Nursing Lecturer

1. BIOMEDICAL WASTE
MANAGEMENT IN HOSPITAL
Prepared by,
Pinki Sah
Lecturer
BHC

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.

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 there to 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. DEFINITION (1/2)
• According to WHO “health care waste” (HCW) is defined as the
total waste stream from a healthcare facility (HCF) that includes
both potential risk waste and non risk material.”

9. DEFINITION (2/2)
• According to Bio-Medical Waste (Management and Handling) Rules,
1998 of India “Bio-medical waste”, “any solid, fluid or liquid waste,
including its container and any intermediate product, which is
generated during the diagnosis, treatment or immunization of human
beings or animals, in research pertaining there to, or in the
production or testing of biological and the animal waste from
slaughter houses or any other like establishments”.

10. WHO CLASSIFICATION OF WASTE
WASTE CATEGORIES DESCRIPTION AND EXAMPLES
1.General waste No risk to human health e.g.: office paper, wrapper,
kitchen waste, general sweeping etc.
2. Pathological waste Human Tissue or fluid e.g.: body parts, blood, body
fluids etc.
3. Sharps Sharp waste e.g.: Needle, scalpels, knives, blades
etc.
4. Infectious waste Which may transmit bacterial, viral or parasitic a
disease to human being, waste suspected to contain
pathogen e.g.: laboratory culture, tissues(swabs)
bandage etc.

11. WHO CLASSIFICATION OF WASTE
WASTE CATEGORIES DESCRIPTION AND EXAMPLES
5. Chemical waste E.g.: Laboratory reagent, disinfectants, Film
Developer
6. Radio-active waste E.g.: unused liquid from radiotherapy or lab
research, contaminated glassware etc.
7. Pharmaceutical waste Expired outdated drugs/chemicals
8. Pressurized container Gas cylinder, arousal cans etc.
9. Genotoxic waste Waste Containing Cytotoxic drugs(often Used In
Cancer Therapy)

12. CATEGORIZATION IN NEPAL
CONTEXT(1/3)
At the present context, HCFs in Nepal are still at infancy in the HCWM
practices. Proper management of above categorized HCWs is a big
challenge for Nepal.
Wherever possible, classification by UNEP/SBC/WHO is recommended
for the segregation of HCWs.

13. CATEGORIZATION IN NEPAL
CONTEXT(2/3)
However, it is recommended that the non-risk HCW should not
be mixed with other types of HCWs. Non-risk HCW should at
least be separated into:
• Bio-degradable
• Non-biodegradable

14. CATEGORIZATION IN NEPAL
CONTEXT(3/3)
Risk health care wastes should at least be separated into six
categories as mentioned below:
• Pathological Waste
• Infectious waste
• Sharp waste
• Cytotoxic waste
• Pharmaceutical waste
• Other hazardous waste

16. SOURCES OF HEALTH CARE WASTE
• Hospitals
• Health clinics
• Dental clinics
• Dispensaries
• Blood bank & blood collection
service
• Dialysis centers
• Medical & bio medical
laboratories
• Medical Research centers
• Military medical services
• Animal research & testing

17. COMPOSITION OF HEALTH CARE
WASTE
• 80 % general health care waste
• 15 % pathological & infectious waste
• 1 % sharp waste
• 3 % chemical or pharmaceutical waste
• Less than 1% special waste (radio active ,cytotoxic, pressurized
containers or broken thermometer & used batteries)

18. RISK GROUPS (1/2)
• 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 (2/2)
• 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. HEALTH HAZARDS FROM HEALTH
CARE WASTE (1/3)
Exposure to hazardous health-care waste can resulting disease or
injury because:
• It contains infectious agents.
• It is genotoxic.
• It contains toxic chemicals or pharmaceuticals.
• It is radioactive.
• It contains sharp.
• It contains carcinogenic agents and gaseous chemicals.

21. HEALTH HAZARDS FROM HEALTH
CARE WASTE (2/3)
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
• Genotoxic effects, affects genetic materials

22. HEALTH HAZARDS FROM HEALTH
CARE WASTE (3/3)
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.

23. HEALTH CARE WASTE GENERATION IN
NEPAL (1/3)
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

24. HEALTH CARE WASTE GENERATION IN
NEPAL (2/3)
• 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

25. HEALTH CARE WASTE GENERATION IN
NEPAL (3/3)
• 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

26. MANAGEMENT OF HEALTH CARE
WASTE (1/2)
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;

27. MANAGEMENT OF HEALTH CARE
WASTE (2/2)
• 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.

28. Aims of proper waste management (1/2)
Proper waste management aims in preventing:
Injuries from sharps leading to infection to health personnel and waste
handler.
Nosocomial infections in patients from proper infection control
practices and poor waste management.
Risk of infection outside hospital for waste handlers and scavengers
and at time general public living in the vicinity of hospitals.

