POINTS FOR CONSIDERATION OF THE WORKING
GROUP ON HEALTH CARE WASTE MANAGEMENT
ISWA (ISTANBUL)-SEPTEMBER, 2005
Health care waste management in the underdeveloped, developing, and transitional countries is far from satisfactory. Though some improvements have taken place these are in pockets, and at many places it is not effective or scientific defeating the purpose of investment in health care waste management. There are two main reasons. One is lack of awareness and low level of education and the other is that the planners in a health care institution find it confusing to start any waste management plan scientifically. In order to help planners in the hospitals and health care institutions in these countries two aspects are of great relevance, and these are: -

A. CLASSIFICATION AS PER RECOMMENDED OPTIONS

Suggested Classification in a Hospital in Developing Countries: -

Another way of classification can be as per recommended options finalised for a hospital. This way number of categories would be less and options would be clearly defined as against present recommended option/s where many alternatives have been listed causing confusion in the mind of the planner in a hospital and in the mind of unskilled or semi-skilled waste handlers. This would reduce the number of collection boxes/containers required in a hospital. However on each of these collection containers recommended option and items to be discarded in that particular container will have to be clearly written in local language. Number of containers or collection boxes required will be in accordance with the size and technical capacity of a hospital or health care facility. For example in case of rural health care waste it may not be possible to have an incinerator for disposal of human/animal body parts and tissue waste. Therefore landfill will have to be alternative option. Similarly in case autoclave cannot be provided then chemical disinfection would be the alternative. Therefore waste management plan at a health care facility will have to be modified according to options which may be made available at that place. If this concept of option based classification is applied HCW may be classified in following five categories as below: -

Category A. Hydroclavable Waste: -

1. Infected Paper waste
2. Paper wrappings from wards & patient care areas
3. Linen waste, soiled cotton & swabs waste etc
4. Food Waste-left over from patients, or otherwise from the hospital kitchen/cafeteria

Category B. Autoclavable Waste: -

1. Pathological waste in the labs
2. Metal waste
3. Glass waste
4. Sharps waste

Category C. Incinerable Waste: -

Human & Animal tissue waste/parts

Category D. Microwavable Waste: -

Plastic waste

Category E. Landfill Waste: -

1. Human & Animal Tissue Specimen waste after washing to remove chemicals
2. Sharps waste after disinfection in small HCF
3. Sharps waste non-infected in small HCF
4. Human and Animal tissue waste, and amputated parts in small HCF where facilities for incineration is not available, nor there is an incinerator nearby to share
5. Disinfected and Shredded Metallic waste in small HCF

Thus one can see that categorization as per the recommended option would be different. It would not only reduce number of containers required but will also be clearly defined. At the same time system can be easily modified as per the type of HCF, its location, connectivity, and local practices and prejudices.

B. STEPWISE DEVELOPMENT

Steps for Formulating a Waste Management Plan: -

To lay down a waste management plan it would be simpler and perhaps much easier to follow certain steps. Stepwise development and application of a comprehensive waste management plan in a hospital/health care institution would entail the following: -

