UNIT 1 DEFINITIONS, TYPES AND CATEGORIES OF WASTE

Structure
1.0 1.1 1.2 Objectives Introduction Definition of Waste
1.2.1 Municipal Waste 1.2.2 Health Care Waste 1.2.3 Sources of Health Care Waste

Definitions, Types and Categories of Waste

1.3

Types of Health Care Waste

1.3.1 Infectious and Non-infectious Waste 1.3.2 Hazardous Health Care Waste 1.3.3 Solid Health Care Waste and its Sources 1.3.4 Liquid Health Care Waste and its Sources 1.3.5 Biodegradable and Non-biodegradable Waste

1.4

Categories of Health Care Waste

1.4.1 Categories as Per World Health Organization 1.4.2 Categories as Per Gazette Notification of India 1.4.3 Categories as Per Thailand Authorities 1.4.4 Categories as Per Indonesian Authorities 1.4.5 Emerging Concepts of Categorisation in South-East Asian Countries

1.5 1.6 1.7 1.8

Let Us Sum Up Key Words Answers to Check Your Progress Further Readings

1.0
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OBJECTIVES
define types of waste generated in a health care facility and its sources; differentiate between hazardous and non-hazardous waste; understand various categories of health care waste; and describe emerging concepts of categorisation of waste in SEAR countries.

After going through this unit, you should be able to:

1.1

INTRODUCTION

Hospitals and other health care facilities, diagnostic centres, blood banks, dental centres and research centres are visited by patients for diagnostic and treatment procedures in the process which generate a variety of wastes. A few examples of health care wastes are dressing material, food waste, anatomical body parts, plastic disposable items, needles,

Health Care Waste: Definitions

drugs, chemicals, mercury, corrosive agents, radioactive substancesall of which ultimately become part of health care waste. These wastes if not managed properly become a health hazard and spread diseases in the society. In addition, ill managed health care waste can also be responsible for environmental pollution and degradation. Waste generated in health care facilities is much more complex than the municipal waste as it poses a direct threat to human health as well as the environment. With rapid urbanisation and population pressure, natures cleansing system has started breaking down. Most health care facilities in SEAR countries have outdated waste management procedures, hardly any facility has a sound system of waste management. Improvement of waste management in health care facilities is urgently needed for safeguarding the population, eliminating occupational health hazards and protecting the environment. Proper health care waste management encompasses various processes, such as waste generation, collection, handling, transportation within the health care facility and outside, storage and final disposal without causing hazard and risks to society, environment and waste handlers. For effective health care waste management, formulation of objectives and developing procedures for accomplishing the objectives are important. This requires finalising an appropriate strategy of waste management in the health care facility and allocating the resources. The strategy and procedure for managing waste has to be within framework of national and local law of the country and state. This unit will cover the definition, types and categories of waste generated and other aspects of waste management will be covered in the later units.

1.2
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DEFINITION OF WASTE
Industrial Waste-chemical, gases, vapour, etc. Municipal Solid Waste-paper, food, street refuge, animal excreta, etc. Health Care Waste-waste coming out of health care facilities. Biodegradable -paper, food, cotton, bandages. Non-biodegradable -glassware, plastics, plaster of paris, metals like mercury, etc.

Waste can be broadly classified as:

Based on biodegradable properties, waste is further subdivided into two groups:

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Another way of classifying waste is as per their chemical properties and usefulness. Following are a few such examples:
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Organic Waste-kitchen waste, vegetables, flowers, leaves, fruits, foliage, etc. Hazardous Toxic Waste-- old medicines, paints, chemicals, bulbs, spray cans, fertilizer and pesticide containers, batteries, shoe polish, etc. Recyclable -paper, glass, metals, mercury, plastics, etc. Soiled-hospital waste such as cotton, bandages, soiled with blood and other body fluids, etc.

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1.2.1

Municipal Waste

The concept of municipal waste is very old and defined differently in different countries. Municipal waste is commonly known as trash or garbage and is a by-product of modern life.
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The word municipal means anything that is operated and controlled by elected local officials such as city or country governments. Usually municipal solid waste (MSW)

refers to what people throw away at home, schools and businesses. Practical definition of municipal waste is solid waste generated by a community. The municipal authorities in most cities and towns have traditionally handled urban solid wastes. Municipal solid waste is total waste excluding industrial waste, agricultural waste and sewerage sludge, and all categories of hazardous wastes including batteries and health care waste. It includes domestic refuse as well as commercial or a trade refuse, which because of its nature or composition is similar to domestic refuse. US Environment Protection Agency defines municipal solid waste as including durable goods, containers and packaging, food wastes, yard wastes and miscellaneous inorganic wastes from residential, commercial, institutional and industrial sources. Americans generate more than 180 million tons of municipal solid waste each year, 1,300 pounds for each person each year. It means that on an average, approximately 4 pounds of garbage is generated every day per person. 1 Wastes that can be degraded by micro-organisms are called biodegradable wastes. Vegetable wastes, old food, tea-leaves, egg shells and dry leaves are some examples of biodegradable waste. Wastes that cannot be degraded by micro-organisms are called non-biodegradable wastes. Polythene bags and scrap metal are examples of non-biodegradable waste. Over the last few years, the consumer market has grown rapidly leading to products being packed in cans, aluminum foils, plastics, and other such non-biodegradable items that cause tremendous damage to environment. In India, some municipal areas have banned the use of plastics and they seem to have achieved success. For example, today one will not see use of plastic in the entire district of Ladakh where the local authorities imposed a ban on plastics in 1998. One positive note is that many large cities, some shops have begun packing items in reusable or biodegradable bags. Certain biodegradable items can also be composted and reused. In fact proper handling of the biodegradable waste will considerably lessen the burden of solid waste that each city has to tackle. Few examples of organic and recyclable waste are elucidated in Table 1.1.
Table 1.1: Categories of Municipal Solid Waste Organic Waste Recyclable Others Tetra packs, plastic coated paper and packing material

Definitions, Types and Categories of Waste

Tea-leaves, egg shell, food, Paper, plastic bottles, vegetable, meat, bones cardboard, metal cans, PET bottles

Composition of municipal solid waste is shown in Table 1.2.

