Health Care Waste Management in Pakistan

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Healthcare waste is such waste which is generated from healthcare facilities, natal care, treatment centers of human and animals. It mainly includes different types of wastes such as sharps, infected syringes, animal and human tissues, drugs and medicines. There are different health risks associated with each type of waste so their management is necessary.
Healthcare waste is of several types and its exposure to public, nurses, cleanliness staff, patients and paramedical staff is from several routes like inhalation, ingestion and skin contact. Once it gets entry into environment it causes several health impacts which may lead to death. There are guidelines and treatment systems in Pakistan for the treatment of healthcare waste but since there is no system of check and balance so condition is worse here. Most of the diseases are caused from the exposure to different types of healthcare waste. So there is need to treat this waste according to WHO guidelines before its final disposal into environment.
Government and associated departments should step in to control the situation. There is serious need of handling of waste specially sharps and syringes, pathological waste and infectious waste.
Hospitals, which are major part of healthcare waste, must be charged if they don’t handle waste properly.
Workers should be given trainings for the awareness of health hazardous of healthcare waste.
There should be strict rules and regulations for the use of protective equipment such as gloves and masks and special dress for the collection and disposal of waste.
Above all, there should be proper system for the segregation, collection, storage and transportation of waste.
Storage area must be separate and away from healthcare facility so that it cannot affect health of workers.

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Health Care Waste Management in Pakistan

  1. 1. Management of Healthcare Waste in Pakistan Maryam S. Abbasi 1. INTRODUCTION Healthcare waste is such waste which is generated from healthcare facilities, natal care, treatment centers of human and animals. It mainly includes different types of wastes such as sharps, infected syringes, animal and human tissues, drugs and medicines. There are different health risks associated with each type of waste so their management is necessary. 1.1 Types of healthcare waste There are different types of healthcare wastes generated as a result of different activities in healthcare facilities. According to World Health Organization (WHO) following are different components of healthcare waste shown in the figures; 1 Figure 1: Components of healthcare waste Among healthcare waste 10% consists of infectious waste, 85% is non-hazardous healthcare waste and 5% chemical and radioactive waste. Following are different types of healthcare wastes according to WHO; a) Sharp waste In healthcare facilities different types of items are used like blades, needles, scalpels, infusion sets and pipettes. These items are considered highly infectious because they can cause wounds, cuts and can transmit many infectious diseases. They may be dreadful and cause death when absorbed through blood stream. Such items need to be handled with great care.
  2. 2. b) Infectious waste Infectious waste is such waste which can cause infectious diseases if waste is not treated according to standard procedures. This waste usually consists of harmful bacteria, viruses, parasites and fungi. Such waste can cause diseases in susceptible hosts. c) Pathological waste Major part of this waste comes from surgery and consists of human and animal tissues, body parts, body fluids and other waste. This waste is also infectious if tissues of human and animals are infected with some diseases. d) Pharmaceutical waste In healthcare facilities different types of drugs, medicines, and vaccines are used for treatment. If these products are expired and mismanaged then they become infectious. This waste also include different items used during treatment like bottles, boxes containing pharmaceutical residues, gloves, masks and connecting tubes. e) Chemical waste Different chemicals are used in healthcare facilities and wasted products include solid, liquid and gaseous chemicals. They come from diagnostic and experimental work at hospitals and clinics. Chemical waste may be hazardous, corrosive, flammable, radioactive and oxidizing. f) Radioactive waste This waste is generated of diagnosis of body tissues, internal organ imaging and tumor localization. They also come from X-ray units and they should be highly protective to avoid health hazardous because such waste is contaminated with radionuclides. 1.2 Sources of healthcare waste  Hospitals  Clinics  Emergency services  Research laboratories  Animal research laboratories  Blood bank 1.3 HEALTHCARE WASTE MANAGEMENT (HCWM) IN PAKISTAN Management of healthcare waste is very necessary to avoid health hazards. Many countries are facing problems of healthcare waste. Pakistan is also one of them. There will be very few hospitals where hospital waste is managed. There are open pits and grounds full of waste. This type of waste has bad impacts on health and it contaminates air, land and water.
