“Nothing can be more precious than bouts of fresh air, sparkling water and clean stretches of land gifted with ample natural products and biological diversity.”

With the United Nations Development Programme (UNDP) closely linking health care of a nation to its economic development, emerging nations like India have in the last two to three decades focussed largely on improvements in health care, leading to a rise of public and private health organisations both in rural and urban areas. Better health care facilities have caused an alarming and steady growth of the waste produced in recent decades. “The waste which is produced during or after any type of research/prognosis/medication done at medical care centers; be it hospitals, nursing homes, clinics, dispensaries, outpatient service providers, diagnostic centers, research laboratories, immunisation camps, blood banks is termed as Bio Medical Waste (BMW); which can be solid or liquid”. 85% of BMW is similar to general municipal waste but the quantity of BMW that demands utmost care is 15% of which 10% is infectious and approximately 5% is hazardous waste which may be non-infectious (WHO, 2002). Due to the variability in the specialities offered by the various health care centres, the waste as such produced by them is also of a diverse nature and is further classified accordingly. To understand the various classes of this waste, an outline classification of BMW has been stated here, as per which - 85% of non-hazardous waste or ordinary municipal waste can be further subdivided as:

Group I Hospital canteen waste e.g. eatables.

Group II Reprocessable waste e.g. glass & paper items.

Remaining 15% hazardous waste is further sub categorised as 5%toxic waste which consist of poisonous chemicals, cancerous drugs and nuclear waste and rest 10% infectious waste which is of two types:

Group I waste that has used needles, scalpels and blades.

Group II waste that can again be subdivided as: -

1.  Waste that is generated during patient treatments such as blood soaked cotton, wound dressings, plaster of paris (POP) products and all such non plastic waste, the plastic waste that is generated during patient medication can be surgical gloves, intravenous sets, disposable syringes (without needles). 

2.  Research or experimental waste which mostly includes culture media and anatomical waste. Among the group II infectious waste category major share is occupied by the patient medicated waste.

The non-hazardous BMW consists of food items (40%), plastic (19%), paper and cardboard (14%), metal (8%), glass (6%), textile (5%) and other material (8%).

Organic constituents of the recyclable fraction of BMW such as paper & plastics can be reused after recycling and remaining organic components of BMW which cannot be reused or recycled can be used for the production of biofuels and other valuable chemicals. The remaining 15% BMW which needs special attention is broadly categorised as incinerable waste (collected in yellow bags), non-recyclable cytotoxic plastic waste (collected in red bags), sharps (collected in white picture proof bags).

It may seem that a meagre fraction of BMW is of concern yet it is a special category waste due to the following reasons;

1. BMW is posing an increasing threat due to its alarming rise in magnitude and simultaneous increase in its mismanagement. This is because of the developments and increasing use of the one time use and throw away items in medical technologies, easy accessibility to HCF’s (as these facilities are expanding their coverage areas) and growing government investments in this sector that the contribution of BMW to the total waste produced is mounting steadily at a rapid pace especially during and after the COVID 19 era.

2. It is complex in nature because various departments of a HCF generate diverse mixtures of waste streams. To say for operation theatre (OT) waste which forms 20 to 30% of the total BMW generated in a HCF is entirely different from the kitchen and laundry waste generated in the same HCF. Also the composition and amount of BMW differs not only internationally but locally also depending on the type of HCF, its location, infrastructural facilities and human resource strength.

3. The amount of infectious waste depends on how effectively waste is segregated, which is totally dependent on the awareness of the BMW handling staff. To emphasise this concept it becomes all the more mandatory to mention here that the quantity of BMW produced in some advanced nations across the globe is about 1.2 – 200 tonnes more as compared to the advancing nations but the percentage of infectious waste is about 51% in these nations as compared to 63% or more in the many poor Asian and African countries.

4. It has the capacity to damage the complete well being of the society. Studies have shown that health care personnels involved in the management of BMW are prone to biological, physical and chemical hazards/injuries during the exposure to BMW inside and outside the HCF.

5. BMW generation and disposal is a highly concerned issue especially in countries with low income and high population because disposal of recyclable medical waste is up to 5 to 20 times more expensive than disposal of urban domestic waste, also hazardous waste disposition is the costliest affair among all the other types of waste disposal categories and laboratory waste is highly toxic waste demanding special care in its disposal. Government of India in its pilot project in 2018 for bio medical waste management ( BMW M) in a public 1000 bedded super speciality  hospital gave an estimate of 85 lakh per annum cost for onsite  disposal of BMW (R&D 2018). The cost for BMW M can be external (at the CBWTF where treatment followed by final disposal of BMW is done) or internal (in the HCF for segregation, mutilation, disinfection, storage and transportation of BMW to common bio medical waste treatment facility (CBWTF). It is to be noted here that this costing does not include the safety/protective measures taken at each step.

