NALSAR University of Law,Hyderabad
Hospital is a place of almighty, a place to serve the patient. Since beginning, the hospitals are known for the treatment of sick persons but we are unaware about the adverse effects of the garbage and filth generated by them on human body and environment. Now it is a well established fact that there are many adverse and harmful effects to the environment including human beings which are caused by the “Hospital waste” generated during the patient care. Hospital waste is a potential health hazard to the health care workers, public and flora and fauna of the area. Hospital acquired infection, transfusion transmitted diseases, rising incidence of Hepatitis B, and HIV, increasing land and water pollution lead to increasing possibility of catching many diseases. Air pollution due to emission of hazardous gases by incinerator such as Furan, Dioxin, Hydrochloric acid etc. have compelled the authorities to think seriously about hospital waste and the diseases transmitted through improper disposal of hospital waste. This problem has now become a serious threat for the public health and, ultimately, the Central Government had to intervene for enforcing proper handling and disposal of hospital waste and an act was passed in July 1996 and a bio-medical waste (handling and management) rule was introduced in 1998 .
A modern hospital is a complex, multidisciplinary system which consumes thousands of items for delivery of medical care and is a part of physical environment. All these products consumed in the hospital leave some unusable leftovers i.e. hospital waste. The last century witnessed the rapid mushrooming of hospital in the public and private sector, dictated by the needs of expanding population. The advent and acceptance of “disposable” has made the generation of hospital waste a significant factor in current scenario .
HISTORY OF HOSPITAL WASTE MANAGEMENT
Waste management is one of the important public health measures. If we go into the historical background, before discovery of bacteria as cause of disease, the principle focus of preventive medicine and public health has been on sanitation. The provision of potable water, disposal of odour from sewage and refuse were considered the important factors in causing epidemics. The invention of water closet by John Harrington (1561-1612) facilitated flushing away human waste and helped to keep some dwellings clean, but flow from those indoor privies ran into cesspools and ultimately into waterways and wells. In 1848, the description by Edwin Chadwick of the sanitary conditions and health of English workers however had a great impact on the upper class and the governing bodies. His standard for proper removal of sewage and the protection of water supply was a stimulus to the govt. of Britain as was Rudolph Virchow’s militant advocacy of public health measures in Germany. The great glories of Roman hygiene were the water supply and the sanitation system. In several areas of Europe, public health remains primarily the responsibility of the inhabitant (for example—street cleaning and drainage) but laws were created and inspectors were assigned for enforcement. ‘Scavengers’ were appointed to collect the garbage and space outside was assigned for dumping.
THE ORIGIN OF BIO-MEDICAL WASTE MANAGEMENT IN THE INDIAN SUB-CONTINENT
In the Indian Sub-continent, until Sir Mortimer Wheeler’s work at Harappa in 1946, nothing was known with certainty of the way in which this people dispose of their dead, but from a cemetery than discovered, containing at least 57 graves, each appears-the burial was a usual rite. The whole cemetery has not been excavated and the evidence is not yet fully assessed, but it is clear that the dead were buried in an extended posture with pottery and personal belongings. Coming back to modern age, in the 21st century with increased use of disposable material and the presence of dreaded disease like Hepatitis – B and AIDS, it is utmost important to take care of the infected and hazardous waste to save the mankind from disaste r. The Health care institution or hospitals which are responsible for care of morbid population are emitting voluminous quantity of rubbish, garbage and Bio Medical Waste matter each day from wards, operation theatre and outpatient areas. Proper management of hospital waste is essential to maintain hygiene, aesthetics, cleanliness and control of environmental pollution. The hospital waste like body parts, organs, tissues, blood and body fluids along with soiled linen, cotton, bandage and plaster casts from infected and contaminated areas are very essential to be properly collected, segregated, stored, transported, treated and disposed of in safe manner to prevent nosocomial or hospital acquired infection . Various communicable diseases, which spread through water, sweat, blood, body fluids and contaminated 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, IV sets and other article 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.
With the proliferation of blood born diseases, more attention being focus on the issue of infectious medical waste and its disposal. Health care institutions must be aware of the potential risk in handling infectious waste, and adhere to the highest standard of transport & disposal. Education of the staff, patients and community about the management of the infectious waste is crucial in today’s health care arena .
