Disposal of Clinical Wastes:

Tata Memorial Hospital Experience

Dr Rohini Kelkar
M.D., D.P.B.
Professor Hea!, Dept of Micro"iolo#$
Tata Memorial Hospital, M%m"ai
No one was ever
really taught.
Each has to
teach himself.
Swami
Vivekananda
The Reality

Ignorance

ommerciali!ation of science

"#athy
The oncerns

$ccu#ational

%u&lic health

Environmental

The only documented risk of transmission of infections from waste to

healthcare workers is through sharps

There is however a potential for transmission of several microbial

infections due to dumping of untreated wastes by healthcare facilities.

Mixing of a small quantity of infectious waste with municipal garbage

converts the entire waste to infectious

Segregation of wastes at source followed by appropriate treatment is the

key to the success of a waste management strategy
The Science
Hospital waste
Hazardous
Non-hazardous
Noninfectious Infectious
Kitchen Recyclables
Non-sharps
Patient contaminated
waste
Anatomical
Equipment
Specimens
Laboratory
waste
Non-plastics
Sharps: needles, scalpel
blades, scalp veins, glass
contaminated with blood
Radioactive
Cytotoxic drugs
Toxic Chemicals
Plastics
PVC, PE PET, PS contaminated cotton
waste, gauze, linen
The Social Issue: Ragpickers
The TMH Pathway

Closure of the incinerator

Awareness programs for all the staff

Refashioning the storage area

Street play

Posters
Incinerator circa 1994
&
.


C
'
E
(
R
'
)

D
E
*
+
,
E

T
H
E

P
R
-
B
'
E
M

Appropriate placement of Colour
Coded Bins
Radioactive Waste
Segregation at source into defined categories using a simplified system.
.. *-C/0 -, 0E1RE1(T+-, *+R0T
Sharps Disposal
2. +,0T+T/TE ( 0H(RP0
M(,(1EME,T 0)0TEM
Waste Audit
3. KEEP *-C/0 -, RED/CT+-,
About Sharps:
The only documented transmission of infection from waste to HCWs is through sharp
injuries. Thus safe disposal of sharps is the first priority.
Sharp injuries:

Before or during use (17%)

After Use but before disposal (70%)

During or after disposal (13%)

(Our Experience: Majority of sharp injuries occur due to improper disposal and waste
handlers are the victims)
Safe Disposal of Sharps:
Do not recap needles.
If essential learn the right way to do
so.
4. E,0/RE W-RKER 0(*ET)
THR-/1H ED/C(T+-,, TR(+,+,1
(,D PR-PER PER0-,('
PR-TECT+5E E6/+PME,T
Collection network.
.
7. PR-5+DE 0EC/RE C-''ECT+-,
(,D TR(,0P-RT(T+-,
Waste management Strategy:
1. Reduce Risks and Liabilities: This should be detailed through written policies
and continuing training and education of hospital staff.
2. Control Costs: Audit of current practices, search for waste minimization
practices is a continuing process.
3. Plan for Future: Look for alternative technologies, co-operative facilities and
means of diversification.
4. Commitment towards protecting Human Health and the Environment
8. DE5E'-P P'(,0 (,D P-'+C+E0
Infection
Awareness
Week
Street
Play
9
.