This has led to the focusing on waste management by the health care institutions all over the world which mainly revolves around strategic planning and opting newer technologies for safe disposal. The main issue dealing with BMW is not its generation because this is unavoidable but it is the quantity and composition of BMW that is a matter of grave concern since it varies from source to source depending on the extent of medical care it is delivering and most importantly the practices it follows in the waste management. Thus BMW M needs special attention. 2.4 billion tons of BMW is produced annually worldwide; which needs to be sustainably handled meaning dealing with its hazardous nature in an enviro friendly and budget favourable manner. To accomplish this agenda when the cost was calculated, some staggering figures came as a blow, as an approximate expenditure of $11.77 billion were spent in 2018, which is likely to rise upto $17.89 billion in 2026; an annual compound increase in expenditure rates for BMW management comes as 5.3% These figures are well above the annual incomes of many poor nations of the world (R&D reports and data, 2020). The worst way to deal with any kind of waste is its disposal.

Effective BMW M involves a hierarchy which includes strategies to avert contaminations, waste minimization, waste reprocessing, treatment and destruction, with waste minimisation being the most desirable preference and destruction the least. Waste management is a technical practice which focuses on refining of waste to make it environ friendly after it is created and for this it is mandatory to have a critical knowledge of the production of waste at the source and then it requires concentrating on reprocessing of waste which means consuming of waste if possible or if not feasible then harnessing energy from the waste for which a detailed insight into the composition of waste generated is required. Thus scientific attitude, time and resources are required for BMW M. COVID-19 pandemic era saw a huge rise in the amount of BMW generation. The secure and scientific management and disposal of BMW during COVID pandemic was a major concern and a big challenge to be dealt with. Despite framing and implementing rules and regulations, signing international treaties and agreements on BMW lacunae do exist particularly in the developing nations. Also as per WHO, 2015 the SEARO member countries of South East Asia Regional Office follow least safe disposal practices for BMW as only 44% of HCF follow scientific BMW M practices and open dumping and burning of BMW have been reported.

Different types of Wastes and their percent fraction

Domestic waste            54%

Commercial waste        31%

Industrial waste            13%

BMW                            2%

Though the % contribution of BMW in the diverse types of waste produced appears to be less than 5, yet it has been recognised as a specific category waste.

Sources of BMW These are categorised as major and minor:-

The major sources for BMW include large hospitals, community health centers, nursing homes, diagnostic centers and research laboratories whereas emergency medical services, military medical installations, sanatoriums, hospital ambulances, poly clinics, quarantine stations all of these are minor sources of BMW.

BMW Categorial Constitution as per Indian Scenario:

65 - 70% - is the ordinary municipal waste, thus a large proportion of this waste is similar to domestic waste, if the specific care waste portion is not mixed into it. Rest 30-35% is the toxic special care waste, of which the largest share of 11% is occupied  by the various types of drugs and chemicals, followed by infectious/pathogenic waste and sharp waste both having a share of app. 8% and anatomical waste which may be upto 4%.

 In India generally speaking approximately 35 - 40% of BMW is a specific class waste which needs critical appraisal, cause it can be a threat and also because its %age fluctuates highly as per the management policies adopted by the individual HCFs in handling of BMW and it is this point which has to be studied extensively so that the waste effects can be reduced.

Chemical Composition of BMW

Carbon                 50%

Oxygen                 20%

Hydrogen              24%

Other elements      6%

Agreements and Conventions on BMWM.

International Scenario-

The Basel Convention

It regulates the international movement of hazardous and other waste to prevent illegal trafficking.

The Stockholm Convention, 2006

It deals with the air emission standards for incinerators which should not be higher than .1 ng I-TEQ / Nm3 for nano air contaminants such as ubiquitous organic pollutants (POPs) dibenzo - dioxins and furans released during combustion of BMW.

WHO Guidelines

Promotes and Suggests sustainable waste management practices. In 1999 it issued a “Blue Book” related to BMW handling which was further modified in its 2nd issue in 2014 to incorporate sustainable issues pertaining to BMW M.

