SPREADING INFECTION? Healthcare facilities in Delhi
Spreading Infections?
Toxics Link Toxics A report by i Healthcare facilities in delhi About Toxics Link Toxics Link is an Indian environmental research and advocacy organization set up in 1996, engaged in disseminating information to help strengthen the campaign against toxics pollution, provide cleaner alternatives and bring together groups and people affected by this problem. Toxics Link’s Mission Statement - “Working together for environmental justice and freedom from toxics. We have taken upon ourselves to collect and share both information about the sources and the dangers of poisons in our environment and bodies, and information about clean and sustainable alternatives for India and the rest of the world.” Toxics Link has a unique expertise in areas of hazardous, medical and municipal wastes, international waste trade, and the emerging issues of pesticides, Persistent Organic Pollutants (POPs), hazardous heavy metal contamination etc. from the environment and public health point of view. We have successfully implemented various best practices and have brought in policy changes in the aforementioned areas apart from creating awareness among several stakeholder groups.
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Report and Study by Priti Banthia Mahesh, Dr Sabin Syed
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Spreading Infections? ii Healthcare facilities in delhi CONTENTS
1. BACKGROUND 1 1.1. Bio Medical Waste Management Rules, India 3 1.2. Health Care Sector in Delhi 5 2. STUDY METHODOLOGY 7 2.1. Objectives of the Study 7 2.2. Secondary Research and Networking 8 2.3. Biomedical Waste Management Assessment in Healthcare Facilities 8 2.4. Limitations 8 3. MANAGEMENT OF BMW IN DELHI 9 3.1. Bio Medical Waste Management Practices across HCFs in Delhi 10 3.1.1. BMW Segregation 10 3.1.2. BMW Management Infrastructure 10 3.1.3. Intramural Transport and Storage of BMW 11 3.1.4. Availability and Condition of Central Storage Facility 12 3.1.5. Observed Onsite BMW Treatment Practices 12 3.1.6. Offsite Treatment 13 3.1.7. Policy and Capacity Building 13 3.1.8. Occupational Safety 14 3.1.9. Records Maintenance 14 3.1.10 Bio Medical Waste Management Condition in small HCFs 15 3.2. CBWTF (Common Bio Medical Waste Treatment Facilities) Visits 16 3.3. Dumping Sites 17 3.4. Summary of the Findings 18 3.5. Summary of the Findings 18 4. RECOMMENDATIONS 20 5. REFERENCES 22
Spreading Infections? v Healthcare facilities in delhi LIST OF TABLES AND FIGURES
Table 1: Bio medical waste segregation 7 Table 2: Effluent treatment standards for HCFs, India 8 Table 3: Healthcare facilities in Delhi 9 Table 4: Annual report information on bio-medical waste management scenario in Delhi for 2017 {(As submitted by DPCCs and DGAFMS) as on 02.05.2019} 10 Table 5: CBWTFs in Delhi 10 Table 6: Intra mural transportation in HCFs in Delhi 16 Table 7: Occupational safety concerns in Delhi HCFs 21 Table 8: Summarized salient features of CBMWTF(s) of Delhi [Source: Field Visit] 24 Table 9: Storage area infrastructure 96 Table 10: Onsite treatment in HCFs in Delhi 96 Table 11: Record maintenance in Delhi HCFs 97
Figure 1: HCFs assessed in Delhi (in percentage) 12 Figure 2: Color coded waste segregation in one of the hospitals visited 13 Figure 3: Handling of cytotoxic waste in Delhi HCFs 14 Figure 4: Needle cutter in use in one of the survyed HCFs 14 Figure 5: Bins with bio hazard symbol in use in Delhi HCFs 15 Figure 6: Availability of needle cutter in the surveyed HCFs 15 Figure 7: Bio-medical waste lying in open in an HCF 17 Figure 8: Onsite disinfection in one of the hospitals 18 Figure 9: Onsite liquid waste disposal in Delhi HCFs 19 Figure 10: Frequency of training programs on BMW in Delhi HCFs 20 Figure 11: Training session in progress in one of HCFs in Delhi 20 Figure 12: Record keeping in Delhi HCFs 22 Figure 13: Medical waste dumped along with solid waste in Delhi 25 Figure 14: Major gaps identified in the study 27 Figure 15: Availability of central storage for waste 96
