Friday, October 21, 2011

New Delhi
October 17, 2011

Comments/Suggestions on draft BMW Rules – 2011
From Indian Society of Hospital Waste Management (ISHWM)
in reference to extraordinary gazette dated August 24, 2011

1. Add para 3 below para 2 and renumber paragraphs

“3. Objectives: Biomedical wastes pose serious hazard to the environment and human health as it contains infectious and or hazardous waste and therefore should always be treated with appropriate technologies as approved by the CPCB and disposed without any likelihood of causing damage to the environment and adverse impact on human health”

Rationale: It is essential to insert the basic approach to BMW management so as to make all stakeholders aware of the basis of the rules.

2. Add para 4 as under and renumber the paragraphs:

“There are certain cardinal principles which should be kept in mind while drafting protocol/standard operating procedure for BMW management in hospitals and other healthcare facilities. These are:
a. Disinfection nearest to the source of generation,
b. Mutilation after disinfection at the earliest opportunity,
c. Involved process does ‘no harm’ to the environment or to human health,
d. A solution does not become a problem.”

Rationale: Those who generate BMW and those handling the wastes should be aware of principles of management, handling, treatment and disposal. It will be easier for the hospitals to prepare waste management plan.

3. Redraft para 3. (7) as under:

“Common Biomedical Waste and Treatment Facility (CBWTF) means any composite system laid for treating biomedical waste by different technologies approved by the CPCB, and in accordance with these Rules. It may include waste management system in a hospital/healthcare facility or outside the hospital”

Rationale: Disposal is a separate activity and should not be included in this paragraph. For example, recycling, reuse, and recovery of certain items may be at the hospitals etc itself and not at the common facility. Mercury spill may be captured and reused after distillation at hospital itself.

4. Add after ‘administrative’ words “and/or functional” at para 3. (8)

5. Para 4 (Duties of Occupier), 1. add “ and to ensure safety to patients, waste handlers, healthcare workers, visitors, and public from harmful and adverse effects of biomedical wastes”

6. Para 4. 2. Amend to read “To provide regular and periodic training, including practical demonstration etc.”

7. Para 4. 3 – It may not be technically sound to immunize all healthcare workers against possible diseases and afflictions that may be transmitted through BMW. There are many! It would be prudent to immunize only high risk groups who may be identified and listed, and only possible infection/affliction as per his or her post. Paragraph may be reworded as under:

“To identify, list and immunize all high risk group of healthcare workers against possible infections/ afflictions through biomedical wastes depending upon their place of duty and activity in discharge of their functional responsibility.”

8. Para 4. 4 It appears out of place here. Segregation, collection and transporting waste is basic duty expected of an ‘occupier’ and may be placed at the first.

9. Para 4. 5 : Insert “clothing” before word “equipment”.

10. Para 4. 8 : Include ‘treatment and disposal’ in place of ‘disposal’ only.

11. Para 4. 9: Accidents and incidents should be reported immediately to the ‘occupier’ and corrective action/measures instituted then and there, and not wait for a year, although it may be included in the yearly report.

12. Para 4. 11: Joint meetings of the waste management and infection control committees should be held every 2 months at least. 6 months interval is too long and may not bear fruits.

13. One of the responsibilities of the ‘occupier’ should also be to develop and practice a waste management plan in form of an SOP specific to that healthcare facility.

14. Para 5. 3: The operators of CBWTF are not to open the waste bags. In that case how will they know defective bagging? At the same time it is true that they may not be authorized to open and inspect the bags as that may lead to pilferage. Provision at para 5.3 does not appear implementable and is not practical.

15. Para 5. 4: add words “regular and periodic”

16. Para 5.6.: add ‘clothing and” equipment

17. Para 5.7. : add “incidents” after the word “accidents”. And add road accidents, spillage of the waste being carried. Spillage of mercury is not an apt example as that may occur mostly in hospitals and other healthcare facilities, and not during transportation. Instead spillage of infected wastes may be a better example.

18. Para 11.2.(v): Redraft as “A representative of the Indian Society of Hospital Waste Management (ISHWM) to be nominated by the President, ISHWM and approved by the DGAFMS”.

19. Schedule 1 (Categories and options): Category 1 and 2 may be combined as one category as the treatment and disposal may be the same. Deep burial should also be an option for rural areas and for healthcare facilities away from any incinerator. Otherwise the provision will remain un-implementable in many instances.

20. Schedule 1, cat 4: Sharps also may cause abrasion and should be mentioned.

21. Schedule 1, cat 6: Cat 6 waste may not be incinerated as that would give rise to emission of particulates. And, this category waste may be recycled after disinfection in an autoclave, including Waste Sterilization Unit (WSU) generally referred to as hydroclave, vapoclave etc. In order to reduce load on the incinerators thus avoiding particulate emission cat 6 waste may not be incinerated. Particulates have been greatly implicated in causation of respiratory diseases. Moreover all cat 6 waste may be already treated with disinfectants or similar chemicals in the course of patient care hence not incinerable (see note below schedule I)

22. Schedule V, Add minimum standards for dioxin & furans, and mercury emission.

23. Schedule V Note below, Three monthly monitoring may be very costly. The periodicity may be enhanced to 6 monthly and once a year for dioxin estimation.

