IOP Conference Series: Earth and Environmental Science

PAPER • OPEN ACCESS You may also like

- Comparison and analysis of several
Sustainable Management of Bio Medical Waste in medical waste treatment technologies
Lufeng Xu, Kun Dong, Yiming Zhang et al.
Chennai: A case study - Description of the Characteristics of Solid
Medical Waste in the Environment During
the COVID - 19 Pandemic: Case Study
To cite this article: Kavitha Suresh and Suresh Ramamurthy 2023 IOP Conf. Ser.: Earth Environ. Sci. Hospital X Covid-19 Referral in Semarang
1210 012022 City
N Himayati, T Joko and M Raharjo

- Planning and Implementation of

Hazardous Waste Management
Emergency Response Program – A Case
View the article online for updates and enhancements. Study of PT. X Medical Hazardous Waste
Treatment
M Candra Nugraha Deni and Aulia
Shabirah

This content was downloaded from IP address 106.221.167.254 on 24/01/2024 at 06:46

ICDIMSE-2022 IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1210 (2023) 012022 doi:10.1088/1755-1315/1210/1/012022

Sustainable Management of Bio Medical Waste in Chennai: A

case study

Kavitha Suresh1, Suresh Ramamurthy2

1
Assistant Professor, Department of Architecture Sathyabama Institute of Science and
Technology, Tamil Nadu, India.
2
Assistant Professor, MARG Institute of Design and Architecture, Tamil Nadu, India.

E-mail: [email protected],[email protected]

Abstract. The aim of the current research article is to study various treatment techniques
involved in the management of bio medical waste and select the most appropriate treatment
method in terms of cost savings, energy recovery and waste volume reduction in a sustainable
manner. Most of the HCF (Health Care Facilities) lacks the provision for on-site waste
treatment facility. One of the major reasons might be the fear of high pollutant emission levels
from multiple machines or equipment used in the treatment process. At times, it could be due
to lack of sufficient space within the clinical premises. To overcome this situation, a minor
amendment has to be introduced in the bio medical waste management rules 2016, which
includes providing a suitable area necessary for medical waste treatment within the premises,
during the construction stage itself. Further, the identification of appropriate treatment
techniques based on the type of waste generated is also important. Even a primary HCF too
should be equipped with the requisite treatment facilities, considering the emission levels to be
within the standards. This sort of installing an on-site waste treatment facility will reduce the
amount spent upon external agencies for disposal and treatment of the medical waste. Then, the
leftover residue is securely landfilled in the dedicated site or even be liable to mix with the
municipal solid garbage. The current study concludes that the implementation of one of the
treatment techniques in a specific hospital helps in energy recovery, huge reduction in the
volume of waste generation and avoids illegal dumping of the waste, thereby creating less
impact on the surrounding environment.

1. Introduction
Biomedical waste corresponds to the waste generated in diagnosis, treatment and immunization
processes of human beings or animals along with the radioactive waste or waste produced from the
laboratories. Bio medical waste management rules 2016 have to be amended marginally so that the bio
waste generated in a healthcare facility is managed within the premises itself, where the waste is
produced. For example, during the construction of a healthcare facility itself, it is important to
consider providing a suitable land area for the treatment of medical waste. This way, the illegal
dumping of the medical waste can be avoided. Majority of the medical wastes is generated in public
and private hospitals while a sizeable quantity of the waste is generated by small clinics, dispensaries,
nursing homes, mortuaries, and autopsy facilities. In general, Indian hospitals generate 1.5kg of
medical waste per bed per day. In this scenario, proper disposal and treatment of the medical waste
should be prioritized. Medical waste management, treatment and disposal and raising awareness about
the processes among the medical professionals and the public have become a significant concern.

Content from this work may be used under the terms of the Creative Commons Attribution 3.0 licence. Any further distribution
of this work must maintain attribution to the author(s) and the title of the work, journal citation and DOI.
Published under licence by IOP Publishing Ltd 1
ICDIMSE-2022 IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1210 (2023) 012022 doi:10.1088/1755-1315/1210/1/012022

Instead of collecting and arranging the waste to be collected by external agencies, the waste should be
treated on-site which provides high number of benefits to the Health Care Facilities (HCFs). In
general, incineration, autoclave, microwave, plasma pyrolysis, shredding, encapsulation, chemical
disinfection, secured landfill, sharp pits etc. are some of the treatment and disposal methods used for
the treatment of biomedical waste. One of the main concepts of sustainability is ‘three R’s’ (Reduce,
Reuse and Recycle) in medical waste management. In this context, the purpose of implementing the
three R’s concept is to reduce the volume of biomedical waste generation, reuse the medical
equipment after sterilization and recover or recycle the waste into energy by onsite treatment
techniques that lead to environmental protection.

