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Hospital waste management is one of the most critical and yet underrated kind of waste management .The growing number of hospitals and the unhealthy eating habits of the people has contributed to the rising number of patients in hospitals. Wastes that are improperly disposed lead to spreading of infection. This will lead to the unhealthy society as a whole. Modern day societies place high importance on preventing the manufacturing of plastic and its By-products but they overlook the importance of collecting and disposing the existing plastic products that are in circulation. This is applicable for the hospital waste management as well. Hence it is imperative to focus and understand the procedures used for hospital waste management.
The hospital waste management process contains the following stages. Stage 1: [Acquiring the contract]
The hospital invites tenders from prospective waste management agencies via newspaper agencies. Hospital follows a strict selection procedure which includes the experience of the agencies eco friendliness and regulatory constraints. Some of the constraints are * Number of workers deployed in the site of waste management * The precautionary measures taken by each worker deployed * Removal of waste on weekly basis
* Proper reusability of waste
Stage 2: [Resource Allocation]
Resource will be allocated based on the waste generated by the hospital on day to day basis. Now generally the agency calculates the amount of waste based on the bed capacity on the respective hospitals. Ex: St.John’s medical college hospital which is located in Hosur main road, Koramangala is one of the biggest hospitals in Bangalore and it has 2500 beds and generates a lot of hospital waste.
Stage 3: [Collecting the waste]
Hospitals give a separate area in their premises to the agency to segregate the waste generated by them. The ward boys collect the waste on an hourly basis. The collected waste is disposed into two distinctive bags namely red color for Bio-hazardous waste and yellow for non- hazardous waste. The agencies collect the waste from this segregated area.
Stage 4: [Segregation]
The waste collected in Red and Yellow bags will be further segregated based on the composition of that particular waste. Bio-hazardous waste such as needles, amputated limbs and any other material that was contaminated by blood are first sorted and packed in special containers. These containers are sent to a place located in the outskirts of the city for final disposable.
State authorities in India have made several strategic decisions pertaining to HCW management. One decision was how to refine the technology options included in the Biomedical Waste Rules. Although the rules list incineration as an option for certain categories of BMW, concerted efforts by NGOs—including Srishti, Toxic Link, and Jyotsna Chauhan Associates—and the press have convinced some SPCBs to rule out the use of onsite incineration.
In the State of Andhra Pradesh, for example, where most health care facilities are in the heart of cities, the Andhra Pradesh Pollution Control Board prohibited incineration at health care facilities in the entire state after considering the potential adverse impacts of pollutant emissions from substandard incinerators. The Kerala Pollution Control Board recently opted for autoclaving and deep burial of BMWs instead of incineration. The Tamil Nadu Pollution Control Board has banned incineration of BMWs—except for body parts and human tissues— in favor of autoclaving and sanitary land filling.
National and state authorities have made some technology choices for HCW management taking into account human health impacts in urban and rural areas. The Biomedical Waste Rules specify that incineration is the disposal scheme required for human anatomical and animal wastes for cities with population greater than 500,000, and deep burial is the disposal scheme required for such wastes for smaller cities and rural areas. In the State of Karnataka, however, because of the poor performance of incinerators at health care facilities, on-site incineration has been prohibited within the limits of six city municipal corporations and in all district headquarters.
Of these locations in Karnataka, where the population exceeds 500,000, destruction of human anatomical and animal wastes is to be accomplished by incineration only at CWTFs to comply with both the Biomedical Waste Rules and state requirements. Bangalore, Hubli- Dharwad, and Mysore comply with this requirement, but in Mangalore, human anatomical and animal wastes are currently disposed of by deep burial. In Andhra Pradesh, state authorities have selected deep burial as the disposal scheme for biodegradable infectious wastes in areas with a population less than 500,000.
This approach is not in compliance with the Biomedical Waste Rules, which require local autoclaving, microwaving, or incineration instead of deep burial, but it is in accordance with the 1999 WHO guidelines for the safe management of wastes from health care activities. Another strategic decision for state authorities in India was whether to opt for on-site treatment of BMWs or common treatment of BMWs. Common treatment of BMWs offers several advantages. 1. CWTF can be located away from hospital premises and urban areas, significantly reducing the potential adverse human health impacts.