+
,
5
E
0
T

+
,

T
R
(
+
,
+
,
1
:. DE5E'-P THE +,*R(0TR/CT/RE
&;. E<al%ation of Technolo#ies
E<al%ation of ,on B%rn
Technolo#ies for Me!ical
Waste Treatment
&. Demonstrate!
Performance
Category Rating Weight Score
1.1 Stage of Development
1.2 Number of Operational Systems
1. !ear of Successful Operations
.. Technical Performance
Criteria
Category Rating Weight Score
2.1 "rocess Capacity
2.2 Waste #$clusions or %imitations
2. Waste Si&e %imitations
2.' Weight Change
2.( )olume Change
2.* Recogni&ability + Disfigurement
2., Decontamination
2.- "erformance Data
2.. "rocess Comple$ity
2.1/ Operator Training
2. 5en!or
6%alifications
Category Rating Weight Score
.1 Number of )en0ors
.2 )en0or Resources
. )en0or Diversity an0 Services
3. En<ironmental
Permittin# +ss%es
Category Rating Weight Score
'.1 1ir #missions
'.2 %i2ui0 #ffluents
'. Treate0 Resi0ues
'.' "ermit ability
'.( "ublic "erception
4. -cc%pational
Health 0afet$
+ss%es
Category Rating Weight Score
(.1 Routine #$posures
(.2 3aintenance an0 Repair #$posures
7. *acilit$:
+nfrastr%ct%ral
Re=%irements
Category Rating Weight Score
*.1 Space Re2uirements
*.2 Construction Re2uirements
*. 4tility Re2uirements
*.' Space + 5acility Re2uirements
8. Economics
Category Rating Weight Score
,.1 Capital Costs
,.2 1nnual Costs
,. %ife6Cycle Costs
7R1ND TOT1% SCOR#
-n 0eptem"er &;, &:::, >ell "efore the first !ea! line set "$ the Ministr$ of
En<ironment an! *orest, 2& Decem"er &:::.
+na%#%ration of Tata Memorial Hospital >aste treatment facilit$
Selection of Technology and
mplementation is not the setting sun
Evaluation is a continuous process
2000 2001 2002 2003 2004 2005 2006 2007
Max. medical
waste collected in
a day
341 394 350 362 396 530 429 514
Average no. of
loads re!ired"day
5 4 4 4 4 4 4 4
Average medical
waste treated in
#gs"day
217 224 176 241 250 2$9 253 277
Average medical
waste collected in
a mont%
5&49$ 5&643 5&266 5&917 6&2$4 7&225 6&369 6&959
'ercentage down
time of t%e system
1.6 5.7 4.$ 5.$ $.2 0 10 1.2
TMH Waste (%!it ,o<. &::: to Dec. .;;8
Total infectious waste treated 614 tonnes.
83,511 kg. in 2007. ost of treat!ent " #s. 14.86 $
kg.
2008 2009
Max. medical
waste collected in
a day
447 505
Average no. of
loads re!ired"day
4 4
Average medical
waste treated in
#gs"day
29$ 304
Average medical
waste collected in
a mont%
7&623 7&674
'ercentage down
time of t%e system
0 0.33
TMH Infectious Waste Audit 2008 - 2009
Total infectious waste treated 2000%200&" 800 tonnes.
ost of treat!ent " #s. 14 $ kg.
TM! "aste Management
Waste is 0terili?e!, Deh%mi!ifie!, 0hre!!e! an! re!%ce! in terms of
Wei#ht an! 5ol%me "$ 84@.
+t is not reco#ni?a"le as Me!ical Waste
Ha?ar!o%s Waste
En<ironment ,e>s
1reenpeace
March 8th, .;;&
K-D(+K(,(', +n!ia AA 1reenpeace
to!a$ acc%se! (n#loAD%tch
m%ltinational /nile<er, o>ners of
'ipton Tea an! Do<e soap, of !o%"le
stan!ar!s an! shamef%l ne#li#ence
for allo>in# its +n!ian s%"si!iar$,
Hin!%stan 'e<er, to !%mp se<eral
tonnes of hi#hl$ toxic merc%r$ >aste
in the !ensel$ pop%late! to%rist resort
of Ko!aikanal an! the s%rro%n!in#
protecte! nat%re reser<e of Pam"ar
0hola, in Tamilna!%, 0o%thern +n!ia.
