BIO-MEDICAL

WASTE MANAGEMENT

A project submitted in partial fulfilment of

requirements for degree of
MBA (HOSPITAL ADMINISTRATION)
BY
MOHD SAIF
[Roll No: 2367033003]
[Session: 2023-2025]

Under the Supervision of

DR. ABHISHEK MITTAL
[Associate Professor]
School of Commerce & Management

IIMT UNIVERSITY
‘O’ Pocket, Ganga Nagar Colony,
Mawana Road, Meerut (U.P.), India
DECLARATION BY THE CANDIDATE

The Research work embodied in this project entitled “Bio-medical

waste management” has been carried out at the School of Commerce
and management, IIMT University, Meerut, U.P. The extent of
information derived from the existing literature has been indicated in
the body of the project at appropriate places along with the source of
information. The work is original and has not been submitted in part or
for any degree or diploma of this or any other University.

Date: 10/05/2025 Mohd Saif Place:Meerut

[RollNo:2367033003]
 CERTIFICATE BY THE SUPERVISOR

The Research This is to certify that the project report entitled “Bio-
medical waste management” submitted by Mohd Saif in partial
fulfilment of requirements for degree of MBA (Hospital
Administration) at the “School of Commerce & Management,
IIMT University, Meerut, U.P.” is a record of the candidate own
work carried out by him under my supervision. The matter embodied in
this project is original and has not submitted for the award of any other
degree.

Supervisor: Hod:

Dr. Abhishek Mittal Dr. Neeraj Gupta

 ACKNOWLEDGEMENT
I am greatly thankful to Dr. Vineet Kaushik, [Dean] School of
Commerce & Management IIMT University, Meerut U.P. India for
providing necessary infrastructure to carry out my project work at the
university. I am express my sincere thanks and gratitude to Dr. Neeraj
Gupta, [Associate Professor & Head] School of Commerce &
Management IIMT University. Meerut, U.P. India for his moral
support. valuable guidance and encouragement during the various
stages of my work.
I am feeling oblige intaking the opportunity to sincerely thanks to Dr.
Abhishek Mittal, [Associate Professor] School of Commerce &
Management IIMT University, Meerut U.P. India for his valuable
guidance, valuable advice and whole heartedly co-operation. His
sincerity, thoroughness, timely help, and constructive criticism has
been a constant source of inspiration for me.
I would also like to acknowledge my parents and friends for the
whole hearted moral support and unending encouragement they
provided me during my project work.

Date: 10/05/2025 Mohd Saif

Place:Meerut [RollNo:2367033003]
 1.INTRODUCTION
Health-care activities are a means of protecting health, curing patients and saving lives. But
they also generate waste, 20 percent of which entail risks either of infection, of trauma or of
chemical or radiation exposure.
Although the risks associated with hazardous medical waste and the ways and means of
managing that waste are relatively well known and described in manuals and other literature,
the treatment and elimination methods advocated require considerable technical and
financial resources and a legal framework, which are often lacking in the contexts in which
the International Committee of the Red Cross (ICRC) works. The staff is often unequipped
for coping with this task.
Poor waste management can jeopardize care staff, employ- ees who handle medical waste,
patients and their families, and the neighboring population. In addition, the inapt-propriate
treatment or disposal of that waste can lead to environmental contamination or pollution.

In unfavorable contexts, the risks associated with hazardous medical waste can
be significantly reduced through simple and appropriate measures. This manual is intended
as a practical and pragmatic tool for the routine management of dangerous hospital wastes. It
does not under any circumstances replace any existing national waste management
legislation and plans.
This manual is designed for the medical, technical or administrative staff working
in medium-sized hospitals (approximately 100-bed capacity) that are managed or
supported by the ICRC.

The manual includes data sheets in the Annex. It deals with wastes that are created during
surgical, medical, laboratory and radiological activities apart from specialties such as
oncology, nuclear medicine or pros- thetic/orthotic workshops. It deals mainly with so-called
hazardous or special medical waste except for genotoxic waste such as cytotoxic substances
or radioactive material, which are wastes that ICRC health care activities generally do not
produce.
 2. DEFINITION AND
DESCRIPTION OF
“MEDICAL WASTE”
2.1 Description of medical waste

The term “medical waste” covers all wastes produced in healthcare or diagnostic activities.

75 % to 90 % of hospital wastes are like

household refuse or municipal waste and do not
entail any hazard.

Refuse like household waste can be put through the same collection, recycling and
processing procedure as the community’s municipal waste. The other 10% to 25% is called
hazardous medical waste or special waste. This type of waste entails health risks.
It can be divided into five categories according to the risks involved. Table 2.1 gives a
description of those various categories and their sub-groups.
 Table 2.1 Classification of hazardous medical waste

1. Sharps ◻ Waste entailing risk of injury.

2. Waste entailing risk of ◻ Waste containing blood,
secretions or excreta entailing a
contamination
risk of contamination.
Anatomical waste
◻ Body parts, tissue entailing a
risk of
Infectious waste contamination

◻ Waste containing large quantities

of material, substances or cultures
entailing the risk of propagating
infectious agents (cultures of
infectious agents, waste from
infectious patients placed in
isolation wards).

3. Pharmaceutical waste ◻ Spilled/unused medicines, expired

drugs and used medication
receptacles.
Cytotoxic waste
◻ Expired or leftover cytotoxic
drugs, equipment contaminated with
cytotoxic substances.
◻ Batteries, mercury waste (broken
Waste containing heavy
metals thermometers or manometers,
fluorescent or compact fluorescent
light tubes).

◻ Waste containing chemical

Chemical waste substances:
leftover laboratory solvents,
disinfectants, photographic
developers and fixers.

4. Pressurized containers ◻ Gas cylinders, aerosol cans.

5. Radioactive waste ◻ Waste containing radioactive
substances: radionuclides used in
laboratories or nuclear medicine,
urine or excreta of patients treated.
The various categories of waste are set out in detail in the data sheets in Annex 1 (sheets 1 to
11). Cytotoxic and radio- active wastes are dealt with briefly in that annex.

2.2 Quantification of medical waste

The quantity of waste produced in a hospital depends on the level of national income and
the type of facility concerned. A university hospital in a high-income country can produce
up to 10 kg of waste per bed per day, all categories combined.
An ICRC hospital with 100 beds will produce an average of 1.5 to 3 kg of waste per patient
per day depending on the context (all categories combined and including household
refuse).
An estimate of the quantities of waste produced must be drawn up in each facility (see
chapter 5.3 and Annex 3.1).
3. MEDICAL WASTE RISKS
AND IMPACT ON HEALTH AND
THE ENVIRONMENT
3.1 Persons potentially exposed
All persons who are in contact with hazardous medical waste are potentially exposed to the
various risks it entails: persons inside the establishment generating the waste, those who
handle it, and persons outside the facility who may be in contact with hazardous wastes or
their by-products, if there is no medical waste management or if that management is
inadequate.

The following groups of persons are potentially exposed:

◻ Inside the hospital: care staff (doctors, nursing staff, auxiliaries), stretcher-bearers,
scientific, technical and logistic personnel (cleaners, laundry staff, waste managers,
carriers, maintenance personnel,
pharmacists, laboratory technicians, patients, families and visitors).

◻ Outside the hospital: off-site transport personnel, personnel employed in processing or

disposal infrastructures, the general population (including adults or children who salvage
objects found around the hospital or in open dumps).

3.2 Risks associated with hazardous medical waste

The health risks associated with hazardous medical
waste can be divided into five categories:
◻ risk of trauma
(waste category 1);
◻ risk of infection
(waste categories 1 and 2);

◻ chemical risk
(waste categories 3 and 4);
◻ risk of fire or explosion
(waste categories 3 and
4);
◻ risk of radioactivity
(waste category 5, which is not dealt with in this manual).

The risk of environmental pollution and contamination must be added to these categories.

3.2.1 RISKS OF TRAUMA AND INFECTION

Health-care wastes are a source of potentially dangerous micro-organisms that can infect
hospital patients, personnel and the public. There are many different expo- sure routes:
through injury (cut, prick), through contact with the skin or mucous membranes, through
inhalation or through ingestion.
Table 3.1 gives examples of infections that can be caused by hazardous medical waste.
Table 3.1 Examples of infections that can be caused by hazardous medical waste

Type of Infective agent Transmission agent

infection

Gastrointestinal Enterobacteria Faeces, vomit

infections
(Salmonella, Vibrio
cholerae, Shigella, etc.)

Respiratory Mycobacterium Inhaled secretions, saliva

infections tuberculosis, Streptococcus
pneumoniae, SARS virus
(severe acute respiratory
syndrome), measles virus

Eye infections Herpes virus Eye secretions

Skin infections Streptococcus Pus
Anthrax Bacillus anthracis Skin secretions
Meningitis Neisseria meningitidis Cerebro-spinal fluid
AIDS Human Immunodeficiency Blood, sexual secretions,
Virus (HIV) other body fluids
 Hemorrhagic Lassa, Ebola, Marburg, Blood and secretions
fever and Junin viruses

Viral hepatitis A Hepatitis A virus Faeces

Viral hepatitis B Hepatitis B and C viruses Blood and other biological

and C fluids
Avian influenza H5N1 virus Blood, faeces

Some accidental exposure to blood (AEB) or to other body fluids are examples of accidental
exposure to hazardous medical waste.