2. CWTF reduces treatment and disposal costs by treating large quantities of wastes collected from many facilities (that is, it offers economies of scale), although the savings must be balanced by the additional transportation costs from all the facilities to the CWTF.
3. CWTF can employ specially trained personnel who could not be easily supported by individual health care facilities, resulting in better and more efficient operation.
4. The permitting, monitoring, and enforcement efforts by regulatory agencies of one CWTF are likely to be fairly effective. Nonetheless, there are challenges associated with a common treatment of BMWs. A CWTF approach imposes a direct financial burden on the operators of health care facilities, who previously paid minimal amounts for services associated with waste management. It also requires operational and behavioral changes by the operators of health care facility operators, who must properly segregate wastes into the types of BMW accepted by the CWTF operator. A more important concern is the difficulty of ensuring continued involvement of the private sector in a CWTF when the market is uncertain because of the absence of a culture of compliance and a weak enforcement regime. India’s central government views common waste treatment as the most appropriate approach to the treatment of BMWs generated in urban areas.
Andhra Pradesh was the first state to devise and implement a CWTF scheme. Initially, resistance to the scheme arose from doctors who were unwilling to accept a CWTF approach for the “Twin Cities” area of Hyderabad and Secunderabad and objected to the charges required for BMW treatment and disposal. Workshops were held with doctors and other facility staff to overcome their resistance, and mass awareness campaigns were conducted in Andhra Pradesh about the need for safe BMW treatment and disposal. Two privately owned CWTFs were set up in the state to treat BMWs from Hyderabad and Warangal Districts, using the same types of technologies (incineration and autoclaving).
The successful model for a privately owned and operated CWTF used in Andhra Pradesh was subsequently emulated in other states—including Karnataka, Maharashtra, Punjab, Rajasthan, Tamil Nadu—and plans for similar CWTFs have recently been adopted in the States of Gujarat, Kerala, New Delhi, Uttar Pradesh, and West Bengal. • Karnataka: In Karnataka, two CWTFs—one in north and the other in south Bangalore— have been operating using incineration and microwave technologies to serve about 6,000 beds in the city.
Another CWTF in Mysore, which uses the incineration and autoclave technologies, was commissioned for 67 health care facilities with 7,000 beds. Two additional CWTFs, both based on the incineration technology, were com-missioner recently in Belgaum and Hubli- Dhardwad. Three additional CWTFs are going into place in Karnataka at Gulbarga, Mangalore, and Shimoga. All the CWTFs in Karnataka are located away from the city limits, with transportation of BMWs provided by the CWTF operator.
Stage 5: [Selling the waste to the Wholesaler]
The segregated scrap is then sold to the wholesaler .There are 3 types of wholesalers namely
* Glass based
* Paper based
* Plastic based
* Glass based: Once the glass based wholesaler receives the bottles, he segregates the bottles which can be reused and sends it back to the respective companies and the bottles which cannot be reused are crushed and then melted and made into different glass products . * Paper based: Once the paper based wholesaler receives the segregated papers the cotton boxes are crushed and treated then it is converted to a carton box again .
The papers are separated on the basis of their color and then treated for ink removal and then sent to paper mills. * Plastic based: The sorted plastic is first washed with chemicals to remove all hazards and then it is grinded and it is made into powder so that it loses its original shape. Then this particular powder is sold to the factories, they melt it and make it into different products. Materials and methods
There are a few amenities required by the waste management agencies to function in effective manner. 1. The yard provided by the hospital should have a roof .The yard should be ventilated properly .Otherwise most of the products are wet, they start emitting bad odor .This may cause infection to the workers in the yard.
2. Each and every worker should be provided with a pair of surgical gloves .He also has to wear proper footwear. There are chances of infected material coming to the yard, so this will prevent them from getting infected.
