Health Care Waste and its Management

UNIT 2 PRINCIPLES OF HEALTH CARE WASTE MANAGEMENT

Structure
2.0 2.1 2.2 Objectives Introduction General Principles of Waste Management
2.2.1 Do No Harm 2.2.2 Disposables versus Durables (Non-disposables) 2.2.3 Reduce, Recycle, Reuse and Recover 2.2.4 Flow of Bio-medical Waste (Life Cycle Approach)

2.3

Principles of Managing Different Categories of Waste

2.3.1 Principles of Managing Sharps 2.3.2 Chemical Disinfectants 2.3.3 Waste from Dental Clinics 2.3.4 Waste from Laboratories and Blood Banks 2.3.5 Waste from Other Patient Care Areas 2.3.6 Radioactive Waste 2.3.7 Expired Pharmaceuticals 2.3.8 Attenuated Vaccines

2.4 2.5 2.6 2.7 2.8 2.9

Principles of Accident Reporting Occupational Hazards Due to Health Care Waste Principles of Segregation, Collection, Transportation and Disposal of Health Care Waste Let Us Sum Up Key Words Answers to Check Your Progress

2.10 Further Readings

2.0 OBJECTIVES
After going through this unit, you will be familiar with: the importance of segregation at source, proper collection and transportation; principles of minimization of waste; timely and proper treatment of waste through selection of appropriate technology; the need for training and teaching of health care workers in proper waste management; and mechanisms for accident reporting and safety of health care workers handling health care waste.

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2.1 INTRODUCTION
In Unit 1 of this block, definition, types and categories of waste were discussed. Making the students aware of municipal waste and health care waste, sources of health care waste, their categorisation and the hazardous nature of bio-medical waste. This unit primarily deals with principles of managing health care waste in different areas and issues related to occupational safety of the health workers handling bio-medical waste. Since early recovery of patients and health of clinical staff directly depends on a clean and hygienic environment, it is essential that health care waste is managed properly, by practicing segregation, collection, storage and disposal in a proper and scientific manner. Health care waste management is thus, part of hygiene and maintenance activities. Excellent hygiene practices in health care facilities are the prerequisite for good medical waste management.

Principles of Health Care Waste Management

2.2 GENERAL PRINCIPLES OF WASTE MANAGEMENT

Proper management of health care waste requires following principles to be followed by all stakeholders involved in the management of the waste.

2.2.1 Do No Harm
Bio-medical waste is potentially hazardous and may lead to physical, chemical, biological, mechanical and stress hazard. The staff, the attendants as well as the patients may be the victim of hazards due to exposure to various pathogens, leading to a variety of infections e.g. Salmonellosis, Hepatitis A, Streptococcal infection, etc. Persons coming in contact with bio-medical waste are prone to get injury from sharps, which form a very important component of waste. Injury due to sharps leads to life threatening conditions like HIV, Hepatitis B and C. Besides bio-medical waste is genotoxic as it also contains the chemotherapeutic compounds used for treatment against various malignancies. It also contains chemicals toxic in nature and heavy metals that are also a cause of concern e.g. mercury, lead. Florence Nightingale, in 1860, said Health care facilities should do no harm to sick. It is the moral responsibility of all health care institutions to ensure proper disposal of bio-medical waste, to ensure safety to the patients, visitors and staff taking care of sick. Though health care managers are responsible for safe disposal of waste, but it requires active co-operation of general public viz. a) b) Not throwing eatables and other refuse here and there and keeping the health care institution clean. Spitting should be done in separate bowl or in washbasin and water poured. Infected sputum should be put in sputum container, which may contain chemical disinfectants like cresol or bleach solution. Paan eaters should not spit on the institutions walls and they should take special precaution for spitting. Polythene bags must not be brought to the health care institution as they cause many problems, block drainage, and kill animals if consumed by mistake.

c)

Implementation of environmental law and safe practices is not the responsibility of government alone, active participation of people is also essential.

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Health Care Waste: Definitions

2.2.2 Disposables versus Durables (Non-disposables)

Use of disposable items in health institutions has increased in a big way. Items like syringes, needles, IV bottles, catheters, sharps, gloves, aprons, gown, mask etc. are being put to single use and disposed. There are a number of advantages with the single use items viz. convenience to carry and use, reduction in infections, avoidance of repacking and sterilization. These items do not require additional manpower for further process. The outreach community programmes can be better planned without compromising sterilization process. However, in the changed scenario for concern for waste management, a number of issues, with regard to increased quantum of waste, increase in environmental pollution, carrying cost, recycling costs, allergic reactions to waste handlers, packing costs and even disposal of packing materials etc. have to be looked into. One has to be extra careful to ensure handling and disposing sharps, blood bags, etc., so that these are not recycled and do not cause injuries to waste handlers. In fact disposables increase the quantum of health care waste and require additional space and manpower to deal with disposal and maintenance of records. As regards to durables, they are more environment friendly and in case properly sterilized under supervision of experienced persons, safety is assured. However, these require plenty of running water at different stages of sterilization. Appropriate set up for sterilization, quality control by properly trained persons is required. Alarms were raised after a few reports on disposable syringes being reused in the remote areas. Also lack of proper disposal arrangements has been reported. Recently, Madhya Pradesh Government in India has speeded up its efforts in remote areas by providing pressure cookers, stoves and contingency funds to ensure effective sterilization of glass syringes and needles. There have been many other reports that plastic syringes were not being destroyed properly and syringes get repacked and circulated in the market. It may be difficult to make a generalized decision with regard to disposable versus durables. Factors like convenience, cost effectiveness, availability of materials, sterilization practices and quality control, disposal facilities, environmental consideration, trained manpower, proper accounting of materials, etc., may have to be considered for individual items and their use. Yet, if a 100 per cent sterilization cannot be guaranteed, the final choice should be for disposable devices.

2.2.3 Reduce, Recycle, Reuse and Recover

Waste minimization is the key to efficient waste management in health care facilities. Reduction of waste can be achieved by means of reuse, recycle and other programmes. The potential benefits of waste minimization are environmental protection, occupational safety and hospital economy (by means of reduction in cost expenditure towards health, waste treatment technologies, etc.). The various steps that can be adopted to minimize the waste are: Reduction at source by adopting good purchase procedures. Substituting biodegradable products in place of products that generate toxic hazardous wastes. Purchase of multiple use products instead of single use products. Maintenance of optimum level of inventory. Consume oldest batch of product [first in first out (FIFO) principle].
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Checking the expiry date of each product at the time of delivering.

