Case study of TATA Memorial Hospital

1. Disposal of Clinical Wastes:
Tata Memorial Hospital Experience
Ankit Kumar Surana

2. “No one was
ever really
taught.
Each has to
teach himself.”
Swami
Vivekananda
The Reality
• Ignorance
• Commercialization of science
• Apathy
The Concerns
• Occupational
• Public health
• Environmental

3. • The only documented risk of transmission of infections from waste to
healthcare workers is through sharps
• There is however a potential for transmission of several microbial
infections due to dumping of untreated wastes by healthcare facilities.
• Mixing of a small quantity of infectious waste with municipal garbage
converts the entire waste to “ infectious”
• Segregation of wastes at source followed by appropriate treatment is the
key to the success of a waste management strategy
The Science

4. Hospital waste
Hazardous Non-hazardous
Noninfectious Infectious
Kitchen Recyclables
Non-sharps
Patient
contaminated waste
Anatomical
Equipment
Specimens
Laboratory
waste
Non-plastics
Sharps: needles, scalpel
blades, scalp veins, glass
contaminated with blood
Radioactive
Cytotoxic drugs
Toxic Chemicals
Plastics
PVC, PE PET, PS contaminated cotton
waste, gauze, linen

5. The Social Issue: Ragpickers

6. The TMH Pathway
• Closure of the incinerator
• Awareness programs for all the staff
• Refashioning the storage area
• Street play
• Posters

7. Incinerator circa 1994

8. Appropriate placement
of Colour Coded Bins
Radioactive Waste
Segregation at source into defined categories
using a simplified system.
2. FOCUS ON SEGREGATION FIRST

9. Sharps Disposal
3. INSTITUTE A SHARPS
MANAGEMENT SYSTEM

10. Waste Audit
4. KEEP FOCUS ON REDUCTION

11. About Sharps:
The only documented transmission of infection from waste to HCWs is through
sharp injuries. Thus safe disposal of sharps is the first priority.
Sharp injuries:
•Before or during use (17%)
•After Use but before disposal (70%)
•During or after disposal (13%)
(Our Experience: Majority of sharp injuries occur due to improper disposal and
waste handlers are the victims)
Safe Disposal of Sharps:
Do not recap needles.
If essential learn the right
way to do so.
5. ENSURE WORKER SAFETY
THROUGH EDUCATION, TRAINING
AND PROPER PERSONAL
PROTECTIVE EQUIPMENT

12. Collection network.
.6. PROVIDE SECURE COLLECTION
AND TRANSPORTATION

13. Waste management Strategy:
1. Reduce Risks and Liabilities: This should be detailed through written
policies and continuing training and education of hospital staff.
2. Control Costs: Audit of current practices, search for waste minimization
practices is a continuing process.
3. Plan for Future: Look for alternative technologies, co-operative facilities
and means of diversification.
4. Commitment towards protecting Human Health and the
Environment
7. DEVELOP PLANS AND POLICIES

14. Infection
Awareness
Week
Street
Play

15. 9. DEVELOP THE INFRASTRUCTURE

16. 10. Evaluation of Technologies

17. Evaluation of Non Burn
Technologies for
Medical Waste
Treatment

18. 1. Demonstrated
Performance
Category Rating Weight Score
1.1 Stage of Development
1.2 Number of Operational Systems
1.3 Year of Successful Operations

19. 2. Technical &
Performance Criteria
Category Rating Weight Score
2.1 Process Capacity
2.2 Waste Exclusions or Limitations
2.3 Waste Size Limitations
2.4 Weight Change
2.5 Volume Change
2.6 Recognizability / Disfigurement
2.7 Decontamination
2.8 Performance Data
2.9 Process Complexity
2.10 Operator Training

20. 3. Vendor
Qualifications
Category Rating Weight Score
3.1 Number of Vendors
3.2 Vendor Resources
3.3 Vendor Diversity and Services

21. 4. Environmental &
Permitting Issues
Category Rating Weight Score
4.1 Air Emissions
4.2 Liquid Effluents
4.3 Treated Residues
4.4 Permit ability
4.5 Public Perception