2. Earlier studies
In plasma pyrolysis system, destruction efficiencies better than 99.99% were achieved in case of
organic contaminants. This system yields extremely high destruction performance and releases the
dioxins and furans in the range of 0.005-0.009 ng/m3. This value is well below the global
environmental standards [1]. Plasma pyrolysis over incineration is considered as an appropriate
technique due to its characteristics such as low emissions, energy recovery and cost savings. Thermal
plasma technique is also viewed as a possible alternative in the past few decades. It is used to treat
highly-toxic wastes such as Air Pollutant Control (APC) residues, radioactive, and medical wastes
[2][3]. Further, this technique has also been revealed to be environmentally benign, thus creating only
inert slag and releasing minimal air pollutants that are well within the regional regulations. Instead of
conventional autoclave method, microwave technique can be used to treat the medical waste, which
helps in cost savings to a considerable amount. Further, microwaves also hold a great potential as one
of the emerging technologies to treat biohazardous waste generated in the healthcare facilities.
Microwave technology may be especially helpful in resolving some specific issues with waste in the
developing countries [4]. Based on the earlier studies, the current research article primarily focuses on
incorporating the possibility of on-site treatment in the identified case study.

3. Methodology
According to Yin, one of the rationales behind following single case study method is to reveal
something to unknown. In this method, the investigator gets an opportunity to observe and analyse a
fact within a limited duration [5]. Besides, one can also develop an in-depth understanding about a
specific phenomenon [6]. In this paper, single case study method is adopted to get insights, be familiar
about the phenomenon and gain a better understanding about the topic by exploring it. In this method,
the major emphasis is upon analysing and exploring the appropriate treatment techniques to be
followed based on the space available in the premises. Besides, this paper also explores the domain by
understanding about various treatment techniques available for bio-medical waste treatment as per the
relevant norms/standards.

4. Biomedical Waste Treatment Techniques

4.1. Incineration
Incineration is a dry oxidation process that converts the organic and combustible waste to inorganic,
non-combustible waste, thus reducing the volume and weight of the waste. This procedure is often
used to treat the waste that cannot be recycled, repurposed, or disposed of. Burning organic
compounds emits high volumes of gases such as carbon dioxide, nitrogen oxides, some other toxic
substances, particulate matter and solid residue in the form of ashes. So, the incinerators must meet the
operating and emission criteria. According to the regulations, the Combustion Efficiency (CE) must be
at least 99.00 percent.

4.2. Autoclaving
Autoclaving is a highly efficient wet thermal disinfection method. Autoclaves are often used in
hospitals to treat the reusable medical equipment. It is normally reserved for highly contagious waste
such as microbiological cultures or sharps, because they can only process a small volume of waste.

2
ICDIMSE-2022 IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1210 (2023) 012022 doi:10.1088/1755-1315/1210/1/012022

Needles are autoclaved before being transferred to the needle pit and sharps from the needles are
collected in puncture-resistant receptacles. All the microbiological waste, containers, plates, and tubes
are autoclaved before recycling or disposal. Due to the difficulty or ineffectiveness of the chemical
treatments, the blood banks must autoclave the discarded/infected units before disposal.

4.3. Microwave
Microwave is a brand-new method to deal with biohazardous waste generated by the healthcare
facilities. Microwave technique is commonly used to inactivate the germs. Though it makes sense in
some instances, it may lead to a misconception that the microwave systems cannot be used to
inactivate the solid ‘dry’ waste. Conventional microwave devices, on the other hand, are unable to
control the inactivation process, particularly in case of waste with moisture content. However, a few
sophisticated microwave procedures have been proved to effectively inactivate the biohazardous
compounds, when followed under proper measures. Such methods are effective inactivation tools and
some of them are available commercially too. It is also crucial to note that the waste should be
inactivated at the earliest possible time from the time of waste generation. The biohazardous waste
should only be disposed of with extreme caution.
Microwave technique also saves energy compared to the conventionally used autoclaves. A bulk of
bacteria gets killed by the microwave technique at a frequency of around 2450 MHz and a wavelength
of 12.24 cm. As the microwaves rapidly heat the water present within the waves, the pathogenic
components are removed by the heat conduction. In the United States, a regular bacteriological test,
using Bacillus subtitles, is advised to show a 99.99 percent reduction of the active spores. Two
categories of microwave treatment technologies exist such as the conventional process and a
sophisticated microwave treatment technique.
In principle, two system designs exist for advanced microwave technologies such as batch processes
and semi-continuous microwave systems [7].
Sanitec waste disposal system is an example for continuous microwave technology, including a
shredding system [8]. This system is designed for the treatment of large amounts of biological waste,
which necessitates the collection of waste at the source, transport it and inactivate it at a single
location. For small amounts of waste, other microwave technologies combined with shredding are
available as well [9].