1 Source: A. Prüss, E. Giroult, and P. Rushbrook, Safe management of wastes from health-
care activities, WHO, 1999.

As regards viral infections such as AIDS and hepatitis B and C, it is nursing staff who
are most at risk of infection through contaminated needles. Sharps and pathogenic
cultures are regarded as the most hazardous medical waste.
In 2000, the World Health Organization (WHO) estimated that at world level accidents
caused by sharps accounted for 66,000 cases of infection with the hepatitis B virus, 16,000
cases of infection with hepatitis C virus and 200 to 5,000 cases of HIV infection amongst the
personnel of health-care facilities.
Some wastes, such as anatomical wastes, do not necessarily entail a health risk or risk for the
environment but must be treated as special wastes for ethical or cultural reasons.

A further potential risk is that of the propagation of micro- organisms outside health-care
facilities which are present in those facilities, and which can sometimes be resistant − a
phenomenon that has not yet been sufficiently studied.

3.2.2 SURVIVAL OF MICRO-ORGANISMS IN THE ENVIRONMENT

Pathogenic micro-organisms have a limited capacity of survival in the environment. Survival
depends on each micro- organism and on environmental conditions (temperature, humidity,
solar radiation, availability of organic substrate, presence of disinfectants, etc.). Bacteria are
less resistant than viruses. Very little is known yet about the survival of prions and the agents
of degenerative neurological dis- eases (such as Creutzfeldt-Jakob’s disease, Kuru, and so
on), which seem to be more resistant than viruses.

Table 3.2 gives a summary of what is known about the survival of various pathogens.
Table 3.2: Examples of the survival time of certain pathogens

Pathogenic micro- Observed survival time

organism

Hepatitis B virus ◻ Several weeks on a surface in dry air

◻ 1 week on a surface at 25°C

◻ Several weeks in dried blood

◻ 10 hours at 60°C
◻ Survives 70% ethanol.
Infectious dose ◻ 1 week in a drop of blood in a hypodermic
of hepatitis B and needle
C viruses

Hepatitis C ◻ 7 days in blood at 4°C.

HIV ◻ 3 − 7 days in ambient air

◻ Inactivated at 56°C

◻ 15 minutes in 70% ethanol

◻ 21 days in 2 μl of blood at
ambient temperature

◻ Drying the virus reduces its

concentration by 90-99% within the next
few hours.

The role played by carriers such as rats and insects must also be considered in the evaluation
of micro-organism survival time in the environment. They are passive carriers of pathogens,
and measures must be taken to control their proliferation.

3.2.3 BIOLOGICAL RISKS ASSOCIATED WITH EXPOSURE TO

SOLID HOUSEHOLD REFUSE
Since exposure conditions are often the same for employ- ees dealing with household refuse
and those dealing with medical waste, the impact on the health of the former can be used as
an indicator for the latter.

Various studies conducted in high-income countries have shown the following results:
Compared to the general population, in the case of per- sons employed in the processing of
household waste

◻ the risk of infection is 6 times higher;

◻ the risk of contracting an allergic pulmonary disease is 2.6 times higher;

◻ the risk of contracting chronic bronchitis is 2.5 times higher;

◻ and the risk of contracting hepatitis is 1.2 times higher.

Pulmonary diseases and bronchitis are caused by exposure to the bio-aerosols contained in
the air at the sites where the refuse is dumped, stored or processed.3

3.2.4 CHEMICAL RISKS

Many chemical and pharmaceutical products are used in health-care facilities. Most of them
entail a health risk due to their properties (toxic, carcinogenic, mutagenic, repro- toxic,
irritant, corrosive, sensitizing, explosive, flammable, etc.). There are various exposure routes
for contact with these substances: inhalation of gas, vapour or droplets, contact with the skin
or mucous membranes, or ingestion. Some substances (such as chlorine and acids) are
incompatible and can generate toxic gases when mixed.

3. These bio-aerosols contain gram-positive and gram-negative bacteria, aerobic

Actinomycetes and sewage fungi.

The identification of potential hazards caused by certain substances or chemical preparations

can be easily done through labelling: symbols, warning statements or hazard statements.
More detailed information is set out
in the material safety data sheet (MSDS).
Some examples of the European and international hazard symbols are shown in Annex 4.
Figures 3.1 and 3.2 give examples of European and international labelling (Globally
Harmonized System - GHS).
Cleaning products and disinfectants are examples of dangerous chemicals which are used in
large quantities in hospitals. Most are irritant or even corrosive, and some disinfectants
(such as formaldehyde) can be sensitizing and toxic.

Figure 3.1: Example of the labelling of chemicals (European system applicable until
2015)
 Figure 3.2: Example of the labelling of chemicals according to the new
(international) system (GHS)
Mercury is a heavy metal in liquid form at room temperature and pressure. It is very dense (1
liter of mercury weighs 13.5 kg!). It evaporates readily and can remain for up to a year in the
atmosphere. It accumulates in sediments, where it is converted into methylmercury, a more
toxic organic derivative. Mercury is found mainly in thermometers, manometers, dental
alloys, certain types of battery, electronic components and fluorescent or compact
fluorescent light tubes. Health-care facilities are one of the main sources of mercury in the
atmosphere due to the incinerate of medical waste. These facilities are also responsible for
the mercurial pollution of surface water.
Mercury is highly toxic. There is no threshold under which it does not produce any
undesirable effect.
Mercury can cause fatal poisoning when inhaled. It is also harmful in the event of
transcutaneous absorption and has dangerous effects on pregnancy.
Silver is another toxic element that is found in hospitals (photographic developers). It is
bactericidal. Bacteria which develop resistance to silver are also thought to be resistant to
antibiotics.
The trading and use of expired medicines also entail a public health risk whenever this
type of waste is not controlled. This manual does not cover the risk associated with cyto-
toxic drugs (see information outlined in Annex 1 – data sheet no. 6).

3.3 Risks associated with the inappropriate processing and dumping of

hazardous medical waste
3.3.1 INCINERATION RISKS
In some cases, particularly when wastes are incinerated at low temperature (less than 800°C)
or when plastics containing polyvinyl chloride (PVC) are incinerated, hydrochloric acid
(which causes acid rain), dioxins, furans and various other toxic air-borne pollutants are
formed. They are found in emissions but also in residual and other air-borne ash and in the
effluent gases released through incinerator chimneys. Exposure to dioxins, furans and other
coplanar polychlorinated biphenyls can have effects that are harmful to public health.

The disease caused by exposure to mercury is called mercurialize.

Anon 2007, Chopra 2007, Senjen & Illuminato 2009.
5 Long-term exposures to low doses of dioxins and furans can result in immune system
disorders in humans as well as abnormal development of the nervous system, endocrine
disruption and reproductive damage. Short-term exposure to high doses can cause skin
lesions and impaired liver function. The International Agency for Research on Cancer
(IARC)
These substances are persistent the molecules do not break down in the environment and they
accumulate in the food chain. The bulk of human exposure to dioxins, furans and coplanar
polychlorinated biphenyls takes place through food intake.

Even in high-temperature incinerators (over 800°C) there are cooler pockets at the beginning
or the end of the incineration process where dioxins and furans can form. Optimization of the
process can reduce the formation of these substances if it is ensured, for example, that
incineration takes place only at temperatures above 800°C and if the formation of
combustion gas is prevented at temperatures of 200 - 400°C (see good incineration practices
in Chapter 10.2).

And lastly, the incineration of metals or of materials with a high metal content
(especially lead, mercury and cadmium) can result in metals being released into the
environment.

3.3.2 RISKS RELATED TO RANDOM DISPOSAL OR

UNCONTROLLED DUMPING
In addition to the above-mentioned risks, burial and random dumping on uncontrolled sites
can have a direct impact on the environment in terms of soil and water pollution.

3.3.3 RISKS RELATED TO THE DISCHARGE OF RAW SEWAGE

Poor management of wastewater and sewage sludge can result in the contamination of water
and soil with pathogens or toxic chemicals.
Pouring chemical and pharmaceutical wastes down the drain can impair the functioning of
biological sewage treatment plants or septic tanks. These can end up polluting the ecosystem
and water sources septiques. Antibiotics and their metabolites are excreted in the urine and
faeces of patients under treatment and end up in sewage. Hospital sewage contains 2 to 10
times more antibiotic-resistant bacteria than domestic wastewater, a phenomenon which
contributes to the emergence and propagation of pathogens such as MRSA (methicillin-
resistant Staphylococcus aureus ).
 4. LEGISLATION
4.1 International agreements
Several international agreements have been concluded which lay down fundamental
principles concerning public health, environmental protection and the safe management of
hazardous wastes. These principles and conventions are set out below and must be
considered in the planning of hazardous medical waste management.

Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and

Their Disposal (UNEP, 1992)
The main objectives of the Basel Convention are to minimize the generation of hazardous
wastes, treat those wastes as close as possible to where they were generated and reduce
transboundary movements of hazardous wastes.
It stipulates that the only case where the cross-border movement of hazardous waste is
legitimate is the export of waste from a country which does not have the expertise or the
infrastructure for safe disposal to a country which does.

Bamako Convention (1991)

This treaty banning the importation of any hazardous wastes into Africa has been signed
by 12 nations.

Stockholm Convention on Persistent Organic Pollutants (UNEP, 2004)

This convention aims to reduce the production and use of persistent organic pollutants and to
eliminate uncontrolled emissions of substances such as dioxins and furans.

Polluter pays principle

Any producer of waste is legally and financially liable for disposing of that waste in a manner
that is safe for people and the environment (even if some of the processes are sub-contracted).

Precautionary principle
When the risk is uncertain it must be regarded as significant and protective measures must be
taken accordingly.
Proximity principle
Hazardous wastes must be treated and disposed of as close as possible to where they
are produced.

Agenda 21 (plan of action for the 21st century adopted by 173 heads of State at the
Earth Summit held in Rio in 1992 To minimize the generation of waste, to re-use and
recycle, treat and dispose of waste products by safe and environmentally sound
methods, placing all residue in sanitary landfills.

WHO and UNEP initiatives concerning mercury and Decision VIII/33 of the Conference of
the Parties to the Basel Convention on mercury wastes
Measures should be taken as soon as possible to identify populations at risk of exposure to
mercury and to reduce anthropogenic wastes. The WHO is ready to guide countries in
implementing a long-term strategy to ban appliances containing mercury.
The ISWA7 (International Solid Waste Association) is an international network of waste
treatment and management experts. Its purpose is to exchange information with a view to
promoting modern waste management strategies and environmentally sound disposal
technologies. The ISWA is currently active in over 20 countries with some 1200 members
throughout the world.

4.2 National Legislation

National legislation constitutes a basis which must be drawn on to improve waste
treatment practices in a country. Many countries are currently drawing up national medical
waste management plans. The Global Alliance for Vaccines and Immunization (GAVI)
has been financing a project in collaboration with the WHO in this context since 2006, the
aim being to help 72 countries adopt a policy, strategy and plan for managing the wastes
generated in health-care activities.

The following countries are concerned:

Africa
Angola, Benin, Burkina Faso, Burundi, Cameroon, Chad, Comoros, Congo, Central African
Republic, Côte d’Ivoire, Eritrea, Ethiopia, Gambia, Ghana, Guinea, Guinea Bissau, Kenya,
Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Niger, Nigeria,
Uganda, Rwanda, Senegal, Sierra Leone, Somalia, Sudan, Tanzania, Togo, Zambia,
Zimbabwe.
South America
Bolivia, Cuba, Guyana, Haiti, Honduras, Nicaragua.

Middle East:
Afghanistan, Djibouti, Pakistan, Yemen.

Europe
Armenia, Azerbaijan, Kyrgyzstan, Georgia, Moldavia, Uzbekistan, Tajikistan, Ukraine.

Asia
Bangladesh, Bhutan, Cambodia, Democratic People’s Republic of Korea, India, Indonesia,
Laos, Mongolia, Myanmar, Nepal, Solomon Islands, Sri Lanka, Timor-Leste, Viet Nam.
The ICRC will have to investigate these various measures. Other national legislative
provisions will have to be considered in the medical waste management context:
◻ general legislation on waste;

◻ legislation on public health and environmental protection;

◻ legislation on air and water quality;

◻ legislation on the prevention and control of infections;

◻ legislation on radiation protection;

◻ legislation on the transport of hazardous substances;

◻ occupational safety and health legislations and regulations.

 5. FUNDAMENTAL PRINCIPLES
OF A WASTE MANAGEMENT
PROGRAMME
5.1 Assigning responsibilities

A “waste management” working group must thus be set up by the hospital manager. That team
must include the following members: the hospital project manager, the water and habitat
engineer, the local waste manager, and mem- bers of the hospital staff, such as the hospital
administrator, the head nurse, the head of radiology, the chief pharmacist and the head of
laboratory.

Duties of the hospital project manager

The hospital project manager has the overall responsibility of ensuring that the hospital wastes
are managed in compliance with national legislation and international conventions. He is
also responsible for:

◻ setting up a working group in charge of drafting the waste management plan;

◻ appointing the local waste manager, who will supervise and coordinate the
waste management plan daily;
◻ assigning duties; drawing up job descriptions;

◻ allocating financial and human resources;

◻ implementing the waste disposal plan;
 ◻ conducting audits and continuously updating and improving the waste
management system.

Duties of the water and habitat engineer

The water and habitat engineer are responsible for:

◻ carrying out an initial assessment of the waste situation;

◻ proposing a waste management plan to the working group (including the choice of
treatment/disposal methods) that is in line with any existing national waste management
plan;
◻ planning the construction and maintenance of waste storage and disposal facilities;

◻ assessing the environmental impact of waste management (monitoring

contamination, conducting hydrogeological assessments, etc.);
◻ regularly analyzing risks for the personnel;

◻ supervising the local waste manager;

◻ training.

Duties of the local waste manager

The local waste manager is the person in charge of administering the waste management plan
daily. He8 is the guarantor of the long-term sustainability of the system and must thus be in
direct contact with all the members of the working group and all hospital employees. His
duties include:

◻ monitoring the collection, storage and transport of wastes daily;

◻ monitoring the stocks of receptacles and containers, bags and personal protective
equipment as well as the maintenance of the means of transport used; forwarding orders
to the hospital administrator;

◻ supervising the persons in charge of collecting and transporting wastes;

◻ monitoring the measures to be taken in the event of an accident (posting notices,

informing the staff);

◻ monitoring protective measures;

◻ investigating incidents/accidents involving wastes;

◻ drawing up reports (quantities of waste produced, incidents);

◻ ensuring the maintenance of storage and treatment facilities.

 Duties of the hospital administrator
The hospital administrator is responsible for:

◻ ensuring that stocks of consumables (bags, receptacles and containers, personal

protective equipment, etc.) are permanently available;
◻ examining and evaluating costs;

◻ drawing up contracts with third parties (carriers, sub-contractors);

◻ giving advice on purchasing policies with a view to minimize/substitute certain

items (mercury-free equipment, PVC-free equipment, etc.);
◻ monitoring proper implementation of protective measures;

◻ supervising in the absence of the water and habitat engineer.

Duties of the head nurse

The head nurse is responsible for:

◻ training care staff in waste management (paying special attention to new staff members);
◻ monitoring sorting, collection, storage and transport procedures in the various wards;

◻ monitoring protective measures;

◻ supervising the hospital hygiene and taking measures to control infection.

Duties of the chief pharmacist

The chief pharmacist is responsible for:

◻ maintaining medicine stocks and minimizing expired stock;

◻ managing waste containing mercury.

◻ In the absence of the pharmacist, the hospital administrator takes over

these responsibilities.

Duties of the head of laboratory

The head of laboratory is responsible for:
 ◻ maintaining the stock of chemicals and
minimizing chemical wastes;
◻ managing chemical wastes.

5.2 Sub-contracting, regional cooperation

In certain circumstances the ICRC may have to choose a transport/treatment/disposal
solution outside the hospital, either by requesting the services of a private company or by
organizing cooperation amongst the health-care facilities in the region.
The hospital remains responsible under all circumstances for the wastes it produces and for
their impact on persons or the environment.
The facility will thus have to call in companies qualified to handle special wastes and ensure
that the treatment/disposal procedures followed by them are compatible with national
legislation and international agreements.

5.3 Initial assessment

The first stage when drawing up a waste management plan is to carry out an initial
assessment of needs and resources, that is, of describing the initial situation.
A checklist (Annex 3.2) can be used to describe the initial situation and resources. This
stage involves making an inventory and consists of gathering information on national waste
policy and legislation, local waste management practices and the staff involved.
It will be up to the water and habitat engineer (or, in his/her absence, the hospital
administrator) to draw up this inven- tory together with the members of the waste
management group and the heads of department and consulting the national authorities,
where possible.
Form 3.1 (Annex 3) can be used to evaluate the quantity of waste produced by the hospital.
The categories used must match those registered in the national directives (policies,
legislations and regulations). Where there are no such directives, the waste categories set out
in the present manual (Table 2.1) must be referred to. The purpose of
this stage of the procedure is to determine the quantity of waste produced per category and
per department.

