S.N.M. Hospital, located in Leh, is the primary civilian medical care facility in the region of Ladakh. Despite its somewhat limited range of services, the hospital is the lifeline of local people especially those who cannot go out of Ladakh to avail treatment. Consequently, the hospital receives a high number of patients and produces substantial amount of waste.
Hospitals produce two kinds of waste: general and biomedical. General waste consists of food waste, paper and plastic packaging whereas biomedical waste includes, among several other things, anatomical waste, chemical waste, and items contaminated with human waste like sharp metals, plastics, glassware and cloth materials (1). Biomedical waste is hazardous because it infects whatever it comes in contact with - soil, water, animals and humans.
The first step in managing biomedical waste in S.N.M. Hospital is segregated collection of waste for which the colour-coded container system specified in the guidelines issued by Ministry of Health and Family Welfare, Government of India, is followed. Four colour-coded containers are placed in each department of the hospital: (a) Yellow for human anatomical waste (human tissues and organs), and items contaminated with blood and body fluids (linen, dressing, plaster, cotton swab), chemical waste; (b) Red for contaminated waste (disposable items such as intravenous tubes and sets, catheters, urine bags, syringes, fixed needle syringes, gloves); (c) Blue for glassware (broken or discarded and contaminated glass including medicine vials and ampoules); (d) White (Translucent) for sharps (used, discarded, contaminated sharp objects like needles, scalpels, blades). In addition to these four, there are two other colour-coded containers for non-medical waste: (e) Black for general waste which in the case of the hospital refers to a mixed waste of plastic, paper and cardboard; (f) Green for food waste (2).
Rise in medical procedures in recent years has led to increase in quantity of biomedical waste produced in the hospital. But currently, due to the outbreak of Covid, far fewer patients are visiting the hospital than usual hence the amount of waste generated is also significantly less.
Biomedical waste has to be handled with utmost care right from collection and treatment until final disposal. The most hazardous of all the biomedical waste, which is human waste and items contaminated with blood and body fluids, is incinerated directly without any treatment. S.N.M. Hospital has an incinerator of 50 kgs per hour capacity. This capacity is not met on a daily basis so the untreated infected waste is stored upto 48 hours, in accordance with government regulations, to collect more waste before running the incinerator (4). The incinerator has a tall chimney which releases smoke at a height doing less harm to human and environmental health. Before escaping into the air, the smoke passes through a water compartment where some of the toxins are filtered out. Ashes from the incinerator - also a form of waste - are turned over to municipality waste collection trucks. The hospital also receives biomedical waste from other medical facilities in the city for incinerating. The incinerator is operated by a staff trained specially for the job.
In case of nonfunctioning of the incinerator, anatomical and infected waste are disposed in Deep Burial which is basically a decomposing repository constructed at a depth of about 2 metres to prevent access by animals. Acid is poured on the waste to disinfect it while decomposing. Standards of deep burial stipulate a covering of galvanised iron or wire mesh but the deep burial at the hospital is covered with plastic lid and does not have an enclosure either (5). The pit gives off strong odour of human waste which may attract dogs but it is believed that dogs do not go near the pit.
Recyclable plastic waste is first disinfected by treating in bleaching powder for 6-8 hrs then shredded by machine and finally sold off to plastic scrap buyers. Who exactly buys the plastic is not known nor what happens to it thereafter. All kinds of plastic, from intravenous sets to insulin syringes, are shredded and sent out of the hospital premises.
Glassware is disinfected in the same way as recyclable plastic waste by treating for 6-8 hrs in bleaching powder after which it is stored in a fenced area in the open. Glass ampoules in particular are a worry to Sanitary Inspectors since these are generated in huge quantity but not being designated for incineration, crushing or burial, are simply accumulating in heaps. According to Sanitary Inspectors, glass ampoules can be reused by refilling medicine.
For discarding sharp objects, translucent boxes are used which are made of puncture-proof plastic. The content of the boxes are emptied in a Sharp Pit which is an underground chamber having a narrow tubular opening with a metal lock designed to prevent access by animals.
General waste, which constitutes the highest share of daily waste, is given to the municipality. Food waste is also given to the municipality normally but during these Covid times, it is incinerated. Sanitary Inspectors say that managing the biomedical waste of the hospital is challenging. The level of training and knowledge among the different cadres of medical staff is insufficient. For example, there is no clarity as to how to dispose rubber gloves. Rubber gloves are often found in the wrong container or left lying on the table. Earlier rubber gloves were disinfected and stored but of late they are incinerated.
The number of sanitary workers falls short of the actual need. Currently, there are about 35 workers - at least 15 more are required. However, as there are no more job positions in the sanitation department, the strength of sanitary workers cannot go higher. The hospital also needs an ETP (Effluent Treatment Plant) because liquid waste is left untreated and sent to septic tanks. But if the ETP is installed, the liquid waste can be disinfected and passed into the municipal sewage system which is being constructed by the PHE (Public Health Engineering) department. Earlier, under the J&K state administration, there was no budget for waste management in the hospital but under the UT administration, a certain amount is allocated for biohazard waste management. Therefore it is likely that in the near future the ETP would get installed. However, enhancing the training, knowledge and practical application of biomedical waste management among the hospital staff is a need that the hospital administration has to look into at length.
Notes:
The sources of biomedical waste include hospitals, nursing homes, clinics, medical laboratories, blood banks, mortuaries, medical research and training centre and biotechnology institutions/production houses. Such waste can also be generated in households if medical care is being provided to patient at home. [Slide Presentation by Dr. Navpreet, Assistant Professor, Department of Community Medicine, Government Medical College and Hospital, Chandigarh. Accessed online at https://gmch.gov.in/e-study/e%20lectures/Community%20Medicine/Biomedical%20Waste%20Management.pdf on 20 August 2020].
For latest guidelines on categorisation and management options of biomedical waste, see "Bio Medical Waste Management Rules - 2016." [Department of Health Research, Ministry of Health and Family Welfare, Government of India. Accessed online at https://dhr.gov.in/sites/default/files/Bio-medical_Waste_Management_Rules_2016.pdf on 20 August 2020].
Data provided by Sanitary Inspectors of the hospital in personal interview.
In case for any reason it becomes necessary to store infected waste beyond 48 hrs, the prescribed authority has to be informed about the reasons for doing so and appropriate measures have to be taken to ensure that the waste does not adversely affect human and environmental health. ["Bio Medical Waste Management Rules - 2016," p.8. [Department of Health Research, Ministry of Health and Family Welfare, Government of India].
See "Standards for Treatment and Disposal of Bio-medical Wastes", Madhya Pradesh Pollution Control Board. [Accessed online at http://www.mppcb.nic.in/stand_disposal.htm#:~:text=spores%20per%20milliliter.-,STANDARDS%20FOR%20DEEP%20BURIAL,any%20access%20to%20burial%20sites on 26 September 2020].
Acknowledgement
We thank the following persons at S.N.M Hospital: Dr. Tsering Samphel, Medical Superintendent, for approving our study of the biomedical waste management; Tsering Dorjey and Sonam Angchuk, Sanitary Inspectors, for showing us the disposal method for the different types of waste and answering all our questions related to the study topic; Chonyit Dolma, Early Interventionist and Special Educator, District Early Intervention Center, for encouraging our plan to study biomedical waste and assisting us on every visit to the hospital. We specially thank Tashi Motup Kau, General-Secretary, Asoka Mission, for making the study possible.
Very good study. Cheers