Table 1.2: Composition of Municipal Solid Waste Contents Paper Yard Waste Metals Glass Food Plastics Miscellaneous Percentage 40.0 17.5 8.5 7.0 7.4 8.0 11.6

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1 Source:

www.stark.ak.us/dec/eksw.index.htm

Health Care Waste: Definitions

Together, these components create a lot of trash that must be disposed off each day. Though municipal waste is non-infectious and usually does not cause direct public health hazard, but the large volumes of municipal waste can definitely be attractive to rats and flies, thus they have to be disposed off properly. Key Facts on Waste Issues
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According to the United Nations Centre for Human Settlements, only between 25 and 55 per cent of all waste generated in large cities is collected by municipal authorities. The UN Development Programme (UNDP) estimates that more than five million people die each year from diseases related to inadequate waste disposal systems. At least 60 per cent of the countries that submitted national reports to the United Nations in advance of the 1992 Earth Summit said that solid waste disposal was among their biggest environmental concerns. More than half of the worlds municipal waste is generated in developed countries. In the United States e.g. the US Environment Protection Agency estimates that the average American produces well over 0.75 tons of trash each year. Industrialized countries generate more than 90 per cent of the worlds annual total of some 325-375 million tons of toxic and hazardous waste, mostly from the chemical and petrochemical industries. Most countries in the developed world only introduced laws to control hazardous waste disposal in the 1970s and are left with a vast heritage of pre-legislation sites.

1.2.2 Health Care Waste

Health care waste is defined as, the waste resulting from patients diagnosis, prevention, research and treatment procedures as well as waste generated from all other health care establishments, research facilities and laboratories. Health care wastes are generated as a by-product of health care delivery system. Waste generation in a health care facility cannot be avoided, but it can be minimised. Health care waste is generated during the diagnosis, treatment, or immunization of human beings or animals or in research activities in these fields. Health care waste includes wastes like sharps, soiled waste, body fluids, disposables, anatomical waste, cultures, discarded medicines, chemical wastes, used needles and syringes, glass slides with blood stains, biopsy tissue, foetuses, placenta, infected dressing material, human excreta, etc. Bio-medical waste has been defined under Indian Gazette of Bio-medical Waste (Management and Handling) Rules 1998 as any waste which is generated during the diagnosis, treatment and immunization of human beings or animals in research activities pertaining thereto or in the production or testing of biological and includes categories mentioned in Schedule I of the Rules. For this Programme we will use bio-medical waste as an equivalent to health care waste. The subject of health care waste management is by and large an environmental issue and should be looked at it is in totality. Each health care facility has its unique requirement of infectious and other waste management procedures and that they cannot be equated or generalized with that of the others. The policy and steps taken for waste management should be sustainable.

Check Your Progress 1 1) Indian Gazette of Bio-medical Rules apply to: ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... 2) A few examples of hospital waste are: ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ......................................................................................................................

Definitions, Types and Categories of Waste

1.2.3 Sources of Health Care Waste

With high population growth and rapid urbanization, generation of waste has increased considerably. This is also true for health care facilities. Quantum of per patient waste generation has also increased considerably, more so after introduction of disposables in health care delivery system, which has made the task of waste disposal more difficult. Along with poor waste management practices waste can read to spread of communicable diseases and infections. Waste generation is not uniform in all health care facilities. The urban health care facilities generate considerably large quantity of waste vis--vis the health care facility of same size, located in rural areas. There could be many reasons for this regional variation like rural facility treating less serious patients, lesser use of disposables, socio-economic status of patients visiting the facility, dietary habits, social customs, reading habits, etc. A few of these factors are summed up in Table 1.3.
Table 1.3: Factors Governing Quantum of Hospital Waste a) Type of health care facility Primary, secondary or tertiary; Speciality centre or general hospital b) Use of disposables in hospital c) Admission and discharge policy of hospital d) Geographical Location e) Clinical services management (CSM) policy of hospital f) Availability of ancillary services like blood bank, diagnostic facilities, etc. g) Procurement Policy of the hospital

h) Layout of the hospital i) j) Socio-economic status of patients Dietary habits

k) Reading habits

l)

Social custom like carrying bouquet

The sources of health care waste can be classified as major, minor or support services, according to the quantities produced. Major Sources of Health Care Waste 1) 2) Hospitals University hospital, General hospital, District hospital Health Centres----Primary health centre, Community health centre.
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Health Care Waste: Definitions

3) 4) 5) 6) 7)

Outreach Services----Sub-centres, immunisation clinics Diagnostic Centres Blood Banks Mortuary, crematoria Dental Centres and dental clinics

Few of hospital areas generating large quantity of the waste are elucidated in Table 1.4.
Table 1.4: Hospital Departments Generating Large Quantity of Waste
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Surgery Department Medicine Department Out Patient Department Immunisation Clinics Intensive Care Unit Department Laboratory

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Gynaecology Department Accident and Emergency Department Plaster Room Operation Theatre Blood Bank Renal Dialysis Units

Other Health Care Establishments Generating Waste

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Emergency medical care services Dispensaries Obstetric and maternity clinics Consultation chambers Polyclinics Health posts Long-term rehabilitation centres Transfusion centres Home care of chronic conditions diabetes, colostomy, catheterisation Geriatric health care services

Minor Sources of Health Care Waste 1) Small Health Care Establishments

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Physicians offices Acupuncturists

2)

Specialized Health Care Establishments and Institutions with Low Waste Generation
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Convalescent nursing homes Psychiatric hospitals Rehabilitation centres

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3)

Non-health Activities Involving Intravenous or Subcutaneous Interventions

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Definitions, Types and Categories of Waste

Cosmetic ear-piercing and tattoo parlours IV drug users addicts Patients getting sporadic treatment at home Composition of Health Care Waste

The composition of wastes is often characteristic of the type of source, from the different units within a health care facility. ICUs and Intermediate Care Wards: Mainly infectious waste such as dressings, bandages, sticking plaster, gloves, disposable medical items, used hypodermic needles and intravenous sets, body fluids, contaminated packaging and food waste. Operation Theatres and Surgical Wards and Obstetric Units: Mainly anatomical waste such as tissues, organs, foetuses and body parts, other infectious waste and sharps. Other Health Care Units: Mostly general waste with a small percentage of infectious waste. Laboratories: Mainly pathological (including some anatomical), highly infectious waste (small pieces of tissue, microbiological cultures, stocks of infectious agents, infected animal carcasses, blood and other body fluids), discarded specimens, sharps and chemical waste. Medical Stores, Dispensary and Chemical Stores: Expired drugs and chemicals, packaging materials, aluminum foils and general waste.

