Hospital waste management

1. Hari Prasad Kafle
Lecturer, SHAS, FST
Pokhara University

2. Health Care Waste
 Health care waste includes all waste generated
by health care establishment, research facilities
and laboratories etc.
 It also includes waste originating from minor
or scattered sources e.g. health care undertaken
at home (dialysis, insulin injection etc.)

3. Health Care Waste
 75-90% health care waste are non risk waste
as compared to household waste.
 10-25% health care waste is regarded as
hazardous and can create varieties of health
risks.
 Broadly, health care waste has been divided
into three subsets: Hospital waste, Medical
waste and potentially infectious waste.

4. Health Care Waste
Hospital
Waste
Medical
waste
Infectious
waste

5. Health Care Waste
 Hospital waste: are waste generated from health
care facilities including cafeteria, office and
construction waste.
 Medical waste (a subset of Hospital waste): waste
generated as a result of patient diagnosis,
treatment and immunization of human beings or
animals.
 Potentially infectious waste (a sub set of medical
waste): that % of medical waste potential to
transmit infectious disease (10-25%).

6. Bio-medical Waste
 “Bio-Medical Waste" means any waste, which
is generated during the diagnosis, treatment or
immunization of human beings or animals or
in research activities pertaining thereto or in
the production or testing of biological.

7. Bio-medical Waste
 It includes infectious and non-infectious waste.
 Infectious waste includes pathological waste,
cotton, dressing, used needles, syringes,
scalpels, blades, glass etc.
 Non-infectious waste includes general waste
from the kitchen/canteen, packaging material
including radioactive wastes, mercury
containing instruments, PVC plastics.

8. Classification of Health Care Waste

9. Classification of Health Care Waste
Waste
Category
Description and example
Infectious
waste
Waste suspected to contain pathogens
e.g. laboratory cultures; waste from
isolation wards; tissue(swabs);
material or equipment that have been
contact with infected patients: excreta
etc.
Pathological
waste
Human tissue or fluids e.g. body parts;
blood and other body fluids; fetuses

10. Classification of Health Care Waste
Waste
Category
Description and example
Pharmaceuti
cal waste
Waste containing pharmaceuticals e.g.
Pharmaceuticals that are expired or no
longer needed; items contaminated by
or containing pharmaceutical (bottles,
boxes)
Genotoxic
waste
Waste containing substances with
genotoxic properties e.g. waste
containing cytostatic drugs( often used
in cancer therapy); genotoxic chemicals

11. Classification of Health Care Waste
Waste
Category
Description and example
Chemical waste Waste containing chemical
substances e.g. laboratory reagents;
film developers; disinfectants that
are expired and no longer needed;
solvents
Waste with high
contents of
Heavy metals
Batteries; broken thermometers;
blood pressure gauze etc.

12. Classification of Health Care Waste
Waste
Category
Description and example
Pressurized
containers
Gas cylinders; gas cartridges; aerosol
cans etc.
Radio
active
waste
Waste containing radioactive Substances
e.g. unused liquid form radiotherapy or
laboratory research; contaminated glass
wire, packages, or absorbent paper; urine
and excreta from patient treated or tested
with unsealed radionuclides; sealed
sources etc.

13. Classification of Health Care Waste
Waste
Category
Description and example
Gases
waste
Gaseous waste generated during
burning of health care waste. Either
open burning or drum incinerator or
incinerator produce several gaseous
pollutants: CO2, H2O, HCL, HF, SO2,
NO etc

14. Classification of Health Care Waste
Waste
Category
Description and example
Liquid
waste
Waste in liquid form. Waste such as
infected urine, expired blood, body
fluids and fluids coming from wound.
Waste water coming from different
wards and laboratories.
Incineration
Ash
Could be highly toxic (both bottom ash
and Fly ash). Contains high concentrated
toxic chemicals and other heavy metals
including dioxin and furans.

15. Sources of Health Care Waste
 Government hospitals
 Private hospitals
 Nursing homes
 Private clinics
 Dentists clinic
 Dispensaries
 Primary Health Centers
 Medical research and training institutions

16. Sources of Health care waste
 Blood bank and collection centers
 Animal houses
 Slaughter houses
 Laboratories
 Research organizations
 Vaccination centers
 Bio-technology institution and product units

17. Composition of Health care waste
 80% general health care waste (which may be
dealt with by the normal domestic and urban
waste management system).
 15% pathological and infectious waste.
 1% sharp waste.
 3% chemical or pharmaceutical waste.
 <1 % special waste, such as radio active or
cytotoxic waste , pressurized container or
broken thermometer & used batteries.