Step I
Base Line Survey: Its Aims and Purpose would be to: -
o Study geographical dimension – This is important and of greater relevance to a hospital, as it would give an idea whether a hospital is of vertical dimension or of horizontal spread, ratio between built up area and the total available area for the hospital, and the disciplines and departments etc. It would also give an indication whether on site treatment of waste can be planned or not. Is there enough space on the premises, and if so, what would be the impact on human health and environment. Therefore it is important that one carries out a detailed study of geographical and technical dimension of the hospital, which may be recorded as a technical map of the hospital, and will also help in planning movement of waste, establishing terminal treatment options etc. Public Health engineering aspect may also need to be studied so as to plan an appropriate liquid waste disposal system.
o Estimation of quantum of waste generated – Waste generation is calculated by conducting a survey. Normally waste generation is mentioned as Kg per bed per day. There are two fallacies in this. One, when one talks about Kg/bed/day obviously the total bio-medical waste generated in the hospital is divided by the number of beds to arrive at an average figure. But if the bed occupancy is lower or higher than 100 % results may be fallacious. Second, in absence of proper segregation practices mixing of infected and non-infected waste will normally take place, and in that case the survey result would again be fallacious. And in case segregation is not being practiced it would be pointless to talk about quantum of infected waste. Both these conditions are common in the developing countries and therefore researchers must be careful while coming to a conclusion about quantum of waste generated in a hospital or a HCF. Therefore it would be more realistic to express biomedical waste generation in Kg per patient per day, and to consider total waste generated in a HCF as bio-medical waste till segregation practices are put in place. Survey is the most important part of waste management plan. Though most difficult and cumbersome, it must be done meticulously. This step would achieve almost half of the task related to developing a waste management plan.
o Estimation of quantum in each category – Hospital waste is heterogeneous and contains items with different physical characteristics and attributes. Infected waste is one category, but within the definition of infected waste one would find many types of ingredients, and each one may require to be treated differently. Plastic waste for example cannot or should not be incinerated. Disinfection of sharps may requir disifection and mutilation immediately after generation. Strategy for injection waste disposal in a rural area would be separate and different.
o Determine waste generation points – Waste generation points may be many in a hospital/health care institution. It must be recorded and mapped which will help in placing containers for source separation and collection. Once the points and type and quantum at each waste generation point has been recorded capacity of waste collection bins can be planned. A hospital or health care establishment will have many OPD points where intermediary intervention in the form of needle destroyer - cum - syringe cutters may be required to be placed in sufficient number to take care of injection waste. There may be an attached dental unit where waste management may have to be planned to disinfect injection waste as well as planned strategy for disposal of chemicals waste. Laboratories will have to be visited and one may have to record work schedule so as to determine appropriate technology. Infectious wards where HIV patients are admitted will need special precautionary measure to be implemented. Similarly highly infectious wards where victims of SARS or Avian Flu are admitted will require special protocols for collection, safety precaution and handling. Thus one would see that there are many points of waste generation in a hospital where interventions will be required. What has been described above is only illustrative. Plan will have to be devised specific to a hospital or a health care institution. But determining waste generation points would be an essential step.
o Determine disinfectants and chemicals used: There are many chemicals, which are used in patient care and disinfection. Selection of terminal treatment technology would be guided by whether an item has been treated chemically. Effects of these chemicals on human health, and on environment should be studied and recorded. This would be helpful while planning waste management system.
o Chart out most appropriate route of waste movement: Route of waste movement should not cross the route normally taken for supply of medicines or patient’s food. At the same time its movement should also be away from the populated areas, or from the route of supply of medicines and food of the health care institution. Many a times it may not be possible to move the waste separately on an exclusive route but knowing the principle would lead to an informed decision, which is better than an ad hoc or uninformed decision.
o Study present system, if any: One may find no system existing in a health care institution, or a system existing but not on accepted scientific basis. Here it must be understood that a system is stepwise description of an activity, and not of any action, which neither has any scientific basis nor has stepwise attributes. Study of present prevailing system or practice and prejudices will give an idea to the planner as to what are the weaknesses, and what are the compulsions. This would help the planner in establishing an acceptable and durable system. It may not be enough to suggest and establish a system but also to ensure that it is durable. One may plan and establish a ‘State of Art’ system but if the technical and attitudinal capacity is not supportive the system established at enormous cost may deteriorate in no time. Study of the present system/practice will also provide information on the weaknesses where the planner may decide to apply educational or attitudinal intervention.
o Determine weak points in the system: Weak points in a system can be found at any stage. Old proverb that ‘chain is as strong as the weakest link’ should be kept in mind. One cannot become stronger unless the weak points are identified and corrected. That is why it is necessary to detect weak points. In fact once the weak points have been detected and recorded corrective measures can be applied in a systematic manner, not only in the initial phase when the system is being developed but also later – periodically. While conducting study to detect weak points one may dtect low level of awareness. In that case it would be beneficial to undertake measures to improve awareness and education at the initial stage itself. Methodology may be accordingly planned, such as didactic approach or IEC approach or a combination of measures, which will improve awareness. Depending upon factors such as increase in the level of awareness periodicity of such training and awareness programme may be laid down. It may be the very first step since knowledgeable health care workers would better realise the importance of waste management, and would be supportive to waste management programme. Similarly if during the study one finds that there is no system of accident reporting one would remember to include it in the waste management protocol. In a scenario of rural health care system one may find that the connectivity to the rural areas is rather poor (which may be the case in hilly terrain). In that case alternate methods for transporting waste from the PHCs to a central point for treatment of waste may have to be planned, or one may decide to disinfection and mutilation at the PHC level itself. Therefore study of the current practice and system to detect weak points are essential in developing a sound waste management system.
o Study prevalent infection control procedures and sharp management: There may not be any system of infection control or sharp management in the health care institution or there may be some system existing but not proper. In either case study will help in formulating appropriate plan for infection control.
o Study waste minimization, recycling, and reuse policies: Waste minimization and reuse or recycle policies should be studied with a view to find opportunities for waste minimization, recycling, reuse (recover), and included in the waste management protocol. Proper segregation, reuse and recycling are measures that lead to waste minimization, which in turn saves financial resources for treatment and disposal of infectious bio-medical and chemical waste.