ABBREVIATIONS
BIS Bureau of Indian Standards BMW Bio-medical Waste BMWM Bio-medical Waste Management CBWTF Common Bio-medical Waste Treatment Facility CPCB Central Pollution Control Board ETP Effluent Treatment Plant STP Sewerage Treatment Plant HCF Healthcare Facility DPCC Delhi Pollution Control Board MoEFCC Ministry of Environment, Forest & Climate Change PPE Personal Protective Equipment NSI Needle Stick Injury PEP Post Exposure Prophylaxis WHO World Health Organization
Spreading Infections? vi Healthcare facilities in delhi BACKGROUND
Bio-Medical Waste (BMW) refers to any waste, which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining thereto or in the production or testing of biological or in health camps, including categories mentioned in Schedule I of the Bio-Medical Waste (Management and Handling) Rules, 1998. Biomedical Waste (Management and Handling) Rules (BMW Rules) were promulgated under the Environment (Protection) Act, 1986.
In recent years, hospital waste has become a growing issue of concern, with the increasing evidence suggesting health hazards related to health care waste, inflicted upon the healthcare workers, patients and the community as a whole. Healthcare waste is both an environmental and public safety issue, due to the waste’s infectious and hazardous character; particularly in devel- oping countries where its management is sad- dled with technological, economic difficulties and inadequate skilled manpower. Studies over the years have shown that inadequate waste management can cause growth, multiplication and transmission of vector-borne diseases and other injuries. In addition to health risks asso- ciated with poor management of medical waste, focus must also be given to the impact on the environment, especially to the risks of pollution of water, air and soil.
Background 1 Of the total amount of waste generated by health-care activities, about 85% is general, non- hazardous waste. The remaining 15% is considered hazardous material that may be infectious, toxic or radioactive. This waste consists of the materials which have been in contact with the patient’s blood, secretions, infected parts, biological liquids such as chemicals, medical supplies, medicines, lab discharge, sharps metallic and glassware, plastics etc. The complexity of infectious healthcare waste problems and the recent rise in the transmittable diseases open up a greater risk of contamination through mishandling and unsafe disposal practices.
In India, Bio-Medical waste (term defined to denote the hazardous faction) is to be managed as per BMWM Rules, 2016. According to the last published report (20171) of Central Pollution Control Board Healthcare (CPCB), there are 2, 38,259 of Healthcare Facilities in India, out of Facilities in India which 87,281 are bedded and 1, 5 1,302 are non-bedded. As per BMWM 2,38,259 Rules, 2016, both bedded and non-bedded Healthcare Facilities are required to obtain authorization, irrespective of quantity of biomedical waste generation. Out of 2,38,259 of HCFs, 97,099 (40%) HCFs have Bedded Non-bedded applied for authorization and 84,805 (35%) HCFs have been granted 87,281 1, 5 1,302 authorization under BMWM Rules, 2016.