18. Risk Groups
 Medical doctors, nurses, health care auxiliaries
and hospital maintenance personnel
 Patients in health care establishments.
 Visitors to health care establishments.
 Workers in support services allied to health care
establishments such as laundries, waste
handling and transportation.

19. Risk Groups
 Workers in waste disposal facilities such as
land fills or incinerators
 Waste pickers (scavenger);
 Waste recyclers;
 Drug addicts (who scavenge for used needles
and disposed medicines); and
 The entire community.

20. Thank You!

21. Health hazards from health care waste
 Exposure to hazardous health-care waste can
resulting disease or injury because:
 It contains infectious agents.
 It is genototic.
 It contains toxic chemicals or
pharmaceuticals.
 It is radioactive.
 It contains sharp.
 It contains carcinogenic agents and gaseous
chemicals.

22. Health hazards from health care waste
1. Hazards from infectious waste and sharps
 HIV, hepatitis B &C, microbial resistance
2. Hazards from chemical and pharmaceutical
waste
 Intoxication, burn, poisoning, shock due to
inhalation
3. Hazards from genotoxic waste
 Gentoxic effects, affects genetic materials

23. Health hazards from health care waste
4. Hazards from radioactive waste
 Headache, dizziness, vomiting,
unconsciousness and also genotoxic effects.
5. Public sensitivity
 General public is very sensitive to visual
impact of health care waste particularly
anatomical waste.

24. Infection caused by health-care waste
Type of
infection
Causative
organism
Transmission
vehicles
Gastro enteric
infections
Entero bacteria: e.g.
salmonella, Shigella
spp., Vibrio cholera,
helminthes.
Faeces and or
vomit
Respiratory
infection
M. tuberculosis,
measles virus,
streptococcus
pneumoniae
Inhaled
secretions; saliva

25. Infection caused by health-care waste
Type of
infection
Causative organism Transmission
vehicles
Ocular
infections
Herpes virus Eye secretions
Genital
infections
Neisseria gonorrhoeae,
herpes virus
Genital secretions
Skin
infections
Streptococcus spp. Pus
Anthrax Bacillus anthracis Skin secretions

26. Infection caused by health-care waste
Type of
infection
Causative organism Transmission
vehicles
Meningitis Neisseria
meningitidis
Cerebro-spinal
fluid
AIDS Human deficiency
virus (HIV)
Blood, sexual
secretions
Hemorrhagic
fever
Junín, Lasssa, Ebola
and Marburg viruses
all body products
and secretions
Septicemia Staphylococcus spp. Blood

27. Infection caused by health-care waste
Type of
infection
Causative organism Transmission
vehicles
Bacteraemia Staphylococcus spp.,
enterobacter, Klebsiella
and streptococcus spp.
Blood
Candidaemia Candida albicans Blood
Viral
hepatitis A
Hepatitis A virus Faeces
Viral
hepatitis B
& C
Staphylococcus spp. Blood and
body fluids

28. Health care waste generation in Nepal
Studies are carried out on:
 92 governmental hospitals ( 67 under MOHP, 3
community hospital, 8 teaching hospitals, 14
NGO’s hospitals)
 74 private health facilities/ nursing homes
 16 eye hospitals

29. Health care waste generation in Nepal
 Medical waste composition: 23% infectious,
3% sharp, 12% saline bottles and remaining
62% non infections.
 Infectious waste generation rate
0.48kg/person/day.
 Total medical waste generation rate
1.7kg/person/day.
 Average incinarable waste: 396.77gm/day/bed.

30. Health care waste generation in Nepal
 On an average , a 150 bed hospital have about
50-100 thermometer breakage in a months and
each thermometer contain 0.5-1 gram mercury.
 On an average 1 gram mercury has been used
for dental restoration in 4 patients.
 Source: MOHP 2009, Ale Devika 2005, NHRC 2002, ENPHO
2000, CEPHED 2006, 2008.