  3. 3. According to one of the estimate Pakistan generates 2.0kg of waste per bed per day. This waste includes used syringes, blades, used gloves, chemicals and drugs etc. 2 1.3.1 Status of Healthcare Waste Management 1.3.1.1 Introduction/ Background A survey was carried out in May 2007 in four provinces Azad Jammu and Kashmir and Federal capital area. This survey was done by Health Services Academy, Islamabad in collaboration with Federal Ministry of Health, Provincial Health Departments, Ministry of Environment and World Health Organization. This survey was to analyze the hospital waste management. 1.3.1.2 Methodology and sampling area From each province under study fourteen healthcare establishments were selected. In this survey 78 healthcare facilities were included and its waste management was analyzed on visit to each facility. There were three types of hospitals under studies. First category was of large hospital with more than 100 beds. Second category is of medium sized hospitals with 50-100 beds and last category was small size hospitals with less than 50 beds. Out of 78 hospitals 34% were having out patients department, 24% facilities were tertiary care hospitals and 27% were secondary care hospitals. Primary care hospitals were 41%. In this survey public and private sectors were included. 1.3.1.3 Results and discussion Out of 78 hospitals 30% were having Health Care Waste Management (HCWM) teams or Infection Control Teams in place. Those hospitals which were having internal rules and regulations for healthcare waste management were 41% while 27% were planning to manage for healthcare waste. Regular training was given to 23% hospitals regarding hospital waste management. 33 % staff was unaware from the health risk of healthcare waste management and its associated risk factors. Reporting system was also very poor in most of the health care facilities under study. 19% hospitals were not having any segregation system for the hospital waste while in 27% hospitals only sharps were segregated and at 21% sites infectious waste were separated from healthcare waste. Other types of waste such as pharmaceutical, anatomical, radioactive and chemical waste were separated from 3-11% hospitals. There were very few hospitals (32%) were having properly labeled containers and 48% hospitals were using separate containers for infectious and non-infectious waste. Color coding was observed in 5% wards, 8% operation theaters separately and 31% overall in theaters and wards and 1% was seen in OPDs. So overall condition was not good enough for the health of patients and doctors and general public. According to survey 18% were not having much knowledge for response but 67%, a major portion, were not having knowledge of healthcare waste. Highly infectious waste from
  4. 4. laboratories were segregated and handled separately from 30% facilities. There were 74% facilities which were using needle removers and needle cutters in 74% facilities. As far as use of different containers is concerned minimal concept for the segregation of healthcare waste exists. 47% healthcare facilities were using simple plastic boxes for the separation of sharps while 5% used yellow color coded system is used. 28% facilities throw sharps in ordinary dustbins while 5% use card board boxes, 33% used dustbins and 6% used steel containers but 22% didn’t use any kind of container for the segregation of healthcare waste. There were 37% healthcare facilities using dedicated trolleys for internal transportation of HCW bags. As far as protective material and clothing is concerned with the waste handlers only 46% healthcare facilities were provided. When concerned to the temporary storage areas within the healthcare facilities, 45% had temporary storage areas while 46% had central storage area. For the separation of general and hazardous waste 31% were separating in central storage areas whereas 33% facilities were segregating the waste from temporary storage areas. In 35% of the facilities, central storage areas were having closed doors and 27% were having ceiling. 6% facilities were refrigerated but 30% were washed periodically. 41% facilities were having easy access to central storage areas. Trolleys were used for the onsite transportation of waste in 36% facilities and two wheel bin containers in 22%. Municipality vehicles were used in 50% vehicles and 18% vehicles were using 18% facilities for off-site transportation. There was no treatment of hospital waste for onsite waste in 60% of the facilities. 17% were using direct fire system, 18% incineration and only 1% used chemical disinfection. The majority of waste is disposed of in municipal dumping sites. Even bags were thrown without proper burial. There were 11% facilities keeping arrangements of disposal system. 1.3.1.4 Conclusion The above said survey concludes that the knowledge, attitude and practices of hospital waste management are not up to the required standard in most of the private and public hospitals. These pose serious health impacts to the visitors to the healthcare facilities so they need serious attention for its standard management. 1.3.2 Healthcare waste management in Karachi According to one of the survey by Pakistan Medical Research Council (PMRC) showed that there was lack of knowledge among 137 personnel involved in hospital waste management of 68 randomly selected healthcare sites in city of Karachi. The study showed that workers dispose of infectious and non-infectious waste in open bins without proper segregation of waste. Workers directly deal with waste without protective clothes, gloves etc. Majority of the workers were not interested in medical checkup. They were not having any protective equipment. There is no
