thanks to all contributors

1. 6/13/2016 1
WELCOME TO
SEMINAR

2. 6/13/2016 2

3. 6/13/2016 3
Discovered during a waste audit: a leg destined for disposal via the municipal system
(Nakarmi/HECAF).

4. 6/13/2016 4

5. Contd…
One extreme case from Brazil demonstrated a
carcinogenic impact on the general population from
an unintended exposure to radioactive waste from a
health-care facility. While moving to a new site, a
radiotherapy institute left a sealed radioactive source
in equipment at its old premises. An individual who
gained access to these premises removed the sealed
source, took it home and broke open the casing to
reveal the radioactive material. As a consequence, 249
people were exposed, of whom several died or
suffered severe health problems, (International Agency
for Research on Cancer (IARC,1988).
6/13/2016 5

6. 6/13/2016 6
HEALTHCARE WASTE
MANAGEMENT
Pabitra Sharma

7. General objective
At the end of the session the participants will be
able to explain Health care waste management.
6/13/2016 7

8. Specific Objectives
• define waste.
• define health care waste.
• state the types of health care waste.
• identify sources of health care waste.
• explain impact of health care waste.
• state the types of infection by Health Care
Waste.
• list the principles of health care waste
management.
• explain the steps of health care waste
management.
6/13/2016 8

9. Specific Objectives Cont..
identify different organization in health care waste
management.
identify the legislation regarding Health Care
Waste Management in Nepal.
6/13/2016 9

10. Waste Definition
• Waste (also known as rubbish, trash, refuse,
garbage, junk, litter) is unwanted or useless
materials.
• “Substances or objects which are disposed of or
are intended to be disposed of or are required to
be disposed of by the provisions of the law,”
(Basel Convention,2003).
6/13/2016 10

11. Health Care Waste (HCW)
Health-care waste includes all the waste
generated by health-care establishments, research
facilities, and laboratories. In addition, it includes
the waste originating from “minor” or “scattered”
source such as that produced in the course of
health care undertaken in the home (dialysis,
insulin injections, etc.), (WHO,1999).
6/13/2016 11

12. HCW Contd..
Medical waste means the hazardous waste
produced and discharged from hospitals, clinics,
pharmacies, dispensaries, blood banks, pathology
laboratories, veterinary institutions and health
research centers, (Solid Waste Management Act,
2011,Nepal).
6/13/2016 12

13. HCW Contd..
HCW
80% general/ non
hazardous
15% hazardous
(10% infective
waste
5% non- infectious
but hazardous1%
is sharp
6/13/2016 13

14. 6/13/2016 14
Classifications of waste

15. Categorization of HCW
a) Based on UNEP/SBC/WHO (United Nation Environment
Programme/Secretariat Basal Convention,2004)
1. Non-risk HCW.
2. HCW requiring special attention.
3. Infectious and highly infectious waste.
4. Other hazardous waste.
5. Radioactive waste .
156/13/2016

16. 1) Non risk HCW
Non-risk health care waste (Comparable to the
domestic waste)
1.1. Recyclable HCW - paper, card board, non-
contaminated plastic or metal, cans or glass
1.2 . Biodegradable HCW – waste that can be
composted
1.3. Other non-risk HCW – clay equipment.
6/13/2016 16

17. HCW which needs special attention for disposal
2.1. Human anatomical waste -human body parts,
organs and tissues
2.2. Sharp Waste-
2.3. Pharmaceutical waste
- Non- hazardous pharmacological waste- Normal
saline, Dextrin or Cough syrup etc.
6/13/2016 17
2. Health care waste requiring
special attention

18. HCW with special attention
contd..
- Potentially hazardous pharmaceutical
waste- Date expired medicine.
- Hazardous pharmaceutical waste-
unidentifiable pharmaceuticals as well as heavy
metal containing disinfectants
6/13/2016 18

19. Contd…
6/13/2016 19
A dog finds some pathological waste on a Kathmandu street (Nakarmi/HECAF).

20. Contd….
In China, 21 dead babies were found in a lake;
some had hospital identity tags and one was
wrapped in plastic and labeled “medical waste,”
(human right and medical waste, 2011).
6/13/2016 20