1.3
a)

TYPES OF HEALTH CARE WASTE

Contents
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The types of waste generated may be discussed on the basis of : Solid Liquid Sharp General

b)

Composition
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General Solid waste Bio-medical waste Other Special waste Liquid Waste

c)

European Union Classification

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Domestic waste Industrial waste Hazardous waste Health care waste Bacteriological contaminated waste Radiological waste
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Health Care Waste: Definitions

d)

USA Classification
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Isolation waste Cultures and stock of infectious agents Sharps Human blood and blood products Animal waste Unused sharps Cytotoxic waste Radioactive waste

e)

WHO Classification The WHO classification of health care waste is elucidated in Table 1.5. 2
Table 1.5: Categories of Health Care Waste Waste Category 1) Infectious waste Examples Waste suspected to contain pathogens e.g. laboratory culture, waste from isolation wards, tissue materials, equipment that has been in contact with infected patients, excreta Human tissue or fluids e.g. body parts, blood and other body fluids, foetuses Sharp waste e.g. needles, infusion sets, scalpels, knives, blades, broken glass Waste containing pharmaceuticals e.g. expired drugs Waste containing substances with genotoxic properties e.g. Cytotoxic drugs and chemicals Laboratory reagents, film developers Batteries, broken thermometers and BP instruments

2)

Pathological waste

3)

Sharps

4) 5)

Pharmaceutical waste Genotoxic waste

6) 7)

Chemical waste Wastes with high content of heavy metals

8) 9)

Pressurised containers Gas cylinders, aerosol cans Radioactive waste Unused liquid from radiotherapy units, packaging of radioactive material, excreta of patients treated or tested with unsealed radionuclides

1.3.1

Infectious and Non-infectious Waste

Health care facilities are required to segregate waste, treat it and dispose off in a safe manner, so that it does not harm the environment and human health. It is essential for them to take care to dispose off highly contaminated and infectious waste. The relative proportion of infectious waste coming from a health care facility is generally small. It usually represents 10-20 per cent of total waste generation, depending upon segregation practices and type of the facility.
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Source: Pruss, A., E. Giroult and P. Rushbrook, Safe Management of Wastes from Healthcare Activities, WHO, Geneva, 1999(3).

Infectious wastes include the waste which has been in contact with the body fluids and all of the following substances or categories of substances: 1) Sharp wastes used in the treatment, diagnosis or inoculation of human beings or animals or that have or are likely to have, come in contact with infectious agents in medical research or industrial laboratories, including hypodermic needles and syringes, scalpel blades, catheters and glass articles that have been broken; Human and animal blood specimens and blood products that are being disposed off, provided that with regard to blood specimens and blood products from animals, the animals were or are likely to have been exposed to a zoonotic or infectious agent; Pathological wastes, human and animal tissues, organs and body parts, body fluids and excreta that are contaminated with or are likely to be contaminated with infectious agents, removed or obtained during surgery or autopsy or for diagnostic evaluation, provided that, with regard to pathological wastes from animals, the animals have or are likely to have been exposed to a zoonotic or infectious agent; Laboratory wastes that were, or are likely to have been, in contact with infectious agents that may present a substantial threat to public health if improperly managed; Cultures and stocks of infectious agents and associated biologicals specimen cultures, cultures and stocks of infectious agents, wastes from production of biologicals and discarded live and attenuated vaccines; Contaminated carcasses, body parts and bedding of animals that were intentionally exposed to infectious agents from zoonotic or human diseases during research, production of biologicals, or testing of pharmaceuticals that may present a substantial threat to public health if improperly managed; Waste materials from the rooms of humans or the enclosures of animals that have been isolated because of diagnosed communicable diseases that are likely to transmit infectious agents. Also included are waste materials from rooms of patients who have been placed on blood and body fluid; Any other waste materials generated in the diagnosis, treatment or immunisation of human beings or animals, in research, or in the production or testing of biological, identifies as infectious wastes after determining that the wastes present a substantial threat to human health when improperly managed because they are contaminated with or are likely to be contaminated with infectious agents; Dressing material, POP cast (from compound fracture patients), etc.;

Definitions, Types and Categories of Waste

2)

3)

4) 5)

6)

7)

Broad Composition of Health Care Waste 15%

8)

85% Infectious Waste Non-infectious Waste

9)

10) Any other waste material the generator designates as infectious wastes. 75 and 90 per cent of the waste produced by heath care providers is non-risk or general health care waste, similar to domestic waste. Health care waste comes mostly from the administrative and housekeeping functions of health care establishments and may also include waste generated during maintenance of health care premises. But, if infectious wastes are not properly separated at source, all the waste volumes need to be considered hazardous.

1.3.2

Hazardous Health Care Waste

It is critical to define waste as hazardous. Hazardous health care wastes are unique forms of solid, liquid waste generated in the diagnosis, treatment or research of human and animal disease. Often hazardous wastes are mixed with non-hazard solid waste and disposed off by uncontrolled landfills, where they contribute to environmental pollution. Hazardous waste may be infectious (10 per cent) or non-infectious (5 per cent), but all types of infectious waste is hazardous. If the disposal of the hazardous waste is inadequate

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Health Care Waste: Definitions

and/or improper, it poses major risks not only to the patients and care giving staff but also to the community and to the environment. Hazardous waste has physical, chemical or biological characteristics that can place human health at risk or adversely affect the natural environment. Beyond health care facilities, hazardous wastes are often by-products of a large number of manufacturing and industrial practices. Any waste arising from medical, dental, pathological or similar practice investigation, treatment, teaching or research or collection of blood for transfusion, being waste may cause infection or accident to any person coming into contact with it. The hazards may be from needle prick injuries or laceration of body due to broken glass piece/blades, it may be blood splatter in eyes or exposure to aerosol spray of microorganism in laboratory. It may be ergonomics issue due to lifting of waste bags or exposure to chemicals and hazardous drugs; it may be heat and steam from treatment options or noise and elevated temperature in incinerators and hydroclave units. It may be volatile organic/inorganic compound or toxic pollutants from treatment equipment at workplace or at final treatment facility. Health risk may be due to radiation from nuclear medicine waste or electromagnetic waves of microwave. The hazards can be minimised significantly if a scientific process of effective system management with minimal occupational hazards to health care workers, patients and their relatives is developed and also carried out. All bags, containers must be labelled as per national/international regulations. As in India as per the Schedule III of Bio-medical Waste (Management and Handling) Rules 1998 the waste containers/bags must be labelled. This can be done by writing the information on the bag/outer container or by self-adhesive labels or the tags. Labels should be nonwashable and prominently visible. Chemical waste from health care may be hazardous, if it has at least one of the following properties:
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Toxic Corrosive Flammable Reactive Genotoxic

