75679 v2 Mainstreaming Environmental Management in the Health Care Sector A Tool-kit for Managers VOLUME II Mainstreaming Environmental Management in the Health Care Sector in India Tool-kit for Managers VOLUME II February 2012 @ 2012 The International Bank for Reconstruction and Development/The World Bank 1818 H Street, NW, Washington, D.C. 20433 USA Disclaimer This report has been discussed with the Government of India but does not bear their approval for all its contents, especially where the Bank has stated its judgment/opinion/policy recommendations. The findings, interpretations and conclusions expressed in this paper are based on staff analysis and recommendations and do not necessarily reflect the views of the Executive Directors of The World Bank. Rights and Permissions The material in this work is copyrighted. Copying and/or transmitting portions or all of this work without permission may be a violation of applicable law. The International Bank for Reconstruction and Development/ The World Bank encourages dissemination of its work and will normally grant permission promptly. All queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, The World Bank, 1818 H Street, NW, Washington, DC  20433, USA, fax:  202-522-2422, email: pubrights@worldbank.org. Environment-health Logo Concept and Design J.P. Dangmann von Odernheim Designed and printed by Macro Graphics Pvt. Ltd. www.macrographics.com Acknowledgements The report “Mainstreaming Environmental invaluable help and administrative support provided Management in the Health Care Sector: by Genevieve Maria Dutta and Madhu Phillips. The Implementation Experience in India and a Tool-kit team is grateful for the technical inputs provided for Managers� was written by Ruma Tavorath, Senior by peer reviewers, including Mariam Claeson, Kees Environmental Specialist, South Asia Environment Kostermans, Preeti Kudesia and Vikram Rajan from and Water Resources Unit with the support of core the South Asia Health, Nutrition and Population consultant Dr. Megha Rathi. Unit. Alexander Von Hildebrand from World Health Organization and Ravi Agarwal from Toxics Link The ndings, analysis and recommendations (New Delhi) also provided guidance on the early presented in this report are based on the direct drafts. The team acknowledges the �nancial support involvement of the author in the implementation from the Regional Safeguards Unit comprising Sanjay of World Bank-supported health sector projects in Srivastava and Eric Brusberg, and from the Bank- India, which includes reviews of institutional and Netherlands Partnership Program through the SAR policy frameworks in the sector, analysis of the AIDS multi-sector work program. environmental components, discussions with project authorities, facility of cials and donor partners, and This report would not have been possible without �eld visits to health-care facilities and centralized the continued encouragement and support of the waste treatment facilities. management of South Asia Environment, Water Resources and Climate Change Unit, including Jack The team appreciates the technical expertise and Stein, Herbert Acquay, Charles Cormier, Karin guidance provided by David Hanrahan and the Kemper and Ernesto Sanchez-Triana. CONTENTS Executive Summary ........................................................................................................................................... ix Introduction ........................................................................................................................................................ xi Section I: Overview of Health-Care Waste ................................................................................................. 1 Section II: Legislative Framework ................................................................................................................ 5 Section III: CPCB Guidelines on Health-Care Waste Management ............................................................ 13 Section IV: Road Map on Management of Waste in India ........................................................................... 19 Section V: Health-Care Waste Management Plan ....................................................................................... 21 Section VI: Infection Management and Environment Plan ......................................................................... 33 Section VII: Selection Criteria for Health-Care Waste Treatment Technologies ......................................... 35 Section VIII: Wastewater Treatment Systems in Health-Care Facilities ........................................................ 45 Section IX: Costs of Health-Care Waste Management ................................................................................. 51 Section X: Mercury in Health-Care ............................................................................................................ 53 Section XI: Engineering Controls for Infection Prevention in Health-Care Facilities ................................ 57 Section XII: Standard Operating Procedures for Laboratories ...................................................................... 61 Section XIII: World Bank Safeguard Policies .................................................................................................. 65 Section XIV: World Bank Guidelines for Small Construction Works ........................................................... 67 Section XV: World Bank Projects in the Health Sector ................................................................................ 71 Section XVI: World Bank Supervision Template ........................................................................................... 75 Section XVII: World Bank Performance Indicator Template .......................................................................... 81 Section XVIII: Key Resource Documents for Health-Care Waste Management and Infection Control .......... 83 Section XIX: Website References .................................................................................................................... 95 List of Tables Table 1: Categories as per Bio-Medical Waste (Management and Handling) Rules, 1998) (Schedule I) ............ 6 Table 2: Draft Bio-Medical Waste Rules, 2011 vs. Bio-Medical Waste Rules, 1998 ........................................... 7 Table 3: Categories as per Draft Bio-Medical Waste (Management and Handling) Rules, 2011 (Schedule I)...... 9 Table 4: Color coding and type of container for disposal as per Draft Bio-Medical Waste Rules, 2011 (Schedule II)��������������������������������������������������������������������������������������������������������� 10 Table 5: The role of different stakeholders in health-care waste management������������������������������������������������ 12 Table 6: Categories of health-care waste and their final disposal��������������������������������������������������������������������� 24 Table 7: Overview of waste treatment and disposal technologies������������������������������������������������������������������� 28 Table 8: Technical selection criteria for bio-medical waste: Autoclaves��������������������������������������������������������� 35 Table 9: Technical selection criteria for bio-medical waste shredder�������������������������������������������������������������� 37 Table 10: Technical selection criteria for advanced steam systems (hybrid autoclaves) and microwave units����� 39 Table 11: Suggested parameters for the analysis of wastewater from health-care facilities������������������������������� 48 Table 12: Cost of construction and operation of a health-care waste treatment plant�������������������������������������� 51 List of Figures (Including photographs) Figure 1: Composition of health-care waste������������������������������������������������������������������������������������������������������� 1 Figure 2: Waste management committee���������������������������������������������������������������������������������������������������������� 22 Figure 3: Segregation of waste as prescribed in the Bio-Med Rules������������������������������������������������������������������ 24 Figure 4: Deep burial pit����������������������������������������������������������������������������������������������������������������������������������� 27 Figure 5: Thematic representation of wastewater treatment process��������������������������������������������������������������� 46 Figure 6: Organizational structure for health-care wastewater treatment�������������������������������������������������������� 47 Figure 7: Liquid disinfection unit for small facilities (10 beds and below)������������������������������������������������������� 49 Figure 8: Liquid disinfection unit for small facilities (30-400 beds)������������������������������������������������������������������ 50 Acronyms and Abbreviations AD Syringe Auto Disable Syringe MoHFW Ministry of Health and Family Welfare AIDS Acquired Immuno Deficiency Syndrome MPCB Maharashtra Pollution Control Board BMW Bio-Medical Waste MSDS Material Safety Data Sheet CDC Center for Disease Control MSW Municipal Solid Waste CHC Community Health Center NACP National AIDS Control Programme CPCB Central Pollution Control Board NGO Non-Government Organization CTF Centralized Waste Treatment Facility NRHM National Rural Health Mission CBWTF Centralized Bio-Medical Waste Treatment PATH Program for Appropriate Technology in Health Facility PCC Pollution Control Committee DDT Dichlorodiphenyltrichloroethane PHC Primary Health Center DfID Department for International Development PCDDs Polychlorinated Dibenzodioxins DGHS Directorate General of Health Services PMU Project Management Unit DMC Designated Microscopic Center POPs Persistent Organic Pollutants DOH Department of Health PPP Public Private Partnership DOTS Directly Observed Treatment Short-Course PRI Panchayati Raj Institutions DPH Directorate of Public Health RCH Reproductive Child Health EA Environment Assessment RKS Rogi Kalyan Samities EMP Environment Management Plan RNTCP Revised National Tuberculosis Control Programme EPA Environment Protection Act SBC Secretariat of Basal Convention ETP Effluent Treatment Plant SC Sub-Centre GEF Global Environment Facility SHSP State Health Systems Project GoI Government of India SPCB State Pollution Control Board GTZ German Society for Technical Cooperation TB Tuberculosis HAI Hospital-Acquired Infections TEQ Toxic Equivalent HBV Hepatitis B Virus TNHSDP Tamil Nadu Health Systems Development HCF Health-Care Facility Project HCV Hepatitis C Virus TNPCB Tamil Nadu Pollution Control Board HCW Health-Care Waste UN United Nations HCWM Health-Care Waste Management UNDP United Nations Development Programme HIV Human Immuno Deficiency Virus UNEP United Nations Environment Programme IGNOU Indira Gandhi National Open University UNICEF United Nations Children’s Fund IPHS Indian Public Health Standards USEPA United States Environment Protection Act KMC Kolkata Municipal Corporation VBD Vector-Borne Disease LUB Local Urban Bodies VBDCP Vector-Borne Disease Control Programme MDGs Millennium Development Goals VCT Voluntary HIV Counseling and Testing MoEF Ministry of Environment and Forests WB World Bank MoH Ministry of Health WHO World Health Organization Executive Summary Environment management in the health-care sector sector, and almost a decade in promoting environmental comprises waste management, water and sanitation management, speci cally infection control and and associated practices related to infection control and waste management, in this sector. Implementation occupational health and safety of health-care workers. experience from interventions at national and state Mitigation and management of these issues has an over- levels through the World Bank, Development Partners arching impact on health service delivery by reducing and Government Health projects and disease-control the risk of infection and providing a safe and hygienic programs has generated valuable lessons on how to health-care infrastructure. improve operational practices, upgrade institutional capacity and establish effective systems. Of the gamut of environment management issues, infection control practices and health-care waste Implementing systematic waste management systems constitute the highest potential risk of infection and in the health sector faces a range of challenges, from environmental pollution. While it is a challenge harmonizing internal practices to increasing the use to collect data on the direct correlation between of external services for utilities and waste disposal. An disease burden and poor waste management and essential element is to support awareness and attitudinal inadequate infection control practices, there is changes among healthcare professionals and workers suf�cient understanding and literature on the linkages with regard to the mitigation measures on infection and associated potential risks and hazards to the control and waste management. Coordinated approaches environment and human health. Over the past few are needed to ensure effective implementation of cross- years, there has been increasing recognition of the need cutting activities at the decentralized level of health for safe and hygienic health-care services. Accordingly services delivery, and to work across sectors, with the Government of India has taken substantive steps municipalities and environmental agencies. in establishing the legal, institutional and budgetary context for the improvement of infection control and An increasing number of health-care facilities are health-care waste management. implementing best environmental management practices by fully integrating environmental guidelines The World Bank has had 20 years of experience in with overall facility management. In other facilities, supporting the Government of India in the health-care critical activities such as sharps management and waste segregation are being put in place, although which cuts across all health and disease-specific institutional coordination mechanisms are yet to be programs and other relevant sectors. It includes strengthened. examples of emerging good practices and implementation constraints and shortcomings and This report emphasizes the importance of moving provides guidance to project managers on systematic beyond a single focus on infection control and waste approaches for achieving holistic and effective management, to mainstream key environmental environment management systems within the health- management issues, using an integrated approach care sector. x Mainstreaming Environmental Management in the Health Care Sector Introduction Background Environment management is usually seen as an external issue for the health sector, although the sector is Provision of good quality health care for its one consistently facing a range of signi cant environmental billion citizens is a major concern for India, for which challenges ranging from waste management, water the Government has dedicated signi cant resources supply and water quality, to sanitation and sewage, and at both national and state levels. There are many associated infection control. All of these affect the health speci�c problems which are being tackled through and safety of people, patients, health-care- and non- a variety of targeted programs, such as the national health-care-workers. Mitigation and management of programs for HIV, TB and malaria prevention and these issues can have an overall impact on health service control. However, there is a need to upgrade the level delivery by reducing the risk of infection and providing and quality of services and facilities. Implementing a safe and hygienic health-care infrastructure. basic environmental management systems is part of the overall efforts for the development of this Of the gamut of environment management issues sector. related to the health-care sector, poor management Risks to environment and health from poorly managed health-care waste Photo credit: Megha Rathi of health-care wastes presents a potential high risk of Agencies and facilities with existing basic infection and environmental pollution. This issue is infrastructures can proceed to instituting higher challenging – not only because it involves behavior- standards of environmental management, which change interventions but also due to the complex requires a strong institutional mechanism and an structure of its implementation – which require integrated approach for enhancing coordination coordination of stakeholders across sectors, upgrading among multiple departments and stakeholders. This of technology and the need to address resource can eventually lead to accreditation of the health-care allocation. facilities under the relevant regulations. The health sector in India provides useful lessons for Useful lessons have been learned from this phased environment management as the sector covers a wide approach, primarily from the state- specific health range of services from elite facilities in urban centers reform projects which have provided the platform for to primary health care services spread across disparate engaging in a dialogue within a structured institutional rural areas. In the last few decades, India has made set-up, over a period of time. This document seeks significant progress in regulating and institutionalizing to bring together these experiences in India in a infection control and waste management issues in comprehensive manner. its health-care systems, while aiming to improve its national health care delivery system. With the A key finding is that a disjointed approach, focusing only emergence of India as an international hub of medical on discrete activities of procurement, capacity-building tourism, it is critical that the health-care sector and contractual arrangements, is not sustainable. This undertakes continuing efforts to provide a clean, document builds its analysis and recommendations safe and hygienic environment. This task requires for a conceptual approach which includes Policy, moving beyond implementing basic health-care waste Institutions, Planning, Budget, Capacity-Building management to mainstreaming core environmental and Monitoring. It is hoped that such an integrated management issues into planning, policies, programs and cohesive approach will help create a common and budgetary allocations. understanding of how the different elements inter- connect and facilitate a more strategic, phased, focused The World Bank and other development partners and sustained implementation. Such an approach will have been working with national and state partners provide the direction whereby the essential costs of in India on health projects over the past twenty improved environmental management are internalized years. For almost a decade the World Bank has been by the health-care system at multiple levels. promoting environmental management in the sector, with a particular emphasis on infection control and The pace and quality of progress depends on the waste management. Recognizing the systemic issues context and on the availability of resources. However, and implementation challenges, the World Bank has good progress has been made in many different health promoted environmental management through a phased systems, due to leadership, strong commitment and approach. The aim has been to introduce the essential strategic vision, despite limited resources. The lessons elements early, and to establish a base for ongoing learned and relevant recommendations, which are improvement as part of general health care upgrading. summarized here, provide direction for future efforts. The most relevant issue is related to the control and disposal of infectious health-care waste. Improvement in bio-medical waste disposal translates into direct Objectives health benefits, while also creating a basic institutional This document is organized into two parts, and is and physical infrastructure, and strengthening a core intended to review lessons learned in India (Volume I) public health function – a public good with large and to use those lessons and other experiences globally, externalities. (Section I of Volume II). to serve as a guidance tool-kit for task managers and xii Mainstreaming Environmental Management in the Health Care Sector program officers in the health-care sector (Volume II). management in the health care sector of the second The aim of the first part (Volume I), is to demonstrate most populous country in the world. It provides practical and feasible responses to the challenges faced recommendations for improving the existing systems while implementing and improving environmental and also for mainstreaming and scaling-up the larger management. It is hoped that the experience set of environmental management issues, including summarized here will enhance understanding of the water, sanitation and solid waste management, importance of core environmental management and through an integrated and inter-sectoral approach. thus support the planning, budgeting and monitoring The recommendations are separated into short and of environment management activities in the context medium-term operational actions, and longer-term of an inter-sectoral, integrated and coordinated strategic policy changes. operational approach. Volume II of the report – “Tool-kit for Managers� provides references and synopses of national and Structure of the document international guidelines on key technical issues, Volume I of this report titled “Mainstreaming operational and cost parameters. It sets out relevant Environmental Management in the Health-Care national laws and regulations and also the associated Sector – Implementing Experience in India� World Bank Safeguard Operational Policies, along provides a detailed analysis of the challenges and with sample monitoring and supervision templates practical lessons learnt in implementing the basic and guidance on technology and construction standards of infection control and health care waste management. Tool-kit for Managers: Volume II xiii I Overview of Health-Care Waste 1. Issues on health-care waste establishments, as well as the waste generated during management the general maintenance of health-care premises. The remaining 10-25 percent of health-care waste is Health-care waste includes all the waste generated regarded as hazardous. Other waste streams generated by health-care establishments, research facilities and by health-care facilities could include reusable medical laboratories. In addition, it includes waste originating equipment, condemned equipment and secondary from “minor� or “scattered� sources such as that waste created through disposal technologies. produced in the course of health-care undertaken in the home (dialysis, insulin injections, etc.). Figure 1: Composition of health-care waste 3% 1% Most waste generated in health-care establishments 1% can be treated as regular solid municipal waste. But 15% General a varying proportion of health-care waste requires Infectious special attention, including sharps (e.g. needles, razors Sharps and scalpels), pathological waste, other potentially Chemicals infectious waste, pharmaceutical waste, biological Heavy metals waste, and hazardous chemical waste. Collectively, these wastes are known as “special health-care waste�. 80% Also, all waste generated under certain circumstances, such as in isolation wards and microbiological laboratories, requires special attention. The mismanagement of health-care waste poses risks to people and the environment. Health-care workers, A large proportion of 75-90 percent of the waste patients, waste-handlers, waste-pickers, and the general produced by health-care providers is non-risk or public are exposed to health risks from infectious waste general health-care waste, comparable to domestic (particularly sharps), chemicals, and other special waste. It also comes mostly from the administrative health-care waste. Improper disposal of special health- and housekeeping functions and packaging of care waste, including open dumping and uncontrolled consumables and equipment in the health-care burning, increases the risk of spreading infections and of exposure to toxic emissions from incomplete ii. Hazardous waste: This waste consists of several combustion. different sub-categories: a. Infectious: Discarded materials from Transmission of disease generally occurs through health-care activities performed on injuries from contaminated sharps. Infections of humans or animals, which have the particular concern are Hepatitis B Virus (HBV), potential of transmitting infectious agents Hepatitis C Virus (HCV), and the Human Immuno Deficiency Virus (HIV). HBV, for example, can remain to humans. These include: first of all, infectious for a week, even after it has dried at room discarded materials or equipment from temperature, and the probability that a single needle the diagnosis, treatment and prevention stick will result in sero-conversion is approximately of disease, assessment of health status or 30 percent.1 identification purposes, that have been in contact with blood and its derivatives, Proper management of health-care waste can minimize tissues, tissue fluids; secondly, excreta or the risks both within and outside health-care facilities. wastes from infection isolation wards. The first priority is to segregate wastes, preferably Such wastes include, but are not limited at the point of generation, into reusable and non- to: (i) cultures and stocks; (ii) tissues; reusable, hazardous and non-hazardous components. (iii) dressings, swabs or other items Other important steps are the institution of a sharps soaked with blood; (iv) syringe needles; management system, waste reduction, avoidance of (v) scalpels; (vi) diapers; and (vi) blood hazardous substances whenever possible (e.g. PVC- bags. Incontinence materials from nursing containing products, mercury thermometers), ensuring homes, home treatment or from specialized worker safety, providing secure methods of waste health-care establishments which do collection and transportation, and installing safe not routinely treat infectious diseases treatment and disposal mechanisms. (e.g. psychiatric clinics) are an exception to this definition and are not considered 2. Composition of health-care waste as infectious health-care waste. Sharps, whether contaminated or not, should be Health-care waste2 is defined as the total waste stream considered as a sub-group of infectious from health-care establishments, research facilities, health-care waste. They include syringe laboratories, and emergency relief donations. It needles, scalpels, infusion sets, knives, includes several different waste streams, some of blades and broken glass. which require more stringent care and disposal. These are the following: b. Anatomical: This consists of recognizable body parts. i. General waste: This comprises all solid waste c. Pharmaceutical: This consists of/or contains not including infectious, chemical or radioactive (i) pharmaceuticals, including those that waste. This waste stream can include items have expired, or are no longer needed; such as packaging materials and office supplies. and (ii) containers and/or packaging Generally, this stream can be disposed of in items contaminated by or containing a communal sanitary landfill or other such pharmaceuticals (bottles and boxes). arrangement. Segregation of materials that can be reused or recycled will greatly reduce the d. Genotoxic: This consists of/or contains impact burden of this waste stream. substances with genotoxic properties, 1 World Bank, Health-care Waste Guidance Note, May 2000. 2 WHO, “ Safe Management of Wastes from Health-care Activities,� 1999. 2 Mainstreaming Environmental Management in the Health Care Sector including (i) cytotoxic and antineoplasic h. Radioactive materials: This includes: drugs; and (ii) genotoxic chemicals. (i) unused liquids from radiotherapy or laboratory research; (ii) contaminated e. Chemical: This consists of/or contains glassware, packages or absorbent paper; chemical substances, including: (i) laboratory chemicals; (ii) film developer; (iii) disinfectants (iii) urine and excreta from patients treated expired or no longer needed; and (iv) solvents, or tested with unsealed radionuclides; and cleaning agents and others. (iv) sealed sources. f. Heavy metals: This consists of both Health-care waste needs to be managed appropriately materials and equipment with heavy to minimize the spread of infections. Segregation at metals and derivatives, including batteries, source, secure collection and appropriate treatment thermometers and manometers. and disposal options are important steps in waste g. Pressurized containers: This consists of management. These steps have to go hand-in-hand full or empty containers with pressurized with occupational safety, infection control and patient liquids, gas, or powdered materials, safety for successful implementation of health-care including gas containers and aerosol cans. waste management. Tool-kit for Managers: Volume II 3 II Legislative Framework 1. Bio-Medical Waste (Management � The terminology de�ned includes bio-medical and Handling) Rules, 19983 wastes, biological, authorization, etc. � The unique feature is that it prescribes requirement The Bio-Medical Wastes (Management and Handling) for segregation of wastes at source along with Rules, 1998 provide control over the generation, appropriate packaging and labeling details. collection, segregation, packaging, storage, transportation, treatment and disposal of bio-medical � The details on the treatment disposal technologies wastes. These rules include wastes generated from are provided in the rules. medical and health institutions, bio-technology � The speci c standards required for various treatment and biological testing organizations, laboratories, disposal techniques are given within the rules. animal wastes, etc., including those from veterinary � Every occupier of an institution generating institutions and wastes from slaughter houses. medical waste is to ensure handling of such wastes without causing any adverse effect on human The salient features of these rules are4: health and environment. � The Bio-Medical Wastes (Management and � Every occupier of an institution or operator Handling) Rules are noti�ed under the of a facility is to make an application for grant Environment Protection Act, 1986. of authorization in Form I to the prescribed � The Ministry of Environment and Forests (MoEF) authority. is the nodal agency for enforcement of these rules. � The application for authorization is to accompany � These rules are applicable to persons involved in an authorization fee as prescribed by the state generation and handling of bio-medical wastes in government. any form. � The authorization should be granted by the � The rules are applicable to ten categories of prescribed authority within 90 days from the date wastes listed in Schedule I. of application and should be valid for three years. 3 All GoI legislations and detailed guidelines can be downloaded from the Ministry of Environment and Forests website http://www.mohfw.nic.in/ 4 Raghupathy L; Management of bio-medical wastes: World Environment Foundation, 2000 June, pg. 57-60. ŒŒ The prescribed authority should be appointed in ŒŒ Treatment and disposal should be in accordance every state and union territory within one month with those given in Schedule I and in compliance of the rules coming into force. with standards prescribed in Schedule V. ŒŒ The prescribed authority should function under ŒŒ Treatment disposal facilities should be set up within the supervision of the state government. the prescribed time frame given in Schedule VI. ŒŒ An advisory committee should be constituted ŒŒ The annual report should be submitted to a prescribed in every state and union territory. It should authority in Form II by January 31 every year. include municipal administrators, NGOs, ŒŒ Records of generation, collection, reception, representatives from state PCBs etc. to advise the storage, transportation, treatment, disposal, and government. handling should be maintained. It should be ŒŒ Segregation should take place at source. subject to inspection of a prescribed authority. ŒŒ Waste should be packaged in containers as given ŒŒ Any accident in the institution or facility should in Schedule II. be reported in Form III. ŒŒ Containers should be labeled according to ŒŒ There should be a provision for appeal to a Schedule III with information in Schedule IV. prescribed authority within 30 days from the date of issue of the order. ŒŒ Transportation should be in accordance with the Motor Vehicles Act, 1988 and the rules there The Bio-Medical Waste (Management and Handling), under. Rules 1998 have been amended further in the year ŒŒ No untreated bio-medical waste should be stored 2000 and 2003. The Bio-Medical Waste Rules can be beyond 48 hours. downloaded from http://www.envfor.nic.in/ Table 1: Categories as per Bio-Medical Waste (Management and Handling) Rules, 1998 (Schedule I) No. Waste class Types of waste Treatment and disposal 1 Human Anatomical Human tissues, organs, body parts Incineration@/deep burial* Waste 2 Animal Waste Animal tissues, organs, body parts, carcasses, bleeding parts, Incineration@/deep burial* fluids, blood and experimental animals used in research and waste generated by veterinary hospitals and colleges, discharge from hospitals, animal houses. 