India - Uttar Pradesh Health Systems Development Project : environmental assessment

E- 310 Uttar Pradesh Health Systems Development Project I Hospital Waste Management Assessment and Plan Need for Hospital Waste Management In the past years, the focus in health care institutions universally has been on delivery of services and not on its side effects. Large volumes of wastes are generated in these institutions as by-products of many services and procedures. Dressing of wounds, surgical procedures, investigations, deliveries, dental procedures, post mortem, dialysis are some activities which produce wastes part of which are infectious and hazardous in nature. Waste dumps may even contain unused medical supplies. While advances in rnedical and health care delivery have had a positive impact on the health status of the community, the careless dumping of health care waste and the consequent environmental impact have had a significant negative impact on the community. This has led to an increasing awareness of the need to understand the nature of hospital wastes and clevelopment of effective strategies for its disposal. Existing situation There is currently no effective, hygienic and systematic approach for health care waste management in health care facilities in the State. The system prevailing is at best, collection of all categories of wastes including plastic and body parts in cardboard boxes or metallic bins and dumping them into a pit where the waste is periodically burnt. The disposable syringes and catheters are reused after inadequate sterilisation. Infectious pathological liquid waste is drained into sewerage without decontamination. Hazards and risks from Hospital waste exposure Indiscriminate disposal of health care facility waste has been found responsible for many health hazards for different cross sections of the community. The following may be listed as important: - * Occupational hazard to personnel handling wastes. E.g. Hospital staff, contract worker like milkman, laundering staff etc. * Health hazard to patient's visitors, by spread of nosocomial infections. * Community health through blocked drains, flies and mosquitoes, rag pickers, children. Fatal diseases like HIV, Hepatitis B & C and epidemic diseases like cholera, Typhoid may spread. * Environmental hazards from burning plastics such as PVC, discarding equipment with mercury and cyto-toxic drugs, contamination of drinking water sources by leachate. * The ugly stench and sight of these indiscriminately disposed bio medical wastes may be highly discouraging for users of these health facilities. Studies in developed and developing countries have revealed that the amount of waste generated per patient per day depends on the type of services offered and the extent 1  of disposable syringes etc., used in the institution. While developing countries generate as high as 4-5 kg of wastc per bed day the W'-HO estimate for low income group countries ranges from 0.5 to 3 kg/bed day (Average 1.5 kg). Although on the surface, the risk of improper management of a voluminous waste exists, it is known from studies that in fact only 15-20 percent of the total health care waste is infectious and/or bio-hazardous. The rest 80-85 percent of waste is made up of general or domestic type of waste, which is non-infectious and non-hazardous. Thus, the issue of concern is to recognise the potential hazard of bio-medical waste from hospitals and to identify means of segregating and effectively disposing the bio-hazardous components of the waste. Legal Issues: The Goverrnent of India, recognising the importance of sanitary disposal of health care waste, developed draft Bio-medical rules in 1995 under the Environment (protection) Act 1986, and modified the same in 1997. Finally in July 1998, the Bio- medical Waste (Management and Handling) Rules have been notified. The Rules spell out roles and responsibilities for all those concerned in the generation and effective disposal of health care waste. As per these rules, hospital waste is bio-medical waste generated in treatment and diagnostic facilities by various laboratories, surgical and delivery procedures. It needs to be collected and disposed off in an effective and hygienic way to prevent occupational and environmental hazards and nosocomial infections in hospitals. The salient features of the rules are as under: - 1. The medical officer in-charge of the health care facility is the "Authorised Person" who is authorised to generate and handle waste as per guidelines. 2. Bio-medical waste facility is any facility where treatment, disposal of bio-medical waste is carried out. 3. Bio-medical wastes have been categorised in to 10 groups. 4. Bio-medical waste should be segregated, packed, treated, and transported, stored and finally disposed as per specified guidelines. 5. The generator of the waste should follow technologies and specified standards given in guidelines. 