  5. 5. education given to the safe disposal of healthcare facilities waste. Workers were doing jobs for the sake of earning only. 3 1.3.3 Healthcare waste management in Lahore According to one of the study conducted at Lahore, showed that majority of sweepers were aware of the fact that their job is harmful for them but they were doing for economic purposes. More than 70% workers didn’t use protective equipment because they believe that only rich nations can take such measures. Most of workers don’t understand the meaning of training so they are unawareness for the health impacts of health care waste. Majority of the hospital waste is thrown into the waste bins and some hospitals treat waste with incineration and recycled. The disposal system in not efficient and workforce involved in its disposal is ignorant of risk involved. 4 1.3.4 Healthcare waste management in Rawalpindi According to one of the study done by Maryam S. Abbasi with her group (un-published), 2010, showed that the hospitals in Rawalpindi and Islamabad most of the facilities don’t follow procedures for the management of waste. In one of the governmental hospital in Rawalpindi condition was worse. Staff wasn’t using separate containers for the segregation of waste. Pathological waste was thrown on open ground adjacent to Gynecology ward. There was no concept of segregation of sharps. It was collected by workers from open bins and they were infected via cuts and wounds. Bed sheets were contaminated with blood of patients and not changed regularly. The worse condition was that staff was unaware of the fact that they can be infected with infectious diseases. Expired solid medicines and drugs were thrown in same bins and those bins were observed open in the entire hospital. On the other hand, condition of the facility of Islamabad was comparatively better. They were having separate bins and color coded bins for the segregation of waste. Workers were equipped with protective equipment and they use trolley for the transportation of waste. They use incineration process for handling of waste and incinerator was within that facility but away from treatment areas. They had closed pit to dispose off waste after incineration process. But there is lack of the proper management of nuclear waste. There is no system for the control of flue gases which are released as a result of incineration. There is no mechanism for the medical check- up of workers dealing with waste. 1.4 WHO guidelines for management of healthcare waste Healthcare waste should be managed properly so that infectious diseases can be controlled and environment could be contaminant free from healthcare waste. Following are the principals for the disposal of healthcare waste; 5  Segregation
  6. 6.    Collection Interim storage Transportation 1.4.1 Segregation Wastes are segregated at their place of production to reduce the health risk from the infectious factions. Labeling of waste containers is used to identify the source, record the type and quantities of waste produced in each area, and allow problems with waste segregation to be traced back to a medical area. A simple approach is to attach a label to each filled container with the details of the medical area, date and time of closure of the container, and the name of the person filling out the label. Using an international hazard symbol on each waste container is also recommended. Few symbols are as follows; Corrosive Highly flammable Toxic Harmful
  7. 7. Explosive Oxidizing Irritant Extremely flammable Very toxic Dangerous for environment (N) 1.4.2 Collection General waste and infectious health-care waste is collected separately and at least once a day. Collection is at regular times and is reliable. Waste bags and sharps containers should be filled to no more than three quarters full. Once this level is reached, they should be sealed ready for collection. Plastic bags should never be stapled but may be tied or sealed with a plastic bag or tie. Replacement bags or containers should be available at each waste-collection location so that full ones can immediately be replaced. Waste bags and containers should be labeled with the date, type of waste and point of generation to allow them to be tracked through to disposal. Where possible, weight should also be routinely recorded. Anomalies between departments with similar medical services or over time at one location can show up differences in recycling opportunities, or problems such as poor segregation and diversion of waste for unauthorized reuse. 1.4.3 Interim storage Where possible, hazardous waste generated in medical areas should be stored in utility rooms, which are designated for cleaning equipment, dirty linen and waste. From here, the waste can be kept away from patients before removal, then collected conveniently and transported to a central storage facility. This is known as interim or short-term storage. Infectious waste, general waste and used sharps waste are stored in separate colour-coded containers and locations within medical areas, and subsequently at a central storage site at a health-care facility. Central storage area(s) are fenced, lockable and isolated from patients and the public. Maximum storage times before treatment or disposal of infectious waste are not longer than  Temperate climate: 72 hours in winter and 48 hours in summer
  8. 8.     Warm climate: 48 hours during the cooler season and 24 hours during the hot season. Staff receives instruction on three-bin waste segregation and safe handling and storage of health-care wastes. Staff is aware of how to protect themselves from injuries and infection from waste. Waste containers and storage areas are cleaned regularly. 1.4.4 Transportation Waste containers and onsite transport trolleys are closed with lids to isolate wastes from patients and the public. Where wastes are transported offsite for disposal, the vehicle is able to carry wastes in a closed or covered container, and the driver knows what to do if there is an accident or incident during transportation on public roads. Transport vehicle should be labelled with symbols. It should be noticed that the climate is very necessary for the disposal of waste. It shouldn’t be raining because during transportation liquid chemical waste as well as solid waste may leach onto roads and can be addition to ground water ultimately which may cause havoc. Transport staff is vaccinated at least against hepatitis A and B, polio and tetanus. Transport vehicle should be cleaned after disposal of waste. Documentation should be maintained and checked by respective authorities. 1.5 Treatment methods of healthcare waste Incineration is the most popular method of choice in most of the countries. The choice of method should be on the following basis; 6-7                 Disinfection efficiency Health and environmental considerations volume and mass reduction Occupational health and safety considerations Quantity of wastes for treatment and disposal/capacity of the system; Types of waste for treatment and disposal; infrastructure requirements locally available treatment options and technologies options available for final disposal training requirements for operation of the method Operation and maintenance considerations Available space Location and surroundings of the treatment site and disposal facility investment and operating costs Public acceptability Regulatory requirements 1.5.1 Incineration Incineration is a high-temperature dry oxidation process that reduces organic and combustible waste to inorganic, incombustible matter and results in a very significant reduction of waste