31. Composition of hospital waste in India
 Paper : 15 %
 Plastics: 10%
 Rags: 15%
 Metal including sharps: 1
 Infectious waste: 1.5%
 Glass: 4%
 General waste: 53.3 %
Source: National Environmental Engineering Research Institute
1997.

32. Medical Waste Generation in Asia
Estimates of medical waste generation in some countries

33. Medical Waste Generation in Asia

34. Medical Waste Generation in Asia
 0.33 million tons/year in India
 0.25 million tons/year in Pakistan
 (100 ton/day from Karachi alone)
 2,000 tons/day in china
 60,000 tons/year in Vietnam
 255 tons/day in Dhaka alone
 47 tons/day in Metro Manila
 (11 tons/day illegally dumped)
 Source: Healthcare waste composition in developing Asian countries
(WHO,1999)

35. Management of health care waste
Effective waste management needs:
 National Policy, Strategy, plan, guidelines and
SOP;
 Legislation/Rules for waste management;
 Political commitment;
 Committed manpower;
 Good management;
 Proper budgetary allocation;

36. Management of health care waste
 Application of local available technology and
also according to resource; envelop;
 Involvement of NGOs;
 Community participation;
 Proper capacity development of the service
providers;
 Development of information system in relation
to MWM as a part of MIS;
 Supportive supervision and monitoring.

37. WHO Waste management Cycle
Waste
minimization
Waste identification
Waste
Segregation
Waste handling
Waste treatment &
disposal
Record
keeping
Training
Supervision and
monitoring

38. Waste Minimization
 Care full management prevents the
accumulation of large quantity of waste.
 Health care service providers and institutions
administrator can play important role in
reduction of waste volume.
 Waste minimization is directly proportional
with waste management cost and related risk.
 Institution can adopt many policies and
practices that might reduce the waste volume.

39. Waste Minimization
Some policies of waste minimization are-
1. Source reduction- Purchasing and supplies
materials which are less wasteful and or
generate less medical waste.
2. Stock management- Frequent auditing; use
oldest stock first and checking the expired
date of products during receiving and supplies
of goods.

40. Waste Minimization
Some policies of waste minimization are-
3. Encourage use of Recyclable products- Use
materials that can be recycled both off-site or
on-site.
4. Control at institution level- Centralized
purchase and monitoring the receipt and
supply procedure of medical goods.

41. Waste Segregation
 The key of effective waste management is the
waste segregation.
 The waste should be segregated on the basis of
the category of waste.
 The whole waste management depends upon
effective waste segregation, because incorrect
segregation creates lot of hassles in the down
stream of waste management.

42. Waste Segregation
 If waste is properly segregated, small amount
are needed for disposal instead of large
quantity of waste, ultimately related manpower,
related cost, related risk lowered.
 If segregation is not properly done, small
quantity of hazardous waste has a chance to
mix with large volume of non-hazardous waste
making the whole volume into hazardous
waste.

43. Waste Segregation
 Segregation of medical waste should always be
the responsibility of waste producer and waste
should be segregated at the point just after its
generation.
 Once waste is segregated, staffs should never
attempt to correct of wrong segregation by
placing/transferring items from one container
to another.

44. Waste Identification
 An appropriate way of identifying the waste is
by sorting the waste into different COLOR
CODE.
 Color code is easy for identification and
thereby easy for safe handling, transportation
and waste treatment.
 The color code varies from country to country,
due to socioeconomic status, literacy rate,
availability of local resources, countries
classification of waste etc.

45. WHO recommended Color Code
for developing countries

46. Waste Handling
 Waste handling means the links between
packing, storage and transportation of medical
waste from every area of the institution by
designated individual.

47. Waste Collection
 Waste should not accumulate at the point of
birthplace.
 The designated personnel should collect the
waste containers by a routine program through
the designated route as a part of the waste
management plan.

48. Guidelines for waste collection
 Collectors must wear protective materials.
 Collection of waste in colored bag or colored
covered bins.
 Content of the container should not exceed
three quarter of its capacity.
 If bag is used for waste collection, tie the neck
tightly.
 Avoid throwing, dragging over floor or holding
the bottom of the containers.

