Bio Medical Waste Generation and Management Practices in V.S.S. Medical College & Hospital, Burla, Odisha, India

Background: An important issue of environmental protection process is the solid waste management that includes responsible planning of collecting, transporting, processing and disposing of hazardous and non-hazardous solid waste material. The health of public, patients and professionals alike are affected by poor waste management practices. The study highlights a holistic approach of biomedical waste management with regards to the chain of environmental and health risks and concerns aimed in achieving the fundamental premises for a systemic approach of biomedical waste management. An attempt has been made to critically review the current management practices adopted in V.S.S. Medical college & Hospital. Following the Rules and Regulation the methods for segregation, packaging, labeling and the treatment techniques for reduction in volume, neutralization and final disposal of the biomedical waste are analysed. Methods: Personal observations of the waste treatment and disposal practices and Assessment of knowledge, attitude and practices of working personnel with the help of questionnaires were followed in this study. The information obtained has been confirmed by means of direct spot visit. The views and suggestions of working personnel over existing conditions/methods of biomedical waste management in the hospitals were also recorded. The information obtained was later confirmed by means of direct observations. Results:There are 20 units having total bed capacity of 1006. The daily generation of category 1 & 2 is 40-50 kg/day. The daily generation of category 3 waste is 2-3 kg which was measured one day after one day. Category 4&5 waste generation amounting 30-40 Kg/ day. The Solid waste, (category 6) generation amounting 80-90kg/ day. The solid waste, category 7 waste generation is 30-40 kg/ day. Waste generated from laboratory (category,8) was estimated and found to be 30-40 litres/ day and the incineration ash category 9 generation was recorded as 3-4 Kg/ day. The chemical waste category 10 was not properly assessed by the CBWTF.The current segregation practice is not that efficient in reducing the waste going to incinerator. According to the opinion of employees at V.S.S.Medical College and hospital burla, the important reasons for the improper segregation of wastes are; inappropriate location of waste bins, waste bins being full and lack of knowledge regarding the constituents of medical waste. Conclusion: The performance of CBWTF can be enhanced with cooperative efforts of BMW generators possible if a healthy co-ordination exists between CBWTF and BMW generators.


Background
Many strides have been made in the field of health care system over the years. Ironically, along with restoring and maintaining community health, health care settings also threatened their well-being. The health of public, patients and professionals alike are affected by poor waste management practices [1]. In addition to this, it also contributes to environmental degradation. In 1983, a meeting was held at Bergen, Norway. The meeting was convened by the World Health Organization (WHO) regional office for Europe. The Biomedical waste management issue was first discussed during this meeting. Now, years later, this has turned into a global humanitarian issue.
Current Waste Management practices are characterized by poor quality collection service and improper disposal at open dumpsites. Hospital, hazardous and household wastes are mixed together at site. Recoverable wastes, paper and glass are destroyed than separated and recycled for economic use.
Uncontrolled burning of medical wastes may pollute the air with acidic gases, dioxins, furans and heavy metals [2]. A clear relationship between the burning of chlorinated organic chemical products and wastes, especially PVC and dioxin emissions from combustion facilities was reported by a host of studies conducted at the University of Florida [3,4,5,6,7,8]. A number of common initiatives to manage heath care waste are reported from developed countries. Most of the western nations had common incinerators, which are now banned in some of the developed countries. The shifting from burning to non-burning technology is being undertaken in a phased manner [9]. Paul Carnet reported that a number centralized treatment and disposal facilities for hospital wastes existing in USA in Canada. The technology used in combination of incineration and landfill.
Incineration utilizes thermal energy to decline waste materials to non-combustible residue or ash and exhaust gases [10]. The Fly and bottom residues produced after medical waste incineration contain high level of heavy metal like Pb, Cd, Ni, Cr, Cu and Zn. However, despite of public concerns about incinerators, it is the most frequently used option, due to its advantages regarding the sterilization of pathological and anatomic waste, volume and mass reduction, and energy recovery [11]. Autoclaving/sterilization is the second most commonly used waste disposal technology. The process involves steaming the waste materials at lethal temperatures to penetrate and potentially kill pathogens [12]. Autoclave is viewed as a more costly method than incineration [13]. One of the major disadvantages of autoclave pointed out is that it doesn't reduce the size of waste fed in to the system. The treated waste then has to go to the landfill sites which again cause many environmental threats. Many studies shows that a shredder incorporated with an autoclave can be the best option to treat the medical waste [12].
The microwave process utilizes the radiant energy to kill infectious agents by converting radiant energy to heat and pressure. Shredding is usually combined with microwave technology. A combined on site Microwave -small scale incinerator technology is the most cost effective and environmental friendly treatment technology [14].The disinfection efficiency of microwave can be a performance issue for microwave [15]. In chemical treatments, chemicals like chlorine, formaldehyde, ethylene oxide etcetera are used as disinfectants. Again the effectiveness of disinfection is questioned as it is dependent on the temperature, pH and surface area [15]. None of the alternative technologies are totally risk free, they can be combined with an effective program of waste reduction and segregation to reduce the environmental impacts and financial cost of medical waste disposal. The criteria's used to evaluate technological option should consider environmental, health and economic factors [16]. The best technology for the medical waste treatment will be different for different hospitals. It may depend on the local conditions and the requirement of the hospital.
For selecting the most efficient treatment method of hospital wastes, the composition analysis is considered to be the fundamental information. Currently there is no information done regarding the characteristics biomedical waste generated in V.S.S.Medical College and Hospital. With the above background the present study was carried out to assess the quantum of biomedical waste generation as well as the present state of management practices in the hospital.

