Running head: BIOMEDICAL WASTE 1

Student Name: Nicie Velancia Pinheiro

ID Number: S18581

Unit Code: GDN 3987

Title of Assignment: Biomedical Waste Management Policy in India

Name of Unit Coordinator: Fiona D’costa Box

Due Date: 1st April 2019

Word Count: 3215

BIOMEDICAL WASTE 2

Biomedical Waste Management Policy in India

Any liquid or solid waste inclusive of any containers or products produced in the course

of treatment, diagnosis, immunization and research on animals and humans is termed as Bio-

medical waste which can be classified as hazardous or non-hazardous (Rao, Dhakshaini,

Kurthukoti & Doddawad, 2018; Pullishery, Panchmal, Siddique & Abraham, 2016). The

hazardous biomedical waste which comprises of chemicals, body parts, soiled dressings, etc. is

highly infectious and can result in contamination of environment and hence ill health effects on

the public (Njue, Cheboi & Oiye, 2015; Pullishery, Panchmal, Siddique & Abraham, 2016).

Today, a major issue which is faced by many countries is healthcare waste and its management

(Njue, Cheboi & Oiye, 2015). Biomedical or healthcare waste management is an essential

element of hygienic practice and control of infection in hospital settings (Amin, Sochaliya &

Kartha, 2018).

This highlights the significant role of nursing practices as healthcare providers. It is the

duty of all healthcare personnel, especially nurses to ensure that health care associated infections

are prevented. They can do so by employing the best infection control processes, biomedical

waste management being one of them (Gaikwad et al., 2018). Nurses have to be trained via

practical simulating sessions so as to equip them with proper skills and know how required for

effectively controlling management of waste. Then they would be able to implement what they

have learnt and thus minimize health risks to others and themselves (Gaikwad et al., 2018).

After considering the inherent dangers and the far reaching impact of medical waste,

governments of several countries laid down a clear cut policy for healthcare waste management

(Mahajan & Chaudhary, 2018). In 1998, Bio-Medical Waste Management (BMWM) rules were

implemented in India. However those rules were changed and amended four times. Today, the
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Bio-Medical Waste Management rules of 2016 by the ‘Ministry of Environment, Forest and

Climate change’ are in existence (Datta, Mohi & Chander, 2018). It is not enough only to

establish policies, but it is of prime importance to generate knowledge and encourage the use of

BMWM guidelines amongst health care professionals (Rajpal, Garg, Bano & Singh, 2018;

Mahajan & Chaudhary, 2018; Rao, Dhakshaini, Kurthukoti & Doddawad, 2018).

The process of waste disposal

Biomedical waste management is a long and complicated process (Joshi et al., 2015).

Handling, identifying, segregating, storing, transporting, and finally disposing are the stages to

carry out Bio-Medical Waste Management safely and scientifically (Njue, Cheboi & Oiye,

2015). Several steps of the process are mostly engineering tasks which can be done by

machines. However, the preliminary steps of handling, segregating and storage of waste are the

nurse’s responsibility (Joshi et al., 2015). Numerous problems arise during the execution of this

chore. Separating each category of waste as hazardous/infectious and non-hazardous is

necessary. The waste has to be removed and disposed in time and in a correct manner.

Haphazard and careless handling of waste can lead to an increased risk of infection. Therefore,

the seriousness of the issue of biomedical waste management has led to the emergence of a

streamlined step-by-step waste management system, right from waste generation, to its disposal.

The outcome is a reliable method of controlling infections (Joshi et al., 2015). Staff can achieve

success, if they are dedicated to overcome the challenges they experience in following and

adhering to the guidelines of management of waste (Njue, Cheboi & Oiye, 2015).

In developed countries, the menace of healthcare waste has been eliminated completely

due to legal actions being taken against offenders of law like hospitals. Together with the rules,

nursing practices are also monitored and improved on continuously (Joshi et al., 2015). In India,
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the new rules of BMWM in 2016 made classification and authorization of the waste easier. This,

enhanced segregation, moving and disposal of waste which would help in reducing pollution of

the environment (Datta, Mohi & Chander, 2018). Color coding of bags or containers for

segregation is reduced to four colors which are red, blue, yellow and white. This reduces the

chances of confusion when health care workers segregate biomedical waste at source (Datta,

Mohi & Chander, 2018).

Segregation with the use of color code

Different colored bags are used for segregation and disposal of biomedical waste (Capoor

& Tapas Bhowmik, 2017). These bags must be waterproof and strong enough not to tear apart.