49. Guidelines for waste collection
 No container should be used if damaged or
licked.
 All bins should be covered with lid during
collection and transportation of waste.
 Waste should not be collected more the ¾ of
containers capacity.
 No container should be transported without
labeling.

50. Guidelines for waste collection
 During collection each containers should be
replaced with a new one.
 Collection of Sharp medical waste under
maximum precaution.
 If there is spillage of waste from the container
(gently collect the waste into a bin, soak the
area with 2% Lysol solution, wait for 30
minutes, then wash and wipe.

51. Waste collection materials
 Character of the materials depends upon the type
of generated medical waste.
 Its better that the materials should be domestic in
origin, so that sustainability of supply could be
ensured.
 The commonly used materials are Colored waste
containers or bins, puncture proof container,
heavy duty gloves, rubber service gum boots,
hand tray, Balcha, waste carrying trolley, rubber
apron etc.

52. Placement of color bins
 Appropriate container should be placed at all
important location where particular wastes are
generated.
 Instruction on waste identification should be
pasted over the containers.

53. Placement of color bins
 General waste (Black color bin) could be
placed at landing area of the staircase, in the
straight long corridor bin could be placed at 50
meter distance, yellow colored bin could be
placed out side of the toilet in female ward for
collection of sanitary napkins.
 During replacement of the bin, same colored
another bin should be placed at the site.

54. Labeling
 Waste container should be labeled with some
basic information’s: about its waste category,
weight of the waste materials, date of
collection, and site of waste production.
 These information could be written on
preprinted labels with irremovable or water
resistance ink.
 All waste should be labeled and marked with
international symbol especially during
transportation.

55. Security
 Security of medical waste throughout its
lifecycle is significantly a challenge, as
because there is chance of scavenging in every
point of its lifecycle.
 Scavenging of medical waste especially at the
generation site and disposal site must be
recognized as threats to institutional infection
control program, quality of patient care and
community health hazard.

56. Health and safety
 To ensure the health and safety of the cleaner
in waste management through continuous
monitoring is important.
 An appropriate health and safety program
includes
a. Training of the worker about related risk.
b. Timely issue and encourage wearing
personal protective materials.

57. Health and Safety
c. Immunization of the worker under
occupational safety program especially
against Hepatitis-B virus and Tetanus.
d. Ensure reporting and post exposure
prophylactic treatment.
e. Ensure periodical medical checkup system.
f. Medical surveillance.

58. Personal hygiene
 In medical waste management personal
hygiene is very important.
 The working place should be provided with
continuous water supply and soap/detergent.
 Hand washing should be ensured on arrival for
work, before meal, before living the working
area and whenever is necessary.

59. Response to injury and exposure
 Service providers should be trained to deal
with injury and exposure.
 This program may include
 In case of accident immediate reporting to
the designated authority.
 Identify items involved in accident.
 Immediate first aid measure
 Giving medical attention as soon as possible.
 Record keeping.

60. Emergency response
 Should be prepare for accident and or unexpected
situation.
 Should be trained to manage common emergencies,
necessary equipment should be in hand and ready
at all times.
 Some common emergencies are
 Accidental spillage
 Equipment failure
 Accidental tear or breakage of containers.
 Explosion and or fire.

61. In-house transportation
 Means transportation of waste from the site of
origin or collection to temporary storage area
within the institution.
 Waste should be transported by designated
trolley, through the designated route according
to time schedule given by the institutional
authority.

62. In-house transportation
 A consignment note should accompany the
waste during transportation.
 The trolley or handcart should be easy to clean,
loading and unloading, leak proof body, should
not be used in any other case other then waste
transportation.

63. Temporary in-house storage
 The store will be a room or area or building
within the health care facility depending upon
the quantity and quality of waste production
and frequency of waste collection.
 Normally waste should not be stored more then
24 hours.

64. Selection criteria for Temporary in-
house storage area
 Should be properly located to prevent access of
unauthorized person.
 Should have an easy access for workers and
collection vehicle.
 Should be away from food preparation, processing
and food store.
 Provided with sufficient light and sufficient water
supply.
 Should be inaccessible for scavenger, animal and
rodents.