3 Microbiology and Waste from laboratory cultures, stocks or specimens of micro- Local autoclaving/ Bio- Technology organisms including genetically engineered micro-organisms, microwaving/ Wastes live or attenuated vaccines, human and animal cell cultures incineration@ used in research and infectious agents from research and industrial laboratories, wastes from production of biological toxins, dishes and devices used to transfer of cultures. 4 Waste Sharps Needles syringes, scalpels, blades, glass, etc. that are capable Disinfection by chemical of causing punctures and cuts. This includes both used and treatment@@/autoclaving/ unused sharps. microwaving/shredding## 5 Discarded Medicines Wastes consisting of outdated, contaminated and discarded Incineration@ destruction and Cytotoxic medicines. and drugs disposal in Drugs secured sanitary landfills 6 Soiled Waste Items contaminated with blood and body fluids including Incineration@/autoclaving/ cotton, dressings, plaster-casts, linen, bedding, other materials microwaving contaminated with blood. 6 Mainstreaming Environmental Management in the Health Care Sector No. Waste class Types of waste Treatment and disposal 7 Solid Waste Waste generated from disposable items other than the waste Disinfection by chemical sharps, such as tubing, catheters, intravenous sets etc. treatment@@/autoclaving/ microwaving/shredding## 8 Liquid Waste Waste generated from laboratory and washing, cleaning, Disinfection by chemical house-keeping and disinfection activities. treatment@@ and discharge into drains 9 Incineration Ash Ash from incineration of bio-medical waste. Disposal in municipal sanitary landfills 10 Chemical Waste Chemicals used in production of biological, chemicals used in Chemical treatment@@ disinfection, such as insecticides, etc. and discharge into drains for liquids and secured sanitary landfills for solids * Deep burial shall be an option available only in towns with population less than five lakhs and in rural areas. @ There will be no chemical pre-treatment before incineration. Chlorinated plastics shall not be incinerated. @@ Chemical treatment using at least 1% hypochlorite solution or any other equivalent chemical reagent. It must be ensured that chemical treatment induces complete disinfection. ## Mutilation/shredding must be such so as to prevent unauthorized reuse. 2. Draft Bio-Medical Waste ensuring its proper treatment and disposal, so as to ensure (Management and Handling) environmentally sound management of these wastes. Rules, 20115 These rules are in supersession of Bio-Med Rules, Salient features 1998. The rules apply to all persons who generate, collect, receive, store, transport, treat, dispose and These rules are based on implementation experiences of handle bio-medical waste, regardless of the number the 1998 rules and enable the prescribed authorities to of patients being serviced by them. Every occupier implement the rules more effectively, thereby reducing of a health-care facility and operator of CBWTF, hazards from bio-medical waste generation, as well as irrespective of the quantum of waste generated, shall Table 2: Draft Bio-Medical Waste Rules, 2011 vs. Bio-Medical Waste Rules, 19986 2011 draft rules 1998 rules Every occupier generating BMW, irrespective of the quantum of wastes, Occupiers with more than 1000 beds comes under the BMW Rules and requires to obtain authorization required to obtain authorization Duties of the operator listed Operator duties absent Categories of bio-medical waste reduced to eight Bio-medical waste divided into ten categories Treatment and disposal of BMW made mandatory for all the HCEs Rules restricted to HCEs with more than 1000 beds The Schedule VI of the rules specify the roles and responsibilities of the This Schedule was not included earlier concerned authorities such as MoEF, MoH&F, Ministry of Defense, CPCB, SPCB, Municipal authorities, towards implementation of the rules. A format for Annual Report appended with the Rules No format for Annual Report Form VI i.e. the report of the operator on HCEs not handing over the Form VI absent BMW added to the Rules 5 MoEF website: envfor.nic.in/ 6 CSE, Sadia Sohail, Bio-medical waste rules made more stringent, http://cseindia.org/node/3702 Tool-kit for Managers: Volume II 7 apply for authorization. The Rules are not applicable also made it mandatory for all the HCEs with 30 or for radioactive waste, hazardous waste, municipal solid more beds to set up a cell or unit to deal with the BMW waste and battery waste, which would be dealt with management. The cell has to meet every six months under their respective rules. and minutes of the meeting have to be submitted along with the Annual Report to the prescribed authority. The new Rules have incorporated that the State Ministry of Health may grant licenses to health-care facilities only Mandatory treatment and disposal after they get authorization from the SPCBs. The new Rules have bridged the gap, since earlier, the health-care The draft Rules have made the treatment and disposal facilities were only required to obtain licenses from the of bio-medical wastes mandatory for all the institutions State Ministry of Health to carry out their functions, generating them. The Rules clearly mention that every but now they have to obtain prior authorization before occupier should set up adequate treatment facilities commencing their activities. SPCBs will now make sure like autoclave/microwave/incinerator/hydroclave, that the health-care facilities have the necessary capacity shredder etc., prior to commencement of its operations and adequate equipments and then grant them the or ensure that the wastes are treated at a common bio- authorization or renew their authorization. medical waste treatment facility or an authorized waste treatment facility. Another feature of the rule is the clause on promotion of new technologies. The rules Duty of occupier and operators state that if an occupier or operator intends to install Duties of the occupier have been elaborated in the new technologies for treatment and disposal of wastes, present Rules.  Proper training has to be imparted by the they can approach the Central Government or Central occupier to the health-care workers engaged in handling Pollution Control Board (CPCB) for prior approval. bio-medical waste. The training for staff concerned However, the draft Rules have omitted the necessity with hospital waste management involves a number of of an incinerator as one of the pre requisites for on- parameters. The Rules merely mention proper training, site treatment of BMW. The omission is owing to the a set of guidelines or regulations need to be drafted by various environmental impacts of incineration. The the health-care facilities in consultation with health and draft Rules say that an occupier having 500 or more safety experts, as a part of the training module. beds may install an incinerator subject to compliance with all the other guidelines. However, studies in Apart from the duties of the occupier, the present rules the past have shown that even the state-of-the-art have also listed duties for the operators of common incinerators lead to some emission of toxic gases. Thus BMW treatment facilities. The operators now have to there should be certain conditions for allowing the ensure that the bio-medical waste is collected from all use of incinerators for disposing BMW. Incinerators the health-care facilities and is transported, handled, can be allowed for a cluster of hospitals, or positioned stored, treated and disposed of in an environmentally at convenient locations in cities, so that health-care sound manner. The operators also have to inform the facilities can transport their waste to them instead of prescribed authority if any health-care facilities are not each having one installed at their premises. handling the segregated BMW as per the guidelines prescribed in the rules.  Deep burial for disposal of BMW has been restricted to only rural areas with no access to CTF, with prior approval from the prescribed authority. Accident reporting formats Accidents that take place during the management of Simplified waste categories wastes have been defined in the draft Bio-Med Rules, 2011. Accidents like injuries from sharps, mercury spills The Bio-Medical Waste (Management and Handling) and fire hazards now have to be reported in Form III Rules, 1998 contained ten categories of wastes  which along with the remedial action taken. The Rules have have been reduced in the draft rules to eight categories. 8 Mainstreaming Environmental Management in the Health Care Sector Table 3: Categories as per Draft Bio-Medical Waste (Management and Handling) Rules, 2011 (Schedule I) Category Waste category (type) Treatment and disposal option 1 Human Anatomical Waste Incineration@@ (Human tissues, organs, body parts) 2 Animal Waste Incineration@@ (Animal tissues, organs, body parts, carcasses, bleeding parts, fluid, blood and experimental animals used in research, waste generated by veterinary hospitals/colleges, discharge from hospitals, animal houses) 3 Microbiology & Biotechnology Waste and other Disinfection at source by chemical Laboratory Waste treatment@ or by autoclaving/microwaving followed by mutilation/shredding## and (Wastes from clinical samples, pathology, bio-chemistry, after treatment final disposal in secured haematology, blood bank, laboratory cultures, stocks or landfill, or disposal of recyclable wastes specimens of micro- organisms, live or attenuated vaccines, (plastics or glass) through registered or human and animal cell culture used in research, infectious authorized recyclers agents from research and industrial laboratories, wastes from production of biological toxins, dishes and devices used for transfer of cultures) 4 Waste Sharps Disinfection by chemical treatment@ or destruction by needle and tip-cutters, (Needles, glass syringes or syringes with fixed needles, autoclaving or microwaving followed by scalpels, blades, glass, etc. that may cause punctures and cuts. mutilation or shredding##, whichever This includes both used and unused sharps) is applicable, and final disposal through authorized CBWTF or disposal in secured landfill or designated concrete waste sharps pit 5 Discarded Medicines and Cytotoxic Drugs Disposal in secured land fill or incineration@@ (Wastes comprising of outdated, contaminated and discarded medicines) 6 Soiled Waste Incineration@@ (Items contaminated with blood and body fluids including cotton, dressings, soiled plaster-casts, linen, bedding, other materials contaminated with blood) 7 Infectious Solid Waste Disinfection by chemical treatment@ or autoclaving or microwaving followed (Wastes generated from disposable items other than the by mutilation or shredding## and after waste sharps, such as tubing, hand-gloves, saline bottles with treatment final disposal through registered or IV tubes, catheters, glass, intravenous sets etc). authorized recyclers 8 Chemical Waste Chemical treatment@ and discharge into drains, meeting the norms notified under (Chemicals used in production of biological toxins, these rules and solids disposal in secured chemicals used in disinfection, as insecticides etc.) landfills @ Chemical treatment using at least 1% hypochlorite solution or any other equivalent chemical reagent. It must be ensured that chemical treatment induces complete disinfection. ## Mutilation/shredding must be such that so as to prevent unauthorized reuse. @@ There will be no chemical pre-treatment before incineration. Chlorinated plastics/bags shall not be incinerated. Disposal of bio-medical waste by deep burial shall be prohibited in towns and cities. Disposal by deep burial is permitted only in rural areas where there is no access to common bio-medical waste treatment facility, with prior approval from the prescribed authority. The deep burial facility shall be located as per provisions and guidelines issued by Central Pollution Control Board from time to time. Tool-kit for Managers: Volume II 9 Liquid waste generated from laboratories and from out by placing chemical indicator strips on the waste washing, cleaning, housekeeping and disinfecting packages to check whether a certain temperature has activities, shall be appropriately treated so as to meet been reached, has been made mandatory for every the discharge standards stipulated under these rules. batch of wastes being autoclaved. Incineration ash (ash from incineration of any bio- One of the directives in the rules talks about setting medical waste) shall be disposed of into secured up of ‘District Level Monitoring Committees’ in the landfills, if toxic or hazardous constituents are present districts to scrutinize compliance with the new Rules beyond the prescribed limits as given in Hazardous in the hospitals and other agencies generating BMW, Waste (Management, Handling and Trans-boundary and facilities engaged in the treatment and disposal of Movement) Rules, 2008. BMW. As per the rules, the District Level Monitoring Color coding and type of container for disposal as per Draft Bio-Medical Waste Rules, 2011 Table 4:  (Schedule II) Color Type of container to be used Waste category number Treatment options as per Schedule i Yellow Non-chlorinated plastic bags Category 1, 2, 5, 6 Incineration Red Non-chlorinated plastic bags/ Category 3, 4, 7 As per Schedule I (Rule 7) puncture-proof containers for Soiled Wastes sharps Blue Non-chlorinated plastic bags/ Category 8 (chemical wastes) As per Schedule I (Rule 7) containers Black Non-chlorinated plastic bags Municipal waste Disposal in municipal dump sites Notes: 1. Waste collection bags for waste types needing incineration shall not be made of chlorinated plastics. 2. Category 3, if disinfected locally, need not be put in containers/non-chlorinated plastic bags. The municipal waste such as office waste (like paper waste), kitchen waste, food waste and other non-infectious waste shall be stored 3.  in black-colored containers/bags, and shall be disposed of in accordance with Municipal Solid Waste (Management and Handling) Rules, 2000. New inclusion Committee would be headed by the District Medical Officer or his nominee. The Committee is also The Bio-Med Rules, 1998 only mentioned about the entrusted with the task of preparing and submitting a occupiers and operators to submit an annual report to half-yearly report on the status of health-care facilities the prescribed authority but no information of what data should be furnished in the report was mentioned. under its jurisdiction to the State Level Advisory A detailed format for the Annual Report has thus been Committee. A copy of the report should also be sent included in the new Rules. to Central Pollution Control Board or Ministry of Environment and Forests and the State Pollution Form VI is also a new addition in the draft rules. It Control Board/Pollution Control Committee, as the empowers the operator of CWTF to report against the case may be, for necessary action. HCEs who are not carrying out proper segregation of their wastes. For conducting the validation test during The Rules have also taken into account Government autoclaving certain changes have been introduced. For hospitals and their lack of capacity and resources. spore testing the frequency has been stipulated. It has These hospitals generally charge a pittance and to be conducted once in three months and records have serve a large proportion of the populace. Managing to be maintained. Routine Tests, which are carried the BMW wastes in these hospitals would require 10 Mainstreaming Environmental Management in the Health Care Sector adequate infrastructure, manpower and expertise, 3.3 The Water (Prevention and Control of which they lack. The Rules have instructed State Pollution) Act, 1974 Governments and Union Territories to allocate and provide separate funds to all such health-care facilities The Act establishes standards for water quality for appropriate management of their BMW. The State and effluents, and also establishes an institutional Governments have also been instructed to procure structure for preventing and reducing water pollution. and allocate the relevant treatment equipment for Polluting industries must seek permission to discharge government HCFs.  waste into effluent bodies such as drains, or even other water bodies like rivers or lakes. The Central Pollution Control Board (CPCB) was constituted 3. Other regulations related to the under this Act. management of health-care waste 3.4 Environmental Impact Assessment A number of environmental laws, regulations, which impact the health care sector and services, have been Notification, 2004 promulgated. Among those that focus on health care This notification states that any large construction waste management include: project, that is for 1,000 persons or above, or which discharges sewage of more than 50,000 liters per day, and having an investment of US$ 10.9 million or above, 3.1 Environmental Protection Act, 1986 requires an Environmental Impact Assessment (EIA) The Government of India enacted the Environmental to be cleared by the MoEF before construction work Protection Act (EPA) under Article 253 of the can commence. This notification is therefore applicable Constitution. This Act serves as an “umbrella� to investments in new facilities or modifications for legislation to provide a framework for coordination secondary, tertiary and larger health-care facilities and of environment activities of various established medical colleges. central and state authorities. It also empowers the Central Government to take appropriate measures to protect and improve environmental quality, 3.5 The Factories Act, 1948 and to prevent, control and reduce environmental This law specifically focuses on occupational health pollution, including collection and dissemination and safety, and identifies the need for Material Safety of information. There are rules and notifications Data Sheets (MSDS). The basic provisions for a safe under this Act, which are directly relevant to the workplace provided under this Act can be applied health sector. as a baseline, but needs to be updated to reflect the current understanding of health and safety issues. 3.2 Municipal Solid Wastes (Management Under this Act, waste management units such as common effluent treatment plants, and common and Handling) Rules, 2000 treatment facilities are not classified under hazardous As a result of the plague epidemic in Surat, industries. Gujarat in 1994, the Supreme Court, under pressure from civic and environmental activists, directed 3.6 Right to Information Act, 2005 the Ministry of Environment and Forests (MoEF) to draft the Municipal Solid Wastes (MSW) Rules in The RTI Act confers the right to every citizen to 2000. These rules apply to every municipal authority secure access to information under the control of responsible for collection, segregation, storage, public authorities, consistent with public interest, transportation, processing, and disposal of municipal in order to promote openness, transparency and solid wastes. accountability. It provides for the constitution of a Tool-kit for Managers: Volume II 11 Central or State Information Commission(s), which 4. The role of different stakeholders are empowered to enquire into complaints from in health-care waste management persons who have not been able to secure information requested under the Act. The Indian Courts have The role of different stakeholders has been described also allowed citizens and social action groups and in the chapter on stakeholder participation pressure groups access to public records, subject (Chapter 3 Vol. I). The matrix below gives an overview to the condition that disclosure may be refused for of various activities carried out by the different reasons of security7. stakeholders. Table 5: The role of different stakeholders in health-care waste management Stakeholder Roles and responsibilities sustainability Research and Enforcement development and disposal Policies and Monitoring Legislation Collection Executing Financing guidelines allocation Capacity building agency Land and MoEF Yes* Yes Yes Yes Yes Yes MoHFW Yes Yes Yes Yes Yes Yes CPCB Yes Yes Yes Yes Yes Yes SPCB Yes Yes Yes Yes Yes Yes Municipal Yes Yes Yes Yes Yes Yes Bodies WHO Yes Yes Yes Yes Yes Multilateral Yes Yes Yes Yes Yes Organizations NGOs and Yes Yes Yes Yes others Health-care Yes Yes Yes Yes Yes Yes Yes Facilities Centralized Yes Yes Facilities and Private sector/ Yes Yes Yes Yes Yes Accreditation Bodies Yes*: This refers to the active involvement of the organization/institution in the activity specified in the column head. 7 Lal and Goswami, International Comparative Legal Guide Series on Environmental Law, India Associated Law Advisers. 12 Mainstreaming Environmental Management in the Health Care Sector III CPCB Guidelines on Health-Care Waste Management 1. Guidelines for establishing and � Facility for bin-washing, floor-washing, operating a common bio-medical vehicle-washing. waste treatment facility � Effluent Treatment Plan A Common Waste Treatment Facility for Health- � Secured sanitary land ll (Until a secured Care Facilities (CWTF) is a set up where health- sanitary land ll comes up in the area, space care waste, generated from a number of health-care within the CBWTF facility shall be used). units, undergoes necessary treatment to reduce any ii. Only waste Categories 1 and 2 as described in the adverse effects that this waste may pose. The Bio-Medical Waste Rules shall be incinerated (if CWTFs are cost effective, easy to operate and secured sanitary land�ll is not available, waste maintain, rather than individual health-care facilities Category 5 may also be incinerated). having their own waste treatment and disposal iii. All other infected waste shall be subjected options. The CPCB has developed detailed guidelines for CWTFs, wherefrom the following checklist has to autoclaving/hydroclaving/microwaving been reproduced here. as applicable under the Bio-Medical Waste (Management and Handling) Rules, 1998. iv. Incinerator, autoclave/hydroclave/microwave 1.1 Treatment facility shall be PLC based with tamper-proof control i. The following amenities shall be provided in any panel and recording devices. common waste treatment facility: � Autoclave (Pre-vacuum horizontal feeding)/ 1.2 Location Hydroclave/Microwave. Reasonably away from residential and sensitive area. � Incineration (for waste belonging to Categories 1, 2 and 5 only). � Shredder 1.3 Land � Sharps pit/Encapsulation/Recovery of metal Preferably not less than one acre land may be required in some factory may be considered. to set up all the requisite facilities. 1.4 Coverage area ŒŒ The inner surface of the waste-carrying cabin shall be made of a smooth surface to minimize In any area, only one CBWTF may be allowed to water retention. cater up to 10,000 beds at the approved rate by the Prescribed Authority. A CBWTF shall not be allowed ŒŒ The waste cabin shall have provisions of sufficient openings in the rear and/or sides so that waste to cater to health-care units situated beyond a radius containers can be easily loaded and unloaded. of 150 km. However, in an area where 10,000 beds are not available within a radius of 150 km, another ŒŒ The vehicle shall be labeled with the bio-medical CBWTF may be allowed to cater to the health-care waste symbol (as per the Schedule III of the units situated outside the said 150 km. Rules) and should display the name, address and telephone number of the CBWTF. 1.5 Segregation 1.8 Storage ŒŒ Segregation shall be as per the Bio-Medical Waste (Management and Handling) Rules, 1998 as well ŒŒ Sufficient ventilated storage space for untreated as be compatible with treatment facilities at and treated bio-medical waste shall be provided. CBWTF as suggested by the operator. ŒŒ The flooring and walls (to a height of 2 m from ŒŒ The generator is responsible for providing floor) shall be finished with smooth and fine segregated waste to the operator. material. There shall be a minimum number of joints. ŒŒ The operator shall not accept unsegregated waste and report the matter to the SPCB. 1.9 Record keeping 1.6 Collection ŒŒ Documents such as collection advice taken from health-care units for each category of waste, ŒŒ Each colored bag should be kept in a similar records of waste movements, logbook for the colored container i.e. colored bags shall not be equipment and site records shall be maintained. kept directly in the transportation vehicles. ŒŒ All the records shall be available at the CBWTF ŒŒ Sharps shall be collected in puncture-resistant site for inspection. containers. ŒŒ Temporary storage at health-care units shall be 1.10 Disposal done in designated areas. ŒŒ Incineration ash – Secured sanitary landfill ŒŒ Treated solid waste – Municipal sanitary landfill 1.7 Transport vehicle ŒŒ Plastic waste after disinfection and shredding – ŒŒ A dedicated vehicle should be there for the Recycling or municipal sanitary landfill collection of bio-medical waste. ŒŒ Sharps, after disinfection (if encapsulated) – ŒŒ Separate cabins shall be provided for driver/staff Municipal sanitary landfill and the bio-medical waste containers. ŒŒ Treated wastewater – Sewer/drain or recycling ŒŒ The base of the waste-carrying cabin shall be made leak-proof to avoid leakage of liquid during ŒŒ Oil and grease – Incineration transportation. ŒŒ The waste cabin may be designed for storing 1.11 Setting up and operation of CBWTF waste containers in tiers. ŒŒ The proponent shall submit a detailed work- ŒŒ The waste cabin shall be designed such that it is plan of the proposed CBWTF to the Prescribed easy to wash and disinfect. Authority SPCB for issuance of "Consent 14 Mainstreaming Environmental Management in the Health Care Sector to Establish". The work plan should include ŒŒ A storage area for treated waste that could also be complete details of the project such as site details, the storage for domestic waste, located for easy coverage area, infrastructure set up, manner of removal of municipal solid waste. transportation of bio-medical waste, operating ŒŒ Drainage to receive condensate and wastewater procedures etc. from the wash areas. ŒŒ The CBWTF operator shall carry out stack ŒŒ Slightly sloping floor to direct water towards the emission test of incinerator, incineration ash drains. test, validation test of autoclave/microwave/ hydroclave and compliance with applicable ŒŒ Floor and walls constructed of a material that is parameters of any effluent being discharged from easy to wash. the CBWTF, and have it ratified at least quarterly ŒŒ Good ventilation to protect workers from odors, from the approved laboratory and submit the volatilized gases and steam. quarterly report of the same to the SPCB/PCC. 3. Guidelines for design and 2. Some design principles for a waste construction of BMW incinerator treatment and storage facility ŒŒ Waste flow from “dirty� to “clean� in a 3.1 General straight forward manner that prevents cross- i. These guidelines shall be applicable only to the contamination, i.e., avoid having clean materials new installation of incinerators. However, the (including treated waste) from passing through existing incinerators shall be retrofitted with Air dirty areas and coming in contact with infected Pollution Control Device as mentioned in these materials. guidelines. ŒŒ A safe and easy way to bring in infectious waste ii. Incinerators shall be allowed only at Common Bio- (such as having the treatment system at loading Medical Waste Treatment Facilities (CBWTF). dock height so that waste from a truck could iii. Installation of individual incineration facility simply be rolled on to the treatment platform). by a health-care unit shall be discouraged as far ŒŒ A storage area for untreated waste that meets as possible but approval may be granted only the WHO standards and is located close to the in certain inevitable situations where no other treatment system. option is available. ŒŒ An area to wash and disinfect bins as close as possible to where the bins are emptied when the 3.2 Incinerator waste is placed in the treatment system. The following design criteria may be adopted for better ŒŒ A space to store empty (washed) bins that is performance: easily accessible to workers that need more bins i. The incinerator shall be designed for a capacity for waste collection. of more than 50 kg/hr. For 50 kg/hr capacity, ŒŒ If the CTF uses a shredder, the shredder should the minimum hearth area shall be 0.75 sq. m be on the “clean� side of the waste flow after the (8 sq. feet) and the minimum flow of the flue gas treatment system. in the secondary chamber shall be 0.6 m3/sec at ŒŒ An emergency wash area for workers who are 1050°C. Each incinerator must be installed with accidentally exposed. an air pollution control system (as specified in ŒŒ A space to store clean PPE located such that the the Section 3). worker has access to the PPE before entering the ii. The size of the opening through which the waste “dirty� areas. is charged shall be larger than the size of the waste Tool-kit for Managers: Volume II 15 bag used for feeding. The volume of the primary The refractory lining of the chamber shall be viii. chamber shall be at least five times the volume of strong enough to sustain minimum temperature one batch. of 1000°C in the primary chamber and 1200°C iii. The double chamber incinerator shall preferably in the secondary chamber. The refractory and be designed on "controlled-air" incineration insulation bricks shall have a minimum of principle, as particulate matter emission is low 115 mm thickness each and conform to IS:8-1983 in such incinerators. Minimum 100% excess & IS:2042-1972 respectively. air shall be used for overall design. Air supply ix. The incinerator shell shall be made of mild in the primary and secondary chamber shall steel plate of adequate thickness (minimum be regulated between 30-80% and 170-120% of 5 mm thick) and painted externally with heat- stoichiometric amount respectively. Primary air resistant aluminum paint with proper surface shall be admitted near/at the hearth for better preparation, suitable to withstand a temperature contact. Flow meter/suitable flow measurement of 250°C. Refractory lining of the hot duct shall device shall be provided on the primary and be done with refractory castable (minimum secondary air ducting. The combustion air shall 45 mm thick) and insulating castable (minimum be supplied through a separate forced draft fan 80 mm thick). after accounting for the air supplied through x. Ceramic wool shall be used at hot duct flanges burners. and expansion joints. Optional: For higher capacity incinerators, xi. The thermocouple location shall be as follows: typically above 250 kg/hr, other design e.g. Rotary Kiln shall be preferred. ŒŒ In primary chamber – Before admission of secondary air. iv. A minimum negative draft of 1.27 to 2.54 mm of WC (Water Column) shall be maintained in ŒŒ In secondary chamber – At the end of the primary chamber to avoid leakage of gaseous secondary chamber or before admission of emissions from the chamber and for safety reasons. dilution medium to cool the gas. Provision shall be made in the primary chamber xii. There shall be a separate burner each for the to measure the Water Column pressure. primary and secondary chambers. The heat input v. The waste shall be fed into the incinerator in small capacity of each burner shall be sufficient to raise batches after the fixed interval of time in case of the temperature in the primary and secondary fixed hearth incinerators and continuous charging chambers to 800±50°C and 1050±50°C using appropriate feeding mechanisms in case respectively, within a maximum of 60 minutes of rotary kiln incinerators, or as recommended prior to waste charging. The burners shall have by the manufacturer. The size of the hearth i.e. automatic switching “off/on� control to avoid primary chamber shall be designed properly. the fluctuations of temperatures beyond the vi. The sides and the top portion of the primary and required temperature range: secondary chambers shall preferably have rounded ŒŒ Each burner shall be equipped with spark corners on the inside to avoid the possibility of igniter and main burner. formation of black pockets/dead zones. ŒŒ Proper flame safeguard of the burner shall be vii. The size of the secondary chamber shall be installed. properly designed so as to facilitate a minimum ŒŒ Provide view ports to observe the flame of of one second of residence time to gas flow. the burner. For the estimation of residence time in the secondary chamber, its volume shall be calculated ŒŒ Flame of the primary burner: starting from the secondary burner tip to the –– shall be pointing towards the centre of thermocouple. the hearth. 