Indian Waste ManagementIssues & Status Update

Dr. B.J. Sonowal

Technical Advisor, BD India Pvt. Ltd

Infection Control Workshop for District and area Hospitals

November 29, 2010

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Contents

International Norms

International Practices

Indian Practices

Highlighting the Indian Issues

Probable Solutions

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International Norms & Practices

Indian Practices

Highlighting the Indian Issues

Probable Solutions

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Analyze NSI in your workplace

Set priorities and strategies for NSI (data)

Ensure HCW are trained on NSI

Modify work practice that pose NSI hazard

Promote Safety awareness in workplace

Establish procedures for reporting & follow up PEP

Evaluate effectiveness of prevention efforts

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Worldwide Needlestick and Sharp

Object Injury estimates

USA - CDC estimates 385,000 needlesticks and other sharps related injuries each year (hospital based HCWs only)1

Canada – More than 69,000 sharps injuries to HCWs every year

UK - An estimated 100,000 HCWs suffer needlestick injuries each year

Australia – An estimated 13,000 sharps injuries to HCWs every year2

1. Estimates derived by combining data from the EPINet and NaSH networks

2. Report on the Inquiry into Nursing - The patient profession: Time for action. June 2002

http://www.aph.gov.au/senate/committee/clac_ctte/completed_inquiries/2002-04/nursing/report/ (Accessed 25 February 2008)

What is the true magnitude

of the NSI problem??

HCW surveys indicate 40% or more

underreporting rates of needlestick and

other sharp object injuries

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Estimated Costs for Sharps Injuries

Management of occupational exposure to blood and body fluids is costly; the best way to avoid these costs is by prevention of exposures1

“Cost” of needlestick injury not well documented

Direct costs: lab testing (source pt, HCW), counseling time, testing downtime, cost of PEP medication, Downtime from side-effects, administrative work & follow up, workers compensation, device acquisition etc

Indirect costs: emotional impact to HCW & family, psychological impact to HCW, damage to reputation of Institution etc

Unknown: Litigation, HCW as a source of transmission

1. O’Malley, Scott et al, Costs of Management of Occupational Exposures to Blood and Body Fluids, Infection Control and Hospital Epidemiology 28 (7): 774-782, 2007

2. Assume 80% uncomplicated low risk injury, 40% under reporting rate. Cost study commissioned by BD, 2006 Unpublished. ©

Estimated NSI cost in

Australia ~$31 mm2Uncomplicated low risk NSI ~ $500.00

Complicated high risk NSI ~ $6500.00

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“As many as 1/3 of all sharp injuries” are disposal related.”

NIOSH Guidelines for Sharps

Developed Countries -

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Developing Countries - Kenya

Safety Boxes to be introduced

District health facilities should be equipped with low-cost medical waste incinerator

Preferably syringes and needles should be incinerated at the health facility level

An alternative temporary solution would be open burning in a specified protected pit at the health facility level

Where not existing, appropriate pit should be dug and fenced to be used for both burning and burying

Specific guidelines will be issued for safe disposal of injection equipment

A plan will be drawn for the transportation of all filled safety boxes to the incinerators

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• Manifest

• Other documentation

Transport

Vehicle

Transfer

in transfer

containers

China Waste Management Process Flow

Transport by

recommended

routes

Central Treatment Facility

Temp

Storage

Area

Incineration

Steam

treatment

General

landfill

Hazardous

landfill

Transfer

Institution

Waste

Temp Storage

Area

• Packing bags

• Transfer containers

Medical InstitutionClincians at bedside

Kidney dish

Disposal Room

MW Collection Team

push to

Temporary Storage Area(in basement or another building)

On-site incineration

Segregation

General Waste

(Black Bags)

General MW

(Yellow Bags)

Sharps MW

(Sharps Collectors)

by hand

MW Elevator(in covered trolleys)

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International Norms & Practices

Indian Practices

Highlighting the Indian Issues

Probable Solutions

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Waste Generation

Segregation

BMW – Current Scenario on sharps Management

Collection / Storage

Transport

Treatment

Disposal

Immunization Out Reach

GP / RMP

Waste generated Waste generated

Reusable hub cutters cut needles

Hub cutters brought back from outreach to

PHC

1% Sodium Hypochlorite every 3-4

hours

Safety pit constructed in PHC – needles

thrown into it

Collected in plastic containers

With Kitchen waste

Reusable hub cutters cut needles

Autoclave

CBMWM

Plastics recycled, metal into landfill

Collected in plastic containers

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Waste Generation

Segregation

BMW – Current Scenario on sharps Management - Hospitals

Collection / Storage

Transport

Treatment

Disposal

Hospitals with CBMWM

Hospitals without CBMWM

Waste generated Waste generated

Reusable hub cutters cut needles

Needle Burnt in needle burner

1% Sodium Hypochlorite every 3-4

hours

Safety pit constructed in hospital – needles

thrown into it

Stubs collected in plastic containers

Needle / syringe collected in Sharps

container

Autoclave

CBMWM

Plastics recycled, metal into landfill

48 hr norm

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Twin Buckets

Outer Bucket with 1% Sodium Hypochlorite solution

Inner Perforated Bucket

Variants of Hub Cutters

available in Indian

Immunization settings and

market

A safety Pit

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Syringes in plastic bags

A needle burner

Disposal according to color coding

Needles in needle burner

A sharps container

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Current Scenario – IDU Program

Issues at each step

Out Reach Workers

Collect used needles and syringes from out reach

sites

IDU Centers

All such used needles and syringes are

brought to these places

Final Disposal

Needle burning by the worker at the IDU

center

•Worker recaps the used needles

•Collects the used needles from sites by hand

•Extremely risky in terms of HIV / HBV and HCV

•Worker brings used needles and syringes in a plastic bag (tearing likely, may drop)