The bags should also have the words ‘biomedical waste’ and the international symbol for

biohazard imprinted on them (Saber, Howlett, Waterman & Tantillo, 2018). Separation is done

according to their treatment options and the type of waste (Datta, Mohi & Chander, 2018). All

the bags are filled up to 3/4th level, then labelled and carefully tied (Capoor & Tapas Bhowmik,

2017).

A red bag is used for all plastic materials which are recyclable (Capoor & Tapas

Bhowmik, 2017). As backed by the World Health Organization (WHO), the need of the hour is

to make environmentally healthy waste management procedures and strategies while providing

safe patient care (Saber, Howlett, Waterman & Tantillo, 2018). Therefore, some healthcare

establishments have partnered with environmental consultants or organizations to encourage

reduction of the waste by collaboratively designing action plans to deliver environmentally fit

healthcare systems (Saber, Howlett, Waterman & Tantillo, 2018). Plastic medical items like

gloves, intravenous bottles, urobags and others which are segregated in red bags are cut or

nicked right after usage with a scissor kept especially for the purpose. This would prevent reuse
BIOMEDICAL WASTE 5

of the items. Then, these are given to the common biomedical waste treatment facility for

recycling (Capoor & Tapas Bhowmik, 2017). Sharps too have to be cut into pieces by a

destroyer. Good practices for disposal of sharps include the use of an electric needle destroyer

immediately after use, discarding sharps in puncture and leak proof transparent container

containing 0.5% chlorine solution, followed by transportation for final disposal by incineration.

If the encapsulation technique is used, then the sharps can be recycled into different things like

benches, bricks and hangers (Capoor & Tapas Bhowmik, 2017).

A yellow bag is used for antibiotics and other drugs which are labelled as ‘biohazard’.

For intravenous solutions, vitamins, eye drops, cough syrups, amino acids, salts and other

liquids, the method to be used is to dilute in water and throw in a sewer (Capoor & Tapas

Bhowmik, 2017). Cytotoxic drugs which have expired have to be returned to the supplier or the

pharmaceutical company manufacturing them. They have to be incinerated at more than

1200 degree Celsius. On the other hand, all the cytotoxic waste together with all the material

which has been contaminated by cytotoxic drugs has to be placed in a yellow container which

has not been chlorinated. The container must then be sealed and labelled wherein ‘cytotoxic’ is

written (Capoor & Tapas Bhowmik, 2017). Infectious waste like human or animal anatomical

waste, linen or mattresses or dressings soiled with body fluids, gauze, cotton, bandages and any

chemical waste is placed in a yellow bag. According to guidelines of WHO, waste which is

infectious has to be first treated by autoclaving in autoclave safe containers or plastic bags. Then

it must be dispatched in yellow bags for incineration or plasma pyrolysis or deep burial (Capoor

& Tapas Bhowmik, 2017; Datta, Mohi & Chander, 2018). A Blue bag is used for glassware and

any metallic body implants which are disinfected by either microwaving, hydroclaving or

autoclaving which are then sent for recycling (Capoor & Tapas Bhowmik, 2017)
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Biomedical wastes bags are to be labelled with certain details like the type of waste, the

place it was generated and the date of generation. The biomedical waste is sent via a specific

route at a particular reliable time. It is conveyed on trolleys which are covered and leakproof.

The trolleys are colour coded. They are stored in a common waste collection location. Later

they are taken for last treatment and disposal within forty eight hours. It is imperative for the

personnel involved in transportation to be equipped with protective gear (Capoor & Tapas

Bhowmik, 2017). WHO guidelines mandate a weekly cleaning of the central storage site with a

hard non porous floor. The site must have sufficient water supply, exhaust and a proper drainage

system. There has to be enough space to store such waste separately from the general waste

(Capoor & Tapas Bhowmik, 2017).

Issues of BMWM Policy among nurses and other health care workers

Nurses are an integral component that serves as the hands and the heart of the healthcare

system. It is therefore crucial that they are competent enough in waste management practices

which are one of the major aspects of infection control in the hospital and in the environment at

large (Gaikwad et al., 2018). There are short certification courses and short lectures conducted

in some hospitals for nurses. These are not mandatory but a personal choice which does not

guarantee training of nurses as a whole. Hence emphasis on the topic of BMWM in the nursing

education curriculum would be beneficial (Gaikwad et al., 2018). In a systematic review

conducted on BMWM in dental hospitals and clinics by Kapoor, Nirola, Kapoor & Gambhir

(2014), it was concluded that there was insufficient awareness about BMWM policy and rules.