3. The burning of the hazardous waste material should be done outside the city limits where the population is minimal and the ashes should be buried minimum 20 feet below the ground. There should be a minimum of 50 feet chimney to let the smoke outside .The ashes should not be buried anyway next to ground water irrigation.
4. The glass and plastic wholesaler should take extra care to see to that the materials are washed properly with the right chemicals to prevent any kind of infection.
5. The workers in the yard and the wholesaler’s warehouse should follow strict precautionary measures and they should be provided with hand sanitizer.
The marketing strategy of hospital waste management varies depending on their operational capabilities. Large scale operators like Maridi based in Hyderabad and Synergy based in Delhi use advertising campaigns to attract prospective customers while small players like Sathya Eco-Management based in Bangalore, follow variant of direct marketing by approaching hospitals to collect Hospital waste
Financing and Incentives
The following table describes approximate revenue of Sathya Eco-Management
The revenues in 2008 were boosted by The Beijing Olympics where large quantities of scrap were exported from India to China. This year was unusual as compared to other years where the revenues fluctuated within the range of 12 to 16 lakhs. The financial cycle begins with the invitation of the tenders from the hospitals. Prospective bidders who satisfy the selection criteria pay the required amount in demand draft. The waste management agencies would then sell the procured material to the wholesalers. The wholesaler then sells his product to the different factories. The factories convert the procured material into the product and sell it back to the consumers. The wages are made every week on a daily rate basis.
India was the first country in South Asia to establish a legal framework for the management of health care wastes. The development of India’s legal framework began in 1995.At that time; the scope of the HCW problem was rather large. According to the Central Pollution Control Board (CPCB)—the technical arm of India’s Ministry of Environment and Forests—an estimated 150 tons/day of biomedical waste generated from health care facilities were being mixed in with communal wastes without adequate attention to proper waste management procedures (CPCB 2000).
In 1995, India’s Ministry of Environment and Forests drafted rules for managing BMWs that proposed
(a) Each health care facility with more than 30 beds or serving more than 1,000 patients per month installs an incinerator on its premises.
(b) Smaller health care facilities set up a common incinerator facility. Shortly thereafter, in March 1996, the Supreme Court directed the Government of India to install incinerators at all hospitals in the New Delhi area that had more than 50 beds. Sixty incinerators were installed in the New Delhi area, and 26 of them are still in service. Only one of these incinerators meets today’s national norms—an incinerator at RML Hospital that was re engineered by CPCB.
Meanwhile, in 1995, Srishti, a nongovernmental organization (NGO), had taken a survey that revealed unsanitary practices and associated risks in dealing with HCWs in India. In 1996, Srishti initiated public interest litigation against the government that led the Supreme Court to revise its initial position for incineration at health care facilities by ordering India’s Central Pollution Control Board (CPCB)—the technical arm of the Ministry of Environment and Forests—to consider alternative and safer technologies in HCW management rules and to set up technology standards.
A major drawback of incineration is that it produces toxic air emissions. The principal pollutants in terms of public health are heavy metals (such as cadmium, mercury, and lead), hazardous by-products from combustion (such as dioxins and furans), and particulate matter. Srishti asked the Supreme Court to require alternative and safer technologies in the rules and the setting up of standards for these alternative technologies.
At Srishti’s urging, India’s Supreme Court revised its initial position and ordered CPCB to consider alternative BMW treatment and disposal technologies. Between 1996 and 1998, while CPCB was evaluating alternative technologies, there were intensive consultations among government officials, health care representatives, scientists, members of the industry, and NGOs. The culmination of all these efforts was the preparation and publication by India’s Ministry of Environment and Forests of the Biomedical Waste (Handling and Management) Rules of 1998.Those rules are discussed further below.
The Biomedical Waste Rules of 1998
India’s Biomedical Waste Rules of 1998, which were amended twice in 2000, are based on the principle of segregation of communal waste from BMWs, followed by containment, treatment, and disposal of different categories of BMW .The rules classify BMWs into 10 categories and require specific containment, treatment, and disposal methods for each waste category. An overview of the BMW treatment and disposal technologies specified in the Biomedical Waste Rules. BMW treatment options include autoclaving, microwaving, incineration, and chemical treatment; in addition, hydroclaving has been approved by CPCB as an alternative treatment technology. BMW disposal options include deep burial and secure and municipal land filling for solid wastes, and discharge into drains (after chemical treatment) for liquid wastes.