22. 5. Occupational
Health & Safety
Issues
Category Rating Weight Score
5.1 Routine Exposures
5.2 Maintenance and Repair Exposures

23. 6. Facility: &
Infrastructural
Requirements
Category Rating Weight Score
6.1 Space Requirements
6.2 Construction Requirements
6.3 Utility Requirements
6.4 Space / Facility Requirements

24. 7. Economics
Category Rating Weight Score
7.1 Capital Costs
7.2 Annual Costs
7.3 Life-Cycle Costs
GRAND TOTAL SCORE

25. On September 10, 1999, well before the first dead line set by
the Ministry of Environment and Forest, 31 December 1999.
Inauguration of Tata Memorial Hospital waste treatment facility

26. Selection of Technology and
Implementation is not the setting sun
Evaluation is a continuous process

27. 2000 2001 2002 2003 2004 2005 2006 2007
Max. medical
waste collected in
a day
341 394 350 362 396 530 429 514
Average no. of
loads required/day
5 4 4 4 4 4 4 4
Average medical
waste treated in
kgs/day
217 224 176 241 250 289 253 277
Average medical
waste collected in
a month
5,498 5,643 5,266 5,917 6,284 7,225 6,369 6,959
Percentage down
time of the system
1.6 5.7 4.8 5.8 8.2 0 10 1.2
TMH Waste Audit Nov. 1999 to Dec. 2007
Total infectious waste treated – 614 tonnes.
 83,511 kg. in 2007.  Cost of treatment = Rs. 14.86 / kg.

28. 2008 2009
Max. medical
waste collected in
a day
447 505
Average no. of
loads required/day
4 4
Average medical
waste treated in
kgs/day
298 304
Average medical
waste collected in
a month
7,623 7,674
Percentage down
time of the system
0 0.33
TMH Infectious Waste Audit 2008 - 2009
Total infectious waste treated 2000-2009= 800 tonnes.
Cost of treatment = Rs. 14 / kg.

29. TMH Waste Management
Waste is Sterilized, Dehumidified, Shredded and
reduced in terms of Weight and Volume by 75%.
It is not recognizable as Medical Waste

30. Hazardous Waste

31. Environment News
Greenpeace
March 7th, 2001
KODAIKANAL, India -- Greenpeace
today accused Anglo-Dutch
multinational Unilever, owners of
Lipton Tea and Dove soap, of double
standards and shameful negligence
for allowing its Indian subsidiary,
Hindustan Lever, to dump several
tonnes of highly toxic mercury waste
in the densely populated tourist resort
of Kodaikanal and the surrounding
protected nature reserve of Pambar
Shola, in Tamilnadu, Southern India.
On 15 April, 2005, a 51 year-old
asbestos laden ship, Kong Fredrick IX
was on its way to Alang ship breaking
yard, Gujarat for scrapping.
The ship's new owners Jupiter Ship
Management, a Mumbai based
company, had renamed it to 'MV Riky'.
Connie Hedegaard, Denmark's
environment minister alerted the
Indian environment minister saying,
"I believe our interests are joint - and I
call on you to co-operate in this case
by denying the ship to be dismantled
in India - and refer the ship to return to
Denmark to be stripped of the
hazardous waste."

32. India’s significant economic growth and
rise in industrialization coupled by lax
government enforcement of anti-pollution
laws and regulations have had a
detrimental effect on India’s natural
environment.
Hazardous waste from industrial
processes, medical waste and India’s
thriving scrap recycling businesses
pollutes Indian air, soils and waterways.

33. India is a signatory to the three
conventions on hazardous chemicals and
waste:
The Basel Convention on the Control of
Trans-boundary Movement of Hazardous
Waste and their Disposal,
The Rotterdam Convention on the Prior
Informed Consent Procedure for Certain
Hazardous Chemicals and Pesticides in
International Trade and
The Stockholm Convention of Persistent
Organic Pollutants.

34. The Hazardous Substances Management Division (HSM)
of the Ministry of Environment and Forests (MoEF) has
the responsibility for promoting safe management and
use of hazardous substances, including hazardous waste.
The HSM has established three sets of rules:
The Hazardous Wastes (Management and Handling)
Rules (1989, amended in 2003),
The Bio-medial Wastes (Management and Handling)
Rules (1998/2000), and
The Batteries (Management and Handling) Rules (2001).