16 Mainstreaming Environmental Management in the Health Care Sector –– shall have a length such that it touches and operating parameters such as temperatures in the waste but does not impinge directly both the chambers. CO, CO2, and O2 in gaseous on the refractory floor or wall. emissions shall also be measured daily (at least ½ ŒŒ The secondary burner shall be positioned in hour at one minute intervals). such a way that the flue gas passes through xvii. The possibility of providing heat recovery the flame. system/heat exchanger with the incinerator shall xiii. There shall not be any manual handling during also be considered wherever possible. charging of waste into the primary chamber xviii. The structural design of the chimney/stack of the incinerator. The waste shall be charged shall be as per IS:6533-1989. The chimney/stack in bags through an automatic feeding device shall be lined from inside with at least 3 mm at the manufacturers recommended intervals, thick natural hard rubber suitable for the duty ensuring that there is no direct exposure of conditions, and shall also conform to IS:4682 furnace atmosphere to the operator. The device Part I-1968 to avoid corrosion due to oxygen and shall prevent leakage of the hot flue gas and any acids in the flue gas. backfire. The waste shall be introduced on the xix. The location and specifications of the porthole, hearth in such a way so as to prevent any heap platform ladder etc. shall be as per the Emission formation. Suitable raking arrangements shall be Regulations, Part-3 (COINDS/20/1984-85), provided for uniform spreading of waste on the published by CPCB. hearth. xiv. A tamper-proof PLC (Programmable Logic 4. Air pollution control device Control)-based control system shall be installed It is not possible to comply with the emission limit of to prevent: 150 mg/Nm3 (corrected to 12% CO2) for particulate ŒŒ Waste charging until the required matter, without an Air Pollution Control Device temperature in the chambers is attained (APCD). Therefore, a bio-medical waste incinerator during the beginning of the operation of the shall always be equipped with an APCD. incinerator. ŒŒ No incinerator shall be allowed to operate unless ŒŒ Waste charging unless primary and secondary equipped with APCD. The incinerator shall be chambers are maintained at the specified equipped with High Pressure Venturi Scrubber temperature range. System as ordinary APCD such as wet scrubber or ŒŒ Waste charging in case of any unsafe cyclonic separator cannot achieve the prescribed conditions such as – very high temperature emission limit. in the primary and secondary chambers; ŒŒ For the facilities operating for 24 hrs a day, an failure of the combustion air fan, ID fan, APCD in terms of dry lime injection followed by recirculation pump; low water pressure, and bag filter can be considered. The details of High high temperature of the flue gas at the outlet Pressure Venturi Scrubber System are given in of air pollution control device. Section VII. xv. The incineration system must have an emergency vent. The emergency vent shall remain closed 5. Incinerator room and waste i.e. it shall not emit flue gases during normal storage room operation of the incinerator. i. The incinerator structure shall be built in a room xvi. Each incineration system shall have graphic with proper roofing and cross ventilation. There or computer recording devices which shall shall be a minimum of 1.5 m clear distance in all automatically and continuously monitor and directions from the incinerator structure to the record dates, time of day, batch sequential number wall of the incinerator room. Tool-kit for Managers: Volume II 17 ii. Adjacent to the incinerator room, there shall 7. Details of high pressure venturi be a waste storage area. It shall be properly scrubber system ventilated and designed such that waste can be i. The Venturi scrubber shall have a minimum stored in racks and washing can be done very pressure drop of 350 mm WC to achieve the easily. The waste storage room shall be washed prescribed emission limit. The temperature of and chemically disinfected daily. the flue gas at the outlet of the Venturi scrubber iii. The floor and inner wall of the incinerator shall be approx 70-80°C to ensure the saturation and storage rooms shall have an outer of the flue gas. covering of impervious and glazed material so ii. The Venturi scrubber shall preferably be made as to avoid retention of moisture and for easy of stainless steel – 316L grade or better material cleaning. or mild steel-lined with acid resistant bricks to iv. The incineration ash shall be stored in a closed avoid corrosion. sturdy container in a masonry room to avoid any iii. The water to be used in the Venturi scrubber shall pilferage. Finally, the ash shall be disposed of in be mixed with caustic soda solution to maintain a secured landfill. the pH of the scrubbing liquid above 6.5. iv. The scrubbing medium shall be circulated 6. Operator of the incinerator @  2-2.5 ltrs/m3 of saturated flue gas at the i. A skilled person shall be designated to operate and Venturi outlet. This shall be done using a pump maintain the incinerator. The operator shall have and piping made of stainless steel – 316 grade or adequate qualification in relevant subjects and better material. The scrubbing medium shall be shall be trained and certified by the incinerator re-circulated as far as possible. supplier in operation and maintenance of the v. The Venturi scrubber shall be followed by incinerator. centrifugal type droplet separator to remove ii. There shall be at least one assistant designated water droplets from the flue gas. at the incinerator plant to keep track of the vi. The material of construction of the droplet wastes, records of incinerator operation, separator and interconnecting ducting from the cleanliness of the surrounding area and Venturi scrubber to droplet separator, droplet incinerator and waste storage room. They shall separator to ID fan and ID fan to stack, shall be also take care of waste charging and incineration mild steel-lined from the inside with minimum ash disposal. 3 mm thick natural hard rubber suitable for the iii. All the staff at the incinerator plant shall put on duty conditions. It shall also conform to IS:4682 protective gears such as gumboots, gloves, eye, Part I-1968 to avoid corrosion due to oxygen and glasses, etc., for safety reasons. acids in the wet flue gas. iv. Any accident that occurs shall immediately be vii. The wastewater generated from the air pollution reported to the facility operator. The facility control device shall be properly handled so as operator shall have well-defined strategies to deal to avoid any non-compliance of the regulatory with such accidents/emergencies. requirements. [The guidelines will help in selection/installation Stack emission monitoring and ash analysis as viii. of better incinerator systems. However, it shall per the requirement of the Bio-Medical Waste be ensured that the incinerators shall be in (Management and Handling) Rules, 1998, shall compliance with the standards stipulated in the be done quarterly i.e. once in every three months Bio-Medical Waste (Management and Handling) and relevant records shall be maintained by the Rules, 1998.] facility operator. 18 Mainstreaming Environmental Management in the Health Care Sector IV Road Map on Management of Waste in India The following are the recommendations from the Bio-Medical Waste Treatment Facilities) for Report of the Committee to Evolve Road Map on veri cation of compliance of provisions of the Management of Wastes in India8 on improving health- Rules and CPCB guidelines issued from time to care waste management in the country. time. 1. A national inventory should be made for all 5. SPCB/PCC/CPCB should set up a dedicated bio-medical waste generators (Government/ “Bio-Medical Waste Management Cell� within Private or others). Health-Care Facilities the organization with requisite dedicated (HCFs)/dispensaries/blood-banks/laboratories/ manpower and infrastructure for monitoring and animal husbandries/consultants etc. in terms implementing the action plan and the provisions of number and kg/day to be made by the State of the BMWM Rules. Requisite funds could be Pollution Control Board (SPCB)/Pollution utilized from the authorization/consent fees. Control Committee (PCC) (for HCFs as de�ned Additional nancial assistance may be obtained under the Bio-Medical Waste Management and from the MoEF. Handling (BMWM) Rules) and HCFs falling 6. Adequate funds should be allocated for under the purview of Director General, Armed bio-medical waste management as well as Forces Medical Services. procurement and supply of disposal equipments 2. The existing BMWM Rules should be reviewed to such as autoclaves, microwaves/hydroclaves, incorporate more stringent penalty for violation. shredders, needle-cutters, mercury-spill kits to A strategy must be evolved for safer management all the Govt. HCFs within one year. of bio-medical waste in the country. 7. All the HCFs should be brought under the ambit 3. The responsibilities of the Operator of a facility of BMWM Rules and not be permitted to operate should be clearly de ned. without authorization of the SPCB/PCCs. 4. SPCB/PCC/CPCB (Central Pollution Control 8. All HCFs in operation should be registered Board) should undertake strict and periodic with the State/UT (Union Territory) Deptt. of monitoring of HCFs/CWTFs (Centralized Health/Ministry of Health and Family Welfare. 8 Ministry of Environment and Forest website http://www.mohfw.nic.in/ 9. CPCB should make random checks on inventory at the district, state, national and international reports submitted by the SPCB/PCC and Director levels for HCFs for all the officials dealing General, Armed Forces Medical Services. with the bio-medical waste management-related activities. SPCB/PCC/CPCB/MoEF/Ministry 10. MoEF (as per SPCBs and PCCs and Ministry of Health and Family Welfare Director General, of Defense)/Ministry of Health & Family Armed Forces Medical Services/State/UT Welfare should finalize National Inventory on Deptt. of Health and Centres of Excellence are Bio-Medical Waste Generation from HCFs, to implement these programs. Veterinary Hospitals, Armed Forces Health- Care Establishments. 16. State/nationwide awareness programs should be created for the general public for dissemination 11. SPCB/PCC, Director General, Armed Forces through mass media like TV, Radio, newspapers, Medical Services should make an assessment of hoardings etc. existing capacity of Bio-Medical Waste Treatment Facilities in every State/UT along with the 17. It should be made mandatory for every 50- and respective coverage area. SPCB/PCC may above-bedded HCFs to have at least one person identify additional treatment facilities required who has undertaken a three/six months distance vis-à-vis existing facilities. learning program on BMWM or similar courses accredited by CPCB. 12. SPCB/PCC/Ministry of Health and Family Welfare/MoEF/Ministry of Defence should 18. HCFs need to install some equipment for identify and allocate land for setting up of treatment other than captive incinerators, additional CWTFs, invite private entrepreneurs especially for mitigating and minimizing the for setting up CWTFs. In cases, where no spread of infection. entrepreneur comes forward to set up a CWTF, 19. HCFs need to install a laboratory to carry out submit proposals along with fund details to CPCB/ tests such as Routine Environmental checks, MoEF/Ministry of Defence for seeking financial Disinfectant In-Use test, Validation/Efficacy tests assistance from MoEF. In places where the of autoclave/microwave/hydroclave etc. installed. location is such that CWTFs can cater to districts 20. HCFs should be encouraged to use non-mercury- in neighboring states, interstate transportation of based instruments in place of mercury-based BMW could be allowed since this helps the HCFs thermometers and Sphygmomanometers. and makes the CWTF more viable. 21. CPCB/MoEF should review gaseous emission 13. SPCB/PCC/CPCB should initiate action against standards and effluent discharge norms in HCFs and CWTFs violating the provisions consultation with various Stakeholders. of BMWM Rules and the Guidelines issued by CPCB from time to time. 22. Registrations of those hospitals that do not set up an individual treatment/disposal facility 14. Ministry of Health and Family Welfare, State/ or join a common treatment facility should be UT Department of Health should initiate cancelled. New hospitals should not be allowed action against HCFs and CWTFs violating to commence operations without making the conditions of registration. HCFs which sure that they have the facility for treatment/ store and sell used plastic disposables to disposal of bio-medical waste or are a member unauthorized contractors for repackaging, of a CWTF. Segregation of bio-medical waste at and/or resell “tainted disposables like syringes, source, according to its type, should be ensured gloves, catheters, IV sets etc� should be severely in each hospital and HCF. Segregation could punished and their registrations cancelled. be simplified into 5 types of waste by clubbing 15. Training workshops should be organized on the 10 categories of waste presently specified in bio-medical waste management-related activities Schedule 1 (described above). 20 Mainstreaming Environmental Management in the Health Care Sector V Health-Care Waste Management Plan Health care waste management needs to be integrated The Health-Care Waste Management Committee into the day-to-day activities of health-care facilities. could include the following hospital personnel: A plan for developing an infection control and waste � Head of the Hospital management system has been provided in this section. � Waste Management Of cer More detailed guidance is available from documents prepared by WHO, as referenced in Section XIX. � Heads of the Hospital Departments � Nursing Superintendent 1. STEP 1: Waste management � Doctor/Nurse from Infection Control Committee committee � Sanitary Supervisor Developing a sound Health-care waste management and � Store In-charge and infection control policy at the facility level requires the support and commitment of the administration and a � Other departmental heads and committed carefully designed health- care waste management plan. individuals. The �rst step is to formulate a waste management/ infection control committee headed by the head of 2. STEP 2: Waste management plan the institution and to appoint a waste management The second step is to describe the activities for of�cer. The size of the waste management committee implementation of a waste management plan and depends on the size and structure of the health-care prepare an action plan. The execution of the waste facility. Before executing a waste management plan, management system could be either by the members a clear understanding of the roles and responsibilities of the waste management committee or by an external of each member of the waste management committee agency (like consultants/NGOs working in this area). and the entire hospital staff needs to be clearly de ned. As health-care waste management is a cross-cutting The basic steps to be included in the waste management issue, the waste management committee must ensure plan are: that, while implementing different national and state health programs, common, everyday messages are � Waste assessment communicated to the health-care workers. � Training and capacity-building Figure 2: Waste management committee Hospital’s Nodal officer Nursing Superintendent Sanitary supervisor store In charge Continuing Epidemiology Nurse Education (Infection Controal Nurse) Waste Implementation of Medical Director & Management the system Administrative Head Committee Members from other Regular Monitoring departments Policies & Regulations ŒŒ Procurement of equipments and supplies 3.2 Training and capacity-building ŒŒ Implementing the waste management system Training needs to be imparted to all health-care ŒŒ Monitoring and record-keeping professionals on waste management issues, not only to provide them with the core knowledge, skills and ŒŒ Any other relevant issue attitude to effectively work for the implementation of proper waste management, but also to make them 3. STEP 3: Waste assessment, understand the importance of good waste management training and procurement practices within and outside the health-care facility. The role of different health-care providers and common 3.1 Waste assessment messages on proper waste management practices should Before implementing the waste management system be communicated to health care workers. in the health-care facility, a waste audit needs to be Training and awareness programs help in changing the conducted to assess: (i) the status of authorization; mindset of the health-care professionals and workers (ii) the points of waste generation; (iii) type and towards health-care waste. Regular and ongoing training quantity of waste generated; (iv) present waste and awareness programs for all the staff members – management practices; (v) sharps management; from the top administrator to the housekeeping staff (vi) options for final treatment and disposal; should be organized to reinforce the message of proper (vii) level of awareness; (viii) universal precautions waste management practices. and infection control measures adopted by the health- care workers; (ix) mercury reduction program; Training programs should broadly include the (x) waste minimization measures; (xi) recycling and following topics: reuse options; and (xii) bio-safety measures in the ŒŒ Hazards of health-care waste laboratories. Based on the findings of the survey, the waste management system in the health-care ŒŒ Infection control measures facility such as procurement of bins, needle-cutters, ŒŒ Bio-Medical Waste (Management and Handling) etc should be planned. Rules 22 Mainstreaming Environmental Management in the Health Care Sector ŒŒ Waste management steps: waste collection, 3.4 Checklist of supplies segregation, transportation, storage, treatment ŒŒ Chemical disinfectants and disposal ŒŒ Bags and bins of different sizes and colors ŒŒ Liquid waste management ŒŒ Equipment for personal protection and ŒŒ Cleaning of spills immunization of personnel ŒŒ Waste minimization ŒŒ Needle destroyer/cutters ŒŒ Alternatives to hazardous chemicals ŒŒ Waste trolleys/carts ŒŒ Occupational safety issues. ŒŒ Waste treatment equipment like autoclave, shredder 3.2.1 Tools for training and awareness ŒŒ Construction of deep burial pits i. Channels for training: ŒŒ Mercury-free equipment ŒŒ Distance learning ŒŒ Energy efficient purchases. ŒŒ Workshops ŒŒ Seminars 4. STEP 4: Implementation of waste ŒŒ Classroom teaching management and infection control ŒŒ Practical Hands-on training – training at the system place of work. After waste assessment, training and procurement of ii. Awareness activities through: supplies for waste management, the waste management and infection control system needs to be set in ŒŒ Newsletters and factsheets place. The basic steps for waste management are the ŒŒ Health-care waste management as part of the following. hospital accreditation system ŒŒ Incentives for good waste management 4.1 Segregation practices ŒŒ Electronic and print media Segregation of waste at source is the single most important step in bio-medical waste management. ŒŒ Posters Once bio-medical waste gets mixed with the ŒŒ Banners general waste, the problem magnifies and becomes ŒŒ Skits and plays. unmanageable. Thus it is critical that segregation of waste takes place at the point of generation. The segregation of waste should be done as per the Bio- 3.3 Procurement Medical Waste Rules. After the waste audit the health-care facilities must prepare a comprehensive quantification and 4.2 Collection and storage specification of all the items for procurement. Procurement of waste management equipment and The segregated waste must be collected and consumables must be as per the specified standards stored in specified labeled colored containers and in line with the demand of quantities for one-time made of good plastic or any other strong material. purchase of equipment and recurrent annual supplies. The containers must be smooth, without any Procurement of equipment should preferably be along sharp edges, and cleaned regularly. Special puncture- with other implementation activities. This will ensure resistant containers must be used to hold discarded proper use of equipment for sound waste management. sharps. Tool-kit for Managers: Volume II 23 Figure 3: Segregation of waste as prescribed in the Bio-Med Rules Infectious Waste General Non-sharps Anatomical Sharps Waste (Soiled Waste) Waste (Source: IGNOU modules on health care waste management) photo credit Megha Rathi 4.3 Transportation day-to-day activities of the health-care facility. The waste-handlers/waste-pickers must be The waste should be transported from the provided with uniforms, aprons, boots, gloves point of generation to the final disposal site in and masks, to be worn while collecting and properly designed transportation vehicles, transporting the waste. Waste should not be stored such as trolleys, wheel barrows and push-carts. beyond 48 hours. Final waste storage areas must be The transportation route and time must be secure, and unauthorized persons should not have such that it does not interfere with the other access to the area. Table 6: Categories of health-care waste and their final disposal Type of waste Location In-situ End treatment Final disposal treatment CWTF No CWTF CWTF Human tissue, OT, Labor - Incineration Deep Burial inside Incineration ash to body parts and rooms, wards at common the hospital be buried in secured placenta treatment landfill facility Cotton, gauze All wards, OT, - Autoclave/ Deep burial after Land filling after dressings, POPs Labor rooms, Microwave disinfection disinfection and soiled with Lab, ICU, Acute and shredding mutilation blood, pus and wards, Isolation at common other human wards treatment discharges facility All types of All wards and 1% Hypo Autoclave/ Disinfection and Formal recycling plastics, i.e. departments chlorite solution Microwave mutilation plastic syringes, for 30 minutes and shredding I.V. lines, I.V. at common bottles, bags treatment facility 24 Mainstreaming Environmental Management in the Health Care Sector Type of waste Location In-situ End treatment Final disposal treatment CWTF No CWTF CWTF Discarded Stores - Incineration Deep burial Secured landfilling of medicines, at common Incineration ash Cytotoxic treatment drugs and facility heavy chemicals Soiled linen OT, Labor 1% Hypochlo- Washed in Washed in laundry Reused after wash rooms, ICU, rite solution for laundry Isolation wards, 30 minutes Acute wards and other wards General waste All wards & - No treatment Municipal sanitary such as left- departments landfilling of the NA over food in general waste patients plates, stationery, fruit waste, unsoiled dressings, gauze and cotton from Green bucket Needles, blades All wards & 1% hypochlo- Deep burial/ Encapsulation or departments rite for 30 encapsulation Deep burial/ formal recycling minutes and encapsulation after disinfection and mutilation by mutilation needle removal devices/de- stroyers and storing them in puncture proof container Broken glass, All wards & 1% hypochlorite Stored in Autoclaved and Formal recycling after bottles, tubes, departments for 30 minutes Puncture Proof stored in Puncture disinfection Vials, petri Containers proof containers dishes Pearl pet with hypo chlorite solution 1% Microbiological Labs 5% Hypochlo- Autoclaving Autoclaving Liquid discarded in samples rite solution for drainage 30 minutes Liquid waste All wards/ 5% Hypochlo- - - Liquid discarded in from wards, Autopsy rooms rite for 30 drainage departments minutes and autopsy room Tool-kit for Managers: Volume II 25 Type of waste Location In-situ End treatment Final disposal treatment CWTF No CWTF CWTF Silver nitrate X-Ray deptt. - - - Formal recycling from X-Ray dept. Broken ther- All wards & Collected safely - - Hazardous land filling mometers and departments in mercury spill sphygmoma- kits nometers Chemicals used Hospital Stores - Send for - Send for incineration in production incineration or secured landfilling of biologicals, or secured used in landfilling disinfection or as insecticides Discarded Blood bank 5% hypochlorite Autoclaved Liquid discarded Liquid discarded expired infected solution for 30 at common in drainage after in drainage after blood or its minutes treatment disinfection disinfection products facility Waste Office - Formal Formal recycling stationery from recycling office Intact glass Lab. 5% Hypochlo- Autoclaved in Autoclaved in CSSD Recycled in hospital tubes, petri rite for 30 CSSD dishes, empty minutes glass bottles 4.4 Treatment and disposal ŒŒ Incineration: This is a high-temperature dry oxidation process that reduces organic and The final step for rendering the bio-medical waste combustible waste to inorganic, incombustible non-infectious is its treatment and disposal. There matter and results in a very significant reduction are different treatment and disposal options available of waste volume and weight. However, due to the according to the Bio-Medical Waste Rules. The final hazardous emissions associated with incineration disposal can either be carried out in the health-care and the high cost of treatment, incineration is facility, or the facility can tie up with a Common Bio- not a preferred option any longer. Medical Waste Treatment Facility (CWTFs). ŒŒ Autoclaving: Autoclaving is an efficient wet ŒŒ Chemical disinfection: This is the process thermal disinfection process that disinfects the of chemically disinfecting the waste by use waste using steam sterilization at 121°C for of disinfectants such as bleaching powder, 60 one bar (100k Pa) pressure. This technology 1 percent sodium hypochlorite, etc. While is user-friendly, easy to operate and is a low-cost using chemical disinfection it is important to achieve the proper concentration and contact form of treatment. time with the waste. The advantages of chemical ŒŒ Hydroclaving: This is an advanced form of disinfection are that it is easy to use, has low cost autoclaving where the waste is not in direct of operation, requires no electricity and can be contact with steam and it is fragmented into carried out at the point of generation. small pieces at the time of disinfection. 26 Mainstreaming Environmental Management in the Health Care Sector ŒŒ Microwaving: Microwave disinfection is a burial. The cost of construction of the steam-based process wherein disinfection occurs waste pit varies between INR 5000-10000/- through the action of moist heat and steam depending on its size and the material of generated by microwave energy. The technology construction. The average life of a deep burial pit in a PHC is between one to is automated and easy to use but has a slightly five years. The health-care facilities can higher cost of operation. construct a deep burial pit as per the ŒŒ Deep burial: After disinfection, the standards specified in the Bio-Medical bio-medical waste can be sent for deep Waste Rules. Specifications for a waste burial pit9 1. A pit or trench should be dug about 2 meters deep. It should be half-filled with waste, and then covered with lime up to 50 cm of the surface, before filling the rest of the pit with soil. 2. Animals should not have any access to the waste burial sites. Covers of galvanized iron/wire meshes may be used to protect the area from trespassing. 3. On each occasion, when wastes are added to the pit, a layer of 10 cm of soil shall be added to cover the wastes. 4. Waste disposal into the pits should be performed under close and dedicated supervision. 5. The deep burial site should be relatively impermeable and no shallow well should be close to the site. 6. The pits should be distant from habitation, and sited so as to ensure that no contamination occurs of any surface water or ground water. The area should not be prone to flooding or erosion. 7. The location of the deep burial site should be authorized by the prescribed authority. 8. The institution should maintain a record of the kind of waste sent for deep burial. Figure 4: Deep burial pit Security fence Cement or embedded wire mesh 50 cm of soil cover Earth mound to keep water out of the pit 2 to 5 meters Soil or soil-lime layer Biomedical waste Bottom clay layer Not drawn to scale 1 to 2 meters 9 Infection Management Environment Plan, Policy Framework. Ministry of Health and Family Welfare, Govt. of India, March 2007. Tool-kit for Managers: Volume II 27 Table 7: Overview of waste treatment and disposal technologies10 Indicator Availability Acceptability Access Sustainability Occupational Regulatory → safety acceptance Technology ↓ Needle Easy Easy to operate. Easily accessible Low initial and Safe for health- Used for Destroyer/ availability, by health care operating cost care workers. mutilation Cutter many vendors workers at but frequent of sharps at (for Sharps) and local each point of maintenance the point of manufacturing. generation. required. generation. Autoclave Easy Easy to Easy access Medium to high Safe for health- Approved availability, operate, ensures when located capital cost, low care workers. technology. many vendors sterilization in a centralized operating cost, All kinds of and local of waste and facility or the and regular waste but for manufacturing. regulatory capacity of maintenance anatomical, compliance; the machine is required; genotoxic and after shredding large enough Operators cytotoxic can the waste is to be shared training be treated acceptable for by other essential. reprocessing institutions Hydroclave Easy Easy to Easy access Medium to high Safe for health- Approved availability, operate, ensures when located capital cost, low care workers. technology. couple of sterilization in a centralized operating cost, All kinds of vendors of waste and facility or the and regular waste but for and local regulatory capacity of maintenance anatomical, manufacturing. compliance, the machine is required. genotoxic and waste is large enough Operators cytotoxic can acceptable for to be shared training be treated. reprocessing. by other essential. institutions. Microwave Easy Easy to Easy access Medium to Safe for health- Approved availability, operate, ensures when located high capital care workers. technology. couple of sterilization in a centralized cost, high All kinds of vendors of waste and facility or the operating cost, waste but for and mostly regulatory capacity of and regular anatomical, imported compliance, the machine is maintenance genotoxic and machines. waste is large enough required. cytotoxic can acceptable for to be shared Operators be treated. reprocessing by other training (metal sharps institutions. essential. are presently not treated due to apprehension of sparks). Chemical Easily Easy to use, Easy access Low capital and Safe for health- Approved Disinfection availability, disinfects the at different running cost. care workers. technology. many waste, regulatory points of waste Used for vendors, local compliance, generation in treating soiled manufacturing. waste is both primary waste, sharps acceptable for and tertiary and liquids. reprocessing. care settings. 10 Adopted from Safe Management of Bio-Medical Sharps Waste in India. WHO-SEARO, 2005. 