The total generation of bio-medical waste in India is about 559 tonnes per day, out of which 518 tonnes are treated in 198 CBWTFs Uttar Pradesh in operation (24 under construction) and 7.81 9,841 HCFs having captive treatment and Delhi 4.4% Bihar disposal facility. States/UTs like Bihar (6 6% %), Delhi (4.4 %), Gujarat (5.21 %), Karnataka Rajasthan (12 %), Kerala (7.35 %), Maharashtra (11.10 4.03% %), Rajasthan (4.03 %), Tamil Nadu (8.39 Gujarat BMW GENERATION %), Uttar Pradesh (7.81 %) & West Bengal 5.21% (5.34 %) are the major biomedical waste Maharashtra West Bengal generating States/UTs. 11.10% 5.34%
In spite of a legal framework in existence Karnataka for more than 20 years, the ground reality 12% on bio medical waste management is far Kerala Tamil Nadu from ideal. Lack of proper segregation at 7.35% 8.39% healthcare facilities, inadequate collection & treatment is still common in most parts of the country. The health-care waste management requires increased attention and diligence to avoid adverse health outcomes associated According to World Health with poor practice, including exposure to infectious Organization, hospital- agents and toxic substances. Therefore there is a need associated infections (HAI) affect to understand the ground reality and assess the gaps. approximately 5% of hospitalized As stated above, Delhi is one of the leading bio medical patients. waste generating states/UTs in India. It is also the center of informal and illegal waste recycling practices. Hence, it is important to understand if the healthcare waste is being managed in a sound manner here. Current assessment of bio-medical waste management in Delhi is an attempt to check the realities and bring in a countrywide sound and sustainable bio-medical waste management system.
1 https://cpcb.nic.in/status-of-bmw-management/
Spreading Infections? 2 Healthcare facilities in delhi 1.1. BIO MEDICAL WASTE MANAGEMENT RULES, INDIA
Bio Medical Waste Rules were notified in 1998. It regulated the disposal of biomedical wastes and laid down the procedures for collection treatment and disposal and standards to be complied with. These rules applied to everyone, who generates, collects, receives, stores, transports, and treats or handles biomedical wastes in any form. Bio medical waste was defined as any waste, which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities etc. According to Bio-Medical Waste (Management and Handling) Rule – 1998, all the bio-medical waste needs to be treated and disposed according to the rule with the help of requisite bio-medical waste treatment facilities like incinerator, autoclave, microwave system for the treatment of waste, or, ensure requisite treatment of waste at a common bio medical waste treatment facility.
The Bio-medical Waste Management Rules, 2016 brings in a wider and more comprehensive regime for bio waste management. Under the new rules, the coverage has increased and it also provides for pre-treatment of lab waste, blood samples, etc. It has simplified categorization and authorization. In addition to the bedded facilities and clinics, the 2016 version adds clarity to the type of facilities to which it applies. The additional establishments, AYUSH Hospitals, Research/educational institutes, Health camps, Medical or surgical camps, Vaccination camps, Blood donation camps, First aid rooms of schools, Forensic laboratories widens the scope of its applicability.
Segregation of biomedical waste at the source of generation is the first and essential step in biomedical waste management & it continues to be the key message and central theme of the BMWM, 2016. Bio Medical Waste Management Rules, 2016 categorizes the bio-medical waste generated from HCFs into four categories based on the segregation pathway. These categories are classified as per the type of waste under each category as follow
Table 1: Bio medical waste segregation CATEGORY TYPES OF WASTE TREATMENT/DISPOSAL Human Anatomical Waste Human tissues, organs, body parts and fetus below the viability peri- od (as per the Medical Termination of Pregnancy Act 1971, amended from time to time). Animal Anatomical Waste Experimental animal carcasses, body parts, organs, tissues, including the waste generated from animals used in experiments or testing in veterinary hospitals or colleges or animal houses. Soiled Waste Items contaminated with blood, body fluids like dressings, plaster casts, cotton swabs and bags containing residual or discarded blood and blood components. Incineration or Plasma Pyrolysis Discarded or Expired Medicine or Deep Burial YELLOW Pharmaceutical waste like antibiotics, Cytotoxic drugs including all items contaminated with Cytotoxic drugs along with glass or plastic ampoules, vials etc. Chemical Waste Chemicals used in production of biological and used or discarded disinfectants Chemical Liquid Waste Liquid waste generated due to the use of chemicals in production of biological and used or discarded disinfectants, Silver X - ray film developing liquid, discarded Formalin, infected secretions, aspirated body fluids , liquid from laboratories and floor washings, cleaning, house - keeping and disinfecting activities etc.
