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Medical waste is now recognized as a major public health hazard.

According to World Health


Organization, each year half a million people globally die due to infections such as Hepatitis B,
and C, HIV and hepatocellular cancer transmitted through unsafe healthcare practices. There is
no information as to what component of this figure comprises healthcare workers. There are also
alarming disclosures about used medical devices and other items getting recycled and repacked
by unscrupulous traders in countries such as ours. This happens when the hospitals do not take
adequate steps to disinfect and mutilate the medical waste as required under the law. Despite the
statutory provision of Biomedical Waste Management, practice in Indian Hospitals has not
achieved the desired standard even after ten years of enforcement of the law. Biomedical waste
has become a serious health hazard in many countries, including India. Careless and
indiscriminate disposal of this waste by healthcare establishments and research institutions can
contribute to the spread of serious diseases such as hepatitis and AIDS (HIV) among those who
handle it and also among the general public

1.Introduction:-

“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 including containers.

Bio-medical waste means “any solid and/or liquid waste including its container and any
intermediate product, which is generated during the diagnosis, treatment or immunization of
human beings or animals.

Components of Bio-medical waste:-

• Human anatomical waste (tissues, organs, body parts etc.).


• Animal waste (as above, generated during research/experimentation, from veterinary
hospitals etc.).
• Microbiology and biotechnology waste, such as, laboratory cultures, micro-organisms,
human and animal cell cultures, toxins etc.
• Waste sharps, such as, hypodermic needles, syringes, scalpels, broken glass etc.
• Discarded medicines and cyto-toxic drugs.
• Soiled waste, such as dressing, bandages, plaster casts, material. contaminated with blood
etc.
• Solid waste (disposable items like tubes, catheters etc. excluding sharps).
• Liquid waste generated from any of the infected areas.
• Incineration ash.
• Chemical waste.

Sources of BMW:-

The major sources of health-care waste are hospitals and other health-care establishments,
laboratories and research centres, mortuary and autopsy centres, animal research and testing
laboratories, blood banks and collection services, and nursing homes for the elderly.

Quantity of BMW :-

Health-care activities - for instance, immunizations, diagnostic tests, medical treatments, and
laboratory examinations - protect and restore health and save lives. But what about the wastes
and by-products they generate?

Hospitals and other health care facilities generate lots of waste which can transmit infections,
particularly HIV, Hepatitis B & C and Tetanus, to the people who handle it or come in contact
with it. High-income countries can generate up to 6 kg of hazardous waste per person per year.
In the majority of low-income countries, health-care waste is usually not separated into
hazardous or non-hazardous waste. In these countries, the total health-care waste per person per
year is anywhere from 0.5 to 3 kg.

Segregation

Segregation refers to the basic separation of different categories of waste generated at source and
thereby reducing the risks as well as cost of handling and disposal. Segregation is the most
crucial step in bio-medical waste management. Effective segregation alone can ensure effective
bio-medical waste management. The BMWs must be segregated accordance to guidelines laid
down under schedule 1 of BMW Rules, 1998.

How does segregation help?

• Segregation reduces the amount of waste needs special handling and treatment
• Effective segregation process prevents the mixture of medical waste like sharps with the
general municipal waste.
• Prevents illegally reuse of certain components of medical waste like used syringes,
needles and other plastics.
• Provides an opportunity for recycling certain components of medical waste like plastics
after proper and thorough disinfection.
• Recycled plastic material can be used for non-food grade applications.
• Of the general waste, the biodegradable waste can be composted within the hospital
premises and can be used for gardening purposes.
• Recycling is a good environmental practice, which can also double as a revenue
generating activity.

Reduces the cost of treatment and disposal (80 per cent of a hospital’s waste is general waste,
which does not require special treatment, provided it is not contaminated with other infectious
waste)
People at Risk:-
The main groups at risk are the following:
• Doctors, nurses, ambulance staff and hospital sweepers;
• Patients in health-care establishments or under home care;
• Workers in support services to health-care establishments, such as laundries, waste
handling and transportation, waste disposal facilities including incinerators and other
persons separating and recovering materials from waste;
• Inappropriate or inadvertent end-users such as scavengers and customers in secondary
markets for reuse (i.e. households, local medical clinics, etc.)

Health Concern –hazards of Bio-medical waste:-

Biomedical waste poses hazard due to two principal reasons – the first is infectivity and other
toxicity. According to the WHO, the global life expectancy is increasing year after year.
However, deaths due to infectious disease are also increasing. A study conducted by the WHO
reveals that more than 50,000 people die everyday from infectious diseases. One of the causes
for the increase in infectious diseases is improper waste management. Blood, body fluids and
body secretions which are constituents of bio-medical waste harbour most of the viruses, bacteria
and parasites that cause infection. This passes via a number of human contacts, all of whom are
potential ‘recipients’ of the infection. Human Immunodeficiency Virus (HIV) and hepatitis
viruses spearhead an extensive list of infections and diseases documented to have spread through
bio-medical waste. Tuberculosis, pneumonia, diarrhea diseases, tetanus, whooping cough etc.,
are other common diseases spread due to improper waste management.