21. HCW Require Attention
Contd..
2.4 Cytotoxic pharmaceutical waste - alkylated
substances, antimetabolites, antibiotics, plant
alkaloids, hormones, and others.
2.5. Blood and body fluids waste
human or animal blood, secretions and excretions.
E.g dressing material, s􏰂wabs, syringes without
needle, infusion equipment.
6/13/2016 21

22. 3. Infectious and highly infectious Waste
3.1. Infectious waste- potential of transmitting infectious
agents to humans or animals. E.g isolation wards,
dialysis wards or centers for patients infected with
hepatitis viruses (yellow dialysis); pathology
departments; operating theatres etc.
3.2. Highly infectious waste- All microbiological
cultures and 􏰂laboratory waste.
6/13/2016 22

23. 4. Other Hazardous Waste
Include chemicals, heavy metals, pressurized containers,
discarded gaseous, liquid and solid generated during
diagnostic and experimental 􏰂,disinfecting procedures,
cleaning processes and house-keeping with features of,
o Toxic
o Corrosive acids
o Flammable
o Reactive, explosive, shock sensitive
o Cytotoxic or genotoxic properties
6/13/2016 23

24. 5. Radioactive Waste
• Include materials contaminated with radio􏰂
nuclides, which arise from the medical or
research use of radio-nuclide.
• Sealed radiation source, liquid and gaseous
material contaminated 􏰂with radionuclide,
excreta of patients etc.
6/13/2016 24

25. WHO Classification
a) Hazardous health-care waste
• Sharps waste
• Infectious waste
• Pathological waste
• Pharmaceutical waste,
• cytotoxic waste
• Chemical waste
• Radioactive waste
b) Non-hazardous or general health-care waste
6/13/2016 25(WHO,2014)

26. Categorizations According to BMW
Schedule ,2011
• Category 1- Human Anatomical
• Category 2- Animal
• Category 3- Microbiology/Biotechnology
• Category 4- Sharp
• Category 5- Discarded Medication and Cytotoxic
6/13/2016 26

27. BMW Categorization
Contd..
• Category 6- Soiled Water
• Category 7- Solid Waste
• Category 8- Liquid Waste
• Category 9- Incinerator Ash
• Category 10- Chemical Waste
6/13/2016 27

28. Categorization in Nepal
Based on UNEP/SBS/WHO
1) Non risk HCW
• Biodegradable
• Non-biodegradable
6/13/2016 28NHCWM Guideline,2014

29. Categorization
Contd..
2) Risk health care wastes
• Pathological Waste
• Infectious waste Sharp Waste
• Cytotoxic Waste
• Pharmaceutical Waste
• Other hazardous Waste
6/13/2016 29NHCWM Guideline,2014

30. Categorization by NHRC
• Non hazardous waste/ general waste
• Hazardous/ contaminated waste
• Sharp( infected or not infected)
6/13/2016 30

31. Research
Worldwide, an estimated 16 billion injections are
administered every year. Not all needles and
syringes are disposed of safely, creating a risk of
injury and infection and opportunities for reuse.
6/13/2016 31
" I am Committed for Safe Injection".
(BMWS,2011)

32. 6/13/2016 32
Production of HCW

33. Production of HCW
A) Globally
• Developed countries - 1- 5kg/bed/day
• Developing countries - 1-2/kg/day
- The waste generation rate (kg/bed/day) hospital
USA - 4.5 , Netherlands 2.7 and France 2.5.
6/13/2016 33
(WHO,2014)

34. - Average HCW - 1-4.5 kg/bed/day in Latin
American countries( e.g Chile, Brazil Argentina
and Venezuela )
- Hazardous waste - 5% in Denmark , 28% in
USA
(Monreal, 1991).
6/13/2016 34
Production
Contd…

35. B) Production of Waste in South East
Region (by 2001)
Country Waste(kg/bed/day) Annual waste
Bangladesh 0.8-1.67 93,0755 tons
Bhutan 0.27 73 tons
India 1.0- 2.0 0.33 million tons
Maldives NA 146 tons
Nepal 0.5 2,018 tons
Pakistan 1.63-3.69 0.25 million tons
Srilanka 0.36 6,600 tons
WHO,2001
6/13/2016 35