28 Mainstreaming Environmental Management in the Health Care Sector Indicator Availability Acceptability Access Sustainability Occupational Regulatory → safety acceptance Technology ↓ Encapsulation Can be done Simple Is available in Low capital Safe for health- Does not have (for sharps) in small technique with a centralized and running care workers a mention in containers little investment facility, when cost. Need to and the the rules or and later be and does not individual ensure that the community. the guidelines. disposed of require skilled health-care encapsulated according to manpower. facilities have sharps are not the availability one. accessible to of space. scavengers. Waste burial Due to lack Simple Due to lack of Low initial and Safe for health- Does not have pit of space, technique with space, presently running cost. care workers a mention in construction little investment individual and the the rules but Due to lack of of waste burial and does not health-care community. the guidelines space cannot be pit is a major require skilled facilities find it Need to ensure mention the sustained for problem. manpower. difficult to share that the pit is deep burial of long. with other leach-proof sharps. facilities. Life of and not the sharps pit is accessible to small. scavengers. Double Technology Requires Suitable for Moderate Safe for health- Approved chamber, widely engineering skills medium to capital and care workers technology, pyrolitic available now. for operation and large facilities operating cost. provided specific incineration maintenance. or as CWTF Costs reduced appropriate guidelines Skilled for treatment by establishing PPE and available. manpower of moderate to CWTF. Standard Approved required for large amount Operating for infectious Require set up supervision. of waste. Procedures are waste. in designated followed. Good area. disinfection efficiency and large reduction in waste volume is achieved. Deep burial Simple to Simple Due to lack of Low initial and Safe for health Approved by pits construct. technique with space presently running cost. care workers legislation. little investment individual and the Standardized Due to lack Due to lack of and does not health-care community. guidelines for of space space cannot be require skilled facilities find Need to ensure construction construction of sustained for manpower. it difficult to that the pit is and operation sharps pit is a long. share with leach-proof present. major problem other facilities. and not in cities, hence Life of the accessible to suitable for burial pit is scavengers. rural and small. remote areas. Unsuitable for specific terrains e.g. high water table near sea, deserts, hills. Tool-kit for Managers: Volume II 29 5. STEP 5: Monitoring, reporting and ŒŒ Staff immunizations; feedback ŒŒ Accident reporting; Monitoring and reporting protocols for infection ŒŒ Authorization; control and waste management should be ŒŒ Final treatment and disposal; institutionalized into the waste management ŒŒ Infection control and hand-washing measures; plans from the time of inception of the plan. Regular monitoring by the members of the waste ŒŒ Hygiene and sanitation. management committee, different health-care workers, external agencies and self-monitoring will 6. STEP 6: Sustaining the system help in establishing a sound waste management Recognition: In order to encourage setting up of system. infection control and waste management systems, trophies, awards and incentives for good performance Records on the quantity of waste generated, different should be introduced. This will boost the morale of worker practices and accident reporting should be health-care workers and help achieve a better waste maintained at each point of waste generation. In case management. of any emergency, protocols specifying the immediate actions and long-term actions must be developed by the Budget allocation: A dedicated system of funding has facility. Monitoring and reporting protocols provide to be allocated to waste management and infection feedback about the waste management system and help control activities to sustain and improve the waste in improving the system. To effectively monitor the management system further. system, other than just physical monitoring, a waste- tracking software needs to be installed at each nursing Ongoing efforts: Along with ongoing training and station which will maintain records and raise an alarm monitoring, it is important to look at the problem of in case of any mismanagement. health-care waste management in a holistic manner. It needs to be integrated with water and sanitation, patient The waste management plan cannot be complete safety and infection control all of which are important without the mention of proper sanitation systems. factors to fight infections in health-care facilities. Safety As poor sanitation and water quality results in a large is a fundamental principle of patient-care and a critical number of infections, health-care facilities need to component of quality management. Its improvement take mitigation measures that comply with national demands a complex system, wide effort, involving a standards. Prototype designs of wastewater sewerage broad range of actions in performance improvement, system for various groups and types of health-care environmental safety and risk management, including facilities could be developed and implemented for infection control, safe use of medicines, equipment onsite disposal or treatment of wastewater. Further safety, and safe clinical practice. The various issues that initiatives need to be taken by the state governments need to be looked into for sustained health-care waste to improve the overall situation of water quality and management, patient safety and infection control sanitation in the state. measures broadly include: ŒŒ Regular update/review of the infection control 5.1 Monitoring and reporting checklist measures; ŒŒ Points of waste generation; ŒŒ Adhering to universal precautions; ŒŒ Sharps management; ŒŒ Emphasis on hand washing; ŒŒ Waste collection and transportation in ŒŒ Monitoring of infectious agents; appropriate containers; ŒŒ Identifying hazards as well as the steps to reduce ŒŒ Use of Personal Protective Equipment; them; 30 Mainstreaming Environmental Management in the Health Care Sector ŒŒ Blood safety measures; ŒŒ Appropriate staff health program; ŒŒ Injection safety policy; ŒŒ Immunizations and vaccinations for health-care ŒŒ Architectural modifications for patient safety; workers; ŒŒ Hygienic environment; ŒŒ Waste minimization; ŒŒ Sharps management; ŒŒ Elimination of mercury from health care settings; ŒŒ Accident reporting and post exposure ŒŒ Switching to energy efficient systems and prophylaxis; reducing the carbon footprints of the facility. Tool-kit for Managers: Volume II 31 VI Infection Management and Environment Plan The Infection Management and Environment Plan to central and state level institutions on the (IMEP) was developed by the Ministry of Health type of systems and processes to be established and Family Welfare (MoHFW) in 2004 under the for infection control and bio-medical waste Reproductive and Child Health Program. The management. document was developed with technical assistance � A set of Standard Operational Guidelines from the World Bank and DfID. IMEP provides a which are designed as instruction manuals for structured and systematic approach to manage the healthcare workers at primary level health- environmental and public health risks associated care facilities, i.e. Community Health Centers, with health-care activities. It describes appropriate Primary Health Centers and Sub Centers. These disinfection and sterilization techniques, management guidelines are in the form of simple pictorial of nosocomial infection control and maintenance of representations of the various steps needed to sanitary conditions, appropriate technology, basic manage infectious waste in a hygienic, safe and infrastructural requirements for delivery of primary environmentally sound manner. services, good occupational work practices and the effective institutional framework required to manage Since its publication and wide-scale dissemination, the these risks effectively. IMEP Guidelines have been implemented and monitored under the auspices of the National Rural Health Mission The IMEP comprises two volumes: (NRHM) and has made headway in internalizing good � A Policy Framework document which gives a practices in managing health and environment risks in broad overview and contains generic guidance the health- care institutions across India. VII Selection Criteria for Health-Care Waste Treatment Technologies These selection criteria for health-care waste can be used as the basis for the Terms of Reference treatment technologies have been prepared under and technical speci cations in for an impartial the Global Project on Health care Waste and systematic process for the selection of the Management, funded by GEF/UNDP11. These criteria technologies. Table 8: Technical selection criteria for bio-medical wastes: Autoclaves* Criterion Units Basis for selection Priority Related to size Capacity kg/hour Closest value to capacity calculated from base- High line assessment Typical operating cycle (for batch Minutes The lower the better High systems only) External dimensions (length x width mm The smaller the better Low x height) Related to design Type of autoclave (gravity or Description Multiple vacuum > pre/post vacuum > pre- High vacuum) vacuum > gravity displacement Material of construction of the Type of metal Stainless steel for the inside walls that are in Medium sterilization chamber contact with steam Typical service life of equipment Years The longer the better High Maximum rated pressure In psig or kPa The higher the better Medium gauge Type of chamber door Description Rotating locking ring breech-lock or wedge- Medium lock, radial locking wheel, multiple locking nuts (evaluate safety, ease of opening, minimum maintenance) 11 www.gefmedwaste.org Criterion Units Basis for selection Priority Steam generation Specification High efficiency boiler Medium Electrical requirements can be Yes or No Yes High adapted to 220V, 50 Hz, single-phase Availability of optional features and List the available For example: autoclavable bins or autoclavable auxiliary equipment features and carts, tracks or lift tables, automatic loaders, auxiliary conveyors, odor removal, cart washing equipment equipment, etc. Related to operating parameters Range of working pressures In bar, psig, mm 1 to 2 bar gauge, or 15 psig to 30 psig, or 1540 High Hg or kPa gauge to 2280 mm Hg absolute, or 103 – 207 kPa or higher Range of working temperatures ºC 121 – 134 ºC or higher High For vacuum autoclaves: vacuum level Negative pressure The higher the vacuum the better Medium Related to safety and ergonomics Number and description of safety Description At least two safety features: a pressure release High features to prevent overpressure valve plus a spring-loaded safety release valve or replaceable rupture disk; the more safety features for overpressure the better Worker safety features Description Insulation to maintain low surface High temperatures and prevent burns, door interlock to prevent opening chamber when under pressure, ergonomic design Ease of placement and removal of Description The easier the better Medium waste Ease of operation Description Computer controls to minimize operator error, Medium simple electronic controls, ergonomic design Related to standards Data on microbial inactivation Test results Test by regulatory authority or certified High efficacy showing compliance with showing lab; test by independent third party; test STAATT II or III standard compliance by hospital;, test by vendor (evaluate also challenge test procedure) Compliance with international Specify Compliance with EN 13445, EN 285 and/or High standards for pressure vessels ASME section VIII or equivalent Related to procurement, vendor, and cost Equipment cost and freight USD/local Lowest price High currency Delivery time for equipment after Weeks The shorter the better Medium order is placed Cost of spare parts, including most USD/local The lower the better Medium common maintenance items (e.g., currency (unit cost gaskets and heating elements) of spare parts) Cost of optional features and USD/local Lowest cost for autoclavable bins or Medium auxiliary equipment currency (unit autoclavable carts, automatic loaders, odor cost of features control, cart washing equipment, etc. and auxiliary equipment) Equipment warranty Provisions Evaluate coverage and length of time of High warranty 36 Mainstreaming Environmental Management in the Health Care Sector Criterion Units Basis for selection Priority Local Vendor/Representative of Yes or No Yes High vendor in the region Track record and history of the Description Good track record; The longer in business the Medium vendor/manufacturer better Customer service Evaluate Medium Number of existing installations of List of installations Evaluate list Medium the technology in operation or customers Related to installation, maintenance, and repair Ease of installation Description Site installation requirements, typical length of Medium time for installation Installation, maintenance, and repair Description The more comprehensive the better Medium manual Ease of replacement of heating Description The quicker the better Medium elements and gaskets Availability of technical support Yes or No Yes High and repair technician in the region RELATED TO TRAINING Training of maintenance and repair Yes or No Yes: included in package Medium technician provided? Operator training Yes or No Yes: included in package High * The World Bank does not recommend any specific technology. Table 9: Technical selection criteria for bio-medical waste shredder Criterion Response What we need Priority Related to size Approximate capacity kg/hr Closest value to capacity calculated from High baseline assessment Hopper opening (length x width) mm The larger the better High Throat opening (length x width) mm The larger the better, but depends on cutter Medium geometry Screen size mm 10 to 20 mm Medium External dimensions (length x mm The more compact the better Low width x height) Related to design Specially designed for shredding all Yes or No Yes High types of medical waste Type of shredder Description Usually, multiple shaft shredders are better medium Typical service life of equipment Years The longer the better High Number of cutters/knives and Description Evaluate Medium cutter geometry Drive motor horsepower HP or kW The higher the better High Hydraulic ram to push waste Yes or No Yes Medium Rotor bearing Description High quality with long service life; evaluate Vibration damping Description Evaluate Tool-kit for Managers: Volume II 37 Criterion Response What we need Priority Reinforcements Description Evaluate Materials of construction Description Corrosion resistant, durable, heavy duty Electrical requirements Voltage, 230V, 50 Hz, single-phase High frequency, phase Other features Description Automatic bin-loader, self-cleaning, conveyor, Low magnetic separator, liquid waste, etc. Related to safety and ergonomics Safety feature: protection of worker Description Evaluate High from projectiles from the hopper Safety feature: emergency cut-off Yes or No Yes, easily accessible to the operator High switch Safety feature: lock or security Yes or No Yes Medium switch to prevent unauthorized use Safety feature: rails, shields, and Description Evaluate High other barriers to protect the operator Safety feature: hopper viewing Yes or No Yes Low mirror Special features for bio-medical Description Shaft protection for excessive torque or High waste overload protection, cutting blade protection for hard waste Special features for bio-medical Description Auto-reverse feature to disentangle soft waste High waste Noise level during operation dB The lower the better Low Ease of operation Description Computer/electronic controls, ergonomic Medium design Ease of introducing waste into the Description Evaluate Medium hopper Ease of removal of shredded waste The easier the better Low bin Related to procurement, vendor, and cost Equipment cost and freight USD/local Lowest price High currency Delivery time after placement of Weeks The shorter the better Medium order Cost of spare parts including USD local The lower the better Medium replacement cutters or knives, belts, currency (unit cost and screens of spare parts) Cost of optional features and USD/unit Lowest cost for automatic bin-loader, self- Low auxiliary equipment currency (unit cleaning system, conveyor, magnetic separator, cost of features liquid waste management system, etc. and auxiliary equipment) Equipment warranty Provisions Evaluate coverage and length of time of High warranty Local vendor/Representative of Yes or No Yes High vendor in the region 38 Mainstreaming Environmental Management in the Health Care Sector Criterion Response What we need Priority Track record and history of the Description Good track record; The longer in business the Medium vendor/manufacturer better Customer service Evaluate Medium Number of existing installations of List of installations Evaluate list; verify maintenance requirements Medium the technology in operation or customers and equipment life span Related to installation, maintenance, and repair Ease of installation Description Site installation requirements, typical length of Medium time for installation Maintenance and repair manual Evaluate maintenance requirements and Medium manual Ease of repair Evaluate repair manual Medium Ease of replacement of cutters or Description The quicker the better High knives, belts, and screens Availability of technical support Yes or No Yes High and repair technician in the region Related to training Training of maintenance and repair Yes or No Yes: included in package Medium technician provided? Operator training Yes or No Yes: included in package High Table 10: Technical selection criteria for advanced steam systems (hybrid autoclaves) and microwave units Criterion Units Basis for selection Priority Related to size Capacity kg/hour Closest value to capacity calculated from High baseline assessment External dimensions (length x km The smaller the better Low width × height) Related to design Type of treatment technology Description Evaluate Low Technical capacity to treat Yes or No Evaluate High pathological waste (i.e., anatomical waste, tissue, body parts) Typical operating cycle (for batch Minutes The lower the better High systems only) Type of internal shredding or Description Evaluate High mixing in the treatment chamber, if applicable Material of construction of the Type of metal Stainless steel for the inside walls that are in Medium sterilization chamber contact with steam Typical service life of equipment Years The longer the better High Type of chamber door (if the system Description Rotating locking ring breech-lock or wedge- Medium operates above atmospheric pressure lock, radial locking wheel, multiple locking only) nuts (evaluate safety, ease of opening, minimum maintenance) Steam or microwave generation Specification Efficiency of boiler or magnetron Medium Tool-kit for Managers: Volume II 39 Criterion Units Basis for selection Priority Electrical requirements can be Yes or No Yes High adapted to 220V, 50 Hz, single-phase Availability of optional features and List the available For example: bins or carts, automatic loaders, auxiliary equipment features and conveyors, odor removal, cart washing auxiliary equipment equipment, etc. Related to operating parameters Range of working pressures In bar, psig, mm 1 to 2 bar gauge, or 15 psig to 30 psig, or 1540 High (for systems that operate above Hg or kPa gauge to 2280 mm Hg absolute, or 103 – 207 kPa or atmospheric pressure only) higher Temperature range which the waste ºC The higher the better High is exposed to For systems that use a vacuum in Negative pressure The higher the vacuum the better Medium the treatment chamber: vacuum level Related to safety and ergonomics Number and description of safety Description At least two safety features: a pressure release High features to prevent overpressure valve plus a spring-loaded safety release valve (for systems that operate above or replaceable rupture disk; the more safety atmospheric pressure only) features for overpressure the better Worker safety features Description Evaluate High Ease of placement and removal of Description The easier the better Medium waste Ease of operation Description Computer controls to minimize operator Medium error, simple electronic controls, ergonomic design Related to standards Data on microbial inactivation Test results Test by regulatory authority or certified High efficacy showing compliance showing lab; test by independent third party; test by with STAATT II or III standard, compliance hospital; test by vendor (evaluate also challenge especially in relation to pathological test procedure) or surrogate animal waste Compliance with international Specify Compliance with EN 13445, EN 285 and/or High standards for pressure vessels ASME section VIII or equivalent (for systems that operate above atmospheric pressure only) Related to procurement, vendor, and cost Equipment cost and freight USD/local Lowest price High currency Delivery time for equipment after Weeks The shorter the better Medium order is placed Cost of spare parts, including most USD/local The lower the better Medium common maintenance items currency (unit cost of spare parts) Cost of optional features and USD/Local Lowest cost for bins or carts, automatic Medium auxiliary equipment currency (unit loaders, conveyors, odor removal, cart washing cost of features equipment, etc. and auxiliary equipment) 40 Mainstreaming Environmental Management in the Health Care Sector Criterion Units Basis for selection Priority Equipment warranty Provisions Evaluate coverage and length of time of High warranty Local Vendor/Representative of Yes or No Yes High vendor in the region Track record and history of the Description Good track record; The longer in business the Medium vendor/manufacturer better Customer service Evaluate Medium Number of existing installations of List of installations Evaluate list; verify maintenance requirements Medium the technology in operation or customers and equipment life span Related to installation, maintenance, and repair Ease of installation Description Site installation requirements, typical length of Medium time for installation Installation, maintenance, and Description The more comprehensive the better Medium repair manual Ease of replacement of spare parts Description The quicker the better Medium Availability of technical support Yes or No Yes High and repair technician in the region Related to training Training of maintenance and repair Yes or No Yes: included in package Medium technician provided? Operator training Yes or No Yes: included in package High Guidelines on best available Emission limits techniques for medical waste For best available techniques, performance levels in air incineration under the Stockholm emissions of dioxins should not exceed 0.1 nanograms Convention I-TEQ/normal cubic meter at 11% O2. Moreover, Under the guidelines, “single-chamber, drum and brick dioxins in the wastewater of treatment plants treating incinerators� are not allowed. An incineration plant effluents from any gas treatment scrubber effluents should consist of the following units: should be well below 0.1 nanograms I-TEQ per liter. i. Furnace or kiln as the primary combustion chamber General and organizational measures ii. Afterburning chamber as the secondary When incinerating wastes that contain chlorine and chamber heavy metals (as is generally the case for medical waste), iii. Flue gas cleaning device system a combination of primary and secondary measures, iv. Wastewater treatment plant if a wet flue gas as described below, are needed to meet the emission cleaning system is used. limits. Health-care wastes should be incinerated only in dedicated incinerators or in larger incinerators for The thermal treatment process used in the furnace hazardous waste. If a dedicated incinerator is not used, or kiln could be one of the following: pyrolysis a separate charging system should be used. or gasification, rotary kiln, grate incineration specially adapted for health-care waste, fluidized bed Operation of the incinerator requires trained, qualified incineration, or modular excess air or controlled air personnel. The personnel should wear protective incineration. clothing. Periodic maintenance should include cleaning Tool-kit for Managers: Volume II 41 of the combustion chamber and de-clogging of air opposed to batch processes) should be the method of flows and fuel burners. As part of secondary measures, choice. Upsets should be minimized through periodic frequent cleaning of those sections of the incinerator inspection and preventive maintenance. Operators wherein flue gas passes, especially at the critical should not feed waste during severe combustion upsets temperature range, is important. There should be or during a filter bypass (dump stack) operation. regular and/or continuous measurement of pollutants, as well as auditing and reporting systems. Secondary measures In order to reduce dioxin emissions to less than Primary measures 0.1 ng TEQ/m3, the secondary measures below (an The guidelines list the following primary measures to appropriate combination of dedusting and other reduce dioxin emissions: equipment to further reduce dioxins) should be applied i. Introduction of the waste in the combustion as best available techniques. chamber only at temperatures of 850°C; the plant i. Dedusting: should have an automatic system to prevent waste ŒŒ Fabric filters used at temperatures feed before the above-mentioned temperature is below 260ºC reached. ŒŒ Ceramic filters used at temperatures between ii. Installation of auxiliary burners (for start-up and 800 to 1000ºC shut-down operations). ŒŒ Cyclones used for pre-cleaning of flue gases iii. Avoidance of starts and stops of the incineration process. ŒŒ Electrostatic precipitators used at temperatures of around 450ºC iv. Avoidance of temperatures below 850°C and no cold regions in the flue gas. ŒŒ High-performance adsorption units with activated charcoal (electrodynamic venturi) v. Control of oxygen input depending on the heating value and consistency of feed material. ii. Techniques to further reduce emissions and PCDD/F: vi. Minimum residence time of 2 seconds above 850°C in the secondary chamber after the last ŒŒ Catalytic oxidation injection of air, or at 1100°C for wastes containing ŒŒ Gas quenching more than 1% halogenated organic substances (as ŒŒ Catalyst-coated fabric filters is generally the case for medical waste), and 6% ŒŒ Different types of wet and dry adsorption oxygen by volume. systems using mixtures of activated charcoal, vii. High turbulence of exhaust gases and reduction coke, lime and limestone solutions in fixed- of air excess by injection of secondary air or re- bed reactors (adsorption with activated circulated flue gas, pre-heating of the air-streams, charcoal or open hearth coke), moving-bed or regulated air inflow. reactors, or fluidized bed reactors (entrained viii. On-line monitoring for combustion control flow or circulating fluidized beds with (temperature, oxygen content, carbon monoxide, activated coke/lime or limestone followed dust), and operation and regulation of the by the use of fabric filters). incinerator from a central console. Notes: Fabric filters used at temperatures above Cold starts, upset conditions, and shutdowns generally the critical temperature range for dioxin formation create the conditions for dioxin formation. Therefore, can reduce emissions efficiently. However, the preheating and initial co-firing with a clean fossil operating temperatures would depend on the fuel is recommended, and continuous operation (as type of fabric material used. Cyclones are efficient 42 Mainstreaming Environmental Management in the Health Care Sector only in removing the larger particles. Note that ŒŒ Immobilization methods (e.g., solidification with electrostatic precipitators could promote de novo cement) and subsequent land filling. synthesis of dioxins especially if operated at the critical temperature range for dioxin formation. Bottom and fly ash should be handled, transported Electrostatic precipitators are inefficient for removal and disposed of in an environmentally sound manner, of fine particles and may result in higher nitrogen including the use of covered hauling and dedicated dioxide emissions. High-performance adsorption sanitary landfills. units with activated charcoal can be used for removal of fine dust. Monitoring With regards to monitoring, carbon monoxide, oxygen Disposal of residues in the flue gas, particulate matter, hydrogen chloride, Fly and bottom ash, as well as wastewater, should sulfur dioxide, nitrogen oxides, hydrogen fluoride, be treated appropriately. Proper treatment of these airflows and temperatures, pressure drops, and pH in residues includes: the flue gas should be routinely monitored. ŒŒ Disposal in safe sanitary landfills (Note: Periodic measurement or semi-continuous Examples of disposal methods are land filling in measurement (continuous sampling and periodic proper double-walled containers, solidification analysis) of polychlorinated dioxins and furans help and subsequent land filling, or thermal post- insure that the incinerator is operating properly. treatment). Unfortunately, sampling and analysis of dioxins are ŒŒ Catalytic treatment of fabric filter dusts. difficult and expensive for most developing countries. ŒŒ Scrubbing of fabric filter dusts by the 3-R process In general, stack sampling requires 4 to 8 hours of (extraction of heavy metals by acids). continuous iso-kinetic sampling, and analysis is carried out using high resolution gas chromatography- ŒŒ Thermal post-treatment (e.g., rotary kiln or high resolution mass spectrometry. Stringent quality Hagenmeier trommel followed by a fabric filter control procedures are required. For waste incinerators and scrubber; plasma technology). with a capacity of less than 2 tons per hour, simplified ŒŒ Vitrification of fabric filter dusts and subsequent bioassay methods for dioxins could be used for periodic land filling. measurements. Tool-kit for Managers: Volume II 43 VIII Wastewater Treatment Systems in Health-Care Facilities The following section focuses on the requirements microbes. The bacteria and protozoa consume for starting wastewater treatment plants in health- biodegradable soluble organic contaminants (e.g. care facilities and describes the various parameters for sugars, fats, organic short-chain carbon molecules, analysis of wastewater from health-care facilities.12 etc.) and bind much of the less soluble fractions into floc particles. For mineralization and nitri�cation Ef�cient on-site treatment of health-care wastewater the micro-organisms require oxygen and a substrate should include the following operations: on which to live. To provide these two essentials, different systems are available which can be divided in 1. Primary treatment �xed �lm systems or suspended growth systems. To prevent the damage or clogging of the wastewater In �xed �lm systems such as trickling �lters, rotating treatment equipment and to produce a generally biological contactors, fluidized bed reactors or homogeneous liquid capable of being treated biological aerated �lters, the biomass grows on media biologically, a mechanical treatment is carried out. A and the sewage passes over its surface. Oxygen is either raked screen is used to remove large objects; afterwards supplied to the biota by spraying or trickling the the velocity of incoming wastewater is reduced to wastewater over the �lter materials or the systems are allow the settlement of sand, grit and stones. For mechanically aerated. the skimming of floating material such as grease and plastics and to allow fecal solids to settle, primary In suspended growth systems the biota is living sedimentation tanks are installed. on the sludge (called activated sludge). The activated sludge is mixed with the sewage and is aerated in a tank or basin. In a clari�er, the activated sludge can 2. Secondary treatment settle and is returned to the aeration tank. Typical The task of the secondary treatment is the removal systems are activated sludge plants or surface-aerated of dissolved carbon and nitrogen components by basins. 