Step II
Develop hospital specific protocol: All information collected during the previous steps would lead to development of a protocol. While the basics in the protocol would be the same modifications may have to be incorporated to suite specific health care institution. For example in a tertiary care teaching hospital one may have to include method for treatment and disposal of pathology specimen, which may not be required for a smaller hospital. Similarly protocol for a dental centre would have to be only inclusive of injection and chemical waste treatment and disposal. But safety precautions to be adopted will remain the same whether it is a large or small hospital, or a dental centre. Thus some of the features of the protocol would remain common; some may be different depending upon size and type of the health care institution.

Specific responsibility, duty, and authority should be clearly spelt out in the protocol. One senior person must be designated as the in charge of the waste management system. A committee should be formed which should work in close liaison with the infection control committee because one of the important aims of health care waste management is to eliminate infection, the other being environmental protection.

Efforts should be to use alternate technologies, and alternate source of energy. Many hospitals have switched on to using solar panels to meet their hot water requirements. Incinerators should be avoided as much as is possible since it stands implicated in environmental pollution and causing adverse impact on human health. Most importantly the management protocol should remain dynamic so that it can assimilate emerging technologies and system modification at the working level.

The protocol must describe source separation & collection of waste, its movement from the waste generation point to a common and movement from the common area to the terminal treatment facility, final disposal, safety measures, disinfection schedules, spill management protocol, sharp management and infection control measures, liquid waste treatment and disposal, and many other important features. Some of these are described below, in detail.

Essentially a protocol should be inclusive of a general description of the hospital or health care institution describing in short:
 Its departments and technical capacity
 Quantum and type of waste generated
 Waste generation points
 Chemicals used for patient care, and for disinfection
 Technical and non-technical manpower
 Awareness level regarding waste management amongst different groups of health care workers
 Present practice and prejudices or compulsions, if any
 Description of installed equipment and its capacity, if any
 Assigned responsibility, if any
 Infection Control Committee if existing
 Health care waste management Committee if in existence

Note: -Many hospitals would be required to treat patients of highly infectious and contagious diseases. This may include victims of AIDS, SARS, and Avian Flu etc. These patients would normally be in isolation, and waste from these wards (including floor wash etc) would have to be disinfected at the earliest, and safety precaution of the highest order will have to be instituted.