-n &4 (pril, .;;4, a 4& $earAol!
as"estos la!en ship, Kon# *re!rick +B
>as on its >a$ to (lan# ship "reakin#
$ar!, 1%Carat for scrappin#.
The shipDs ne> o>ners E%piter 0hip
Mana#ement, a M%m"ai "ase!
compan$, ha! rename! it to DM5 Rik$D.
Connie He!e#aar!, DenmarkDs
en<ironment minister alerte! the
+n!ian en<ironment minister sa$in#,
F+ "elie<e o%r interests are Coint A an! +
call on $o% to coAoperate in this case
"$ !en$in# the ship to "e !ismantle!
in +n!ia A an! refer the ship to ret%rn to
Denmark to "e strippe! of the
ha?ar!o%s >aste.F
+n!iaGs si#nificant economic #ro>th an! rise in
in!%striali?ation co%ple! "$ lax #o<ernment enforcement
of antiApoll%tion la>s an! re#%lations ha<e ha! a
!etrimental effect on +n!iaGs nat%ral en<ironment.
Ha?ar!o%s >aste from in!%strial processes, me!ical
>aste an! +n!iaGs thri<in# scrap rec$clin# "%sinesses
poll%tes +n!ian air, soils an! >ater>a$s.
+n!ia is a si#nator$ to the three con<entions on
ha?ar!o%s chemicals an! >aste:
The Basel Con<ention on the Control of TransA"o%n!ar$
Mo<ement of Ha?ar!o%s Waste an! their Disposal,
The Rotter!am Con<ention on the Prior +nforme!
Consent Proce!%re for Certain Ha?ar!o%s Chemicals an!
Pestici!es in +nternational Tra!e an!
The 0tockholm Con<ention of Persistent -r#anic
Poll%tants.
The Ha?ar!o%s 0%"stances Mana#ement Di<ision HH0MI of the Ministr$ of
En<ironment an! *orests HMoE*I has the responsi"ilit$ for promotin# safe
mana#ement an! %se of ha?ar!o%s s%"stances, incl%!in# ha?ar!o%s >aste.
The H0M has esta"lishe! three sets of r%les:
The Ha?ar!o%s Wastes HMana#ement an! Han!lin#I R%les H&:9:, amen!e!
in .;;2I,
The BioAme!ial Wastes HMana#ement an! Han!lin#I R%les H&::9J.;;;I, an!
The Batteries HMana#ement an! Han!lin#I R%les H.;;&I.
The H0M relies primaril$ on the
The Central Poll%tion Control Boar! HCPCBI,
The 0tate Poll%tion Control Boar!s H0PCBsI or 0tate Poll%tion Control
Committees H0PCCsI, an!
The en<ironmental !epartments in +n!iaGs .4 states
to implement, monitor an! prosec%te.
(pproximatel$ 4 million tonnes of ha?ar!o%s >aste is pro!%ce! ann%all$ in
+n!ia.
(ccor!in# to a .;;2 report, +n!ian in!%stries in the follo>in# fi<e states
ha! #enerate! o<er 9;@ of the co%ntr$Gs ha?ar!o%s >aste:
(n!hra Pra!esh,
1%Carat,
Karnataka,
Maharashtra an!
Tamil ,a!%.
Landfill Composting Incineration Reccling Transportation
Air !mission of CH"#
C$2% odours
!mission of
CH"# C$2%
odours
!mission of &$2#
'$(# HCl# H)#
'M*$C# C$# C$2
'2$# dio(ins#
di+en,ofurans# -ea.
metals/0n# 1+# Cu# As2
!missions of
dust
!missions of dust
'$(# &$2# release of
-a,ardous
su+stances from
accidental spills
Water Leac-ing of salts#
-ea. metals#
+iodegrada+le and
persistent organics
to ground3ater
4eposition of
-a,ardous su+stances
on surface 3ater
Waste 3ater
disc-arges
Ris5 of surface 3ater
and ground3ater
contamination from
accidental spills
&oil Accumulation of
-a,ardous
su+stances in soil
Landfilling of slags#
fl as- and scrap
Landfilling of
final residues
Ris5 of soil
contamination from
accidental spills
#uropean Commission focus on 8aste management
"itfalls of the currently available technologies for managing 8astes