36. Production
Contd…
C) In Nepal
• Kathmandu Metropolitan City have organized a
study on biomedical waste in hospital located
Kathmandu
- (Results- 1.72kg waste/ day / patients)
- Out of which26% waste was infectious and
hazardous.
6/13/2016 36

37. Production in Nepal
Contd…
• Estimated at 0.533 kg/bed /day Out of which
 0.256 kg/bed/ day is general
 0.147 kg/bed/day -biodegradable waste,
 0.120 kg/bed-day- infectious waste sharps
 0.009 kg/bed-day - hazardous
chemical/pharmaceutical waste.
(UNEP, 2012)
6/13/2016 37

38. Hospital No Total
bed
HCW /
ton
HCWR
(ton)
Government, teaching
including MoHP
92 6601
3080 905.54
Government hospital under
other ministry
3 1036
Private hospital 157 9207
7192.49 2115.44
Private teaching hospital 14 8626
Mission hospital 8 612 246 72
Country hospital 274 26082 105119 3093
Source: MoHP Poster Presentation in first HCWM International Workshop,
Nepal; 2012
Total health care facilities with bed and
corresponding waste generation
6/13/2016 38

39. Contd…
Assessment study at Civil Service Hospital(CSH),
Kathmandu Waste generation
- 64.58 kg per day, with occupancy rate of 55.65% (1.73
kg per bed per day).
- Pre-separation scenario (71% is risk waste and 29% is
non-risk). Post-separation scenario (25% risk and non-
risk is around 29%) (CSH,2011).
6/13/2016 39

40. Production in Nepal
Contd…
Hospitals Average
productio
ns (kg/d)
General
(kg/d)
Hazardou
s
(kg/d)
Sharp
(kg/d)
Patan 594.0 kg 377
(63.5%)
165 (27.8%) 52 (8.8%)
Koshi Zonal 441.14 kg 302
(68.4%)
125 (28.4%) 14 (3.1%)
National
kidney
center
28 kg 14 (50%) , 5 (17%) 9 ( 33%)
6/13/2016 (JHNRC,vol 11,2013)
Out of 24 health care institution, from only 3 HCI information
available

41. • Enayetullah et al., (2011) stated average HCW
generation in Pokhara city is est. - 1.22 kg/bed.
- From outdoor facility is est. 0.34kg/day
• From all HCF facilities (Pokhara) - 2.8 ton/day
(22% HCWs is hazardous and infectious and the
rest general waste. )
6/13/2016 (JHNRC,vol 11,2013)
Contd….

42. Sources of HCW
a) Major sources of health-care waste
Hospitals
• University hospital
• General hospital
• District hospital
6/13/2016 42
(SBS,2004

43. Sources
Contd..
b) Medium Sources
Medical centers , OPD, Mortuary/ Autopsy center,
Hospices, Abortions clinics, Medical laboratories,
Medical research facilities, Animal hospital, Blood
bank and transfusions vices etc.
6/13/2016 43(SBS,2004)

44. Sources Contd..
c) Small Sources
General medical practitioners, Convalescent
homes, Nursing and remedial homes, Medical
consulting rooms, Dental practitioner, Animal
boarding, Tattooists, Acupuncturist, Veterinary
practitioner, Pharmacies, Cosmetic piercers etc.
(SBS,2004)
6/13/2016 44

45. Possible Impact
6/13/2016 45
Sanitation
worker
Medical
paramedical
staff
Patients and
visitors
surroundings
environment

46. Route of infection
Hazards
Ingestion
Inhalatio
n
Mucous
membranes
Skin
cut
injury
6/13/2016 46

47. A study done by Adhikari et al.,
showed that 53.5% had NSI , only 46.8% had
reported to concerned authority, whereas all
students were aware of the fact that HIV and HBV
is transmitted through needle stick injuries
6/13/2016 47
Contd…

48. • One cross-sectional study in GMC-TH
showed that 70.79% health care workers had
experienced Needle Stick Injury (NSI) among them
- 52.5% suffered from NSI with unused needles ,
- 47.5% NSI from used needles and
- 68.42% of NSI sufferer of used needles reported the
incident (NHCW guideline, 2014) .
6/13/2016 48
Contd…