4.4. Plasma pyrolysis

Plasma pyrolysis System is equipped with a ‘CASS’ (Complete Automated Safety System) that
assures a safe operating environment.
Installation, operations, and maintenance expenses for plasma pyrolysis system are equivalent to that
of the standard incineration facilities of comparable capacity. Its inherent simplicity, absence of any
moving parts, system redundancy, automation, and the proven stability of the plasma pyrolysis system
ensure outstanding reliability with little downtime and maintenance requirements.

Figure 1. A schematic representation of the processes involved in plasma

pyrolysis system

3
ICDIMSE-2022 IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1210 (2023) 012022 doi:10.1088/1755-1315/1210/1/012022

The amount of electricity incurred in this system is lesser. It uses less than one kilowatt-hour per
kilogram of the charge (approx.). The plasma field is generally sufficient to maintain the operational
temperatures, with the exception of starting and shut down. Further, the operating costs are
significantly lesser for a standard waste processing or energy production systems on the market today,
thanks to the addition of oxygen generators and co-generation. Plasma pyrolysis is the state-of-the-art
technology for safe disposal of the medical waste. This technology turns organic waste into
commercially useful by-products that are environmentally benign. The extreme heat of the plasma
allows it to safely and reliably dispose of all the forms of waste including municipal solid waste,
biological waste and hazardous waste. When medical waste comes into touch with the plasma-arc, it
gets pyrolyzed into CO, H2, and hydrocarbons. When these gases are consumed, a high temperature
(up to 1200 °C) is produced. The hot gases are then quenched from 500°C to 70°C during the plasma
pyrolysis process to avoid the recombination reactions of gaseous molecules, which in turn prevent the
creation of dioxin and furans. Consumables in this plasma pyrolysis process are mainly electricity and
graphite electrode. In this technology, the possibility of energy recovery is high.
Table 1 compares various treatment techniques identified based on the specifications such as waste
type, heat source, temperature, emission level, consumable, acceptance, cost economics, safe operation
and power requirements.

Table 1. Comparison among various treatment techniques

Specification Plasma Incineration Microwave Autoclave

pyrolysis
Waste type Bio medical, Biomedical Biomedical Biomedical
Plastic, PVC
Heat Source Plasma Arc Diesel Steam Steam
(Electrical
Energy)
Temperatures in Core plasma 700-1000°C in the 100-180°C 100-180°C
reaction zone temperatures chamber
are above
5000°C
Formation of Not formed - Higher possibility Not formed Not formed
dioxin, furan and much below of formation due
aromatic detectable to low
compounds limits temperature
Soot and N0 As per CPCB Excess formation Not formed Not formed
(nitrogen Norms is observed
oxide)formation
Consumables Electricity, Electricity, Electricity Electricity
Plasma forming Diesel, coal and
mediums Oxygen/air
Acceptance Globally Globally getting Globally accepted Globally accepted
accepted as a banned for because of its
clean disposal of sophisticated look
technology biomedical waste
Cost Economics Biomedical Biomedical waste Biomedical waste Biomedical waste
waste disposal disposal cost is disposal cost is @ disposal cost is @
@ Rs 18/- per substantially high 15/- per kg 15-20/- per kg
kg for 50kg/hr (>20 kg/- per kg)
system with all if all emissions

4
ICDIMSE-2022 IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1210 (2023) 012022 doi:10.1088/1755-1315/1210/1/012022

emissions are brought under

under control the norms.
Safe operation Environment Occupationally Safe Safe
friendly and unsafe
occupationally
safe
Power 30kw-75kw 50kw onwards 3kw-20kw 18kw onwards

Amongst all the techniques discussed above, plasma pyrolysis and microwave treatment techniques
are considered highly appropriate for the treatment of medical waste, thanks to its specifications over
other techniques, as shown in the table.