6. Records and reports shall be maintained on the formats shown in the rules. Classification of Wastes The type of service decides the category of wastes that the facility generates. E.g., Operation theatre generates most of the pathological and highly infectious wastes whereas laboratory generates chemical wastes and sharps. Bed occupation and type of service facilities decide the quantity and the category of waste generated. While sub- centres and block PHCs mostly generate general wastes, sharps and some infectious and pathological wastes, CHCs and sub-district hospitals generate substantial amounts of infectious, pharmaceutical and pathological wastes and some chemical wastes. The category of health care facilities in UP and their waste profile is given in the following table. 2  Table 1 Tvpe & Amount of Waste by Type of Health facility S. I Facility with Type of service Categorv of waste Amount of j No bed strength [ waste * X Sub-Centre 1 Treatment of minor illness, General waste, sharps, Negligible Preventive-care. Phannaceutical waste, 2 FP and immunisation Limited infectious waste 3 Ante natal care 4 Delivery services 2 PHC/Block PHC Out patient services General waste, infectious 5 Kgs per 4 beds Curative and preventive care waste, pharmaceutical day Inpatient services for waste and pathological delivery waste 3 CHC Outpatient and in-patient General waste, infectious 36 Kgs per 30 beds care. Waste, pharnaceutical day Some speciality care Waste, pathological waste, Some minor and major Chemical waste surgery ___ Some diagnostic services 4 Combined All of the above & more All of the above 120 KGs per Hospital speciality care. day 100 beds . 5 District Hospital All of the above and radio All of the above and 200-400 200 to 400 beds Active treatment Radioactive waste KGs per day 6 Speciality All of the above and radio All of the above and 300-500 Hospital active treatment radioactive waste KGs per > 400 beds day *Calculated for an attainable bed occupied rate of 80% On an average, hospitals produce 1.5 Kg of waste per bed day of which only 15%, i.e., 0.22 Kg / bed day is infectious and / or hazardous and needs pre-disposal treatment. Accordingly, the total waste, which needs to be segregated and treated in BPHC, 30,100, 200 and more than 200 bedded hospitals, will be I Kg, 7 Kg, 23 Kg, 46 Kg, and 70 Kg respectively. The waste generated by the healthcare facilities in the fall into the following categories of wastes defined in the Bio-medical Waste (Management and Handling) R ules. 3  Table 2 Types of Waste Produced in Health Care Facilities Waste category Description Area where produced General Papers, magazines, packaging material, IReception, corridors, (domestic/Non- plastics, used containers, food waste, waiting rooms, wards, hazardous) vegetable, and fruit peels. consulting rooms and waste offices. Infectious and hazardous wastes: Category 1 Human tissues and organs, Operation theatre, Body parts and body fluids, Delivery room, casualty, Placenta, infected laboratory, and post- Blood-soaked linen etc. mortem room. Category 3 Microbiology and micro technology Laboratory. waste (Laboratory culture, stocks, specimens, etc.) Category 4 Waste sharps (needles, syringes, blades, Injection rooms and glass, nails etc. dressing rooms, operation theatres, wards casualty, labour room, and dental surgery. Category 5 Discarded medicines and cyto-toxic Pharmacy, dispensary, drugs (out dated, contaminated and and wards. discarded medicines). Category 6 Solid waste (items contaminated with Operation theatre, labour blood and body fluids like cotton, ward, casualty, wards, dressings, plaster casts, bedding, etc.) dressing room. Category 7 Solid waste (waste from disposable Casualty, Operation items like intravenous bottles, sets, theatre, labour room, catheters etc). wards. Category 8 Liquid waste Laboratory Category 10 Chemical waste (Chemicals, disinfectant All areas of hospital and other biological used) I Note: Category 2 & 9 are not likely to be produced in healthcare facilities. 4  Procedure for Waste Disposal Hospital waste is generated in the fonn of liquid and solid waste. The liquid waste, part of which can be infectious, such as one from laboratory, may be disposed into the closed drainage through the sink-s after decontamination. The solid waste disposal technique involves the following steps, which have been recommended in the Government of India gazette notification on Bio-medical Waste (Management and Handling) Rules, 1998. Step 1: Source Segregation anid Collectionz of Waste Infectious and hazardous hospital waste such as pathological waste, pharmaceutical waste, chemical waste, waste sharps, microbiological waste and clinical waste are carefully segregated at point of generation and collected in thick, non-corrosive plastic bags of specific colours as indicated in the rules. These bags are kept inside a hard plastic reusable container of the same colour with a swinging lid. The containers are labelled appropriately using non-washable material. These are placed at points of waste generation. Segregation at source of infectious waste from non-infectious waste reduces risk of occupational and environmental hazards, makes the technology cost effective and helps to retrieve recyclable waste. Plastic bags when three quarters full with waste are collected daily for disposal. Step 2: Internal Transportation Waste containing bags from source are