Hazardous chemical wastes must be handled more carefully (treated, stabilized and put in properly managed double lined landfills). The types of hazardous chemicals most commonly used are discussed below: a) Formaldehyde

Formaldehyde is a significant chemical waste in health care facilities. It is used to clean and disinfect (e.g. haemodialysis or surgical equipment), to preserve specimens, to disinfect liquid infectious waste and in pathology, autopsy, dialysis, embalming and nursing units. b) Photographic Chemicals

Photographic fixing and developing solutions are used in x-ray department. The fixer usually contains 5-10 per cent hydroquinone, 1-5 per cent potassium hydroxide, and less than 1 per cent silver. The developer contains approximately 45 per cent glutaraldehyde. Acetic acid is used in both stop baths and fixer solutions. c) Solvents

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Wastes containing solvents are generated in various departments of a health care facility, including pathology and histology laboratories and engineering departments. Solvents used in health care facilities include halogenated compounds, such as methylene

chloroform, trichloroethylene, and refrigerants and non-halogenated compounds such as xylene, methanol, acetone, isopropanol, toluene, ethyl acetate and acetonitrile. d) Organic Chemicals

Definitions, Types and Categories of Waste

Waste organic chemicals generated in health care facilities include:

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Disinfecting and cleaning solutions such as phenol-based chemicals used for scrubbing floors, perchlorethylene used in workshops and laundries; Oils such as vacuum-pump oils, used engine oil from vehicles (particularly if there is a vehicle service station within the health care facility premises). Insecticides, rodenticides to ensure pest control. Inorganic Chemicals

e)

Waste inorganic chemicals consist mainly of acids and alkalis (e.g. sulphuric, hydrochloric, nitric and chromic acids, sodium hydroxide and ammonia solutions). They also include oxidants, such as potassium permanganate (KMnO 4 ) and potassium dichromate (K2 C2 O7) and reducing agents, such as sodium bisulfite (NaHSO 3 ) and sodium sulfite (Na2 SO3 ).

1.3.3

Solid Health Care Waste and its Sources

Effective solid waste management is the need of the hour today. Solid waste is infectious or non-infectious in nature. These two categories of waste require distinct waste management options. Waste segregation is the key to waste management. The segregated non-clinical/non-infectious waste is collected in black/green bags for disposal in municipal dumps. Non-infectious waste, comprising mainly of packaging material, office and kitchen waste constitute 80-90 per cent of hospital waste is similar to general municipal waste and carries no infection. While infectious solid wastes from health care establishments consisting of sharps, tubings, bandages, sponges, cultures/stocks from the laboratory and wastes from surgeries and autopsies are usually of infectious nature. Clinical wastes, deserve special attention for on-site storage, handling, transportation, treatment and ultimate disposal. In most health care facilities in the SEAR, both clinical and non-clinical wastes are still collected and disposed off together, without much effort taken for separating them. The accumulation of rubbish presents both aesthetic and environmental problems and a loss of valuable resources. Health care waste also act as a source of income for rag-pickers, since many of the materials are re-used, often improperly. The consequences of such practices would prove disastrous in the long run and pose serious threats to the entire community, especially in terms of infections and diseases. Recycling technology and profit from the re-processing and resale of recyclable materials should be encouraged and reuse should be totally discouraged. Solid waste management is a rapidly growing issue. Excessive solids can cause problems at sewage treatment plants. Other issues of concern are disposal of faeces and urine from patients in isolation wards, particularly during epidemics where emergency disinfection of waste from a large number of infectious patients is required. Infectious effluents from health care facilities need special treatment. Waste of one industry has been used as a resource for another industry, examples are the waste to energy concept, reuse of packing material, recycling of waste such as plastics, mercury, lead, cadmium, etc. Various studies have shown that 20-88 per cent waste can be recycled. Japan recycles 50 per cent of its paper waste, 55 per cent glass bottles, 66 per cent food, and beverage cans. In USA 23 per cent paper waste, 9 per cent glass waste, 25 per cent aluminum waste are recycled. Mining of old landfills more than 40 years is now being undertaken to recover metal waste from these sites.

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Health Care Waste: Definitions

1.3.4

Liquid Health Care Waste and its Sources

Body fluids have the potential to harbour pathogens such as HIV and hepatitis B viruses and various other pathogens. It includes blood, serum, plasma, semen, vaginal secretions, CSF, synovial, pleural, peritoneal, pericardial and amniotic fluids. Body secretions e.g. nasal discharges, saline, sputum, tears, urine and vomitus shall not be considered biomedical waste unless visibly contaminated with blood. Table 1.6 contains list of commonly found pathogens in body fluids.
Table 1.6: Commonly Found Pathogens in Body Fluids Pathogens in Body Fluids Blood Staphylococcus sp. Human immunodeficiency virus (HIV) Staphylococcus aureus, Enterobacter, Enterococcus, Klebsiella, Streptococcus sp. Candida albicans Junin, Lassa, Ebola viruses Hepatitis B and C viruses Faeces and/or Vomit Salmonella, Shigella sp. Vibrio cholerae Helminthes Hepatitis A virus (faeces only) Saliva Mycobacterium tuberculosis, measles Gastroenteric infections Viral hepatitis A Type of Infection Septicaemia Acquired immunodeficiency syndrome (AIDS) Bacteraemia

Candidaemia Haemorrhagic fevers Hepatitis B and C

Respiratory and systemic infections

Liquid waste from health care facilities contains hazardous chemicals, pharmaceuticals and radioactive isotopes besides containing microbiological pathogens. Chemicals used in health care establishments are potential source of pollution, mainly to water system via the sewer system. Micro-organisms from health care waste water might cause outbreaks of diarrhoeal diseases, e.g., cholera, gastroenteritis, dysentery, etc. Health care facility effluents not only have chemical impurities but also contain high loads of multiple drug resistant bacteria thus discarding untreated/undiluted effluents into the municipal sewage system is a grave public hazard. Liquid waste may have multiple drug resistant (MDR) bacteria which may cause infections in the community and would pose a serious therapeutic problem. This can be more dangerous than the infections caused by normal strain. In order to avoid mixing of health care facility liquid waste with the municipal sewer system, it is essential to install an effluent treatment plant, at least in large health care facilities. While infectious and solid waste have received some attention, the management of liquid waste has often been overlooked. Liquid waste when improperly handled and disposed off, poses a serious threat to human health because of their possibility to enter and pollute ground water and drinking water.