12 (Extracted from WHO –‘Safe Management of Wastes from Health Care Activities’, UNDP/GEF project documents, Guidelines for Healthcare Wastewater Management, prepared by ET Log, Germany). As fixed-film systems are more able to cope with drastic step to remove suspended organic matter must be changes in the amount of biological material, can better carried out prior to the disinfection. adjust to specific wastewater and can provide higher removal rates for organic material and suspended To remove suspended organic matter, sand filtration, solids, these systems are normally used for health-care lagooning by means of planted horizontal gravel filters wastewater treatment. can be done. Also constructed wetlands and engineered reed bed systems are in use today. To remove nitrogen a biological oxidation of nitrogen from ammonia to nitrate takes place by nitrification Disinfection of wastewater from health-care involving nitrifying bacteria such as Nitrospira and establishment is often required and should be carried Nitrosomonus. This is followed by the reduction out, especially if the wastewater is discharged into any from nitrate to nitrogen gas (de-nitrification), which water body used for recreational activities or used is released to the atmosphere. De-nitrification requires as a source of drinking water (including aquifers). anoxic conditions and might be carried out during Disinfection of the wastewater is particularly important the tertiary treatment in a sand filter or a reed bed. if it is discharged into coastal waters close to shellfish Nitrification and de-nitrification requires carefully habitats, especially if local people are in the habit of controlled conditions to encourage the appropriate eating raw shellfish. biological communities to form. Before the wastewater treatment facility becomes 3. Tertiary treatment of wastewater operational, it is essential to analyze wastewater Tertiary treatment, also called “effluent polishing� samples of the health-care facility in order to is the final step in the wastewater treatment process determine if the proposed facility can effectively before the effluent is discharged to the receiving treat the wastewater produced according to the environment. More than one tertiary treatment required regulations. The data thus collected will be process can be used. If disinfection of the effluents as supplemented into the wastewater treatment plant the final treatment step is required, always another operating procedures. Figure 5: Thematic representation of wastewater treatment process Bar Raw Effluent Screen from Laundry, Clarifier Canteen, etc. Aeration Tank Oil and Effluent Grease Collection Biosludge Trap Tank Sludge All Other Effluent Streams from Filtrate Sludge the Premises Bar Drying Screen Beds Treated Chlorine Pressure Filter Water Contact Sand Feed Treated Tank Tank Filter Tank Effluent 46 Mainstreaming Environmental Management in the Health Care Sector Figure 6: Organizational structure for health-care wastewater treatment Sources Wastewater Categories Treatment Method Domestic Onsite/ Central Grease treatment Medical wards Kitchen interceptor system Washing liquid, detergents Coagulation pH settlement Laboratory Chemicals adjustment Photochemicals Storage Removal Storage for decay to Radioactive isotope Dilution clearance level Operation theatre Detergents Deoxidization Biological Neutralization treatment Electrolysis (Na2S2O3) equipment Experiment Disinfectant Deoxidization Disinfectants (Na2S2O3) on animals destruction Biological Reproductivity Monitoring General area (super cleaned) treatment well equipment Rain water and Waste screen and sand Grease vehicle washing water settlement tank interceptor Discharge into environment Tool-kit for Managers: Volume II 47 The table below gives a list of parameters that should an EU directive,13 an EPA study in 1991,14 and on be considered in the testing of wastewater from pollutants that may be reasonably expected to be general hospitals. These parameters are based on found in hospital wastewater. Table 11: Suggested parameters for the analysis of wastewater from health-care facilities Parameter Concentration Reference pH 6-9 is a typical acceptable range* BOD5 at 20°C 25 mg/l O2 EU Council Directive 91/271/EEC COD 125 mg/l O2 EU Council Directive 91/271/EEC Total suspended solids 35 mg/l EU Council Directive 91/271/EEC Oils and grease (also called 100 mg/l From North Carolina Department of Environment and fats/oils/grease or FOG) Natural Resources15 Phosphate or total 6-15 mg/l is the range for Major pollutant found in hospitals by EPA (see footnote 14) phosphorus several US cities Surfactants See examples* Major pollutant found in hospitals by EPA (see footnote 14) Phenols See examples* Major pollutant found in hospitals by EPA (see footnote 14) Formaldehyde 0.1 mg/l (based on the Major pollutant found in hospitals by EPA (see footnote 14) 96-hr LC50 environmental toxicity to blue gill) Fluoride See examples* Major pollutant found in hospitals by EPA (see footnote 14) Arsenic, barium, cadmium, See examples* Major pollutant found in hospitals by EPA (see footnote 14) chromium (total), copper, iron, lead, nickel, selenium, silver, and zinc Mercury See examples* GEF project and WHO Trihalomethanes and (0.08 for Major concern since chlorinated organics can lead to dioxin chlorinated organics trihalomethanes**) formation in wastewater Haloacetic acid and (0.06 for haloacetic acid**) Major concern since trichlorophenols can lead to dioxin trichlorophenols formation in wastewater Ammonia See examples* Ammonia in the wastewater is expected Nitrate See examples* Nitrates expected due to ammonia and other nitrogen compounds Fecal coliform See note below*** Expected in hospital wastewater** Total coliform See note below*** Expected in hospital wastewater** * For examples of concentration limits, see examples below for the EU, two cities in the US and Canada, the Philippines, and various countries in Latin America. ** These values are for informational purposes only and may not apply to wastewater since they are based on the Maximum Contaminant Levels (MCLs) for drinking water in the US as regulated by the US EPA. *** If the wastewater goes directly to a river or coastal waters without treatment, the coliform count should be tested. Also, if the wastewater goes directly to a river or coastal waters without treatment, other microorganisms of interest should be tested: pathogenic E. coli, enterococci, Clostridium perfringens, and aeromonas are the typical indicator species tested in wastewater. 13 EU Council Directive 91/271/EEC http://ec.europa.eu/environment/water/water-urbanwaste/directiv.html 14 In a study by the US EPA of hospital wastewater, the following pollutants were found to have the highest average concentrations: total dissolved solids, chemical oxygen demand (COD), phosphate, surfactants, formaldehyde, phenol, and fluoride. In addition, the most frequently detected pollutants in hospital wastewater were: COD, phenol, silver, lead, copper, and zinc. Other pollutants found were: total chromium, nickel, arsenic, cadmium, selenium, and mercury. Reference: “Supplemental Manual on the Development and Implementation of Local Discharge Limitations Under the Pretreatment Program: Residential and Commercial Toxic Pollutant Loadings and POTW Removal, US EPA, Office of Water Enforcement and Compliance, May 1, 1991 http://www.epa.gov/npdes/pubs/owm0013.pdf 15 “Considerations for Management of the Discharge of FOG to Sanitary Sewer Systems,� Appendix F, NC Department of Environment and Natural Resources, North Carolina, USA, June 2002. 48 Mainstreaming Environmental Management in the Health Care Sector 4. Sampling and frequency of testing 700-bed hospital would be equivalent to a very small wastewater urban wastewater treatment plant (2000 to 9999 p.e.). For this size, EU Council Directive 91/271/EEC Flow-proportional or time-based 24-hour samples requires 12 samples for the �rst year and four samples should be collected at the same well-de�ned point in in subsequent years if the effluent complies with all the the outlet. Flow-proportional or time-based sampling provisions. If one of the four samples fails, 12 samples is generally done using an automatic sampler linked have to be taken the following year. Some regulatory to a flow meter or timer. International standards authorities may allow a deviation of individual for laboratory practices to minimize degradation of parameters not exceeding 100% or may require that samples between collection and analysis should be the annual average conform to the parametric value. followed. These include following recommended sample containers, preservation techniques, and maximum holding times. 5. Wastewater treatment plants for smaller health-care facilities17 The frequency of testing is generally based on population The size of the liquid disinfection unit is determined equivalent (p.e.), also called the unit per capita loading. according to the size of the facility and quantity of The p.e. refers to the ratio of the organic biodegradable liquid waste generated. Separate plumbing is done to load produced during a 24-hour period by the facility in carry the bio-medical liquid waste to the disinfection relation to the individual organic biodegradable load in unit uniquely designed for the purpose which is household sewage produced by one person in the same approved by Karnataka State Pollution Control period of time. For calculations, one unit is generally Board. These designs have been implemented under assumed to be equal to 54 g of BOD per 24 hours or a the World Bank funded Karnataka Health System �ve-day biochemical oxygen demand (BOD5) of 60 g Development & Reform project. The design allows of oxygen per 24-hour day. The BOD5 values for a suf�cient contact time between the liquid waste and wide range of hospitals correspond to about 3 p.e. chlorine for effective disinfection, and is innovative in per patient.16 Thus, the sewage treatment plant for a that it has no moving parts. Figure 7: Liquid disinfection unit for small facilities (10 beds and below) 5 liters tank for Hypochlorite Solution Existing Granite Platform Existing Wash Basin Plastic tank 25 liters Support for sink slab Valve in Laboratory at PHC Nahani-Trap To Sewer/Soak Pit/Septic Tank Photo credit: World Bank Missions 16 “Hospital effluents as a source of emerging pollutants: An overview of micropollutants and sustainable treatment options,� P. Verlicchi et al., Journal of Hydrology, 389, 416–428 (2010). 17 From Karnataka Health System Development & Reform Project. Tool-kit for Managers: Volume II 49 The operational guidelines Step 4: Open the outlet valve of the 50 l can every day morning so that entire disinfected liquid is drained to Step 1: Fill the top 5 liter can with 1% hypochlorite the sewer. solution. Step 2: Start collection of the liquid bio-medical waste Step 5: Close the outlet valve of the 50 l can and start from the wash basins to the 50 l can below and keep �lling the liquid bio-medical waste. the outlet valve closed. Repeat every day. Keep the records for the Step 3: Drain the 1% solution from the 5 l can to consumption of the bleaching powder/Chlorine the 50 l can and adjust the quantity of the solution solution daily for the veri cation. such that it contains > 2 mg/l of chlorine next day morning. The residual chlorine should be measured using a Chloroscope. Figure 8: Liquid disinfection unit for small facilities (30-400 beds) PLAN Hypo clorite 12mm PVC Pipe 6kg/cm2 Solution Material of Construction-GRP For inspection [Glass Reinforced Plastic] by Gravity 12mm PVC Pipe(Air vent) 12mm PVC to nearby Manhole/Inseption Pipe (Air vent) to Chamber nearby Manhole/ 200mm Inseption Chamber 600mm Hazardous 100mm liquid 150mm0 150mm 200mm Biomedical Baffle waste wall 50mm PVC Pipe 12kg/cm2 600mm 150mm 600mm PVC Pipe Disinfected effluent to sewer/ Nala 150mm 6mm 1200mm Thick Wall Elevation Cross Section-xx Photo credit: World Bank Missions The operational guidelines the quantity of the solution such that out flowing effluent contains >1 mg/l of chlorine by trial and Step 1: Fill the top 10 liter can with 1% hypochlorite error. The residual chlorine should be measured using solution. a Chloroscope. Step 2: Drain the liquid bio-medical waste from the Repeat every day. Keep the records of the receipts and wash basins to the disinfection unit provided. consumption of the bleaching powder/Hypochlorite solution daily for the veri cation. Step 3: Drain the 1% disinfection solution from the 10 l can to the disinfection unit provided and adjust Note: Sewage should not be allowed inside disinfection unit. 50 Mainstreaming Environmental Management in the Health Care Sector IX Costs of Health-Care Waste Management All hospitals need to establish accounting procedures individual. Health-care waste costs should be the to document the costs they incur in managing subject of a separate budget line; this allows costs for health-care waste. Accurate record-keeping and different periods to be compared and helps to reduce cost analysis must be undertaken by a designated management costs. Table 12: Cost of construction and operation of a health-care waste treatment plant18 Site Direct operating costs Cost of land Manpower requirements (manager, operators, drivers etc.) Rights of way Yellow bags with tags for infectious wastes Site preparation and infrastructure Black bags for non-risk waste Provision of utilities to site Sharps containers Consultancy fees Transportation costs Environmental/waste management consultant Utilities (fuel, water, electricity) Engineering Chemicals (for flue-gas cleaning) Architectural Legal fees Infrastructure costs Indirect operating costs Building for treatment technology such as Training incinerator and autoclave Treatment technology (such as incinerator’s and autoclave’s) Waste storage room maintenance and parts replacement Of ces Vehicle maintenance Treatment technology cost Uniforms and safety equipment Cost of incinerator, autoclave or any other Ash disposal cost technology Compliance monitoring of flue-gas emissions Freight and storage charges Project management and administrative costs for the organization Waste transport costs responsible for the execution and long-term operation of the project Waste collection trucks Bins/containers for transporting waste from hospitals to incinerator site 18 Adapted from Safe Management of Health-Care Waste, WHO, 1999. Table 12: Cost of construction and operation of a health-care waste treatment plant (Contd...) Equipment costs Trolleys for collecting waste bags from wards Bag-holders to be located at all sources of waste in hospitals Weighing machines for weighing waste bags Refrigerators for storage of waste if necessary Financing charges Interest Taxes Accounting and audit fees The above box lists the elements that should be ii. Comprehensive planning included in the cost assessment for – in this example – ŒŒ Development and implementation a health-care waste management system comprising an of a comprehensive health-care waste treatment facility. management strategy, within the framework of the hospital waste management plan, which If a waste treatment project is undertaken by a includes the above recommendations. private concern, charges for the service should be ŒŒ Planning collection and transport in such a way computed, so that all costs can be recovered from that all operations are safe and cost- efficient. those using the services, i.e. both government and private health-care establishments. To ensure that the ŒŒ Possible cooperative use of regional project is self-supporting, charges should reflect the incineration facilities, including private full cost of operations, maintenance, depreciation, sector facilities where appropriate. debt amortization, and interest. The inclusion of an ŒŒ Establishment of a wastewater disposal plan. amortization factor ensures the availability of funds iii. Documentation for future plant and equipment replacements. If the ŒŒ Waste management and cost documentation: charges levied do not cover all costs, the system will assessment of the true costs makes it easier need to be subsidized and a financing plan should be to identify priorities for cost reduction and designed accordingly. to monitor progress in the achievement of objectives. Recommendations for cost reductions iv. Choice of adequate treatment or disposal method Cost reductions can be achieved by taking particular ŒŒ Selection of a treatment and disposal option measures at different stages in the management of that is appropriate for waste type and local wastes: circumstances. i. On-site management ŒŒ Use of treatment equipment of appropriate ŒŒ Comprehensive management of chemicals type and capacity. and pharmaceuticals stores. ŒŒ Out sourcing of final treatment and disposal ŒŒ Substitution of disposable medical-care items of the waste to a centralized waste treatment by recyclable items. facility. ŒŒ Adequate segregation of waste to avoid costly v. Measures at personnel level or inadequate treatment of waste that does ŒŒ Development of training programs for workers not require it. 1to improve quality and quantity of work. ŒŒ Improved waste identification to simplify ŒŒ Protection of workers against occupational segregation, treatment, and recycling. risks. 52 Mainstreaming Environmental Management in the Health Care Sector X Mercury in Health-Care 1. Overview19 2. Contribution from the health-care Mercury is a naturally occurring heavy metal. At sector and regulation ambient temperature and pressure, mercury is a Health-care facilities are one of the main sources silvery-white liquid that readily vaporizes and may of mercury release into the atmosphere because of stay in the atmosphere for up to a year. When emissions from the incineration of medical waste. The released to the air, mercury is transported and Environment Minister of the Canadian province of deposited globally. Mercury ultimately cumulates in Ontario declared on December 2002 that emissions from lake-bottom sediments, where it is transformed into incinerators were the fourth-largest source of mercury. its more toxic organic form, methyl mercury, which In the United States, according to the US Environmental accumulates in sh tissue. Mercury is highly toxic, Protection Agency (EPA) in a 1997 report, medical especially when metabolized into methyl mercury. waste incinerators may have been responsible for as It may be fatal if inhaled and harmful if absorbed much as 10% of all mercury air releases. through the skin. Around 80% of the inhaled mercury vapor is absorbed by the blood through the lungs. It Health-care facilities are also responsible for mercury may cause harmful effects to the nervous, digestive, pollution taking place in water bodies from the respiratory, immune systems and to the kidneys, release of untreated wastewater. According to a besides causing lung damage. Adverse health effects 1999 report, health-care facilities may also have been from mercury exposure can be: tremors, impaired responsible for as much as 5% of all mercury releases vision and hearing, paralysis, insomnia, emotional in wastewater. Environment Canada estimates that instability, developmental de cits during fetal more than one-third of the mercury load in sewerage development, and attention de cit and developmental systems is due to dental practice. delays during childhood. Recent studies suggest that mercury may have no threshold below which some Dental amalgam is the most commonly used dental adverse effects do not occur. lling material. It is a mixture of mercury and a metal 19 Extracted from WHO policy paper on Mercury in Health Care, 2005. alloy. The normal composition is 45-55% mercury; consequences. Since mercury vapor is odorless and approximately 30% silver and other metals such colorless, people can breathe mercury vapor and not as copper, tin and zinc. In 1991, the World Health know it. For liquid metallic mercury, inhalation is the Organization confirmed that mercury contained in route of exposure that poses the greatest health risk. A dental amalgam is the greatest source of mercury vapor variety of studies demonstrate that mercury containing in non-industrialized settings, exposing the concerned health-care equipment will invariably break. Small population to mercury levels significantly exceeding spills of elemental mercury on a smooth, non-porous those set for food and for air20. surface can be safely and easily cleaned up with proper techniques. However, beads of mercury can settle into According to a report submitted to the OSPAR cracks or cling to porous materials like carpets, fabric, Commission, in the United Kingdom, annually or wood, making the mercury extremely difficult 7.41 tons of mercury from dental amalgam is discharged to remove. Spilled mercury can also be tracked on to the sewers, atmosphere or land, with another 11.5 footwear. Inadequate cleaning and disposal may expose tons sent for recycling or disposed with the clinical already compromised patients and health-care staff to waste stream. Together, mercury contained in dental potentially dangerous exposures. amalgam and in laboratory and medical devices, account for about 53% of the total mercury emissions. 4. Alternatives Waste incineration and crematoria are also listed A recent study found that at least one manufacturer of as major sources of mercury emissions. Many the non-mercury alternative was identified where the countries, such as Armenia, Cameroon, Ghana, cost differences between mercury and non-mercury Honduras, Pakistan, and Peru, recognize the technologies were minimal. The research findings contributions from hospital thermometers, dental suggest that many non-mercury alternatives are amalgams, hospital waste and/or medical waste available to address the full range of functions required incinerators but lack quantitative data. Despite the by consumer products. lack of data, there is good reason to believe that mercury releases from the health sector in general are For health care, these include blood pressure devices, substantial. gastrointestinal devices, thermometers, barometers, and in other studies, include the use of mercury Some countries have restricted the use of mercury fixatives used in labs. Both mercury and aneroid thermometers or have banned them without sphygmomanometers have been in use for about prescription. A variety of associations have adopted 100 years, and when working properly, either gives resolutions encouraging physicians and hospitals to accurate results. Of all mercury instruments used in reduce and eliminate their use of mercury containing health care, the largest amount of mercury is used in equipment. mercury sphygmomanometers (80 to 100g/unit), and their widespread use, collectively make them one of the largest mercury reservoirs in the health-care setting. 3. Occupational health hazard By choosing a mercury-free alternative a health-care The most common potential mode of occupational institution can make a tremendous impact in reducing exposure to mercury is via inhalation of metallic liquid the potential for mercury exposure to patients, staff mercury vapors. If not cleaned up properly, spills of and the environment. even small amounts of elemental mercury, such as from breakage of thermometers, can contaminate indoor air Aneroid sphygmomanometers provide accurate above recommended limits and lead to serious health pressure measurements when a proper maintenance 20 Source:http://www.who.int/ipcs/publications/cicad/en/cicad50.pdf 54 Mainstreaming Environmental Management in the Health Care Sector protocol is followed. It is important to recognize facilities will need to keep mercury as the “gold� that no matter what type of blood pressure standard to ensure proper calibration of mercury measurement device is used, both aneroid and mercury sphygmomanometers. sphygmomanometers must be checked regularly in order to avoid errors in blood pressure measurement Medium-term: Increase efforts to reduce the number and consequently the diagnosis and treatment of of unnecessary use of mercury equipment. Hospitals hypertension. should inventory their use of mercury. This inventory should be categorized into immediately replaceable 5. The way forward and gradually replaceable. Replaced devices should be taken back by the manufacturer or taken back To understand better the problem of mercury in the by the alternative equipment provider. Progressively health-care sector, it is recommended that countries discourage the import and sale of mercury-containing conduct assessments of current mercury usage and health-care devices and mercury use in health-care waste management programs. WHO proposes to work settings, and also use global multi-lateral environmental in collaboration with countries through the following agreements to this end. Provide support to countries strategic steps: to make sure that the recovered mercury equipment is not pushed back in the supply chain. Short-term: Develop mercury clean up and waste handling and storage procedures. Until countries in Long-term: Support a ban against the use of mercury- transition and developing countries have access to containing devices and effectively promote the use mercury-free alternatives, it is imperative that safe of mercury-free alternatives. Support countries in handling procedures be instituted which minimize developing a national guidance manual for sound and eliminate patient, occupational, and community management of health-care mercury waste. Support exposures. Proper procedures should include spill countries in the development and implementation of a cleanup response, educational programs, protective national plan, policies and legislation on mercury health- gear, appropriate waste storage containment, staff care waste. Promote the principles of environmentally training, and engineered storage facilities. Countries sound management of health-care waste containing that have access to affordable alternatives should mercury, as set out in the UN Basel Convention on the develop and implement plans to reduce the use of Control of Trans-boundary Movements of Hazardous mercury equipment and replace them with mercury- Wastes and their Disposal. Support the allocation of free alternatives. Before final replacement has taken human and financial resources to ensure procurement place, and to ensure that new devices conform with of mercury-free alternatives and a sound management recommended validation protocols, health-care of health-care waste containing mercury. Tool-kit for Managers: Volume II 55 XI Engineering Controls for Infection Prevention in Health-Care Facilities According to the World Alliance for Patient Safety21, i. Engineering controls are built into the design at any given time over 1.4 million people worldwide of a health-care facility. An Infection Control are suffering from infections acquired in hospitals. In Risk assessment should be done to evaluate the US, one out of every 136 hospital patients becomes and mitigate potential risks for micro-organism seriously ill as a result of acquiring an infection in transmission by means of air, water and hospital; this is equivalent to 2 million cases and about environmental sources, and trained professionals 80,000 deaths per year. In England, more than 100,000 should be involved in the design and planning. cases of health care-associated infection lead to over ii. Administrative controls include protocols for 5,000 deaths directly attributed to infections each hand hygiene, immunization of residents and year. In Mexico, the estimated 450,000 cases each year care-givers, protocols for managing care-givers of health care-associated infections caused 32 deaths and clients during an outbreak, and protocols for per 100,000 inhabitants. According to the Center for caring for clients with communicable diseases. Disease Control and Prevention (CDC), Health Care- Associated Infections (HAI) are estimated to be 1 of iii. Personal protective equipment helps to control the top 10 causes of death in the United States. hazards as it does not eliminate them, but merely contains the hazard and is dependent on its 1. Hierarchy of infection control appropriate use by educated, knowledgeable staff. measures22, 23 2. Air Controlling infections in health care facilities by working with occupational health and safety groups A variety of airborne infections in susceptible and building engineers has created a framework hosts can result from exposures to clinically that includes: engineering controls, administrative signi�cant micro-organisms released into the air controls and personal protective measures in health- when environmental reservoirs (i.e., soil, water, care facilities. dust, and decaying organic matter) are disturbed. 21 World Alliance for Patient Safety, Global Patient Safety Challenge 2005- 2006, Clear Care is Safe Care, World Health Organization, 2005. 22 Source: Guidelines for Environmental Infection Control in Health-Care Facilities, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC), CDC, 2003. 23 Adapted from BC Centre for Disease Control Document on Respiratory Outbreaks. Heating, ventilation, and air conditioning (HVAC) to monitor the growth of organisms. If any sample is systems in health-care facilities are designed to culture-positive, diagnostic testing is recommended for maintain the indoor air temperature and humidity, all patients with health care–associated pneumonia. control odors, remove contaminated air, facilitate If >30% of the samples are culture-positive, air-handling requirements to protect susceptible decontamination of the facility’s potable water system patients and minimize the risk for transmission of is warranted. airborne pathogens from infected patients. Decreased performance of health-care facility HVAC systems, 4. Green buildings and energy filter inefficiencies, improper installation, and poor efficiency in health care facilities24 maintenance can contribute to the spread of health care–associated airborne infections. Construction ‘Green’ or ‘sustainable’ buildings use key resources like design and function considerations for environmental energy, water, materials, and land more efficiently than infection control are detailed in the original CDC buildings that are just built to code. With more natural document (as referred above). light and better air quality, green buildings typically contribute to improved employee and patient health, comfort, and productivity.25 3. Water There are many water-related infections in health-care While building healthy hospitals the following facilities. These can be reduced by taking special care strategies can be adopted26: of the water supply in health-care facilities. Details of ŒŒ Energy Efficiency – integrated design and HVAC water systems in health-care facilities is provided in systems Section VI. ŒŒ Process water efficiency ŒŒ Sustainable flooring-Proper material selection 3.1 Supplemental treatment of water with ŒŒ Indoor air quality: Proper materials selection heat and/or chemicals ŒŒ Lighting efficiency – optimizing artificial and In addition to using supplemental treatment natural lighting. methods as remediation measures after inadvertent contamination of water systems, health-care facilities Green buildings provide financial benefits that sometimes could use special measures to control conventional buildings do not. These benefits include water-borne micro-organisms on a sustained basis. energy and water savings, reduced waste, improved This decision is most often associated with outbreaks indoor environmental quality, greater employee of infections. comfort/productivity, reduced employee health costs and lower operations and maintenance costs. 3.2 Primary prevention of infections The advantages of green buildings, when compared to Health-care facilities could use at least two general conventional buildings, are: strategies to prevent health care–associated water- ŒŒ On average 25-30% more energy-efficient borne infections when no cases or only sporadic cases have been detected. The first is an environmental ŒŒ Characterized by even lower electricity peak surveillance approach involving periodic culturing of consumption water samples from the hospital’s potable water system ŒŒ More likely to generate renewable energy on-site 24 Green Building Costs and Financial Benefits, by Gregory H. Kats, 2003. 25 Green Building Costs and Financial Benefits, by Gregory H. Kats, 2003. 26 Top 5 Green Building Strategies for Health Care: http://www.epa.gov/region9/waste/p2/greenbldg.html 58 Mainstreaming Environmental Management in the Health Care Sector ŒŒ More likely to purchase grid power generated substitutes for products containing mercury or other from renewable energy sources (green power toxic substances, purchasing decisions can have a major and/or tradable renewable certificates). impact in providing health care without harm.  Environmentally preferable products are generally: 5. Environmentally preferred ŒŒ Less toxic purchasing ŒŒ Minimally polluting Hospitals purchase thousands of different products ŒŒ More energy-efficient requested by dozens of different departments. Often ŒŒ Safer and healthier for patients, workers, and the unknowingly, hospitals may purchase items that are toxic environment to workers or patients, or have serious environmental impacts. Environmentally Preferable Purchasing (EPP) ŒŒ With higher recycled content is a system that identifies and avoids these problems. ŒŒ With less packaging From eliminating unnecessary packaging, to seeking ŒŒ Fragrance-free. Tool-kit for Managers: Volume II 59 XII Standard Operating Procedures for Laboratories Laboratories are unique workplaces where a wide environments encountered, maintenance error variety of chemicals are handled on a routine basis. and operator error. This section briefly outlines the required good practices vii. Label all chemical containers with appropriate with regard to safe handling of chemicals, which are to identi�cation and hazard information. be followed by laboratory technicians. viii. Use only those chemicals for which there are appropriate exposure controls (such as a chemical 1. General guidelines27 fume hood) and administrative programs/ i. Carefully read the label before using a chemical. procedures (training, restricted access, etc.). ii. The manufacturer's or supplier's Material Safety ix. Always ensure that there is adequate ventilation Data Sheet (MSDS) will provide special handling when working with chemicals. information. x. Operations using large quantities (500 milliliters) iii. Be aware of the potential hazards existing in the of volatile substances with workplace standards laboratory and the appropriate safety precautions. at or below 50 ppm should be performed in a chemical fume hood. iv. Know the location and proper use of emergency equipment, the appropriate procedures for xi. Use hazardous chemicals and all laboratory responding to emergencies, and the proper equipment only as directed or for their intended methods for storage, transport and disposal of purpose. chemicals within the facility. xii. Inspect equipment or apparatus for damage v. Employees should not work alone in the before use and before adding a hazardous laboratory. chemical. vi. Anyone considering running an experiment xiii. Do not use damaged equipment. unattended should consider the possible xiv. Inspect personal protective apparel and hazards that could occur as a result of equipment for integrity or proper functioning failures, malfunctions, operational methods, before use. 27 Extracted from Standard Operating Guidelines for World Bank Funded project on Capacity -Building of Food and Drug Laboratories, prepared for Govt. of India by Centre for Environmental and Occupational Health (COEH) of the Maulana Azad Medical College, New Delhi. xv. Malfunctioning laboratory equipment (hood) Remember, there is no harm in being overprotected. should be labeled or tagged "out of service" so Appropriate personal protective equipment should be that others will not inadvertently use it before put on by employees. repairs are made. xvi. Handle and store laboratory glassware with care. 3. Laboratory safety equipment xvii. Do not use damaged glassware. In the laboratory, the chemical hood is the primary means of controlling inhalation exposures. Hoods are Use extra care with Dewar flasks and other xviii. designed to retain vapors and gases released within evacuated glass apparatus; shield or wrap them them, protecting the laboratory employee's breathing before-hand to contain chemicals or fragments zone from the contaminant. should implosion occur. xix. Do not purchase or dispense more of a hazardous This protection is accomplished by having a curtain chemical than is needed for immediate use. of air (approximately 100 linear feet per minute) move constantly through the face (open sash) of the hood. 2. Protective clothing and laboratory Chemical hoods can also be used to isolate apparatus safety equipment or chemicals that may present physical hazards to employees. The closed sash on a hood serves as an Personal protective clothing and equipment should effective barrier to fires, flying objects, chemical be selected carefully and used in situations where splashes or spattering and small implosions and engineering and administrative controls cannot be explosions. Hoods can also effectively contain spills, used or while such controls are being established. which might occur during dispensing procedures, These devices are viewed as less protective than particularly if trays are placed in the bottom of the other controls because they rely heavily on each hoods. When using a chemical fume hood keep the employee's work-practices and an effective training. following principles of safe operation in mind: The engineering and administrative controls which should always be considered first when reducing ŒŒ Keep all chemicals and apparatus at least six or eliminating exposures to hazardous chemicals inches inside the hood (behind sash). include: ŒŒ Hoods are not intended for storage of chemicals. ŒŒ Substitution by a less hazardous substance Materials stored in them should be kept to a minimum. ŒŒ Scaling down the size of experiment ŒŒ Stored chemicals should not block vents or alter ŒŒ Isolation of the operator or the process air flow patterns. ŒŒ Local and general ventilation (e.g., use of fume ŒŒ Keep the hood sash at a minimum height (4 to hoods) 6 inches) when not manipulating chemicals or adjusting apparatus within the hood. The Material Safety Data Sheet (MSDS) will list the Personal Protective Equipment (PPE) recommended ŒŒ When working in front of a fume hood, make for use with the chemical. The MSDS addresses worst sure the sash opening is appropriate. This can be case conditions. Therefore, all the equipment shown achieved by lining up to arrows placed on the may not be necessary for a specific laboratory scale sash door and hood frame. This sash opening will task. ensure an adequate air velocity through the face of the hood. The Environment Health Safety Officer (EHS Officer) ŒŒ Do not allow objects such as paper to enter the can assist in determining which personal protective exhaust ducts. This can clog ducts and adversely devices are required for each task. affect their operation. 