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Bio-medical Factsheet liquid Number 28 / July 2006

Concerns and management AT A GLANCE

n expansion in the number of health These limits are applicable to O Most existing facilities across the country and the that are either connected with sewers without technologies and Aburgeoning problem of un-treated bio- terminal treatment plant or not con- practices are failing medical waste had led to the passing of the nected to public sewers for discharge into to deal with the Biomedical Waste (Management and Han- public sewers with terminal facilities, the gen- problem of liquid dling) rules 1998, but almost eight years eral standards as notified under the Environ- bio-medical waste. down the line, much more needs to be done ment (Protection) Act, 1986 should be ap- on the ground. plicable. O Handling of bio-medical waste is proving Section (3) of the Act states: “For the The Environment to be an overwhelming challenge for the gov- purpose of protecting and improving the qual- Protection Act lists ernment and the health sector. However, ity of the environment and preventing and 35 parameters for within the broader theme of bio-medical abating the environmental , the the discharge of waste, liquid bio-medical waste is emerging standards for emission or discharge of envi- effluents into as particularly difficult to handle. Liquid bio- ronmental from the industries, op- municipal sewage. medical waste is far more mobile and moves erations or processes shall be specified in to a wider area after entering the subsurface schedule I or IV.” O Many hospitals, in water bodies or underground aquifers. The schedule contains general standards particular those that for discharge of effluents. Thirty-five param- are not connected to Challenge of liquid bio-medical waste eters are specified for those to be discharged any municipal Most existing systems and technologies into municipal sewage. treatment plant, being used in handling liquid bio-medical have their own 2 waste are failing to address this problem. For Minimal safety requirements instance, the routine exercise of pouring bio- Where medical establishments cannot af- Plants (STPs) or medical liquid waste is being questioned for ford treatment of biomedical liquid waste, Effluent Treatment posing higher threat to medical staff following measures should be undertaken to Plants (ETPs). due to its susceptability to spilling, splashing reduce risks: and aerosolising. Liquid bio-medical waste, N Patients with enteric diseases should be O There is no doubt if untreated, contains a wide variety of mate- isolated to wards where their excreta can that liquid medical rial that poses health hazards. be collected in buckets for chemical disin- fection. This is of utmost importance in is a major problem Liquid bio-medical waste standards cases of cholera outbreaks. for healthcare According to the Biomedical Waste (Man- N No chemicals or pharmaceuticals should facilities and their agement and Handling) Rules 1998, liquid be discharged into the sewer. employees. However, pathological and should be N Sludges from cesspools should be technology and appropriately treated before discharge into the dehydrated on natural drying beds and treatment solutions sewer. Pathological waste must be treated with disinfected chemically (for exmple, with are available. chemical disinfectants, neutralised and then sodium hypochlorite, chlorine gas, or pref- flushed into the sewage system. Chemical erably chlorine dioxide). waste should first be neutralised with appro- N Sewage from these establishments should priate reagents and then flushed into the sewer never be used for agricultural, aqua-cul- sysrem. tural, drinking water, or recreational pur- The treated effluent should conform to the poses. limits shown in Table 1 on the next page.