29. Aims of proper waste management (2/2)
 Risk associated with hazardous chemicals, drugs to persons handling wastes
at all levels.
“Disposable being repacked and sold by unscrupulous elements without
even being washed.
Drugs which have been disposed of, being repacked and sold off to
unsuspecting buyers.
Risk of air, water and soil pollution directly due to waste, or due to defective
incineration emissions and ash.

31. Waste minimization (1/3)
• 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.

32. Waste minimization (2/3)
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.

33. Waste minimization (3/3)
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.

34. 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.

35. WHO recommended color code for
developing countries
Type of waste Color code
Highly infectious Red
Infectious, pathological, anatomical Yellow
Sharp Yellow colored box
Chemical, pharmaceuticals Brown
Radioactive Silver
General waste Black

36. Color coding (Nepal)
Color coding of
polyethylene bag
Type of waste material collected
Black Non-infectious and non-hazardous waste
Red Microbiological waste from pathological laboratory,
items contaminated with blood and body fluids, and
waste generated from disposable items other than
sharps etc.
Yellow Human anatomical waste, microbiological waste form
pathological laboratory, items contaminated with blood
and body fluids and waste generated.
Blue Waste sharps, solid waste generated form disposable
items other than the waste sharps such as tubing,
catheter, IV sets, etc.

37. Waste segregation (1/2)
• 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.

38. Waste segregation (2/2)
• 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.

39. Waste handling
• Waste handling means the links between packing or collection,
storage and transportation of medical waste from every area of
the institution by designated individual.

40. 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.

41. Guidelines for waste collection (1/3)
• 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.

42. Guidelines for waste collection (2/3)
• 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 than ¾ of containers
capacity.
• No container should be transported without labeling.

43. Guidelines for waste collection (3/3)
• 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.

44. 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.

45. Placement of color bins (1/2)
• Appropriate container should be placed at all important location
where particular wastes are generated.
• Instruction on waste identification should be pasted over the
containers.

46. Placement of color bins (2/2)
• 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.

47. 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.

49. 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.

50. Health and safety (1/2)
• 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.

51. Health and safety (2/2)
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.

52. 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.

53. 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.

54. 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.

55. In-house transportation (1/2)
• 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.

56. In-house transportation (2/2)
• 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.

57. 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.

58. Selection criteria for temporary in-house
storage area (1/2)
• 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.

59. Selection criteria for temporary in-house
storage area (2/2)
• 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.

60. 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.

61. Waste treatment and disposal
• General waste should be dumped at municipal dumping site.
Sanitation officer should be responsible for proper coordination
between municipal and hospital.
• Use of label/symbol is useful in identifying waste for treatment
.e.g.: Risk of corrosion, Danger of Infection, Toxic hazards,
Glass Hazards, Radioactive materials etc.

62. Treatment and disposal technique for
health care waste
I. Incineration
II. Chemical disinfection
III. Wet & dry thermal treatment
IV. Microwave irradiation
V. Land disposal
VI. Inertization

63. I. Incineration
• It is a high temperature dry oxidation process.
• Reduces organic & combustible waste to inorganic &
incombustible waste.
• For most hazardous waste .
• It is used for waste that can’t be recycled.
• Results in significant reduction of waste volume & weight.

64. Not to be incinerated
• Wastes like high mercury, cadmium e.g. broken thermometer,
used batteries
• Ampules containing heavy metals
• Photographic/radiographic wastes

65. II. Chemical disinfection
• To kill or inactivate pathogens it contained.
• Disinfection rather than sterilization
• Most suitable for liquid waste e.g. urine, blood, stool, hospital
sewage, microbiological cultures

66. III. Wet and dry thermal treatment
1. Wet thermal treatment:
• Similar to autoclave sterilization process.
• Inappropriate for the treatment of anatomical waste & animal
carcasses.

67. 2. Screw feed/dry thermal technology:
• Non burn , dry thermal disinfection process in which waste is
shredded & heated in a rotating auger.
• Suitable for infectious waste & sharps.
• But not to be used for pathological ,cytotoxic or radioactive
waste.

68. IV. Microwave irradiation
• Most organism destroyed by the of micro wave of frequency of
2450 MHZ & a wave length of 12.24 nm.
• The efficiency of microwave disinfection checked routinely
through bacteriological and virological test.

69. V. Land disposal
• If hazardous health-care waste cannot be treated or disposed
• Investigate more suitable treatment methods
disposal sites:
• land open dumps
• Sanitary landfills.