62 Mainstreaming Environmental Management in the Health Care Sector Follow the chemical manufacturer or supplier's specific with corrosive or highly acute or chronically instructions for controlling inhalation exposures toxic chemicals, place the container in a with ventilation (chemical fume hood) when using secondary container or a bucket. their products. These instructions are located on the ii. Rubberized buckets are commercially available products MSDS and/or label. and provide both secondary containment as well as "bump" protection. However, it should be noted that these ventilation recommendations are often intended for non- iii. If several bottles must be moved at once, the laboratory work environments and must be adapted to bottles should be transported on a small cart suit the laboratory environment as well as the specific with a substantial rim to prevent slippage from procedure or process. the cart. iv. Wherever available, a freight elevator should be If specific guidance is not available from the chemical used to transport chemicals from one floor to manufacturer or supplier, or if the guidance is another. inappropriate for the laboratory environment, contact the EHS Officer/supervisor and/or review the hood 4.3 Chemical storage in the laboratory using the guidelines given below. i. Carefully read the label before storing a hazardous chemical. 4. Chemical procurement, distribution and storage ii. The MSDS will provide any special storage information as well as information on 4.1 Procurement incompatibilities. i. Before a new substance that is known or suspected iii. Do not store un-segregated chemicals in to be hazardous is received, information on alphabetical order. proper handling, storage, and disposal should be iv. Do not store incompatible chemicals in close known to those who will handle it. proximity to each other. ii. It is the responsibility of the supervisor to ensure that the laboratory facilities in which 5. Emergency preparedness program the substance will be handled are adequate, and that those who will handle the substance have In case of an emergency like fire, spill, electrical received the proper training. shock or natural disaster immediately follow these procedures: iii. The necessary information on proper handling of hazardous substances can be obtained from the i. Call the required help (fire department, medical Material Safety Data Sheets that are provided by department, etc.). the vendor. ii. Activate the building alarm. If not available or iv. Because storage in laboratories is restricted to operational, verbally notify the people in the small containers, order small-container lots to building. avoid hazards associated with repackaging. iii. Isolate the area immediately. v. No container should be accepted without an iv. Shut down all the equipment if possible. adequate identifying label. v. Evacuate to the exit point and follow the instructions of the Supervisor or the person In- 4.2 Distribution charge. i. When hand-carrying open containers of vi. Notify about the hazard and emergency to the hazardous chemicals or unopened containers concerned team of rescue/help. Tool-kit for Managers: Volume II 63 6. Chemical spills & accidents in injury or illness. The rodents cause illnesses like rat bite fever and Weil’s disease. To make the laboratory i. Try to anticipate the types of chemical spills that pest-free a pesticide program should be in place. The can occur in the laboratory and obtain the necessary disinfection of laboratory equipment should be done equipment (spill kits and personal protective by less or non-hazardous chemicals. equipment) to respond to a minor spill. ii. Learn how to safely clean up minor spills of the Pesticide and disinfection programs should be as chemicals used regularly. follows: iii. A MSDS contains special spill clean-up i. Before carrying out pesticide or disinfection information and should also be consulted. programs the laboratory staff should be informed. iv. Chemical spills should only be cleaned up by ii. The person using the pesticides should be well- knowledgeable and experienced personnel. trained and qualified in the use of the pesticides. v. If the spill is too large to handle, is a threat to iii. The person should wear all the required personal health safety or the environment, or involves protective equipment while using the pesticides a highly toxic or reactive chemical, call CHO/ in the laboratory. EHS Officer for assistance immediately. iv. Only non-hazardous or less hazardous pesticides should be used in the laboratory. 7. Fire and fire-related emergencies v. Borax powder is a good pesticide which may be If a fire or fire-related emergency such as abnormal used against German Cockroaches. heating of material, a flammable gas leak, a flammable vi. The disinfection of the laboratory should be done liquid spill, smoke, or odor of burning is noticed, the using 1% – 10% hypochlorite solution as required. procedures mentioned below must be followed: vii. The person carrying out disinfection should i. Notify the Fire Department. know how to prepare the solution of ii. Activate the building alarm (fire pull station). hypochlorite as required. If not available or operational, verbally notify people in the building. Additional Standard Operating Procedures under World Bank-funded projects are detailed below: iii. Isolate the area by closing windows and doors and evacuate the building. i. Laboratory Manual for Technicians (ICTCs, PPTCTCs, Blood banks and PHCs): National iv. Shut down equipment in the immediate area, if AIDS Control Organization (NACO). possible. ii. Biosafety Manual for Public Health Laboratories: v. Use a portable fire extinguisher to: Directorate General of Health Services Ministry ŒŒ Assist oneself to evacuate; of Health and Family Welfare. ŒŒ Assist another to evacuate; and iii. Manual for Laboratory Diagnosis of Common ŒŒ Control a small fire, if possible. Epidemic-prone Diseases for District Public Health Laboratories: Integrated Disease vi. Provide the fire/police teams with the details of Surveillance Project, National Centre for Disease the problem upon their arrival. Control (NCDC). iv. Environmental and Bio-medical Waste 8. Pesticides and disinfection Management Plan for RNTCP-II: Universal The laboratory area should be free from the pests like precautions and SOPs for TB technicians and rodents, cockroaches, termites, etc. These pests cause a centres; Revised National Tuberculosis Control variety of diseases and may lead to a mishap resulting Program (RNTCP). 64 Mainstreaming Environmental Management in the Health Care Sector XIII World Bank Safeguard Policies The operations of the World Bank are guided by a nature, scale, and potential environmental impact comprehensive set of policies and procedures28, dealing of the proposed project. EA evaluates a project's with the Bank's core development objectives and potential environmental risks and impacts in its area of goals. Of these, there are ten key Safeguard Policies influence; examines project alternatives; identi�es ways of which are critical to ensuring that potentially adverse improving project selection, siting, planning, design, and environmental and social consequences are identi ed, implementation, by preventing, minimizing, mitigating, minimized, and mitigated. The World Bank classi�es or compensating for adverse environmental impacts and the proposed projects into one of four categories, enhancing positive impacts; and includes the process of depending on the type, location, sensitivity, and mitigating and managing adverse environmental impacts scale of the project and the nature and magnitude of throughout project implementation. The Bank favors its potential environmental impacts. Health sector preventive measures over mitigatory or compensatory projects are typically classi�ed as Category B (issues measures, wherever feasible. are relatively straightforward and mitigation measures are well-de�ned and implementable). EA takes into account the natural environment (air, Environmental issues associated with health sector water, and land); human health and safety; social projects deal with: aspects (involuntary resettlement, indigenous peoples, and physical cultural resources); and trans-boundary � Infection control practices of health-care workers and global environmental aspects. EA considers and management of health-care waste from the natural and social aspects in an integrated way. It preventive and curative activities of the health- also takes into account the variations in project care sector; and country conditions; the �ndings of country � Management of waste generated during environmental studies; national environmental action construction and refurbishing of health centers; plans; the country's overall policy framework, national � Water and sanitation-related issues. legislation, and institutional capabilities related to the environment and social aspects; and obligations of the country, pertaining to project activities, under relevant 1. Extract of OP 4.0 – Environmental international environmental treaties and agreements. assessment Environmental assessment (EA) is a process whose The borrower is responsible for carrying out the breadth, depth, and type of analysis depend on the EA. The Bank advises the borrower on the Bank's 28 http://go.worldbank.org/L0WZ82PW60 EA requirements. The Bank reviews the findings and During project implementation, the borrower reports recommendations of the EA to determine whether on (a) compliance with measures agreed with the Bank they provide an adequate basis for processing the on the basis of the findings and results of the EA, project for Bank financing. including implementation of any EMP, as set out in the project documents; (b) the status of mitigatory measures; Depending on the project, a range of instruments and (c) the findings of monitoring programs. The can be used to satisfy the Bank's EA requirement: Bank bases supervision of the project's environmental environmental impact assessment (EIA), environmental aspects on the findings and recommendations of the audit, hazard or risk assessment, and environmental EA, including measures set out in the legal agreements, management plan (EMP). The Bank undertakes any EMP, and other project documents. environmental screening of each proposed project to determine the appropriate extent and type of EA. The Bank classifies the proposed project into one of four 2. Timeline for environmental categories, depending on the type, location, sensitivity, assessments and scale of the project as well as the nature and Historically, projects have been most effective magnitude of its potential environmental impacts. when the EA process begins as soon as the project is conceptualized. Incorporating plans to discuss these A proposed project is classified as Category B if it has project requirements with the borrower in the very potential adverse environmental impacts on human early phases of the project is vital. Potential borrowers populations or environmentally important areas– should be provided with information and resources including wetlands, forests, grasslands, and other natural prior to the identification of specific projects. This habitats. These impacts are site-specific; few if any of will enable them to begin the process of establishing them are irreversible; and in most cases mitigatory a country framework that will meet World Bank measures can be designed readily. The EA examines the safeguards in the future, and lessen the number of project's potential negative and positive environmental issues that future projects must address. impacts and recommends any measures needed to prevent, minimize, mitigate, or compensate for adverse impacts and improve environmental performance. 3. Public consultation and disclosure In Category B, the borrower consults project-affected When the borrower has inadequate legal or technical groups and local Non-Governmental Organizations capacity to carry out key EA-related functions (such as (NGOs) about the project's environmental aspects and review of EA, environmental monitoring, inspections, takes their views into account. or management of mitigatory measures) for a proposed project, the project includes components to strengthen The Bank’s document on “Simplifying Safeguards that capacity. Addressing Environmental and Social Issues in Health Projects�, prepared by Safeguards Management and For all Category B projects proposed for IBRD or Review Team (SMART), February 2004 is a process- IDA financing, during the EA process, the borrower oriented guide to simplify safeguards compliance and consults project-affected groups and local Non- reduce transaction costs by helping project task teams Governmental Organizations (NGOs) about the to: (i) anticipate safeguards considerations early in the project's environmental aspects and takes their views project preparation process; (ii) design projects and into account. Public availability in the borrowing project schedules to avoid downstream problems and country and official receipt by the Bank of any delays; and (iii) assist borrowers in complying with Category B EA reports for projects proposed for IDA safeguards work requirements. Another document funding, are prerequisites to Bank appraisal of these to be referred to for HIV-AIDS projects is “Special projects. Once the borrower officially transmits any Procedures for Compliance with Safeguard Policies to separate Category B EA report to the Bank, the Bank Support Accelerated Implementation of HIV/AIDS makes it available through its InfoShop. Projects; March 17, 2003. 66 Mainstreaming Environmental Management in the Health Care Sector XIV World Bank Guidelines for Small Construction Works 1. Guidelines for Small Construction make the premises accident-prone or be a source of Works29 vector breeding. Inferior quality of pipes can result in contamination of the water supply, while sub-standard While health-care waste management is related or banned materials such as asbestos can cause long- to operational activities of the health services, term damage to patients and workers. implementing proper standards for construction and related waste management are up-front, one-time activities. Construction activities generate varied kinds 2. Environmental screening of waste which have the potential of polluting the Usually, the construction of this type of project does not surrounding air, water and land. The neighborhood and create an environmental impact of high magnitude and surrounding areas of any construction can be adversely importance. Most projects are classi�ed as Category B affected by the huge amounts of construction materials, for environmental purposes. However, it is advisable waste and large number of temporary construction to screen sub-projects and construction sites in order to workers, if they are not managed properly. The health, ensure that signi cant issues are identi ed and proper safety and sanitation of these temporary workers are measures included in the project design. The potential an added concern which needs to be addressed during the course of the construction activity. issues depend on the type of construction (small rural schools vs. multi-storied buildings for instance), area Additionally, improper constructions that do not available (congested vs. open area), and the location follow standard practices and legislations can have (urban vs. rural) of the proposed construction. In both an adverse short-term and long-term impact on most cases, construction activities would probably be the environment and continuing services provided by of some concern especially in urban areas in which the health facility. Faulty design and poor quality of avoiding the creation of inconveniences or nuisances to construction can cause inconvenience to patients and certain communities during construction will require even pose a danger to them and the staff within the careful planning of construction activities. facility. Improper drainage and sanitation systems can result in water-logging around the premises Future project sites and projects should be which can damage equipment and infrastructure, screened for: 29 Extracted from World Bank Latin America Toolkit for Health Projects. i. The need for resettlement of families and ŒŒ Safe and secure pedestrian and bicycle crossings businesses, the presence of squatters or any other should be integrated into the design and land titling conflicts; construction of any road/rail crossings. ii. Potential interruption or limitation of accesses ŒŒ The design should harmonize with urban to dwellings or businesses, either permanently or surroundings, including landscaping and planning temporarily (during construction); for other uses, for all additionally created spaces (for instance under-bridges, cul-de-sacs, and iii. Encroachment/reduction of green areas, parks, pedestrian-only streets) in order to minimize and other recreational areas; negative impacts on environmental quality and iv. Demolition of buildings of high architectural or property values. historical value; ŒŒ Alternative solutions and final designs should be v. Potential deterioration of urban quality and subject to public and community consultation property value in the immediate vicinity of the with special emphasis on the property owners works or deterioration of unique architectural directly affected, local NGOs and community characteristics in the neighborhood; organizations, and business and professional vi. Potential for increased accidents in areas organizations. with high density of schools, hospitals, and ŒŒ To minimize public nuisances, construction commercial use; activities should follow strict environmental vii. Effect on urban infrastructure (sidewalks, guidelines. Construction schedules and the power and telephone lines, water and sewerage timing of necessary interruption of public mains, etc.); utilities (electricity, water and telephone) should be informed to the affected community. Potentially unacceptable nuisances viii. during construction (dust, wastes, and heavy ŒŒ All areas and infrastructure affected during construction traffic); and construction should be restored to their original condition, specially sidewalks, green street ix. Potential issues regarding natural hazards dividers, gardens, sidewalk trees, utilities, and (floods, instability). side streets impacted by traffic diversion. ŒŒ The design should contemplate and stimulate the 3. Environmental criteria for the better integration of surrounding urban areas. design and construction of small works 4. Environmental management tools The criteria should include: ŒŒ The designs should avoid or minimize the need 4.1 Environmental considerations for the for resettlement of population, as well as the engineering design impact on green and recreational areas, and The engineering design of the project should take buildings of historical or architectural value. If into consideration: (i) the connection of the building the above impacts are unavoidable, resettlement or infrastructure to the potable water system and the plans, mitigation and compensatory measures capacity of the existing water distribution network, will have to be included in project costs. or the need to establish a water supply system for ŒŒ Access to dwellings and businesses should the building (well, storage tank, pumping station, be guaranteed for both the construction and etc.); (ii) the connection to the sewerage network operational phases. Any restriction or limitation and the need for capacity expansion for receiving of accessibility to properties should be properly collectors or the need for a wastewater treatment mitigated or compensated. system for the building (septic tank, infiltration ditch); 68 Mainstreaming Environmental Management in the Health Care Sector (iii) the treatment of wastewater from cafeterias and in high-traffic avenues and exit ramps; (ii) dust and restaurants before being discharged to the sewerage particulate materials, causing a nuisance to surrounding networks or the wastewater treatment system; (iv) the families and businesses, specially to vulnerable people adequate management of runoff and the facilities for its (children, elders); (iii) undesirable noise levels due recollection and evacuation, having in mind the existing to machinery and equipment specially in areas with downstream systems; (iv) the systems of recollection, hospitals, homes for the elderly, schools; (iv) degradation storage and transportation of solid wastes generated of lateral streets due to heavy equipment machinery in the building, incorporating the structures for and traffic detours; (v) interruption of services (water, separation and recycling; (v) appropriate access systems electricity, telephone, bus routes) during construction; for pedestrians, municipal and inter-municipal buses, (vi) the adequate disposal of garbage, metals, used oils, bicycles, children and handicapped people; (vii) the and excess material, generated during construction; need to integrate building design with architectonic (vii) the need of informing the population about characteristics of the surrounding neighborhood; and construction and work schedules, interruption of (viii) avoiding the use of materials such as wood from services, traffic detour routes, provisional bus routes; tropical forests, lead-based paints, asbestos. and (viii) pedestrian security measures, specially for school children, during construction. All these measures can be included in an environmental manual 4.2 Environmental enhancement that would be part of bidding documents. The architectural and engineering designs of projects should incorporate and reinforce the criteria of Some projects may generate substantial amounts environmentally friendly buildings. This should of construction waste that require appropriate take place during the conceptualization stage and environmental handling. The identification of suitable should include: (i) solar panels to satisfy totally or sites for waste disposal, the environmental management partially the electricity needs; (ii) rain water storage necessary (compacting, re-soiling and re-vegetation, for the irrigation of gardens and green zones; drainage control), and the associated transportation (iii) recycling of wastewater for irrigation; (iv) separation costs should be included in project design and cost of the potable water systems from irrigation systems; estimates. The engineering design will then consider: (v) maximizing natural light in order to minimize (i) the preparation of environmental specifications that artificial light needs; (vi) planting of native species the contractor should follow during the construction; in gardens and green areas; (vii) using windmills and (ii) the constructive design and activity for groundwater exploitation for irrigation water; programming having in mind the minimization of (viii) natural ventilation systems, minimizing the impacts and nuisance to the population. necessities of air-conditioning; and (ix) the stabilization of slopes using vegetative measures. 4.4 Environmental supervision during construction 4.3 Environmental management of The supervision of the construction will include construction activities compliance with the manual and environmental Construction activities could cause a serious impact or specifications by the contractor. nuisance to surrounding areas. Such an impact merits careful planning of construction activities and the 4.5 Environmental measures during the application of strict environmental measures during operational phase construction. Among the aspects that should be kept in mind are: (i) pedestrian safety and traffic congestion During the operational phase of some type of during construction due to the increase of heavy traffic construction works (large isolated buildings, for (of the construction itself and from traffic detours) instance) adequate provisions should guarantee: Tool-kit for Managers: Volume II 69 (i) the maintenance of the systems of collection and ŒŒ Some issues of concern: apply environmental treatment of wastewater; (ii) the adequate collection guidelines for design and construction, and and disposal of solid waste, incorporating recycling further environmental assessment of specific systems and the separation of materials; and projects may be required. (iii) the maintenance of complementary systems (solar ŒŒ Major issues identified: prepare resettlement panels, wind mills, etc.). The engineering design plans, compensation programs (for green should include the preparation of operational manuals areas/natural habitats, for instance), and and maintenance of all systems. archaeological salvage/restoration plans as required. 5. Public consultation The public and community organizations to be consulted For projects in which specific sites are not known include: (i) local professional associations (including in advance engineering and architectural associations); (ii) local ŒŒ Agree on basic environmental and social chambers of commerce and industries; (iii) community principles; organizations (neighborhood organizations) and local ŒŒ No major issues are envisioned: apply NGOs. The consultation program may involve: (i) both environmental guidelines for design and formal and informal presentations and meetings with the construction; target groups; (ii) information dissemination campaigns through fliers, posters and radio announcements; and ŒŒ Some issues of concern are envisioned: agree (iii) an opinion survey. on screening criteria and procedures, agree on TORs for further environmental work, apply environmental guidelines for design and 6. Environmental requirements construction; during project preparation ŒŒ Major issues are envisioned: agree on screening Based on the screening exercise, the environmental criteria and procedures, agree on site-specific work for this type of project may fall within the environmental studies, prepare framework to following categories: deal with resettlement plans, compensation plans (for green areas and natural habitats), For projects in which specific sites are known in and archaeological salvage/restoration plan, advance apply guidelines for design and construction, ŒŒ No major issues identified: apply environmental design community consultation/information guidelines for design and construction. methodology. 70 Mainstreaming Environmental Management in the Health Care Sector XV World Bank Projects in the Health Sector The World Bank is the largest external �nancier in � A policy framework developed by the Ministry the health sector in India. The primary focus of these of Health for the planning, implementation projects has been improving health care for all. Within and management of infection control and the above operations, environment issues have been waste management in health-care facilities receiving increased attention, primarily the need for and standardized operational guidelines to be cradle-to-grave management of infectious and other disseminated under the auspices of the National health-care wastes. Although these issues are not central Rural Health Mission. to the objectives of each operation, they tend to recur � Increased awareness amongst health-care workers in all of them and it is accepted that they should be in the primary and secondary health sector of the taken into account, in a proportionate manner. country. The health sector projects are typically classi�ed � Providing necessary institutional arrangements as Category B (issues are relatively straightforward for proper waste segregation, collection, and mitigation measures are well-de�ned and transportation, storage, treatment and disposal. implementable). For the health sector projects the � Mandatory establishment and use of centralized environmental issues are routinely addressed through facilities. the inclusion of a Health-Care Waste Management Plan (HCWMP) or similar management plan which Health-care waste management has been an integral puts responsibility for the issue under the broad part of the World Bank health sector sponsored mandate of Infection Control. Vector Management in projects at the national and state level. A brief overview public health projects is governed by The World Bank of the projects �nanced by the World Bank in India is Operational Policy 4.09. The OP and BP apply to all provided below: projects involving vector management, whether or not the project �nances pesticides. 