fs-sris-28b.pmd 1 7/31/2006, 10:52 AM Black Toxics Link Factsheet Number 28 / July 2006 Treatment of liquid Standard Operating Procedures bio-medical waste Liquid bio-medical waste such as , mucus, secretions, urine, etc should be disposed through the On-site treatment or pre- following procedure. treatment of wastewater Many hospitals, in particular those that are not connected to any LIQUID WASTE municipal treatment plant, have their own Sewage Treatment Excrement Blood, secretions Plants (STPs) or Effluent Treat- ment Plants (ETPs). These plants carry out primary, second- Basic treatment ary and tertiary treatment of liq- (chemical, disinfectant/ uid bio-medical waste followed by sludge treatment. ) Hospitals with Effluent ETP at Himalayan Institute of Hospital Trust. Treatment Plants Storage tank Raw wastewater is collected from old and new Himalayan Institute of building by gravity in to the collection tank out side Hospital Trust the E.T.P and the raw Influent from laundry comes This is a 750-bed hospital directly into flocculation tank. From flocculation tank (Dilution) near Dehradun and caters to the it passes through tube settler for sedimentation proc- Water Treatment healthcare needs of 700 villages. ess and finally collects in equalization tank for fur- The ETP here was set up on ther aerobic treatment done in aeration tank through System January 2004 at a cost of Rs suspended growth process using diffused membrane 2,00,000, with treatment capac- aeration system. ity of 100 m3 / day. It is based on The secondary clarification of aerated mixed liq- Sewage* aerobic activated sludge process uor takes place in Hopper Bottom Secondary clari- and controls the BOD, COD, fier and is followed by chlorination for disinfection. * Not to be used for cultivation of crops, except for pH and total suspended solid. It Filtration and de-chlorination of excess chlorine is municipal gardening. was set up with the aim of pre- done using multi grade filter and activated carbon venting pollution, filter. Treated water is then collected in water stor- energy conservation, meeting wa- age tank. Treated water is reused for flushing and ter needs and maintaining the gardening and the treated sludge is subjected to thick- Table 1: Limits of treated effluents ground water table. Some of the ening through filter press and used as manures for treated effluent is recycled as fer- plants. The results of effluent testing before and af- Parameters Permissible Limits tilizer for gardens on the hospital ter the ETP are given in Table 3. premises spread over 300 acres. pH ...... 6.5-9.0 Some of this is also sold for use in Choithram Hospital and Research Centre3 Suspended solids...... 100 mg/l the fields nearby. Choithram Hospital and Research Centre is a Oil and grease ...... 10 mg/l The savings in costs and also 350-bed tertiary care center in Indore, with a daily BOD (3 days at 27oC) ...... 30 mg/l in the ground water has encour- OPD attendance of 475 patients. . The total water aged the institute to get another requirement of the hospital is 5,00,000 litres. The COD ...... 250 mg/l STP constructed, which will re- ETP plant here was set in November 2001. Bio-assay test ...... 90% survival of fish after cycle 2,00,000 litre of water per The analysis of the hospital effluent before and ...... 96 hours in 100% effluent day. This water will be supplied after treatment is shown in Table 2 all the physico- to the campus and hostels. chemical parameters are within the specified limits. The chlorination results in complete inactivation of Sir Ganga Ram Hospital7 the Multiple Drug Resistant bacteria and thus makes Sir Ganga Ram is a 625-bed multi-specialty the effluent water safe. hospital located in New Delhi. The ETP in the The daily input of effluent is approximately hospital was installed in the basement of the hospi- 3,39,000 litres and approximately 3,00,000 litres tal and is operated round-the-clock and is monitored of treated water is recovered. The treated effluent by its maintenance and sanitation department. water is used for irrigation and sanitary cleaning. The treatment process employed in this system The hospital does not face water shortage any longer. is Extended Aeration, Suspended growth process Moreover, more than 5,000 kg. of dried sludge is using fine bubble diffused aeration system. available every month as manure for its gardens.

