MEDICAL WASTE MANAGEMENT

Health Facilities in Bangladesh

At Union Level -Union Sub centre (USC)-1362 -Health and Family Welfare Centre (HFWC)- 3053 At Upazila Level Upazila Health Complex-460 At District Level - District Hospital-59 At National Level - Government Medical Colleges- 15 - Postgraduate/specialized hospitals-7 Beside these there are about 33 private medical and dental colleges and 1213 registered clinics in and outside Dhaka. The number of diagnostic centers is 1,541 of which 580 are in Dhaka city. The total number of hospital beds is 51, 684 in 2005.

Medical Waste has been defined as all the Solid, Liquid, Gaseous, high pressurized and scrap of Radioactive waste, effluent, by-product, organism or surplus materials which directly or by broken or by worn out or by contaminated or by damaging develop adverse or negative change/effect or risk to human or environment.

Between 75% and 90% of the waste produced by health-care providers is non-risk or general health-care waste, comparable to domestic waste. It comes mostly from the administrative and housekeeping functions of health-care establishments and may also include waste generated during maintenance of health-care premises. The remaining 10-25% of healthcare waste is regarded as hazardous and may create a variety of health risks.

Major sources of health-care waste

Hospitals University hospital General hospital District hospital Other health-care establishments Emergency medical care services Health-care centres and dispensaries Obstetric and maternity clinics Outpatient clinics Dialysis centres First-aid posts and sick bays Long-term health-care establishments and hospices Transfusion centres Military medical services Related laboratories and research centres Medical and biomedical laboratories Biotechnology laboratories and institutions Medical research centres Mortuary and autopsy centres Animal research and testing Blood banks and blood collection services Nursing homes for the elderly

Hazards of Medical Waste

A small amount of hazardous waste may infected the large amount of general waste Organic portion ferments and attracts fly breeding Injuries from sharps to all categories of health care personnel and waste handlers Increase risk of infections to medical, nursing and other hospital staff Injuries from sharps to health workers and waste handlers Poor infection control can lead to nosocomial infections in patients particularly HIV, Hepatitis B & C Increase in risk associated with hazardous chemicals and drugs being handled by persons handling waste Poor waste management encourages unscrupulous persons to recycle disposables and disposed drugs for repacking and reselling Development of resistant strains of microorganisms

Disadvantages of Poor Health Care Waste Management

RISKS TO HEALTH CARE WORKERS AND WASTE HANDLERS

Poor management of health-care waste can cause serious disease to health-care personnel, to waste workers, patients and to the general public. The greatest risk posed by infectious waste are accidental needle stick injuries, which can cause hepatitis B and hepatitis C and HIV infection. There are however numerous other diseases which could be transmitted by contact with infectious healthcare wastes. During the handling of wastes, injuries occur when syringe-needles or other sharps have not been collected in rigid puncture proof containers. Inappropriate design and/or overflow of existing sharps container and moreover unprotected pits increase risk exposure of the health care workers, of waste handlers and of the community at large, to needle stick injuries.

RISK TO THE GENERAL PUBLIC The reuse of infectious syringes represents a major threat to public health. WHO estimated that, in 2000, worldwide, injections undertaken with contaminated syringes caused about 23 million infections of Hepatitis B and Hepatitis C and HIV. Such situations are very likely to happen when health-care waste is dumped on uncontrolled sites where it can be easily accessed by the public: Children are particularly at risk to come in contact with infectious wastes. The contact with toxic chemicals, such as disinfectants may cause accidents when they are accessible to the public. In 2002, the results of a WHO assessment conducted in 22 developing countries showed that the proportion of health care facilities that do not use proper waste disposal methods range from 18% to 64% .

Persons at risk of the hazards of medical waste

Depending on the type of procedures, the persons at risk and mode of transmission in some common medical procedures are: Patient Health worker, Laboratory personnel, Supporting staff, Transport worker

Classification of Medical Waste in Bangladesh

General Waste

Pieces of paper Boxes Container Cork Food wastes; Fish, Meat, Vegetables, fruit coverings Egg shell, coconut shell Non-infectious dressing gauze, plaster

Infectious Waste

Infected clothing, bandage, sponge/swab, plaster, syringe Coagulated Blood/ Plasma Used sanitary pad Dialysis related waste Ryles tube, Gloves, Masks, Airway Tube, Endotracheal Tube, Catheter, Drainage Tube/bag, Blood Transfuse tube /bag, Culture Media (Autoclaved just immidiate to use) Blood collection Syringe Amputed parts of the body/ tumour, tissues, placenta, etc.