35. The HSM relies primarily on the
The Central Pollution Control Board (CPCB),
The State Pollution Control Boards (SPCBs) or State
Pollution Control Committees (SPCCs), and
The environmental departments in India’s 25 states
to implement, monitor and prosecute.

36. Approximately 5 million tonnes of hazardous waste is
produced annually in India.
According to a 2003 report, Indian industries in the
following five states had generated over 80% of the
country’s hazardous waste:
Andhra Pradesh,
Gujarat,
Karnataka,
Maharashtra and
Tamil Nadu.

37. Landfill Composting Incineration Recycling Transportation
Air Emission of CH4,
CO2; odours
Emission of
CH4, CO2;
odours
Emission of SO2, NOx,
HCl, HF, NMVOC,
CO, CO2 N2O, dioxins,
dibenzofurans, heavy
metals(Zn, Pb, Cu, As)
Emissions of
dust
Emissions of dust
NOx, SO2, release of
hazardous
substances from
accidental spills
Water Leaching of salts,
heavy metals,
biodegradable and
persistent organics
to groundwater
Deposition of
hazardous substances
on surface water
Waste water
discharges
Risk of surface water
and groundwater
contamination from
accidental spills
Soil Accumulation of
hazardous
substances in soil
Landfilling of slags,
fly ash and scrap
Landfilling of
final residues
Risk of soil
contamination from
accidental spills
European Commission focus on waste management
Pitfalls of the currently available technologies for managing wastes

38. Landfill Composting Incineration Recycling Transportation
Landscape Soil occupancy;
restriction on
other land uses
Soil occupancy;
restriction on
other land uses
Visual intrusion;
restriction on
other land uses
Visual
intrusion
Traffic
Ecosystems Contamination
and
accumulation of
toxic substances
in the food chain
Contamination
and
accumulation of
toxic substances
in the food chain
Contamination
and accumulation
of toxic
substances in the
food chain
Risk of
contamination
from accidental
spills
Urban areas Exposure to
hazardous
substances
Exposure to
hazardous
substances
Noise Risk of exposure
to hazardous
substances from
accidental spills;
traffic
European Commission focus on waste management
Pitfalls of the currently available technologies for managing wastes

39. E-waste
How green is your Apple?
Aug 25th 2006
From The Economist print edition

40. God proposes,
man disposes Waste and taste
Dec 11th 2006
From Economist.com
The rubbish tip as cultural artefact
FRESH Kills landfill in New York, until
recently the biggest rubbish tip on earth,
was said to be one of the very few man-
made objects visible from space, along
with the Great Wall of China.

41. LIST OF WASTE SUBSTANCES WITH
CONCENTRATION LIMITS
Class A
Concentration limit: 50 mg/kg
A1 Antimony and antimony compounds
A2 Arsenic and arsenic compounds
A3 beryllium and cadmium compounds
A4 Cadmium and beryllium compounds
A5 Chromium (VI) compounds
A6 Mercury and mercury compounds
A7 Selenium and selenium compounds
A8 Tellurium and tellurium compounds
A9 Thallium and thallium compounds
A10 Inorganic cyanide compounds (cyanides)
A11 Metal carbonyls
A12 Napthalene
A13 Anthracene
A14 Phenanthrene
A15 Chrysene, benzo(a) anthracene, fluoranthene, benzo(a) pyrene,
benzo(K)fluoranthene, indeno(1, 2, 3-ed) pyrene and benzo(ghi)perylene
A16 Halogenated fused aromatic rings, e.g. polychlorobiphenyls plus derivatives
A17 Halogenated aromatic compounds
A18 Benzene
A19 Dieldrin, aldrin, and endrin
A20 Organotin compounds
Ministry of Environment &
Forests:
Hazardous Wastes
(Management and Handling)
Amendment Rules, 2002