Indian Scenario-

India was the first country to implement BMW M rules in 1998 which were amended and drafted in 2003, 2011 under the Environment Protection Act (EPA), 1986. Later the Ministry of Environment Forests and Climate Change (MoEFCC), under the Govt. of India, notified the BMW M rules on 28th March 2016, filling the gaps of the old rules and providing strict regulations for sustainable and safe management of BMW across the country. A brief introduction about BMW M rules, 1998 is given below.

As per these rules BMW is categorised into following 10 categories

Category - i includes Human Body Waste.

Category - ii comprises Animal Waste.

Category - ii has Biotechnological and Microbiological Waste.

Category - iv includes Sharp Wastes.

Category - v comprises Dispensed Medicines and Neoplastic Drugs. 

Category - vi has Solid Waste contaminated with blood / body fluids.

Category - vii includes Disposable Plastic Items i.e. waste such as catheters, IV sets and tubings.

Category - viii comprises Liquid Waste which is termed as hospital waste waters (HWWs).

Category - ix includes Incinerated Ash of solid BMW.

Category - x comprises Chemical Liquid Waste.

Each category of waste has a proposed storage option in colour coded bins and a final disposal method.

Storage Options for different Categories of BMW.

Black Bag contains paper, vegetable, cardboard waste, chemicals and general BMW which accounts for 85% of total generated BMW (WHO). It is non - infected waste similar to Municipal Waste.

The Red Bag contains syringes without needles, gloves, catheters, IV tubings.

Yellow Bag contains pathological and anatomical waste, discarded cytotoxic and expired drugs.

Blue Bag contains medicated metals and glass items which can be consumed after sterilisation at CBWTF.

White puncture proof Bag contains sharps and needles.

Disposal Methods for different categories of BMW.

Category i and ii wastes should be incinerated/deep buried.

Category iii and vi wastes to be incinerated/autoclaved.

Category iv waste should be disinfected with chemical treatment/autoclaved and then mutilated and shredded.

Category v waste should be incinerated /destructed and disposed of by deep burial.

Category vii waste to be disinfected with chemical treatment and autoclaved and then mutilated and shredded.

Category viii waste should be disinfected with chemical treatment and then drained into Municipal Waste Waters (MWWs).

Category ix waste to be land filled.

Category x waste pretreated and then discharged in MWWs.

 Each technique has its importance for the final culmination of different categories of waste; since much of the emphasis has been given on the hazardous/infectious portion of BMW, the most dominant technique for safe disposal of this fraction of BMW is disinfection or ideally speaking sterilisation and thermal treatment or incineration. With disinfection we try to dissolve the infectious nature of BMW and by incineration any type of BMW can be disposed of. Disinfection/sterilisation can be achieved in 5 types -

1. Dry heat/steam sterilisation (Autoclaving) commonly done for moist contagious waste.

2. Moist heat/steam (hydroclaving) which is done by the shredding of the dry infectious waste.

3. Chemical treatment is usually not adopted except for HWW.

4. Non ionising irradiation (microwave short wave frequencies).

5. Ionising irradiation.

Highlighting here is a key point that out of the variety of available thermal procedures such as pyrolysis, plasma treatment and incineration the most widely used method is incineration.

Adopted Methods of BMW M: advantages and disadvantages

Recycling-It is the recovery of materials from used products to be again used as starting material for manufacturing industries. In the BMW context this is a costly affair.

Incineration- Reduces the weight and volume of BMW, it is the most preferred method for BMW M across the globe but produces hazardous solid waste rich in heavy metals.

Autoclave- A heat based safe method for BMW disposal but is practised only in few countries across the globe due to its high operable cost, unappealing appearance of autoclaved waste and its failure in reducing the quantity of waste to be finally disposed of.

Land fill- It can be secured landfill or sanitary landfill, it is easy on the pocket and requires no training but generates additional burden on already limited resources, causes water pollution due to leaching of metals and also is a breeding ground for flies and rats which may act as vectors for zoonotic diseases.

Sewage treatment-Primary treatment of wastewater results in sewage formation which is converted into non-toxic liquid discharge. HWW are rich in organic compounds, drugs, heavy metals and pathogens which may persist after sewage treatment also.

BMW M Rules then and now (a comparison between 1998 and 2016 rules)

1. The umbrella cover of the 1998 BMW rules have been expanded so as to now ensure the effective management of BMW that is generated during immunisation programmes, blood donation camps, even the first aid / any type of medical treatment given in the schools, offices, houses, camps etc i.e. any type of medical programme that is conducted outside the periphery of a HCF.