transported through non sterile corridors of the hospital to a well secured waste store using suitable metallic trolleys or wheel barrows. Step 3: Treatment While non-infectious general waste may be disposed of directly, all infectious and hazardous waste collected must be rendered non infectious, non reusable, less bulky and aesthetically acceptable by undergoing treatment using one of the available techniques. a) Chemical disinfection with a suitable neutral disinfectant, which attains at least level II disinfection (kills vegetative bacteria, fungi, viruses and myco-bacteria) is a relatively cheaper method but with low efficacy. Sodium Hypo-chloride, Bleaching Powder, or other quatemary ammonium compounds may be used. Phenol is less efficacious as its use over years has developed resistant organisms as revealed by some recent studies. Factors like concentration of disinfectant and contact time decide effectiveness of this method of treatment. b) Shredding or mutilation of disposable syringes and needles, plastic IV and blood bags, catheters, rubber tubes gloves etc. by needle and syringe destroyers and scissors. Hospital with bed strength more than 100 may require shredders. c) Microwaving renders all non- infectious waste except that of I and II category of the bio-medical rules. The equipment destroy spores of Bacillus Subtilis at a concentration of lx 104 spores / mm and must comply with efficacy tests. Microwaves of different capacities may be required for hospitals with different bed strengths. d) Incineration is another treatment option, which can be easy, fast, and effective as a method of treatment and disposal. Public perception and fear of toxic emission is the 5  primary disadvantage of using this technology. However, state-of-the art incinerators are available which eliminate the environmental hazards due to noxious emission of gases like dioxin and furons. With careful segregation of chlorine containing plastics and metals, use of incinerators is an appropriate option for effective disposal of waste in hospitals above 100 beds. The cost of incinerator will be funded by the State Government e) Autoclaving of waste is a less cost-effective technology than Microwaving and has the same limitations as Microwaving. Both gravity flow and vacuum autoclaves must conform to standards as given in rules and must answer the required validation test; the capacity of the autoclave depends on the capacity of the hospital. Step: 4: Waste disposal Segregation and treatment groups the hospital waste into the following, which need to be finally disposed off in an appropriate way in accordance with the bio-medical rules: 1. General wastes a) Non. Bio-degradable b) Bio-degradable 2. Recyclable wastes 3. Non-recyclable, and non-infectious wastes. The options available for the disposal of these wastes are: A. Land -fill: Treated, non-biodegradable infectious waste and general waste may be dumped into an engineered landfill. This is a specially constructed area, chosen at a proper location away from service and residential localities. The capacity of such a land fill may vary depending upon the waste generated as shown in the table below: An engineered landfill should have the following features: 1. An impermeable layer of clay/ stone masonry 2. A super structure to prevent rain water flooding. 3. A secured mesh door. 4. Stored earth to cover on the waste disposed. B. Deep burial: Biodegradable organic waste such as human tissue blood soaked linen etc. mentioned in category I and 2 of the bio-medical waste rules should be disposed off into a deep burial without treatment. A deep burial is an excavated pit of depth 6 feet provided with super structure and secured mesh door. A relatively impermeable and elevated land away from service and residential areas and water sources may be chosen for its construction. 6  Table 3 Dimensions for Landflll and Deep Burial SI. 1 Type of hospital Dimension of Capacity Deep burial Capacity(cu. j No T (bed capacity) landfill (ft) (cu. ft) Dimension(ft) ft) lx bx d lx bx d l BPHC 10x5x4 200 4x4x6 96 2 C_H_C__(30) lOx5x5 250 4x4x6 96 _ _ H 3 ) _ _ _ _ Combined hospital lOx lOx5 500 8 x 8 x 6 384 ~4- District hospital 15 x lO x 5 750 ___ (200 to 500) l C. Vermi-compost: Biodegradable general waste from kitchen and wards may be disposed off into a specially constructed Verni-compost, which converts the waste into a useful compost or manure over a period. The area should be well contained to be inaccessible to animals and birds. Strategies for health care facilities in UP There are 907 BPHCs, 307 CHCs, and 303 hospitals of all other types in UP. The strategies for these hospitals take into consideration the geographic settings of the hospital, the quantum of infectious waste generated and the availability of manpower. The Strategy is presented in Table 4. Waste minimization is a key initial ingredient in the strategy for waste management, and relies on intensive training. Waste segregation at source remains the main stay for effective and hygienic waste management in all the healthcare facilities. It ensures cost effectiveness and eliminates misuse of disposable syringes etc. In smaller facilities like BPHCs chemical disinfectants for decontamination of infectious wastes will be appropriate and cost effective. Large quantities of infectious wastes from bigger institutions need a better technology like microwave. The implementation of waste management strategy is limited to project during the first phase of the project, but plans are to then extend it across the state. The Waste Management Strategy will be implemented in the 50 BPHCs during the second year, in the 35 CHCs during the third year and in the 35 district hospitals each in the fourth and fifth years of the project. 