42. LIST OF WASTE SUBSTANCES WITH
CONCENTRATION LIMITS
Ministry of Environment &
Forests:
Hazardous Wastes
(Management and Handling)
Amendment Rules, 2002
Class B
Concentration limit: 5,000 mg/kg
B1 Chromium (III) compounds
B2 Cobalt compounds
B3 Copper compounds
B4 Lead and lead compounds
B5 Molybdenum compounds
B6 Nickel compounds
B7 Tin compounds
B8 Vanadium compounds
B9 Tungsten compounds
B10 Silver compounds
B11 Organic halogen compounds
B12 Organic phosphorus compounds
B13 Organic peroxides
B14 Organic nitro-and nitroso-compounds
B15 Organic azo-and azo-oxy compounds
B16 Nitriles
B17 Amines
B18 (Iso-and thio-) cyanates
B19 Phenol and phenolic compounds
B20 Merceptans
B21 Asbestos
B22 Drilling, cutting, grinding and rolling oil or emulsions thereof
B23 Halogen-silanes
B24 Hydrazine(s)
B25 Fluorine
B26 Chlorine
B27 Bromine
B28 White phosphorus
B29 Ferro-silicon and alloys
B30 Manganese-silicon
B31 Halogen-containing substances which produce acidic vapours on contact with damp air or water, e.g. silicon tetrachloride,

43. LIST OF WASTE SUBSTANCES WITH
CONCENTRATION LIMITS
Ministry of Environment &
Forests:
Hazardous Wastes
(Management and Handling)
Amendment Rules, 2002
Class C
Concentration limit: 20,000 mg/kg
C1 Ammonia and ammonium compounds
C2 Inorganic peroxides
C3 Barium compounds, except barium sulphate
C4 Fluorine compounds
C5 Phosphorus compounds, except the phosphates of aluminum, calcium and iron
C6 Bromates, (hypo)bromites
C7 Chlorates, (hypo)chlorites
C8 Aromatic compounds
C9 Organic silicon compounds
C10 Organic sulphur compounds
C11 Iodates
C12 Nitrates, nitrites
C13 Sulphides
C14 Zinc compounds
C15 Salts of per-acids
C16 Acid halides, acid amides
C17 Acid anhydrides

44. LIST OF WASTE SUBSTANCES WITH
CONCENTRATION LIMITS
Ministry of Environment &
Forests:
Hazardous Wastes
(Management and Handling)
Amendment Rules, 2002
Class D
Concentration limit: 50,000 mg/kg
D1 Sulphur
D2 Inorganic acids
D3 Metal bisulphates
D4 Oxides and hydroxides except those of: hydrogen, carbon, silicon,
iron, aluminum, titanium, manganese, magnesium, calcium
D5 Aliphatic and napthenic hydrocarbons
D6 Organic oxygen compounds
D7 Organic nitrogen compounds
D8 Nitrides
D9 Hydrides

45. LIST OF WASTE SUBSTANCES WITH
CONCENTRATION LIMITS
Ministry of Environment &
Forests:
Hazardous Wastes
(Management and Handling)
Amendment Rules, 2002Class E
Regardless of concentration limit
E.1 Highly flammable substances
E.2 Substances which generate dangerous quantities of
highly flammbale gases on contact with water or damp air.

46. LIST OF PROCESSES GENERATING HAZARDOUS
WASTES
Ministry of Environment & Forests
Hazardous Wastes (Management and Handling) Amendment Rules, 2003
1 Petrochemical processes and pyrolytic operations
2 Drilling operation for oil and gas production
3 Cleaning, emptying and maintenance of petroleum oil storage tanks including ships
4 Petroleum refining/re-refining of used oil/recycling of waste oil
5
Industrial operations using mineral/synthetic oil as lubricant in hydraulic systems or
other applications
6 Secondary production and/or use of zinc
7
Primary production of zinc/lead/copper and other non-ferrous metals except
aluminium
8 Secondary production of copper
9 Secondary production of lead
10 Production and/or use of cadmium and arsenic and their compounds
11 Production of primary and secondary aluminium

