Health Hazards Due to Improper Management of Hospital Waste Dr. P. K. Dash, Nodal Officer, Municipal Corporation of

1. Health Hazards Due to Improper Management of Hospital Waste Dr. P. K. Dash, Nodal Officer, Municipal Corporation of Delhi

2. Introduction Every system in nature progresses towards disintegration and it contributes to creating waste. A modern hospital is a complex multidisciplinary system which consumes thousand of items for delivery of medical care and is part of physical environment. All products consumed in hospitals have some unusable left over i.e. Hospital Waste. This waste is great threat to ecological balance by polluting environment.

3. Definition Any unwanted residual material which cannot be discharged directly, or after suitable treatment can be discharged in the atmosphere or to a receiving water source, or used for landfill is waste. (Wilson, 1981) Infectious waste are all those substances which cannot be resterilised or reused within or brought into patient care (Rearly, 1972)

4. Definition No standard universally accepted definition for the terms HOSPITAL WASTE MEDICAL WASTE. REGULATED MEDICAL WASTE AND INFECTIOUS WASTE

5. Definition Hospital waste: refers to all waste, biological or non biological, that is discarded and is not intended for further use Medical waste: refers to materials generated as a result of patient diagnoses, treatment, immunisation of human beings or animals

6. Definition , Infectious waste: are the portion of medical waste that could transmit an ‘infectious disease’. Medical waste is a sub set of Hospital Waste and Regulated medical waste' which is synonymous with '"infectious waste' from a regulatory perspective is a sub set of medical waste.

7. Evolution of HW Globally Hospital Waste was brought into focus in 1983 when WHO European office convened a working group at Bergen. Medical specialists, hospital engineers, administrators from 19 countries participated & concluded that it required a system approach involving: - Awareness Segregation Source reduction of radio-active waste

8. Evolution of BMW (contd) WHO SEARO questionnaire survey in 1984 conducted largely due to disturbing media reports regarding plight of rag pickers- found inadequacies Beach washings in 1998 of the Florida coast, related to syringes, lead to passing of first healthcare legislation by any country- Medical Waste Tracking Act (MWTA)

9. MAGNITUDE OF THE PROBLEM GLOBALLY- Developed countries generate 1 to 5 kg/bed/day Developing countries: meager data, but figures are lower. 1-2kg/pt./day WHO Report: 85% non hazardous waste : 10% infective waste : 5% non-infectious but hazardous. (Chemical, pharmaceutical and radioactive) INDIA:-No national level study - local or regional level study shows hospitals generate roughly 1-2 kg/bed/day

10. Why hospital waste is hazardous? Infectious waste is capable of producing an ‘infectious disease’. Chances of this are higher with in hospitals than outside. This depends on factors like Dose, Host susceptibility, The presence of a pathogen, The Virulence of a pathogen and The portal of entry (most commonly absent factors)

11. Infectious waste is also generated Dental offices Nursing homes Laboratories Research centers The work environments similar to Hospital environment.

12. WHAT CAUSES HOSPITAL WASTE HAZARDOUS Chemical-medications, Solutions, or Bacteria's like TB, Hepatitis B and C, Gases;- ethylene oxide, formaldehyde, glutaryldehyde, waste anesthetic gases, nitrous oxide, Chemotherapeutic agents, Laser Smoke and Aerosolized medications such as Pentamedine

13. WHAT CAUSES HOSPITAL WASTE HAZARDOUS Physical Ionizing radiation, Lasers, Noise and Electricity

14. Health Hazards of Hospital Waste The hazards are: Fire Breeding of flies and insects Proliferation of rodents Air pollution Water pollution Land pollution Transmission of infections viz hepatitis B, HIV, other microbes Mechanical injury Re-circulation of waste Loss of aesthetics Nuclear waste hazards & carcinogenic effects

15. Improper management of hospital waste can cause serious environmental problems in terms of air, water and land pollution. CLASSIFICATION BY NATURE OF POLLUTANTS a) Biological b) Chemical and c) radio active

16. Categories of Hospital Waste

17. Routes of exposure Ingestion (Swallowed materials) Inhalation: airborne chemicals and pathogens, Dermal absorption-or through skin openings.