49. A study on Incidence Of NSI among PCL Nursing
Students In KTM,
• 46.9 % had NSI, 44.7% experienced > 1 time.
• Out of total 298 injuries- 67.8 % during
medication, 41% while drawing medicine, 20%
recapping the needle.
(International Journal of Scientific & Technology
Research,2013)
6/13/2016 49
Contd…

50. A study by Sorsa et al., 1985 in Finland found an
excess of spontaneous abortions during
pregnancy and malformations in children of
females with a history of working with anticancer
agents (WHO,2014).
6/13/2016 50
Contd…

51. Waste Hazards (e.g.)
Infectious waste and sharps Infection like HIV, hepatitis, resistant to antibiotic
Chemical and pharmaceutical Burn, injury , intoxication even death
Genotoxic Secondary neoplasma, skin eye irritation
Radioactive Headache, dizziness, vomiting
Public sensitivity Public is very sensitive to visual impacts of health
care waste specially anatomical waste.
6/13/2016 51
Effects of HCW

52. 6/13/2016 52
Infection By HCW Contd…

53. 6/13/2016 53
Infection By HCW Contd…
(WHO,1999)

54. Samples taken from different areas of Bir Hospital
• The mercury level was found to be highest in the
Dental OPD/Medical ward (3.78 μg/m3)
• The mercury in water highest in the floor wash
sample of the Dental Ward (0.045 mg/l)
• The mercury concentration in soil sample (area
near maintenance) - (2.72mg/kg)
6/13/2016 54
Interim report on HCWM,Bir Hospital, 2068
Contd…

55. Survival of pathogenic microorganisms
in the environment
The hepatitis B virus
• Is very persistent in dry air.
• can survive for up to 1 week - in discarded
needle, antiseptics like 70% ethanol.
• Viable for 10 hours at 60 °C.
6/13/2016 55

56. Survival of microorganism
Contd..
HIV Virus .
- Survives for no more than 15 min if exposed to
70% ethanol and only three to seven days at
ambient(20°C) temperature.
- It is inactivated at 56 °C.
6/13/2016 56

57. Overview
In 2010, unsafe injections were still responsible for
33, 800 new HIV infections, 1.7 million hepatitis B
infections and 315,000 hepatitis C infections
(WHO,2014).
6/13/2016 57

58. 6/13/2016 58

59. 6/13/2016 59
Need Health care waste management?

60. Guiding Principles of HCWM
• The “Polluer Pays” Principle
• The “Precautionary” Principle
- (adopted under the Rio Declaration on
Environment and Development (UNEP, 1972) )
• The “Duty of Care” Principle
• The “Proximity” Principle
• The “Prior Informed Consent Principle”
6/13/2016 60

61. Steps for the Waste Management
• Waste Minimization
• Waste Segregation
• Waste Collection and Storage
• Waste Transportation
• Waste Treatment and Disposal
(Solid Waste Management Act, 2011 )
6/13/2016 61

62. Waste Minimization
• Waste minimization is defined as the prevention
of waste production and or its reduction at a
source.
6/13/2016 62

63. Waste Minimization Contd..
Waste minimization can be achieved through:
• Avoidence
• Reduction
- Product Substitution
- Product Changes
- Procedural Changes
• Re-Use
• Recycling
6/13/2016 63

64. Waste Segregation
• Waste segregation refers to the process of
separation of waste at the point of generation
and keeping them apart during handling,
collection, interim storage and transportation.
• Segregation of the waste at source is the key
principle of successful and safe waste
minimization and is the most important step for a
successful management of HCW.
6/13/2016 64

65. Color Coding in Segregation
Types of Waste WHO HCWG, 2014 Symbol
Non-risk waste
Biodegradables
Black Green
Non-risk waste Recyclable Dark blue
Other non-risk HCW Light blue
Pathological waste
(Danger! Pathological
waste
Yellow with
biohazard
symbol.
Red
Hazardous Sharps
Danger! contaminated
sharps Do not open
yellow with
sharp
Red
6/13/2016 65

66. Types of Waste WHO HCWG,
2014
Symbol
Pharmaceuticals
(cytotoxic) Danger!
Hazardous Infectious
waste
Brown,
With symbol
Red
Danger! Hazardous
Infectious waste
Brown
Danger! Highly infectious
waste .
Yellow Brown
Other hazardous waste
Danger! To be discarded
by au- thorized staff only
6/13/2016 66
Color Coding contd..

