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Cover page of the Journal of Health Sciences


 
 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 12  |  Issue : 3  |  Page : 202-210

Bio-medical waste disposal in India: From paper to practice, what has been effected


1 Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Member of Institutional Bio Waste Management Committee, ICMR-National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
2 Department of Epidemiology, SRM School of Public Health, SRM University, Kancheepuram, Tamil Nadu, India
3 Department of Medicine, Madurai Medical College, Master Trainee in Bio Medical Waste Management, Madurai, Tamil Nadu, India
4 Department of Clinical Research, Chairperson of Institutional Bio Waste Management Committee, ICMR-National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India

Date of Web Publication15-Oct-2019

Correspondence Address:
Dr. S Ramesh Kumar
ICMR-National Institute for Research in Tuberculosis, Madurai Unit, Ward 62, Government Rajaji Hospital, Madurai - 625 020, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_112_19

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  Abstract 


Bio-medical waste (BMW) disposal is a very important but challenging task. Health-care waste contains potentially harmful microorganisms, which can infect hospital patients, health workers, and the general public. Exposure to hazardous health-care waste can result in disease or injury. The Government of India has been laying down rules, namely, Bio-Medical Waste (Management and Handling) Rules, in 1998, The draft of Bio-Medical Waste (Management and Handling Rules 2011,), and recently Bio-Medical Waste Management Rules, 2016. Evidence from different parts of India show that the knowledge on BMW disposal among health-care personnel is low, and the practice of the same is not satisfactory. Strict implementation of the rules laid down is necessary and is the need of the hour.

Keywords: Bio medical waste disposal, bio-medical waste management rules, 2016, waste disposal practices


How to cite this article:
Kumar S R, Abinaya N V, Venkatesan A, Natrajan M. Bio-medical waste disposal in India: From paper to practice, what has been effected. Indian J Health Sci Biomed Res 2019;12:202-10

How to cite this URL:
Kumar S R, Abinaya N V, Venkatesan A, Natrajan M. Bio-medical waste disposal in India: From paper to practice, what has been effected. Indian J Health Sci Biomed Res [serial online] 2019 [cited 2019 Nov 19];12:202-10. Available from: http://www.ijournalhs.org/text.asp?2019/12/3/202/269192




  Introduction Top


Appropriate biomedical waste (BMW) disposal is very important, from public health point of view, and implementing it is really a challenging task. The World Health Organization (WHO) reports that health-care wastes are the ones generated by health-care activities including a broad range of materials, from used needles and syringes to soiled dressings, body parts, diagnostic samples, blood, chemicals, pharmaceuticals, medical devices, and radioactive materials. As per Government of India gazette, “bio-medical waste” is defined as any waste, which is generated during the diagnosis, treatment or immunisation of human beings or animals or research activities pertaining thereto or in the production or testing of biological or in health camps. A person who experiences one needlestick injury from a needle used on an infected source patient has risks of 30%, 1.8%, and 0.3%, respectively, becoming infected with hepatitis B virus, hepatitis C virus, and HIV.[1] In addition, antibiotic-resistant Escherichia coli have been shown to survive in an activated sludge plant, although there does not seem to be significant transfer of this organism under normal conditions of wastewater disposal and treatment.[2]

BMWs are generated from hospitals, nursing homes, clinics, dispensaries, veterinary institutions, animal houses, pathological laboratories, blood banks, AYUSH hospitals, clinical establishments, research or educational institutions, health camps, medical or surgical camps, vaccination camps, blood donation camps, first aid rooms of schools, forensic laboratories, and research laboratories. Although of the total amount of waste generated by health-care activities, about 85% in general, is nonhazardous waste, the remaining 15% is considered hazardous material that may be infectious, toxic, or radioactive,[1] and hence, it is important for a proper BMW disposal. Health-care waste contains potentially harmful microorganisms, which can infect hospital patients, health workers, and the general public. In this article, we review the rules of BMW disposal laid down by the Government of India from time to time and the published literature evidence related to the practice of BMW disposal across the states of India, and also where we feel the gap needs to be filled.