Purchasing smaller quantities of unstable products. Preventing product wastage during delivery of patient care in wards. Practice of using reusable e.g. for kitchenware, cutlery, linen, wash bowls, personal protective glass, respiratory therapy equipment, rechargeable batteries, x-ray film holders, glass syringes, bottles. Recycling of newspaper, packaging material, office paper, glass, aluminium, plastic containers, construction debris, etc. Composting organic waste. Adopting procedures for recovery viz. mercury from broken thermometers, B.P. instruments, etc., silver from photographic chemicals; lead from batteries. Undamaged pressurized containers can be returned to original supplier for refilling. Use of recyclable sharps i.e. glass, syringes, scalpels, etc., those, which can withstand sterilization processes, only if latter is available and are 100 per cent functional.

Principles of Health Care Waste Management

2.2.4 Flow of Bio-medical Waste (Life Cycle Approach)

Bio-medical waste is generated in every unit and workplace in health care facilities. This waste should follow a particular direction in a system and at each step of this system waste management need to be monitored and supervised. Fig. 2.1 illustrates waste cycle.

Waste Generation

Return Outdated Drugs/Chemicals

Waste Segregation

Recycling of Selected Materials

General Waste
ec tio

Wa s us

te

Waste Collection/Storage

Waste Treatment Incineration Disinfection Autoclaving

Inf

Waste Transport

Waste Disposal

Municipal Landfill/ Sanitary Landfill Drain in Sewer Fig. 2.1: Waste Cycle 31

Health Care Waste: Definitions

Check Your Progress 1 a) Write True or False: Disposables can be reused again. What are the steps in the waste cycle? ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................

(True/False)

b)

2.3 PRINCIPLES OF MANAGING DIFFERENT CATEGORIES OF WASTE

Following principles should be followed during the process of segregation, handling, storage, packaging, transport, treatment and disposal of waste: Scientific waste management practices. Sound waste management policies and procedures in consonance with health legislation. Segregation at source and collection of various categories of waste in separate containers so that each category is treated in a suitable manner to render it harmless. Appropriate vehicles for transport of waste, both within as well as outside the health care facility. Identifying and utilizing proper treatment technology depending upon the category of waste.

2.3.1 Principles of Managing Sharps

Sharp waste is defined as any device capable of cutting or piercing the skin, it could be having acute rigid corners, edges or protuberances. Hypodermic needles, syringes with hypodermic needles, blades, needles with attached tubings, acupuncture needles, root canal files, glass items, such as Pasteur pipettes and blood vials, glass slides or coverslips contaminated with hazardous waste, etc., are a few examples of sharp waste. Following practices must be observed for disposal of sharp waste: a) All discarded sharps used and unused that were handled during patient care should be classified and managed as infectious hazardous waste because of the possibility of piercing the skin and transmission of undiagnosed blood borne disease (e.g. Hepatitis B and AIDS). All sharps that were contaminated by exposure to pathogens (e.g. in the laboratory) should be managed as infectious waste. Waste sharps that are not contaminated still pose the hazards of injury. From consideration of safety, it is best to manage uniformly all waste sharps contaminated as well as uncontaminated in accordance with the practices established for contaminated sharps.

b) c)

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Containment and Mutilation of Sharps Due to the hazards associated with sharps all infectious or non-infectious sharps should be mutilated and disinfected before their final disposal. There are different devices available for mutilation of sharps at the point of generation. The most widely used devices are: Needle and Syringe Destroyers Electrically operated devices where needle is burnt and nozzle of the syringe is cut, in order to make it un-reusable and harmless. The destroyed needles and syringes are further subjected to disinfection.

Principles of Health Care Waste Management

Fig. 2.2: Needle Destroyer

Needle and Syringe Cutters Manually syringe nozzle is cut and needles are collected in container. The needles are disinfected and collected in a sharps container containing chemical disinfectant and mutilated syringes they are disinfected later either by chemical disinfection, autoclaving or microwaving followed by shredding.

Fig. 2.3: Manual Needle Cutter

Sharps Container Mutilated/un-mutilated sharps (subject to further treatment) must be contained in puncture resistant containers to prevent injuries to waste handlers. Plastic bags and heavy-wall corrugate cardboard is not suitable to be designated as sharp container. The container should have the following properties:
Note : IGNOU or WHO does not endose on any products, they are only used as examples of the technique.

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Health Care Waste: Definitions

The container should be rigid, puncture resistant and leak-proof. The container should be designed to prevent needle penetration through the walls of the container when the container is dropped or handled roughly. The sharp containers, which are likely to be sterilized, must have vent holes that allow steam to enter the container. These holes must not be taped/closed. Therefore, containers with open vent holes must be maintained in an upright position prior to treatment to prevent the leakage of fluids. Transport of sharp within the facilities should be carefully planned. Final disposal of sharps should be through encapsulation wherein plastic or steel drum used should be filled 3/4th and remaining space filled by pouring cement/ cement lime mixture. Sharps container containing plastics should not be incinerated but disposed off in a sharps kit. Note: The treatment and disposal of sharps will be dealt in detail in Course 2 (BHM002), Block 2.

Fig. 2.4: Puncture Proof Container Source: WHO, Safe Management of Waste from Health Care Activities, Geneva, 1999.

To ensure proper handling and safety of sharps: Always destroy your own sharp, yourself. Never pass used sharps from one person to another. Never recap used needles. Locate needle destroyer and container near the point of generation to have good visibility.

2.3.2 Chemical Disinfectants

Chemical disinfection is used routinely in institutions for cleaning certain instruments and medical supplies for surgical scrubs and floor washings. It could also be used for rendering the waste safe. The chemical disinfection process uses chemical action as a means of destroying most micro-organisms but not necessarily all bacterial spores and viruses. This type of treatment usually results in disinfection rather than sterilization. Although a wide variety of chemicals are used for disinfection, in general chlorine compounds are preferred because of following reasons: They are economically viable Easy to use Very effective. Disadvantages Requires storage in cool and dry places.
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Rapid loss of effectivity after opening of package containing the chlorine solution.