5.4 Preparing the waste management plan

A draft waste management plan will then have to be drawn up using the data that has been
collected. It must contain the following chapters:

Table 5.1: Tools for drafting the waste management plan

 Stages Tools

Inventory Quantification of waste,

Annex 3.1 Checklist for
describing the current
situation, Annex 3.2

Minimization/recycling and purchasing Chapter 6

policy
Sorting, collection, storage and transport Chapters 7, 8 and 9

Identification and evaluation of Chapter 10

treatment/ disposal options - Diagram of
Example: Annex 3.3
waste flows

Protective measures Chapter 11

Training Chapter 12
Estimating costs Section 5.5

Implementation strategy Audit and Section 5.6

follow-up
Audit checklist, Annex 3.4

9.Further information can be found in the following publication: CEHA, Basic steps in the
preparation of health care waste management plans for health care establishments, 2002,
www.emro.who.int/ceha

A diagram of waste flows should summarize the sorting procedures and treatment chains for
the various types of waste. An example of the system used in Lokichogio (Kenya – 2001) is
included in Annex 3.3.

5.5 Estimating costs

Medical waste management costs vary widely depending on the context, the amount of waste
generated, and the treatment methods chosen. A WHO estimate dating from 2003 shows that
in a small health-care facility the cost per kg of waste incinerated in a SICIM-type single-
chamber incinerator can range from $0,08/kg to $1,36/kg.

The following factors must be considered in the cost estimate:109

 ◻ Investment costs:
cost of the land;
cost of building/purchasing infrastructures (such as an incinerator, a storeroom, or a waste
burial pit);
vehicles;
on-site means of transport (such as
wheelbarrows); bag stands or containers;
personal protective equipment (clothes, boots).

◻ Operating costs
fuel or electricity or water;
spare parts, maintenance of treatment facilities;
staff salaries;
sharps containers and bags;
vehicle maintenance;
personal protective equipment (gloves, masks);
training.

10. Tools for estimating costs: Health-care waste management. Costing Analysis Tool (CAT). Expanded
Costing Analysis Tools (ECAT). http://www. healthcarewaste.org

5.6 Implementing the waste management plan

The hospital project manager is responsible for implement- ing the waste management plan.
He can delegate certain tasks to the water and habitat engineer or the hospital administrator.
The implementation of the plan includes the following steps:

◻ approval and signing of the waste management plan;

◻ allocation of resources;

◻ assignation of tasks;

◻ organization of training;
◻ regular audits and monitoring, on-going improvement of the waste management plan.
A sample checklist for audits is included in Annex 3.4.
6. MINIMIZATION, RECYCLING
The reduction of waste generation must be encouraged by the following practices:

◻ Reducing the amount of waste at source

Choosing products that generate less waste: less wrapping material, for example.
Choosing suppliers who take back empty containers for refilling (cleaning products);
returning gas cylinders to the supplier for refilling.
Preventing wastage: during care, for example, or of cleaning activities.
Choosing equipment that can be reused such as tableware that can be washed rather than
disposable tableware.
It is prohibited to re-use needles or syringes. The plastic part of syringes is recycled in some
regions, but this practice is not recommended in ICRC contexts.

◻ Purchasing policy geared to minimizing risks

Purchase of PVC-free equipment (choosing PET, PE or PP) - see Health Care Without Harm
site.11
Purchase of mercury-free equipment: mercury-free thermometers (ICRC standards), mercury-
free blood pressure gauges).
If possible, purchase of new safe injection and blood- sampling systems (where the needle is
withdrawn automatically).
Opting for the least toxic products (cleaning products, for example)
◻ Product recycling
Recycling of batteries, paper, glass, metals and plastic.
Composting of plant waste (kitchen and garden wastes).
Recycling of the silver used in photographic processing.
Recovering energy for water heating for example.

 Stock management
Centralized purchasing.
Chemical and pharmaceutical stock management aiming to avoid a build-up of expired or
unused items: “first-in – first out” stock management, expiry date monitoring.
Choice of suppliers according to how promptly they deliver small quantities and whether
unused goods can be returned.
7. SORTING, RECEPTACLES
AND HANDLING
7.1 Sorting principles
Sorting consists of clearly identifying the various types of waste and how they can be
collected separately. There are two important principles that must be followed:
Waste sorting must always be the responsibility of the entity that produces them. It must be
done as close as possible to the site where the wastes are produced.
For example, the nursing staff must dispose of sharps in needle containers located as close as
possible to the place where the needles are used so as to avoid any manipulation of used
needles. Ideally, the nursing staff will take the nee- dle container to the patient’s bedside. Do
not put the caps back on syringe needles or remove them from the syringe by hand! It is
much too dangerous to do so.

Maintain sorting throughout the chain (in storage areas and during transport).
There is no point in sorting wastes that undergo
the same treatment process, except for sharps, which must always be separated at source
from other wastes.

Sorting is a significant stage in waste management, which concerns all members of staff.
Training, regular information and frequent checking are essential if the sustainability of the
system that has been established is to be guaranteed.

7.2 How to sort waste

The simplest way to identify the different types of waste and to encourage people to sort
them is to collect the various types of waste in separate containers or plastic bags that are
color coded and/or marked with a symbol. The international recommendations are as
follows:
Table 7.1 Coding recommendations (WHO – UNEP/SBC 2005)

Type of waste Color coding - symbol Type of container

0. Household refuse Black Plastic bag

1. Sharps Sharps container
Yellow and

2a. Waste entailing a Plastic bag or

risk of contamination
container
Yellow and
2b. Anatomical waste

2c. Infectious waste Yellow marked “highly Plastic bag or

container which can
infectious” and be autoclaved

3. Chemical and Brown, marked with a Plastic bag,

pharmaceutical waste suitable symbol (see container
Annex 4, chapter 4:
Labelling of chemicals).

E.g.:

In an emergency, during victim triage it is strongly recommended that all wastes generated
by this activity be considered wastes entailing a risk of contamination and should be stored
in appropriate containers (containers equipped with yellow bags).
Household refuse, in black bags, must be put through the same treatment chain as municipal
waste. But before this is done, recyclable waste and compostable materials must first be
separated at source.
The criteria for choosing sharps containers are set out in detail in data sheet no. 12 (Annex
2). Photo 7.3 shows the sharps containers used by the ICRC.
The bags must be placed either in rigid containers or on castor-fitted stands (see photos 7.1
and 7.2). In certain circumstances, if no plastic bags are available, the containers must first
be emptied, then washed and disinfected (with a 5% active chlorine solution).
Photo 7.1 Container equipped Photo 7.2 Plastic bags stand Photo 7.3 Sharps container
with a black plastic bag on castors (ICRC)
(household refuse)

There must be an adequate stock of bags and containers wherever waste is produced. This is
the responsibility of the local waste manager and the hospital administrator.
The following are the criteria for choosing plastic bags: appropriate size for the container
and the quantity of waste produced, sufficiently thick (70 μm – ISO 7765 2004) and of
suitable quality (tear-resistant), non-halogenated plastic (no PVC).
Anatomical waste cannot always be collected in yellow plastic bags for cultural or religious
reasons. It must be treated in accordance with local customs (often buried).
Chemical and pharmaceutical wastes must be sorted and treated separately. The sub-
categories include mercury wastes, light bulbs, batteries, photographic developers, laboratory
chemicals, pesticides and medicines.
7.3 Handling of bags
8.COLLECTION AND STORAGE
Waste must be collected regularly - at least once a day. It must never be allowed to
accumulate where it is produced. A daily collection programme and collection round must be
planned. Each type of waste must be collected and stored separately.
Infectious wastes (categories 1 and 2) must never be stored in places that are open to the
public.
The personnel in charge of collecting and transporting wastes must be informed to
collect only those yellow bags and sharps containers which the care staff have closed.
They must wear gloves.
The bags that have been collected must be replaced immediately with new bags.
A specific area must be designated for storing medical waste and must meet the
following criteria.

◻ it must be closed, and access must be restricted to authorized persons only;

◻ it must be separate from any food store;

◻ it must be covered and sheltered from the sun;

◻ the flooring must be waterproof with good drainage;

◻ it must be easy to clean;

◻ it must be protected from rodents, birds and other animals;

 ◻ there must be easy access for on-site and off-site means of transport;

◻ it must be well aired and well lit;

◻ it must be compartmented (so that the various types of waste can be sorted);
◻ it must be near the incinerator, if incineration is the treatment method used;

◻ there must be wash basins nearby;

◻ the entrance must be marked with a sign (“No unauthorized access”, “Toxic”, or “Risk of
infection” – see Annex 4, Sections 1 and 2).
 9. TRANSPORT

9.1 Vehicles and means of conveyance

These means of conveyance must meet the following requirements:

◻ they must be easy to load and unload;

◻ they must not have any sharp corners or edges that might tear the bags or damage
the containers;
◻ they must be easy to clean; (with a 5% active chlorine solution);

◻ they must be clearly marked.

Furthermore, off-site means of transport must meet the following requirements:

◻ they must be closed to avoid any spilling on the road;

◻ they must be equipped with a safe loading system (to prevent any spilling inside or
outside the vehicle);

◻ they must be marked according to the legislation in force if the load exceeds 333 kg
(see Annex 3.5).

The vehicles and means of conveyance must be cleaned daily.

9.2 On-site transport
Different means of conveyance may be used inside the facility – wheelbarrows, containers
on wheels, carts (see photos 9.1 and 9.2).