  9. 9. volume and weight. This process is usually selected to treat wastes that cannot be recycled, reused, or disposed of in a landfill site. Incineration has drawbacks as well. Though it reduced waste volume but its emissions into environment are very harmful. During incineration process poisonous gases are release into environment. The solution is the modification to the incinerator. It should be equipped with such system which can collect flue gases and can be re-cycled and re-used. Figure 2: Simplified diagram of incineration process The process of incineration is made environmental friendly to control environmentally hazardous emissions. 1.5.2 Autoclaving Autoclaving is an efficient wet thermal disinfection process. Mostly, autoclaves are used in hospitals for the sterilization medical equipment so that it can be reused. Autoclaves are used
  10. 10. only for highly infectious waste, such as microbial cultures or sharps because of their low capacity. It is recommended that all general hospitals, even those with limited resources, be equipped with autoclaves to sterilize equipment. Minimum contact times and temperatures depend on several factors such as the moisture content of the waste and ease of penetration of the steam. Research has shown that effective inactivation of all vegetative microorganisms and most bacterial spores in a small amount of waste (about 5– 8kg) requires a 60-minute cycle at 121°C (minimum) and 1 bar (100kPa); this allows for full steam penetration of the waste material. 1.5.3 Microwave irradiation Most microorganisms are killed by the action of microwaves of a frequency of about 2450 MHz and a wavelength of 12.24cm. The water contained within the wastes is rapidly heated by the microwaves and the infectious components are irradiated by heat conduction process. 1.5.4 Land disposal If healthcare facility lacks the means to treat wastes before disposal, the use of landfill has to be regarded as an acceptable disposal route. Allowing health-care waste to accumulate at hospitals or elsewhere constitutes a far higher risk of the transmission of infection, to cause infectious diseases, than careful disposal in a municipal landfill, even if the site is not designed to the standard used in higher-income countries. The primary objections to landfill disposal of hazardous health-care waste, especially untreated waste, may be cultural or religious or based on a perceived risk of the release of pathogens to air and water or on the risk of access by scavengers. The landfill site must be closed to avoid the contamination of the environment. It must be far apart from population. Landfill sites should be designed according to waste type. It also depends upon the geology of that disposal site. 1.5.5 Inertization The process of “inertization” involves mixing waste with cement and other substances before disposal in order to minimize the risk of toxic substances contained in the waste transferring into surface water or groundwater. It is especially suitable, for pharmaceuticals and for incineration products with a high metal content (in this case the process is also called “stabilization”). For the inertization of pharmaceutical waste, the packaging should be removed, the pharmaceuticals ground, and a mixture of water, lime, and cement added. A homogeneous mass is formed and got small solid shapes are produced on site and then can be transported to a suitable storage site. Alternatively, the homogeneous mixture can be transported in liquid state to a landfill and poured into municipal waste. The following are typical proportions for the mixture:  65% pharmaceutical waste  15% limes  15% cement  5% water
  11. 11. 1.6 HEALTH RISKS DUE TO HEALTH CARE WASTE Healthcare waste is quite dangerous for health especially waste containing sharps, syringes and body tissues. Such waste is harmful, not only, for the health of patients but also for medical and paramedical staff. Cleanliness staff especially sweepers are more prone to such waste because they directly deal with drugs, syringes and pathological waste. Direct contact with skin causes several diseases. According to World Health Organization, in 2000, contaminated syringes caused8:    21 million population suffered from hepatitis B virus (HBV) infections 2 million suffered from hepatitis C virus (HCV) infections Population of 260 000 suffered from HIV infections Based on general observation, healthcare facilities in Pakistan don’t follow standard guidelines for the management of healthcare waste. But there is need to conduct studies for the monitoring of health of workers dealing with healthcare waste. Healthcare waste also contains micro-organisms which can infect hospital patients, workers and general public. Following are health hazards according to waste type; 9 1.6.1 Health impacts from infectious waste Infectious waste consists of a lot of harmful micro-organisms which can enter into human body inhalation, ingestion and direct skin contact. This transmission is because of contaminated needles with human blood. Needles and sharps can not only cause cut but also transmit harmful viruses which cause vomit, eye and genital secretions, pus, skin secretions, cerebrospinal fluid, blood and faeces. 1.6.2 Health impacts from chemical and pharmaceutical waste This type of waste causes several diseases when come into contact. When it is absorbed into skin or mucous membrane then it causes intoxication and even injuries to the skin and eyes. When drugs, heavy metals like mercury in dentistry etc are thrown into sewerage system, ultimately seeps into ground water and causes several diseases. 1.6.3 Health impacts from genotoxic waste This waste comes out when particular drug is made or open for specific treatment. Its exposure may be via inhalation, skin contact or infected food. These drugs are usually carcinogenic and mutagenic. Cytotoxic drugs cause dizziness, nausea, headache or dermatitis. These should be handled according to standard procedures and wasted items should be handled according to WHO guidelines.