Sharp Wastes All types of needles; hypodermic needles, Infusion sets, saws, scalpels; knives; blades; broken glass, and nails

Recyclable Waste Uninfected plastic materials Papers Cardboard Metallic containers Saline set Mineral water bottle

Radioactive waste Radioactive waste includes solid, liquid, and gaseous materials contaminated with radionuclide. Unused X-Machine Head

Liquid Waste Used Water Vomit, Cough Suction fluid Pus, Serum, coagulated Blood Amniotic fluid Liquid chemical Unused medicine Drainage pipe waste water

Uniform Colour Code

Government initiative to standardize colour coding of hospital wastes for in-house management. Black for general waste Yellow for infectious waste Red for sharp waste Green for recyclable waste Silver for radioactive waste Blue for liquid waste

Medical waste Management

Proper internal management Safe waste transportation Final Disposal management

Proper internal management

Segregation: Separating different types of waste at the point of

generation and keeping them isolated from each other. By doing this, appropriate resource recovery and recycling techniques can be applied to each separate waste stream. The amounts of infectious waste, hazardous waste and low-level radioactive waste that must be treated according to special (and usually costly) requirements are minimized. If not segregated, all hospital waste must be treated as potentially bio-infectious Source Reduction: Minimizing or eliminating the generation of waste at the source itself through techniques such as product substitution, technology change and good operating practices. Resource Recovery and Recycling: Recovery and reuse of materials from the waste stream. The majority of waste from health care facilities is surprisingly similar to that of an office building or hotel -- paper, cardboard and food waste. Hospitals can implement fairly simple programs that divert these materials from the solid waste stream, lowering disposal costs Internal transportation: Internal transportation: Transportation of wastes from its source of generation to central collection/storage section. Central waste disposal: Methods and equipments used to dispose the waste.

Colour Code Black

Types of Waste General Waste

Characteristics of Waste Non-hazardous, noncontaminated, Anatomical, Pathological, infectious, contaminated Contaminated and noncontaminated, Infectious, noninfectious Hazardous, Non-hazardous, Infectious, Non-infectious, Contaminated, Noncontaminated Radioactive

Container Nonpunctured Plastic Bin Nonpunctured Plastic Bin Nonpunctured Plastic Bin, Box Nonpunctured Plastic Bin, Bowl Nonpunctured Lidded Box Nonpunctured Plastic Bin

Yellow

Infectious waste

Red

Sharp Waste

Blue

Liquid Waste

Silver

Radioactive

Green

Recyclable Waste

Non-hazardous, Noninfectious, Non-contaminated

Final Disposal Management

Incineration Autoclaving Deep burial Recycling

Wastes requiring incineration

Anatomical parts and animal carcasses, and Cytotoxic drugs (outdated), toxic laboratory chemicals other than mercury. Patient contaminated non-plastics and non-chlorinated plastics. Waste that cannot be incinerated Chlorinated plastics, volatile toxic wastes such as mercury.

Shredding machine

Hospital Waste Generation

Generation of hospital waste in Bangladesh is 0.78 kg/bed/day. Non-hazardous waste is 0.64 kg/bed/day (82.05%) Infectious waste is 0.11 kg/bed/day (14.10%) Sharp waste is 0.03kg/bed/day (3.85%) World Bank estimates, 36,000 tons of healthcare waste is generated every year in Bangladesh. Out of this amount approximately 7,200 tons may be considered hazardous.

Evidently, Generation of hazardous waste in Specialized Hospitals is more than secondary and tertiary level hospitals

Legal provisions

The Ministry of Health and Family Welfare of Bangladesh formulated the Medical Waste Management Regulations, which is now in the final stage, under The Bangladesh Environment Conservation Act, 1995. In this proposed rule, the responsibilities of medical waste generator has been documented with direction of Internal management (segregation, color coding, packaging, transportation and storage), External transportation, and category wised treatment and disposal methods. In the proposed rule there is also provision of penalty for contravention of rules such as unsafe practices, such as disposing of hazardous health-care waste in municipal areas

Important schedules as enclosed with the proposed rule are as follows; Schedule-1.A: Category wise properties of medical waste (category, type, examples, and treatment and disposal methods). Schedule-1.B: List of health care waste generator (Large and small producers of health-care waste) Schedule-2: Specification of container and color code for storage and transportation of individual types of medical waste Schedule-5 : Standard of treatment and disposal of medical waste

