Healthcare waste refers to all the elements generated by health institutions, research facilities, and laboratories. Extra waste is produced on a minor scale by activities such as home treatment, for example, dialysis. Debere et al. (2013) present the 2010 World Health Organization report, which reveals that over 16 million injections are administered to patients across the world every year. This finding indicates a large number of syringes involved. Consequently, not all of them are disposed of in the right manner afterward. Syringes form part of hazardous healthcare waste. Harmful waste contributes about 15% of the total healthcare waste. The other type, namely, non-hazardous waste, forms approximately 85% of the total waste produced by health care facilities. They can infect people, especially healthcare workers who handle them on a day-to-day basis. This paper will discuss various types of health care waste and their methods of disposal. It will begin by presenting the available international pacts on health care waste.
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International Agreements on Health Care Waste
Various international agreements and principles dictate how healthcare waste should be managed. For effective application of these agreements, it is imperative to adapt them into the national legislation of each state that is a member of such conventions. The agreements include the Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and their Disposal, which was enacted in 1989. This convention calls for the reduction in the production of hazardous healthcare waste. More importantly, the Basel Convention seeks to restrict the movement of hazardous wastes across country borders except where such movement is in accordance with the principles of environmental protection (Debere et al. 2013).
The convention was conceived after it was discovered that developing economies did not exercise care in the manner by which they disposed hazardous medical waste. In addition, the Bamako Convention was a response to the Basel Convention (Article 11), which called for member states to enter into interstate agreements regarding the disposal of hazardous medical waste. The need to enact the Bamako Convention arose from the realization that the earlier (Basel) convention had failed in restricting the transportation of certain hazardous wastes from the developed to less developed countries. The parties to this s convention are African states.
Besides, the Stockholm Convention on Persistent Organic Pollutants (POPs) came into force on 17 May 2004. It seeks to restrict the production of organic pollutants, which are seen as a threat to human life and the environment in general. Under the convention, the emphasis is placed on the need for developed nations to put measures in place to curb the production of POPs (Akum 2014). In addition to the three conventions discussed above, four international principles, namely, duty of care, polluter pays principle, precautionary approach, and proximity principle, have been put in place to safeguard careful disposal of medical waste.
Different Categories of Healthcare Wastes
|Waste Type||Definition and Explanation||Examples||Methods of Disposal|
|Infectious Waste||Wastes that contain pathogens, including bacteria, viruses, fungi, and other parasites whose concentration is enough to pose a health hazard to people who handle it |
Infectious waste is considered one of the most dangerous byproducts of health services
|Surgery waste (tissues and equipment used in the surgical procedure), materials from infected patients such as clothes containing patient’s blood, and bandages, and hypodermic needles, glass slides contaminated with tissues of human beings||Chemical treatment|
|Pathological Waste||Denotes any identifiable human or animal body component, appendages, or tissues (Liu, Wu & Li 2013)||Blood or any liquids from human beings, substances from unborn babies||Incineration|
|Sharps||Denotes materials that may cause cuts or piercings |
For this reason, they require being handled with great care
|Hypodermic needles, blades, and knives used in surgical procedures, infusion apparatus, nails, and damaged glasses||Incineration/ landfill|
|Pharmaceutical Waste||This category involves pharmaceutical items that are out of date, unutilized, leaking, or polluted. They are no longer valuable in the healthcare setup. Hence, they need to be disposed of.||Medicine containers, gloves, masks, tubes, and treatment vials (Liu, Wu & Li 2013)||Incineration/ Landfill|
|Genotoxic Waste||This category consists of highly hazardous materials that require extremely proper handling and disposal because they are suspected to be mutagenic, carcinogenic, and teratogenic (Sharma et al. 2013). They raise grave safety concerns both at the hospital and after disposal||Various cytostatic drugs and radioactive/chemical materials |
Examples of cytostatic drugs are azacitidine, carmustine, chlorozotocin, and cisplatin
|Chemical Waste||Chemical waste involves disposed solid, liquid, and gaseous chemicals. For instance, substances disposed of diagnostic and experimental exercises form part of the chemical waste |
Chemical waste can be dangerous or non-hazardous (Komilis, Fouki & Papadopoulos 2012)
|Dangerous chemical wastes: |
Formaldehyde, Photographic chemicals such as potassium hydroxide, hydroquinone, and silver
Non-hazardous chemical wastes:
Inorganic salts, amino acids, and sugars
|Wastes with High Levels of Heavy Metals||Heavy metal wastes is comprised of highly toxic materials||Mercury waste, which is mainly caused by spillage from broken equipment |
Cadmium is another heavy metal, is found in discarded batteries
|Pressurized containers||This class consists of containers that can explode to the extent of causing injury (Liu, Wu & Li 2013)||Cans, cartridges, and cylinders used to store pressurized gas that is utilized in medical procedures||Landfill|
Managing Waste Steams Inside and Outside the Health Care Facilities
The problem of managing waste is a major concern for all health care facilities. Inappropriate handling of these materials poses health risks such as being infected with diseases, for instance, hepatitis and HIV. Elnour et al. (2013) argue that healthcare waste should be handled separately from other municipal wastes because of the high risk they pose to people who handle them. The waste management process avails an opportunity for improving current strategies, educate health workers on the importance of proper waste disposal, and/or to establish the potential for waste reduction. Waste generation rates are determined in kilograms per day (Elnour et al. 2013). Healthcare facilities manage waste in numerous ways, depending on their (facilities) size. Some methods are suitable for small facilities with little waste while others work best for larger institutions with colossal waste streams.