67. Segregation contd…
Types of
waste
WHO HCWG, 2014 Symbol
Radioactive
Waste
(Danger!
Radioactive
waste )
radiation
symbol
Black
6/13/2016 67

68. Color Coding (BMW)
Colour Category
Yellow 1,2,5,5
Red 3,4,7 ( earlier soiled
water are in red)
Blue 8
Black Municipal waste
6/13/2016 68

69. • The study conducted by MoHP help from WHO
concluded that HCWM is poor and 38.7%
hospitals adopted correct segregation of HCWs,
HCW were disposed at Okharpauwa dumping
site without any pre-treatment. (MoHP,2012)
6/13/2016 69

70. Waste Collection and Storage
• In order to avoid accumulation of the waste, it
must be collected and transported to a central
storage area within the HCF on a regular basis
before being treated or removed
• This area must be marked with warning sign.
6/13/2016 70

71. Collection Contd..
• Bags should be fill not more than 3/4th
• Label of ward
• Types of waste
• Symbol properly
• Weight
• Record register
6/13/2016 71

72. Storage Contd…
• Waste security and restriction of access to
authorized persons
• Easy access for waste collection vehicle, water.
• Protection from sun, rain, strong winds and floods.
• Temperature
- ( Cold area)– max- 72 hour(winter), 48 hour
(summer)
- Hot area max-48 hr(winter), 24 hr(summer)
6/13/2016 72

73. Storage Contd..
• Anatomical Waste - : 3° C to 8° C.
• Infectious waste (if store > week) 3° C to 8° C
• Cytotoxic waste store separately.
• Radioactive waste should be stored in
containers (lead shielding) with labeling.
• Chemical waste
6/13/2016 73

74. Waste Transport
• Suggested collection frequency on room to room
basis is once every shift.
• No bags should be removed unless they are
labeled with their point of production.
• The bags or containers should be replaced
immediately with new ones of the same type.
6/13/2016 74

75. Transportation
Contd..
Follow the guideline strictly in both:
• On-site transport
• Off-site transport
6/13/2016 75

76. 6/13/2016 76

77. Treatment and Disposal
HCW can be treated and disposed through the
following techniques:
i) Biological procedure
ii) Autoclave
iii) Chemical disinfection
iv) Encapsulation
6/13/2016 77
HCWM,Guideline, 2014

78. Treatment and Disposal Contd..
v) Sanitary landfill
vi) Burial
vii) Septic/concrete vault
viii) Incineration
ix) Inertization
6/13/2016 78

79. Biological Procedure
• Biological process uses an enzyme mixture to
decontaminate HCW.
• The technology requires regulation of
temperature, pH, enzyme level and other
variables.
• Composting falls in this category .
6/13/2016 79

80. Vermicomposting
The possible option is the vermicomposting. In this
process, the earthworm of species Eisnia foetida
is used for the composting process.
6/13/2016 80
Biological Procedure
Contd…

81. Biological Procedure
Contd..
• The Chainpur sub health post has been
generating bio-gas from placentas.
• In Bir Hospital Infected gauze and cotton waste
are disinfected using autoclaved then adopt the
process of vermicomposting.
Health care Foundation Nepal(HECAF),2071)
6/13/2016 81

82. Autoclave
• Autoclave is a process of steam sterilization
under pressure.
• Autoclaves are commonly used for the treatment
of highly infectious waste, such as microbial
cultures or sharps, Large volume of blood.
6/13/2016 82

83. Autoclave
Contd…
For effective inactivation of vegetative micro-
organisms, most bacterial spores in a small
amount of waste 􏰂about 5-8 kg􏰂 - 60 minute
cycle at 121°C (minimum) and 1 bar
(100k.pa)(WHO, 1999).
6/13/2016 83

84. Autoclave Contd…
The effectiveness depends on time, temperature,
pressure, load size, stacking, configuration
and packing density, types and integrity of
bags or containers used, physical properties of
the materials, amount of residual air and the
moisture content in the waste (UNEP, 2012).
6/13/2016 84