Materials and Methods
Personal observations of the waste treatment and disposal practices [17,18,19] and Assessment of knowledge, attitude and practices of working personnel with the help of questionnaires were followed in this study [20,21,22,23,24,25]. A questionnaire was prepared that included questions regarding number of inpatients/day, outpatients/day, number of beds (total), awareness about biomedical waste(management and handling) rules, 1998, categories of biomedical waste produced and estimated quantity (kg/day), waste segregation, collection, labeling, transport and disposal, financial and personal resources. The information obtained has been confirmed by means of direct spot visit. The views and suggestions of working personnel over existing conditions/methods of biomedical waste management in the hospitals were also recorded. The information obtained was later confirmed by means of direct observations.

Results
Table1. In the endeavour undertaken by the CBWTF, different category of waste coming to central biomedical waste management facility (CBWTF) the daily generation of category 1 & 2 is 40-50 kg/day. The daily generation of category 3 waste is 2-3 kg which was measured one day after one day. Category 4&5 waste generation amounting 30-40 Kg/ day. The Solid waste, (category 6) generation amounting 80-90kg/ day. The solid waste, category 7 waste generation is 30-40 kg/ day. Waste generated from laboratory (category,8) was estimated and found to be 30-40 litres/ day and the incineration ash category 9 generation was recorded as 3-4 Kg/ day with a bed capacity of 1006 having 20 different units. Number of beds in different treatment units has been depicted in Table 1. Whereas, the chemical waste category 10 was not properly assessed by the CBWTF. The Central Biomedical Waste Management Unit of V.S.S. Medical College Burla collect the biomedical waste generated daily from each unit quantify and maintained the record in a prescribed format. (Table 2a     The total emissions was found to be 23,204.51kg.The calculation of GHG emissions using emission factors is explained in Table 4.

Waste Management Practices in V.S.S. Medical College Burla
The plastic bins as per the norms are kept in each facilities and the waste are collected and transferred to the Biomedical Waste Management Facility.: The wastes were segregated into various categories of waste like incinerable waste and recyclable waste depending upon its composition and properties. The plastics and other glass wares were however recycled immediately and were not stored anywhere as in case of other biomedical waste stored in bins. The waste so generated is stored in drums for a period of 10-15 days and then it is treated after a bulk in heaped. Three separate devices has been installed and used for BMW management.(a)Incinerator(b) Microwave and (c) Shredder.
The capacity of the Incinerator is 70 Kg/ hr and the height of the chimney is 100 ft. through which the gases exhaust to the atmosphere. (Table. 5). There is a facility for cooling and the waste water generated during the process is released directly to the drain. The running time of the incinerator is between 8.30 AM -1.30 PM depends upon the amount of waste collected. Mostly the anatomical and solid based waste has been treated in incinerator. The ashes generated by the process are dumped in sanitary landfill. The microwave installed in the CBWTF has the capacity of 100 Kg/hr. the solid based waste has been treated through microwave to disinfectant the waste and after that the waste has been send for auction. Similarly, the shredder installed in BMW unit of V.S.S Medical has the capacity of 100 Kg/hr. The shredder has been used for cutting the plastics. After disinfectant by microwave the plastics were send for auction for recycle.