This resulted in unsafe and ineffective practices of waste disposal. Therefore, it is important to

impart knowledge through training programs inorder to update their knowledge on infection

control (Gaikwad et al., 2018). It is also equally important to note that knowledge gained may be
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lost over time. Therefore, regular educative seminars in which there are practical sessions should

be held after every six months or at least annually. This will ensure retention of the knowledge.

It would keep the staff up to date with new upcoming strategies (Gaikwad et al., 2018).

Kar, Mishra, Dash, Muduli & Pumwa, (2018) have stated that some factors lead to poor BMWM

practices. One factor is that hospitals give less attention to waste management. Secondly, the

staffs hesitate to accept and implement changes. Thirdly, hospitals do not provide adequate and

appropriate resources to save on the costs of material. However, training and counselling of the

staff through programs can decrease opposition to changes. Although an expense to provide

material is more initially in the proper disposal of waste, it is financially profitable in the long

run due to the enhanced image of the hospital (Kar, Mishra, Dash, Muduli & Pumwa, 2018). It

was also seen from a study by Ezirim & Agbo (2018) in Nigeria that as per suggestions from

World Health Organization, when a person or group is made responsible for everyday activities

of the waste management plans of a facility, there are better outcomes.

The Importance of safe practices of handling Bio-Medical Waste

Needle stick injuries pose high risk of blood borne infections like hepatitis and human

immune deficiency virus. This is true mostly for nurses who are the ones handling syringes and

needles (Cooke & Stephens, 2017). After a needle stick injury, the person who got the injury as

well as the person on whom the needle was used has to be tested for deadly pathogens such as

immune deficiency virus and hepatitis B. Prophylaxis or short and long term treatment should be

started. Some other staff has to cover up for the injured staff. Also, counselling needs to be

done for the wounded person and any compensation claim will have to be borne by the

healthcare facility. Thus, besides being a threat to health, it is an economic burden due to the

cost incurred by the hospital (Cooke & Stephens, 2017). From 2017, countries like Canada, the
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European Union, United Kingdom, the United States of America, Taiwan and Brazil have

enacted legislation pertaining to needle stick injury and safety-engineered devices (Cooke &

Stephens, 2017). The safety needles devices are: ‘manually activated protective sliding shield

and manually activated protective toppling shield’ (Cooke & Stephens, 2017). Although these

are expensive, they are economical in the long run due to fewer occurrences of needle stick

injuries and in the consequent expenses (Cooke & Stephens, 2017).

The needles used are also known to cause injury to other staff who does not handle

sharps example housekeeping staff. This is because the rule to segregate sharps properly in

puncture proof containers are not practiced (Pai Jakribettu et al., 2017). These injuries are also

dangerous as there is a chance of contacting the diseases which are transmitted through blood.

Even though the blood is not seen by the naked eye, a small amount is present in the needle

which is enough to transmit pathogens (Cooke & Stephens, 2017).

In a study conducted in the UK, it was deduced that training of staff is necessary for

proper handling of needles and sharps. Provision of devices and materials needed for proper

disposal should be made. Ward nurse managers must take action to encourage good practices

regarding disposal of sharps. Also, ward managers should be taken into consideration while

making disposal policies (Powell, 2014).

Minimization of waste

The World Health Organization greatly supports minimization of waste at the site where

it is generated. A study was conducted by Saber, Howlett, Waterman & Tantillo (2018), to

analyze the biomedical waste generated during the care of isolated patients and to suggest means

to minimize the same. As a nursing implication for environmental stewardship, it was suggested

that a horizontal isolation approach in hospitals would be cost effective and helpful in decreasing
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biomedical waste. It was seen that a lot of disposable materials were being used to prevent

possible cross contamination (Saber, Howlett, Waterman & Tantillo, 2018). Horizontal

isolation means that patients are isolated according to the way they are infectious, example an

oozing wound and not according to the type of pathogen the patient is carrying. Horizontal

isolation practise would emphasize on meticulous environmental cleaning techniques, thorough

hand hygiene and topically decolonizing targeted patients. This type of practise would lessen the

amount of biomedical waste of disposable materials produced in isolation patient rooms (Saber,

Howlett, Waterman & Tantillo, 2018).

Preventing pollution

According to a new position statement of the International Council of Nurses (ICN) on

climate change and health (2018), nurses share a responsibility in protecting the environment

from pollution and degradation. To achieve this, the proper disposal of biomedical waste is

essential to prevent pollution and thereby degradation of the natural resources. The ICN also

points out that nurses have a role in encouraging government or institutional policies and plans

that minimize negative impact on the environment and public health.