85. Chemical Disinfection
• Chemical disinfections are usually applied for the
treatment of infectious and highly infectious HCW.
• Aldehydes, chlorine compounds, phenolic
compounds are added to HCW to kill or inactivate
pathogens.
• Preferred treatment for liquid infectious wastes,
but can also be used in treating solid waste too.
6/13/2016 85

86. Chemical Disinfection
Contd..
• Useful in treating blood, urine, stools and sewage.
• Chemical systems use heated alkali to destroy
tissues, organs, body parts and other anatomical
waste .
• Chemotherapy waste including bulk cytotoxic agents
can be treated by chemical decomposition.
6/13/2016 86

87. Chemical Disinfection
Contd…
• Sodium Hypochlorite (5%) – 100ml/lit- for 24
hour (for Cytotoxic Waste)
• Calcium Hypochlorite (70% chlorine) 7g/lit-
• Alkaline hydrolysis -process that converts animal
carcasses, human body parts and tissues into a
decontaminated aqueous solution.
- (Later the contents are heated to between 110
°C and 127 °C for 6-8 hours).
6/13/2016 87

88. Chemical Disinfection
Contd…
• Lime milk (calcium oxide) used in liquid wastes
with high organic content (e.g. stool or vomit
during a cholera outbreak)
• lime milk in a ratio of 1:2,for 6 hours. Urine - 1:1
for 2 hours(Robert Koch Institute, 2003).
• Formaldehyde and ethylene oxide are no longer recommended for
waste treatment due to significant hazards related to their use.
6/13/2016 88

89. Encapsulation
• Involves the filling of the containers with waste,
adding an immobilizing material and sealing the
container
• When containers are three quarters filled with
sharps, pharmaceuticals and chemical waste, an
immobilizing agent poured on it.
• It is particularly suitable for sharps and
pharmaceutical waste.
6/13/2016 89

90. Encapsulation
Contd…
The following are typical proportions (by weight)
for the mixture for encapsulation
• 65% pharmaceutical waste
• 15% lime
• 15% cement
• 5% water.
(WHO,2014)
6/13/2016 90

91. Sanitary landfill
• Sanitary landfill is an engineered method,
designed and constructed to keep the waste
isolated from the environment
• It shouldn't contaminate the soil, surface, and
ground water and should limit air pollution,
smells and direct contact with public.
6/13/2016 91

92. Sanitary landfill
Contd..
• Disposing of certain types of HCW (infectious
waste and small quantities of pharmaceutical
waste) is acceptable
• 􏰂Should be at least 50 m away from water
sources.
6/13/2016 92

93. Burial
• Hazardous waste can be buried in a special pit.
• Especially in remote locations, in temporary
refugee encampments.
• Pit should be 􏰂2-5m deep and 1-2􏰂m wide.
• The bottom of the pit should be at least 2 m
above the water level.
6/13/2016 93

94. Burial
Contd…
• In outbreak of an especially virulent infection (as
Ebola virus),lime and soil cover may be added.
• About 50m 􏰂􏰂meters a􏰂way from any 􏰂water
body such as rivers or lakes􏰂.
• After each waste load, it should be covered 􏰂with a
􏰂􏰂􏰂􏰂􏰂 10-30 cm thick soil layer.􏰂
6/13/2016 94

95. Burial
Contd..
• 􏰂large quantities 􏰂higher than 􏰂1 kg􏰂 of
chemical 􏰂pharmaceutical waste should not be
buried.
• When the level of the waste reaches 􏰂􏰂 to 30-
50 􏰂􏰂 cm to the surface of the ground, fill the pit
􏰂with dirt, seal 􏰂with concrete and dig another
pit
6/13/2016 95

96. Septic / concrete vault
• This method can be used for the disposal of
used sharps and syringes
• Dig a pit 1􏰂􏰂m x 1􏰂m x 􏰂􏰂􏰂1.8m depth􏰂
• The site must be isolated and at least 􏰂􏰂􏰂500
feet aw􏰂ay from the ground water sources
• Deposit the collected safety boxes filled with
used sharps and needles inside the
septic/concrete vault
6/13/2016 96

97. Incineration
• Incineration converts combustible materials into
non-combustible residue or ash.
• Incinerators can be oil,􏰂fired or electrically
powered or a combination of both
6/13/2016 97