  12. 12. 1.6.4 Health impacts from radioactive waste Type of disease from radioactive waste depends on its rate of exposure. It can cause headache, dizziness and vomiting. Most of the radioactive waste is genotoxic and it can alter genetic material. It can also cause destruction of tissue so it should be undertaken with the utmost care. The hazards of low-activity waste may arise from contamination of external surfaces of containers or improper mode or duration of waste storage. Health-care workers or wastehandling or cleaning personnel exposed to this radioactivity are at risk. 1.7 Conclusion and suggestions Healthcare waste is of several types and its exposure to public, nurses, cleanliness staff, patients and paramedical staff is from several routes like inhalation, ingestion and skin contact. Once it gets entry into environment it causes several health impacts which may lead to death. There are guidelines and treatment systems in Pakistan for the treatment of healthcare waste but since there is no system of check and balance so condition is worse here. Most of the diseases are caused from the exposure to different types of healthcare waste. So there is need to treat this waste according to WHO guidelines before its final disposal into environment.  Government and associated departments should step in to control the situation. There is serious need of handling of waste specially sharps and syringes, pathological waste and infectious waste.  Hospitals, which are major part of healthcare waste, must be charged if they don’t handle waste properly.  Workers should be given trainings for the awareness of health hazardous of healthcare waste.  There should be strict rules and regulations for the use of protective equipment such as gloves and masks and special dress for the collection and disposal of waste.  Above all, there should be proper system for the segregation, collection, storage and transportation of waste.  Storage area must be separate and away from healthcare facility so that it cannot affect health of workers.  There should be regular check-up for the workers involved in handling of healthcare waste specially who are involved in handling of infectious waste.
  13. 13. References 1. P.Annette , E. Jorge , R. Philip, Z. Raki , S. Ruth, P. Ute ,K. William, W. Susan and C. Yves, 2013, “Safe management of wastes from healthcare activities”, World Health Organization, Second edition, viewed date; 17-9-13. 2. Pakistan Environment. Fact Sheet. http://www.wwfpak.org/ factsheets _hwf.php 3. S. Habibullah, A. Salahuddin, 2007, Waste disposal of government health care facilities in urban area of Karachi. PJMR; 46: 1-4 4. MR Khan, F. Fareedi, B. Rashid, 2006, Techno-economic disposal of hospital wastes in Pakistan. PJMR; 45: 41-45 5. P.Annette , E. Jorge , R. Philip, Z. Raki , S. Ruth, P. Ute ,K. William, W. Susan and C. Yves, 2013, “Safe management of wastes from healthcare activities”, World Health Organization, Second edition, viewed date; 17-9-13. 6. Brunner CPE (1989). Handbook of hazardous waste incineration. Blue Ridge Summit, PA, TAB Books 7. Bartone C (1998). Municipal solid waste management. In: Brazil: managing pollution problems—the brown environmental agenda. Washington, DC, World Bank (Report No. 16635). 8. World Health Organization (WHO), Health Impacts of Healthcare waste, http://www.who.int/water_sanitation_health/medicalwaste/020to030.pdf 9. World Health Organization (WHO), 2000, http://www.who.int/water_sanitation_health/medicalwaste/hcwmpolicy/en/

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