Landfill Composting Incineration Reccling Transportation
Landscape &oil occupanc%
restriction on
ot-er land uses
&oil occupanc%
restriction on
ot-er land uses
*isual intrusion%
restriction on
ot-er land uses
*isual
intrusion
Traffic
!cosstems Contamination
and
accumulation of
to(ic su+stances
in t-e food c-ain
Contamination
and
accumulation of
to(ic su+stances
in t-e food c-ain
Contamination
and accumulation
of to(ic
su+stances in t-e
food c-ain
Ris5 of
contamination
from accidental
spills
6r+an areas !(posure to
-a,ardous
su+stances
!(posure to
-a,ardous
su+stances
'oise Ris5 of e(posure
to -a,ardous
su+stances from
accidental
spills% traffic
#uropean Commission focus on 8aste management
"itfalls of the currently available technologies for managing 8astes
#68aste
9o8 green is your 1pple:
(%# .4th .;;7
*rom The Economist print e!ition
7o0 proposes;
man 0isposes
Waste an0 taste
Dec &&th .;;7
*rom Economist.com
The rubbish tip as cultural artefact
*RE0H Kills lan!fill in ,e> )ork, %ntil
recentl$ the "i##est r%""ish tip on
earth, >as sai! to "e one of the <er$
fe> manAma!e o"Cects <isi"le from
space, alon# >ith the 1reat Wall of
China.
'+0T -* W(0TE 0/B0T(,CE0 W+TH C-,CE,TR(T+-,
'+M+T0
Class 1
Concentration limit< (/ mg+=g
11 1ntimony an0 antimony compoun0s
12 1rsenic an0 arsenic compoun0s
1 beryllium an0 ca0mium compoun0s
1' Ca0mium an0 beryllium compoun0s
1( Chromium >)?@ compoun0s
1* 3ercury an0 mercury compoun0s
1, Selenium an0 selenium compoun0s
1- Tellurium an0 tellurium compoun0s
1. Thallium an0 thallium compoun0s
11/ ?norganic cyani0e compoun0s >cyani0es@
111 3etal carbonyls
112 Napthalene
11 1nthracene
11' "henanthrene
11( Chrysene; ben&o>a@ anthracene; fluoranthene; ben&o>a@ pyrene;
ben&o>A@fluoranthene; in0eno>1; 2; 6e0@ pyrene an0 ben&o>ghi@perylene
11* 9alogenate0 fuse0 aromatic rings; e.g. polychlorobiphenyls plus 0erivatives
11, 9alogenate0 aromatic compoun0s
11- Ben&ene
11. Diel0rin; al0rin; an0 en0rin
12/ Organotin compoun0s
Ministr$ of En<ironment
*orests:
Ha?ar!o%s Wastes
HMana#ement an! Han!lin#I
(men!ment R%les, .;;.
'+0T -* W(0TE 0/B0T(,CE0 W+TH C-,CE,TR(T+-,
'+M+T0
Ministr$ of En<ironment
*orests:
Ha?ar!o%s Wastes
HMana#ement an! Han!lin#I
(men!ment R%les, .;;.
Class B
Concentration limit: (;/// mg+=g
B& Chromi%m H+++I compo%n!s
B. Co"alt compo%n!s
B2 Copper compo%n!s
B3 'ea! an! lea! compo%n!s
B4 Mol$"!en%m compo%n!s
B7 ,ickel compo%n!s
B8 Tin compo%n!s
B9 5ana!i%m compo%n!s
B: T%n#sten compo%n!s
B&; 0il<er compo%n!s
B&& -r#anic halo#en compo%n!s
B&. -r#anic phosphor%s compo%n!s
B&2 -r#anic peroxi!es
B&3 -r#anic nitroAan! nitrosoAcompo%n!s
B&4 -r#anic a?oAan! a?oAox$ compo%n!s
B&7 ,itriles
B&8 (mines
B&9 H+soAan! thioAI c$anates
B&: Phenol an! phenolic compo%n!s
B.; Merceptans
B.& (s"estos
B.. Drillin#, c%ttin#, #rin!in# an! rollin# oil or em%lsions thereof
B.2 Halo#enAsilanes
B.3 H$!ra?ineHsI
B.4 *l%orine
B.7 Chlorine
B.8 Bromine
B.9 White phosphor%s
B.: *erroAsilicon an! allo$s
B2; Man#aneseAsilicon
B2& Halo#enAcontainin# s%"stances >hich pro!%ce aci!ic <apo%rs on contact >ith !amp air or >ater, e.#. silicon tetrachlori!e,
al%min%m chlori!e, titani%m tetrachlori!e