India’s Biomedical Waste Rules are similar to those in international practice, although they have some internal inconsistencies and deviate in some respects from the procedures the World Health Organization (WHO) recommends for managing HCWs. National Guidelines for Implementing the Biomedical Waste Rules Each state or territory in India is responsible for implementing India’s Biomedical Waste Rules, and State Pollution Control Boards in states or Pollution Control Committees in the territories are designated as the prescribed authorities. Although environmental standards and guidelines for the management of BMWs were developed by India’s CPCB in 1996 (CPCB 1996), these were merely technical standards for technology options for health care facilities. In 2000, CPCB published a manual on hospital waste management that provided technical guidance for carrying out India’s Biomedical Waste Rules in the areas of HCW segregation, storage, transport, and treatment (CPCB 2000).
The CPCB manual gave special emphasis to BMW incineration, covering incinerator emissions, maintenance requirements, operational problems and solutions, and pollution control systems. Suggestions regarding common waste treatment facilities (CWTFs) for BMW treatment were also included in the manual. CPCB’s manual was informative, but it was not comprehensive enough to cover all aspects of India’s Biomedical Waste Rules, such as sharps management, handling of infectious liquid wastes, minimization of BMW generation, training of health care facility employees, and recordkeeping and monitoring procedures.
As discussed below, a positive development is that CPCB has recently issued two sets of draft guidelines, one set pertaining to the treatment of BMWs at CWTFs (CPCB) and the other pertaining to the design and construction of BMW incinerators. CPCB’s recent draft guidelines on CWTFs set out requirements for the location, land size, coverage area (in terms of the maximum number of beds served), treatment equipment, and infrastructure setup of the CWTF; collection and transportation of BMWs, and disposal of treated BMWs; and other operational issues. The listed technologies in the draft guidelines include those prescribed in the Biomedical Waste Rules, plus hydroclaving. The draft guidelines’ prescriptions are not always well justified.
For example, the minimum coverage of each CWTF is set at 10,000 health care facility beds, without consideration for local conditions such as the geographical dispersion of the health care facilities; the suggested land area for each CWTF is 1 acre, but no basis for this suggestion is presented. In addition, the draft guidelines propose a 150-km-radius operational area, which would cover health care facilities in rural areas. This proposal becomes more important in the current debates around sharps wastes from immunization in India as the new types of auto disposable plastic syringes are being characterized as safer options than glass syringes. Moreover, CPCB’s draft guidelines appear to be prescriptive on the waste management charge scheme instead of letting the optimum scheme develop on the basis of experience gained in India.
CPCB’s recent draft guidelines for BMW incinerators include requirements for the incinerator design and its air pollution control device, physical structures (incineration and waste storage rooms), operator qualifications, personal protection equipment, and emergency procedures. These guidelines restrict incineration of BMWs only at CWTFs, with the exception of on-site incineration upon special approval by CPCB.
The draft guidelines’ strong bias against on-site incineration at health care facilities is a major deviation from the Biomedical Waste Rules, which are equally applicable to the on-site and CWTF incinerators. It is clear that the new emphasis reflects the recent findings about the poor design and operating conditions of on-site incineration equipment at health care facilities in India vis-à-vis the requirements of the Biomedical Waste Rules.
There is no denying that hospital waste management plays a crucial role in the sustainability and growth of a healthy society. So it is imperative all the stakeholders involved in the hospital waste management industry follow the best possible, environmental friendly, effective and efficient practices. In conclusion, everything boils down to the long term health and sustainability of our earth and it is important to keep in mind that we do not inherit the earth from our ancestors but we borrow it from our children.
* Sathya Eco-management, Bangalore.
* Raja plastic, Mysore Road, Bangalore.
* Maridi Bio-Waste Management (www.maridibmw.com).
* “Health Care Waste Management in India” by BEKIR ONURSAL .