Background 3 Discarded linen, mattresses, beddings contaminated with blood or body fluid, routine mask & gown. Microbiology, Biotechnology and other clinical laboratory waste (Pre-treated) Incineration or Plasma Pyrolysis Microbiology, Biotechnology and other clinical laboratory or Deep Burial
YELLOW waste: Blood bags, Laboratory cultures, stocks or specimens of microorganisms, live or attenuated vaccines, human and animal cell cultures used in research, industrial laboratories, production of biological, residual toxins, dishes and devices used for cultures Wastes generated from disposable items such as tubing, bottles, Autoclave/ Microwave/ intravenous tubes and sets, catheters, urine bags, syringes without Hydroclave& then send it for
RED needles, fixed needle syringes with their needles cut, vacutainers Recycling [not to be sent to and gloves Landfill].
Waste Sharps including metals Needles, syringes with fixed needles, Autoclave/ Dry Heat needles from needle tip cutter or burner, scalpels, blades, or any Sterilization followed by other contaminated sharp object that may cause puncture and cuts. Shredding / Mutilation/ WHITE This includes both used, discarded and contaminated metal sharps Encapsulation
Broken or discarded and contaminated glass including medicine Disinfection or Autoclave/ vials and ampoules except those contaminated with Cytotoxic Microwave/ Hydroclave& then BLUE wastes. send it for recycling
Considering the environmental hazard due to the emission of toxic gases like dioxin & furan ow- ing to inadvertent burning of chlorinated plastics, the 2016 edition of the Rules have made the provision to phase out use of chlorinated plastic bags, gloves and blood bags. These bags shall be in compliance with Bureau of Indian Standards (BIS).
Provision of Bar-Code System for Biomedical waste bags or containers have been also includ- ed and will make it possible to track the biomedical waste bag and the original health care in- stitution can be made accountable for untreated,improperly treated or improperly segregated biomedical waste.
The Rules also mandate training and health check-up of all the health care workers, which has been documented time and again to be of utmost important in improving the situation re- garding biomedical waste.
Effluent Treatment Plant should be provided in every HCF to treat the wastewater generated from the hospital in order to comply with the effluent standards prescribed under the BMWM Rules, 2016. The Rules also specify the standard that the effluent generated or treated from the premises of bedded HCFs before discharge into the sewer should conform to.
Table 2: Effluent treatment standards for HCFs, India Parameters Permissible Limits pH 6.5-9.0 Suspended solids 100 mg/l Oil and grease 10 mg/l BOD 30 mg/l COD 250 mg/l Bio-assay test 90% survival of fish after 96 hours in 100% effluent
Spreading Infections? 4 Healthcare facilities in delhi 1.2. HEALTH CARE SECTOR IN DELHI
Delhi, the capital of India, according to the 2011 census houses over 11 million people, the sec- ond-highest in India while the whole NCT›s population is about 16.8 million. Like the rest of the country, health care sector in the capital city has both private and public sector establishments. According to DPCC (last report available is of Jan- Dec 2017), Delhi has 5394 healthcare facilities, with 1478 bedded facilities (50, 675 beds).