Photo 9.1: An example of a Photo 9.2: An example of

on-site means of conveyance an on-site means of conveyance
(Lokichogio, 2001) (container on wheels)

Inside the facility, wastes must be transported during slacker periods. The itinerary must be
planned to avoid any exposure of staff, patients or the public. It must run through as few
clean zones (sterilization rooms), sensitive areas (operating theatres, intensive care units) or
public areas as possible.

9.3 Off-site transport

The entity producing the waste is responsible for packaging and labelling the waste to be
transported outside the hospital.
Packaging and labelling must be in conformity with national legislation on the transport of
dangerous sub- stances and with the Basel Convention in the case of cross-border transport.
If there is no national legislation on the subject, the [United Nations] Recommendations on
the Transport of Dangerous Goods13 or the European Agreement on the International
Carriage of Dangerous Goods by Road (ADR)14 should be referred to.

If a vehicle is carrying less than 333 kg of medical waste entailing the risk of contamination
(UN 3291), it is not required to be marked. Otherwise, it must bear sign plates.

See Annex 3.5 for further information.

9.4 Cross-border transport

The Basel Convention lays down stringent regulations on the export of wastes. Enquiries
must be made in each individual country as to the provisions in effect. In the case of
Pakistan, for example, which is a signatory of the Basel Convention but has not ratified its
amendments, the requirements are laid down in the Pakistan Environmental Protection Act –
1997.

According to the Basel Convention, the code for clinical wastes from medical care
provided in hospitals, medical center's and clinics is Y1. The code for unwanted/unused
drugs is Y3. And the code for wastes generated in the pro- duction, preparation and use of
photographic products and materials is Y16.
10. TREATMENT AND DISPOSAL
10.1 Choosing treatment and disposal methods
The choice of treatment and disposal techniques depends on a number of parameters: the
quantity and type of wastes produced, whether or not there is a waste treatment site near the
hospital, the cultural acceptance of treatment methods, the availability of reliable means of
transport, whether there is enough space around the hospital, the availability of financial,
material and human resources, the availability of a regular supply of electricity, whether or
not there is national legislation on the subject, the climate, groundwater level, etc.

The method must be selected with a view to minimizing negative impacts on health and the
environment. There is no universal solution for waste treatment. The option chosen can
only be a compromise that depends on local circumstances.

Where there is no appropriate treatment infrastructure in the vicinity, it is the responsibility of

the hospital to treat or pre-treat its wastes on-site. This also has the advantage of avoiding the
complications involved in the transport of hazardous substances (see previous chapter).

The following treatment or disposal techniques may be used for hazardous medical
waste, depending on the circumstances and the type of waste concerned:
◻ disinfection:
chemical: addition of disinfectants (chlorine dioxide, sodium hypochlorite, peracetic acid,
ozone, alkaline hydrolysis);
thermal
low temperatures (100° to 180°C): vapor (autoclave, micro-waves) or hot air (convection,
combustion, infrared heat);
high temperatures (200° to over 1000°C): incineration (combustion, pyrolysis and/or
gasification); by irradiation: UV rays, electron beams; biological: enzymes;

◻ mechanical processes: shredding (a process which does not decontaminate the waste);

◻ encapsulation (or solidification) of sharps;

◻ burial: sanitary landfills, trenches, pits.

The techniques most likely to be used in ICRC operations are described in the present
chapter along with their advantages and disadvantages.
The appropriate treatment and disposal techniques for the various types of waste are set out
in Table 10.1 (and in the data sheets in Annex 1).

Table 10.1 Suitability of treatment techniques by type of waste

Type of waste / 1. Sharps 2a. Waste 2b. 2c. 3a. 3d.

Technique entailing risk Anatomical Infectious Medicinal Chemical
of waste waste waste waste
contaminatio
n

Rotary kiln yes yes yes yes yes yes

900-1200°C

Pyrolytic or yes yes yes yes no no

dual chamber
incinerator
>800°C

Single-chamber yes yes yes yes no no

incinerator
with with with with
300°-400°C
precaution precautions precautions precautions
s

Chemical yes yes no yes no no

disinfection
Autoclave yes yes no yes no no
Encapsulation yes no no no yes yes
small
quantities

On-site burial yes yes yes yes yes no

pit
after small
decontamina quantities
tion

Needle pit yes no no no yes no

small
quantities

Off/site sanitary yes yes no yes no no

landfills
small with after
quantities, precautions decontamina
 using tion
encapsulat
ion

Figure 10.1 is an example of a diagram intended to support decision-making on the treatment

methods to be used in the absence of appropriate regional infrastructures.

Figure 10.1 Example of a diagram intended as a guide for deciding on the

treatment/disposal methods to be used in the absence of appropriate regional
infrastructures

10.2 Incineration
Controlled incineration at high temperatures (over 1000°C) is one of the few technologies
with which all types of health-care waste can be treated properly and it has the advantage of
significantly reducing the volume and weight of the wastes treated.
However, modern large-scale processing plants such as high-temperature incinerators are not
a solution for hospitals; they are designed for centralized networks. Enquiries should be
made as to whether there is an infrastructure of this nature in the region. Another possibility
is to use a household refuse incineration plant. This type of plant generally operates at over
850°C. But medical waste must be fed directly into the kiln hopper, thus bypassing the
bunker.
Cement works incinerators or the blast furnaces used in the metal industry can also
provide an accept- able local solution, although not normally recommended for the
incineration of medical waste (because the waste loading system is not secured and the
emissions are not treated).
There are simple incinerator models for treating small quantities of medical waste. Some are
available on the market, and others must be built with local materials on the spot according
to relatively simple plans. These incinerators consist essentially of one or two combustion
chambers (the primary and secondary chambers) and a discharge chimney. The combustion
and air-borne emission control system is simple; indeed, in some cases there is none.

Links for the technical specifications for small incinerators:

◻ Publication prepared with the assistance of the WHO, Africa Region, Managing
Health Care Waste Disposal (WDU): http://www.healthcarewaste.org/documents/
WDU_guidelines2_en.pdf
◻ See http://www.mw-incinerator.info/en/101_welcome.
html, for further information on the construction of De Montfort incinerators.

There are two De Montfort models – to be constructed with local materials – that can be
considered for ICRC hospitals: the De Montfort 8a (12 kg/h, for hospitals with less than 300
beds) or the De Montfort 7 (for emergencies). These small incinerators are composed of two
combustion chambers. They cost Sfr 1,000 and can be built in three or four days. The
manufacturer indicates a temperature of 800°C in the secondary chamber. The principle of
the De Montfort incinerators is illustrated in Figure 10.2.
Figure 10.2: The principle of De Montfort incinerators (Pr. D.J. Picken)

1 Loading door
2 Primary
combustion

chamber
3 Air inlet
4 Fire grate

5 Ash door
6 Gas transfer
tunnel
7 Secondary
combustion
chamber
8 Chimney
Incinerators can also be imported and assembled on the spot without the use of local
materials. These facilities are generally more reliable, if there is a reliable source of
electricity. They guarantee combustion temperatures of over 800°C and even over 1000°C.
However, they are also more expensive and require more maintenance.

If infectious medical waste is treated in small single-cham- ber or dual-chamber incinerators

on site, fractions of waste such as drugs, chemicals, halogenated materials or wastes with
high heavy metal content (such as batteries, broken thermometers, etc.) must not be treated
in this type of facility. The following best practices must be borne in mind with a view to
minimizing pollutant emissions:161
◻ reduction of waste generated and sorting of wastes at the source.

◻ good incinerator design to ensure optimal combustion conditions: extension of the chimney
(if the height of the chimney is doubled from 3 to 6 meters, the concentrations of pollutants in
the air are 5 to 13 times lower).17

◻ installation of incinerators far from inhabited or cultivated areas;

◻ best operating practices: appropriate startup and cooling, care to obtain a sufficiently high
temperature before feeding the wastes in, adherence to the correct quantity of waste and
fuel, regular removal of ash; the incinerator should be lit with paper, wood or fuel oil; after
30 minutes, small quantities of waste should be loaded at regular intervals (5-10 minutes);
wet waste must be mixed with drier waste; sharps containers must be loaded one by one; the
incinerator must run for long periods (at least 2 hours); heavy-duty gloves, a body
protection, and goggles must always be worn as well as a respirator whenever ash is being
removed;
◻ no incineration of PVC plastics or other wastes containing chlorine;

◻ regular planned maintenance: replacement of faulty parts, inspection, inventory of

spare parts;

◻ regular training for operators, operating manual;

◻ emission control: emissions must not exceed the national limit values, and they
must comply with the BAT/BEP18 recommendations set forth in the Stockholm
Convention.
And lastly, the burning of hazardous medical waste (uncontrolled incineration in barrels or at
dumps) must be always avoided because of the risk for staff, which is due not only to the
emission of toxic gases but also to the fact that infectious wastes are not fully burnt. In an
emergency, how- ever, incineration in a barrel can be a temporary solution until a better
solution is found. In this case, care must be taken to use a barrel with sufficient air intake
below the combustion flame and to protect the top with fine wire mesh (to contain the ash).
It should be noted that Annex C of the Stockholm Convention rejects techniques of
uncontrolled incineration in barrels, at dumping sites or in single- chamber incinerators.
These techniques must be regarded as provisional arrangements.
Table 10.2 Advantages and drawbacks of incineration

Incineration Advantages Drawbacks

High-temperature ◻ The waste is destroyed. ◻ High construction costs (Sfr 25,000

incinerator to 100,000 − Sfr 350,000 in the case
(>1000°C) Rotary ◻ The waste is not recognizable.
of rotary kilns).
kiln (>1200°C) ◻ Waste volume and weight ◻ Relatively high operating and
are significantly reduced. maintenance
◻ Large quantities of waste can costs; the more sophisticated
be treated. the emission
◻ Toxic emissions are reduced. control system, the higher the costs.
◻ Suitable for all types of waste. ◻ Requires electricity, highly skilled
staff, and fuel.