HEALTH IMPACTS:-

Health-care waste is a reservoir of potentially harmful micro-organisms which can infect hospital
patients, health-care workers and the general public. Other potential infectious risks include the
spread of, sometimes resistant, micro-organisms from health-care establishments into the
environment. These risks have so far been only poorly investigated. Wastes and by-products can
also cause injuries, for example radiation burns or sharps-inflicted injuries; poisoning and
pollution, whether through the release of pharmaceutical products, in particular, antibiotics and
cytotoxic drugs, through the waste water or by toxic elements or compounds such as mercury or
dioxins.Some of these are given below:-

Cytotoxic Waste:-Cytotoxic drugs have the ability to stop the growth of certain living cells and
are used as chemo-therapeutic agents. They are carcinogens and can also be mutagenic. Any
material used to handle these products and contaminated in due course would also need to be
disposed off in the same manner.Adverse health effects from both acute and chronic exposures to
cytotoxic drugs have been demonstrated in healthcare personnel.Over a long term, almost all of
these drugs have the potential of damaging cells or adversely affecting cellular growth and
reproduction. The drugs bind directly to genetic material in the cell nucleus, or affect cellular
protein synthesis. In-vivo, in-vitro and human studies have implicated anti-neoplastic drugs in
chromosomal damage, teratogenesis, and carcinogenesis.Testicular and ovarian dysfunction,
including permanent sterility, have been demonstrated in male and female patients, respectively,
who have received these drugs singly, or in combination. Studies in Finland have shown an
increased incidence of foetal loss among nurses routinely working with anti-neoplastic agents
than among those who do not. Other studies have suggested a correlation between exposure to
anti-neoplastic agents and foetal malformation in pregnant nurses. Additionally, organ damage
has been associated with exposure to some anti-neoplastic agents. Liver damage has been
reported in oncology employees, and appears to be related to the duration and the concentration
of the exposure. The risks to workers handling anti-neoplastic agents are a result of the inherent
toxicity of the drugs themselves, and the actual dose that a worker receives. The dose is
dependent on the concentration of the drug, the duration of the exposure, and the route of entry.
The adverse health effects as a result of exposure to a particular drug may depend on whether the
drug enters the body through inhalation, through the skin, or ingestion.

Sharps:-Anything that can cause a cut or a puncture wound is classified as ‘sharps’. These
include needles, hypodermic needles, scalpel and other blades, knives, infusion sets, saws,
broken glass, and nails. Whether or not they are infected, sharps are usually considered highly
hazardous healthcare waste because they have the potential to cross the passive and primary
immunology barrier of the body the skin and thus establish contact with blood. Because of this
double risk of injury and disease transmission sharps are considered very hazardous. The
principal concerns are infections that may be transmitted by subcutaneous introduction of the
causative agent, for example, viral blood infections. Hypodermic needles constitute an important
part of the sharps waste category and are particularly hazardous because they are often
contaminated with blood .Throughout the world every year an estimated 12 000 million
injections are administered. And not all needles and syringes are properly disposed of, generating
a considerable risk for injury and infection and opportunities for re-use.

• Worldwide, 8-16 million hepatitis B, 2.3 to 4.7 million hepatitis C and 80 000 to 160 000
HIV infections are estimated to occur yearly from re-use of syringe needles without
sterilization2. Many of these infections could be avoided if syringes were disposed of
safely. The re-use of disposable syringes and needles for injections is particularly
common in certain African, Asian and Central and Eastern European countries.
• Regarding injection practices, public health authorities in West Bengal, India, have
recommended a shift to re-usable glass syringes, as the disposal requirements for
disposable syringes could not be enforced.
• In developing countries, additional hazards occur from scavenging on waste disposal sites
and manual sorting of the waste recuperated at the back doors of health-care
establishments. These practices are common in many regions of the world. The waste
handlers are at immediate risk of needle-stick injuries and other exposures to toxic or
infectious materials.