1.3.5

Biodegradable and Non-biodegradable Waste

Health care wastes can also be classified into the following categories: a)
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Biodegradable Waste: It consists of mainly organic wastes such as peelings of potatoes, bananas, saw dust and water hyacinth dumped within the municipal

environment and these constitute bulk of the generated wastes. It also includes paper and natural fibres. b) Non-biodegradable Waste: It consists of disinfected plastic syringes, polythene bags, plastic products, toys, process wastes, highly flammable and volatile substances, obsolete electronic devices such as discarded PCs and mobile phones, metal scrap.

Definitions, Types and Categories of Waste

Re-processing of health care wastes can be profitable and it also helps waste reduction. Plastics are non-biodegradable and remain in environment indefinitely as waste. Haphazard disposal of polyethylene and other plastic waste has become a serious environmental and health problem. In the absence of well-established plastic waste recycling norms and facilities, these problems will increase in future. Therefore, as much as possible, the use of plastics should be discouraged notably PVC containing plastics as far as possible in favour of paper, glass, cloth and some other biodegradable material. Use of plastics in certain segments may be unavoidable, but it can definitely be minimised. In such circumstances use of biodegradable plastics should be encouraged in place of nonbiodegradable plastics. Check Your Progress 2 Tick True or False: 1) 2) 3) 4) 5) Exposure to hazardous health care waste can result in disease or infection. All individuals exposed to hazardous health care waste are potentially at risk. After use, a syringe becomes a potential infectious waste. Food waste/non-infectious hospital solid waste is a source of potential risk. Segregation is the key to successful waste management programme. (True/False) (True/False) (True/False) (True/False) (True/False)

1.4

CATEGORIES OF HEALTH CARE WASTE

There are various categories of bio-medical waste. Each category has to be disposed according to its characteristics. Waste has been categorised in many ways. As you have seen above, the waste comes from many sources and can be classified in a number of ways according to its source and attributes, in different institutions and in different countries. Let us learn the categorization as per WHO and Government of India Gazette Notification and categories of health care waste in other countries.

1.4.1 Categories as Per World Health Organization

WHO categorisation of waste has already been elucidated in Table 1.5. Each category is now being elaborated in order to enable you to identify the areas where waste gets generated so that effective measures at the points of generation can be taken to safeguard yourself, those working with you and around you in addition to the environment. a) Infectious Waste Infectious waste is suspected to contain pathogens (bacteria, viruses, parasites or fungi) in sufficient concentration or quantity to cause disease in susceptible hosts. This category includes following:

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Health Care Waste: Definitions

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Infected sharps. Waste from surgery and autopsies on patients with infectious diseases (e.g. tissues, and materials or equipment that have been in contact with blood or other body fluids); Waste from infected patients in isolation wards (e.g. excreta, dressings from infected or surgical wounds, clothes heavily soiled with human blood or other body fluids); Waste that has been in contact with infected patients undergoing haemodialysis (e.g. dialysis equipment such as tubing and filters, disposable towels, gowns, aprons, gloves and laboratory coats); Infected animals from laboratories; Any other instruments or materials that have been in contact with infected persons or animals. Cultures and stocks of infectious agents from laboratory work; waste from autopsies, animal bodies, and other waste items, that have been inoculated, infected or in contact with such agents are considered highly infectious waste. Pathological Waste

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b)

Pathological waste consists of tissues, organs, body parts, human blood and body fluids animal body parts and carcasses. c) Sharps

Sharps are items that could cause cuts and puncture wound or pierce skin and mucosa. It includes needles, hypodermic needles, scalpels, other blades, knives, infusion sets, saws, broken glass and nails. Whether or not they are infected, such items are usually considered as highly hazardous health care waste. d) Pharmaceutical Waste

Pharmaceutical waste includes expired, unused, spilt, contaminated pharmaceutical products and drugs that are no longer required and need to be disposed off appropriately. This category also includes discarded items used in the handling of pharmaceuticals, such as bottles or boxes with residues, gloves, masks, connecting tubing and drug vials. e) Genotoxic Waste

Genotoxic waste is highly hazardous and may have mutagenic, teratogenic and/or carcinogenic properties. It poses serious safety problems both inside health care facilities and outside the health care facilities and should be given special attention. Genotoxic waste may include certain cytotoxic drugs, but also vomit, urine, and/or faeces from patients treated with cytotoxic drugs, chemicals and radioactive material. In specialized cancer hospitals, genotoxic waste (containing cytotoxic or radioactive substances) may constitute as much as one per cent of the total health care wastes. Cytotoxic (or antineoplastic) drugs, the principal substances in this category, have the ability to kill or stop the growth of certain living cells and are used in chemotherapy of cancer. Cytotoxic drugs are most often used in specialized departments such as oncology and radiotherapy units, whose main role is cancer treatment, however, their use in other hospital departments is increasing and they may also be used outside the hospital setting. Cytotoxic wastes are generated from several sources and can include the following:
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Contaminated materials from drug preparation and administration, such as syringes, needles, gauges, vials, packaging;

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Outdated drugs, excess (leftover) solutions, drugs returned from the wards; Urine, faeces and vomit from patients, which may contain potentially hazardous amounts of the administered cytotoxic drugs or of their metabolites and which should be considered genotoxic for at least 48 hours and sometimes up to one week after drug administration. Radioactive Waste

Definitions, Types and Categories of Waste

f)