The solution remains effective for 6 to 8 hours, hence may require preparation two to three times per day depending upon waste generation. Not effective against spores and highly organic waste. For disinfection of sharps and plastic waste, chlorine compounds are added to water to ensure 0.5 per cent of availability of free chlorine in the prepared solution. Quantum of chlorine compounds required for preparation of disinfection solution (containing 0.5 per cent free chlorine) is elucidated in Table 2.1.
Table 2.1: Chlorine Disinfectants Name of Disinfectant Available Chlorine Required Chlorine Required Amount of Chlorine Disinfectant to Contact be Dissolved in Period 1 litre of Water 30 min. 30 min. 30 min. 30 min. 30 min. 100 ml* 7.0 gm 8.5 gm 4 tabs 20 gm.

Principles of Health Care Waste Management

Sodium Hypochlorite Calcium Hypochlorite NaOcl Powder Na Dichloroisocyanurate (NaDCC) tablets Chloramine

5% 70% -----60% 25%

0.5% 0.5% 0.5% 0.5% 0.5%

* 100 ml of Sodium Hypochlorite solution should be added to 900 ml of water to get total volume of 1.0 litre.

Chemical disinfectants are to be discharged in drains. In ideal conditions, their further management will be on the same line as liquid waste coming out of the end point of health care facility i.e. through effluent treatment plan.

2.3.3 Waste from Dental Clinics

Three types of waste are produced in dental clinics: i) ii) Sharps are to be managed on the same principle as discussed in sub-section 2.3.1. Dental Clinic Fluid Waste: a) b) c) Body fluid should be poured into the sanitary sewer drain. Glass collection bottles used at off-site clinics should be cleaned, disinfected and dried before being reattached to the suction system. Plastic collection bottles and suction tubing used in oral surgery should be rinsed free of blood and thoroughly disinfected prior to being placed in the general clinic waste. Fluids that are known or suspected to contain organisms must be rendered harmless before disposal. Prepare disinfectant and run it through suction tubing into collection device. Let it stand for three minutes before pouring into a sanitary sewer drain.

d)

iii) Dental Clinic Solid Waste: a) Used disposable items (e.g. gloves, rubber dams, cotton rolls, gauze, suction tips, air-water suction tips) and blood saturated waste are to be placed in cubicle waste containers meant for infectious waste. Sharps are to be placed in puncture proof containers after mutilation at source. Infectious waste may not be disposed off in regular clinic waste unless it has been appropriately disinfected either at source or sent in a Centralised Bio-medical Wastes Treatment Facility.

b) c)

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Health Care Waste: Definitions

d) e)

Regardless of its origin, no fluid may be disposed with other category of waste. Hazardous waste like mercury, which is extensively used in amalgams should be handled with care and not disposed into the waste bins or drained into the sewers due to the danger associated with its improper disposal to the environment and the community at large. To attain this a mercury trap is installed between the chair and the community waste water system. Inexpensive sedimentation traps, sometimes combined with a filter, exist on the market. These traps are supposed to retain 95 or 99 per cent (depending on model) of the effluent mercury. (More at: mntap.umn.edu/HEALTH/81-DentalWaste.htm).

2.3.4 Waste from Laboratories and Blood Banks

Management of waste coming out of laboratories and blood bank is summarised in Table 2.2.
Table 2.2: Management of Laboratory and Blood Bank Waste No. Classification I) II ) Non-infectious Waste Infectious Waste: 1) Laboratory specimens consisting of blood, body fluids, pus and secretions 2) Urine, faeces, nasal secretions, sputum, tear and vomitus Chemical disinfection followed by drainage in sinks Treatment of Waste Treated as general waste

Urine, faeces and nasal secretions are normal physiological excreta and may be drained into sewers. Sputum containing acid fast bacilli should be autoclaved. Vomitus if it contains blood should be chemically treated and then drained in sewers Chemical disinfection/autoclaving/ Microwaving followed by shredding. Encapsulation, deep burial and landfill Liquid chemicals in kits and expired chemicals may be diluted and drained in sewers. Later, disposal in public sewer after passing through effluent treatment plant Solid chemicals on expiry ----- secured landfill

3) Sharps and disposables

4) Chemicals

5) Human surgery specimens fixed in formaldehyde in path lab 6) Microbiology lab deals with live cultures, stocks of infectious agents, live and attenuated vaccines, contaminated glassware with live organisms 7) Blood bags in the Blood Bank 36

Fixed specimens are not infectious. However, they should be sent for incineration Microbiology cultures autoclaved are to be

As the bags are made of PVC, they should not be incineration. They should ideally be autoclaved and shredded

2.3.5 Waste from Other Patient Care Areas

Patient Care Area comprises of Accident and Emergency departments, OPD services, indoor patients, Operation Theatres, Labour Rooms, Detention/Observation Rooms, Intensive Care Units and other departments of hospitals. Some of the important areas and the waste generated are explained in Table 2.3.
Table 2.3: Points of Waste Generation Procedure 1) Ward Blood sample collection Injection and IV drips Dressing/Bandage Temperature and blood pressure measurement Distributing medicine/drugs Bedpan 2) Operation Theatre Operated parts Blood and secretion IV drips, injection Intubation IV drugs and local anaesthesia 3) Labour Room Amniotic and other secretion Human parts IV injection and drips Suturing 4) OPD Injection room IV Injection and drips, needles, IV sets, canula, wrappers, swabs Soiled pads, cotton swabs etc. Placenta and tissues, umbilical cord, etc. Needles, IV sets, bottles, canula, wrappers Suture needles, thread, wrappers Human body parts, tissues Blood and human secretion Needles, IV sets, syringes, plastic/broken glass tubes or vials Mouth piece, swabs, plastic disposables Vials, ampoules, needles, syringes, scalpel blades, suture Swab, needle, syringe, wrapper Swab, needle, syringe, packaging material, IV drip set, vials Soiled cotton, bandage, antiseptic liquid wastes, wrapper Mercury, broken glass Discarded medicines Urine, sputum, body fluids Waste Generation

Principles of Health Care Waste Management

5) Dressing Room Dressing Antiseptic, cotton dressing, blood and pus, contaminated dressing, etc., cotton swabs, spills of chemicals and blood

Principles to be followed for categories of bio-medical waste in terms of treatment and disposal as explained in Indian Gazette Bio-medical Waste (Management and Handling) Rules 1998 are summarised in Table 2.4.
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Health Care Waste: Definitions