Table 3: Healthcare facilities in Delhi2 TYPE TOTAL In Delhi, Delhi Pollution Control Committee (DPCC) is the apex prescribed authority for im- Number of health care facilities/occupiers 5394 plementation of the provisions of BMWM rules. Bedded facilities 1478 Under bio medical waste management rules, Total number of beds 50675 following duties are required to be performed Dispensaries 452 by DPCC:- Veterinary 46 1. Inventorisation of occupiers and data on Animal houses 27 bio-medical waste generation, treatment & disposal. Pathological laboratories 1167 Blood banks (stand-alone) 11 2. Compilation of data and submission of the same in annual report to Central Pollution Clinical establishments 2169 Control Board within the stipulated time Research institutions 42 period. AYUSH 2
3. Grant and renewal, suspension or refusal, cancellation of authorization under these rules (ap- plicable under Rule 7, 8 and 10 of bio medical waste management rules, 2016). 4. Monitoring of compliance of various provisions and conditions of authorization. 5. Action against health care facilities or common biomedical waste treatment facilities for viola- tion of the rules (Rule 18). 6. Organizing training programs to staff of health care facilities and common bio-medical waste treatment facilities and Pollution Control Committees Staff on segregation, collection, storage, transportation, treatment and disposal of bio-medical wastes. 7. Undertake or support for research or operational research regarding bio-medical waste man- agement. 8. Any other functions under these rules assigned by Ministry of Environment, Forest and Climate Change or Central Pollution Control Board from time to time. 9. Implementation of recommendations of the Advisory Committee. 10. Publish the list of registered or authorized (or give consent) recyclers. 11. Undertake and support third party audits of the common bio-medical waste treatment facilities in Delhi.
According to this last report, 24667.05 kg/day of biomedical waste was being generated from the healthcare facilities in the capital city of India. According to estimates, Delhi and NCR region alone annually generate bio-medical waste of about 5900 tonnes, in which share of Delhi is roughly around 2200 tonnes3. Though the Rules had been in force since 2016, only 959 facilities had applied for au- thorization. This indicates that large amount of the infectious waste may not be treated according to the Rules and may be ending up in dump sites, thereby becoming a risk for human health and the environment.
2 www.dpcc.delhigovt.nic.in/bmw%20annual%20report.pdf/www.dpcc.delhigovt.nic.in/bmw%20annual%20report.pdf 3 https://www.assocham.org/newsdetail.php?id=6719
Background 5 Table 4: Annual Report Information on Bio-medical Waste Management Scenario in Delhi for 2017 {(As submitted by DPCCs and DGAFMS) as on 02.05.2019)} DELHI (25-7-2018) Total no. of Bedded Health Care Facilities (HCFs) 1478 Total no. of Non-bedded Health Care Facilities (HCFs) 3916 Total No. of Health Care Facilities (HCFs) 5394 Total no. of Beds 50675 Total no. of HCFs applied for authorization 959 Total no. of HCFs granted authorization 872 Total no. of HCFs in operation without applying for authorization Nil Total quantity of BMW generated (kg/day) 24667.05 Total quantity of BMW treated and disposed (kg/day) 24667.05 No. of HCFs having Captive Treatment Facilities 3 only autoclave. No of Captive Incinerators Operated by HCFs Nil CBWTFs Operational 2 CBWTFs under construction Nil Total BMW treated by captive treatment facilities by HCFs in (kg/day) 402 Total BMW treated by CBWTFs kg/day) 24264.47 Total No. of show cause notices/directions issued to defaulter HCFs/CBWTFs 557
Healthcare Facilities Including Bedded Generate Facilities 24667.05 kg in Delhi biomedical waste 5394 1478 per day (50,675 beds)
There are two CBWTFs in the state, namely Biotic Waste Solutions Pvt. Ltd. and SMS Water Grace BMW Pvt. Ltd. and the authorised facilities are divided between them for collection of BMW.
Table 5: CBWTFs in Delhi TOTAL BIOTIC SMS WATER GRACE Total no. of health care facilities/occupiers 5394 2378 3016 Bedded facilities 1478 443 1035 Dispensaries 452 224 228 Veterinary 46 23 23 Animal houses 27 27 0 Pathological laboratories 1167 508 659 Blood banks (stand-alone) 11 5 6 Clinical Establishments 2169 1141 1028 Research Institutions 42 5 37 AYUSH 2 2 0 Total number of beds 50675 22753 27922
Spreading Infections? 6 Healthcare facilities in delhi STUDY METHODOLOGY
Delhi is a big healthcare center and people from many parts of the country flock to the city for treatment. Hence, the city treats a large number of people and in the pro- cess generates huge amounts of waste. In spite of being the capital city and being the seat of environmental policy making, the city is unable to manage its hospital waste in a sound manner. Reports suggest that BMWM is inadequate at both macro and micro levels in Delhi and large amount of this infectious waste might be ending up untreated and dumped.