The ionising radiations of interest in medicine include the x-rays, alfa and beta particles, and gamma rays emitted by radioactive substances. An important practical difference between these types of radiation is that x-rays from x-ray tubes are emitted only when generating equipment is switched on, whereas radiation from radionuclides can never be switched off and can be avoided only by shielding the material. Radionuclides continuously undergo spontaneous disintegration (known as radioactive decay) in which energy is liberated, generally resulting in the formation of new nuclides. The process is accompanied by the emission of one or more types of radiation, such as alfa and beta particles and gamma rays. These cause ionization of intracellular material; radioactive substances are, therefore, genotoxic. Radioactive waste includes solid, liquid and gaseous materials contaminated with radionuclides. It is produced as a result of procedures such as in-vitro analysis of body tissue and fluid, in-vivo organ imaging and tumor localization and various investigative and therapeutic practices. In India, radioactive waste and material is required to be handled by the guidelines issued by the Bhabha Atomic Research Centre, Mumbai. (www.barc.ernet.in/ ) g) Chemical Waste

Chemical waste consists of discarded solid, liquid and gaseous chemicals, e.g. from diagnostic and experimental work and from cleaning, housekeeping and disinfecting procedures. Wastes with High Content of Heavy Metals: Wastes with a high heavy-metal content represent a subcategory of hazardous chemical waste and are usually highly toxic. Mercury wastes are typically generated by spillage from broken clinical equipment. Their volume can be decreased by the substitution of solid-state electronic sensing instruments (thermometers, blood pressure gauges, etc.). All efforts must be made to manage and contain spilled mercury, however, small in quantity it may be. (More on mercury spills at www.toxicslink.org) Cadmium waste comes mainly from discarded batteries. Certain reinforced wood panels containing lead are still used in radiation proofing of x-ray and diagnostic departments. A number of drugs contain arsenic, these are treated here as pharmaceutical waste. h) Pressurised Containers

Many types of gases are used in health care and are often stored in pressurized cylinders, cartridges and aerosol cans. Many of these, once empty are of no further use (although they may still contain residues). Whether inert or potentially harmful, gases in pressurized containers should always be handled with care; containers may explode if incinerated or accidentally punctured. Following are commonly used gases used in health care:
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Anaesthetic Gases: Nitrous oxide, volatile halogenated hydrocarbons (such as halothane, isoflurance and enflurane), which have largely replaced ether and chloroform in the operating theatres, during childbirth in maternity hospitals, in ambulances, in general hospital wards during painful procedures, in dentistry, for sedation, etc.

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Health Care Waste: Definitions

Ethylene Oxide: For sterilization of surgical equipment and medical devices, in central supply areas and at times, in operating rooms. Oxygen: Stored in bulk tank or cylinders, in gaseous or liquid form, or supplied by central piping. Compressed Air: In laboratory work, inhalation therapy equipment, maintenance equipment and environmental control systems. Aerosol Containers: In dressing and first aid room.

1.4.2 Categories as Per Gazette Notification of India

Waste categories as per Bio-medical Waste (Management and Handling) Rules 1998 are elucidated in Table 1.7.

1.4.3 Categories as Per Thailand Authorities

Thailands high economic growth since the late 1980s has mostly been due to the countrys rapid industrialisation. Industrialisation has introduced to Thailand, as it has elsewhere, the use of hazardous substances as raw materials and the production of hazardous wastes. The hazardous waste problem in Thailand has dramatically worsened in recent years. Thailand is now a country with a high hazardous waste potential and so far there is no formal definition of hazardous waste in Thailand. The Environmental Quality Standards Division, Office of the National Environment Board, used to provide a definition of hazardous wastes as substances or materials which are not used or cannot be used, which contain or are contaminated with combustible substances, corrosive substances, highly active substances, explosives, toxic substances, soluble substances, radioactive substances, and/or disease producing organisms which are produced by various industrial, community, agricultural activities. A 1999 study co-sponsored by the United States Agency for International Development (USAID) and the United States Environment Protection Agency (USEPA) identified three categories of environmental health risk in Bangkok:
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The high risk category includes: (i) particulate matter, (ii) lead, and (iii) microbiological diseases; The medium risk category includes: (i) carbon monoxide, and (ii) other metals; The low risk category includes: (i) toxic air pollution, (ii) other air pollutants (SO 2 , Nitrogen oxides and Ozone, (iii) surface water contamination, (iv) ground water contamination, (v) food contaminants, and (vi) solid and hazardous waste disposal. (More at: www.ehproject.org/PDF/Lessons_ Learned/comp_risk_assess.pdf )

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Waste generation pattern in Thailand Health Care Quantity of Waste Facility Hospital Clinics 0.43 kg/bed/ day 0.50 kg/ clinics/day

Health care services in Thailand are offered at 33,000 settings. Health care waste generated at health care facilities is 0.43/kg/bed/day and from clinics is 0.50 kg/clinics/day. Total health care waste is 56 tons/day, when properly segregated. The regulation on infectious waste management (2002) is under Public Health Act BE 2535 (1992). Segregation is done at source and containers/bags used for infectious waste are labeled with bio-hazard symbol. The term infectious waste includes:
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Body parts Sharps Discarded materials Waste from wards

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Fig.1.7: Categorisation of Waste as per Indian Authorities Option Waste Category/Class (human tissues, organs, body parts) Category No. 2 Animal Waste (animal tissues, organs, body parts, carcasses, bleeding parts, fluid, blood and experimental animals used in research, waste generated by veterinary hospitals, discharge from hospitals, animal houses) Category No. 3 Microbiology and Biotechnology Waste (wastes from laboratory cultures, stocks or specimens or micro-organisms, live or attenuated vaccines, human and animal cell or culture used in research and infectious agents from research and industrial laboratories, wastes from production of biologicals, toxins, dishes and devices used for transfer of cultures) Category No. 4 Waste Sharps (needles, syringes, scalpels, blades, glass, etc. that may cause puncture and cuts. This includes both used and unused sharps) Category No. 5 Discarded Medicines and Cytotoxic Drugs (wastes comprising of outdated, contaminated and discarded medicines)
5 Category No. 6 Soiled Waste (items contaminated with blood and body fluids including cotton, dressings, soiled plaster casts, linen beddings, other material contaminated with blood)

Definitions, Types and Categories of Waste

Treatment and Disposal Incineration1/Deep burial2 Incineration1/Deep burial2

Category No. 1 Human Anatomical Waste

Local autoclaving/ microwaving incineration1

Disinfection (chemical treatment 3/autoclaving/ microwaving and mutilation/shredding4

Incineration1/destruction and drugs disposal in secured landfills Incineration1 / autoclaving/ microwaving

Category No. 7 Solid Waste (waste generated from disposable items other than the waste sharps such as tubing, catheter, intravenous sets etc.) Category No. 8 Liquid Waste (waste generated from laboratory and washing, cleaning, housekeeping and disinfecting activities) Category No. 9 Incineration Ash (ash from incineration of any biomedical waste) Category No. 10 Chemical Waste (chemicals used in production of biologicals, chemicals used in disinfection, as insecticides, etc.)