2.The duties of the occupier (HCF) and the operator (authorised company) dealing with the final disposal of BMW are well marked, wherein the occupier has to maintain the records of the BMW generated and has to upload the same on the website; Bar coding and GPS is essential for transporting of BMW to CBWTF, also on-site pre-treatment  by disinfection and sterilisation as per WHO guidelines for infectious waste and for hospital wastewater treatment, an effluent treatment plant (ETP) is mandatory. The operator has to maintain emission standards for incinerators, air control devices to be installed on incinerators and it is his responsibility to ensure safe transit of BMW from HCF to CBWTF as per BMW rules.

3. Schedule I of the 2016 rules deals with the segregation practices to ensure sustainable disposal of BMW which revolve around recycling to authorised dealers and focussing on newer waste treatment technologies.

4. Strict monitoring for the compliance of these rules have also been ensured in the 2016 rule book where this authorisation has been granted to the country’s highest pollution regulating organisation, The Central Pollution Control Board (CPCB), receiving timely updates from the MoEFCC. Individual states monitor pollution loads through a state pollution control board which annually submits its report to CPCB. Further a district monitoring committee for safe management of BMW is also advisable as per the BMW draft 2020. Despite all these legal frameworks there have been issues of HCF violating the BMW M rules as the biggest loophole in these rules is that it is silent about the non hazardous fraction of BMW which is frequently mixed with hazardous BMW.

 The management of BMW includes sorting of the waste, temporary storage, transportation and disposal at the common bio medical waste treatment facility (CBWTF) where incineration followed by landfilling, autoclaving and recycling are the routine methods adopted.

BMW M scenario

Global Level

Due to lack of awareness, insufficient resources, poor segregation practices and unscientific disposal methods  used in 22 developing countries 18% to 64% of HCFs manage BMW unsustainably (WHO, 2014). Generally it has been observed that hazardous BMW is mixed with general BMW which poses health risks to about three quarters of the world’s population and has the ability to damage the entire global environment.

In Indian Context

In Indian context, the generated waste is approx. 1- 1.5 kg / bed /day in a multi speciality hospital (this can increase depending on the advancement in medical treatment procedures) and 600 gm/day/bed in a general practitioner's clinic. Assuming that an average of 1 kg/bed/day waste is produced, so in a 100-bedded hospital the waste per day would be 100-200 kg, out of which 5 - 10 kg waste would be hazardous (ISHWM, 2016). As per the report by (CPCB, 2020c), BMW production in the country has grown from 476.18 mt tons/day in 2014 to 618 mt tons/day in 2018, an increase of approximately 4% (these figures do not include the covid duration data since it was the extreme condition witnessed). The data from Associated Chambers of Commerce and Industry of India (ASSOCHAM, 2022) stated that BMW production in India has expanded from 618 tonnes per day to 780 tonnes per day in 2022; an increase of 9.13%. A survey conducted by International Clinical Epidemiology Network in 25 districts of 20 states has highlighted that only Chennai and Mumbai follow sustainable BMW M practices.

The incompetent handling of Bio Medical Waste (BMW) such as lack of management in sorting of waste in destined coloured bins, not packaging as per the rules, its temporary storage (for more than 24 hrs), collection (without GPS facility), transport to CBWTF in open and unauthorised vehicles to its final disposal where old and unscientific methods are adopted have caused environmental and health problems globally. The threats due to improper management of BMW have been reported in India and abroad. It is important to highlight here that as per (WHO, 2014) In the toxicity ranking of wastes, BMW is succeeded only by chemotoxic and nuclear waste and alas it is still mismanaged across many countries of the world.

Human  hazards caused by unsafe handling of BMW.

Unsafe BMW handling poses chemical, physical and biological risks for people working inside a HCF and outside the HCF. The US Environmental Protection Agency (EPA) states that the biological risks by BMW are greater for health care persons than for the general public. Within the HCF the main group exposed to risk are the medical/para medical staff, patients (susceptible to hospital induced infections), visitors, workers of ancillary services of HCF (medical supply stores, laundry and kitchen staff) and the cleaning staff who can directly come in contact with the waste if appropriate safety measures are not taken due to carelessness or unawareness.