Many activities go into ensuring that medical waste is disposed appropriately. These activities include collection, transportation, and disposal. As a requirement (depending on national and local legislations), each health care facility must have certain measures to ensure that each of these processes is carefully effected. The collection of waste is the initial step that begins with separating hazardous and non-hazardous waste. Separation is important since different levels of care are required when handling each category of medical waste. With solid hazardous waste, designated collection bags marked “biohazard” are often used (Debere et al. 2013).
This mark is meant to prompt waste handlers to exercise due care when dealing with dangerous waste to avoid being infected. In addition, the healthcare facility is supposed to provide the waste management staff with protective gear. Appropriate and frequent training must also be availed to the staff members to sensitize them on the ways and importance of proper handling dangerous waste. Where a private contractor is involved in the collection, transportation, and disposal of the waste, the duty of care principle requires the health care facility to conduct supervision to ensure that the processes are carried out effectively.
Transport of medical waste occurs where the designated place of disposal is found outside the hospital compound. Healthcare facilities often contract private companies to transport the waste to the designated places of disposal such as municipal incinerators and landfills. If the healthcare facility has an incinerator or landfill within its compound, transportation may not be an important stage of the disposal procedure. It is important to note that many countries require healthcare facilities to have basic disposal mechanisms for particular types of waste (Rawlance et al. 2015). For instance, chemical disinfection is usually required in handling liquid waste before it is released to the environment. The different methods of waste disposal include incineration, chemical disinfection, and land disposal.
Incineration as a process requires the ‘heating value’ of substances to be at least 2000 kcal/kg (Liu, Wu & Li 2013). For instance, the heating rate of infectious waste is above 4000kcal/kg. Types of incinerators range from those that are extremely sophisticated, operating at high temperatures, to basic combustion units with relatively lower temperatures. Nevertheless, if well used, all furnaces can eradicate infectious agents in refuse while transforming the unwanted materials into ruins. Conversely, some forms of unwanted hospital materials such as compounds and pharmaceutical refuse call for extreme heating to treat (Akum2014).
Chemical disinfection is used to kill microorganisms that exist in medical equipment and on floor surfaces. This method has since been adopted in the treatment of health care waste. Chemicals are put into the waste to kill or render pathogens inactive (Sharma et al. 2013). Chemical disinfection is distinct from sterilization. It is used to treat liquid waste, including stools, blood, and urine, and hospital sewage. This method is sometimes used to treat solid waste, including microbial cultures, and sharps.
When using chemical disinfection, it is important to take into account that some microorganisms are resistant to disinfectants. Such resistant parasites include certain strains of viruses and mycobacteria (Sharma et al. 2013). The survival of indicator microorganisms after disinfection is used to rate the effectiveness of that disinfection method. According to Wood et al. (2014), chemical disinfection is rarely used in developed countries, although it is a common form of waste treatment for healthcare facilities in developing countries. In hospitals that lack the capacity to treat the medical waste, landfill method may be used. It is a generally accepted technique of waste disposal (Liu, Wu & Li 2013). Those who favor the landfill method argue that is safer compared to allowing waste to accumulate at the healthcare facility.
Recent Approaches to Waste Management in Different Countries
Technology continues to advance, resulting in better methods of disposing health care waste. One of the recent methods of treating waste is microwave irradiation. This method involves destroying microorganisms through the action of microwaves. Microwave irradiation is carried out at a frequency of 2450MHZ and a 12.24 cm wavelength (Liu, Wu & Li 2013). The wastes are contained in water, which is rapidly heated by exposing it to the microwave radiation. The high heat produced destroys the infectious components. In microwave treatment, the waste is first shredded then humidified before being placed in the irradiation chamber.
The irradiation chamber is fitted with numerous microwave generators, which irradiate the waste for 20 minutes. The efficacy of this method is examined from time to time through virological and other microbial experiments. Practitioners from America carry out this daily waste disposal experiment using Bacillus subtilis. Because of the high cost of maintenance involved in microwave treatment, it has not been widely adopted in developing countries. Meanwhile, analogous methods have been established to deploy predetermined wavelengths, as well as electron rays.