Disinfection by chemical treatment 3/autoclaving/ microwaving and mutilation/shredding4 Disinfection by chemical treatment 3 and discharge into drains

Disposal in municipal landfill

Chemicals treatment 3 and discharge into drains for liquids and secured landfill for solids

1 There will be no chemical pretreatment before incineration. Chlorinated plastics shall not be incinerated. 2 Deep burial shall be an option available only in towns with population less than five lakhs and in rural areas. 3 Chemical treatment using at least 1% hypochlorite solution or any other equivalent chemical reagent. 4 Multilation/shredding must be such so as to prevent unauthorized reuse. 5 Amended from solid to soiled vide Government of India notification

It must be ensured that chemical treatment ensures disinfection.

dated 2 June 2000.

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Health Care Waste: Definitions

All types of health care waste excluding sharps are packed in red bags. Sharps are packed in red boxes and drums. The National Policy and Plan for infectious waste management advocates that in general principle, the infectious waste would be handled in a proper manner from cradle to grave. The national committee on infectious waste management has been established for defining the national plan for health care waste management, controlling the budget allocation, monitoring the health care waste management system and coordinating amongst relevant agencies. There are three major plans for health care waste management in Thailand:
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Development and establishment of the central health care waste disposal system. Development of the network system for central health care waste management. Capacity building of relevant organizations personnel.

1.4.4

Categories as Per Indonesian Authorities

Indonesia has 5 big Islands and over 13,000 small islands. There are 30 provinces, 362 districts and a total population of 224 million, 4th largest population in the world. Framework of legislation is stipulated for hazardous waste management. Sharps and other health care wastes are classified as infectious waste, which has one of the hazardous characteristics. A waste code has been developed and designated as D-227. Sources of waste are hospitals and clinical laboratories. The health care waste is classified into following categories:
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Chemical Waste Expired Pharmaceuticals Contaminated Aspirations/Sharps Laboratory Waste Incinerator Residue

Following are few of current practices of health care waste management in the country:
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Segregation at source (in most health care facilities but still need improvement, few conducted in health centres) Open burning (in some health care facilities and most centres) Incineration (some health care facilities operate, small coverage) Pit burial (practiced in most health centres) Disposal in landfills (especially in big cities) Recycle process (most preferable, but performed by scavengers and is environmentally not sound)

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1.4.5

Emerging Concepts of Categorisation in South-East Asian Countries

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Hazardous waste is increasingly becoming an important environmental and public health issue in most developing countries. Improper management of hazardous waste can cause serious damage to human health and environment. Therefore, an effective management of hazardous waste is of paramount importance for the protection of human health and environment.

While health care waste management has become a serious concern in South-East Asia Region (SEAR), a few governments in the region have an adequate framework or structure in place to address the issue on a national level. On an average between 0.8-2.2 kg/bed/day waste are generated in health care facilities of the SEAR. Only a small portion of the waste is infectious. Most health care facility do not have a waste management plan or any procedure. In many countries there is no separate legislation for managing health care waste. There is also lack of guideline or manuals. Health care providers do not segregate the waste leaving a maximum opportunity of mixing hazardous with non-hazardous waste. Most of the health care facilities do not have a final treatment system like any autoclave or perfect incinerator. Wastes are not segregated and the main disposal technique is still open air burning or roadside dumping, causing human health hazard and environmental pollution. The United Nation Conference on the Environment and Development (UNCED) in 1992 recommended a set of measures for waste management, which are as follows:
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Definitions, Types and Categories of Waste

Prevent and minimize waste production Reuse and recycle the waste to the extent possible Treat waste by safe and environmentally sound methods Dispose off the final residues by landfill in confined and carefully designed areas.

In November 1996, WHO arranged regional consultation at Chiang Mai in Thailand where representatives of nine SEAR countries outlined an action plan to develop sound management programme for health care waste and legislation on waste management. We shall now learn in brief the current concepts of health care waste management in some of the other SEAR countries. Bhutan Uptill now no specific national policy on health care waste management has been elaborated for Bhutan. The Department of Health acknowledges the necessity of preparing an overall national policy and strategy on health care waste management in order to be able to enforce sufficient and sustainable measures for handling and treatment of health care waste at the individual health care institutions; and basic health units (BHUs). Waste generated at health care institutions in hospitals or BHUs can be divided into the following four main waste groups having the designated colour-codes as shown in Table 1.8.
Table 1.8: Different Waste Groups in Bhutan Category of Waste Infectious waste in the form of sharps Waste Description Cutting and piercing objects used in the care or treatment of patients, e.g. syringes, needles, scalpel-blades, ampoule pieces, etc. Possibly containing micro-organisms from diagnostics and treatment of patients, e.g. petri-dishes containing live bacteria and/ or viral, drain bottles containing blood and/or body fluids, bloody or humid bandage material, blood transfer systems, etc. Colour Code Yellow

Other infectious waste

Red

Ordinary dry waste similar Paper, cardboard, plastics etc. to household waste Food waste Food waste from kitchen facilities and wards