LANDMARK DECISIONS TO STREAMLINE HOSPITAL WASTE MANAGEMENT
with increasing awareness in general population regarding hazards of hospital waste, public interest litigations were filed against erring officials. Some landmark decisions to streamline hospital waste management have been made in the recent past. These are:
1. Supreme Court judgment dated 1st March 1996 in connection with safe disposal of hospital waste ordered that
(a) All hospitals with 50 beds and above should install either their own incinerator or an
equally effective alternative method before 30th November 1996.
(b) The incinerator or the alternative method should be installed with a necessary pollution control mechanism conforming to the standard laid down by Central Pollution Control Board (CPCB).
(c) Hazardous medical waste should be segregated as source and disinfected before final
2. Ministry of Environment & Forest, Govt. of India issued a notification for Biomedical Waste(Management & Handling) Rules 1998 in exercise of powers conferred by Section 6, 8 & 25 of the Environment (Protection) Act, 1986 that was published in The Gazette of India Extraordinary, Part-II, Section 3-Sub-Section (ii) New Delhi, July 27, 1998 .
3. The Delhi Pollution Control Committee has been designated as Prescribed Authority to
implement these rules in the National Capital Territory of Delhi. The Financial Commissioner has been designated as appellate authority in Delhi.
4. In exercise of the Powers conferred by Rule 9 of the Bio-Medical Waste (Management & Handling) Rules, 1998 the Lt. Governor of Delhi has constituted an Advisory Committee Vide No. F. 23 (322)/95/EN/99 to act such authority under the said Rules. The composition of the Advisory Committee has 10 members with Pr. Secretary (Health), Govt. of Delhi as Chairman and Director Health Services as Member Secretary / Convener. Under Chairmanship of Principal Secretary (Health & Family Welfare) this Committee meets from time to time to discuss and decide about various issues connected with these rules. It is primary responsibility of the government to implement the recommendations and directions of the Supreme Court and Biomedical Waste (Management & Handling) Rules 1998 in public interest, so that Bio-medical waste does not cause any harm to men, animal and environment .
BIO-MEDICAL WASTE MANAGEMENT IN HOSPITALS- AN OVERVIEW OF BIO-MEDICAL WASTE (MANAGEMENT AND HANDLING) RULES, 1998
WHAT IS HOSPITAL WASTE?
Hospital waste refers to all waste generated, discarded and not intended for further use in the hospital. It is broadly categorized into the following categories:
1. General Waste
2. Pathological Waste
3. Infectious Waste
5. Pharmaceutical Waste
6. Chemical Waste
7. Radioactive Waste
AMOUNT AND COMPOSITION OF HOSPITAL WASTE GENERATED
Country Quantity (kg/bed/day)
U. K. 2.5
a) Hazardous but non-infective 5%
b) Hazardous and infective 10%
Dry cellublostic solid 45%
Wet cellublostic solid 18%
Any solid, fluid and liquid or liquid waste, including it’s container and any intermediate product, which is generated during the diagnosis, treatment or immunisation of human being or animals, in research pertaining thereto, or in the production or testing of biological and the animal waste from slaughter houses or any other similar establishment. All biomedical waste are hazardous. In hospital it comprises of 15% of total hospital waste .
RATIONALE OF HOSPITAL WASTE MANAGEMENT
Hospital waste management is a part of hospital hygiene and maintenance activities. In fact only 15% of hospital waste i.e. “Biomedical waste” is hazardous, not the complete. But when hazardous waste is not segregated at the source of generation and mixed with nonhazardous waste, then 100% waste becomes hazardous. The question then arises that what is the need or rationale for spending so much resources in terms of money, man power, material and machine for management of hospital waste? The reasons are:
1. Injuries from sharps leading to infection to a.ll categories of hospital personnel and waste handler.
2. nosocomial infections in patients from poor infection control practices and poor waste management.
3. Risk of infection outside hospital for waste handlers and scavengers and at time general public living in the vicinity of hospitals.
4. Risk associated with hazardous chemicals, drugs to persons handling wastes at all levels.
5. “Disposable” being repacked and sold by unscrupulous elements without even being washed.