7  Table 4 Strategy for Each Type of Waste by Institution Waste j Strategy for Strategv for Treatment and Disposal Category Segregation l H BPHC CHC Hospitals General Collect in * No treatment. * No Treatment. * No Treatment. Waste Green Dispose into Dispose into * Dispose into Engine ered Containers Engineered Engineered landfill. landfill. landfill Category 1 Collect in * No * No Treatment. * No Treatment. Yellow Treatment. * Deep burial * Deep burial. containers * Deep burial. Category 3 Collect in * Disinfect * Microwave - Microwave & 6 Red chemically * Dispose into * Dispose into Landfill Containers * Deep burial landfill Category 5 Collect in * Destroy * Destroy * Destroy Black * Dispose into * Dispose into * Dispose into land fill containers Land fill land fill Category 4 Collect in * Disinfect * Microwave * Microwave & 7 Blue Chemically * Mutilate * Shred containers * Mutilate * Store for * Store for Recycling * Store for recycling recycling Category 8 Collect in * Disinfect * Disinfect * Disinfect chemically leak proof chemically chemically Dispose into common drain bucket * Dispose into * Dispose into containing Common common drain disinfectant drain Category 9 - - Category Disinfect * Disinfect * Disinfect * Disinfect chemically 10 chemically chemically chemically * Dispose liquid waste into Dispose into * Dispose * Dispose liquid common drain and solid into Common liquid waste waste into land fill drain into common common drain and drain and solid solid into land fill into land fill Organisation, Training and IEC Health care waste management is a training-dependent, community-participatory and IEC-intensive programme. Before implementing the programme, every hospital should develop a strategy manual, which elaborates a specific waste management plan and guidelines for organisation, training of health and non-health workers and strategies for creating awareness in the community. Training emphasis at the outset will be on identification of waste management opportunities, particularly for waste minimisation. All staff will need to understand what to do to reduce and better manage waste, as well as why they need to do it and what the ramifications are. 8  Budget for Waste Management Table 5 Requirement of supplies & Annual Cost per Hospital Items Number Required Annual Cost per Hospital (Rs. Thousand)- jUnit BPHC CHC C H D H D H BPHC CHC DHF D H IDH ,Price 1>25 ;>250 Capital Investment 1 Land fill (Lump sum) . 100 100 l160 o o! Deep burial (Lump sum) i 50 50~ 80 100 100 Vermi compost (Lump 3 5 8 8 10 sum) Total Civil Works 1 53 l_55 248 108 110 Colour coded Plastic non- 200 20 75 150 250 400 4 15 30 50 80 disposable containers Table top needle and i 1500 1 10 20 30 40 1.5 15j 30 45 60 syringe destroyers _ _ _ _ Shredcler 100000 0 0! 1 1 2 0 0I 100 100 200 Microwave Capital cost 700000 0 1 1 5 5 T 0 700 700 3500 3500 Wheel Barrows & 4000 1 2 41 5 6 4 8 161 20 24 Implements J _ _ _ _ _ 1 Total Equipment 1 1 1 1 1 1 9.51 738 876 37151 38641 Sub-_otal | _ _ _ 162.5 893 1124 38231 39745 Operating Cost _ _ _ _ _ _ _ ________ Disposable plastic bags of 500 3.8 30 60 100 175 1.9 15 30 501 87.5 specified colours in 000s _ _ _ _______ ChemicalDisinfectant/Lt. 1 100 0.25 0.5 1 1.5 21 0.03 0.05 0.1 0.15 0.2 Protective gear for waste 1000 1 3 4 6 6 1 3 4 6 6 handlers Cost of Supplies _ _ _ i 2.93 18.05 34.1 56.15 93.7 Microwave Operating cost 0 I70 70 3501 350 @ 10 % of CC___ _____ Sub-l'otal j j I i I 1 _ 2.93j88.051104.10 406.1St 443.70 9  Table 6 Cost of Implementing Waste Management Strategy _ Year 1 Year 21 Year 3 Year 41 Year 5! Total| Institutions Number to be taken up each year BPHC 451 5 0 0 ol 50 CHC 0 35 0 0 0 35 DHF 0 5 11 16 0 32 DH<250 0 8 8 16 0 32 DH>250 0 3 0 0 3 Item of Expenditure Million Rs. Investment Costs Civil Works 6.891 8.29 3.92 5.70 0.00 24.80 Equipment 0.43k 59.98 50.95 73.46 0.00 184.81 Initial Supplies 0.13 1.27 1.11 1.44 0.00 3.95 Consultancy 0.60 0.60 0.60 0.60 0.00 2.40 Workshops 0.50 0.50 1.00 1.00 0.00 3.00 Training 0.50 0.50 1.00 1.00 0.00 3.00 CEG ___==_ 0.00 Sub-total 9.04 71.14 58.58 83.20 0.00 221.95 Recurring Costs 0.00 Consumables 0.13 1.27 1.11 1.44 0.00 3.95 O& M Cost of Civil Works 0.00 0.69 1.52 1.91 2.48 6.60 O& M Cost of Microwave 0.00 0.00 5.60 4.62 6.72 16.94 Sub-Total 0.13 1.95 8.22 7.97 9.20 27.48 Total [ 9.18 73.09 66.80 91.17 9.20 249.44 Note: One year's supply of colour coded bags and chemical disinfectants have been included in the initial supply. Ten percent of capital cost on civil works (landfill), Equipment and containers is provided for under maintenance. 10