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fs-sris-28b.pmd 2 7/31/2006, 10:52 AM Black Bio-medical liquid waste: concerns and management Alternative use for biotechnology products5 Yashraj Biotechnology Limited is a Mumbai- Table 2: Physico-chemical and bacteriological analysis of effluent water based company manufacturing diagnostic antigens from native source. It specialises in the field of isola- Parameter Value before ETP Value after ETP Limit tion and purification of native antigenic proteins from biological fluids. Ward fluids in disease state (like Total viable bacterial count 9 X 104 Nil - ascites/pleural fluids, cerebrospinal fluid), normal MDR Coli-form [%] 1.5 Nil Nil state (like post delivery residual blood in cord), urine Chem. Oxygen Demand [mg/liter] 280 22.56 <250 and donated or rejected blood are collected by the Biological oxygen demand 45 3.6 <30 company for isolation of human proteins and native biological markers that are used in manufacture of Total Solids 1066 630 <2200 In Vitro Diagnostics as calibrators and controls. Total dissolved solids >mg/ltr. 942 630 <2100 The collection of these fluids is done in leak proof Total suspended solids mg/ltr. 124 <2 <100 plastic bottles (duly labeled with biohazard symbol pH 7 8.8 6.5-9 and the company’s address) containing preserva- tives (anti-microbial and protein stabi- lisers). Once collected the bottles are transported to their manufacturing facil- Table 3: Physico-chemical and bacteriological analysis of effluent water ity in Mumbai under four layer safety packaging on lines of WHO and US BEFORE AFTER Federal laws. This packaging offers safety at four levels beginning with non- Parameters Domestic Laundry Kitchen Boiler Entire Building leaking unbreakable bottles, followed by Peak flow Kl/day 385 75 30 10 individual secondary self-sealing , Oil & Grease mg/L 10-20 50-75 150-175 <1 jumbo bags, hard plastic container se- Suspended solids mg/L 100-150 150-200 300-400 200-250 <1 cured an sealed with strips. Any leftovers are chemically disin- B.O.D. mg/L 200-250 100-150 500-600 20-30 6 fected using one percent hypochlorite so- C.O.D. mg/L 400-600 600-800 1000-1100 40-50 29 lution and disposed in CETP lines, as pH----7.3 per guidelines in Biomedical Waste (Management & Handling) Rules, 1998. They are authorised by MPCB for these activities under contract with Mumbai Biomedical Type of biological fluids collected for various antigens/proteins4 Waste Management Co. Records are maintained for such activities. The company does not offer any Source Material Antigen/Protein Extracted monetary benefit to the hospital and participation is completely voluntary. Human Ascitic/Pleural Fluid C Reactive Protein (CRP) Human Cancer Ascitic/Pleural Fluid Cancer Protein 15-3, 19-9, 125, 72-4 Best management practices for Human Urine Beta 2 Microglobulin (B2M) liquid bio-medical waste management Human Meconium Carcino Embryonic Antigen (CEA) N Medical establishments in remote locations Human Cord Blood Alpha Feto Protein (AFP) should provide for minimal treatment of Human Blood Hepatitis B surface antigen ad and ay wastewater through affordable means (for examle, Human Seminal Fluid Prostrate Specific Antigen (PSA) use of lagoons to achieve an acceptable level of Human Leukocytes Myeloperoxidase (MPO), Proteinase 3 (PR-3) purification, followed by infiltration of final ef- fluent to the land). N Sewage containing such waste should never be N Where feasible, solvents should be recovered for used for agricultural or aquaculture purposes. . N Sewage should not be discharged into or near There is no doubt that liquid biomedical waste water bodies that are used for drinking water. management is a major problem for healthcare fa- N A spill kit should be at hand and staff cilities. However, technology and treatment solutions should be trained to recover the spill using cor- do exist. rect techniques. These solutions, combined with proper training N A properly sized grease interceptor should be in handling of waste will enable healthcare organi- installed and maintained to reduce the discharge sations to diffuse this critical problem while safely, of oil and grease from kitchen and food prepara- and cost effectively, managing their liquid biomedi- tion areas to the system. cal waste.

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fs-sris-28b.pmd 3 7/31/2006, 10:59 AM Black Toxics Link Factsheet Number 28 / July 2006

Figure 1: Schematic flow sheet of Effluent Treatment Plant3

Raw effluent

from laundry, Bar Screen canteen, etc. Clarifer

Aeration Effluent Tank Collection Biosludge Oil and Tank Grease trap Sludge

All other Sludge Bar Screen effluent Filtrate Drying streams fro Beds the premises

Treated Treated Chlorine Pressure Filter Effluent Water Contact Sand Feed Tank Tank Filter Tank

References and suggested reading 6. Capitol Regional District – Code of Practice for Operations http://www.crd.bc.ca/ 1. A. Pruss, E. Giroult and P. Rushbrook (1999) es/environmental_programs/source_control/ documents/schedule_S_laboratory.pdf “Safe management of waste from health-care activities”. Geneva, World Health Organisation. 7. Personal interview with Dr Sudhakar Vira, 2. WHO (1989). Health guidelines for the use of medical superintendent, Sir Ganga Ram Hospital. wastewater in agriculture and aquaculture. Report of a WHO Scientific Group. Geneva, World Health Organization (WHO Technical Report Series, No. 778).

3. “Effluent Treatment Plant: Why and How” Ravikant, Vikrant Chitnis, S P Jaiswal, D S Chitnis, Kamlakar Vaidya-Journal of the Academy of Hospital Ind Medica Administration Compiled and written by Yamini Sharma Vol. 14, No. 1 (2002-01 - 2002-06) with inputs from the Toxics Free Health Care team

4. http://www.yashraj.com/2006/aboutus.html For more information, please contact:

5. Email and telephonic conversation with [email protected] S.K. Gupta, Manager-Quality Assurance & Toxics Link Regulatory Affairs, Yashraj Biotechnology H2 Jungpura Extension Limited, Mumbai Ground Floor New Delhi 110 014 Tel: +91-(0)11-24328006/0711 Website: www.toxicslink.org

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fs-sris-28b.pmd 4 7/31/2006, 10:54 AM Black