Table 2.4: Waste Disposal Options as Per Bio-medical (Management and Handling) Rules 1998 Cat. No. 1 2 3 4 Waste Category Human Anatomical Waste Animal Waste Microbiology and Biotechnology Waste Waste Sharp Items Treatment and Disposal Incineration or Deep Burial Incineration or Deep Burial Local Autoclaving/Microwaving/ Incineration Disinfection, autoclaving, microwaving, mutilation, shredding Incineration, destruction and disposal in secured landfill Incineration or autoclaving or microwaving Disinfection by chemicals, autoclaving, microwaving, mutilation, shredding Chemical treatment, discharge into drain, effluent treatment Disposal in municipal landfills Chemical treatment and discharge into drains for liquids and secured landfills for solids

5 6

Discarded medicines and Cytotoxic Waste Soiled Waste Items contaminated with blood, body fluids, cotton dressing, soiled, plastic cast, bedding Solid Waste Disposable like catheters, tubing, IV sets Liquid Waste Incineration Ash Chemical Waste Solid/Liquid

8 9 10

2.3.6 Radioactive Waste

Radioactive waste in hospitals is required to be disposed as per guidelines issued by Bhabha Atomic Research Centre (BARC) in India or by the International Atomic Energy Agency (IAEA) (See at: www.iaea.org/ ). However few guiding principles for disposal are discussed below: 1) Waste Disposal in Radio-diagnosis Department The waste produced during routine radiography procedures, CT (Computerized Tomography), MRI (Mangnetic Resonance Imaging) is not radioactive. They may be segregated in two groups: i) Recyclable Waste X-ray films Fixer solution Papers Non-recyclable Waste Other waste items may be disposed off as in general hospital waste disposal plan. Developing solution is diluted with water and flushed down the sewer.

ii)

2)

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Waste Disposal in Radiotherapy Department i) Non-radioactive waste may be disposed off as in hospital waste disposal plan. ii) Radioactive waste may be of two types: Contaminated ---- solid, liquid and gaseous waste. Drugs and chemicals used in therapy.

Management of Radioactive Waste Radioactive waste should be carefully managed to protect life and environment. It involves: 1) 2) Sorting and segregation of radioactive waste Disposal of radioactive waste

Principles of Health Care Waste Management

Sorting of Radioactive Waste 1) 2) Liquids in microcurie amounts should be diluted in water and discarded down into the sink drains. Following should be kept in separate containers: Radioactive substances with half life of <90 days Radioactive substances with half life of >90 days Transuranic substances Disposal of Radioactive Waste They are normally classified, according to amount and type of radioactivity in them: 1) 2) 3) Low level Medium level High level

Radioactivity decreases with time. Half-life of isotopes is the time taken for a given isotope to half its radioactivity. Three general principles are employed in management of radioactive waste: 1) 2) 3) Concentrate and Contain Dilute and Disperse Delay and Decay

Low Level Waste a) b) c) Volume is first reduced, compacted and incinerated (in closed container). Usually buried in shallow landfill sites. Liquids may be diluted in large quantities of waste and flushed into sewer over a period of time.

Intermediate Level Waste Intermediate level waste requires special shielding. It may be solidified in concrete or bitumen. Short-lived wastes are buried but long-lived waste is disposed deep under ground. High Level Waste High radioactivity level waste contains highly radioactive fusion products and heavy elements. It generates considerable amount of heat and requires cooling. Special shielding is required during handling and transport. It is isolated for long length of time till most of the radioactivity has decayed. The most favoured method is burial in dry, stable geological formation 500 m deep. Only after being buried for 1000 years most of the radioactivity will have decayed.

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Health Care Waste: Definitions

Multi Barrier Concept Multi barrier concept is used to isolate high level radioactive waste from biosphere: a) b) c) d) e) Immobilize waste in an insoluble matrix e.g. borosilicate glass Seal inside a corrosion resistant container e.g. stainless steel Surround the container with bentonite clay to inhibit ground water movement Locate deep underground in a stable rock structure Site in a remote location.

2.3.7 Expired Pharmaceuticals

Pharmaceuticals that should never be used are considered as pharmaceutical waste. Following are common pharmaceutical waste generated in hospitals: All expired pharmaceuticals All unsealed syrups or eye-drops (expired or otherwise) All cold chain damaged pharmaceuticals irrespective of the period of expiry that should have been stored in cold chain but were not (e.g. insulin, vaccines). All bulk or loose tablets and capsules - If unexpired these should only be used when the container is still sealed, properly labelled or original blister packing is intact. All unsealed tubes of creams, ointments etc. (expired or unexpired). Sorting The objective of sorting is to separate the pharmaceuticals into separate categories for which different disposal methods are required. a) Sort by the Nature of Active Ingredients (Special Disposal Needed) Controlled substances e.g. Narcotics, Psychotropic substances Anti-infective drugs Antineoplastics Cytotoxic-Anticancer drugs, toxic drugs Antiseptics and disinfectants b) Sort by Dosage Form Solids, semisolids and powders - tablets, capsules, granules, powders for injection, mixtures, creams, lotions, gels, suppositories Liquid solutions, suspensions, syrups Ampoules Aerosol canisters - including propellant driver sharps and inhalers. Following are common disposal methods of pharmaceutical waste: 1) Return to Manufacturer/Suppliers: The Preferred Option The drugs nearing expiry can be returned back to the manufacturer. It is key that for this purpose the original packing is kept and all customs documents are well secured. Such return to sender operations are commonly dealt with the support of the Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and their Disposal (More at: www.basel.int/: )

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2)

Highly Engineered Secured Landfill An appropriate landfill consists of an evacuated pit isolated from water bodies and above the water level. Each days solid waste is compacted and covered with soil to maintain sanitary conditions.

Principles of Health Care Waste Management

3)

Waste Immobilization a) Encapsulation: Encapsulation involves immobilizing the pharmaceuticals in a solid block within a plastic or steel drum. They are filled to 75 per cent capacity with solid and semi-solid pharmaceuticals, and the remaining space is filled by pouring in a medium such as cement or cement/lime mixture, plastic foam or bituminous sand. Inertisation: Inertisation is a variant of encapsulation and involves removing the packaging materials, paper, cardboard and plastic from the pharmaceuticals. Pills need to be removed from their blister packs. The pharmaceuticals are then crushed and put in a mix of water, cement and lime added to form a homogenous paste. The paste is then transported in the liquid state by concrete mixer truck to a landfill and decanted into the normal urban waste. (More at: www.who.int/entity/water_sanitation_health/ medicalwaste/hcwmposters.pdf)

b)

4)

Sewer Some liquid pharmaceuticals, e.g. syrups and intravenous fluids, can be diluted with water and flushed into the sewers in small quantities over a period of time without serious public health or environment affect.

