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REVIEW ARTICLE
Biomedical waste management
Veda Hegde
1
, Kulkarni RD
2
, Ajantha GS
3
1
Assistant Professor, Department of Oral Pathology, SDM College of Dental Sciences, Dharwad,
2
Professor and Head,
3
Assistant Professor,
2,3
Department of Microbiology, SDM College of Medical Sciences, Dharwad, India
ABSTRACT
Proper handling, treatment and disposal of biomedical wastes are important
elements of health care ofce infection control programme. Correct procedure
will help protect health care workers, patients and the local community. If
properly designed and applied, waste management can be a relatively effective
and an efcient compliance-related practice. This review article discusses about
the various types of waste, its management and the hazards of indiscriminate
disposal of hospital waste and in brief about dental waste management.
Key words: Biomedical waste, dental waste, hospital waste, waste
management
INTRODUCTION
Until fairly recently, medical waste management was not
generally considered an issue. In the 1980s and 1990s, concerns
about exposure to human immunodeciency virus (HIV) and
hepatitis B virus (HBV) led to questions about potential risks
inherent in medical waste. Thus hospital waste generation
has become a prime concern due to its multidimensional
ramications as a risk factor to the health of patients, hospital
staff and extending beyond the boundaries of the medical
establishment to the general population.
[1,2]
Hospital waste refers to all waste, biologic or non biologic that
is discarded and not intended for further use. Medical waste is
a subset of hospital waste; it refers to the material generated as
a result of diagnosis, treatment or immunization of patients and
associated biomedical research.
[3]
Biomedical waste (BMW)
is generated in hospitals, research institutions, health care
teaching institutes, clinics, laboratories, blood banks, animal
houses and veterinary institutes.
[4]
Although very little disease transmission from medical waste
has been documented, both the American Dental Association
(ADA) and Center for Disease Control recommend that
medical waste disposal must be carried out in accordance
with regulation.
[5]
Hospital waste management has been brought into focus
in India recently, particularly with the notication of the
BMW (Management and Handling) Rules, 1998. The rule
makes it mandatory for the health care establishments to
segregate, disinfect and dispose their waste in an eco-friendly
manner.
[4]
POTENTIAL IMPLICATIONS OF BIOMEDICAL
WASTE
[1,6]
Risk to healthcare workers and waste handlers
Improperly contained contaminated sharps pose greatest
infectious risk associated with hospital waste. There is also
theoretical health risk to medical waste handlers from pathogens
that may be aerosolized during the compacting, grinding or
shredding process that is associated with certain medical waste
management or treatment practices. Physical (injury) and health
hazards are also associated with the high operating temperatures
of incinerators and steam sterilizers and with toxic gases vented
into the atmosphere after waste treatment.
Risk to the public
Public impacts are conned to esthetic degradation of the
environment from careless disposal and the environmental
impact of improperly operated incinerators or other medical
waste treatment equipment.
There may be increased risk of nosocomial infections in
patients due to poor waste management. Improper waste
management can lead to change in microbial ecology and
spread of antibiotic resistance.
CLASSIFICATION
[7,8]
[Figure 1]
Non-hazardous waste
This constitutes about 85% of the waste generated in most
healthcare set-ups. This includes waste comprising of food
remnants, fruit peels, wash water, paper cartons, packaging
material etc.
[8]
Correspondence: Dr. Veda Hegde,
Assistant Professor,
Department of Oral Pathology,
SDM College of Dental Sciences,
Sattur, Dharwad - 580 009, India.
E-mail: hegdeveda6@rediffmail.com
J ournal of Oral and Maxillo Facial Pathology Vol. 11 Issue 1 J an - J un 2007
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Hazardous waste
A) Potentially infectious waste
Over the years different terms for infectious waste have been
used in the scientic literature, in regulation and in the guidance
manuals and standards. These include infectious, infective,
medical, biomedical, hazardous, red bag, contaminated,
medical infectious, regulated and regulated medical waste.
All these terms indicate basically the same type of waste,
although the terms used in regulations are usually dened
more specically.
[9]
It constitutes 10% of the total waste which
includes:
1. Dressings and swabs contaminated with blood, pus and
body uids.
2. Laboratory waste including laboratory culture stocks of
infectious agents
3. Potentially infected material: Excised tumours and organs,
placenta removed during surgery, extracted teeth etc.
4. Potentially infected animals used in diagnostic and research
studies.
5. Sharps, which include needle, syringes, blades etc.
6. Blood and blood products.
[8]
B) Potentially toxic waste
1. Radioactive waste: It includes waste contaminated
with radionuclide; it may be solid, liquid or gaseous
waste. These are generated from in vitro analysis of
body uids and tissue, in vitro imaging and therapeutic
procedures.
[6]
2. Chemical waste: It includes disinfectants (hypochlorite,
gluteraldehyde, iodophors, phenolic derivatives and
alcohol based preparations), X-ray processing solutions,
monomers and associated reagents, base metal debris
(dental amalgam in extracted teeth).