The protocol should include the following: -
• Waste Minimization, Reuse, and Recycle Procedures: Many items of health care waste can be recycled, such as plastic waste, which will reduce burden on the health care waste management and monetary resources. Many items can be recovered, such as mercury waste, which can be collected, distilled and brought to further use in the hospital. Such a venture has paid dividends in many hospitals in the developed countries. It is of course important to remember that all these activities can be undertaken only after proper disinfection, wherever required. Reduce, Recycle, Reuse and Recover, no doubt are basic feature of a waste management plan but it must be initiated and implemented with great care, and under close supervision. It must be remembered that items intended for recycling etc have monetary value and left to loose supervision might result in malpractice.
• Identify Vendors: Recycle plan can only succeed if it is supported by a well-known list of recyclers and vendors. If not available locally it should be found out from adjacent places. Vendors should be explained that it would be an opportunity rather than an investment only. Even if there is no established vendor, say for example for plastic waste, it can be worked out with any plastic industry nearby. In case there are a cluster of smaller health care facilities, and a large facility in the same town or city all the recyclables can be channeled through the bigger facility. Procurement policies of medicines and consumables should also include buy back agreement with the suppliers. This would be specifically important in case of radioactive medicines, and part or whole of redundant equipment/s. Computers parts and other electronic equipments must be contracted at the time of purchase itself with provision of ‘take back’ scheme to reduce quantity of E-waste. Reuse of end product should be a part of the strategy, as far as possible, after waste is treated/disinfected, or rendered harmless.
• Procedure for Liquid Waste Treatment and Disposal: Liquid waste management is often neglected. In days to come liquid waste disposal would be more and more important due to mutant variants of microbes such as SARS and Avian Flu. Floor wash etc from infectious wards will have to be subjected to disinfection before disposal. Safety precautions will have to be strengthened while dealing with such cases. Principle of liquid waste disposal should be to render the liquid waste commensurate with the municipal liquid waste flowing in the sewers. Hospital liquid waste can be discharged in the municipal drains only thereafter. In fact liquid waste from infectious wards etc must be subjected to a treatment by sodium hypochlorite solution in a buffer tank before it is discharged. Many hospitals have installed liquid effluent treatment plant (ETP) on their premises, where liquid waste from all over the hospital is channeled into the ETP, and treated water and sludge is used for gardening etc. Thus the hospitals not only safeguard against environmental pollution but also benefits from such a scheme by saving monetary resources otherwise required for maintaining the green areas. It also adds to the aesthetic look of the hospital.
• Adequate and Periodic Training Programmes: Training and awareness programmes are very important feature of the system. It has to be separately designed for different groups of health care workers. Essentially one programme may be sufficient for the doctors and nurses, one programme for the paramedics, and one programme for the waste handlers. It must be periodic since many members in the staff may be changing, and also to recapitulate and reinforce knowledge. A record must be kept so as to review the schedule subsequently.
• IEC modes: One of the methods of improving awareness is information, dissemination, which can be in the form of posters in local language and displayed at vantage points in the hospital. It should be the duty of the waste management in charge to collect latest information and disseminate it by way of handouts, booklets, posters etc. Communication is another important feature of awareness programmes. Therefore a periodic meeting with all the stakeholders (including waste handlers) is important. This would provide the waste manager and the head of the institution with valuable clues if some intervention or change or modification to the programme is required.
• Periodic monitoring: Monitoring is an important tool of system evaluation. Monitoring should include periodicity, inspection schedule, maintenance of records, certification, assessment of emissions, inspection schedule of equipments, and recording findings of inspection by external agencies. Monitoring may also include results of waste minimization, recycle, & reuse programmes, which may give an indication for further improvements.
• Infection Control Measures: There is no substitute for hygienic practice, and cleanliness. Other measures would include restriction on hospital visits by relatives and public. Restriction on visits would call for a proper information & dissemination system to be developed so that there is no need for the relatives to gather in the hospital. It may call for an attitudinal change as in most places in the developing countries visiting a patient is considered a societal responsibility. Children & elderly must avoid visiting hospitals, as they are more vulnerable to infection.

All these will be required to be included in the protocol for the health care institution. Only then it will develop as a comprehensive plan of waste management.