◻ Produces ash that contains

leached metals, dioxins and furans.

Dual-chamber ◻ Micro-organisms are destroyed. ◻ Relatively high investment costs

incinerator (800°- (Sfr 15,000)
900°C) Household ◻ Waste volume and weight
are significantly reduced ◻ Needs fuel.
refuse incineration
(>95%).
plant ◻ Requires skilled staff and
◻ All types of organic waste permanent monitoring.
(liquid and solid) are destroyed.
◻ Emission of toxic flue gas
◻ Large quantities of waste can (including dioxins and furans).
be treated.
◻ Sharps are not destroyed.

◻ Unsuitable for chemical

and pharmaceutical wastes.

◻ Produces ash that contains

leached metals, dioxins and furans.
Single chamber ◻ Relatively effective disinfection. ◻ Needs fuel.
incinerator (300°- ◻ Waste volume and weight ◻ Wastes are only partially burnt –
400°C) are significantly reduced. risk of incomplete sterilization.
◻ Simple and cheap (Sfr 1000). ◻ Significant levels of emission
of atmospheric pollutants.
◻ Soot needs to be
removed periodically.
 ◻ Ineffective for destroying
heat- resistant
chemicals or pharmaceuticals.

◻ Sharps are not destroyed.

◻ Produces ash that contains

leached metals, dioxins and furans.

10.3 Chemical disinfection

Chemical disinfection, which is commonly used in health facilities to kill micro-organisms on
medical equipment, has been extended to the treatment of health-care wastes. Chemicals are
added to the wastes to kill or inhibit pathogens. However, the chemicals that are used
themselves entail a health risk for the people who handle them and a risk of environmental
pollution.
This type of treatment is suitable mainly for treating liquid infectious wastes such as blood,
urine, faces or hospital sewage. Typically, a 1% bleach (sodium hypochlorite) solution or a
diluted active chlorine solution (0.5%) is used. In the case of liquids with high protein
content, such as blood, a non-diluted solution of bleach is required as well as a contact time
of more than 12 hours. Pay caution that when bleach is mixed with urine, toxic gases are
formed (combination of chlorine and ammonia). Furthermore, liquid waste that has been
disinfected with chlorine must not be discharged into a septic tank.
The other disinfectants used are as follows: lime, ozone, ammonium salts and peracetic acid.
Formaldehyde, glutaraldehyde and ethylene oxide must no longer be used because of their
toxicity (carcinogenic or sensitizing properties). All strong disinfectants irritate the skin,
eyes and respiratory system. They must be handled with caution – in particular, personal
protective equipment must be used – and they must be stored correctly.
Solid medical waste can be chemically disinfected, but they must first be shredded. This
practice poses several safety problems, and the wastes are only disinfected on the surface.
Thermal disinfection must be preferred over chemical disinfection for reasons of
effectiveness and for ecological reasons.

Table 10.3: Advantages and drawbacks of chemical disinfection

Advantages Drawbacks

◻ Simple. ◻ The chemicals used are

themselves dangerous substances,
◻ Relatively cheap.
which must be handled with caution.

◻ Disinfectants are widely ◻ For proper disinfection,

available. the prescribed
contact time and concentrations must
be
 complied with.

◻ The waste volume is not reduced.

◻ The wastes must be shredded

/mixed before being treated
with chemicals.

◻ The final disposal method must

be the same as for untreated medical
waste.

◻ The process generates dangerous

effluents, which need to be treated.

◻ Mixing chlorine/hypochlorite with

organic matter or ammonia creates
toxic substances.

10.4 Autoclaving
Autoclaving is a thermal process at low temperatures where waste is subjected to pressurized
saturated steam for a sufficient length of time to be disinfected (60 minutes at 121°C and 1
bar). Where prions (which cause Creutzfeldt- Jakob’s disease) are present, a cycle of 60
minutes at 134°C is recommended, since they are exceptionally resistant.19 Efficiency tests
(biological or thermal) must in any case be carried out regularly.
Autoclaving is environmentally safe but, in most cases, it requires electricity, which is why
in some regions it is not always suitable for treating wastes.
Small autoclaves are frequently used for sterilizing medical equipment, but the models used
for treating health- care wastes can involve relatively complex and expensive plants (with
internal mixing, shredding and drying systems) requiring meticulous design, proper sorting
and a high level of operating support and maintenance. Furthermore, the effluents must be
disposed of carefully and properly monitored. And lastly, large autoclaves may require a
boiler that generates several types of emissions, which must be monitored.
Once wastes have been processed in an autoclave, they are no longer infectious materials:
they can be landfilled with municipal refuse. Autoclaving is often used for pre-treating
highly infectious waste before it is transported outside the hospital.

Table 10.4: Advantages and drawbacks of steam disinfection

 Advantages Drawbacks

◻ Autoclaved waste becomes ◻ Moderate to high installation

safe household refuse. costs (Sfr 500 to 100,000).
◻ Health facilities are familiar ◻ Requires electricity.
with this processing method.
◻ Produces contaminated effluents,
◻ Ecologically sound which need to undergo special
technology. treatment.
◻ Facilitates the recycling ◻ In some cases a boiler is
of plastics. needed with emission control.
◻ Low operating costs. ◻ Unsuitable for chemical
or pharmaceutical wastes.
◻ The appearance of the waste
does not
change.

◻ Shredding is essential to avoid

re- use.
◻ The weight of the waste does
not change.
◻ Unpleasant Oduors.

◻ Presence of chemicals which

can generate toxic fumes.
◻ Slow and time-consuming.

10.5 Needle extraction or destruction

For safety reasons, the ICRC does not recommend that needles be extracted or destroyed,
although this practice is followed in certain circumstances, mainly for two reasons: when the
needles are removed from used syringes they cannot be re-used, and, secondly, the volume
of sharps is reduced.
Some appliances run on electricity (destroying the needles by melting) and cannot be used
widely in ICRC contexts, particularly in remote areas. Furthermore, these appliances require
regular maintenance and must be handled with care.
Needles can also be removed from syringes immediately after the injection by means of small
manually operated devices. The needles are then discarded into the sharps pit. Plastic
syringes must be disinfected before being disposed of in the household refuse chain or in
plastics recycling.
Further information on needle extractors can be obtained from the Program for Appropriate
Technology in Health (PATH)201 or on the WHO website.

Table 10.5 Advantages and drawbacks of needle extractors and destroyers

Advantages Drawbacks

Needle ◻ Prevents re-use of syringes ◻ Risk of splashing body

extractor and needles. fluids.
◻ Relatively cheap models ◻ Some models run
(Sfr 2 to Sfr 80) are on electricity.
available that are
◻ The needles and
manufactured locally.
syringes remain
contaminated.
◻ The volume of sharps is
◻ Risk of breakdown of
reduced. destroyer.

◻ Plastic from syringes ◻ The needles are prone

can be recycled after being to come out of the
disinfected and shredded. receptacle.

◻ Easy to use. ◻ The safety of the

process has not been
established.
Needle ◻ Destroys the needles ◻ Cost (Sfr 100 to Sfr 600).
destroyer There should be one in each
completely.
room or ward.
◻ Plastic from syringes can
◻ Requires electricity.
be recycled after being
disinfected and shredded. ◻ A sterile part of the
needle remains attached to
the syringe.

10.6 Shredders
Shredders cut the waste into small pieces. This technique requires competent staff for
operating and maintaining the device, since some of these rotary devices are industrial
models. They are often built into closed chemical or thermal disinfection systems. However,
grain mills can be converted into simple shredders, but due to the risk for staff while the
shredder is running only disinfected waste should be treated in these devices. Shredding,
which in certain circumstances provides a means of recycling plastics and needles, should be
considered whenever needles and syringes are available in large quantities, this involves a
centralized system for collecting and transporting wastes from the various facilities.

Table 10.6 Advantages and drawbacks of shredders

Advantages Drawbacks

◻ Makes the ◻ Requires electricity.

waste
unrecognizable. ◻ Some facilities are
very expensive.
◻ Prevents the re-use of
needles and syringes. ◻ The shredder can be damaged
by large pieces of metal.
◻ Reduces volume.
◻ The waste is not disinfected.
◻ Facilitates the recycling
of plastics. ◻ The staff are exposed to air-
borne pathogens when
◻ Enhances the effectiveness of untreated waste is shredded.
chemical or thermal treatment in
closed and integrated systems. ◻ Requires skilled staff
and permanent
monitoring.