98. Incineration
Contd…
• Gases are ventilated through the incinerator
stacks, and the residue or ash is disposed in a
sanitary landfill
• In case of cytotoxic drug- 1200 °C ( but prefer
Autoclave)
6/13/2016 98

99. Incineration contd..
• When 􏰂incinerated at lo􏰂w temperatures or w􏰂
hen plastics that contain polyvinyl chloride 􏰂
PVC􏰂 are incinerated, dioxins, furans and toxic
gases may be produced
• This happens if 􏰂waste are incinerated at
temperatures < 800°C or wastes are not
completely incinerated􏰂
6/13/2016 99

100. Wastes that Should Never be Incinerated
• Pressurized gas containers
• 􏰂large amounts of reactive chemical 􏰂waste
• 􏰂Radioactive waste
• 􏰂Silver salts or radiographic waste
• 􏰂Halogenated plastics 􏰂e􏰂g􏰂 PVC􏰂
• 􏰂Mercury or cadmium
• 􏰂Ampoules of heavy metals
6/13/2016 100

101. Inertization
• Inertization is usually suitable disposal method
for the pharmaceuticals and incinerated ash
􏰀with heavy metal content (􏰂WHO,1999). 􏰂􏰂
􏰂􏰂􏰂
• HCW is mixed with cement􏰂􏰂􏰂, lime, cement
and 􏰂􏰂water􏰂.
• The formed mixture is allowed to set into cubes
or pellets ,the waste must be grinded.6/13/2016 101

102. Treatment for Radioactive waste
• “Decay in storage”, which is the safe storage of
waste a general rule is to store the waste for at
least 10 times the half-life of the longest lived
radionuclide in the waste
• Return to supplier
• long-term storage at an authorized radioactive
waste disposal site.
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103. Treatment of liquid waste/water
• Liquid wastes including hazardous chemicals and
laboratory wastes have not been addressed in
almost all institutions􏰂
• HCFs like Western Regional Hospital, Bir Hospital,
Civil Service Hospital, Manipal Teaching Hospital,
Shahid Gangalal National Heart Centre and some
other HCFs are practicing HCWM system.
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104. Contd…
A study (Center for Public Health and Environmental Development
(CEPHED), 2012) showed
• 90.32% hospitals - not practice environment sound
waste treatment.
• 61.29% hospitals have very poor source separation
• 80.65% hospitals not practise separate waste
collection
• 67.42% hospitals have very poor transportation.
( NHCWMG,2014)
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105. HCWM in Chitwan
• Effective segregation of waste at source.
• Used to transport and disposed by contractor.
• Most hospital are using Incinerators/ burial
method for needle/sharp waste management.
• Planning to produce biogas from placenta, and
leftover food( Already started in Pithuwa
hospital)
• Planning / under construction of waste water
treatment plant
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106. 6/13/2016 106
HCWM Team

107. Past to Current Legislation for addressing
Health Care Waste Management
- The Constitution of Kingdom of Nepal,
1990
The state shall give priority to protection
of the environment and also to the
prevention of its further damage.
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108. Past to Current Legislation for addressing
Health Care Waste Management
• Solid Waste Management and Resource Mobilization Act, 1987
• The Town Development Act, 1988
• The Labor Act, 1991
• Industrial Enterprise Act, 1992
• The Environment Protection Act, 1997
• The Local Self- Governance Act, 1999
(fine anyone up to Rs. 15000.00 for haphazard dumping of solid
waste.)
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109. Past to Current Legislation for addressing
Health Care Waste Management
• The three year Interim Plan of Nepal
Government (2064/65- 2066/67) - mentioned
the programs for Health Care Waste
Management.
• Interim Constitution of Nepal, (2063) 2007 (with
amendment): right of healthy environment for
all.
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110. Past to Current Legislation for addressing
Health Care Waste Management
• Health Care Waste Management Guidelines, (2008/9,
DoHS)
• Urban Environmental Management Guidelines, (2011)
• Second Long Term Health Plan, 2054-74 (1997- 2017)
• Solid Waste Management Act, (2011)
(Fine of Rs 50, 000 to 100, 000 for the first time and the
penalty will be double for the repetition
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111. Organization in HCWM
• Center for Public Health and Environmental
Development
• Epidemiology and disease Control Division
• Ministry of Environment
• Ministry of Health and Population
• Ministry of Science, Technology and Environment
• United Nations Development Programme
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112. Organization in HCWM
Contd..
• United Nations Environment Programme
• Ministry of Urban Development
• Private Hospital Association
• WHO
• UN
• Health Care Foundation Nepal
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113. Bir hospital in HCWM
• Health Care Foundation Nepal (HECAF) has been
working in the field of health care waste
management since 1999
• when it installed the first non-burn medical waste
management system in the National Kidney Centre
• Waste is segregated at source and infectious
materials are disinfected in an autoclave.
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114. Health and Safety Practices
in HCWM
• Infection Prevention
• Personal hygiene and hand hygiene
• Worker’s Protection/training
• Protective clothing
• Immunization
• Injection safety / awaeness
• Response to injury and exposure
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115. Conclusion
Everyday large amount of HCW generate having
different characteristic. To overcome from this
need to proper manage of HCW as well as
treatment of waste.
6/13/2016 115