Landfill disposal, garbage bin disposal and flushing of medications down the drain are

improper practices employed by nurses as well as households (Kinrys, Gold, Worthington &

Nierenberg, 2018). These practices contaminate water bodies and subsequently water supply

with pharmaceutical particles which constitute different kinds of drugs. This is harmful to

humans and wildlife, including aquatic life (Kinrys, Gold, Worthington & Nierenberg, 2018;

Ayele & Mamu, 2018; Kelly, McMillan, Spinks, Bettington & Wheeler, 2018). Destruction of

drugs by incineration requires contained incinerators which produce very high temperatures and

have gas cleaning equipment. Other methods of drug disposal include innovative technologies
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like ‘environmental facility technology reactor, alkaline hydrolysis, and thermophilic anaerobic

digestion’ (Capoor & Kumar, 2017). In a study conducted by Kinrys, Gold, Worthington &

Nierenberg (2018), it was found that ‘medication take-back program’ was successfully

implemented in many places in the United States. Nurses as health professionals are in a good

position to educate patients and their families, at the time of discharge about the proper disposal

of unwanted medications. Nurses can remind them to return unnecessary medicines to the

pharmacy instead of disposing them in the municipality bins (Kelly, McMillan, Spinks,

Bettington & Wheeler, 2018). Returning drugs to the supplier for disposal is yet to be

incorporated in the Indian Drugs Disposal Policy (Capoor & Kumar, 2017).

Final methods of Bio-Medical Waste disposal

Organizations of nursing have embraced their role to advocate for the environment and

climate change from local to national level. Participation of nurses in debate regarding policies

effecting the environment and subsequently human health is necessary (Nicholas & Breakey,

2017). This suggests nurses to not only be content with following the rules of handling and

segregation and the storage but also to be active in coordinating with other professionals who

deal with final disposal processes. By doing so, nurses can demand the use of innovative

technologies thereby, making an impact in an overall development for environmentally safe

disposal of biomedical waste.

Presently used methods of healthcare waste disposal which are mainly landfill and

incineration can lead to adverse effects on the environment. If landfills are not built correctly,

drinking water resources can get contaminated as the incineration ash which is finally disposed

in a landfill also contains dangerous chemicals (Živković, Milošević, Vranjanac, Vasović &

Stević, 2019). Chlorine produced due to incineration of medical materials can form carcinogens
BIOMEDICAL WASTE 11

like furans and dioxins which have adverse health effects on humans. Toxic metals such as

cadmium, mercury and lead can get dispersed in the environment from the process of

incineration of heavy metals or items containing them (Živković, Milošević, Vranjanac, Vasović

& Stević, 2019 ; Datta, Mohi & Chander, 2018). Therefore, to tackle these issues, Živković,

Milošević, Vranjanac, Vasović & Stević (2019) suggest the formation of a group for proper

management of waste. This group would comprise of following members appointed by the

hospital manager: laboratory head, the chief pharmacist, head of radiology, head nurse, the

hospital administrator, hospital staff members, the local waste manager, water and habitat

engineer and a hospital project manager (Živković, Milošević, Vranjanac, Vasović & Stević,

2019). Due to a number of harmful effects of incineration, some countries are moving towards

using alternatives of incineration. While some counties such as Philippines and Denmark have

already banned use and construction of incinerators (Datta, Mohi & Chander, 2018).

Alternatives to incinerators

Photo catalysis is a novel way of using sun rays to destroy microbes and to

decontaminate hospital waste mater. This is an inexpensive and effective technology. In

nanotechnology, the air inside is cleansed using light energy. It also helps in converting toxic

pollutants into water and carbon dioxide, thereby improving air quality (Capoor & Tapas

Bhowmik, 2017). Plasma pyrolysis is a method utilized to deal with dangerous chemical waste,

sharps, infectious plastic and pathological waste. In this, a gas in plasma state is used to produce

extremely high temperatures. A clean alloy is produced in this process which can be used for

construction purposes as well as in the production of metal products. Plasma pyrolysis has very

low levels of emissions of furans and dioxins. However, it is costly and requires constant

maintenance (Capoor & Tapas Bhowmik, 2017; Datta, Mohi & Chander, 2018).
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Conclusion

Biomedical or healthcare waste is a worldwide issue as it is a threat to the environment

as well as to human health. Due to this, laws and policies are being made to ensure proper waste

handling and safe disposal practices. Nurses are an important part of the healthcare system.

Therefore, it is extremely essential to educate them in all the aspects of biomedical waste

management so that they are in a position to act as well as to educate subordinates and the

public. Nurses can be instrumental in bringing about an overall change in attitudes and

behaviours at local as well as national level, thereby making implementation of biomedical

policies easier.
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