Mercury:- Mercury is the only heavy metal that can exist in all three states of matter: it readily
changes from solid to liquid to gaseous form and is a persistent bio-accumulative toxin. It
circulates constantly in the environment. Three major forms of chemical mercury circulate in the
atmosphere: mercury (0), mercury (II) and methyl mercury. Methyl mercury can accumulate in
muscle tissue and bio-magnify via the food chain. Mercury is a neurotoxicant and affects the
brain and the nervous system. Other vital organs like kidneys and lungs are also affected.
Mercury poisoning can be difficult to diagnose since the symptoms are common to other
afflictions. Pregnant women and children are most vulnerable to the effects of mercury. A foetus
exposed to mercury shows nervous system damage.
Vaccine waste:-In June 2000, six children were diagnosed with a mild form of smallpox
(vaccinia virus) after having played with glass ampoules containing expired smallpox
vaccine at a garbage dump in Vladivostok (Russia). Although the infections were not life-
threatening, the vaccine ampoules should have been treated before being discarded.

Pharmaceutical waste:- includes expired, unused, spilt and contaminated pharmaceutical


products, drugs, vaccines and sera that are no longer useful.

Chemicals:- are generally used in diagnostic and experimental work, and in cleaning,
housekeeping and disinfecting procedures. Many chemicals and pharmaceuticals used in
hospitals are hazardous. They are termed hazardous if they have any one of the following
properties: toxic, corrosive, flammable, reactive, genotoxic. Examples of such waste are
formaldehyde, glutaraldehyde and photographic chemicals. They may cause injuries, including
burns. Disinfectants are particularly important members of this group as they are used in large
quantities and are generally corrosive.

Hazards of Bio-medical waste:-


• Injury from sharps to staff and waste handlers associated with the health care
establishment.
• Hospital Acquired Infection(HAI)(Nosocomial) of patients due to spread of infection and
disease through vectors (fly, mosquito, insects etc.).
• Risk of infection outside the hospital for waste handlers/scavengers and eventually
general public.
• Occupational risk associated with hazardous chemicals, drugs etc. Reaction due to use of
discarded medicines
• Unauthorized repackaging and sale of disposable items and unused / date expired drugs
• Toxic emissions from defective/inefficient incinerators.
• Indiscriminate disposal of incinerator ash / residues.
Occupational health hazards :-

The health hazards due to improper waste management


can affect

• The occupants in institutions and spread in the


vicinity of the institutions
• People happened to be in contact with the
institution like laundry workers, nurses,
emergency medical personnel, and refuse workers.
• Risks of infections outside hospital for waste handlers, scavengers and (eventually) the
general public
• Risks associated with hazardous chemicals, drugs, being handled by persons handling
wastes at all levels
• Injuries from sharps and exposure to harmful chemical waste and radioactive waste also
cause health hazards to employees.

Hazards to the general public:-

The general public’s health can also be adversely affected by bio-medical waste.

• Improper practices such as dumping of bio-medical waste in municipal dustbins, open


spaces, water bodies etc., leads to the spread of diseases.
• Emissions from incinerators and open burning also lead to exposure to harmful gases
which can cause cancer and respiratory diseases.
• Exposure to radioactive waste in the waste stream can also cause serious health hazards.

An often-ignored area is the increase of in-home healthcare activities. An increase in the


number of diabetics who inject themselves with insulin, home nurses taking care of
terminally ill patients etc., all generate bio-medical waste, which can cause health
hazards.

RISKS ASSOCIATED WITH WASTE DISPOSAL:-

Although treatment and disposal of health-care wastes aim at reducing risks, indirect health risks
may occur through the release of toxic pollutants into the environment through treatment or
disposal.

• Landfilling can potentially result in contamination of drinking water. Occupational risks


may be associated with the operation of certain disposal facilities. Inadequate
incineration, or incineration of materials unsuitable for incineration can result in the
release of pollutants into the air. The incineration of materials containing chlorine can
generate dioxins and furanse, which are classified as possible human carcinogens and
have been associated with a range of adverse effects. Incineration of heavy metals or
materials with high metal contents (in particular lead, mercury and cadmium) can lead to
the spread of heavy metals in the environment. Dioxins, furans and metals are persistent
and accumulate in the environment. Materials containing chlorine or metal should
therefore not be incinerated.
• Only modern incinerators are able to work at 800-1000 °C, with special emission-
cleaning equipment, can ensure that no dioxins and furans (or only insignificant amounts)
are produced. Smaller devices built with local materials and capable of operating at these
high temperatures are currently being field-tested and implemented in a number of
countries.
• At present, there are practically no environmentally-friendly, low-cost options for safe
disposal of infectious wastes. Incineration of wastes has been widely practised, but
alternatives are becoming available, such as autoclaving, chemical treatment and
microwaving, and may be preferable under certain circumstances. Landfilling may also
be a viable solution for parts of the waste stream if practised safely. However, action is
necessary to prevent the important disease burden currently created by these wastes. In
addition, perceived risks related to health-care waste management may be significant. In
most cultures, disposal of health-care wastes is a sensitive issue and also has ethical
dimensions.

Bio-medical waste can cause health hazards to animals and birds too:-

• Plastic waste can choke animals, which scavenge on open dumps.