5. Case study
For this study, one of the medical college hospitals, functioning at Chennai was identified as a live
case study. At this facility, the bio-medical waste is segregated under four types Yellow, Red, Blue
and White, based on the type of waste generated.
 Yellow: Pathological waste, soiled (infectious) waste, medical chemical waste, clinical lab
waste, pharmaceutical waste (discarded/expired medicines and drugs)
 Red: Contaminated waste (recyclable)
 White (or translucent): Sharps and waste like needles and injections
Blue: Medical glassware waste
Figure 2 shows the segregation of waste based on colour code generated in the hospital

Figure 2. Segregation of the biomedical waste

Apart from the biomedical waste, other wastes like plastic waste are also collected separately in the
premises as shown in figure 3.

Figure 3. Plastic waste

5
ICDIMSE-2022 IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1210 (2023) 012022 doi:10.1088/1755-1315/1210/1/012022

5.1. Data collection

The quantity of the medical waste generated in the live case study is shown in table 2 from 21st Aug
(Friday) to 30th Aug (Sunday) 2020.

Table 2. Quantity of the bio medical waste generated per day

Waste
Collection as
Quantity of the waste generated per day in KG
per 4 color
codes
Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun

Yellow 4.78 8.96 7.90 5.34 3.28 3.82 9.70 4.14 7.8 17.00

Red 4.36 24.5 26.23 24.16 20.90 26.6 23.26 4.20 18.94 25.72
2 1
Blue 1.58 1.96 1.81 1.18 1.83 1.68 1.98 0.54 1.14 5.29
White - - - - - - - - - -
Total 10.72 35.4 35.94 31.31 26.01 32.1 34.94 8.88 27.88 48.01
4 1

5.2. Observation
It has been observed that the bio medical waste, to be disposed of, was kept in the waste storeroom, as
shown in Figure 4. As per the bio medical waste management rules 2016, this waste should not be
stored for more than 48 hrs.

Figure 4. Existing bio medical waste storeroom

Ample space of vacant land is available near the medical waste storeroom, as shown in the figure
(Figure 5). This vacant space can be effectively used to develop an appropriate area for suitable
treatment techniques. Hence, the establishment of the treatment technique facility will not be a
constraint. When the neighbouring small clinics and dispensaries are allowed to use these facilities
(treatment techniques) at a fair cost, the hospital can generate income from the service while the
service takers get to access the facility without spending much amount to the external agencies.
In addition to this, such a facility can also minimize the volume of untreated waste. This helps in
preventing adverse environmental effects. Therefore, the proposal of suitable treatment techniques in
this vacant land will also help in recovering certain amount of energy.

6
ICDIMSE-2022 IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1210 (2023) 012022 doi:10.1088/1755-1315/1210/1/012022

Figure 5. Vacant land near the storeroom

6. Findings and Analysis

From the study, it has been perceived that certain types of waste have to be treated only by appropriate
techniques as per the colour-coded categories prescribed by the Bio medical waste management rules,
2016. Plasma pyrolysis technique is used for treating the yellow color-coded waste whereas
microwave technique is used to treat other color-coded waste (such as red, blue and white). In
comparison with incineration, plasma pyrolysis is a better option since the energy is recovered and
microwave is considered as a suitable option than the autoclave method in terms of overall cost
savings.
Based on the above findings, the study analysis has been further extended by calculating the cost
factors and energy recovery using plasma pyrolysis and cost comparison between microwave and the
autoclave techniques.

Table 3. Calculation of cost factors for plasma pyrolysis technique with an assumption on energy
recovery from waste

Cost
Factors Capital Cost Disposal Operating Cost Energy unit Variable
Cost Cost Cost
For 30KW Rs 12,00,000 Rs 15/Kg Rs 13/Kg Rs 5 Per Margin or
System Kwh Profit is
(Rs15-Rs8)=
Rs 7/Kg
After - - Rs -
Energy 8/Kg(Effective )
Recovery

From the above table, it can be assumed that for a capacity of 30KW system, the capital cost is Rs
12,00,000 approximately. The disposal cost to the external agencies is Rs 15/kg and the operating cost
is Rs 13/kg. When plasma pyrolysis system is used, 1kwh energy can be generated by burning 1 kg of
medical waste. This in turn reduces the operational cost by about Rs 5 as the energy unit cost is Rs
5/Kwh. After energy recovery, the effective operating cost becomes Rs 8/kg. So, by adopting this
treatment technique, the profit would be Rs 7/Kg (i.e Disposal cost through outside agencies –
Effective operating cost which is Rs 15/Kg –Rs 8/Kg =Rs 7/Kg)