'+0T -* W(0TE 0/B0T(,CE0 W+TH C-,CE,TR(T+-,
'+M+T0
Ministr$ of En<ironment
*orests:
Ha?ar!o%s Wastes
HMana#ement an! Han!lin#I
(men!ment R%les, .;;.
Class C
Concentration limit: 2/;/// mg+=g
C& (mmonia an! ammoni%m compo%n!s
C. +nor#anic peroxi!es
C2 Bari%m compo%n!s, except "ari%m s%lphate
C3 *l%orine compo%n!s
C4 Phosphor%s compo%n!s, except the phosphates of al%min%m, calci%m an! iron
C7 Bromates, Hh$poI"romites
C8 Chlorates, Hh$poIchlorites
C9 (romatic compo%n!s
C: -r#anic silicon compo%n!s
C&; -r#anic s%lph%r compo%n!s
C&& +o!ates
C&. ,itrates, nitrites
C&2 0%lphi!es
C&3 Kinc compo%n!s
C&4 0alts of perAaci!s
C&7 (ci! hali!es, aci! ami!es
C&8 (ci! anh$!ri!es
'+0T -* W(0TE 0/B0T(,CE0 W+TH C-,CE,TR(T+-,
'+M+T0
Ministr$ of En<ironment
*orests:
Ha?ar!o%s Wastes
HMana#ement an! Han!lin#I
(men!ment R%les, .;;.
Class D
Concentration limit< (/;/// mg+=g
D1 Sulphur
D2 ?norganic aci0s
D 3etal bisulphates
D' O$i0es an0 hy0ro$i0es e$cept those of< hy0rogen; carbon; silicon;
iron; aluminum; titanium; manganese; magnesium; calcium
D( 1liphatic an0 napthenic hy0rocarbons
D* Organic o$ygen compoun0s
D, Organic nitrogen compoun0s
D- Nitri0es
D. 9y0ri0es
'+0T -* W(0TE 0/B0T(,CE0 W+TH C-,CE,TR(T+-,
'+M+T0
Ministr$ of En<ironment
*orests:
Ha?ar!o%s Wastes
HMana#ement an! Han!lin#I
(men!ment R%les, .;;. Class #
Regar0less of concentration limit
#.1 9ighly flammable substances
#.2 Substances 8hich generate 0angerous 2uantities of
highly flammbale gases on contact 8ith 8ater or 0amp air.
%?ST O5 "ROC#SS#S 7#N#R1T?N7 91C1RDO4S
W1ST#S
Ministr$ of En<ironment *orests
Ha?ar!o%s Wastes HMana#ement an! Han!lin#I (men!ment R%les, .;;2
1
'etroc%emical (rocesses and (yrolytic o(erations
2
)rilling o(eration for oil and gas (rod!ction
3
*leaning& em(tying and maintenance of (etrole!m oil storage tan#s incl!ding s%i(s
4
'etrole!m refining"re+refining of !sed oil"recycling of waste oil
5
,nd!strial o(erations !sing mineral"synt%etic oil as l!-ricant in %ydra!lic systems or
ot%er a((lications
6
.econdary (rod!ction and"or !se of /inc
7
'rimary (rod!ction of /inc"lead"co((er and ot%er non+ferro!s metals exce(t
al!mini!m
$
.econdary (rod!ction of co((er
9
.econdary (rod!ction of lead
10
'rod!ction and"or !se of cadmi!m and arsenic and t%eir com(o!nds
11
'rod!ction of (rimary and secondary al!mini!m
%?ST O5 "ROC#SS#S 7#N#R1T?N7 91C1RDO4S
W1ST#S
Ministr$ of En<ironment *orests
Ha?ar!o%s Wastes HMana#ement an! Han!lin#I (men!ment R%les, .;;2
12
Metal s!rface treatment& s!c% as etc%ing& staining& (olis%ing& galvanising& cleaning&
degreasing& (lating& etc.
13
'rod!ction of iron and steel incl!ding ot%er ferro!s alloys 0electric f!rnaces1 steel
rolling and finis%ing mills1 *o#e oven and -y (rod!ct (lant2
14
3ardening of steel
15
'rod!ction of as-estos or as-estos+containing materials
16
'rod!ction of ca!stic soda and c%lorine
17
'rod!ction of acids
1$
'rod!ction of nitrogeno!s and com(lex fertili/ers
19
'rod!ction of (%enol
20
'rod!ction and"or ind!strial !se of solvents
21
'rod!ction and"or ind!strial !se of (aints& (igments& lac!ers& varnis%es& (lastics and
in#s
22
'rod!ction of (lastic raw materials