18. Routes of exposure depends on Durations of exposure: Dermal absorption-enhanced by Scratches, broken, roughened or abraded skin on surface of hands, ankles, neck or facial areas Dose of toxic components that enter the workers body from the waste: Retention capacity for airborne particulates that carry toxic chemicals and pathogens is highly dependent on particle size.

19. Other Routes of exposure Water soluble toxic chemicals can be absorbed throughout the body Drinking and eating in hospital: should be done in well controlled areas

20. Environmental problems arise from a) Generation of medical waste b) Process of handling, c) Treatment and d) Disposal

21. Effects of 'improper hospital waste management Mismanagement of Hospital Waste implies IMPROPER HANDLING, during generation Collection transportation and treatment

22. IMPROPER HOSPITAL WASTE MANAGEMENT ARE DUE TO: a) Improper handling; Unsafe actions: handling without personal protective equipment (PPE), b) Poor storage (e.g. high temperature conditions combined with prolonged storage time before treatment), c) Manual Transportation for longer distances. d) Use of uncovered containers instead of closed plastic bags e) Exposure times beyond acceptable limits and f) Lack of adequate worker and equipment decontamination process/procedures

23. EFFECTS OF 'IMPROPER HOSPITAL WASTE MANAGEMENT Hospital infections are a major health problem all over the world Can effect the people working or visiting the hospital The community is invariably effected

24. Transmission of Infectious Agents in Healthcare Settings Individuals are exposed to human sources of microorganisms by three primary routes: Contact transmission Direct – organism is transferred directly from one person to another, e.g. scabies or herpetic whitlow Indirect- organism is transferred through contaminated intermediate object or person, e.g. hands or contaminated patient care equipment Droplet Transmission- relatively large ( >5 microns) droplet heavy with moisture that are propelled relatively short distances from the source (3-6 feet) onto the mucous membranes of the nose, mouth or eyes, of the host and environmental surfaces Airborne Transmission- droplet nuclei (<5 microns) that remain suspended in the air for long periods, that may be inhaled by the host into the alveoli of lungs

25. Transmission Of Infectious Agents In All Settings Requires 3 Interrelated Elements THE TRIAD

26. Fundamental Elements to Prevent Transmission of Infectious Agents in Healthcare Settings Administrative measures Education of HC workers, patients and families Hand Hygiene Personal Protective Equipment Safe Work Practices Patient Placement Transport of Patients Environmental measures Patient Care Equipment Textiles and Laundry Dishware and eating utensils Adjunctive measures

27. Personal Protective Equipment When selecting PPE consider the highest level hazard present, the source of the hazard, and the potential for simultaneous exposures. Face protection Goggles or safety glasses with side shields Clothing Lab coats, scrub suits, gowns (long pants only, no open toed shoes) Clothing should be replaced immediately when contaminated Gloves Verify that gloves are compatible with your specific application, process and materials before using Gloves should be replaced immediately if torn Gloves should not be worn outside the lab area Always wear heat resistant gloves and keep your face away from the door when loading and unloading the autoclave Immediately dispose of gloves after contact with hazardous substances Immediately dispose of gloves after contact with hazardous substances

28. RECOMMENDATIONS To reduce the burden of disease, healthcare waste needs sound management, including alternatives to incineration. Management of Healthcare waste requires 'increased attention’ and Diligence. Incinerators provide an interim solution for developing countries where options of waste disposal such as Autoclaving, shredder, microwave or newer technologies like plasma incinerators are limited. Whatever the technology used, best practice must be promoted to ensure optimal operation of the system

29. Best practices include- Construction following detailed dimensional Plans to avoid flaws that can lead to incomplete destruction of waste, higher emissions and premature failure of incinerators. Follow proper operational procedures: utilize appropriate start up and cool down procedures. Periodic maintenance to replace or repair faulty components, regular inspection, maintaining spare parts inventory, record keeping etc.

30. Best practices include- Training and Management: Regular training and upgrading skills Making available an Operating and Maintenance manual and maintenance program for incorporation of certification and inspection programmes for operation and an excellent management oversight are an essential components