7
ICDIMSE-2022 IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1210 (2023) 012022 doi:10.1088/1755-1315/1210/1/012022

6.1. Recovery of capital cost

Based on the assumption that the capital is borrowed with an interest rate of 7% as per the RBI
(Reserve bank of India) directives, it changes from time to time. Therefore, a fixed cost is calculated
for the purpose of recovery in the long-run so as to ensure the profits after achieving the breakeven
point.
Fixed cost
 Interest @ 7 % of the capital cost (Rs.12,00,000): Rs 230 per day
 The capital investment of the machine should be recovered in 3 yrs. So, as assumed, the
 capital cost recovery for 3 years of Rs.12,00,000 becomes Rs.12,00,000/3x365: Rs 1095 per
day
 Maintenance is assumed to be 10% of the capital cost (Rs.12,00,000) which comes to: Rs 329
per day
 Total fixed cost: Rs 1654 per day.

It is presumed that after completion of 3 years, the breakeven point achieved is determined as follows.
Break-even point = Total Fixed cost /Margin or profit (as per table 3)
1654/7=236 Kg.
Thus, the breakeven can be achieved by burning approximately 236 kg of medical waste per day. On
the other hand, if the facility generates such huge volume of medical waste i.e., 236 kg, the investment
made to the extent of Rs.12,00,000 for the initial cost incurred upon the machine can be recovered.
Further, medical waste generated will be a profit.
Considering the bed strength to be 650 as in the live case study, even if 50% of the bed capacity is
occupied i.e, 325 beds (1.5kg/bed/day of waste is generated in hospitals of India), then the waste
amounts to 487.5Kg.
With this assumption, the energy generated will be higher and bring more benefits to the hospital.
Thus, the energy produced can be used to provide electricity to the hospital or the recovered energy
can be used back for the same mechanism, which results in cost savings.

6.2. Energy Recovery using Plasma Pyrolysis Technology

A commercial system related to plasma pyrolysis technology can treat the waste at a rate of 25 kg/h. It
requires a small space (~ 15 ft × 15 ft) for installation. On an average, 1 kW power is required to treat
1 kg of waste. Consumables in this process are mainly electricity, water and gas (N2 or air).
Significant amounts of CO and H2 gas are produced as by-products of plasma pyrolysis of the organic
waste. After the combustion of CO and H2, the exothermic process occurs which releases energy in
the form of heat and light.
 CO + 1/2O2 = CO2, DH = – 67.63 kcal,
 H2 + 1/2O2 = H2O, DH = – 57.82 kcal,
 Total energy released = (i) + (ii), DH = – 125.45 kcal.
This translates into the fact that 125.45 kcal energy gets released from the combustion of one g-mole
of CO and one g-mole of H2. So, it is obvious that the plasma incineration of 1 kg of organic waste
requires around 860 kcal energy, which is equivalent to 1 kW electrical power [1].
Therefore, the energy released when burning the waste is important to create the electrical power.
Finally, burning 1 kilogram of the waste produces 1 kWh of energy in the form of electricity, which
makes it a viable option for energy recovery and cost savings. As shown in the table below (table 4),
the total amount of H2 and CO in the gaseous combination is 49% by volume or more. So, it becomes
hot when burned. When recovering energy in the form of electricity from the residual gas, it must be
free of corrosive and toxic substances and should compose approximately 50% flammable gas. In
addition, some gases such as CO, H2, CH4, CO2 and HCL also get produced during the pyrolysis
process.
Proper treatment of these gases can lead to energy recycling and prevent the air pollution. Carbon
monoxide, methane, hydrogen and other hydrocarbons are combustion gases. The heat generated can
be used as a partial energy source which in turn reduces the cost of the pyrolysis process.

8
ICDIMSE-2022 IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1210 (2023) 012022 doi:10.1088/1755-1315/1210/1/012022

Plasma pyrolysis method has been assessed in this study for its economic viability and energy
recovery using these statistics. The quantity of the gas (in %) liberated is shown in the table below.

Table 4. Gases after pyrolysis process

Gas Quantity
(%)
N2 45.03
H2 22.63
CO 26.65
CH4 1.50
CO2 4.20
C2- 0.45
C5(hydrocarbons:C2H6,C3H8,NC4)
Microwave treatment method can be used to treat other types of waste generated such as blue, red and
sharp items. Microwave - Medister 20 is a batch microwave system, which is suitable for this
treatment purpose as the waste generated is less and can be loaded in a batch-by-batch manner. When
comparing microwave with autoclave, the microwave technique has high advantages in terms of cost
savings.
Both the techniques were compared for cost and the results are shown in table 5 based on the reference
handbook on bio-medical waste management.