Step III
Study procurement and supply procedures &and policies.
Purpose of such a study would be: -
o To suggest minimization
o To suggest recycling, or to identify materials that can be recycled after disinfection
o To suggest restricted movement of medicines from non-infective to infective areas. It may not necessity to allow packaging of medicines to wards (infective area) from the medical stores. This would reduce quantity of infected waste to be taken care of.
o To suggest any change in the inventory of medicines, such as procurement of mercury and other chemicals required in a hospital, and any change guided by principles of waste management. Recently many hospitals in the developed countries have done away with use of mercury, which necessitated change in procurement policy of the hospital.
Step IV
Assessment of level of awareness
Awareness is an important feature of technical capacity. It must be assessed at the beginning so that necessary interventions to improve, and to maintain awareness level amongst health care workers, separately for each group can be planned and applied. Success of a programme would very much depend upon the level of awareness. Purpose of such a study is:
o To assess baseline understanding of awareness amongst each group about hospital waste management & infection control
o To plan effective interventions
o Evaluate progress or the difference these awareness programmes make
o Reevaluate training schedules
o Determine periodicity of training and awareness programmes
o Finalise posters and handouts to improve awareness
o To hold preliminary workshop where level of awareness may be determined emperically in the scale 1-10
o To hold workshop after training and to assess improvement in the level of awareness, again in the scale of 1-10
Step V
Evaluate safety procedures
Health care workers are always at risk since they are in close contact of patients. Nurses are specifically vulnerable to accidental injuries and infection. Many studies done to determine hospital-acquired infection indicates high infection rate amongst the nurses, paramedics, and waste handlers. Adverse impact on the human health has also been noticed due to chemicals used in the health care institutions, and once again it is the nursing staff, paramedics, and waste handlers who are most prone to such adverse effects. Therefore safety to the health care workers should be paramount while planning a health care waste management system. Evaluation of safety measures should be done so as to:
o Describe the present system of safety amongst each group
o Plan interventions, such as:
 Safety clothing and equipment to the health care workers, specifically the waste handlers
 Preventing sharp injuries
 Pre-exposure prophylaxis (PEP) and precaution amongst high risk groups
 Laying protocol for waste audit, which will give an indication of gap or deficiency between waste being generated and treated/ disposed. Apart from many other advantages waste audit also indicates opportunities for minimization, recycling, and reuse/ recovery
 Laying protocol for accident reporting, prevention, and post-exposure management.


Step VI
Selection and installation of equipments

Selection of equipment for waste management is the most crucial part of waste management plan. One must approach this very carefully. It may be Things are more difficult since many alternatives are available and no standardized parameters for each type of equipment are available, unlike in case of medicines and medical equipments. So at times it becomes very difficult to select proper equipment. Purchase of equipments have to follow laid down procedures and policies which may be universal for a group of health care institutions in which case one does not have the flexibility to opt for equipments as per his or her perception. Quality may be compromised due to restrictive procedure. Individual bias may play a dominant role in procurement. There may be flexibility in case of private health care facilities but flexibility cuts both ways. It may be advantageous or disadvantageous depending upon biases and predilection of the administration. Therefore it may be very difficult to lay down thumb rule in this regard. However administration of a health care institution must strive to reach a logical and most appropriate mechanism for procurement.

Scaling or standardization of range of equipments for a health care institution may be possible, but only after an extensive study. Equipments may range from ancillary equipments such as needle destroyer - cum - syringe cutter, shredder which may be required for plastic waste or metallic waste, intermediary disinfection materials such as chemicals etc, waste collection bins of different size etc, and terminal treatment options such as waste sterilization unit (commonly known as Hydroclave, Vapoclave, Bioclave etc), microwave, and autoclave etc; and equipment or machinery to transport the waste within and outside the premises. It is not possible to suggest a universal plan or scale of any of the equipments mentioned above, as it would depend upon the waste management plan devised, type and size of the hospital or the health care institution. Once again waste management plan of a health care institution will have to be specific and would include selection and scaling of equipments. However a modular plan for each group of health care institution may be possible. For example it may be possible to suggest a set of equipment and its scale separately for multidisciplinary tertiary care hospitals, dental establishments, stand alone large laboratories, blood bank; which may be extrapolated for another health care institution of the same type. But one model may not work for all types of health care institution and in all situations. Thus it is clear that scaling will have to be in consonance with the specific overall plan of waste management finalised for that health care establishment.

Once the administration of the health care institution have finalised types and number of equipments, the next step would be its procurement. Process of procurement should be finalised by a Standing Board of Procurement. It must include the head of the institution, logistic incharge, financial head, waste management incharge, head of engineering department, and incharge of infection control committee. One may co-opt other experts as required. It should be a collective wisdom, collective decision, and collective responsibility. And such a Board should remain insulated from influences. It must be kept in mind that equipments required are capital intensive and there may be subject to influences. The Board should finalise procurement of not only the equipments required but also chemicals and other smaller equipments etc required for intermediary interventions. It should also develop final disposal options, which may need to be dovetailed with either the municipal bodies in case of large health care institution, or with a larger hospital in case of smaller health care institution. The Board should be fully knowledgeable on waste generation- its quantity, and type or ingredients. It should be the duty of waste management incharge to collect all information in this regard and place it before the Board. Once options have been decided tender document will be required to be prepared.