47. LIST OF PROCESSES GENERATING HAZARDOUS
WASTES
Ministry of Environment & Forests
Hazardous Wastes (Management and Handling) Amendment Rules, 2003
12
Metal surface treatment, such as etching, staining, polishing, galvanising, cleaning,
degreasing, plating, etc.
13
Production of iron and steel including other ferrous alloys (electric furnaces; steel
rolling and finishing mills; Coke oven and by product plant)
14 Hardening of steel
15 Production of asbestos or asbestos-containing materials
16 Production of caustic soda and chlorine
17 Production of acids
18 Production of nitrogenous and complex fertilizers
19 Production of phenol
20 Production and/or industrial use of solvents
21
Production and/or industrial use of paints, pigments, lacquers, varnishes, plastics and
inks
22 Production of plastic raw materials

48. LIST OF PROCESSES GENERATING HAZARDOUS
WASTES
Ministry of Environment & Forests
Hazardous Wastes (Management and Handling) Amendment Rules, 2003
23 Production and/or industrial use of glues, cements, adhesive and resins
24 Production of canvas and textiles
25 Industrial production and formulation of wood preservatives
26 Production or industrial use of synthetic dyes, dye-intermediates and pigments
27 Production or industrial use of materials made with organo-silicone compounds
28 Production/formulation of drugs/ pharmaceuticals
29 Production, use and formulation of pesticides including stock-piles
30 Leather tanneries
31 Electronic Industry
32 Pulp & Paper Industry
33 Disposal of barrels / containers used for handling of hazardous wastes / chemicals
34 Purification processes for air and water
35 Purification process for organic compounds/solvents
Waste treatment processes, e.g. incineration, distillation, separation and concentration

49. REPORT ON CLINICAL WASTE AUDIT 2005
Infectious waste treated from Jan-Dec 2005 86,704 Kilograms
Average waste treated per month 7,225 Kilograms
Weight of sharps treated in 2005 2,917 Kilograms
Average weight of sharps treated per month 243 Kilograms
Blood & blood products 300 liters
Liquid Wastes:
Total effluent per month 164 lakh litres
Laundry effluent per month 3 lakh litres
X’ray developer per month 140 litres
Hazardous liquids consumed in labs per month 588 litres
Hazardous chemicals as solids weight per month 260 grams
Dilution factor of hazardous liquids 27,333.

50. Hazardous liquid
waste / month:
Sr. No Chemicals / Reagents Lits.
1 10% Formalin 100
2 Xylene 190.1
3 Basic fuchsin 1.17
4 Haematoxylin stain 1.0
5 Nitric Acid 50.5
6 Anhydrous Aluminum
Chloride
.005
7 Hydrochloric acid .800
8 Diamino benzidine 20.0
9 Hydrogen peroxide 53.202
10 Glacial acetic acid 5.225
11 Gluteraldehyde 150.500
12 Ethidium bromide .001
13 Propane / Butane 2.500
14 WD40 (Petroleum distillate) 2.00
15 Benzoin tincture 10.00
16 Lugol’s Iodine 0.42
17 Phenol (carbolic acid) 1.000
18 Ammonia solution .050
19 Lactic acid .045
20 Sulfuric acid .100
Total 588.19

51. Hazardous solid waste / month:
Sr. No Chemicals / Reagents Weight (Grams)
1 Benzidine dihydrochloride 0.5
2 Naphthol phosphate .060
3 Pararosaline hydrochloride 1.0
4 Sodium-fluoride .200
5 Potassium dihydrogen phosphate 8.500
6 Dipotassium hydrogen phosphate 8.500
7 Benzidine G.R. 1.0
8 Zine sulphate 16.5
9 Barium chloride 13.00
10 Phenol crystals 40.00
11 Naphthylamine 16.50
12 Naphthol 16.50
13 Sodium-polyanethol sulphonat 45.00
14 Sodium hydroxide pellet 45.00
15 Sulfonilic acid 45.00
16 Trichloroacetic acid 2.1
Total 259.36

52. In Conclusion: Key Issues
• Awareness and education
• Reporting systems & documentation
• Segregation of identified clinical infectious wastes at
source
• Timely treatment by non-polluting technologies on-site or
off-site
• Waste audit
• Waste monitoring systems
• Elevation of safety standards by all healthcare facilities
• All HCWs must have “hygiene in their genes”.

53. “ Men occasionally stumble over the
truth but most of them pick
themselves up and hurry off as if
nothing has happened.”
- Sir Winston Churchill.

54. Thank You