5)

Incineration The only possible incineration should happen in high temperature incinerators. It may be the method of choice for cytotoxic drugs and toxic laboratory chemicals but it may be very hazardous if the obsolete lots are containing heavy metals such as Mercury, Lead, Cadmium, etc.

6)

Aerosol Canisters Aerosol canisters and inhalers should not be burnt or incinerated, as they may explode. Containers of non-poisonous substances should be disposed in a landfill, dispersed among municipal solid wastes.

2.3.8 Attenuated Vaccines

In India attenuated vaccines are classified under Category 3 of Bio-medical Waste (Management and Handling) Rules 1998 (i.e. Microbiology and Biotechnology Waste). It comprises of waste from laboratory cultures, stocks or specimens of micro-organisms, live or attenuated vaccines, human and infectious agents from research and industrial laboratories, wastes from production of biological, toxins, dishes and devices used for transfer of cultures. Similar to principles discussed in management of laboratory waste, these require local autoclaving/microwaving/incineration without chemical treatment. Check Your Progress 2 Write True or False: a) b) c) d) e) All types of waste generated in hospitals are hazardous. Bulk of disposables are environment friendly. FIFO stands for First in, First out. (True/False) (True/False) (True/False)

Chemical disinfection is commonly used to treat sharps and plastics. (True/False) Microbiology culture waste should be autoclaved. (True/False)
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Health Care Waste: Definitions

f) g)

Incinerator ash should be chemically treated before sending it for landfill. BARC guidelines are applicable for disposal of radioactive waste generated at health care facilities.

(True/False) (True/False)

2.4 PRINCIPLES OF ACCIDENT REPORTING

When any accident occurs at any institution or facility or any other site where bio-medical waste is handled or during transportation of such waste, the authorized person should report the accident in Form III of the Bio-medical Waste (Management and Handling) Rules 1998 as shown below to the prescribed authority forthwith.
Form III (See Rule 12) ACCIDENT REPORTING 1. 2. 3. 4. Date and time of accident: Sequence of events leading to accident: The waste involved in accident: Assessment of the effects of the accident on human health and the environment: Emergency measures taken: Steps taken to alleviate the effects of accident: Steps taken to prevent the recurrence of such an accident:

5. 6. 7.

Date Place

Signature .. Designation .

Training in emergency response should be provided to health care personnel and the necessary equipment should be available to ensure that the required measures can be implemented safely and rapidly. Spillage is probably the most common type of emergency involving infectious and other hazardous material or waste. Spills are an inadvertent discharge that occurs at various places in the health care facility. Spills include accidental tipping over of containers, and dropping and breaking of containers as well as spills, which occur mainly because of splashing during manual transfer, overfilling and leaks in process equipment and piping. Regardless of whether the spillage involves waste or material in use, the response procedures are practically the same and should ensure following: i) ii) The waste management plan is respected; Contaminated areas are cleaned and, if necessary, disinfected;

iii) Exposure of workers is limited as much as possible during the cleaning up operation; iv) The impact on patients, medical and other personnel, and the environment is as limited as possible.

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Accidents or incidents, including near-misses, spillage, damage containers, inappropriate segregation, and any incidents involving sharps should be reported to the waste management committee (if waste is involved) or to another designated person. The report should include the details of: a) b) c) d) The nature of the accident or incident The place and time of the accident or incident The staff who are directly involved Any other relevant circumstances.

Principles of Health Care Waste Management

The waste management officer or other responsible officer, who should also take all possible action to prevent recurrence, should investigate the causes of the accident or incident. The records of the investigation and subsequent remedial measures should be kept.

2.5 OCCUPATIONAL HAZARDS DUE TO HEALTH CARE WASTE

Many of the dangers or hazards associated with bio-medical wastes are hidden. Injuries may not occur right away but might build up or lie dormant in the bodys system for years like Hepatitis B, C and cancers. Hence all suspect/unknown substances should be considered hazardous and universal safety precautions are followed. Potential health hazards of the various wastes are given in Table 2.5.
Table 2.5: Health Hazards of Various Waste Potential Hazards Psychological Stress Infections and Diseases: HIV/AIDS, Hepatitis B and C, Haemorrhagic fever, Herpes, Measles, Shigellosis, Salmonellosis, Pneumonia, Septicaemia, Bacteraemia, Cholera, Tuberculosis, Anthrax, Helminthic infections, Candidiasis and others Infectious Rabies, Anthrax and other Injuries Dermatitis, Conjunctivitis, Bronchitis Cancer, Genetic mutation Poisonings Waste Materials Human anatomical waste Human anatomical waste, Soiled waste, Microbial/Biotech waste, Sharps

Animal waste Sharps, Cytotoxic and Radioactive drugs, Incinerator wastes Chemical, Cytotoxic, Radioactive, Incinerator wastes Cytotoxic, Radioactive drugs and materials, Chemical wastes Cytotoxic and other drugs, Liquid and Chemical wastes

HIV can be transmitted through needle stick injuries contaminated with blood of an HIV infected person. However, the chance of contracting AIDS from a single needle stick, even if the needle does contain HIV infected blood, has been estimated by the Centres for Disease Control to be only approximately 0.3 per cent. The chances of becoming infected with Hepatitis B from a single needle stick, even if the needle contains blood of an infected person, are between 6 per cent and 30 per cent. A persons chances of not

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Health Care Waste: Definitions

contracting the disease from an exposure are usually better if he or she receives prompt medical attention. Injuries are commonly caused by sharps, mainly due to needle sticks coming out of containers and piercing the skin. Not only can sharp puncture the skin, they can also allow disease-causing micro-organisms to get into the blood and body. Medical waste poses great risk of Hepatitis B and HIV infection to the landfill workers and rag pickers. Figure below gives an overview of needle stick frequency in a health facility.
IV-Line Related Cause 5% Collision with HCW/Sharp 21% Recapping 5% Concealed Sharps 28%

Splash of Fluid 5% Disposal Related 11% Restless Patient 10% Fig. 2.5:

Clean Up 11% Handling/Passing Device 4%

Breakdown of Needlestick injuries by Procedure (The data shown are taken from a study in South Glasgow University Hospitals NHS Trust carried out between April 1999 and March 2000)