•Makes community vulnerable to getting a NSI

•Worker needs to reopen the capped needles

•Burning needles requires safety precautions to be taken

•Burning leaves a stub (1/3 of needle)

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International Norms & Practices

Indian Practices

Highlighting the Indian Issues

Probable Solutions

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SummaryMOH MOEF PCB

Regulations

Common Biomedical

Waste Treatment Facilities

Overly dependent on

PCB for execution

Ambiguous requirements on device mutilation & color codes

• BMW Mgmt is not a priority

• Budget & manpower shortage

• Overly dependent on CWTFs

• Poor enforcement – no bite

• Poor awareness of clinical issues

• Operational challenges – improper

segregation, manpower skills &

attrition, logistics issues, cost pressure

• Limited technologies used –

manpower & cost

• Recycling is a revenue source –

sharps containers do not facilitate

recycling of plastics & must be

disposed of in secure landfills

TT

Hospitals

MT Hospitals

GPs / RMPs

• Segregation – inconvenient

• Awareness & training

• Safety – NSI, exposure

• Confusion over regulations

• Cost

Most are not covered by CWTFs,

BMW disposal municipal waste

Manpower attrition leads to

competency shortcomings

Cannot implement best practices due

to inconsistent PCB enforcement

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Medical Waste Management in

India

1. Report of the Committee to Evolve Road Map on Management of Wastes in India: Final/ 9th March 2010

2. Market News July 4th 2007, Klean Industries, Vancouver, Canada

3. “Economic Issues Involved in Biomedical Waste Management & Role of Outsourcing” , Maridi Eco Industries Pvt Ltd presentation (2009)

4. Safe A Report on Alternative Treatment and Non-Burn Disposal Practices Management of Bio-medical Sharps Waste in India. WHO 2005.

5. A. D. Patil and A. V. Shekdar. Journal of Environmental Management (2001). Health-care waste management in India. 63, 211–220.

0.4 - 5.5% waste

is classified as sharps

(includes glass waste) 4,5

Total Tonnage

Between 185,000 tonnes1(2010) to

3 million tonnes per year (2007)2

Projected to grow 8% annually 2 or

20% from 2008-2013 3

~57% waste generated is being

treated either through 159

Common Bio-medical Waste

Treatment Facilities (CWTFs),

or captive treatment facilities 1

Facilities in India

602 Bio-medical Waste Incinerators

About 70% are provided with air pollution control

devices 1

• 2218 autoclaves

• 192 microwaves

• 151 hydroclaves

• 8,038 shredders 1

Revenue from BMW is 8% of

total waste management

revenue (2008) 3

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The Waste Management plan Setting up a team

Create Awareness/Sensitization

Conducting a waste audit - Identify quantum of waste

category wise

Decision on end treatment options

Drawing up a facility wise detail plan

Allocating resources

Training of Trainers

Extend the program to all staff from CEO to sanitary

attendants

Monitor - Implementation of plan

Record / Report

Monitoring, Review & Refresher training

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The Team

A responsible person designated as „Waste

Manager‟ .

Housekeeping manager / Attendant In Charge

(Mukadam).

Nursing Director/Superintendent.

Infection Control Nurse, Key members from the

Infection Control Team.

A representative from the management.

A representative from the Doctors / Consultants.

Sister In Charges.

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Environmental Hazard :

Hospital waste contains a higher amount of

chlorinated plastics.

Dumped in dumping grounds where rag pickers burn

it leading to high levels of pollution

Burning chlorinated plastics under incomplete

combustion releases many harmful pollutants key

among them being Dioxins & Furans

Awareness

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Awareness

Dioxin : A Unique Killer

•Two aspects of Dioxin toxicity from the public health

perspective:

- wide variety of harmful health effects

- low levels of exposure - EPA’s acceptable

daily exposure 0.01 picograms/kg/day.

•Gets transferred through the food chain causing various

health effects

Humans routinely consume 300 to 600 times this amounts

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Based on the facility plan, areas for sample audit

are selected for hospitals > 100 beds, for smaller

hospitals all areas are covered

Is conducted in 2 phases

Before starting the training program

After waste management planning & training

The waste management team is trained to instruct,

segregate & quantify waste as is the current

hospital practice

Time frame one to two weeks based on the hospital

size

Conducting a waste audit

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Implementing Waste Plan

Allocating color coded bags and bins in accordance with

facility plan ensuring segregation as per the rules

TOT – explaining the plan, to also include worker safety

measures

Scheduling the collection timings within the hospital

Transportation system within hospital

Developing Storage facilities in-house

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Institute a sharps management plan

Available option:

Needle burners (are a better option)

Needle cutters after which you disinfect & discard

Disinfect in puncture proof jerry cans with disinfecting solution (like 1% Na Hypochorite) if tranporter takes authorisation from PCB for responsibility of pilferage, the better option is still to mutilate and disinfect before discard.

Sharps Management Plan

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Points to be remembered:

The containers to be puncture proof and bags to be sturdy, leak proof for high risk waste

The bags to be tied by the neck while transportation

Transportation trolleys and specific lifts or timings to be designated

Staff handling this to wear protective clothing, gloves, mask, aprons etc.

If bags tear or get contaminated they be placed in a new clean bags ( double bagging )

Never allow any person to put hands inside the bag

Stringent Infection Control Policies to be formed & implemented

Transportation:

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Evaluation Training Tools:

Conducting pre and post training tests

Monitoring of model sessions by Trainers

Post training exams conducted for trained staff by

trainers

Monitor & Review Training