  Potential Hazards Due to Biomedical Waste Top


Exposure to hazardous health-care waste can result in disease or injury. The hazardous nature of health-care waste may be due to one or more of the following: infectious agents; genotoxic, toxic, or hazardous chemicals or pharmaceuticals; radioactive materials; and sharps.[2] Pathogens in infectious waste may enter the human body by a number of routes, i.e. through a puncture, abrasion, or cut in the skin; through the mucous membranes; and through inhalation and ingestion. Some examples of infections caused by exposure to health-care wastes are gastroenteric infections including Salmonella, Shigella, Vibrio cholerae; helminths infections; respiratory infections including Mycobacterium tuberculosis and Streptococcus pneumoniae; ocular infections; genital infections; skin infections; anthrax; meningitis; acquired immunodeficiency syndrome (AIDS); hemorrhagic fevers; septicemia; bacteremia; candidemia; and viral hepatitis A, B, and C.[2] The transmission vehicles include feces, vomit, inhaled secretions, saliva, eye secretions, genital secretions, pus, skin secretions, cerebrospinal fluid, blood, and sexual secretions.


  What the Government of India Rules Say on Biomedical Waste Disposal Top


Bio-Medical Waste (Management and Handling) Rules, 1998,[3] was published vide notification number S.O. 630 (E) dated July 20, 1998, by the Government of India in the Ministry of Environment and Forests, which provided a regulatory framework for the management of BMWs generated in the country. It laid down that BMWs should be collected by “the occupier” that is the institution generating BMWs (health-care facilities) in accordance with standards laid down in the rules, and also described “the authorized person” or the operator authorized to receive, store, transport, treat, and dispose the BMWs in accordance with the prescribed standards mentioned in the rule. However, it had laid down that the occupier requisite for the prescribed standards was only for those providing services for more than 1000 patients per month. It also laid down that every occupier/operator should submit an annual report to the Central Pollution Control Board (CPCB), and also when an accident occurs in any institution or facility, it has to be reported to the authority. Categories of BMW and color coding of waste categories were also spelt out.

Later, “The draft Bio-Medical Waste (Management and Handling Rules 2011”[4] notified by the Ministry of Environment and Forests stipulated that every occupier irrespective of the number of outpatients serviced had the applicability of the rules. It also listed out the duties of the operator and also clarified and sorted out the issue of overlapping with regard to color coding and segregation of waste mentioned in the earlier rules.

Recently, the Government of India has come out with expanded rules, detailing the responsibilities of different disciplines involved in the BMW disposal. The Ministry of Environment, Forest and Climate Change, Government of India, published in the Gazette of India, Extraordinary, Part II, Section 3, Sub-section (i) Government of India via notification of the rules namely the Bio-Medical Waste Management Rules, 2016[5] which has listed out the duties of occupiers, operators, and authorities and a detailed guidance on the treatment and disposal of BMW. The prescribed authorities for the implementation of the provisions of these rules were named to be the state pollution control boards in respect of states and pollution control committees in respect of union territories, and the rule also describes the procedure for authorization for the occupier and operator. The rule also adds more on the constitution and responsibilities of the advisory committee to be formed in each state or union territory and also mentions the monitoring of implementation of the rules in health-care facilities. While the occupier has to take all necessary steps to ensure that BMW is handled without any adverse effect to human health and the environment, the operator has to take all necessary steps to ensure that the BMW is collected from the occupier in a timely manner and shall display the details of authorization, treatment, annual report, etc., on operators website. Both operators and occupiers have to train their staff, maintain appropriate records, and report major related accidents.

BMW categories and their segregation, collection, treatment, processing, and disposal options are summarized in [Table 1], which shows that the categories reduced to four, with their color coding being yellow, red, white (translucent), and blue. The standards of treatment and disposal have been detailed and also the prescribed authorities and their corresponding duties are tabled. The new rules extend the range of application to include medical, blood, and surgical camps and also introduce the bar coding system, pretreatment of the laboratory waste, microbiological waste, blood samples, and blood bags through disinfection or sterilization onsite in the manner as prescribed by the WHO or National AIDS Control Organisation guidelines prior to being sent to the common BMW treatment facility for final disposal.
Table 1: Biomedical waste categories and their segregation, collection, treatment, processing, and disposal options as laid down under Bio-Medical Waste Management Rules, 2016, Government of India