116. Reference
Ananth, P., Prashanthini, A., and Visvanathan, V.C., (2010). Healthcare
waste management in Asia.
Bir Hospital, (2011). Interim Report of Health Care Waste Management
System In Bir Hospital, Kathmandu. WHO.
CEPHED, (2012). Waste Management: Environmental Health Condition of
Hospitals in Nepal
CDC, (1988). Guideline for Handwashinng and Environmental Control.
CSH, (2013) Health Care Waste Management Policy. Civil Service Hospital.
Minbhawan, Kathmandu
Enayetullah et al., (2011) Feasibility Study for the Establishment and
Operation of Common/Central Treatment Facility (CTF) for Hospital in
Pokhara City.
Joshi,H.D., (2013). Health Care Waste Management Practice in Nepal.
JNHRC.
6/13/2016 116

117. Reference
MoE, (2004). 􏰂Final Report on Hazardous Waste Policy
Study. 􏰂Nepal􏰂: Ministry of Environment
MoH, (2003). Health Care Waste Management in Nepal.
MoHP, 􏰂􏰂􏰂􏰂a: Revised Health Care Waste Management
Guideline( 2014). Ministry of Health and Population,
Department of Health Services
MoHP, (2005). Infection Prevention Reference Manual for
Clinical Service. NHTC.
MoHP, (2005). Infection Prevention Reference Manual for
Clinical Service. NHTC.
NHRC, (2002). 􏰂􏰂􏰂􏰂B: National Health Care Waste
Management Training Manual. Nepal Health Research Council.
6/13/2016 117

118. Reference
MoHP/WHO/NRCS, (2013). Biosafety and Waste Management
Blood Transfusion Services. Nepal
National Planning Commission, (2010). The Three Year Interim
Plan of Nepal Government (2064/65- 2066/67). Retrieve
on, 15th Jan, 2016, from, http://www.npc.gov.np.
Nepal Health Research Council, (2007). Health Care Waste
Management in Selected Health Care Institutions in Nepal.
Kathmandu Nepal: Nepal Health Research Council.
Park, K. (2015). Park’s Textbook of Preventive and Social
Medicine (23rd ed). India: M/S Banarsids Bhanot.
Poudel, et. al, (Sep, 2013). Incidence Of Needle Stick
Injury Among Proficiency Certificate Level Nursing
Students. Kathmandu: International Journal of Scientific
& Technology Research.
6/13/2016 118

119. Reference
MOHP, (2011). Solid Waste Management Act. MOHP
UNEP/SBC/WHO, (2004). Preparation of National Health-
Care Waste Management Plans in Sub-Saharan
Countries; Guidance Manual, Secretariat of the Basel
Convention and World Health Organization
Basel Convention/UNEP, (2003). Technical Guidelines on
the Environmentally Sound Management of
Biomedical and Healthcare Wastes (Y1;Y3). Secretariat
of the Basel Convention,
WHO, (2014). Safe Management of Wastes from Health-
Care Activities, ( 2nd ed.). WHO.
WHO, (2008). Policy Paper on Mercury in Health Care.
Department of Protection of the Human Environment
Water, Sanitation and Health.
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THANK YOU