Biomedical Waste: Handle With Care

Above: Medical waste lying outside a hospital/Photo: Twitter 

A judge has pulled up hospitals and healthcare facilities in Noida, Greater Noida and Ghaziabad for causing 40 percent of recurrent infections in patients by not scientifically disposing of waste

By Dr KK Aggarwal

Healthcare waste is dangerous and infectious. As per the UP Solid Waste Management Monitoring Committee, hospitals and healthcare facilities in Noida, Greater Noida and Ghaziabad are responsible for 40 percent of recurrent infections in patients as they don’t adhere to scientific disposal of biomedical waste through segregation.

Healthcare waste includes all waste generated by healthcare establishments, research facilities and laboratories. In addition, it includes the waste originating from “minor” or “scattered” sources such as that produced in homes (dialysis, insulin injections, etc). Between 75 to 90 percent of the waste produced by healthcare providers is non-risk or “general” waste, comparable to domestic waste. It comes mostly from the administrative and housekeeping functions of healthcare establishments and may include waste generated during the maintenance of these premises. The remaining 10-25 percent of healthcare waste is regarded as hazardous and may create a variety of health risks.

Hazardous healthcare waste (also known as healthcare risk waste) needs special regulation, but general wastes can be dealt with by municipal waste disposal mechanisms. There are different categories of healthcare waste.

• Infectious waste: Waste suspected to contain pathogens such as laboratory cultures, waste from isolation wards, tissues (swabs), materials, or equipment that have been in contact with infected patients, excreta.
• Pathological waste: Human tissues, blood and other body fluids, foetuses.
• Sharps: Sharp waste such as needles, infusion sets, scalpels, knives, blades, broken glass.
• Pharmaceutical waste: Waste containing pharmaceuticals that have expired or are no longer needed, items contaminated by or containing pharmaceuticals (bottles, boxes).
• Genotoxic waste: Waste containing cytostatic drugs (often used in cancer therapy), genotoxic chemicals.
• Chemical waste: Waste containing laboratory reagents, film developers, disinfectants that are expired or no longer needed.
• Solvents: Wastes with high content of batteries, broken thermometers, blood-pressure gauges, heavy metals.
• Pressurised containers: Gas cylinders, gas cartridges, aerosol cans.
• Radioactive waste: Waste containing radioactive substances such as unused liquids from radiotherapy or laboratory research, contaminated glassware, packages or absorbent paper; urine and excreta from patients treated or tested with unsealed radionuclides.

Justice DP Singh, the chairman of the Committee, said that hospitals and healthcare facilities across Noida, Greater Noida and Ghaziabad are making a mockery of biomedical waste handling rules by dumping medical waste with municipal garbage. “I have data from an international source that says about 35-40 percent of the recurrent infections occur from hospitals and medical centres due to such negligence of non-segregated waste,” he said. He has fixed June 30 as the deadline for covering of all open dump sites and segregation of waste at public places, including biomedical waste, in Noida and Ghaziabad.

This directive is important as infectious waste often contains pathogens (bacteria, viruses, parasites or fungi) in sufficient concentration or quantity to cause disease in susceptible hosts. This category includes:

• Cultures and stocks of infectious agents from laboratories.
• Waste from surgery and autopsies on patients with infectious diseases (e.g. tissues, and materials or equipment that have been in contact with blood or other body fluids).
• Waste from infected patients in isolation wards.
• Waste that has been in contact with infected patients undergoing haemodialysis (e.g. dialysis equipment such as tubing and filters, disposable towels, gowns, aprons, gloves and laboratory coats).
• Infected animals from laboratories.
• Any other instruments or materials that have been in contact with infected persons or animals.

On March 19, the government published in the e-gazette, the Bio-Medical Waste Management (Amendment) Rules, 2019. The key points of the amended rules are as follows:

• The occupier of all bedded healthcare units shall maintain and update on a day-to-day basis the biomedical waste management register.
• All bedded healthcare units shall display the monthly record of waste disposal management on their websites.
• Such healthcare facilities (irrespective of any number of beds) shall make the annual report available on their websites before March 19, 2021.
• Healthcare facilities having less than 10 beds shall have to comply with the output discharge standard for liquid waste by December 31, 2019.

In addition, the Indian Penal Code (IPC) too has various sections dealing with such waste. Section 269, IPC, says: “Negligent act likely to spread infection of disease dangerous to life—Whoever unlawfully or negligently does any act which is, and which he knows or has reason to believe to be likely to spread the infection of any disease dangerous to life, shall be punished with imprisonment of either description for a term which may extend to six months, or with fine, or with both.”

Section 270 deals with a “Malignant act likely to spread infection of disease dangerous to life—Whoever malignantly does any act which is, and which he knows or has reason to believe to be, likely to spread the infection of any disease dangerous to life, shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both.”

There are other carriers of infections too. According to a new study in the Emergency Medicine Journal, December 1, 2018, oxygen cylinders act as carriers for a bacterium called methicillin-resistant staphylococcus aureus (MRSA). In the study, researchers tested the surface of nine oxygen cylinders and regulators in ambulances at an emergency medical services station in North Alabama, US, while 70 offsite oxygen cylinders were also tested. Of the nine oxygen cylinders tested in ambulances, all had MRSA colonisation (100 percent). MRSA was also present on 67 of 70 oxygen cylinders (96 percent) tested at the offsite oxygen cylinder storage area.

Last year, a study reported in the September 2018 issue of American Journal of Infection Control found that patient privacy curtains surrounding beds in hospitals become progressively contaminated with bacteria, including MRSA. The increased MRSA positivity was observed between 10 to 14 days after the curtains are hung. By the 14th day, seven (87.5 percent) of the eight tested curtains were positive for MRSA. This was the time to either change or clean the curtains, suggested the study.

A new study published online on December 12, 2018, in the Infection Control and Hospital Epidemiology reported stethoscopes as carriers of infection. Out of 40 stethoscopes in use in an ICU, all had a high abundance of staphylococcus bacteria, with “definitive” S aureus bacteria present on 24 of 40 stethoscopes tested.

The British Medical Journal reported in 2015 that white coats worn by doctors harbour potential contaminants and contribute considerably to the burden of disease acquired in hospital by spreading infection. Research has also shown an association of yoga mats with fungal, bacterial and viral infections.

In addition to healthcare waste, equipment handles, clothes, carpets, etc, are also sources of bacteria. Computers, telephones, telephone mouthpieces, headsets, desks, ATMs, cash machines and elevator buttons have also been reported as potential sources for transmitting infectious microorganisms. Notes and coins are also a source of infection. Bank notes recovered from hospitals may be highly contaminated by staphylococcus aureus, while salmonella, escherichia coli and S aureus are commonly isolated from bank notes from food outlets. Influenza virus, norovirus, rhinovirus, hepatitis A virus and rotavirus can be transmitted through hand contact.

This new study only adds to the growing list of evidence that for all practical purposes, everything used in healthcare can be considered to be contaminated and a potential source of cross-contamination in hospitals. While hand to hand transmission of microbes remains an important route of spread of infection, these studies highlight the role of contaminated environmental surfaces in the transmission of healthcare-associated infections.

The one way to prevent the spread is proper biomedical waste disposal and adoption of universal precautions.

Every surface in a healthcare setting needs to be assumed infected unless proven otherwise.

—The writer is President, Heart Care Foundation of India, and President-elect, Confederation of Medical Associations of Asia and Oceania