Mycobacterium tuberculosis is also transmitted from medical waste to the waste workers where it was processed, i.e., shredded, compacted and finally deactivated. Improper disposal of infected sputum may contaminate the dust that may be inhaled by a healthy person during sweeping or cleaning of the room. Some infections such as Cholera, Shigellosis, Salmonellosis, Bacteraemia and Helminths are transmitted through faecooral route when water gets contaminated with waste. Many diseases can be transmitted from slurry of animals, e.g., Anthrax brucellosis, Foot and Mouth diseases, Leptospirosis, Rabies, Salmonella, E-coli, Q-fever, Yersinia, Giardiasis, Streptococcus infections, etc. Splashing chemicals into eyes or rubbing the eyes with hands that have been contaminated with cytotoxics and other chemicals can cause itch, tears, redness and pain to the affected eye. Injuries, such as burns are also common to health care workers. Strong detergents, bleaches and preservatives (like Formalin) may also cause inflammation of the skin, airways and eyes. Contact or chemicals dermatitis may occur due to exposure of skin to certain irritating chemicals. Any radioactive substance has the potential to damage the chemical make up of the cells. This increases the risk of mutation and birth defects. Any health care waste that causes cell damage can trigger the development of cancer. Mercury is a toxic substance, which is discharged into waste water stream by dentists and breakage of thermometer, BP instrument, etc., can cause poisoning on human exposure. Similarly many chemicals such as gluteraldehyde, benzene, pharmaceutical drugs can cause poisoning. Following steps are required to be undertaken to ensure safety of health workers: Adequate medical help and assistance need to be given to those who have been affected by occupational disease or injuries during the course of waste handling and disposal. To reduce the risk of occupational exposure to potentially infectious disease like HIV infection, hepatitis, etc., standard precautions as prescribed should be taken.
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Health workers who are in high-risk area should be vaccinated against hepatitis, typhoid, rabies, meningitis, etc., and proper immunization record need to be

maintained. Drugs for Post Exposure Prophylaxis for HIV should be readily available. A proper flow chart for management of infectious materials like body fluid and chemical spill, mercury spill and cytotoxic spill should be displayed at appropriate sites. There should be a waste management committee that must ensure segregation at source, mutilation of sharps, waste disinfection, proper containment and transportation, treatment and disposal of waste. The committee should also look at infection control measures, accident reporting and universal precautions being taken by the health care workers while handling waste. Regular training and awareness to different health care workers should also be an integral part of the committee. Safety committee need to be set up by senior medical staff with the representation from engineering, housekeeping, nursing, other related departments who can monitor periodic inspection of the various equipment installation and environment of the health care facility. Proper co-ordination, communication and notification system should be ensured by the health care facility administrator. Personal protective devices should be readily available. The following should be made available to all personnel who collect or handle health care waste: ------------Helmets/cap Face masks depending on operation Eye protectors (safety goggles) depending on operation Overalls (coveralls)/Shield Apron Leg protectors and/or industrial boots Disposable gloves (medical staff) or heavy-duty gloves (waste workers).

Principles of Health Care Waste Management

Basic personal hygiene is important for reducing the risk from handling health care waste and convenient washing facilities (with warm water and soap) should be available for personnel involved in the task. Health care facility staff should ensure that the families of patients undergoing chemotherapy at home are aware of the risks and know how they can be minimized or avoided. Appropriate training and education (with regard to occupational hazards and safe typrecautions) of the workers handling bio-medical waste will minimize various accidents and risks by taking required precautions. Burden of Disease Associated with Unsafe Injection Practices Because injections are so common, unsafe injection practices are a powerful engine to transmit blood-borne pathogens, including Hepatitis B virus (HBV), Hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Because infection with these viruses initially presents no symptoms, it is a silent epidemic. However, the consequences of this silent epidemic are increasingly recognized. Hepatitis B virus: HBV is highly infectious and causes the highest number of infections unsafe injections account for 33 per cent of new HBV infections in developing and transitional countries for a total of 21.7 million people infected each year. [Source: Bulletin of WHO, 1999, 77(10)] Hepatitis C virus: Unsafe injections are the most common cause of HCV infection in developing and transitional countries, causing two million new infections each year and accounting for 42 per cent of cases.
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Health Care Waste: Definitions

Human immunodeficiency virus: Globally nearly 2 per cent of all new HIV infections are caused by unsafe injections with a total of 96000 people infected annually. In South Asia up to 9 per cent of new cases may be caused in this way. Such proportions can no longer be ignored.

2.6 PRINCIPLES OF SEGREGATION, COLLECTION, TRANSPORTATION AND DISPOSAL OF HEALTH CARE WASTE
Segregation is defined as Separation of different types of waste as per treatment and disposal option. It is the most important pre-requisite in the active process of waste management as it allows special attention to be given to the relatively small quantities of infectious and hazardous waste, thereby reducing the risks as well as the cost of handling and disposal. It can rightly be said to be the key to the active process of scientific waste management, as proper sorting or separation into different categories will entail the right treatment and disposal. Segregation of health care waste in a proper manner will depend upon the following factors: i) ii) Type of health care facility/health care institution The motivation and training level of the generator of waste

iii) Sound health care waste policies and procedures in consonance with the legislation. As different types of health care waste need to be disposed off differently on segregation, it is essential that on collection it is put in disposable bags/container following a specific colour scheme in respect of bags/containers thus used for easy identification and final disposal as may be warranted. Table 2.6 lists an example of the colour coding and type of container required for the segregated collection of health care waste. [Based on the Bio-medical Waste (Management and Handling) Rules 1998, India]
Table 2.6: Segregated Collection of Waste Sl. No. Category of Waste 1. 2. 3. 4. 5. 6. 7. 8. 9. Human Anatomical Waste Animal Waste Microbiology and Biotechnology Waste Waste Sharp Discarded medicines and Cytotoxic Waste Soiled (Biological Waste) Soiled (Plastic) Incineration Waste Chemical Waste (Solid) Type of Container Plastic Plastic Plastic Puncture proof container Plastic Bag Plastic Bag Colour Yellow Yellow Yellow/Red Blue/White Translucent Black Yellow

Plastic Bag, Puncture Blue/White proof container Translucent Plastic Bag Plastic Bag Black Black

Following procedures are required to be followed for the segregated collection of health care waste (the colour codes are India specific): All the items sent to incinerator/burial (at Sl. No. 1, 2, 3, 6) should be placed in yellow coloured bags.
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All the biomedical waste to be sent for microwave/autoclave/chemical treatment should be placed in red coloured bags.