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The rules also specify the duties of the related union ministries, state governments, central and state pollution control boards, and the local authorities. While the Ministry of Environment, Forest and Climate Change, Government of India, is to make policies, constitute monitoring committees, and develop manuals for trainers, the Central or State Ministry of Health and Family Welfare is to monitor, refuse, or cancel the license for health-care facilities and grant license with the condition to obtain authorization from the prescribed authority for BMW management (BMWM). A publication of a list of registered health-care facilities with regard to BMW generation, treatment, and disposal and also constitution of expert committees at national or state level for overall review has to be done. While the CPCB has to prepare guidelines on BMWM and randomly inspect or monitor the health-care facilities, the state pollution control boards or pollution control committees are to take action against health-care facilities or common BMW treatment facilities for violation of the rules. The state government or union territory government has to ensure implementation of the rule and also constitute state- or district-level advisory committees under the district magistrate or additional district magistrate to oversee the BMWM in the districts and has to allocate adequate funds to government health-care facilities for BMWM. The local authorities municipalities or corporations, urban local bodies, and gram panchayats have to provide or allocate suitable land for the development of common BMW treatment facilities in their respective jurisdictions. Bio-Medical Waste Management (Amendment) Rules, 2018, were published with minor amendments, rephrasing, adding, and substituting certain areas of the 2016 rules and also publishing the formats for report submission.[6]


  Studies on the Practice of Biomedical Waste Disposal in India Top


We reviewed the literature on the activities of the BMW disposal being done across India (including Pubmed, Indmed, and Google Scholar search) and tried to include all articles on biomedical disposal practices in India. A general review of the situation was done that included the articles from the past 15 years to develop this narrative review. We found that the practices and knowledge on BMW disposal among the personnel involved in the work were not up to expectations. There has been literature evidence from different parts of India, mostly showing that the knowledge on BMW disposal among the health-care personnel is low and the practice of the same is not satisfactory. [Table 2] summarizes the findings of the different studies on BMW disposal done across India. Various publications show that the knowledge among the doctors, nurses, and other health-care workers was low, and the appropriate practices to be followed as laid down in the rules were not followed majority of the times. The International Clinical Epidemiology Network Program Evaluation Network study conducted in 25 districts spread over twenty states of India including urban and rural areas showed that around 82% of primary, 60% of secondary, and 54% of tertiary care health facilities had no credible BMWM system in place.[20] A multivariate analysis done in the study indicated that charts at the point of waste generation, availability of designated person, appropriate containers and bags, availability of functional needle destroyers, availability of personal protective gears, segregation of waste at the point of generation, and log book maintenance were independently (odds ratio between 1.2 and 1.55; P ≤ 0.03) associated with better BMWM system in the health-care facilities. Hence, overall, we feel that the practices on biowaste disposal are not up to the mark by literature evidence.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33]
Table 2: Summary of the findings of the different studies on biowaste disposal done in India

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  What Action is Needed Now? Top


With a detailed description of what and how the BMW disposal has to be done being legally available in India, there is a requirement of full-fledged implementation of the rules, so as to get the required benefits of preventing the illnesses due to the improper disposal. We put forth some suggestions regarding necessary actions that are required as of now in India.

First, wide dissemination of the procedures portrayed in the rules as an urgent measure has to be undertaken. Unless the personnel involved in BMW disposal know the recent updated rules, implementing them is not possible. Educative information on the update, with some pictorial presentations, needs to be circulated and ensured that it reaches the required persons. Physicians could be informed through their respective associations such as the Indian Medical Association, the Associations of Surgeons of India, and the Indian Association of Paediatricians. Simultaneously ensuring that the “Operators” are also updated on the rules is also necessary. When the authorities make monitoring visits to check the “operators,” the knowledge of their staff should be assessed at periodic intervals. Second, training the staff working on the BMW disposal at regular intervals is of utmost necessity, which would improvise the BMW disposal practices drastically.[21],[22] Certifying the staff members, of hospitals, other institutions, and the agencies collecting and disposing the waste, after training them and ensuring that only certified staff are given the job would improve the quality of the work. Third, it is important to ensure that charts on BMW disposal are in place at the point of waste generation, to ensure the availability of designated persons, to ensure the availability of appropriate containers and bags and other materials, to ensure segregation of waste at the point of generation, and to ensure log book maintenance, all of which would improve the practices of BMW disposal as shown by published evidence.[20] Fourth, as suggested by the thumb rule “avoiding monopoly prevents market failure,” it is better to encourage multiple players in the “operators” side, so as to induce a competition among the operators, thereby improving the service of the operations. Fifth, strict enforcement of the laws by the authorities concerned is much more important; not just stressing the hospital authorities, but also monitoring and supervising the activities of the “operators” as laid down in the 2016 rules is an important requirement. Some recommendations specific to the agencies: the central and state governments should engage in operational research activities to evaluate the implementation challenges. District-level committees should concentrate on strong implementation of the existing policies. Hospital administrators should impart regular training activities for the staff, and the pollution control boards should conduct productive and regular monitoring.