Discussion
There are no reliable data available of the quantum of waste generated per person per day either in indoors or out door patient in Indian Hospital particularly in Odisha. Even there is no uniformity in the data on the quantum of biomedical waste being generated. From the data available from Armed Forces Medical College where the average daily waste generated of anatomical waste is 5.6 kg, Animal tissue waste 7.1 kg, Micro and Biotechnological waste 5 kg, Discarded medicines and cytotoxic drugs nil, waste soiled 9.5 kg, solid waste 149 kg, liquid waste 73 litres, incinerator ash nil, chemical waste 7.1 kg, waste sharpes not assessed [27]. In the present study the average daily waste particularly the anatomical waste shows high quantity i.e. 40-50kg/day, the waste sharps generation shows 30-40kg/day. The variation in the quantum of waste generation differs not only from country to country but also within the country which depends on the type of health care establishment, hospital specialization, proportion of reusable items employed in the health care centres and proportion of patients treated on a day-care basis.
According to WHO, the hazardous waste in an hospital is around 10-25% of the total health care waste. This study shows that the medical waste generated at V.S.S. Medical College is 49 % of the total health care waste produced in the hospital, which clearly states that the current segregation practice is not that efficient in reducing the waste going to incinerator. According to the opinion of employees at V.S.S.Medical College and hospital Burla, the important reasons for the improper segregation of wastes are; inappropriate location of waste bins, waste bins being full and lack of knowledge regarding the constituents of medical waste. Thus the study shows that the waste management activities at the V.S.S.Medical College and hospital have to be improved.
The knowledge about the constituents of medical reason is generally considered as one of the main barrier towards proper medical waste management [,28]. But the study shows that the health care workers at V.S.S.Medical College and hospital seemed to be aware about the constituents and the hazardous nature of medical waste. This may be because of the familiarity of health care workers with syringes and needles and also with accidents that happen as a result of sharps injury [29,30]. Some confusion does exist among workers especially about chemicals, unused medicines and pressurized containers. These confusions can be avoided by proper training. But these wastes account for only a small amount of the medical waste and cannot be assumed as the reason behind higher generation of hazardous waste. One of the reasons behind inefficiencies in the sustainable waste management practices are related to the behavior of individuals [31]. Considering the fact that most of the workers have enough knowledge about the constituents of medical waste and employees being satisfied with the current waste management practices, it can be interpreted from the study that there is a value -action gap between their intended behaviour and actual practice towards waste management. Lack of incentives, awareness of recycling provision and apathy have crucial role in framing such behaviour [32]. Appropriate facilities, opportunities to put right waste in the right bin, convenience, time and space are some of the factors affecting this behaviour [33,34].
Various studies shows that due to the high capital and maintenance cost involved, developed countries are bringing an end to the incinerators and are investing more on the alternative treatment technologies impact [35,36,37,38,39,40]. Well the argument is true for municipal waste, but for medical waste when considered from the hospitals perspective, incineration seems to be a better option from the available technological alternatives.
As V.S.S. Medical college is a very big hospital with almost every health care facilities it was important that the on site treatment plant selected should treat all the types of waste. Incinerator is not a very bad idea if the future energy requirements and the potential long-term health effects are considered along with the environmental impacts [41]. If properly handled and proper segregations are done, incineration would be the suitable method to treat clinical waste [13,1]. There has been an increase in public concern about the medical waste management over the years [1].There has been a wide protest against the incineration plants around the globe [42,43].

Conclusions
The study presents the status of existing CBWTF at V.S.S. medical college & Hospita, Bural Odisha, India. An appropriate strategy for safe management of BMW has been taken up integrating technical, financial, institutional, managerial, social and environmental issues. The technology used in CBWTF is a combination of incineration, microwave, shredder and secured landfill. The unit started operation in 2006. All the BMW generators are yet to get enrolled to utilize this off-site facility. The facility has to face problems while burning BMW, as many BMW generators do not adhere to the rules of segregation in to the container bags at the point of generation and are ot labeled according to Schedule III of BMW (Management and Handling) Rules, 1998. The performance of CBWTF can be enhanced with cooperative efforts of BMW generators possible if a healthy co-ordination exists between CBWTF and BMW generators.