Any waste which is sent to shredder after autoclaving/microwaving/chemical treatment is to be packed in blue/white translucent bags/containers. Any waste being sent to a secured landfill should be placed in black coloured bags. Location of Containers: All containers having different coloured polythene bags should be located at the point of generation of waste, i.e., near OT tables, injection rooms, diagnostic service areas. The colour of containers/plastic bags used for collection of segregated biomedical waste should be prominent and easily identifiable. Labelling: All the bags/containers must be labelled according to the rules [Schedule III of Bio-medical Waste (Management and Handling) Rules 1998.] Bags/Containers: It should be ensured that waste bags/containers are effectively secured and filled up to only three fourth capacities and removed from site of generation regularly and timely. Pre-treatment Procedures: Certain categories of waste which may need pre- treatment (decontamination/disinfection) at the site of generation such as plastic and sharp materials etc. should be removed from the site of generation only after treatment. Note: In the subsequent unit segregation shall be dealt with in more detail.

Principles of Health Care Waste Management

Yellow Bin
Waste for Incineration/ Secured Landfill Disposal Human anatomical waste, microbiological, pathological, cytotoxic and discarded medicines

Red Bin
Waste for Nonincineration Treatment Disposal Infected plastics, syringes, tubings, catheter, gloves, blood bags, urine bags, cotton, dressings, etc.

White Bin
Waste Requiring no Treatment Paper, packaging material, cardboard, general waste, etc.

Green Bin
Waste Requiring no Treatment Vegetables, fruit peels, left over food, leaves and garden wastes, etc.

Blue Bin
All sharps in puncture proof containers

Fig. 2.6: Segregation of waste based on colour codes and treatment method

Transportation Types of Transport There are two types of transport of wastes: 1) 2) Intramural (Internal) Transport: Within the health care facility Extramural (External) Transport: Outside the premises of the health care facility

Intramural Transport refers to the transport of waste from the point of generation, collection and storage in different areas to the point where it is kept (or storage room), pending transportation to the actual site of disposal. Extramural Transport refers to the transport of wastes from a central collection point (storage room) to the site of final disposal like to a centralized facility.

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Health Care Waste: Definitions

Vehicles for Transport Internal Transport i) Push Cart: Ideally made up of stainless steel of robust construction and have good, durable castors. Mainly used to remove or transfer one or two bin/containers of waste from the sluice room or treatment room to the garbage trolley outside the ward.

Fig. 2.7: Push Cart (Source: WHO, Safe Management of Waste from Health Care Activities, Geneva, 1999)

ii)

Waste Trolley: A large trolley made of stainless steel with four revolving castors and handle on one side. It should be leak proof and it should be covered.

Fig. 2.8: Waste Trolley (Source: WHO, Safe Management of Waste from Health Care Activities, Geneva, 1999)

iii) Wheel Barrow: This can be used for transporting waste bags collected from point of generation within the health care facility premises and transport to the municipal dumping grounds or the final waste storage/treatment site. It should be leak proof and ideally be covered.

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Fig. 2.9: Wheel Barrow (Source: WHO, Safe Management of Waste from Health Care Activities, Geneva, 1999)

External Transport i) ii) Cycle Rickshaw: It is covered on all sides and has a secure lid on top. Used in those institutions where disposal sight is nearby. Van/Waste Lorry: The specific lorry should be earmarked for waste transport, properly identifiable with the labelling Bio-medical Waste both at the sides and rear (Fig. 2.10). It should be fully covered, lined internally with aluminium or metal to give smooth finish and rounded covers without edges and angles for effective cleaning and disinfection. The drivers cabin should be fully separated by a bulkhead and load compartment should be securely locked during transit.

Principles of Health Care Waste Management

Fig. 2.10: Waste Lorry (Source: WHO, Safe Management of Waste from Health Care Activities, Geneva, 1999)

Treatment of Waste Treatment is a term used for those processes that modify the waste in some way before it is finally disposed off, with the main objective of disinfecting or decontaminating it by some means. After such treatments the residues can be handled safely, transported, stored and disposed off. There are five broad categories of biomedical waste treatment technologies: a) Chemical Treatment

Chemical disinfection is mainly used for sharps and plastic waste. Commonly used option is freshly prepared chlorine solution. b) Thermal Treatment

These processes use heat to decontaminate or destroy medical wastes. Common technologies used are: Autoclave, Hydroclave, Microwave and Incinerator. Details of treatment technologies will be explained in subsequent units of this programme. c) Mechanical Treatment

This comprises primarily of compaction and shredding. Compaction involves compressing the waste into containers to reduce its volume and shredding includes granulation, grinding, pulping, etc. d) Irradiation Treatment

This involves exposing the medical waste to ultraviolet or ionising radiations, help in sterilization of wastes by destruction of pathogenic organism. Irradiation technology is expensive.

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Health Care Waste: Definitions

e)

Biological Treatment

A system is being developed using biological enzymes for treating medical wastes. It is claimed that biological reactions will not only decontaminate the waste, but also cause the destruction of all the organic constituents so that only plastics, glass and other inert substance remain in residues. Disposal Depending upon the size and location of the health care facility, the following disposal methods can be used for liquid waste: Discharge into Sewers: Liquid waste along with associated colloidal and crystalloid solids should be drained. Chemical wastes should be treated first before being discharged into sewers. Soak Pits: It can be a very useful method for final disposal of liquid wastes in rural and small health care institutions as they are cheap, simple to build and require only tools for digging. These are not effective in rainy season. Waste Stabilizing Pond: It is a very useful and economical method provided space is available. It consists of an aerobic filter with activated sludge technology.

Disposal of Human Anatomical Waste, Blood and Body Fluids: The preferred treatment for this category of waste is by incineration. After incineration, the ash is sent for specialized landfills as it is sterile. Sharps: The sharps are that category of waste that needs maximum precaution and care. The needles, which comprise of the bulk of the sharps can be destroyed by needle destroyers or by using syringe melting and disposal system. The manual needle cutters use a stainless steel blade and the electrical ones use a platinum plate, which is heated to 800C and melts the needle. Mutilated needles should be disinfected in 0.5 chlorine solution for about 30 minutes at the point of generation and then sent for shredding, encapsulation and disposal in landfills. Microbiology and Biotechnological Waste: Disposal is done after treating the waste by any of the technological options, autoclaving, hydroclaving, microwave or incineration. Pharmaceutical and Infectious Solid Waste: This can be done by incineration and the ash can be finally disposed off in specialized landfills. Chemical Waste: Non-hazardous chemical wastes can be disposed off by the same method as general wastes, while those which can be recycled, should be packed, labelled properly and stored for recycling (specially heavy metals like mercury). Hazardous chemical waste should be recycled if possible, otherwise chemically treated and discharged in sewers after dilution (for liquid) and incineration (for solid). The ash is then disposed off in specialized landfills. Radioactive Waste: There are two main principles of disposal : (1) concentration and storage used principally for solid wastes, and (2) dilution and dispersal usually applied to liquid and gaseous radioactive wastes. Pressurized Containers: These should be disposed off along with general waste, in specialized landfills.

