 4, Cat. 7. Autoclaving/Microwaving/ Chemical Treatment and destruction/shredding Black Plastic bag Cat. 5 and Cat. 9 and Cat. 10. (solid) Disposal in secured landfill Notes: 1. Colour coding of waste categories with multiple treatment options as defined in Schedule I, shall be selected depending on treatment option chosen, which shall be as specified in Schedule I. 2. Waste collection bags for waste types needing incineration shall not be made of chlorinated plastics. 3. Categories 8 and 10 (liquid) do not require containers/ bags. 4. Category 3 if disinfected locally need not be put in containers/bags. SCHEDULE III LABEL FOR BIOMEDICAL WASTE CONTAINERS/BAGS HANDLE WITH CARE Note : Label shall be non-washable and prominently visible 40
. SCHEDULE V STANDARDS FOR TREATMENT AND DISPOSAL OF BIO-MEDICAL WASTES STANDARDS FOR INCINERATORS: All incinerators shall meet the following operating and emission standards A. Operating Standards 1. Combustion efficiency (CE) shall be at least 99.00%. 2. The Combustion efficiency is computed 3. The temperature of the primary chamber shall be 800 ± 50 deg. C. 4. The secondary chamber gas residence time shall be at least I (one) second at 1050 ± 50 C, with minimum 3% Oxygen in the stack gas. B. Emission Standards Parameters Concentration mg/nm 3 at (12% CO 2 correction) Note : Suitably designed pollution control devices should be installed/retrofitted with the incinerator to achieve the above emission limits, if necessary. Wastes to be incinerated shall not be chemically treated with any chlorinated disinfectants. Chlorinated plastics shall not be incinerated. Toxic metals in incineration ash shall be limited within the regulatory quantities as defined under the Hazardous Waste (Management and Handling Rules,) 1989. Only low sulphur fuel like L.D.0dLS.H.S.1Diesel shall be used as fuel in the incinerator. SCHEDULE VI SCHEDULE FOR WASTE TREATMENT FACILITIES LIKE INCINERATOR/ AUTOCLAVE / MICRO- WAVE SYSTEM New Bio-Medical Waste Management Rules Notified The major salient features of BMW Management Rules in India, 2016 include the following:- (a) (b) (c) (d) (e) (f) (g) The ambit of the rules has been expanded to include vaccination camps, blood donation camps, surgical camps or any other healthcare activity; Phase-out the use of chlorinated plastic bags, gloves and blood bags within two years; Pre-treatment of the laboratory waste, microbiological waste, blood samples and blood bags through disinfection or sterilisation on-site in the manner as prescribed by WHO or NACO; Provide training to all its health care workers and immunise all health workers regularly; Establish a Bar-Code System for bags or containers containing bio-medical waste for disposal; Report major accidents; Existing incinerators to achieve the standards for retention time in secondary chamber and Dioxin and Furans within two years. STANDARDS FOR WASTE AUTOCLAVING: The autoclave should be dedicated for the purposes of disinfecting and treating bio-medical waste, (I) When operating a gravity flow autoclave, medical waste shall be subjected to : (i) a temperature of not less than 121 C' and pressure of 15 pounds per square inch (psi) for an autoclave residence time of not less than 60 minutes; or (ii) a temperature of not less than 135 C and a pressure of 31 psi for an autoclave residence time of not less than 45 minutes; or (iii) a temperature of not less than 149 C and a pressure of 52 psi for an autoclave residence time of not less than 30 minutes. (II) When operating a vacuum autoclave, medical waste shall be subjected to a minimum of one pre-vacuum pulse to purge the autoclave of all air. The waste shall be subjected to the following: (i) a temperature of not less than 121 C and pressure of 15 psi per an autoclave residence time of not less than 45 minutes; or (ii) a temperature of not less than 135 C and a pressure of 31 psi for an autoclave residence time of not less than 30 minutes; (III) Medical waste shall not be considered properly treated unless the time, temperature and pressure indicators indicate that the required time, temperature and pressure were reached during the autoclave process. If for any reasons, time temperature or pressure indicator indicates that the required temperature, pressure or residence time was not reached, the entire load of medical waste must be autoclaved again until the proper temperature, pressure and residence time were achieved. 41