10.7 Encapsulation
Encapsulation (or solidification) consists of containing a small number of hazardous items or
materials in a mass of inert material. The purpose of the treatment is to prevent humans and
the environment from any risk of contact.

Encapsulation involves filling containers with waste, add- ing an immobilizing material, and
sealing the containers. The process uses either cubic boxes made of high-density
polyethylene or metallic drums, which are three-quarters filled with sharps, chemical or
pharmaceutical residues, or incinerator ash. The containers or boxes are then filled up with a
medium such as plastic foam, bituminous sand, lime, cement mortar, or clay. Once the
medium has dried, the containers are sealed and disposed of in a sanitary landfill or waste
burial pit.

The following proportions are recommended, for exam- ple: 65% pharmaceutical waste,
15% lime, 15% cement, 5% water.
The main advantage of the process is that it is very effective in reducing the risk of
scavengers gaining access to the hazardous waste. Encapsulation of sharps is generally not
considered to be a long-term solution. Encapsulation of sharps or unwanted vaccines could,
however, be envisaged in temporary settings, such as camps or vaccination campaigns.
Table 10.7 Advantages and drawbacks of encapsulation

Advantages Drawbacks

◻ Simple, inexpensive and safe. ◻ To be regarded as a

temporary solution.
◻ A solution that can be
envisaged for sharps and ◻ The quantities of waste
pharmaceutical wastes. treated are small.
◻ The risks for scavengers ◻ The weight and volume of
are reduced. the waste is increased.

10.8 Disposal in a sanitary landfill or waste burial pit

The disposal of untreated health-care waste in an uncontrolled dump is not recommended
and must only be used as a last resort.

It can be disposed of in a sanitary landfill, subject to certain precautions: it is important that

health-care waste be covered rapidly. One technique is to dig a trench down to the level
where old municipal refuse (over three months old) has been buried and to immediately
bury health-care waste that is discarded at this level under a 2-metre layer of fresh
municipal refuse.

The following are the essential factors that must be taken into consideration in the design and
use of a sanitary landfill:

◻ access must be restricted and controlled;

◻ competent staff must be available;

◻ the discarding areas must be planned;

◻ the bottom of the landfill must be waterproofed;

◻ the water table must be more than 2 meters below the bottom of the landfill;
◻ there must be no drinking water sources or wells in the vicinity of the site;

◻ chemicals must not be disposed of on these sites;

◻ the waste must be covered daily and vectors (insects, rodents, etc.) must be controlled;
◻ the landfill must be equipped with a final cover to prevent rainwater infiltration;

◻ leachates must be collected and treated.

Whenever a municipal landfill is being used, the water and habitat engineer must inspect the
site before hazardous medical waste is discarded there.

Further information on the design of sanitary landfills can be found in Solid Waste Landfills in
Middle- and Lower- Income Countries: A Technical Guide to Planning, Design, and
Operation. Rushbrook, Philip and Pugh, Michael. 1999. World Bank Technical Paper No.
426. The World Bank, Washington, D.C. pp. 248.

A purpose-built burial pit could also be used, preferably on the hospital site. Ideally, the pit
should be lined with low- permeability material such as clay to prevent the pollution of
shallow groundwater and should be fenced in to prevent scavenger access. Health-care
wastes must be buried immediately under a layer of soil after each unloading operation. It is
suggested that lime be spread on the waste for added health protection (in the event of an
epidemic, for example) or to eliminate Oduor. The pit should be sealed once it has been
filled.

Examples of burial pits or wells for anatomical waste or sharps are presented in Annex 2
(data sheets 13, 14 and 15).
Table 10.8 Advantages and drawbacks of disposal by burial

Advantages Drawbacks

Sanitary ◻ Simple and ◻ The health-care wastes are

landfill, inexpensive not treated and remain
trench operating costs. hazardous.
method
◻ Can be carried out ◻ The landfill must be
secure, fenced in, and
guarded.
using an existing ◻ Scavengers and animals need to
municipal waste be
management system.
controlled.
◻ Scavengers cannot
◻ A high degree of coordination is
access the health-care
needed between collectors and
waste if the landfill is
landfill operators.
well managed.
◻ Makes health workers less
aware of the need to sort the
various types of waste.

◻ Transport to the landfill can be

lengthy
and costly operation.

◻ Risk of water pollution.

Separate pit ◻ Simple and ◻ The health-care waste is

on hospital relatively not treated and remains
site inexpensive to build hazardous.
and manage.
◻ Risk of water pollution.
◻ Problem of Oduor.
◻ Dangerous
◻ Vectors (insects, rodents, etc.)
substances are not
need to be
transported outside
the hospital. controlled.
◻ Control is ◻ Space is needed around
facilitated. the hospital.

10.9 Disposal of liquid wastes in the sewage

In general, the sewage system should not be used to dispose of chemicals. It is strictly
prohibited to dilute wastewater discharges so that the concentration falls below the
exemption thresholds in force in the country. Scientific or legislative data on exemption
thresholds are rare. The exemption thresholds in effect in Switzerland are set out in Table
10.9.
Table 10.9 Permissible limits in force in Switzerland (Decree on water protection,
Switzerland)

Chemicals Permissible limits Practical disposal

Acids – alkalis pH between 6.5 et 9 Exceptions are allowed if the

chemicals are mixed with
enough other sewer effluents.

Silver 50 mg/l If less than 1000 litres are

produced per year.
Total hydrocarbons 20 mg/l Tolerance allowed for
Organic solvents products which biodegrade
easily, and which are
disposed of in small
quantities, provided there is
no noteworthy effect on
health or the environment.

Volatile halogenated 0,1 mg/l Chlorine No tolerance.

hydrocarbons
Volatile halogenated
solvents
11. STAFF
PROTECTION
MEASURES

The handling of waste entails health risks for staff through- out the chain. The purpose of
protective measures is to reduce the risks of accident/exposure or the consequences.
Preventive measures can be divided into two categories: primary and secondary. Primary
prevention comprises four levels of action:

Primary prevention:

◻ Eliminating hazard: for example, by using fewer toxic substances, eliminating mercury,
or using self-locking injection equipment.
◻ Collective and technical prevention: for example, using needle receptacles, ventilation.

◻ Organizational prevention: such as assigning duties and responsibilities to all

involved, management (sorting, packaging, labelling, storage, transport), best practices
(such as refraining from putting the caps back on syringes), training.

◻ Individual prevention: personal protective equipment,

vaccination, washing hands.

Secondary prevention:
Measures in the event of an accident (accidental exposure to blood, spills).

The local waste manager, hospital administrator and head nurse will be responsible for
checking regularly to see whether the protective measures are being complied with. The
water and habitat engineer must analyze risks on a regular basis to monitor the effectiveness
of the measures taken and to identify any additional steps to be taken.

Protective measures depend on the risk concerned. In addition to the risk of infection, the
other risks must be borne in mind: chemical risks, mechanical risks involved with
machinery/plants, risk of burns (incinerators, autoclaves), risks associated with physical load
or the absence of ergo- nomic principles (when drums that are unsuitable for containing
wastes are being shifted, for example), risk of falling when working in wet areas, etc.

11.1 Personal protective equipment

The following personal protective equipment is generally available:

Table 11.1 Personal protective equipment (PPE)

Face protection - visor To be worn during all activities where

Eye protection – safety body fluids or chemicals are liable to be
goggles splashed, and for work at an incinerator.

Respiratory protection – FFP1 dust respirators23 for staff

masks and respirators involved in any activity that generates
dust (removing ash, sweeping out the
waste storage facility).
FFP2 respirators24 for staff involved in
handling waste from patients suffering, for
example, from tuberculosis.
N.B.:

◻ FFP1-FFP2-FFP3 dust respirators do

not provide protection from gas and fumes
(such as mercury or solvent fumes);
◻ surgical masks protect the patient;
they provide
only limited protection for staff (see
Photos 11.1
and 11.2).
 Body protection – aprons, For staff involved in collecting,
protective suits transporting and treating wastes.
Hand protection – gloves Disposable gloves for care staff or cleaning
staff (vinyl
or nitrile).
Disposable gloves for laboratory staff
(nitrile). Heavy-duty protective gloves
for staff involved in transporting and
treating wastes.
N.B.:

◻ latex gloves are to be avoided (can

cause allergy);
◻ nitrile is more chemical-resistant
and tear-resistant than vinyl.

Foot and leg protection – Closed, non-slip shoes for all staff.
boots, shoes Puncture-proof safety shoes or
boots.