3. Pharmaceutical waste: It includes anesthetics, sedatives,
antibiotics, analgesics etc.
[10]
STEPS IN WASTE MANAGEMENT
[1,7,8,11,12]
Medical waste should be managed according to its type and
characteristics. For waste management to be effective, the
waste should be managed at every step, from acquisition to
disposal. The following are the elements of a comprehensive
waste management system: waste survey, segregation,
accumulation and storage, transportation, treatment, disposal
and also waste minimization.
Waste survey
The survey should differentiate and quantify the waste
generated. It should determine the points of generation, the
type of waste at each point and the level of generation and
disinfection within the hospital. This helps to determine the
method of disposal.
Waste segregation
This consists of placing different kinds of wastes in different
containers or coded bags at the point of generation [Table
1]. It helps to reduce the bulk of infectious waste as well as
treatment costs. Segregation also helps to contain the spread
of infection and reduces the chances of infecting other health
care workers.
Waste accumulation and storage
Waste accumulation and storage occurs between the point of
waste generation and site of waste treatment and disposal.
While accumulation refers to the temporary holding of small
quantities of waste near the point of generation, storage of
waste is characterized by longer holding periods and large
waste quantity. Storage areas are usually located near where
the waste is treated. Any offsite holding of waste is also
considered storage.
To contain spills, storage areas should not have oor drains
and should be recessed to hold liquids. Floor and walls should
be impervious to liquid and easy to clean. They should be
disinfected regularly. Refrigeration may be required for
prolonged storage of putriable and other wastes. Storage area
should be posted with EXPLICIT signs.
Table 1: Categorisation and color coding of the
container
[12]
Substance / Category Color
waste material coded bags
Human tissues organs, 1 Red
animal waste, blood
and body uids
Animal and slaughter 2 Orange
house waste
Microbiological and 3 Yellow
biotechnological waste
Waste sharps 4 Blue
Discarded medicines 5 Blue
Solid wastes 6 Yellow/black
Disposables 7 Yellow/black
Chemical 9 Yellow/black
Biomedical waste management Hegde V et al.
Figure 1: Classication of biomedical waste
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Waste transportation
When medical waste is not treated on site, untreated waste
must be transported from the generation facility to another
site for treatment and disposal.
Waste treatment
The term treatment refers to the process that modies the
waste in some way before it is taken to its nal resting place.
Treatment is mainly required to disinfect or decontaminate
the waste, right at source so that it is no longer the source of
pathogenic organisms. After such treatment, the residue can
be handled safely, transported and stored.
Needles and syringe nozzle shredded in needle destroyer
and syringe cutters
Scalpel blades/ Lancet/ Broken glass should be put in
separate containers with bleach, transferred to plastic/
cardboard boxes; sealed to prevent spillage and transported
to incubators
Glassware should be disinfected, cleaned and sterilized
Culture plates with viable culture should be autoclaved;
media are placed in appropriate bags and disposed off. The
plates can be reused after sterilization
Gloves should be shredded / cut / mutilated before
disposal.
Swabs should be chemically disinfected followed by
incineration. If they contain only a small amount of blood
that does not drip, they can be placed in the garbage.
Disposable items are often recycled and have the risk
of being used illegally. Dipping in freshly prepared 1%
sodium hypochlorite for 30 min. one hour, followed by
mutilation before disposal should be the policy adopted
for such items.
Under no circumstances, should heat be used for disposal
of amalgam. The heat will cause mercury to volatize and
be released to the environment. So teeth with amalgam
restoration should be treated by immersion in high-level
disinfectant (e.g. Gluteraldehyde) for 30 min. Treated teeth
can then be rinsed.
Liquid waste generated by the laboratory is either
pathological or chemical in nature. Non-infectious waste
should be neutralized with reagents.
Liquid infectious waste should be treated with a chemical
disinfectant for contamination and then neutralized.
Waste disposal
The waste disposal methods vary in their capabilities, cost,
availability to generation and impacts on the environment. The
various disposal methods include incineration, autoclaving,
chemical methods, thermal methods (low and high), ionizing
radiation process, deep burial and microwaving [Table 2].
Incineration and autoclaving are considered traditional
methods. Chitnis et al.
[20]
have devised a solar heating
system for disinfecting infectious waste in economically less
developed countries. They obtained a considerable reduction
in the amount of viable bacteria by this method. However,
considerable reduction in viable number of bacteria seems to
be misleading term. The medical waste should be completely
free of pathogenic bacteria before disposal. This would ensure
maximum public hygiene quality.
Untreated medical waste can be disposed off in sanitary
landlls. Disposal without treatment is not recommended for
human tissues, sharps and culture from clinical laboratories.
Waste minimization
Whereas ordinary solid or liquid waste requires no treatment
before disposal, practically all infectious waste must rst
be treated. The cost for disposal of infectious waste may
be ten times the cost for disposal of ordinary solid waste.