1. Reproductive and Child Health India is now a global front-runner in the health- Programme II care waste management agenda. Some of the key The GoI’s national family program has been in place achievements are: since the 1950s and was expanded to include aspects of maternal and child health beyond family planning, 1997 with DOTS (Directly Observed Treatment, short- child immunization, ante- and post-natal care and course), a comprehensive strategy for TB control. The emergency obstetric care. basic unit of the program is the Designated Microscopy Center which is a sputum microscopy laboratory set The Reproductive and Child Health Program (RCH-II) up for a population of about 1,00,000 in normal areas encompasses a number of innovations and reforms. Its and 50,000 in tribal and hilly areas. development objective is to bring about improved and equitable child health, maternal health and population The RNTCP is implemented through the state health stabilization through assured, responsive, quality system and is just one of the many national programs health services, especially in states with low human being implemented in any given health center. The development indicators. In the RCH II program, an RNTCP forms a small component of a multi-pronged Infection Management and Environment Plan (IMEP) infrastructure, and exists at most centers in the form was prepared which consists of a set of national guideline of a laboratory and/or designated treatment center. documents for safe management of health-care waste at Though a separate waste management policy has been the policy level and at different institutional levels. formulated for the RNTCP program, the management of waste generated under RNTCP is to be seen as an 2. National AIDS Control Programme integral component of the peripheral institutions’ overall waste management activities. The National AIDS Control Program Phase III (NACP-III, 2006-2011) aims to support the GoI in achieving its goal of halting and reversing the HIV/AIDS epidemic 4. Food Safety and Quality Control of through: (i) integrating prevention, care, support and Drugs treatment programs; (ii) focusing on increasing awareness The Food Safety and Quality Control of Drugs of HIV/AIDS; (iii) screening of blood for HIV; and program strives at improving the quality and safety of (iv) testing of individuals practising risky behavior. food and drugs in the country. The long-term strategy includes creating common standards and approaches Provision of preventive and treatment services under the and policy reforms related to existing government NACP-III is expected to generate infectious bio-medical regulations regarding licensing, transparency and wastes such as sharps (infected needles and syringes, enforcement of quality of drugs and food safety in surgical equipment, IV sets) infected blood, HIV test the country. A number of initiatives have been taken kits used in Voluntary Counseling and Testing centers, in last few years to improve the capacity of testing blood banks and laboratories and pharmaceutical laboratories and to upgrade systems and procedures. wastes. These wastes, if not managed and disposed of properly, can have direct environmental and public One of the keys areas proposed within the Food health implications. Health-care workers are at great and Drug Capacity-Building project relates to the risk as most blood-borne occupational infections occur upgradation of capacity and competency of the central through injuries from sharps contaminated with blood and state food and drugs testing laboratories. At the through accidents or unsafe practices. Systematic policy level, the project allows the enhancement of the management of such clinical waste from source to existing set of laws and regulatory provisions to clearly disposal is therefore integral to prevention of infection and specifically address the handling and management and control of the epidemic. of hazardous chemicals and bio-hazardous wastes used and generated in such drug and food testing laboratories. An environmental management action plan has been 3. Revised National Tuberculosis implemented to minimize negative environmental Control Programme impacts of current and future operations and to The Revised National Tuberculosis Control Program increase the overall safety at these laboratories. The (RNTCP) is being implemented in the country since environmental plan accords the existing national good 72 Mainstreaming Environmental Management in the Health Care Sector laboratory practices guidelines with an environmental and engineering control measures, in addition to management health and safety component and standard pesticide use that would be reduced under this codes of practice. strategy. 5. Vector-Borne Disease Control 6. State Health Systems Development Project Projects The Vector-Borne Disease Control Project (VBDCP) The World Bank, through the State Health Systems supports GoI in achieving its stated goal of reducing Development Projects, aims at assisting the states in mortality and morbidity from vector-borne diseases, improving their health-care services. In order to ensure namely malaria, dengue, Japanese encephalitis, visceral better health for all, the states are working towards: leishmaniasis, and lymphatic filariasis. improving efficiency in the allocation and use of health resources through policy and institutional The VBDCP has a certain amount of environmental development; strengthening their institutional risk, as provision of preventive and treatment services capacities; upgrading community/sub-divisional involves the use, storage, transportation, and disposal and district hospitals; upgrading clinical and support of insecticides and pesticides in various applications. services; and improving access to primary health care The management of these insecticides requires stringent in remote and underdeveloped areas, that is, upgrade and systematic cradle-to-grave management, otherwise primary health centers in the state and increase access there could be direct environmental and public health to primary care services. In the process of strengthening implications. The Environmental Management Plan the health systems, the environment of the health care (EMP) for the VBDCP consists of a set of mitigation, facility plays a vital role. monitoring, and institutional measures to be taken during implementation and operation of the project The World Bank has supported the following states in to eliminate these adverse environmental and social strengthening their health systems: impacts, offset them, or reduce them to acceptable Andhra Pradesh, West Bengal, Maharashtra, Orissa, levels. Many of these requirements are provided for in Punjab, Uttar Pradesh, and Uttarakhand, Karnataka, GoI’s Insecticides Act, 1971. Rajasthan, and Tamil Nadu. Under the Pest Management Policy, the World Bank supports a strategy that promotes the use of biological 7. Integrated Disease Surveillance or environmental control methods and reduces reliance The project objective was to improve the information on synthetic chemical pesticides. It emphasizes that the available to the government health services and pesticides used must: (i) have negligible adverse human private health-care providers on some high-priority health effects; (i) be effective against the target species; diseases and risk factors, with a view to improving (iii) have minimal effect on non-target species and the on-the-ground responses to such diseases and risk the natural environment; and (iv) take into account factors. Subsequent to the Avian Influence epidemic, the need to prevent the development of resistance. the project was revised to include support for The policy requires that pesticides used for vector preparedness for the prevention, control and response control be manufactured, packaged, labeled, handled, to an influenza pandemic, including Avian Influenza stored, disposed of, and applied according to national and other zoonoses from domestic poultry. In 2010, standards and the standards acceptable to the World the project was further restructured to support the Bank. The World Bank promotes the institutions GoI to strengthen the integrated disease surveillance to support sound, effective, and environmentally system for epidemic-prone diseases by enhancing viable pest management practices, such as integrated central level monitoring and coordination functions, vector management through judicious use of biological and improving state/district surveillance and response Tool-kit for Managers: Volume II 73 capacity with emphasis on selected states. Under have been vaccinated and trained. Personal Protective this project, infection control and bio-medical waste Equipment and antiviral drugs have been provided to management practices have been strengthened in all laboratories. Training videos, developed with WHO laboratories. Standard Operating Procedures have support on occupational and bio-safety practices has been developed and disseminated and all technicians been developed and disseminated. 74 Mainstreaming Environmental Management in the Health Care Sector XVI World Bank Supervision Template 1. Checklist for state project ii. What is the mechanism for monitoring implementation unit segregation of health-care waste at project sites? iii. What corrective actions are undertaken in case of 1.1 Organizational structure and functions non-compliance at one or more sites? i. What is the organizational structure of PMU? iv. What is the present status of procurement of waste ii. What is the staf ng status for implementation of management equipment and materials at various infection control and waste management? project sites? Are all facilities well equipped? iii. Are the roles and responsibilities of PMU staff speci�ed? Is there duality in roles and 1.3 Procurement checklist responsibilities? i. How is the procurement plan prepared for the iv. What is the level of importance and commitment state? How often do facilities provide their accorded to infection control and waste estimates and requirements? management by the state government? ii. What are the reasons for delay in procurement? v. Has the project resulted in a modi�cation/ How can this be corrected? orientation in the state government’s policies and iii. What actions may be planned for prevention of plan with regard to infection control and waste such delays in future? management? iv. What provisions are there in place to assure vi. Has the state department of health instituted quality of equipment and material procured? a multi-sectoral committee to review policy, v. Has the supply been subjected to or planned for compliance and implementation issues? third party quality inspection? vi. What provisions are there in place for repair and 1.2 Planning and implementation maintenance of equipment? Is there a maintenance i. Is the health-care waste management plan plan for equipment? Are critical components comprehensive and adequate? spares available for early repair? vii. What is the status of power supply and are facilities 1.5 Occupational health and safety provided with power back-up generators? i. What is the medical surveillance plan for the What systems are in place for monitoring viii. employees of facilities and its implementation; water, sewage, sanitation and municipal ii. Who ensures adequacy and appropriateness waste management at the facilities? In case of of protective equipment required for different inadequacies, what role is the PMU playing for categories of workers? improving implementation? iii. What are the operational control procedures for collection, segregation, transportation, on- 1.4 Storage and disposal of health-care waste site storage, hand washing, equipment hygiene, i. Do all project sites have separate storage areas for building and general sanitation; general and hazardous waste? What provisions iv. Is there a plan for immunization of health-care are in place for regular cleaning and prevention workers against tetanus and Hepatitis B? What is of access to unauthorized persons? the present status of immunization? ii. How is regular transportation of hazardous v. How is the monitoring of accidents, e.g. needle waste from hospital to disposal site ensured? stick injuries and waste spills carried out? What corrective and preventive actions are there for the delay in transport? vi. Are quality circles functioning in project facilities? Do these include coverage of infection iii. What is the present status of construction of deep control and waste management activities? burial pits at different project sites? vii. What are the prevalent rates of hospital-borne iv. How is the construction quality of the deep burial infection in different state hospitals? Are these pits assured by PMU? What is the mechanism for statistics available? If yes, provide details. If not, determining the number of such pits required for is the system going to be instituted? the state or facility? v. What criteria have been followed for assessing 1.6 Information, Education and capabilities of transportation agencies for safe transport of health-care waste to? What Communication (IEC) contingency plans are there in place for failure of i. Are health-care waste management committees transportation of health-care waste? constituted and functioning at project facilities? vi. How many facilities are currently availing of How is their performance monitored by PMU? the services of the centralized treatment facilities ii. What is the procedure for providing proper authorized by the state government? Are more information to project functionaries posted project sites being planned for such services in at different facilities? Is there in existence the near future? a newsletter that could be useful for this vii. What measures are taken to increase compliance purpose? with waste treatment and disposal? iii. Is PMU considering developing a web-based viii. What are the charges for contracted services? data collection system on health-care waste What is the comparison of the cost of contracting management? treatment and disposal services as compared to iv. Are awareness materials, for example posters, having a dedicated treatment option? Provide booklets, etc. available with project facilities? Is rough estimates. the health-care waste management plan available ix. Are sanitation activities at health facilities at all project sites for reference? being outsourced? If yes, how is their technical v. What are the current channels for communication competencies assessed? with external interested groups, for example 76 Mainstreaming Environmental Management in the Health Care Sector urban local bodies, gram panchayats, NGOs etc.? compliance requirements have been specified by How are they consulted in decision making on the state Pollution Control Board? health care waste management? xi. What is the quantity of different types of wastes generated at the facility? 1.7 Health-care waste management training xii. What is the mode of collection and transpor- i. Are trained master trainers available at all project tation of different types of waste? Specify the facilities? following: ii. What is the present status of training by these ŒŒ Are trolleys, drums, etc. available in master trainers? sufficient number? iii. Do all facilities provide training plans and ŒŒ Are these cleaned and maintained on a schedules? How does PMU monitor progress of regular basis? on-going training activities? ŒŒ What are the provisions in place for disinfection of sharps before disposal? 1.8 Future plans and sustainability ŒŒ What provisions are there in place to dispose of the liquid waste? What are the plans of the project to ensure future sustainability with regard to on-going training and Are the containers and bags for waste collection xiii. contracting of private services and coordinating with available in sufficient quantities and are they in other agencies and stakeholders? accordance with the color-coding as per the Bio- med Waste Management Rules? 2. Check list for health-care facilities xiv. Does the facility use reusable syringes? Do you have sterilization equipment in place? If yes: 2.1 General ŒŒ Are there standard procedures available for i. Name & address of health-care facility sterilization? ii. Name & designation of responding person ŒŒ Is there a preventive maintenance schedule iii. Population of city/town for repair and maintenance? iv. No. of beds in hospital ŒŒ What is the availability of alternatives, for example, disposable syringes in case of v. What is the average occupancy rate for the last procedural failure? six months? xv. Are needle cutters available in the facility? If yes, vi. What is the average OPD attendance for the last specify: six months? ŒŒ Are these available in all required work vii. What kind of care is primarily provided, areas? for example surgery, intensive care, deliveries, laboratory, radiology, dental, ŒŒ Proportion of functioning needle cutters out immunizations etc.? of total present at workplace. Who is in-charge of health-care waste management viii. ŒŒ Main reasons for non-functioning or activities, and has the designated focal point difficulties in their usage. received appropriate training? xvi. Are deep burial pits constructed within the ix. Is there a site-specific health-care waste premises? If yes, specify: management plan available at the facility? ŒŒ Total number of pits planned and constructed x. Does the facility have all its environmental ŒŒ Are these constructed as per specifications in clearances and authorizations? What specific the Bio-med Waste Management Rules? Tool-kit for Managers: Volume II 77 ŒŒ What is the present state of the pits operation xxvi. How is the monitoring done for: and maintenance? ŒŒ Adequacy of segregation of waste during xvii. Are autoclaves used at the site for waste treatment? generation If yes, please specify: ŒŒ Segregation during storage ŒŒ Number of autoclaves available and operation ŒŒ Duration of on-site storage and maintenance conditions. ŒŒ Day-to-day disposal into the deep burial pits ŒŒ Validation testing status for performance by spore testing. ŒŒ Day-to-day functioning of on-site treatment equipment ŒŒ Contingency plan in case of breakdown of equipment. ŒŒ Transportation by external treatment facility xviii. If the facility is contracted to centralized treatment and disposal facilities, please specify: What are the provisions for the health and xxvii. ŒŒ Method of storage of segregated waste at the safety of health-care workers? Specify: site. ŒŒ Availability of adequate number of protective ŒŒ Status of storage area, for example cleanliness, gear e.g., gowns, aprons, gloves etc. accessibility, maintenance, etc. ŒŒ Usage of protective gear by different ŒŒ Frequency and mode of transportation. categories of workers. ŒŒ Authorization of transporter. ŒŒ Immunization schedule for employees against Hepatitis B and Tetanus. ŒŒ Measures for safe transportation including protective gear of transport workers. ŒŒ Periodic medical surveillance of health-care workers on annual basis. ŒŒ Contingency plan in case of failure of transportation. ŒŒ Provisions for hand, equipment and building xix. What are the contractual rates with the service hygiene. provider? ŒŒ Provisions for reporting and management xx. What is the average quantity of waste sent for of needle-stick injuries and chemical spills, treatment? Please specify in categories. and associated management procedures, equipment, training. xxi. What is the level of awareness and training provided to the different levels of facility staff? How frequently is the site inspected by PMU/ xxviii. How often has training been provided? Is there Department of Health/Pollution Control ongoing refresher training? Board? What have been major observations and recommendations? xxii. Who supervises training and refresher training? xxix. What has been the attitude of the community/ xxiii. Who is responsible for monitoring day-to-day NGOs towards waste management by the segregation and collection practices within the facility? Have there been any complaints? facility? Is there a reporting system? xxx. Does the municipality regularly clean up the xxiv. What is the composition of the health-care waste management committee at the facility, solid waste? Are there problems with rag- their frequency of meeting and major decisions picking? taken in the past three months? xxxi. Does the facility plastic waste get sent off for xxv. Does the facility provide regular reports to the treatment and disposal or is it sold for recycling? PMU/Department of Health/Pollution control xxxii. What are the concerns with clean water and Board? sanitation within and outside the facility premise? 78 Mainstreaming Environmental Management in the Health Care Sector What are the five major constraints faced in xxxiii. v. What are the modes of collection – how implementing health-care waste management many vehicles? What is standard of operation systems? Have there been any actions taken to and maintenance? Are the drivers trained in further improve these systems? infection control? xxxiv. Is the facility interested in moving towards vi. What are the contractual charges? Has higher environmental standards? there been a revision in rates? Is the facility viable? 3. Check list for common treatment vii. Are there specific guidelines or directives facility specified by the Pollution Control Board? i. Name, address and location. What are the environmental clearances viii. ii. How many facilities (public and private; and and authorizations required? How often number of beds) are contracted? does the facility get monitored? How often iii. What is the quantum of health waste generated/ and what are the reports that have to be day? submitted? iv. What is the timing and frequency of collection ix. Have the employees received training in of waste? infection control? Tool-kit for Managers: Volume II 79 XVII World Bank Performance Indicator Template 1. Monitoring indicators: Department ii. Segregation and storage practices are at 100%. of health iii. Reducing number of needle-stick injuries and i. Number of health-care facilities with medical chemical spills. of cers and hospital authorities and staff trained iv. Strict monitoring of hospital-acquired infections. in health-care waste management. v. Excellent sharps safety systems in place. ii. Number of facilities attached to centralized vi. Storage of waste not longer than 48 hours. treatment facilities. vii. 100% immunization coverage of all health-care iii. Institutional mechanism set up across workers and staff. departments, and disease control programs for coordination of health care waste management. viii. Clean water and proper sanitation maintained in the facility. 2. Monitoring indicators: Health-care ix. Facility attaining NABH standards. facilities x. Innovative measures being taken for eco-friendly i. All staff trained in infection control and waste environment. management. XVIII Key Resource Documents for Health-Care Waste Management and Infection Control In this section a brief description of the key resource 3. Basic Steps in the Preparation of Health-care documents used in environment planning of the health Waste Management Plans for Health Care sector has been described. The intention is to provide Establishments, Mr. Raki Zghondi - WHO the different stakeholders working in health sector EMRO/CEHA, 2002. with brief and handy descriptions of key and useful The lack of policies, strategies and enforcement of documents. This section has been divided topic wise legislation for the handling and disposing of health- for easy navigation and understanding. care waste in many Eastern Mediterranean countries has resulted in poor management of such waste. This I. Key documents on health-care document provides practical steps for the development waste management of plans for small, medium and large health care 1. A Global Inventory of Alternative Medical Waste establishments in the region. Treatment Technologies, Health Care without 4. Better Health-Care Waste Management: An Harm, 2007. Integral Component of Health Investment Raki Zghondi - WHO/CEHA and Philip Rushbrook, This document is intended to provide a global listing World Bank, 2005. of alternative technologies for the treatment of infectious waste. The inventory is intended for use The overall objective of this publication is to by different agencies and organizations, planners, demystify the topic of health-care waste management policymakers, etc. and demonstrate that positive improvements are 2. Aide-mémoire for a National Strategy for health possible in almost every situation with relatively care waste management, WHO, 2000. modest levels of effort and investment. 5. Bio-Medical Waste Management Case Study To assist health-care planners at the national level, NCT – Delhi, CPCB, June 2000. an aide-mémoire has been produced which provides an overview of the main aspects that have to be dealt This CPCB manual has been prepared to help health- with: a checklist for actions at the national and local care facilities with setting up a sound health- care waste level is also included. management system and provide a nal treatment and disposal option as per the bio-medical waste management in their country, and the availability of management and handling rules. resources. 6. Bio-Medical Waste: Status in National Capital 10. Core Principles for Achieving Safe and Sustainable Territory of Delhi, DHS, Govt. of NCT Delhi, Management of Health-Care Waste Management, 2006. WHO, 2007. This document provides the overview of health-care This document was prepared during the international waste management in Delhi hospitals and provides meeting organized by WHO in Geneva in June 2007. the recommendations proposed by the Government It highlights the core principles required for health- of Delhi to further improve the situation of waste care waste management by all those who are directly management. linked with the health sector. While financing and 7. Certificate in Health-Care Waste Management, supporting health-care, provision for the costs of IGNOU – WHO-SEARO, 2006. managing health-care waste should be incorporated in the health plans. IGNOU in collaboration with WHO-SEARO has prepared a 14 credit, six- month certificate program 11. Draft Regional Guidelines for Hospital Waste on health-care waste management for health-care Management in Developing Countries, Dennis professionals and others who have passed the twelfth C. B. Saw, WHO - Western Pacific Regional class examination. The program highlights the Office – EHC, 1993. importance of capacity-building and training of health- This document is among the initial guidelines provided care professionals. by the WHO and covers issues such as hospital waste 8. Compilation of Steam-based Treatment categories; basic steps of waste management; and Technology Vendors, UN/GEF Global Health- planning. care Waste Project. May 19th, 2010 12. Environmental and Bio-Medical Waste This document provides a partial list of non- Management Plan for RNTCP-II, Revised incineration technologies for the treatment of health- National Tuberculosis Control Programme, care waste. The technologies include autoclaves, DGHS, MoHFW, GoI, June 2005. microwave units, hybrid steam treatment systems, These guidelines are prepared as a part of the RNTCP. and other steam-based technologies. It does not They specify how to deal with specific waste generated include vendors of chemical disinfection, irradiation, during activities related to TB and also specify the biological treatment, and incineration or incineration- importance of integrating these guidelines and activities like technologies. Please note that the UNDP GEF in health-care facilities with the overall activities related Project does not endorse any of the technologies, to health-care waste management. companies, or brand names in this list. 13. Environmentally Sound Management of Mercury 9. Core Competencies Related to Health-care Waste Waste in Health-Care Facilities (Draft report), Management, September 2009 UNDP GEF Central Pollution Control Board (Ministry of Project,  UN/GEF Global Health-care Waste Environment & Forests), September 07, 2010. Project, January 12th, 2010. The Central Pollution Control Board has prepared This outline provides core competencies related draft guidelines on management of mercury waste from to health-care waste management that can be health-care facilities. These guidelines are prepared to used to define standards that become the basis for help health-care facilities manage their mercury waste training curricula, professional development, and and switch to non-mercury based devices. accreditation. Some countries may have to modify the core competencies to reflect their current practices, 14. Findings on an Assessment of Small-Scale the level of development of health-care waste Incinerators for Health-Care Waste, WHO 2004. 84 Mainstreaming Environmental Management in the Health Care Sector This report provides an analysis of low-cost, small- As health facilities phase out mercury devices, proper scale incinerators used to dispose of health-care waste methods of storage and transport are needed. This in developing countries, specifically sharps waste (used document is intended for project countries where and possibly infected syringes and needles). The report national norms and guidelines for clean-up, storage, includes a situation analysis, a “best practices� guide and transport of mercury waste do not exist at this to small-scale incineration, a screening-level health risk time. These suggested guidelines should become part assessment for ingestion and inhalation exposure to of a broader plan for sequestration and phase-out of dioxin-like compounds, and other information related mercury. to the operation and evaluation of the incineration 19. Guidelines for Safe Disposal of Unwanted option for health-care waste. Pharmaceuticals in and after Emergencies, WHO, 15. For Proper Disposal: A Global Inventory 1999. of Alternative Medical Waste Treatment In this document guidance is provided on the Technologies: Health Care Without Harm, 2007. disposal of drugs in difficult situations in or after Health Care Without Harm (HCWH) developed this emergencies, in relation to armed conflicts, natural inventory to provide a global listing of alternative disasters or others. In such situations, it is possible technologies for the treatment of infectious waste. These that large quantities of unwanted drugs accumulate alternative technologies operate under conditions that due to difficulties, mismanagement of stocks and help to avoid the formation of dioxins and furans. The inappropriate donations. The guidance provided inventory is intended for use by health and environment consists of relatively simple and low-cost measures and ministries, international organizations, aid agencies, is addressed to local authorities, health-care personnel multilateral lending institutions, national and local or other professionals confronted with this type planners, policymakers, health-care professionals, and of problem. The main thrust is on existing disposal non-governmental organizations involved in health-care methods, and recommended disposal methods by waste management or in the development of national waste category. and local health-care waste management plans. 20. Guidance on the Microbiological Challenge 16. Four Steps for the Sound Management of Health- Testing of Health-care Waste Treatment Care Waste in Emergencies, Y Chartier, WHO, Autoclaves UN/GEF Global Healthcare Waste 2005. Project, September 22nd, 2010. This four-step document expresses public health risks, Two components of the UNDP GEF Project on management, simple disposal options and a long-term Global Health-care Waste involve the demonstration approach for emergency situations. of non-incineration health-care waste treatment technologies, the most common of which is the 17. Global Movement for Mercury-Free Health Care, autoclave. This document provides a microbiological Health-care Waste Management, Oct. 2008. challenge test protocol for validation testing of This report documents the state of the global gravity-displacement or vacuum autoclaves used for movement toward mercury-free health care by the treatment of medical waste. The objective of describing the relevant issues, the challenges the the test protocol is to demonstrate the ability of an health-care sector faces in replacing mercury-based autoclave to effectively treat medical waste according medical devices, and a series of successes including to accepted treatment standards. pilot projects and policy models that are already 21. Handbook of Hazardous Health-Care Waste achieving meaningful changes on the ground. Management in 10 and 30 bed Community 18. Guidance on Clean-up Storage and Transport Hospitals, Sanitation Division and of Mercury from Health Care,  UN/GEF Global Environmental Health Center, Ministry of Health-care Waste Project, July 22nd, 2010. Public Health, Thailand, 1995. Tool-kit for Managers: Volume II 85 This document deals mainly with waste collection, 26. Health-care Waste Management Guidance Note, transportation and final disposal. The other steps Lars M. Johannessen, et al, The World Bank, (minimization, generation, storage) are briefly 1999. mentioned. As the title shows, this handbook is The main focus of the document is to: describe the intended to help manage hazardous health-care waste scope of the problem; provide guidance for small and in small to medium sized community hospitals. large health-care facilities; offer guidance for municipal, 22. Health- care Waste Management: Costing Analysis metropolitan or regional health-care waste projects; and Tool (CAT), The Protection of the Human provide guidance for national health-care waste projects Environment Departments/Water, Sanitation along with information sources and references. This and Health Unit at WHO, 2006. guidance note should be viewed as an internal World This costing tool has been created to help estimate and Bank working document that attempts to synthesize calculate costs related to health-care waste management the currently available knowledge and information in at national and health care facility levels. the field of health-care waste management. 23. Health-care Waste Management: Expanded 27. Health-Care Waste Management: Guidance Costing Analysis Tools (ECAT), WHO, 2007. for the Development and Implementation of a National Action Plan, WHO, 2005. Allocating insufficient financial resources to manage health-care waste properly has an even greater This document provides guidance to assess and financial cost in the medium and long term in terms analyze the health care waste management situation at of morbidity and mortality, as well as environmental the national level, and to draft a national HCWMP, damage that will in the end impact negatively on with the aim of improving the overall systems in the peoples’ health. The Expanded Costing Analysis country. The draft Plan would then be reviewed by Tool (ECAT) is a modified version of the Cost persons involved in the national or regional policy Analysis Tool (CAT) and provides more options setting, interested donor agencies, NGOs and other and approaches than CAT. It was created to help concerned organizations or stakeholders; roles and the user estimate costs related to health-care waste resources for its implementation would be identified. management at the health-care facility, CWTFs or 28. Health-Care Waste Management in India; cluster, and national levels. Onsural B, The World Bank, October 2003. 