Wet and dry thermal treatment is another recent method of managing health care waste. It involves the exposing shredded waste to high temperatures and pressure. It is used to treat highly infectious waste. It works by the same mechanism as autoclave sterilization (Liu, Wu & Li 2013). Wet thermal refuse disposal method should not be used in the management of anatomical materials and lifeless organisms, as well as compound and pharmaceutical substances. The method is ineffective in handling the above types of refuse. One of the main disadvantages of the wet thermal process is that the shredder may break down (Ali, Wang & Chaudhry 2015). Additionally, the success of the wet thermal process depends on highly sensitive operational conditions.
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Case Study of Waste Management Deficiency
Developing countries are known to encounter challenges with healthcare waste disposal. In Sudan, limited resources have led to disposal methods that do not conform to the standards recommended by the World Health Organization (Debere et al. 2013; Rawlance et al. 2015).A study conducted by Elnour et al. (2013) revealed that healthcare waste treatment and disposal in Sudan was not being accorded the priority it deserves. As such, many health risks have arisen in the country because of exposure to hazardous waste. The study by Elnour et al. (2013) targeted three hospitals in the White Nile region of Sudan: Rabak Hospital, Eduiem Hospital, and Kosti Hospital. These facilities were found to generate large amounts of hazardous waste on a daily basis, yet mechanisms for proper disposal remained limited. For instance, no color-coded plastic bags for carrying waste were available in these three hospitals (Elnour et al. 2013).
Elnour et al. (2013) further established that the three hospitals were dumping their health care waste alongside municipal refuse. A private company had been contracted to collect this waste. It would mix it up with the municipal waste. No treatment was performed on the healthcare waste before it was mixed with municipal refuse (Elnour et al. 2013). The final dumpsite for all waste was an open area on the outskirts of towns that was easily accessible, yet no precautions were given regarding the risk posed by this waste. In addition, no landfills were used to dispose this health care waste at the open area dumpsite (Elnour et al. 2013). The three hospitals lacked a subcommittee to monitor the final disposal of health care waste, thus leaving the private company with the entire responsibility of deliberating on how to dispose the waste. The situation here was a clear contravention of the World Health Organization guidelines on the disposal of health care waste.
One of the major risks posed by this method of disposing health care waste is the ease of access by scavengers. According to Elnour et al. (2013), the World Health Organization reveals that health care waste left in the open can be scavenged from disposal areas and reused. This exposes patients, health workers, and third parties to the risk of contracting diseases such as HIV and hepatitis. In addition, animals, birds, and insects can access waste left in the open, thus increasing the risk of spreading diseases to human settlements. Where the healthcare waste is not treated before being mixed with municipal waste, it poses a risk to dumpsite workers who obviously handle the waste without understanding the health risks involved (Elnour et al. 2013). There is also the risk of expired and unused medicine being accessed by scavengers. Such medicine may then be repackaged and resold, posing a great risk to people who buy them unknowingly.
Elnour et al.(2013) also found that vehicles used by the three hospitals to transport waste were small and open, causing waste materials to fall off on the road. These wastes lying on the road pose a health risk to pedestrians. Scavengers may also access them. Besides, staff members hired to handle waste by the private company did not use protective gear (Elnour et al. 2013). Protective equipment for waste handling includes an overall gown, gloves, and protective boots. According to Chartier (2014), failing to wear the correct protective equipment during waste handling can present the personnel with a great health risk. Sometimes, containers and bags containing hazardous wastes do not bear the Biohazard mark. As a result, the personnel is not cautious when handling this waste (Elnour et al. 2013).
Because of the grave risks that poor waste management in these three hospitals poses, it is important to devise new ways of handling waste. First, bags and containers designated for carrying hazardous waste should be marked “Biohazard.” This strategy will ensure the relevant personnel is careful when handling the waste. In addition, the hospitals should designate a land disposals area within their compound for disposal of wastes. The disposal should be by way of sanitary fills to prevent access by scavengers (Elnour et al. 2013). Additionally, this move will ensure health care waste from the hospitals is no longer mixed with ordinary waste from the municipal.
An Interview with a Health Care Waste Specialist
In a one-on-one interview with Mohamed, a health care waste specialist in Metropolitan Medical Center, Dubai. The respondent explained that the main types of waste produced by healthcare facilities within Dubai Municipality, including his hospital, are both hazardous and non-hazardous in nature. The waste could be solid, including syringes, chemicals, and body organs, or liquid such as wastewater, blood samples, and liquid chemicals. Regarding the management of the different types of waste, various legislations and guidelines are in place to guarantee effective disposal. The Local Order No. 115 of 1997 establishes regulations for safe disposal of medical waste, as well as penalties for non-compliance. One important requirement under this order is that healthcare facilities must separate hazardous and non-hazardous waste at the collection stage.