%?ST O5 "ROC#SS#S 7#N#R1T?N7 91C1RDO4S
W1ST#S
Ministr$ of En<ironment *orests
Ha?ar!o%s Wastes HMana#ement an! Han!lin#I (men!ment R%les, .;;2
23
'rod!ction and"or ind!strial !se of gl!es& cements& ad%esive and resins
24
'rod!ction of canvas and textiles
25
,nd!strial (rod!ction and form!lation of wood (reservatives
26
'rod!ction or ind!strial !se of synt%etic dyes& dye+intermediates and (igments
27
'rod!ction or ind!strial !se of materials made wit% organo+silicone com(o!nds
2$
'rod!ction"form!lation of dr!gs" (%armace!ticals
29
'rod!ction& !se and form!lation of (esticides incl!ding stoc#+(iles
30
4eat%er tanneries
31
5lectronic ,nd!stry
32
'!l( 6 'a(er ,nd!stry
33
)is(osal of -arrels " containers !sed for %andling of %a/ardo!s wastes " c%emicals
34
'!rification (rocesses for air and water
35
'!rification (rocess for organic com(o!nds"solvents
36
7aste treatment (rocesses& e.g. incineration& distillation& se(aration and concentration
tec%ni!es
R#"ORT ON C%?N?C1% W1ST# 14D?T 2//(
?nfectious 8aste treate0 from Dan6Dec 2//( 97,8;3 Kilo#rams
(<era#e >aste treate! per month 8,..4 Kilo#rams
Wei#ht of sharps treate! in .;;4 .,:&8 Kilo#rams
(<era#e >ei#ht of sharps treate! per month .32 Kilo#rams
Bloo! "loo! pro!%cts 2;; liters
%i2ui0 Wastes<
Total effl%ent per month &73 lakh litres
'a%n!r$ effl%ent per month 2 lakh litres
BGra$ !e<eloper per month &3; litres
Ha?ar!o%s li=%i!s cons%me! in la"s per month 499 litres
Ha?ar!o%s chemicals as soli!s >ei#ht per month .7; #rams
Dil%tion factor of ha?ar!o%s li=%i!s .8,222.
9a&ar0ous li2ui0
8aste + month<
Sr. No Chemicals + Reagents %its.
1 1/E 5ormalin 1//
2 Fylene 1./.1
Basic fuchsin 1.1,
' 9aemato$ylin stain 1./
( Nitric 1ci0 (/.(
* 1nhy0rous 1luminum
Chlori0e
.//(
, 9y0rochloric aci0 .-//
- Diamino ben&i0ine 2/./
. 9y0rogen pero$i0e (.2/2
1/ 7lacial acetic aci0 (.22(
11 7luteral0ehy0e 1(/.(//
12 #thi0ium bromi0e .//1
1 "ropane + Butane 2.(//
1' WD'/ >"etroleum 0istillate@ 2.//
1( Ben&oin tincture 1/.//
1* %ugolGs ?o0ine /.'2
1, "henol >carbolic aci0@ 1.///
1- 1mmonia solution ./(/
1. %actic aci0 ./'(
2/ Sulfuric aci0 .1//
Total (--.1.
9a&ar0ous soli0 8aste + month<
Sr. No Chemicals + Reagents Weight >7rams@
1 Ben&i0ine 0ihy0rochlori0e /.(
2 Naphthol phosphate ./*/
"ararosaline hy0rochlori0e 1./
' So0ium6fluori0e .2//
( "otassium 0ihy0rogen phosphate -.(//
* Dipotassium hy0rogen phosphate -.(//
, Ben&i0ine 7.R. 1./
- Cine sulphate 1*.(
. Barium chlori0e 1.//
1/ "henol crystals '/.//
11 Naphthylamine 1*.(/
12 Naphthol 1*.(/
1 So0ium6polyanethol sulphonat '(.//
1' So0ium hy0ro$i0e pellet '(.//
1( Sulfonilic aci0 '(.//
1* Trichloroacetic aci0 2.1
Total 2(..*
n #onclusion$ %ey ssues

Awareness and education

Reporting systems & documentation

Segregation of identified clinical infectious wastes at source

Timely treatment by non-polluting technologies on-site or off-site

Waste audit

Waste monitoring systems

Elevation of safety standards by all healthcare facilities

All HCWs must have hygiene in their genes.

'en occasionally stum&le over the
truth &ut most of them #ick
themselves u# and hurry off as if
nothing has ha##ened.
( Sir )inston hurchill.

Thank *ou