6. Drugs which have been disposed of, being repacked and sold off to unsuspecting buyers.
7. Risk of air, water and soil pollution directly due to waste, or due to defective incineration emissions and ash.
APPROACH FOR HOSPITAL WASTE MANAGEMENT
Based on Bio-medical Waste (Management and Handling) Rules 1998, notified under the Environment Protection Act by the Ministry of Environment and Forest (Government of India) .
1. Segregation of waste
Segregation is the essence of waste management and should be done at the source of generation of Bio-medical waste e.g. all patient care activity areas, diagnostic services areas, operation theaters, labour rooms, treatment rooms etc. The responsibility of segregation should be with the generator of biomedical waste i.e. doctors, nurses, technicians etc. (medical and paramedical personnel). The biomedical waste should be segregated as per categories mentioned in the rules .(Annexure IV)
2. Collection of bio-medical waste
Collection of bio-medical waste should be done as per Bio-medical waste (Management and Handling) Rules. At ordinary room temperature the collected waste should not be stored for more than 24 hours.
Within hospital, waste routes must be designated to avoid the passage of waste through patient care areas. Separate time should be earmarked for transportation of bio-medical waste to reduce chances of it’s mixing with general waste. Desiccated wheeled containers, trolleys or carts should be used to transport the waste/plastic bags to the site of storage/ treatment .
4. Treatment of hospital waste
4.1 General waste
The 85% of the waste generated in the hospital belongs to this category. The, safe disposal of this waste is the responsibility of the local authority.
4.2 bio-medical waste: 15% of hospital waste
1. Deep burial
2. Autoclave and microwave treatment (Annexure II)
3. Shredding (Annexure II)
4. Secured landfill
5. Incineration (Annexure III)
5. Safety measures
5.1 All the generators of bio–medical waste should adopt universal precautions and appropriate safety measures while doing therapeutic and diagnostic activities and also while handling the bio-medical waste.
5.2 It should be ensured that:
1. Drivers, collectors and other handlers are aware of the nature and risk of the waste.
2. Written instructions, provided regarding the procedures to be adopted in the event of spillage/ accidents.
3. Protective gears provided and instructions regarding their use are given.
4. workers are protected by vaccination against tetanus and hepatitis B
1. Each and every hospital must have well planned awareness and training programme for all category of personnel including administrators (medical, paramedical and administrative).
2. All the medical professionals must be made aware of Bio-medical Waste (Management and Handling) Rules 1998.
3. To institute awards for safe hospital waste management and universal precaution practices.
4. Training should be conducted to all categories of staff in appropriate language/medium and in an acceptable manner.
7. Management and administration
Heads of each hospital will have to take authorization for generation of waste from appropriate authorities as notified by the concerned State/U.T. Government, well in time and to get it renewed as per time schedule laid down in the rules. Each hospital should constitute a hospital waste management committee, chaired by the head of the Institute and having wide representation from all major departments. This committee should be responsible for making Hospital specific action plan for hospital waste management and its supervision, monitoring and implementation. The annual reports, accident reports, as required under BMW rules should be submitted to the concerned authorities as per BMW rules format .
8. Measures for waste minimization
As far as possible, purchase of reusable items made of glass and metal should be encouraged. Select non PVC plastic items. Adopt procedures and policies for proper management of waste generated, the mainstay of which is segregation to reduce the quantity of waste to be treated. Establish effective and sound recycling policy for plastic recycling and get in touch with authorised manufactures.
BIO-MEDICAL/HOSPITAL WASTE MANAGEMENT SCENARIO IN DELHI
THE ORGANIZATION-WISE INSTITUTIONS
There is a big network of Health Care Institutions in Delhi. Although, these are not under one banner but these can be utilized by better coordination among different organizations.
These Health Care Institutions are inclusive of Allopathy, ISM and Homeopathy. The large chunk of hospitals and dispensaries are under Delhi Government, Municipal Corporation of Delhi, New Delhi Municipal Council, Employees State Insurance Corporation and Central Government Health Scheme. Equally important is the private sector comprising of major hospitals, nursing homes, clinics, blood banks, diagnostic laboratories, and Unani, homeopathy and Sidda Dava-khanas. At present there are 504 registered nursing homes registered under this directorate in Delhi. Bed-wise Distribution these Nursing homes is as follows
CENTRALISED TREATMENT FACILITY-STEPS TAKEN BY THE GOVERNMENT TO SOLVE THE PROBLEM
Keeping in view the difficulties faced by private hospitals/nursing homes in treatment of biomedical waste, the Govt. of NCT of Delhi has allowed these units to avail the facility through India Waste Energy Development ltd. at DDU hospital, LBS hospital, GTB hospital and BJRM hospital. Currently IWEDL is operating the facilities at DDU hospital only. This is an interim arrangement and government is planning for centralized facility.