Green Blue 23

Health Care Waste: Definitions

Organic waste such as human tissue and organs (placentas, etc.) are typically handed over to relatives for burial according to Bhutanese tradition. A vital part of the national strategy now is to integrate the revised existing National Guideline on Infection Control in Health Care Settings, which also addresses the question of waste management in order to establish a common frame of reference between the National Environment Commission, and the Department of Health under Ministry of Health and Education. The Environmental Code of Best Practices (ECOP) for hazardous waste management forms a part of several ECOP prepared by the National Environmental Commission (NEC). Bangladesh Bangladesh is a densely populated country of about 130 million people which lies in the northeastern part of South Asia. Population pressure, shrinking employment opportunity, inequity of access to quality education has limited the impact of poverty eradication process undertaken by Government of Bangladesh. Presently there are around 645 public and 288 private sector health care establishments. Safe disposal of waste is still absent in health care facilities, despite several sustained efforts. Understanding the problems caused by health care waste, very recently the Bangladesh government has framed the draft Hazardous Health Care Waste Management Rules 2003, which are similar to the Indian regulations. Even with the rules in place waste generated in most urban and rural areas is disposed off in open dumps, waste has also been known to clog sewerage and encroach on roadway, give off unpleasant odor and dust. Wind also carries pathogens and hazardous materials, from the site of origin to other places. The waste pickers (Tokai) sort out through the waste usually at open dumps and sell anything that can be replaced or reused. These situations are similar to the ones found in India. Nepal In Nepal there were no specific National policies on waste till 1996. Studies have revealed that majority of health care institutions do not practice safe waste handling storage and disposal methods. Under the National Health Care Technology Strategy of the Second Health Plan (1997-2017), a functional guideline to manage medical waste at all levels, including private sector, has been envisioned. Recently for the first time a bill has been tabled in the parliament with provision of managing health care waste. Under the National Health Care Technology Strategy of the Second Health Plan (1997-2017), a functional guideline to manage medical waste at all levels, including private sector, has been envisaged. Recently for the first time a bill has been tabled in the parliament with provision of managing health care waste. One estimate of the quantum of health care waste in the country is shown in Table 1.9.
Table 1.9: Health Care Waste Generation in Nepal Generation of Health Care Waste Small HCFs per day Health posts etc. per day Medium HCFs per day Large HCFs per day Total per day Quantum of Generation (in kilograms) 456 1,910 1,130 2,034 5,530 20,18,450

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Total per year

Sri Lanka Sri Lanka has a population of over 19 million of which some 16 per cent are urban dwellers. Life expectancy in the country is 73 years. The overall generation of health care waste is approximately estimated at 15 tons a day. 25 per cent production of health care waste comes from the Greater Colombo area alone. The production of sharps at health care facilities varies between 0.01 and 0.02 kg/bed/day. Existing health care waste management policies are not well implemented thus inducing harmful environmental effects. There are attempts in all medical institutions to segregate different types of waste at source. Nevertheless, segregation is often not maintained during collection, transportation and disposal. Hence the current health care waste management result in significant risks to the public health. Health care waste management does not guarantee a satisfactory control on the transmission of nosocomial infections throughout the health care facilities. A potential National Action Plan proposes measures to be taken up by MOH for the whole country. Current legislation is to be modified by editing a specific regulatory document (law or decree) for the management and disposal of health care waste. It is proposed to upgrade the current health care waste management process in Sri Lanka under NAP by: 1) 2) 3) 4) 5) 6) Consolidating legal, regulatory and monitoring framework for management and disposal of waste, Equipping the medical institutions, Facilitating health care waste management systems at medical institutions and at provincial levels, Reinforcement of ongoing awareness and training programmes, Development of specific financial resources through the implementation of adequate cost recovery mechanism, Plan to minimize health care waste and pollution.

Definitions, Types and Categories of Waste

Check Your Progress 3 Tick the correct answer: 1) All of the following should be carried in protected containers, except: a) b) c) d) e) 2) Pus Blood product Contaminated liquids Human flesh Fruit peels

Which of the following wastes are generated in a hospital, except: a) b) c) d) e) f) g) h) Paper Wool Human flesh Blood product Sharp Glasses Cotton Fruit and vegetable peels
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Health Care Waste: Definitions

1.5

LET US SUM UP

In this unit, you have learnt as to what is waste, definition of waste and why management of health care waste effectively is important and that all health care facilities must have a sound health care waste management system. The aim being, to minimize the health hazards for providers of health care services and those who seek it. The need for identification, segregation, collection, storage and disposal of hazardous waste as only 10-15 per cent of health care waste is hazardous if mixed with rest of the 85 per cent of non-hazardous waste it will make the whole waste hazardous. You have also learnt the various types of wastes generated, their source and different categories of waste, their definition and classification as per different religion, nationality and standard. After having studied this unit with respect to concept, importance, definition and classification you should be able to organize an efficient and effective waste management system in your organization or wherever you serve.

1.6 KEY WORDS

BHU BMW ECOP HCF HIV MDR MOH MSW NAP NEC POP SEAR UNDP USEPA WHO : Basic Health Unit : Biomedical Waste : Environmental Code of Best Practices : Health Care Facility : Human Immunodeficiency Virus : Multi Drug Resistant : Ministry of Health : Municipal Solid Waste : National Action Plan : National Environmental Commission : Plaster of Paris : South-East Asian Region : United Nations Development Programme : United States Environment Protection Agency : World Health Organization

UNCED : United Nations Conference on Environment and Development

1.7 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1 1) Bio-medical Waste (Management and Handling) Rules 1998 (and subsequent amendments) are applicable to all persons who generate, collect, receive, store, transport, treat, dispose and/or handle bio-medical waste in any form. All health care facilities attending to 1000 (one thousand) patients per month are required to seek authorisation from the prescribed authority. Health care waste includes wastes like sharps, soiled dressings, body fluids, disposables, anatomical parts, microbiological cultures, discarded medicines, chemical waste, syringes, glass bottles (broken and intact, both) and ampoules, glass slides, tissue for histopathological examination, foetuses, placenta, samples in pathology department, etc.

2)

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Check Your Progress 2 1) 2) 3) 4) 5) True True True False True

Definitions, Types and Categories of Waste

Check Your Progress 3 1) 2) e) b) Fruit peels Wool

1.8 FURTHER READINGS

Govt. of India, Bio-medical Waste (Management and Handling) Rules, 1998, The Gazette of India. Ministry of Environment and Forest. Pruss, A. and Townend, W.K., Teachers Guide: Safe Management of Waste from Health Care Activities, WHO, 1998. WHO, National Guidelines for Implementation of Health Care Waste Management, WHO IND EHH 001. WHO, Survey of Health Care Waste Management in South-East Asia Region, SEARO, New Delhi.

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