Noting this, it was felt that there is a need to comprehend the ongoing practices of BMW in Delhi so as to identify gaps in contemporary practices which are still looming in the HCFs. This assessment is an attempt from Toxics link to highlight the prevailing practices of bio medical waste management across different types of bedded HCFs in Del- hi and subsequently bring about a complaint and sustain- able bio-medical waste management system. 2.1. OBJECTIVES OF THE STUDY
An overall objective of the study is to evaluate the cur- rent status of Bio-medical Waste Management (BMWM) in Delhi.
Specific objectives include:
To map the bedded healthcare facilities (HCFs) in Del- hi;
To document the current practices in selected hospi- tals in terms of Segregation, Transportation, Disposal etc. of BMW;
To estimate the amount of BMW generated from the bedded HCFs in Delhi;
Study Methodology 7 To evaluate the Knowledge, Attitude and Practices (KAP) followed in the HCFs of Delhi;
To investigate if there are any illegal practices by the hospitals prevailed in the state, i.e., dump- ing of waste or illegal sales etc.;
To explore the practices followed in CBWTFs, and the quantum of waste being managed by them in Delhi, and
To analyze and assess the gaps in the current system. 2.2 SECONDARY RESEARCH AND NETWORKING
Secondary research was carried out to gather data and information from the existing studies on BMW, from Delhi Pollution Control Committee (DPCC) and health departments. This also required identifying secondary sources, like, different state departments or BMWM committees or associa- tions, etc. and proactive networking and following up with them to get access to the information. 2.3 BIOMEDICAL WASTE MANAGEMENT ASSESSMENT IN HEALTHCARE FACILITIES A total number of 38 assessment surveys were conducted in bedded healthcare facilities across Delhi. The survey was carried out covering all the 11 Figure 1: HCFs assessed in Delhi districts of Delhi (New Delhi, North, North West, (in percentage) West, South West, South, South East, Central, North East, Shahdara, East), in order to under- stand a broad representation on status of BMWM in the territory.
To understand the BMWM situation at various Government Private tiers of the healthcare system, different catego- 34.21 65.78 ries of the healthcare facilities were investigated through the survey.
25 private HCFs and 13 Government run HCFs (10 government hospitals and 3 government medical colleges) were visited, surveyed and assessed for Bio Medical Waste Management practices.
2.4 LIMITATIONS
Bio medical waste management rules have been in force in India since 1998, but still there is a lack of reliable data related to number of HCFs as well as the amount of waste generated. Though we had access to the Delhi Pollution Control Committee and Central Pollution Control Board data (available online), these were not up to date. Our attempts to get current data through RTI failed as DPCC claimed that they did not have compiled data available with them.
The study had set out to assess the current BMW management in the state, but getting access to healthcare facilities was a big challenge as the facilities were not open to such assessment. Though the team managed to visit bedded facilities, non-bedded facilities could not be included in this edi- tion of the study as we could not get access in these.
Spreading Infections? 8 Healthcare facilities in delhi MANAGEMENT OF BMW IN DELHI
In Delhi, as in most large cities in India, healthcare is divided among private and government-run facilities. Apart from around 1500 bedded facil- ities, the capital city also houses a huge number of private and government run clinics, path labs Hospitals etc. which serve thousands of people everyday. All these facilities have to adhere to the provi- sions laid down in the Bio Medical Rules, 2016. The 2019 Rules has clearly laid down roles and Path Labs responsibilities for the waste generators as well as treatment facilities. This study looked at some of the key provisions, listed out in the Rules, to evaluate the status of BMW management in the Clinics city; with focus on HCFs and CBWTFs.