To conclude, the Government of India rules on BMW disposal are in place, but the practices currently are not up to the mark. Spreading awareness of the rules and their strict implementation is necessary and it is the need of the hour.

Financial support and sponsorship

Institutional support has been provided for this study.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO Factsheet on Health Care Waste. Available from: http://www.who.int/mediacentre/factsheets/fs253/en/. [Last accessed on 2018 Feb 08].  Back to cited text no. 1
    
2.
Health Impacts of Health Care Waste. Available from: http://www.who.int/water_sanitation_health/medicalwaste/020to030.pdf. [Last accessed on 2018 Feb 08].  Back to cited text no. 2
    
3.
Bio-Medical Waste (Management and Handling) Rules, 1998, Government of India. Available from: http://www.moef.nic.in/legis/hsm/biomed.html. [Last accessed on 2018 Feb 08].  Back to cited text no. 3
    
4.
Draft Bio-Medical Waste (Management and Handling) Rules 2011, Government of India. Available from: http://www.moef.nic.in/downloads/public-information/salient-features-draft-bmwmh.pdf. [Last accessed on 2018 Feb 08].  Back to cited text no. 4
    
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Bio-Medical Waste Management Rules, 2016. Government of India. Available from: http://envfor.nic.in/content/gsr-343e-28-03-2016-bio-medical-waste-management-rules2016 [Last accessed on 2018 Feb 08].  Back to cited text no. 5
    
6.
Bio-Medical Waste Management (Amendment) Rules, 2018. GSR. 234 (E). Ministry of Environment, Forest and Climate Change, Government of India. Available from: http://www.indiaenvironmentportal.org.in/files/file/Bio%20medical%20waste%20management%20.(amendment) 183847.pdf. [Last accessed on 2019 Jun 28].  Back to cited text no. 6
    
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Chethana T, Thapsey H, Gautham MS, Sreekantaiah P, Suryanarayana SP. Situation analysis and issues in management of biomedical waste in select small health care facilities in a ward under Bruhat Bengaluru Mahanagara Palike, Bangalore, India. J Community Health 2014;39:310-5.  Back to cited text no. 7
    
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Kishore J, Agarwal R, Kohli C, Sharma PK, Kamat N, Tyagi S. Status of biomedical waste management in nursing homes of Delhi, India. J Clin Diagn Res 2014;8:56-8.  Back to cited text no. 8
    
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Bhagawati G, Nandwani S, Singhal S. Awareness and practices regarding bio-medical waste management among health care workers in a tertiary care hospital in Delhi. Indian J Med Microbiol 2015;33:580-2.  Back to cited text no. 9
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Nandwani S. Study of biomedical waste management practices in a private hospital and evaluation of the benefits after implementing remedial measures for the same. J Commun Dis 2010;42:39-44.  Back to cited text no. 10
    
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Pullishery F, Panchmal GS, Siddique S, Anna A. Awareness, knowledge and practices on bio-medical waste management among health care professionals in Mangalore – A cross sectional study. Int Arch Integr Med 2016;3:29-35.  Back to cited text no. 11
    
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Acharya A, Gokhale VA, Joshi D. Impact of biomedical waste on city environment: Case study of Pune, India. IOSR J Appl Chem 2014;6:21-7.  Back to cited text no. 12
    
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Archisman M, Manoj KG, Siddharudha S, Mishra CP, Mohapatra SC. Biomedical waste management practices of doctors: An online snapshot. Natl J Community Med 2012;3:227-31.  Back to cited text no. 14
    
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Pandit NB, Mehta HK, Kartha GP, Choudhary SK. Management of bio-medical waste: Awareness and practices in a district of Gujarat. Indian J Public Health 2005;49:245-7.  Back to cited text no. 17
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INCLEN Program Evaluation Network (IPEN) Study Group, New Delhi, India. Bio-medical waste management: Situational analysis and predictors of performances in 25 districts across 20 Indian states. Indian J Med Res 2014;139:141-53.  Back to cited text no. 20
    
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Pawan P, Kapil G, Sartaj A, Rahul B, Gurmeet K. Impact of training on awareness of bio-medical waste management among paramedical workers of a tertiary care hospital, Meerut. Int J Contemp Med 2014;2:128 32.  Back to cited text no. 21
    
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Sharma A, Sharma V, Sharma S, Singh P. Awareness of biomedical waste management among health care personnel in Jaipur, India. Oral Health Dent Manag 2013;12:32-40.  Back to cited text no. 28
    
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