RECENT TRENDS and CURRENT CONDITIONS

Hospital waste management in Bangladesh is still not satisfactory. Earlier no provision of proper segregation and collection system in the health care facilities. The waste generated inside the hospitals were collected by untrained, unprotected and unaware cleaners without necessary protective equipment. The wastes were dumped either into the dustbin or in outside hospital premises or dumped on the ground within the hospital premises. Only few facilities have incinerator, but not properly working or used. Lack of awareness. Absence of training facilities for the concerned staff. Shortage of supply of equipment and materials required for the disposal of hospital wastes. Hospital waste recycling trade is very small and in a very confidential way mainly from primary collection site.

RECENT TRENDS and CURRENT CONDITIONS

In 2003, under HNSPS, DGHS started to implement one Operational Plan (OP) for hospital waste management in 20 upazilas and now extended to 133. A financially viable program for elimination of environmental and health hazards

Component of the program

Training Waste Segregation at source in colour bin Waste Collection by trolley, provision of Personal Protective Devices for handlers. Waste Storage in a separate room out side of hospital building Disposal General wastes over to the municipal waste collectors or bins. The infectious and sharp materials are to be kept in double chambered concrete pit constructed in the hospital premises for dumping .

Medical Waste Management for Private and NGO Facilities

Recently some organizations are operating hospital waste management pilot projects under public-private partnership arrangement Dhaka, Khulna, Rajshahi City Corporations, Bogra and Gazipur Pourashava Only the private and NGO health Care Facilities are participating with support of Local Government Institute

Case Study- Khulna

Khulna city, however, is now an exception. It remains the only city in the country with a hospital waste management program (HWMP) running since 2000 under a public-private partnership arrangement. At present the number of participating facilities under this project is 42 including the Khulna Sadar Hospital A number of dialogues, workshops, seminars and roundtable discussions with the Bangladesh Medical Association (BMA), the clinic owners association and some progressive doctors of Khulna were held to build consensus. Finally all concerned parties agreed to participate in the program. The participating hospitals and clinics agreed to pay a service charge between Tk. 100 and Tk. 600 (US$ 1.5 to 9) depending on the volume of waste generated

Three Pillars

The Program has been delivering quality service. Awareness among healthcare institutions has been raised through meetings and dialogues. There have also been public awareness campaigns, which in turns put pressure on the healthcare institutions to demonstrate their social responsibility in managing their waste properly. The Khulna City Corporation has issued letters to the citys healthcare facilities to encourage them to join this program and reduce public health hazards. KCC has also leased a piece of land measuring about 2,000 sq ft (185 sq. m) in the citys dumpsite area for the final disposal of hospital waste.

Component

Training The first step was to train doctors, nurses, ayas (female aides) and cleaners about segregating and safely storing various kinds of waste i. Segregation and storage The producers categorize the wastes by sorting and keep them in to color coded plastic bags or containers. Needles and sharps: A fresh plastic bottle is used for storage . Syringe, saline bag and other plastics: In a covered plastic bin. Gauze, bandages, human organs, paper materials and others: In separate covered plastic bin. Kitchen waste: Kept outside in a plastic covered bin. Collection and transportation Collection staff collects the waste everyday from each participating clinic, load it into a specially designed 1.5 ton capacity truck . waste collectors wear protective clothing including face masks, aprons, boot and globes through out the time of handling waste. Final Disposal All sharps (e.g. needles, blades) and plastics are placed in a container dipped in the disinfectant solution and then kept in a concrete pit with a lockable lid. All bandages, gauze, cotton, body parts, and paper are burned in locally-made/ imported incinerator and incinerated right on the day.
Non-hazardous kitchen waste is disposed of in the municipal dumpsite.

Recent developments in waste handling equipments

Compactors

Shredding machine:

waste is crushed by rotating anvils, and then forced through perforations of about diameter in a stationery plate

Slurry waste system:

volume of waste

slurry or pulping system reduce the

Pneumatic system:

used for transporting soiled linens reduce the waste to a solid brick

Hammermill System:

Compactors

Reducer

KEY ISSUES FOR CONSIDERATION

Development of public-private partnership in managing the hospital wastes Financing system Proposed regulation Best Management Practices (including technology selection). Institutional structure and capacity building.