70. VI. Inertization
• Mixing waste with cement & other substances before disposal
• Inhibits the waste migrating into the surface & ground water
• Proportion of mixture is 65% pharmaceutical
waste,15%lime,15% cement & 5% water.

71. Record keeping (1/2)
• 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

72. Record keeping (2/2)
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.

73. Training (1/4)
• Health related institutions and hospitals must train managers,
supervisors, and employees in waste management and reinforce
knowledge with promotional activities and special emphasis
programs.

74. Training (2/4)
• Training program must be revised as new equipment is
introduced or as technological change occurs.
• All casual staff needs to be trained in waste management before
starting employment.

75. Training (3/4)
The following topics should be covered:
• Operating manuals, outlining safe and approved work practices
• Material safety data sheet (MSDS)
• Staff awareness of policies at orientation to the health care
institution
• Legislative compliance

76. Training (4/4)
• Provision of and compliance with the use of personal protective
equipment;
• Hygiene procedures
• Waste stream definitions and waste segregation practices
• Costs and benefits of waste management
• Explanation of recycling programs
• Details of employee vaccination program

77. Supervision and monitoring (1/4)
Regular monitoring must be performed in each institution with regard to
health care waste management. The importance of monitoring lies in the
fact that it provides:
• Feedback to the state of affairs in the various stages of health care waste
management;
• Information on the trends of waste generation for proactive future action;

78. Supervision and monitoring (2/4)
• Information on the areas of weakness and strength so as to reinforce the
management system with appropriate corrective actions;
• Information on the effectiveness of various health care waste management
strategies;
• Information on the achievements of stated targets and standards

79. Supervision and monitoring (3/4)
Three types of monitoring mechanism need to be enforced for the
progressive improvement and sustainability of the health care
waste management system. They are;
• Baseline monitoring
• Compliance monitoring
• Impact monitoring

80. Supervision and monitoring (4/4)
Baseline and compliance monitoring are performed by the person
(s)/authority designated by existing waste management committee.
Impact monitoring is performed externally.

81. Baseline monitoring
Baseline monitoring monitors the changes in baseline environmental
conditions. The following parameters should be monitored to examine
changes in baseline environmental conditions.
Waste handling and management practices at health care institutions
Present practices/trend of waste handling in institutions
 Air quality at treatment facility
 Water quality at treatment facility, or at landfill site

82. Compliance monitoring (1/2)
• Compliance monitoring ensures that all the parties concerned in the
health care waste management system follows the provisions of
guidelines or rules. Compliance monitoring should be done at two
stages, one during construction treatment unit/facility and another
during the operation of entire operation.

83. Compliance monitoring (2/2)
• During construction it is important to check that the right kind
of equipment is being bought and installed in a proper way.
• During operation, it is important to ensure that hazardous is
being handled properly and the equipment is being operated as
per the instruction of the manufacturer.

84. Impact monitoring (1/2)
• Impact monitoring identifies any positive or negative changes that have
been brought by the established health care waste management system.
• It requires a repetitive measurement of certain key indicators for the
establishment of cause effect relationship.

85. Impact monitoring (2/2)
The following parameters could be monitored to evaluate the impact of the
health care waste management system.
• Opinion of patients and visitors
• Opinion of workers in health care institution
• Opinion of health care institution
• Inventory of waste handled
• Payment by health care institutions to service providers, etc.

86. STRATEGY OF MEDICAL WASTE
MANAGEMENT (1/3)
• 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;

87. STRATEGY OF MEDICAL WASTE
MANAGEMENT (2/3)
• Development and adoption of option for the final disposal of
waste depending upon the situation, type of hospital, amount of
waste production;
• Supply of logistics like different color bin, needle crusher,
service gloves, boot, mask etc;
• Establishment of accountability framework;

88. STRATEGY OF MEDICAL WASTE
MANAGEMENT (3/3)
• Formation of “Local waste management committee” and plan
for implementation;
• Refresher training program for service providers;
• Effective Monitoring and supervision.

89. 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.

90. Key consideration cont….
• 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.

91. REFERENCES
• https://www.slideshare.net/harikafle944/hospital-waste-management-
47700029
• https://www.slideshare.net/RAVIKANTAMISHRA/health-care-
waste-management-43382758
• https://www.slideshare.net/sharrygajuryalnepal/hospital-waste-
management-30528327
• https://www.slideshare.net/PrakashGhimire5/health-care-waste-
management-guideline-2014-108174177
• http://nhrc.gov.np/wp-content/uploads/2017/02/National-Health-
Care-Waste-Management-Guidelines.pdf
• https://www.academia.edu/10449353/BIOMEDICAL_WASTE_MA
NAGEMENT_IN_NEPAL_A_REVIEW?auto=download