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Check Your Progress 3 Fill in the blanks: a) b) c) d) The two most common metals, which can be recovered from hospital waste are: ......................................................................................................................... Colour of bag for collection of placenta is ....................................... Incinerator ash should be collected in ............................... colour bag. Strength of chlorine solution for chemical disinfection should be ............................. per cent (availability of free chlorine) for routine disinfection.

Principles of Health Care Waste Management

2.7 LET US SUM UP

In this unit, you have learnt the importance of properly handling health care waste in health care institutions to ensure that it does not result in transferring infections and other hazards to waste handlers in health institutions. You have also learnt that there cannot be any generalized action plan for all types of waste generated. Each category of waste requires specific treatment to ensure minimization of occupational risk exposure to biomedical waste in health institutions. In this regard, introduction of waste audit is essential. To ensure safety of workers, proper waste management plan, teaching and training of workers and a proper work environment with provision of essential personal protective devices are essential. Accordingly, individual hospitals should formulate their waste management plan and communicate the same to each functionary.

2.8 KEY WORDS

Accident Acquired Immunodeficiency Syndrome (AIDS) Case Act : An unanticipated event, commonly leading to injury. : A complex sum of symptoms and signs originated due to the infection of HIV. : A statute or law adopted (enacted) by a national or state legislative or other governing body. Acts are distinguished from resolutions, which are usually used to express legislative opinion or to regulate affairs of the governing body itself and from ordinance or by laws of municipal corporation and rules and regulations of administration. : A place where animals are reared/kept for experiments or testing purposes. : Refers to disinfectants, which are applied to the skin or to living tissues. : The process of destruction of micro-organisms by steam under pressure. : Any facility wherein treatment, disposal of bio-medical waste or processes incidental to such treatment or disposal is carried out. : Blood Pressure. : An agent that can cause cancer.

Animal House Antiseptic Autoclaving Bio-medical Waste Treatment Facility BP Carcinogen

Chemical Disinfection : A process that eliminates virtually all recognized pathogenic organisms but not necessarily all microbial forms (e.g. bacterial endospores) on inanimate objects. Disinfectant : A chemical or physical agent that can destroy vegetative micro-organisms and viruses.
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Health Care Waste: Definitions

Disinfection

: A process used to reduce the number of viable microorganisms on a surface or in a load, but which may not necessarily inactivate some microbial contamination, as by sterilization. : Any phenomenon that has the potential to cause disruption or damage to people and their environment, a threat to people and what they value, a threat to life, well being, material goods, and environment from the extremes of natural processes and technology, potential for an agent or process to do harm. : Means hospital, nursing home, polyclinic, dispensary, health centre, research or diagnostic laboratory where human blood or body organs or products are used. : A serious liver disease caused by a virus called Hepatitis B virus (HBV). This may lead to scarring (cirrhosis) of the liver, liver cancer, chronic hepatitis, liver failure and even death. : The controlled burning of solid, liquid or gaseous combustible wastes to produce gases and residues containing little or no combustible material. Incineration is the high temperature combustion under controlled conditions. : Bodily lesion at the organic level resulting from acute exposure to energy (mechanical, thermal, electrical, chemical or radiant) interacting with the body in amounts or rates that exceed the threshold of physiological tolerance. : Heats the material inside out, thereby ensuring rapid uniform heating leading to high level of disinfection and is considered as a safe method for the disposal of hazardous medical waste. Short wavelength radio frequency energy is having more penetration depth. : Consists of, but is not limited to, gloves, face shields, masks, and eye protection, gowns, aprons and similar items. : Often referred to as the opposite of risk, it is practically certain that adverse effects will occur on use of a substance either in excess or less as proposed; it is the freedom from danger and risks. : Pipe or conduit through which sewage is carried. : A validated process used to render a product free from viable micro-organisms. It achieves the complete killing or removing of all types of micro-organisms, including the spores of tetani and gas gangrene bacilli which are resistance to most disinfectants and more resistant to heat than non-sporing micro-organism.

Hazard

Health Care Institution Hepatitis B

Incineration

Injury

Microwave

Personal Protective Equipment Safety

Sewer Sterilization

Universal Precautions : An infection control system which assumes that any direct contact with a patient, particularly their body fluids, has the potential for transmitting disease. Waste Treatment : Any method, technique or process designed to change the character or composition of any waste so as to either neutralize such waste or to render such waste non-infectious or nonhazardous. There are five broad categories of medical waste treatment technologies: (1) Mechanical, (2) Thermal, (3) Chemical, (4) Irradiation, and (5) Biological.

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2.9 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1 a) b) False Waste segregation Waste collection/storage Waste transport Waste disposal. Check Your Progress 2 a) b) c) d) e) f) g) False False True True True False True

Principles of Health Care Waste Management

Check Your Progress 3 a) b) c) d) Mercury and Cadmium yellow. black 0.5

2.10 FURTHER READINGS

Manual for Control of Hospital Infections Standard Operative Procedures, NACO, Ministry of Health and Family Welfare, Govt. of India, New Delhi, 1999. Newsletter of Hospital Infection Society India, Vol. 2, No. 2, Delhi, October 2003. Pruss, A., Giroult, E., Rushbrook P. (eds.), Safe Management of Waste from Health Care Activities, WHO, Geneva, 1999. Sristhi, Managing Health Care Waste A Guide for Health Care Facilities, September, 2000. WHO, Assessment of the Health Risks of Dioxins: Re-evaluation of the Tolerable Daily Intake (TDI). Executive Summary of the WHO Consultation, May 25-29, 1998, Geneva, Switzerland. WHO Guidelines for Safe Disposal of Unwanted Pharmaceuticals in and after Emergencies, WHO, Geneva, 1999. WHO Management of Solid Health Care Waste at Primary Health Care Centres: A Decision-making Guide, WHO, Geneva, 2005.

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