. (IV) Recording of operational parameters Each autoclave shall have graphic or computer recording devices which will automatically and continu ously monitor and record dates, time of day, load identification number and operating parameters throughout the entire length of the autoclave cycle. (V) Validation test Spore testing The autoclave should completely and consistently kill the approved biological indicator at the maximum design capacity of each autoclave unit. Biological indicator for autoclave shall be Bacillus stearothermophilus spores using vials or spore Strips; with at least 1X10 4 spores per millilitre. Under no circumstances will an autoclave have minimum operating parameters less than a residence time of 30 minutes, regardless of temperature and pressure, a temperature less than 121 C or a pressure less than 15 psi. (VI) Routine Test A chemical indicator strip/tape the changes colour when a certain temperature is reached can be used to verify that a specific temperature has been achieved. It may be necessary to use more than one strip over the waste package at different location to ensure that the inner content of the package has been adequately autoclaved STANDARD FOR LIQUID WASTE The effluent generated from the hospital should conform to the following limits PARAMETERS PERMISSIBLE LIMITS These limits are applicable to those, hospitals, which are either connected with sewers without terminal sewage treatment plant or not connected to public sewers. For discharge into public sewers with terminal facilities, the general standards as notified under the Environment (Protection) Act, 1986 shall be applicable. STANDAR DS OF MICROWAVING 1 Microwave treatment shall not be used for cytotoxic, hazardous or radioactive wastes, contaminated animal car cases, body parts and large metal items. 2. The microwave system shall comply with the efficacy test/routine tests and a performance guarantee may be provided by the supplier before operation of the limit. 3. The microwave should completely and consistently kill the bacteria and other pathogenic organisms that is ensured by approved biological indicator at the maximum design capacity of each microwave unit. Biological indicators for microwave shall be Bacillus Subtilis spores using vials or spore strips with at least 1 x 101 spores per milli liter. STANDARDS FOR DEEP BURIAL 1. A pit or trench should he dug about 2 meters deep. It should be half filled with waste, then covered with lime within 50 cm of the surface, before filling the rest of the pit with soil. 2. It must be ensured that animals do not have any access to burial sites. Covers of galvanised iron/wire meshes may be used. 3. On each occasion, when wastes are added to the pit, a layer of 10 em of soil shall be added to cover the wastes. 4. Burial must be performed under close and dedicated supervision. 5. The deep burial site should be relatively impermeable and no shallow well should be close to the site. 6. The pits should be distant from habitation, and sited so as to ensure that no contamination occurs of any surface water or ground water. The area should not be prone to flooding or erosion. 7. The location of the deep burial site will be authorised by the prescribed authority. 8. The institution shall maintain a record of all pits for deep burial. CONCLUSION Risks associated with final elimination of biomedical waste should also be considered within health care and environmental protection program. Medical wastes should be classified according to their source, typology and risk factors associated with their handling, storage and ultimate disposal. The segregation of waste at source is the key step and reduction, reuse and recycling should be considered in proper perspectives. We need to consider innovative and radical measures to cleanup the distressing picture of lack of civic concern on the part of hospitals and slackness in government implementation of bare minimum rules, as waste generation particularly biomedical waste imposes increasing direct and indirect costs on society. The challenge before us, therefore, is to scientifically manage growing quantities of biomedical waste that go beyond past practices. The functioning of biomedical waste management system should be periodically reformulated, according to the situation. If we want to protect our environment and health of the community we must sensitize ourselves to this important issue not only in the interest of health managers but also in the interest of community. REFERENCES CEET (2008) Biomedical Waste Management- Burgeoning issue. Celikyay S, Uzun N, Bulucea CA, Mastorakis NE, Bulucea CA, Boteanu N and Stinga A (2010 ) Major components of Environmental Protection Process, 5th WSEAS Int. Conference on Environment, Ecosystem and Development FED Dec 14-16, 2007 Diaz LF and Savage GM (2003) Risks and Costs Associated with Management of Infectious Wastes, WHO/WPRO, Manila, Philippines. 42
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