24. Health-care Waste Management: Rapid Assessment This report presents an overview of the responses and Tool (RAT), WHO, UNEP/SBC, 2004. concerns in India, associated with health-care waste This assessment tool has been created to help get an management at the central, state, and local levels. The overall picture of the health-care waste management report is based on the World Bank’s experience in situation prevailing within a country at all levels working with clients and draws heavily on an internal (ministerial down to small health-care facilities). It helps review of the World Bank’s operations. assess management, training, regulatory, technical and 29. Healthy Hospitals – Healthy Planet: How the financial issues; its analysis should help pinpoint critical Health Sector can Reduce Its Climate Footprint , issues that need to be addressed within the framework WHO-Health Care Without Harm, 2009. of a National Action Plan (NAP). This discussion draft is based on WHO’s mandate from 25. Health-Care Waste Management, World Bank member states to develop a program for the health sector and WHO, December 2003. that will reduce their greenhouse gas emissions. The This is a five-page document highlighting the paper defines a framework for analyzing and addressing importance of good health-care waste management, the health sector’s climate footprint and demonstrates the do’s and don’ts, and describes the related project that the health sector is already beginning to provide cycle. examples in setting up climate-friendly hospitals. 86 Mainstreaming Environmental Management in the Health Care Sector 30. Hospital Waste: Time to Act, Compilation of waste: segregation, containment, handling and storage, Facts Sheets, Srishti, 2002. transport, treatment or destruction, and disposal. This document is a compilation of 14 facts sheets 35. Land-filling Health-Care Waste: Sustainable published by Srishti in the area of health-care waste Methods of Disposal or Threat to Public Health?  management. These fact sheets provide information Kristof Bostoen, WEDC - Department of Civil on a wide range of issues such as universal precautions, and Building Engineering, 1997. plastics, incineration, mercury and alternative This report analyses the risk linked to land filling of technology in health-care facilities. health care wastes, the risk of transmission of infectious 31. Infection Management and Environment Plan, diseases, toxicology as well as an overview on sanitary Policy Framework, MoHFW, GoI, March 2007. landfill practices. The report argues that in low-income countries, land-filling health care-waste is more likely to This document contains generic guidance to central- be a benefit to public health, compared to crude dumping and state-level institutions on the type of systems and commonly practiced in many of these countries. processes to be established for infection control and waste management. 36. Lurking Menace: Mercury in the Health-Care Sector, Toxics Link, 2005. 32. Infection Management and Environment Plan, Guidance Manuals, MoHFW, GoI, March 2007. This report highlights the use of mercury in the health sector, the hazards caused by mercury use and Guidance Manuals for Community Health Care, case studies of good practices and benefits of moving Primary Health Care and Sub-centres are designed towards non-mercury devices. as instruction manuals for health-care workers at the primary level facilities. These guidelines are in the 37. Management of Solid Health-Care waste at form of simple pictorial presentations of the various Primary Health Care Centres: A Decision-Making steps needed to manage infectious waste in a hygienic, Guide, WHO, 2005. safe and environmentally sound manner. The objective of this document is to provide guidance 33. Islamic Republic of Iran Management of Health- for selecting the most appropriate waste management Care Waste Policy Note, Water, Environment, methods for safely managing solid waste generated at Social and Rural Development Department, primary health-care centres in developing countries. Middle East and North Africa Region, The World The main tool of this guide consists of six decision-trees Bank, October 17, 2005. aimed at assisting the user in identifying appropriate waste management methods. The guide takes into The objective of this policy note is to present a consideration the most relevant local conditions, the diagnosis of the main issues and barriers towards a well- safety of workers and the general public as well as structured health-care waste management system, and environmental criteria. set a recommended action plan for better performance. The policy note focuses on accomplishments and 38. Management of Waste from Injection Activities at future challenges for sector actions to increase the District Level: Guidelines for District Health efficiency of the institutional framework, at both the Managers, WHO, 2006. national and municipal levels. This guide is designed as a simple and practical tool 34. Key Steps in Sharps Waste Disposal, PATH, to help district health managers formulate a realistic 2006. district-level plan to reduce improper disposal of waste from injection activities. This training aid was developed as part of Training Health Workers in the Management of Sharps Waste. 39. Management of Wastes from Immunization The aid includes a graphic representation of the key Campaign Activities: Practical Guidelines for steps involved in the safe management of health-care Planners and Managers, WHO, 2004. Tool-kit for Managers: Volume II 87 This document, developed by WHO and UNICEF, policies and plans through National Steering provides practical guidelines for planners, managers Committees and National Working Groups. of health-care facilities or mobile vaccine team 45. Non-Incineration Medical Waste Treatment leaders to improve planning and coordination at the Technologies, Health Care without Harm, 2001. central level, as well as waste management practices at the local level where immunization activities are This document provides in detail the advantages conducted. of non-burn waste treatment technologies and an overview of non-incineration technologies (thermal, 40. Managing Health-Care Waste Disposal, WHO chemical, irradiative, biological, mechanical), Africa and PATH Children's Vaccine Program, describing each of them as well as discussing factors 2005. to consider while selecting a technology. The guidelines focus on the product specification, 46. Preparation of National Health-Care Waste installation, operation and maintenance of a waste Management Plans in Sub-Saharan Countries: disposal unit for managing health-care waste. A Guidance Manual. WHO and UNEP/SBC, 41. Managing Hospital Waste: A Guide for Health- 2004. Care Facilities, Megha Kela, Samir Nazareth, The manual aims at identifying appropriate practices Anu Goel, Ravi Agarwal, Srishti, 1998. for health-care waste management by providing This is a hands-on manual on hospital waste, describing assessment and planning tools applicable in most Sub- the different kinds of waste generated in health-care Saharan countries of Africa. facilities and their handling and disposal options at 47. Recommended Elements of a Model Facility Policy different points of waste generation. It also highlights on Health-Care Waste Management, UNDP, the importance of training and awareness, and the role GEF, April 2009. of rag-pickers and the municipality. This is a policy document to be used by hospitals for 42. Mercury in Health Care, Policy Paper, WHO, setting up and running health-care waste management 2005. especially the hospitals under the Global Environment The technical paper on mercury recommends that Facility (GEF). countries conduct assessments of current mercury 48. Regulated Medical Waste Reduction, Hospitals usage and health-care waste management programs. for a Healthy Environment, 2003. The WHO proposes to work in collaboration with countries through short- medium- and long-term The manual describes different steps for implementing strategic steps presented in this document. a regulated medical-waste reduction plan in health- care facilities. The manual provides 10 steps for waste 43. National Guidelines on Hospital Waste reduction. Management, MoH&FW, GoI, March 2002. 49. Report of the Committee to Evolve Road Map These guidelines, apart from covering the aspects on Management of Wastes in India, MoEF, GoI included in the Bio-Medical Rules, also lays down Delhi, March 2010. recommendations for safety measures, training, management and administrative functions. This report provides recommendations and suggested future actions to be taken up by the 44. National Steering Committees and National Government and other implementing agencies to Working Groups for Health-Care Waste improve the overall waste management situation in Management Policy Development and Planning, the country. It covers all the different kinds of waste, WHO, 2006. including health-care waste, and provides a specific This paper describes an organizational model and action plan to improve health-care waste management strategy for developing health-care waste management in the country. 88 Mainstreaming Environmental Management in the Health Care Sector 50. Report: Non-Incineration Medical Waste The study documents successful sharps management Treatment Pilot Project at Bagamoyo District systems by use of non-burn treatment and disposal Hospital, Tanzania, Health Care Without Harm technologies in urban health-care facilities in India. & Partners, September 22nd, 2010. The document also provides recommendations of the possibilities of material recovery of these syringes. Since October 2008, Bagamoyo Hospital in Tanzania has been using an autoclave and shredder to render their 55. Safe Management of Wastes from Health- waste harmless before disposal. A year of monitoring Care Activities, Annette Pruess, E. Giroult, after the project initiation demonstrated that this P. Rushbrook, WHO, 1999. technology can work well in the African context. This This handbook provides a one-stop solution to health- report shows how steam-based disinfection rather than care waste management. It covers all the issues including incineration was used in the hospital to treat medical financing and minimal requirements for rural settings. waste. By publishing this handbook WHO aims not only to 51. Review of Health Impacts from Microbiological promote a sound managerial approach and the use of Hazards in Health-Care Wastes, WHO, 2004. appropriate technologies, but also to inform countries about the health risks that result from inadequate This technical guideline aims at reviewing the management of health-care waste. The advice and scientific literature for findings on health impacts guidance offered are intended to assist national bodies from microbiological hazards of health-care wastes. and individual medical institutions. It also reviews health impacts of similar exposures in identical circumstances, to evaluate health risks by 56. Segregation of Medical Waste, PATH, 2006. analogy. The document is targeted at scientists and This training aid was developed as part of “Training public health professionals, and those involved in Health Workers in the Management of Sharps policy setting. Waste.� The aid includes a graphic representation of 52. Risks and Costs Associated with the Management the segregation of medical waste into three categories: of Infectious Wastes, WHO Regional Office for non-infectious, infectious, and sharps. Over the Western Pacific, 2003. last few years a number of countries have adapted the basic concepts and developed country-specific This report deals with the risks associated with the versions of this for use in training as well as posters treatment and disposal of health-care wastes by means in health facilities. An example adapted for Kenya is of technologies that have been demonstrated in the also available. field. Information regarding the risks associated with each one of the treatment or disposal methods has 57. Small-Scale Autoclaves to Manage Medical been reported in the document from the results of Waste: A Buyer’s Guide to Selecting Autoclaves research, and in some cases from research conducted Manufactured in India, USAID and PATH, Sept. on the treatment or disposal of medical wastes. 2008. 53. Rules and Regulation on Health-Care Waste This document shows that there is a growing interest, Management US EPA, 1997. globally, in more sustainable non-incineration approaches to the treatment of medical waste. These legal documents deal with standards of However, currently there is very little information on performance for new stationary sources and emission practical alternatives for treating medical waste in low guidelines for existing sources: hospital/medical/ resource settings. In this guide, PATH has gathered infectious waste incinerators. information from manufacturers of small-scale Indian 54. Safe Management of Bio-Medical Sharps Waste autoclaves as one option for treatment of medical in India: A Report on Alternative Treatment and waste. India was chosen as the focus country for the Non-Burn Disposal Practices for Sharps Disposal, guide because of its large number of manufacturers of WHO-SEARO, 2005. low-cost, small-scale autoclaves. Tool-kit for Managers: Volume II 89 58. Starting Health-Care Waste Management in aspects, the information and recommendations should Medical Institutions: A Practical Approach, be economically feasible and easy to undertake. It also Philip Rushbrook et al. WHO, Regional Office makes allowances for technical progress for Europe, 2000.    62. Testing and Evaluation of Needle Destroyers, This document has been prepared in response to PATH, 2000.    numerous requests for advice and assistance by staff This is a report published by PATH on the testing in ministries of health and health-care institutions, and evaluation of several needle destroyers available particularly from those who are responsible for in the market. The report classifies the needle introducing better waste management practices in destroyers according to functional, safety and user medical institutions, so as to reduce infection risks and considerations. improve hygiene. 63. The Costs of Recycling the Plastic of Auto Disable 59. Teacher's Guide: Management of Waste from Syringes in Ukraine, WHO, 2005. Health-Care Activities, A. Prüss, W.K. Townend, WHO, 1998. The objective of this study is to estimate the costs of recycling the plastic of Auto Disable (AD) syringes as The teacher's guide accompanies the WHO carried out in a pilot project launched in April 2003 publication on management of wastes from health- in Khmelnytsky Oblast and Kiev city in Ukraine care activities. It provides teaching materials (ready-to- with the support of the WHO European Regional copy texts for overhead transparencies, lecture notes, Office. Information on cost is essential to assess the handouts, exercises and course evaluation forms) and feasibility and sustainability of expanding the new recommendations for a three-day training course. waste management system to a wider scale. It is designed mainly for managers of health-care 64. Toward the Tipping Point: WHO-HCWH establishments, public health professionals and policy Global Initiative to Substitute Mercury-Based makers. A selection of pictures to support training in Medical Devices in Health Care by World Health health-care waste management is available on line. Organization & Health Care Without Harm,  60. Technical Guidelines on the Environmentally June 3rd, 2010. Sound Management of Bio-Medical and Health- Care Waste, Basel Convention (SBC - UNEP), The report documents the progress of dozens of 2000. countries from around the world moving toward mercury-free health care. The progress report finds This document provides the guidelines prepared for that, “Momentum is growing and mercury-free health use under the Basel Convention. It describes definition care is increasingly becoming the status quo in many and the hazards of bio-medical and health-care wastes; countries. The Global Initiative is moving closer to a source identification of waste; applicable state-of-the- tipping point that will shift the dynamics of supply and art management, treatment and disposal technologies; demand in the global thermometer and blood pressure and waste management auditing techniques. device markets away from mercury and toward the 61. Technical Guidelines on the Environmentally alternatives.� Sound Management of Bio-Medical and Health- 65. Training of health-care professionals- GoI, Care Wastes (Y1, Y2), (SCB - UNEP), 2003. MoHFW Bio-medical waste management self- learning document for doctors, superintendents The guidelines provide information on the proper and administrators, prepared by EPTRI, treatment of wastes from health-care establishments Hyderabad, for MoEF, GoI, 2010. (public and private). The information provided takes due consideration of the waste management This manual is useful for refreshing and or upgradation requirements of disposal and recovery measures as of knowledge of doctors, superintendents and well as hygiene requirements. In addition to ecological administrators on bio-medical waste management. This 90 Mainstreaming Environmental Management in the Health Care Sector will sensitize the reader about the impacts of improper without incineration or open burning during a mass waste management and acquaint them with laws and immunization campaign. practices in India 70. WHO Policy Paper on Safe Health-Care Waste 66. Training Health Workers in the Management of Management, WHO, August 2004. Sharps Waste PATH, 2006. The policy document calls on countries to develop and This document contains a set of training modules implement national plans, policies, and legislation on designed to be adapted for use in various health-care health-care waste. settings. The purpose of these materials is to train health workers in the management of sharps waste. II. Key documents on infection These materials are divided into two training guides: control, sanitation and water one for training injection providers, and second for supply training waste-handlers. 71. Bio-Safety in Microbiological and Bio-Medical 67. Treatment Alternatives for Medical Waste Laboratories, U.S. Department of Health and Disposal , PATH, 2005. Human Services Public Health Service, Centers The purpose of this document is to inform the reader for Disease Control and Prevention and National about different technology options for the treatment Institutes of Health, Fourth Edition, April 1999. of infectious medical waste, particularly for developing This publication describes the combinations of countries. It describes incineration, chemical treatment, standard and special microbiological practices, safety autoclaving, microwaving, and shredding/compacting. equipment, and facilities constituting Bio-Safety Performance issues, environmental impact, and Levels 1-4, which are recommended for working with perspectives from several developing countries are a variety of infectious agents in various laboratory described. settings. 68. Union Audit (CAG) Reports, Scientific 72. Bio-Technology: Laboratories for Research, Departments, Management of Waste in India Development and Analysis – Guidance (Performance Audit - Report No. 14 of 2008), for Handling, Inactivating and Testing of 2006-2007. Waste,   European Committee for Standardization This report has been prepared by the Comptroller and "CEN", 1997. Auditor General of India for the year ended March This document was prepared by the technical 2007 to assess and audit the management of waste in committee CEN/TC233. It provides guidance on India. The auditing conclusions and recommendations methods for handling, inactivating and testing of of the report are based on the current situation and waste containing micro-organisms arising from bio- good practices regarding waste management in India technology and microbiology laboratory activities and in other countries. and processes. It focuses on methods to reduce the 69. Waste Management and Disposal during the risks arising from exposure to waste derived from Philippines Follow-Up Measles Campaign 2004, laboratory-scale activities both for humans, animals Health Care Without Harm (HCWH) and and the environment in general. Department of Health, Philippines, June 2004. 73. Environmental Management for Construction Activities, Addendum, NACP-III, MoHFW, GoI, This report focuses on the waste disposal of the September 2006. Philippines Follow-Up Measles Elimination Campaign, targeted at an estimated 18 million These guidelines deal with the issues related to children during February 2004. The report documents construction activities and provide measures for the disposal method of the large quantities of waste environment management of construction activities in generated during the immunization campaign, the health care facilities. Tool-kit for Managers: Volume II 91 74. Environmental Management Plan for the Vector- The “Guideline for Hand Hygiene in Health-Care Borne Disease Control Project India, National Settings� provides health-care workers with a review Institute of Malaria Research (Indian Council of of data regarding hand washing and hand antisepsis Medical Research), December 2006. in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene These environment management plans (EMPs) are practices and reduce transmission of pathogenic micro- prepared to help in setting up an environmentally sound organisms to patients and personnel in health-care VBDC program in the country. These guidelines will settings. This report also reviews studies published help in ensuring that the project is environmentally since the 1985 CDC guidelines on infection control. sound and sustainable by recommending measures needed to prevent, minimize, mitigate, or compensate 78. Guidelines for Infection Control in Health-Care for adverse impacts and improve environmental Personnel, Elizabeth A. Bolyard, RN, MPH, a management performance. Ofelia C. Tablan, MD, Walter W. Williams, MD, 75. Essential Environmental Health Standards B Michele L. Pearson, MD, A Craig, N. Shapiro, in Health Care, edited by John Adams, Jamie MD, A Scott, D. Deitchman, MD, C and The Bartram, Yves Chartier, WHO 2008. Hospital Infection Control Practices Advisory Committee CDC, 1998. This document deals specifically with essential environmental health standards required for health- This guideline updates and replaces the previous edition care settings in medium- and low-resource countries of the Center for Disease Control and Prevention to: (i) assess prevailing situations and plan for the (CDC), “Guideline for Infection Control in Hospital improvements that are required; (ii) develop and Personnel,� published in 1983. The revised guideline, reach essential safety standards as a first goal; and designed to: (i) provide methods for reducing the (iii) support the development and application of transmission of infections from patients to health- national policies. These guidelines have been written care personnel and from personnel to patients; and for use by health managers and planners, architects, (ii) provide recommendations for infection control. urban planners, water and sanitation staff, clinical 79. Guidelines for Isolation Precautions: Preventing and nursing staff, and other health-care providers, and Transmission of Infectious Agents in Health- health promoters. Care Settings 2007, Jane D. Siegel, MD; Emily 76. Guidance Note on Health-Care Worker Safety Rhinehart, RN MPH CIC; Marguerite Jackson, from HIV and other Blood-Borne Infections, PhD; Linda Chiarello, RN MS; The Health-Care Julian Gold, Maggy Tomkins, Phillip Melling, Infection Control Practices Advisory Committee, Nicholas Bates, May 2004. 2007. This guidance document is to focus on the occupational This guideline updates the 1996 Guideline for safety issues of health-care workers and encourage Isolation Precautions in Hospitals. This document is policy makers to include health-care waste safety intended for use by infection control staff, health care as a component in all health policies, protocols and epidemiologists, health care administrators, nurses, guidelines. The guidance note provides some strategies other health-care providers, and persons responsible as to how this may be achieved as well as guidelines for for developing, implementing, and evaluating infection the content of policies. control programs for health-care settings across the continuum of care. 77. Guidelines for Hand Hygiene in Health-Care Settings, Recommendations of the Health Care 80. Guidelines for Environmental Infection Control Infection Control Practices, Advisory Committee in Health-Care Facilities: Recommendations and the HICPAC/SHEA/APIC/IDSA, Hand of CDC and the Health Care Infection Control Hygiene Task Force, Morbidity and Mortality Practices Advisory Committee (HICPAC), U.S. Weekly Report, CDC, Oct. 2002. Department of Health and Human Services 92 Mainstreaming Environmental Management in the Health Care Sector Centers for Disease Control and Prevention attention, and make recommendations to improve the (CDC) Atlanta, GA 30333, 2003. EA effectiveness. This report reviews previous guidelines and strategies 84. Infection Control Annual Report, 2006- 2007, for preventing environment-associated infections in Royal National Orthopedic, Vishal Sookhoo. health-care facilities and offers recommendations. This report outlines the activities of the organization These include: (i) evidence-based recommendations relating to infection control from April 2006 to March supported by studies; (ii) requirements of federal 2007. The report states that control of infection agencies; (iii) guidelines and standards from building has always been taken very seriously by the Royal and equipment professionals; (iv) recommendations National Orthopaedic Hospital and describes the derived from scientific theory or rationale; and reasons for the 50 percent reduction in health care- (iv) experienced opinions based upon infection-control associated infections up to March 2008. and engineering practices. The report also suggests 85. Laboratory Bio-Safety Manual – Third Edition, a series of performance measurements as a means to WHO 2004. evaluate infection-control efforts. 81. Health through Safe Health Care: Safe Water, This manual is intended to provide practical guidance Basic Sanitation and Waste Management in on bio-safety techniques for use in laboratories at all Health-Care settings, WHO, 2005. levels. This revised edition covers risk assessment and safe use of recombinant DNA technology, and provides This document combines the need for sanitation and guidelines for the commissioning and certification of good health. It states that health-care facilities require laboratories. It also includes the latest regulations for access to safe water, basic sanitation, hygiene and safe the transport of infectious substances. disposal of wastes. Goal 4, target 5 of the Millennium 86. Management of Waste from Blood Transfusion Development Goals aims at reducing the death rate Activities, WHO, 2008. for children under five by two-thirds, while goal 5, target 6 aims at reducing maternal mortality by three- These WHO guidelines recommend best practices in quarters. the management of waste related to blood transfusion activities in the health-care system (blood transfusion 82. Healthy Hospitals: Controlling Pests without services, blood banks and hospitals). Harmful Pesticides, Kagan Owens, Beyond Pesticides, Beyond Pesticides and HCWH, 2003. 87. Municipal Waste (Management and Handling) Rules, 2000, GoI. This report is intended to inform hospital officials, the public and policy makers about: (i) a number of These are the national regulations for managing potential health hazards associated with the use of municipal waste and do not cover bio-medical waste. pesticides in hospitals; (ii) the findings of a national 88. National Environmental Auditing Manual for hospital pest management practices survey; and Hospitals, Lebanese Ministry of Environment and (iii) the availability of and need for safer pest UNDP. management practices and disclosure of hospital pesticide use to patients, visitors and staff. This manual has been prepared to assist health-care establishments with environmental auditing tools to 83. India: Review of the Effectiveness of Environmental provide a clear and detailed way of assessing the overall Assessments in World Bank–Assisted Projects, performance of audited facilities by pinpointing the Fiscal 1990–97, Environment Sector Management potential threats and suggesting a series of mitigation Unit South Asia Region, The World Bank, 1999. measures and recommendations. This report is published to communicate to the 89. Occupational Health and Safety, Susan Wilburn, development community the results of the World MPH, RN American Nurses Association, Seattle, Bank’s work by identifying areas requiring further Washington. Tool-kit for Managers: Volume II 93 This document highlights the occupational hazards This document describes the various regulatory in the health-care facility, the existing legislation, provisions for environmental health and sanitation in and recommendations for a safe and healthy work health-care facilities by the New York Department of environment. Environment and Natural Resources. 90. Practical Guidelines for Infection Control 93. The Environmentally Responsible Dental Office: in Health-Care Facilities, World Health A Guide to Proper Waste Management in Dental Organization, Regional Office for South-East Asia Offices, Northeast Natural Resource Center of the and Regional Office for Western Pacific, 2004. National Wildlife Federation and the Vermont State Dental Society, June 1999. These guidelines should help countries strengthen their infection control practices in health-care facilities. This This guide shows how dental offices can limit the would help prevent further spread of infection and deal amount of mercury and other chemicals entering effectively with new infectious diseases like SARS as well the environment by using common-sense pollution as other hospital-associated infections. The guidelines prevention and waste management techniques. It also address all aspects of an infection control program with provides tips for the proper handling of other harmful special attention on SARS. Since information on SARS chemicals present in dental offices. is still evolving, these guidelines will be updated as more 94. The Evolution of Environmental Assessment specific information becomes available. in the World Bank from "Approval" to Results, 91. Safer Water, Better Health: Costs, Benefits and World Bank 1999. Sustainability of Interventions to Protect and Promote Health, Prüss-Üstün A, Bos R, Gore F, This paper suggests that the quality of EA of a Bartram J. World Health Organization, 2008. project is necessary, but insufficient for successful EA. There are three main constraints to successful This document provides evidence and information EA in developing countries at present. First is lack of related to water and health. It compiles information political will; second, the institutional capacity; and on drinking water supply, sanitation, hygiene, and the third adequate financial resources. For a successful development and management of water resources. The EA, it is very important to conduct an EMP, and document further provides data that support policy provide funds and capacity before the project is decisions, namely the disease burden at stake, the accepted. effectiveness of interventions, their costs and impacts, and implications for financing. 95. World Alliance for Patient Safety, Global Patient Safety Challenge 2005 – 2006, Clean Care is Safer 92. Sanitation of Hospitals, Nursing Homes, Adult Care, WHO 2005. Care Homes, and Other Institutions, Chapter 18, Environmental Health, 18a Sanitation, This document describes the prevention of infection Department of Environment and Natural associated with health care, the Elements of the Global Resources, NC Department of Environment and Patient Safety Challenge and steps for implementing Natural Resources, February 2004. the Global Patient Safety Challenge. 94 Mainstreaming Environmental Management in the Health Care Sector XIX Website References 1. Ministry of Health and Family Welfare: http://www.mohfw.nic.in/ 2. Ministry of Environment and Forests: http://www.envfor.nic.in/ 3. Central Pollution Control Board: http://www.cpcb.nic.in/ 4. World Health Organization: http://www.who.int/en/ 5. World Health Organization – Health Care Waste Management site http://www.healthcarewaste.org/ http://www.who.int/immunization_safety/waste_management/en/ 6. World Bank: http://www.worldbank.org 7. PATH: http://www.path.org 8. Health Care Without Harm: http://www.noharm.org/ 9. Global Environment Facility: http://www.gefmedwaste.org/ 10. Toxics Link: http://www.toxicslink.org 11. Centre for Environment Education: http://www.ceeindia.org/cee/waste.html 12. Mercury-free Health Care; www.mercuryfreehealthcare.org 13. Centre for Diseases and Control and Prevention: www.cdc.gov 14. Occupational Safety and Health Administration: www.osha.gov