24. Schedule V (3), this may be ok for general liquid waste discharge but not for floor wash from laboratories and infectious wards having patents of SARS, Avian Flu etc. Floor wash from these areas should be passed through a buffer tank having sodium hypochlorite solution of 5 %, refreshed once a day.

25. Schedule V (5), Secured landfill may not be recommended where water table is high, such as in Kerala. This may be clearly mentioned in the rules.

26. Schedule VI Col 1 – financial assistance should also be made available to eligible and willing NGOs and scientific societies so that training and awareness may have a wider outreach.

27. Schedule VI Col 2 (i) – Grant of license and renewal may be added.

28. Schedule VI Col 7 – Recommending CBWTF in the rural areas is impractical. Separate schedule for management of biomedical wastes at PHCs and CHCs may be framed.

29. Form I – add DGAFMS in the bracket.

30. Form II – License no. and expiry date may be included in the details of the healthcare facility. This will link the validity of license and authorization.

31. Form II Col 5 (ii) – Remove shredder from the list as it is not a treatment equipment but only an ancillary equipment as it may be confusing. Add sharps blaster (if already approved by the CPCB), plasma technology, or any other technology as approved by CPCB. Also add Advanced autoclave (hydroclave, vapoclave, rotoclave etc together may be known as ‘Waste Sterilization Unit or WSU’).

32. Form III – add ‘incidents’ after ‘accidents’ and describe types such as sharps accidents/incidents, mercury spill incident, motor vehicle carrying BMW accident, undue exposure to exposure to medical gases, or emissions from an incinerator etc.

33. Form VI – add “in prescribed manner”.

Some suggestions:
• Disinfection and mutilation of needle and syringes may be thought to be at the hospitals and other healthcare facilities itself to minimize risks of sharps injuries in transit.
• MSW segregation may follow what is orvided in the MSW Rules 2000.
• Schedule I – Chlorinated plastic waste bags, such as blood bags may be mentioned as a separate category with option of disinfection etc in autoclave/microwave, discharge of content in sewer, and recycling of the waste blood bags.
• Schedule II – There appears to be repetition at Blue and Black bags (Col 3 & 4) – in both non chlorinated plastic bags have been mentioned. This may be clarified/rectified.
• Schedule II – Instead of black bags for MSW the colour may be in accordance with MSW Rules – 2000.
• No colour code has been provided for chlorinated plastic waste bags, which may be white as blue colour coding may be confusing with other municipal solid waste collection system.
• Waste may also be categorised as per intended option. This way number of waste categories will be less thus saving on cost. It may be better understood and compliance may be easier. Option based categorization, meaning thereby collection of biomedical waste may be as per the intended option as follows:

1. Bio-degradable-
i. Papers, linen, cotton swabs etc
ii. Pathological waste
iii. Human & animal tissue & parts
iv. Food waste
v. Wrappings of medicine removed
in the wards/ patient care area
vi. Miscellaneous disposables used During patient care, in OT, and in laboratories
vii. Food waste (which has come in contact with the patients)
i. Paper, linen etc
ii. Food waste (from kitchen, cafeteria etc.)
iii. Medicine wrappings removed before medicines are issued to the wards/ patient care areas
iv. Miscellaneous items

2. Bio-non-degradable
i. Infected. (including linen soiled/contaminated with blood and/or body fluids, intended to be reused)
ii. Plastic waste
iii. Metals used in healthcare
iv. Plastic & glass tubes used in patient care
v. Sharps
vi. Reusable plastic & rubber items
vii. Gloves
viii. Discarded POP casts

i. Plastic waste
ii. Plastic wrappings
iii. Metals & glass
iv. Sharps
v. Rubberized items

3. Liquid Waste
i. Wash from wards, OT, labor room, laboratory etc
ii. Wash from infectious & quarantine wards
iii. Faeces & urine waste from patients known to be suffering from renal and GI infections
Notes: -
• Liquid waste from healthcare facilities should be suspected to be infectious unless determined otherwise.
• Liquid waste in large HCF can be treated in Effluent Treatment Plant (ETP), which would afford added advantage of ensuring waste treatment, and also generate the reusable water.
• Liquid waste from highly infectious areas, such as from infectious wards and special wards (such as wards having SARS patients or patients suffering from Avian flu), should be contained and treated before letting it in the channel for ETP.
4. Recyclables

Categorization as per the recommended option would be different. It would not only reduce number of containers required, but will also be clearly defined. At the same time system can be easily modified as per the type of HCF, its location, connectivity etc.



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