• Injuries from sharps are common feature affecting animals.
• Harmful chemicals such as dioxins and furans can cause serious health hazards to
animals and birds.
• Heavy metals can even affect the reproductive health of the animals
• Change in microbial ecology, spread of antibiotic resistance

Situation of BMWM in India:-

Most countries of the world, especially the developing nations, are facing the grim situation
arising out of environmental pollution due to pathological waste arising from increasing
populations and the consequent rapid growth in the number of health care centres. India is no
exception to this and it is estimated that there are more than 15,000 small and private hospitals
and nursing homes in the country. This is apart from clinics and pathological labs, which also
generate sizeable amounts of medical waste.

India generates around three million tonnes of medical wastes every year and the amount is
expected to grow at eight per cent annually.

Barring a few large private hospitals in metros, none of the other smaller hospitals and nursing
homes have any effective system to safely dispose of their wastes. With no care or caution, these
health establishments have been dumping waste in local municipal bins or even worse, out in
the open. Such irresponsible dumping has been promoting unauthorized reuse of medical
waste by the rag pickers for some years now.

Legal aspect of BMWM in India:-

The Central Government, to perform its functions effectively as contemplated under sections 6,
8, and 25 of the Environment Protection Act, 1986, has made various Rules, Notifications and
Orders including the Bio-medical wastes (Management & Handling) Rules, 1998.A brief
summary of the provisions in Bio-medical wastes (Management & Handling) Rules, 1998 is
given below.

• Section 3 establishes the authority of the government to undertake various steps for
protection and improvement of the environment.
• Section 5 provides for issuance of directions in writing.
• Section 6 empowers the government to make rules.
• Section 8 permits the education of individuals dealing with hazardous wastes regarding
various safety measures.
• Section 10 bestows authority to enter the premises and inspect.
• Section 15 allows the government to take punitive steps against defaulters. This
involves imprisonment up to five years or penalty of upto rupees one lakh or both.
In case the default continues, it would then attract a penalty of rupees five thousand
per day up to one year and thereafter imprisonment up to seven years.
• Section 17 provides for punishment in case of violations by government departments.

Even after the June, 2000 deadline most of the large hospitals have not complied with these
Rules, as there is no specified authority to monitor the implementation of these Rules. But, the
fact is that in most of the states, the pollution control boards that are connected with waste in
general do not have adequate powers or commitment to enforce the Rules.

Applicability of BMW Rules, 1998


The BMW Rules are applicable to every occupier of an institution generating biomedical waste
which includes a hospital, nursing homes, clinic, dispensary, veterinary institutions, animal
houses, pathological lab, blood bank by whatever name called, the rules are applicable to even
handlers.

Common Biomedical wastes treatment facility [CBWTFs]

The Common Biomedical wastes treatment facility, (see rules 14, amended in June 2000, which
cast the responsibilities on municipal bodies to collect biomedical wastes/treated biomedical
wastes and also provide sites for setting up of incinerator.) The owner of CBWTFs are service
providers, who are providing services to health care units for collection of BMWs for its final
disposal to their site.
CATEGORIES OF BIOMEDICAL WASTE SCHEDULE – I

WASTE TREATMENT AND


TYPE OF WASTE
CATEGORY DISPOSAL OPTION
Category No. 1 Human Anatomical Waste (Human tissues, organs, body parts) Incineration@ / deep burial*
Animal Waste
(Animal tissues, organs, body parts, carcasses, bleeding parts,
Category No. 2 fluid, blood and experimental animals used in research, waste Incineration@ / deep burial*
generated by veterinary hospitals and colleges, discharge from
hospitals, animal houses)
Microbiology & Biotechnology Waste (Wastes from laboratory
cultures, stocks or specimen of live micro organisms or
attenuated vaccines, human and animal cell cultures used in Local autoclaving/
Category No. 3
research and infectious agents from research and industrial microwaving / incineration@
laboratories, wastes from production of biologicals, toxins and
devices used for transfer of cultures)
Disinfecting (chemical
Waste Sharps (Needles, syringes, scalpels, blades, glass, etc. that
treatment@@ / autoclaving /
Category No. 4 may cause puncture and cuts. This includes both used and
microwaving and mutilation /
unused sharps)
shredding##
Incineration@ / destruction
Discarded Medicine and Cytotoxic drugs (Wastes comprising of
Category No. 5 and drugs disposal in secured
outdated, contaminated and discarded medicines)
landfills
Soiled Waste (Items contaminated with body fluids including
Incineration@ / autoclaving /
Category No. 6 cotton, dressings, soiled plaster casts, lines, bedding and other
microwaving
materials contaminated with blood.)
Disinfecting by chemical
Solid Waste (Waste generated from disposable items other than treatment@@ / autoclaving /