The smaller Nursing Homes and Clinics, which cannot make their own arrangements due to high cost involved in waste treatment facilities, require some alternative modalities. To solve the problems of Nursing Homes/Clinics/Blood Banks/Diagnostic Laboratories etc., Government is taking initiatives to establish centralized waste treatment facilities. The Government of NCT of Delhi (GNCTD) has purchased land from Delhi Development Authority (DDA) for establishment of Centralized Biomedical Waste treatment facilities 1000 sq. meter each at Okhla and Gazipur in Delhi. The tenders for centralized facility at Okhla have already been finalised .
THE BED STRENGTH IN DELHI GOVT. HOSPITALS
The Government of NCT of Delhi has planned to utilize the above two sites for establishing Centralized Bio-Medical Waste Treatment facilities as a joint venture with the private sector/NGO etc. to be identified and selected through a transparent process. For this venture, Government of NCT of Delhi shall only provide infrastructural support to the selected party/agency in terms of transfer of the above sites on such terms and conditions as shall be approved by the Delhi Development Authority. Neither any additional capital expenditure for the establishment of the facility nor any recurring revenue expenditure for operation and maintenance of the facility will be forthcoming from the GNCTD. Given the above conditions, the party for the joint venture shall be selected who is able to offer the services to the Hospitals/Nursing Homes/Clinics etc. at the most reasonable rates conforming to all the required statutory conditions. There are 26 Hospitals under Government of Delhi, out of which 11 are under DHS. Six hospitals are having Incinerators and 9 hospitals are having Autoclaves and Shredders for Scientific Management of Bio-Medical Waste. Bio-Medical Waste from the Hospitals, where such facilities are not available are segregated and transported in special van to Hospitals where such facilities exist. Under Biomedical Waste (Management & Handling) Rules 1998, all health care institutions are required to handle biomedical waste in a specified manner. Delhi is generating approximately 6000 metric tons of waste out of which 60 tons are Biomedical Waste. The Government hospitals and major private hospitals have their own arrangement for treatment of biomedical waste. Total no of beds in hospitals under Government of NCT of Delhi are 5641 .
BIOMEDICAL WASTE GENERATED IN DELHI GOVERNMENT HOSPITALS
All the 26 Delhi Govt. hospitals and 167 Dispensaries under this Directorate have obtained authorization from DPCC under Bio-medical Waste (Management & Handling) Rules 1998.
The govt. of national capital territory of Delhi had made adequate arrangements for meeting any contingencies arising out of the handling, treatment and disposal of bio medical waste much before any other government any where. Funds were made available to the hospitals to procure incinerators, and state of the art autoclaves and shredders were imported so that the prescribed methods of medical waste treatment under the law could be met. The vacuum type of autoclaves procured by Delhi govt. are the best available anywhere. These are ideal to disinfect plastic, PVC and other categories of medical waste. Adequate funds have always been provided to all hospitals for purchasing accessories such as bags, trolleys and the disinfectants. So there should be no excuse for not properly disposing bio medical waste .
Delhi govt. had signed a MOU with the Government of Australia in 1998 to have experts visiting from that country and advising and assisting our hospitals to learn and understand a variety of issues related to bio medical waste management. This collaborative programme resulted in developing training modules, which have been made available to all.
Total Treatment 8.5 MT/D
INITIATIVES TAKEN FOR EFFECTIVE MANAGEMENT OF BIO-MEDICAL WASTE
• Twice a year inspections are conducted in the 100 bedded or more, hospitals which contribute about 70% of the total waste generated.
• Air and effluent quality analysis in these major hospitals is done by IIT, Delhi.
• Authorisation has been granted to 1365 healthcare establishments.
• 6800 health care professionals have been trained.
• Efforts are being made to ensure that no medical unit in Delhi escapes the responsibilities enjoined upon them for proper storage, treatment and disposal of bio-medical waste generated by it.