The infectious part of BMW contains a diverse range of pathogenic microorganisms which can cause severe to mild infections and that can find their way into the human body through cuts, abrasions, punctures in the skin caused while handling the sharp content of BMW.  Contaminated blood bags, needles, cotton dressings soaked in patient’s blood can be a source of transmission for hepatitis virus, AIDS, septicemia and hemorrhagic fevers. To quote a few reported incidences of human hazards caused by BMW are HBV outbreak (240 infected) in Gujarat, India in 2009; In 2010 illegal consumption due to recirculation of used injections led to the registering of  33,800 novel HIV cases, 3,15,000 hepatitis C cases and a mounting figure of 17 lakh serum hepatitis cases. In 2018 as per WHO report this data expanded to 2,60,000 HIV cases, 20 lakh new hepatitis C infections and  2 hundred 10 lakh new hepatitis B reported cases (a very concerning growth) which represent 32%,  40% and 5% of total recorded cases. Apart from these, infectious injuries to scavengers (16 lakh) in Afghanistan due to tonnes of BMW generated in mass immunisation campaigns were also reported. The fraction of BMW that is hazardous has genotoxic, chemotoxic and radioactive properties unacceptable for healthy human living.

Environmental Hazards

These hazards can be due to the direct release of raw/untreated hospital waste waters (HWWs) or due to the incineration of solid BMW. Since hospitals consume a variety of chemicals the main being disinfectants, surfactants, antibiotics,analgesics,  endocrine disruptors - as such their concentrations are unacceptable in the wastewater discharged. These are one of the causes of bacterial resistivity and microbial genotoxicity; apart from their eco toxic effects due to biomagnification and bioaccumulation caused on aquatic life. Since the consumption of pharmaceuticals has increased many folds these are released in HWW and as such their disposal should be a highly scientific affair, for which their 4 categories are recognised ;

1. Cytotoxic and cytostatic drugs

2. Non-hazardous drugs

3. Pharmaceutically inactive drugs

4. Medicines that are flammable, harmful irritants, oxidising or ecotoxic.

Each category requires its own disposal method; though unfortunately all drugs are disposed of in HWWs. Next the ash that is released after incineration of BMW is equally harmful as it is a rich source of heavy metals that can leach into the surface or ground waters, also incomplete combustion of BMW is a prime source of release of poly aromatic hydrocarbons (PAHs), dioxins and furans in the environment. The illness generated due to polluted environment can be either -

1. Chronic illness caused due to extended exposures to low concentrations of harmful substances.

2. Acute illness due to momentary exposures to high concentrations of harmful chemicals.

However, sadly the hospital authorities, despite the fact that stringent laws for handling this waste have been formulated, are neglecting these major aspects of biomedical waste. We are closely related to our surroundings. We cannot achieve the goals of good public health in an unhygienic environment. Therefore, it is much more important to focus on the waste generated from hospitals, laboratories and diagnostic centers, manage its proper disposal, and hence minimise its negative impact on the environment.

Minimum waste generation strategies

As per the BMW rules 2016 every occupier who has more than 30 bed treatment facilities  should have a well developed and structured BMW M system  with a focus on waste minimisation and waste recycling agenda, which are presently seen lacking. For this a waste management working group should be appointed in each such HCF which should draft an action plan for waste management by taking into consideration; technical, financial and environmental aspects.

The technical aspect ensures safe BMW M by monitoring the quality and quantity of waste produced by each ward/any type of medical activity/laboratories etc. then analysing the total magnitude of waste being produced, percent of infectious waste, fraction of sharp content of the waste, segregation of the waste etc.  It should affirm by its internal policies to reduce the amount of waste generation by choosing those products;

1. That generates less waste

2. Can be recycled

3. Avoid  over purchasing or over stocking of products such as chemicals and drugs

4. Preventing over use of products such as disinfectants and surfactants while performing sterilisation in the HCF.

The financial aspect includes empowering human resources for BMW M, allocating budget and ensuring regular training schedules for the entire staff (medical, para medical, cleaners, administrators, office workers etc) as all have a direct or indirect role in BMW M.

The environmental aspects of the working group includes safety of the healthcare personnel involved in BMW handling, the safe storage and transit of BMW to CBWTF, reducing the infectious nature of BMW by pre-treating it, if permissible depending on the infectious nature of BMW produced at the medical care center and recommending best disposal options based on the available infrastructural facilities.

Thus to conclude BMW M is an important aspect of health care facilities as without its proper management the goals of a healthy society can never be achieved.