65. Selection criteria for Temporary in-
house storage area
 Should be sufficient space for washing and
cleaning.
 Should be equipped with sand, cleaning
equipments and fire fitting equipments and
reagents.
 Floor should be elevated and impervious with
proper drainage facility.
 There should be weighting and recording facility.
 The room should be properly ventilated.

66. Record keeping
 Accurate record keeping is needed for effective
medical waste management.
 Record keeping might give some important
information’s, which are needed for:
a. Assess the recurrent expenditure
b. Assess the quality and quantity of generated
waste

67. Record keeping
c.Assess the cost directly related with the man
and materials
d.Assess the cost related with waste treatment
and disposal method
e.Assess the risk involved with generated waste,
amount and nature of accident, amount of
damage, measure taken against accident etc.
f. Assess the failures, problem and obstacle in
waste management for better compliance of
the program.

68. Thank you!

69. Transportation for out house
management
 Means collection of stored waste from the
health care facilities to the final disposal site.

 Collection of waste from different institute
should be in a covered Van.
 The driver area should be totally separated
from waste carrying area.

70. Strategy of medical waste
management
 Development of awareness among the service
providers by sensitization;
 Proper capacity development of the service
providers by providing training;
 Development of in-house management of
waste;
 Development and adoption of option for the
final disposal of waste depending upon the
situation, type of hospital, amount of waste
production;

71. Strategy of medical waste
management
 Supply of logistics like different color bin,
needle crusher, service gloves, boot, mask etc;
 Establishment of accountability framework;
 Formation of “Local waste management
committee” and plan for implementation;
 Refresher training program for service
providers;
 Effective Monitoring and supervision.

72. Key consideration for the better
management of medical waste
 Strongly believes the need of alternative
approach of MWM.
 Hospitals will bear the responsibility of safe
management of its generated waste.
 Need for attitude change of service providers,
patients and community people.
 Service providers can contribute positively in
reducing waste volume and segregation.

73. Key consideration for the better
management of medical waste
 Committed and well motivated hospital staff
can adopts an effective strategy for proper
MWM.
 Government should take positive steps in
making guideline Legislation and policy on
HWM with ensuring monitoring and
supervision.

74. Disposal & Treatment Methods Suitable
for Different Categories of Medical Waste
Technology or
method
Infecti
ous
waste
Anato
mical
waste
Shar
ps
Pharma
ceutical
waste
Cytotoxi
c waste
Chemica
l waste
Radioactive
waste
Rotary kiln Yes Yes Yes Yes Yes Yes
Low-level
infectious
waste
Pyrolytic
incinerator Yes Yes Yes
Small
quantiti
es No
Small
quantiti
es
Low-level
infectious
waste
Single-chamber
incinerator Yes Yes Yes No No No
Low-level
infectious
waste
Drum or brick
incinerator Yes Yes Yes No No No No

75. Disposal & Treatment Methods Suitable
for Different Categories of Medical Waste
Technology
or method
Infectio
us
waste
Anatomi
cal waste
Sharp
s
Pharmaceu
tical waste
Cytotoxic
waste
Chemical
waste
Radioactiv
e waste
Chemical
disinfection Yes No Yes No No No No
Wet
thermal
treatment Yes No Yes No No No No
Microwave
irradiation Yes No Yes No No No No
Encapsulati
on No No Yes Yes
Small
quantitie
s
Small
quantitie
s No

76. Disposal & Treatment Methods Suitable
for Different Categories of Medical Waste
Technology
or method
Infectio
us
waste
Anatomi
cal waste
Sharp
s
Pharmaceu
tical waste
Cytotoxic
waste
Chemical
waste
Radioactiv
e waste
Safe burial
on hospital
premises Yes Yes Yes
Small
quantities No
Small
quantitie
s No
Sanitary
landfill Yes No No
Small
quantities No No No
Discharge
to sewer No No No
Small
quantities No No
Low-level
liquid
waste

77. Disposal & Treatment Methods Suitable
for Different Categories of Medical Waste
Technology
or method
Infecti
ous
waste
Anatom
ical
waste
Sharp
s
Pharmace
utical
waste
Cytotoxi
c waste
Chemical
waste
Radioactive
waste
Inertization No No No Yes Yes No No
Other
methods
Return
expired
drugs to
supplier
Return
expired
drugs to
supplier
Return
unused
chemicals
to supplier
Decay by
storage

78. Technologies for Treatment and
Final Disposal
 Incineration
 Chemical disinfection
 Render inert

79. Incineration
 Description: A high temperature dry oxidation
process that reduces organic and combustible
waste to inorganic matter. Many different types
of incinerator ranging from the sophisticated to
the basic; however, basic incinerators often
cause serious emissions problems.
 Advantages:
 Requires no pre-treatment.
 Good disinfection efficiency.