Any measures that decrease the amount of infectious waste
generated will simultaneously decrease the cost of infectious
waste disposal.
[9]
Cost of biomedical waste management
The cost of construction, operation and maintenance of
system for managing waste represents a signicant part of
overall budget of a hospital if the BMW handling rules have
to be implemented in their true spirit. Self-contained on-site
treatment methods may be desirable and feasible for large
healthcare facilities. They will not be practical or economical
for smaller institutes. An acceptable common system should
be in place which will provide regular supply of color coded
bags, daily collection of infectious waste, safe transportation
of waste to off site treatment facility and nal disposal with
suitable technology.
[2]
DENTAL WASTES OF ENVIRONMENTAL
CONCERN
Amalgam
Dental Amalgam particles are a source of mercury, which
is known to be neurotoxic and nephrotoxic. Fetuses and
Table 2: Disposal methods
[12]
Category of waste Disposal methods
Category 1 Incineration / deep burial
Category 2 Disinfection and deep burial
Category 3 Autoclaving/microwaving
Category 4 Shredding and deep burial
Category 5 Shredding and deep burial
Category 6 Disinfection and machine
cleaning
Category 7 Disinfection-chemical/
Autoclaving, shredding, burial
Biomedical waste management Hegde V et al.
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newborn babies are more sensitive to mercury than adults
and there seems to be a great difference in sensitivity among
individuals.
[13]

Management includes disposal of amalgam scrap as hazardous
waste or more aptly sent to a recycler.
[14-16]
Waste mercury is
disposed similarly. Empty amalgam capsules are to be disposed
off in the garbage.
[17]
Since amalgam decomposes on heating;
amalgam scrap should not be disposed in the waste that could
eventually be incinerated.
[18]
To minimize the amount of mercury vapour emitted from waste
amalgam, ADA recommends that it be stored under a small
amount of photographic xer in a closed container. It should
be labeled as scrap amalgam.
[17]
X-ray wastes
1. X-ray xer solution: It is considered a hazardous waste
because of its high silver content.
[16]
In the environment,
free ionic silver acts as an enzyme inhibitor by interfering
with the metabolic processes of organisms.
[14]
These have
to be disposed off as a hazardous waste or sent to a silver
recovery system.
[14,17]
2. X-ray developer solution: Developer solution can typically
go into the wastewater drain.
[5,8]
Developer and xer
solutions should not be mixed with xer solutions. If
mixed, they should be separated and treated independently
as required.
[14,17]
3. X-ray cleaner solution: Many cleaners for X-ray developer
system contain chromium. If the cleaner solution used
contains chromium, it should be disposed as a hazardous
waste or switch to a non-chrome cleaner.
[17]
4. X-ray lead foil / lead shields: The lead foils and lead
shields contain pure lead.
[15,18]
Lead is a heavy metal that
affects neurological development and functions and can
potentially leach from landlls into the environment. These
are hazardous waste unless they are recycled for their scrap
metal content or disposed off as hazardous waste.
[14,17]
PLASTIC IN HEALTH CARE
[19]
Disposable syringes, bottles, blood and uro bags, catheters,
surgical gloves, etc are some of the examples of plastic usage
in health care. Plastic has been associated with decline in
sperm count, genital abnormalities and a rise in the incidence
of breast cancer. Burning of plastics releases carcinogens
like dioxin and furan. Once hailed as a wonder material,
plastic is now a serious environmental and health concern,
essentially due to its non-biodegradable nature. The options
for plastic waste disposal are environmentally compatible long-
term land lling or recycling. All disposable plastic should
be subjected to shredding before disposing off to vendor.
Designing eco-friendly, biodegradable plastics are the need
of the hour. Minimizing the generation of plastic waste is also
very important.
CONCLUSION
Safe and effective management of waste is not only a legal
necessity but also a social responsibility. Lack of concern,
motivation, awareness and cost factor are some of the problems
faced in the proper hospital waste management. Proper surveys
of waste management procedures in dental practices are
needed. Clearly there is a need for education as to the hazards
associated with improper waste disposal. Lack of apathy to the
concept of waste management is a major stymie to the practice
of waste disposal. An effective communication strategy is
imperative keeping in view the low awareness level among
different category of staff in the health care establishments
regarding biomedical waste management.
Proper collection and segregation of biomedical waste are
important. At the same time, the quantity of waste generated
is equally important. A lesser amount of biomedical waste
means a lesser burden on waste disposal work, cost-saving
and a more efcient waste disposal system. Hence, health care
providers should always try to reduce the waste generation in
day-to-day work in the clinic or at the hospital.
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Biomedical waste management Hegde V et al.
Source of Support: Nil, Conict of Interest: None declared.
Three-labelled copies/3 labelled CD should be sent.
Dr. K. Ranganathan
October 10th
T Rajasekaran award for the best photography in Oral and Maxillofacial Pathology, instituted in 2006 by Dr. TR
Saraswathi, would be awarded to the best photograph by active members of the IAOMP
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