Since standard parameters of waste management equipments, as for clinical equipment are not available tender documents must be prepared with great care. Quality of equipment should be of paramount consideration, and not the cost. Tender document should be so prepared that quality takes precedence over price. This is important since there are many manufacturers of waste management equipment in the developing countries whose quality may not always be as desired. Import of equipment should be avoided, as that would sap the meagre resources available for health care waste management. Within the given policy of procurement one may be able to get the best equipment available even though it may be the cheapest. Budget being limited one will have to strike a balance between price and quality. Time frame of supply, installation, and testing periodicity should form part of tendering. Penalty in case of delay or default should be included in the tender document. Maintenance schedules, periodic inspections, authorization, and certification etc, should be required to be included in the bids in response to the tender. It must be ensured that what is being procured is within the rules, and there would not be any difficulty in obtaining certification from regulatory authorities. Placing of order should conform to the laid down procedures, and clearly spell out the time frame and penal provisions. Installation and demonstration after installation should be a part of the order. In fact, heavier equipments should be contracted on ‘turn- key’ basis.

The health care institution/hospital should be made ready to receive the equipments before these start arriving on the site. In other words the hospital should have decided about waste movement and storage etc beforehand. Waste storage should already have been constructed so that installation of equipment is at the right place, and without waste of time. Waste Management Committee of the hospital and the hospital engineer should be closely associated with installation right from the beginning, so as to fully understand and grasp technical details of the equipment, its functioning, and maintenance schedules etc. Installation should include training to the hospital staff regarding functioning of the equipment, and all waste handlers who would be working on the equipment should be exposed to such a programme. For example, while installing needle - cum - syringe cutter/destroyer or needle remover equipment all nursing staff and the paramedics should be exposed to a training module about use and maintenance of the equipment. Similarly in case of installation of other equipments such as a Waste Sterilization Unit (Hydroclave etc), autoclave, incinerator, or microwave all those who may be working on the equipment may be trained by the supplier on how the equipment should be used, how it should be maintained, its technical details, cleaning schedules, shut down procedures and trouble-shooting measures. Once installation has been completed equipment should be run on experimental basis for some time. Record of parameters should be maintained right from the beginning so that appropriate data is generated for reference in future. End products should be subjected to predetermined laboratory tests, and other physical and chemical tests, and records maintained. Installed equipments require periodic maintenance and cleaning that must be done as per the schedule and guidelines provided by the supplier.

Step VII

Evaluate Against Performance Indicators: Any programme is launched with clear aims in mind, and for possible improvement in a system. Health care waste management is also intended to bring about positive results in overall health care delivery. It may be cleaner environment, reduction in nosocomial infection, or better health amongst health care workers. It may not be possible to measure such improvements in all spheres but there are certain areas where indeed it can be measured. The tool with which it is measured is termed as ‘Performance Indicators’. Neither laid down performance indicators are available, nor there is any textbook model, but performance indicators can be framed taking a clue from the aims and objects of an activity. It would give an indication to success of a programme and also will indicate any midway corrections/modification in the programme. It is true for all types of programmes and is also true in case of health care waste management programmes. It helps in evaluation and serves as a reference point for the future. Selection of performance indicators has to be done with great care since it is likely to affect future implementation of management plan. In case of health care waste management some of the performance indicators are suggested below:
o Decreasing incidence of accidents
o Decreasing incidence of mercury spillage
o Decreasing incidence of sharp injuries
o Increasing quantity of recycled waste
o Reducing quantity of gap between waste generated and waste treated
o Reducing nosocomial infection, and hospital infection in general
o Reducing incidence of communicable diseases in the hospital staff. For this it would be advisable to list out the diseases, which can be put under surveillance and note the incidence periodically to determine reducing trend. It could be skin disease, lung infection, HIV, HBV, HCV etc, and upper respiratory tract infection. Protocol to measure changes in the incidence will have to be determined prospectively.
o Increase in the awareness amongst each group which can be empirically measured by holding workshops on health care waste management separately for each group
By no means it is a fixed list, and may be modified as per the type and capacity of a health care institution. List may vary, and in some cases only a few of the indicators mentioned above may be applicable.




(LK Verma)
New Delhi, India
Member ISWA