80. Incineration
 Disadvantages:
 If not operated effectively may pollute atmosphere
 High capital and operational costs. Low cost incineration is
possible by using a drum or brick incinerator, however,
these present large emission problems and are not as
effective in the destruction of hazards.
 Suitable condition:
 >60% combustible
 Moisture content < 30%.
 Not suitable for pressurized gas canisters, reactive chemical
waste, PVC, wastes with high heavy metal content,
photographic or radiography wastes.

81. Chemical disinfection
 Description: Chemicals added to the waste to
kill/inactivate the pathogens. Shredding is
usually necessary before disinfection, as only
the surface of intact solid waste will be treated.
The waste is then disposed of in a conventional
way, e.g. landfill.
 Advantages:
 Efficient disinfection when operated well.
 Some chemical disinfectants are low cost.
 Shredding reduces volume of waste.

82. Chemical disinfection
 Disadvantages:
 Disinfectants may themselves be hazardous to
operators & pose risks in the case of leakage and
subsequent disposal.
 Needs highly trained operators.
 Shredder liable to mechanical failure.
 Suitable condition:
 Best for liquid or sewage
 Inadequate for pharmaceutical, chemical and some
types of infectious waste.

83. Render inert
 Description:
 Mixing the waste with cement in order to
prevent migration of toxic substances from
waste into ground water etc.
 Advantages:
 Relatively low cost.
 Low-technology

84. Render inert
 Disadvantages:
 Bulky and heavy final waste product to be
disposed of.
 Especially suitable for pharmaceuticals.
 Suitable condition
 Not suitable for infectious waste.

85. Wet thermal treatment
(including autoclaving)
 Description: Exposure of shredded waste to
high temperature, high-pressure steam. If
temperature and contact time is sufficient, most
micro-organisms are inactivated. Waste can
subsequently be disposed of as municipal
waste.
 Advantages:
 Relatively low capital and operating costs.
 Low environmental impact.

86. Wet thermal treatment
(including autoclaving)
 Disadvantages:
 Shredder liable to mechanical failure.
 Efficiency of disinfection very sensitive to
operational conditions.
 Suitable condition
 Not suitable for anatomical, pharmaceutical
or chemical wastes.

87. Microwave irradiation
 Description: Waste shredded, humidified and
then irradiated by microwaves. The heat
generated destroys micro-organisms.
 Advantages:
 Very efficient disinfection when operated
well. Environmentally sound. Reduction in
volume of waste.

88. Microwave irradiation
 Disadvantages:
 Relatively high capital and operating costs.
 Potential operation and maintenance
problems.
 Suitable condition
 Not suitable for pharmaceutical or chemical
wastes
 Not suitable for large metal objects.

89. Landfill (Sanitary)
 Description: Landfill isolates waste from the
environment; it requires appropriate
engineering preparation, staff to control
operations, organized deposition and covering
of waste. Waste may be pre-treated (see above).
Ideally, healthcare waste is separated from
municipal waste.
 Advantages:
 Simple, low cost & safe when operated
properly.

90. Landfill (Sanitary)
 Disadvantages:
 If not operated properly scavengers may
access the waste and it may cause pollution
of environment etc.
 Suitable condition
 Generally suitable

91. Encapsulate
 Description: Pre-treatment involving filling
containers with waste, adding an immobilizing
material and sealing the container e.g.
bituminous sand, cement mortar.
 Advantages:
 Preventing access to HC waste by
scavengers.
 Relatively simple, low cost & safe

92. Encapsulate
 Disadvantages:
 Not recommended as sole method for non-
sharp infectious waste.
 Bulky and heavy final waste product to be
disposed of.
 Suitable condition
 Appropriate for establishments using
minimal programs for disposal of sharps,
chemical or pharmaceutical residue.
 Source: WHO, 1999

93. Thank You!