SPREADING INFECTION? Healthcare facilities in Delhi Toxics Link Toxics Spreading Infections? A report by 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. Copyright © Toxics Link, 2019 Report and Study by Priti Banthia Mahesh, Dr Sabin Syed Toxics Link H-2, Jungpura Extension New Delhi – 110014, India Phone: +91-(11)-24328006, 24320711 Fax: +91-(11)-24321747 Web: www.toxicslink.org 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.