Table 5. Calculation of cost comparison (Microwave & Autoclave)

Key parameters Microwave Autoclave
Electrical energy consumption 3.5kwh Maximum 18kwh
Cost of energy/hr (Rs onwards
4.50/kwh) Rs 16 Rs 81
Cost of Energy per day (8 hrs
shift) Rs 128 Rs 648
Cost of energy per year (350
days)
On single shift basis Rs 44,800 Rs 2,26,800
On double shift basis Rs 89,600 Rs 4,53,600
Saving
1 year Rs 1,82,000 Nil
5 years Rs 9,10,000 Nil
10 years Rs 18,20,000 Nil
The equipment cost = Rs 15, 00,000
From table 5, it can be concluded that the microwave equipment is highly advantageous over
autoclave in terms of cost savings by electrical energy consumption. After 10 years, the amount saved
for the microwave will be 18,20,000 INR (savings) - 15,00,000 INR (Equipment cost) =Rs 3,20,000
Hence, on an average, Rs 32,000 can be saved per year and the waste gets almost reduced by more
than 80% of the original volume. So, batch microwave –Medister 20 is to be considered for this
purpose.

7. Discussion & Conclusion

After the treatment of medical waste using plasma pyrolysis and microwave techniques, the remaining
residue must be transferred to the burial pit carefully.
The vacant land, shown in this case study, is large enough to act as an on-site treatment center.
However, in case of other HCFs such as nursing homes, dispensaries, or small clinics with limited
space, a small treatment machine such as a microwave or possibly a plasma pyrolysis machine with a

9
ICDIMSE-2022 IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1210 (2023) 012022 doi:10.1088/1755-1315/1210/1/012022

minimum footprint of 225 sq.ft can be provided near its backyard or service area. But the treatment
machine's emission levels should be checked before on-site installation. If such a method is successful,
the problems of waste management, disposal, and treatment can be effectively addressed. Further,
there is no need to pay waste treatment cost for the external agencies. HCF in the nearby areas can also
use this on site facility as already stated in the case if it is not feasible for them to have a own
treatment machine. As a result, unlawful medical waste disposal can be avoided. Health-care staff
should be educated on such waste treatment methods. If the process of energy recovery and reuse of
plastic medical waste are implemented properly and successfully, hospitals of all sizes can benefit
greatly and also achieve a sustainable operation.

REFERENCES
[1] Nema, S. K., & Ganeshprasad, K. S. (2002). Plasma pyrolysis of medical waste. Current
science, 271-278.
[2] Chu, J. P., Hwang, I. J., Tzeng, C. C., Kuo, Y. Y., & Yu, Y. J. (1998). Characterization
of vitrified slag from mixed medical waste surrogates treated by a thermal plasma
system. Journal of Hazardous Materials, 58(1-3), 179-194.
[3] Rutberg, Ph G., A. N. Bratsev, A. A. Safronov, A. V. Surov, and V. V. Schegolev. "The
technology and execution of plasmachemical disinfection of hazardous medical waste."
IEEE transactions on plasma science 30, no. 4 (2002): 1445-1448.
[4] de Titto, E., Savino, A. A., & Townend, W. K. (2012). Healthcare waste management: the
current issues in developing countries. Waste Management & Research, 30(6), 559-561.
[5] Yin, R. K. (2009). Case study research: Design and methods (Vol. 5). sage.
[6] Gustafsson, J. (2017). Single case studies vs. multiple case studies: A comparative study.
[7] Chartier, Y. (Ed.). (2014). Safe management of wastes from health-care activities. World
Health Organization.
[8] Edlich, R., Borel, L., Jensen, H. G., Winters, K. L., Long III, W. B., Buschbacher, R. M.,... &
Tafel, J. A. (2006). Revolutionary advances in medical waste management. The Sanitec®
system. Journal of Long-Term Effects of Medical Implants, 16(1).
[9] Veronesi, P., Leonelli, C., Moscato, U., Cappi, A., & Figurelli, O. (2005). Non-incineration
microwave assisted sterilization of medical waste. Journal of Microwave Power and
Electromagnetic Energy, 40(4), 211-218.

10