Standard EN149: 2001 and European Directive 89/686/EEC on personal protective

equipment (PPE).
See the following publications for further details: GERES, Manuel pratique : prévention
et prise en charge des AES, 2008, or WHO/ ILO, Post-exposure prophylaxis to prevent
HIV infection, 2007. http://whqlibdoc.who.int/publications/2007/9789241596374_
eng.pdf
Photo 11.1: Surgical mask Photo 11.2: FFP1, FFP2,
FFP3 respirator
◻ Protects against aerosols exhaled by the wearer ◻ Protects the wearer against the
risk ◻ Effectiveness rated for exhalation of inhaling
particles (dust)

11.2 Personal hygiene

Elementary personal hygiene is important for reducing risks of infections and breaking the
infection chain when medical waste is being handled.
Washing one’s hands meticulously with enough water and soap eliminates over 90 %
of the micro-organisms present.

Ideally, wash basins with hot water and soap should be installed wherever wastes are
handled (storage and treatment areas).

11.3 Vaccination
The hepatitis B virus disease can be avoided by vaccination, which has been available since
1980. Numerous studies have shown that the vaccine is effective in preventing all of the
forms of infection with hepatitis B virus. Although this vaccination is safe, effective and
cost- efficient, it is still under-used.
Staff handling wastes must be appropriately protected by vaccination, including vaccination
against hepatitis A and B and tetanus.
11.4 Measures to be taken in the event of accidental exposure to blood

See the following publications for further details: GERES, Manuel pratique : prévention et
prise en charge des AES, 2008, or WHO/ILO, Post-exposure prophylaxis to prevent HIV
infection, 2007. http://whqlibdoc.who.int/ publications/2007/9789241596374_eng.pdf.
The risk of the infection being transmitted after a needle- prick injury is presented in Table
11.2.

Table 11.2 Risk of transmission of infection after percutaneous exposure to

contaminated blood

Virus Risk of transmission of infection

HIV 0,3 %
Hepatitis B Virus 5-30 %
Hepatitis C Virus 1-3 %

AEB management should comprise the following:

◻ the measures to be taken in the event of an accident must be displayed on a poster

(a sample poster is shown in Annex 3.6):
wash the contaminated area with soap and water; do not make the area bleed; disinfect the
area (freshly diluted bleach (0.5%), active chlorine or Betadine® or 70° alcohol or stabilized
Dakin’s solution, contact time of more than 5 minutes); telephone number at which
competent help is always available.

◻ a competent person must take charge of the situation (evaluation, tests, post-exposure
prophylaxis [HIV, tuberculosis, hepatitis B], follow-up, information, psychological care
for the victim);

◻ registration of incidents/accidents, investigation

and corrective action.
Post-exposure prophylaxis reduces the risk of developing the HIV disease by 80%.
11.5 Emergency measures in the event of spills or contamination of surfaces
Most accidents involving the spilling of chemicals or infectious material occur in
laboratories. But accidents can also involve mercury waste (breaking a thermometer, blood
pressure gauge or glass receptacle containing mercury) or they can occur during the
transport of chemical wastes (knocking over poorly closed cans, breaking glass bottles), or if
bags containing infectious wastes tear.

Spills of infectious biological material on a mattress or on the floor

◻ Change gowns and clothes that are visibly soiled immediately.

◻ Warn the other colleagues present and protect the contaminated area.

◻ Wear disposable gloves and, if aerosols are present, goggles and a respirator for
protection from particles (FFP1 or FFP2).
◻ Cover the contaminated area with absorbent paper soaked with disinfectant.

◻ Cover the contaminated area with a disinfectant, working in concentric circles from the
edges towards the Centre. Avoid spraying the disinfectant or pouring it from a height,
since this can produce aerosols.
◻ Let the disinfectant take effect, depending on its properties (generally at least 3 minutes).

◻ Sponge the area and dispose of all the wastes and soiled material in the appropriate
container (infectious wastes). Be very careful with fragments of sharps, which must be
picked up with tweezers and placed in the sharp's container.

◻ Disinfect all the items on the mattress, the surface of furniture or equipment that
might have been contaminated.
◻ Remove personal protective equipment, dispose of the
contaminated material in the infectious waste bin and autoclave it (or, if there is no autoclave,
incinerate it).
◻ Disinfect your hands.
◻ Register the accident.t.

Chemical spill procedure

◻ Warn people in the immediate area.

◻ Put on gown, gloves and protective goggles.
 ◻ Avoid breathing fumes.

◻ If the spilled substances are flammable, switch off all sources of ignition and heat.

◻ Open the windows and air the area; close the doors of the affected rooms.
◻ Cover the spill with absorbent material (absorbent cloth or granules), working from
the edges towards the center in concentric circles.
◻ Mix gently with a wooden spatula until all the
spilled chemical has been completely absorbed.
◻ Dispose of the granules or cloth as special waste.

◻ Clean the soiled area thoroughly with water (unless

the chemical concerned is incompatible with water!).

Mercury spill procedure

◻ Mark out the area to be decontaminated and prohibit access.

◻ It is essential to gather up all the mercury that has been spilled (also check under
instruments, in cracks, etc.) without dispersing it. Wear disposable (single use) gloves. Use
a mercury sponge, a glass or plastic pipette, or two sheets of paper to pick up the mercury
beads (do not use a brush or broom or a vacuum cleaner).

◻ Put the mercury and the gathering equipment in a leak-proof container. Close the
container tightly and label it as specials mercury waste and take it to the pharmacy.
◻ Shine a beam of light on the area (using a flashlight,
for example) to check that all the mercury beads have been collected.

11.6 Emergency measures if persons have been contaminated Splashing of

chemicals onto the skin and eyes

◻ Rinse the exposed areas thoroughly with water for 15 minutes, without rubbing. Do not
use a neutralizing agent or any other product (detergent, cream, etc.).

◻ If the chemical has gone into the eye, rinse the eye with running water for 10-30 minutes
(opening the eyelids wide, holding head tilted to one side with the affected eye lower
down). Consult an ophthalmologist urgently.

◻ Using gloves, remove contaminated clothing with care (in the case of chemical burns).

◻ Seek medical attention urgently.

Procedure in the event of chemical ingestion

◻ Rinse out the mouth thoroughly with water.

◻ Do not induce vomiting or give the person anything to drink.

◻ Seek medical attention urgently.

Procedure in the event of inhalation of toxic gases

◻ Leave the contaminated area immediately.

◻ Seek medical attention urgently, even if there are no symptoms.
 12. TRAINING

12.1 Why and how

The purpose of training is to develop skills on the one hand and to raise awareness on the other.
It is important to highlight the role(s) to be played by each individual staff member.

To facilitate communication amongst the various actors, it is recommended that training be

targeted at a multidisciplinary group and provided at the workplace to promote best practices
and teamwork. However, it is recommended that groups should not exceed 20 participants.

Refresher courses should be held regularly as well as courses to inform staff of any changes
that have taken place in the waste management plan and, of course, training courses for new
members of staff.

The training can be provided by the water and habitat engineer, the hospital administrator or
an external body.

Some examples of training in waste management:

◻ The WHO published a training manual entitled Teachers’ guide: management of

wastes from health- care activities26 in 1998. This training material, which contains
recommendations, is intended for a 3-day training course targeting mainly hospital
administrators, public health professionals and policy makers. The WHO also proposes a
basic 3-day training course for waste managers in care facilities.27
◻ The Indira Ghandi National Open University, New Delhi, offers a distance-learning
course in collaboration with the WHO. This is a 6-month course leading to a health- care
waste management certificate.

It is recommended that ICRC hospitals prepare training material specific to each context.
12.2 Content
This training must focus on presenting a waste management plan, the risk associated with
wastes, protective measures, the role and responsibilities of each member of staff, and
the technical instructions concerning the activities carried out by each category of staff.

Additional training for care staff

Emphasis must be laid on sorting, sharps management and AEB management.

Additional training for staff handling waste

Emphasis must be laid on sorting, collection and transport procedures, cleaning and personal
hygiene, PPE, protective measures when handling bags (see Chapter 7.3) and measures in
the event of an accident.

Additional training for staff in charge of waste treatment plants or sanitary landfills
In addition to the general modules described above, the following subjects must be covered:
plant operation, maintenance, environmental impact.

Additional training for management and administrative staff

Emphasis must be laid on national legislations and international conventions,
responsibilities, and purchasing/minimization policy.
 13. FURTHER INFORMATION

A. Prüss, E. Giroult, and P. Rushbrook, Safe management of wastes from health-care

activities,
WHO, 2010.

WHO sites (about health-care wastes):

http://www.who.int/topics/medical_waste/fr/index.html http://www.healthcarewaste.org

Non-Incineration Medical Waste Treatment Technologies, Health Care Without Harm, 2001.

Health Care Without Harm site:

http://www.noharm.org

GERES/ESTHER, Prevention et prise en charge des AES, manuel pratique, 2008.

PATH publications (needle removers and destroyers): http://www.path.org/publications/browse.php?

k=10

ISWA technical policy No. 11: Healthcare Waste, ISWA, 2007.

O. Aki Kleiner, Healthcare waste management assessment in three Afghani hospitals, ICRC,
2003.

S. Praplan, Hospital waste management in Lopiding surgical hospital, Lokichokio, Kenya,

Evaluation report, ICRC, 2001.