SERIOUS ISSUES OBSERVED AS A GENERAL TREND IN THE DELHI HOSPITALS
(1) The segregation of waste in almost all hospitals is not satisfactory.
(2) Colour coding for various categories of waste is not followed.
(3) The storage of BMW is not in isolated area and proper hygiene is not maintained.
(4) Personal protective equipment and accessories are not provided.
(5) Most of the hospitals do not have proper waste treatment and disposal facilities. In the cities where common treatment facilities have come up, many medical establishments are yet to join the common facility.
(6) Emission monitoring of five incinerators indicated that they do not meet the emission norms.
(7) Most of the incinerators are not properly operated and maintained, resulting in poor performance.
(8) Sometimes plastics are also incinerated leading to possible emission of harmful gases.
(9) Several hospitals have not applied to State Pollution Control Board for authorisation under the rules.
(10) General awareness among the hospital staff regarding BMW is lacking.
Judicious reuse of materials contributes towards better infection control, reduces disposables and also reduces the cost. Safe handling of BMW continues to be a matter of serious concern for health authorities in India. Thousands of tonnes of BMW originating from hospitals, nursing homes and clinics in the form of cotton swabs and bandages infected with blood, needles, catheters, human tissues and body parts, etc continue to be dumped in open garbage bins on the roads in most parts of the country. With apparently no machinery for granting permission to new nursing homes in any of the states, the generation of these dangerous wastes is only expected to increase in the days to come . Barring a few large private hospitals in metros, none of the other smaller hospitals and nursing homes has any effective system to safely dispose of their wastes. The attitude of the government and municipal hospitals is no better than these private hospitals and nursing homes. Such irresponsible dumping of these dangerous wastes in open bins has been promoting unauthorised reuse of medical waste by the rag pickers for some years now.
After a spate of Public Interest litigations, bio medical waste (management and handling) rules were formulated and notified in July 1998. These were enforced in phased manner and are now applicable throughout the country. In Delhi these became applicable on 1st July 2000. It is guesstimated that out of about 6000-7000 tons of solid waste generated in Delhi, about 1% is medical waste. This makes the amount of medical waste generated 60-70 metric tons/day. If proper segregation is done by healthcare personnel which the rules prescribe, then the bio medical waste generation in Delhi should not be more than 20-25 metric tons/day or even less. This amounts to great savings in financial terms.
CONCLUSION AND SUGGESTIONS TO COMBAT BIO-MEDICAL WASTE IN HOSPITALS
The hospitals and bio medical facilities meant to ensure better health have unfortunately become a potential health risk due to mismanagement of the infectious waste. BMW from hospitals, nursing home and other health centers composed of variety of wastes like hypodermic needles, scalpels blades, surgical cottons, gloves bandages, clothes, discarded medicine, blood and body fluids, human tissues and organs, radio-active substances and chemicals etc. This area of waste management is grossly neglected.
The researcher, therefore, states that there needs to be requisite emphasis on the following which could be done through a program that includes:
1. Updated Guidelines for the segregation, management and disposal of infectious or potentially infectious biomedical waste.
2. Reduce the incidence of health care worker and the public from contacting a disease or injury from biomedical waste.
3. Provide guidance to the health care system on the opportunities for waste minimization and the reduction of air contamination from incineration of biomedical waste.
4. Strategies and appropriate handling techniques for bio-medical waste management
5. Create awareness about Hospital accreditation with focus on guidelines related to healthcare safety issues related with disposal of Bio-Medical Waste.
6. Understand the new technologies available for Safe disposal of Bio medical Waste from Environment friendliness point of view & infection control in hospitals
7. Economic issue involved in Management of Bio-Medical Waste & Role of Public-Private Partnership
Also, it should be made mandatory for the following to be a part of the above mentioned programme in order to increase the awareness among them so as to ensure better treatment of the bio-medical waste in the hospitals:
1. Medical Superintendents/ Hospital Administrators
2. Doctors running their own healthcare facility
3. Hospital Laboratory Services Providers.
4. Hospital Administrators
5. Senior Nurses and paramedical staff
6. Allied Health Professionals
8. Healthcare Waste Management related industry Owners
9. Quality Managers
10. Hospital House Keeping Officers