Mohamed explained that under the health care facilities are required to have a landfill for handling solid wastes while liquid wastes should be treated through chemical disinfection to kill or deactivate the microorganisms. Additionally, Dubai operates a major incinerator for managing all solid medical wastes that have not been treated at different healthcare facilities, including Metropolitan Medical Center. He further explained that the incinerator is meant to discourage the use of landfills since they have been found to have a major impact on the environment.
Mohamed explained that the municipality relies on the services of eight private companies to collect and deposit the health care waste in the designated treatment sites. Trashco is the most renowned healthcare waste collector within the Dubai Municipality. Regarding the legal framework for addressing medical waste, Mohamed explained that strict laws govern its collection and disposal. Hefty fines have been put in place as stipulated under the Local Order No. 7 of 2002 for healthcare facilities that do not exercise due diligence when disposing medical waste.
According to Mohamed, strict precautions have been established to guide the collection and disposal of hazardous waste. Collectively, these guidelines are captured under the Code of Practice for the Management of Medical Wastes from Hospitals, Clinics, and related Health Care Premises in Dubai. The guidelines touch on all aspects of waste management from the collection, storage, treatment, transport and finally, its safe disposal. Other important provisions on the management of healthcare waste include Technical Guideline No. 59 for the handling of refuse that is generated in clinics and laboratories, and Technical Guideline No. 26, which regulates the disposal of hazardous materials within Dubai Municipality.
Technical Guideline 50 provides for the transportation of hazardous waste. Mohamed explained that the transportation of the waste is an important stage in the disposal process mainly because waste is subjected to high temperatures in the vans. Bacteria and viruses generally thrive in high temperatures. Because temperatures in the vans may rise to levels that are conducive for these microorganisms, the vans must be fitted with coolers. Importantly, all waste handlers are subjected to an intensive training on health and safety based on French standards. This training also captures the handling of emergencies such as accidents that involve waste collection vans. Mohamed further explained that the waste management staff is given a vaccination for hepatitis B among other diseases as a precautionary measure.
When asked if any gaps exist in handling the different types, Mohamed explained that landfills pose the greatest challenge against effective healthcare waste management in Dubai. These landfills not only occupy the useful land but also pose the risk of scavengers accessing the waste and reusing it. Mohamed explained that the reuse of medical waste such as syringes could pose serious health risks to patients. Mohamed also argued that old incinerators within the municipality produce emissions that may pose health risks to the inhabitants of Dubai. Mohamed observed that the management of medical waste in Dubai could be improved by adopting modern technology. Already, a highly efficient incinerator with zero emissions has been installed in the city. This incinerator treats about 20 tons of solid medical waste per day. Mohamed also explained that plans are underway to install a waste-to-energy (WTE) plant that will ensure all wastes within Dubai city are converted into useful energy.
Mohamed explained that contractors who are hired to collect medical waste are required to operate under strict guidelines. Failure to follow these guidelines attracts heavy fines of up to DH20, 000. It may also lead to the termination of the collection contract. When asked if the healthcare facility may be held liable for negligence perpetrated by the contractor during the disposal of medical waste, Mohamed answered in an affirmative manner. According to him, health facilities have the inherent responsibility of ensuring that medical waste is disposed of properly. This responsibility is provided for under the Code of Practice.
The responsibility extends to offering adequate support and training to the waste management staff. Importantly, the healthcare facility must assign a designated staff member to supervise the disposal of special clinical waste. Therefore, improper disposal by the contractor may be seen as having been partly contributed by negligence on the part of the healthcare facility. For this reason, the healthcare facility could be jointly liable for the negligence of the contractor. Mohamed advised that the waste management company should choose the waste collection company carefully since the federal law provides that the waste generator be held accountable for all the stages of waste management. These stages include collection, transport, and disposal of waste.
Regarding waste reduction in healthcare facilities, Mohamed explained that several key performance indicators (KPIs) had been put in place. Dubai Municipality recognizes that the best approach to minimizing waste production is simply not producing the waste in the first place. According to Mohamed, this step calls for healthcare facilities to adopt a practice that uses fewer materials. At the purchasing stage, heath care facilities should ensure that they buy supplies that produce less waste and/or are less hazardous. In addition, facilities should move toward physical disinfection practices such as steam disinfection as opposed to chemical sanitization. Importantly, the use of chemicals in the healthcare institution should be carefully monitored. Mohamed also explained that purchasing in smaller quantities as opposed to bulk purchase was an efficient way of reducing waste production. According to Mohamed, waste minimization is beneficial to the healthcare facility since it cuts the operations cost.
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