OPEN ACCESS JOURNALS
Journal of Public Health and Epidemiology
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Healthcare Waste (HCW) constitutes a special category of waste because they contain potentially harmful materials. The problem of how to manage HCW has become one of critical concerns in developing countries. A cross sectional descriptive study was carried out between June and September 2008 at a tertiary health facility (Teaching Hospital) in Nigeria with the aim of assessing the current practices and commitment to sustainable HCW management in a tertiary healthcare facility. The study approach involved the estimation of the quantity of HCW generated, evaluation of the waste segregation practices and determination of the knowledge of healthcare workers regarding HCW management. Daily waste inventory of each ward was carried out. A total of 52 health workers, including doctors and nurses were interviewed to determine their knowledge and practice with regards to HCW. An evaluation of the status of the waste management practice in the health facility was carried out using the following criteria: waste management (responsibility, segregation, storage and packaging); waste transport; waste recycling and reuse; waste treatment and final disposal. Results show that the average amount of HCW was 0.62 kg/person/day at the out-patient units and 0.81 kg/bed/day in the in- patient wards. The proportion of respondents who had received specific training in the management of HCW was 11.5% (6/52). The number who understood the importance of HCW management in the provision of safety to the public was 46% (24/52). The level of healthcare waste management practice was found to be 0 (that is, unsustainable). This paper has highlighted the pitfalls of HCW management in Nigeria, a developing country where resources are limited. The paper concluded by recommending measures to improve the HCW management practices in the country.
Key words: Healthcare waste, microbial infections, public health, waste segregation, sustainability.
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The sustainable management of Healthcare Waste (HCW) has continued to generate increasing public interest due to the health problems associated with exposure of human beings to potentially hazardous wastes arising from healthcare (Tudor et al., 2005; Ferreira, 2003; Da Silver et al., 2005). Presently considerable gap exist with regard to the assessment of healthcare waste management practices particularly in Nigeria and in several other countries in sub – Saharan Africa. The nature and quantity of healthcare waste generated as well as institutional practices with regards to sustainable methods of healthcare waste management, including waste segregation and waste recycling are often poorly examined and documented in several countries of the world despite the health risks posed by the improper handling of HCW (Farzadika et al., 2009; Oke, 2005). It is also of serious concern that the level of awareness, particularly of health workers regarding healthcare waste has not been adequately documented. HCW are a special category of waste because they often contain materials that may be harmful and can cause ill health to those exposed to it. A number of studies have indicated that the inappropriate handling and disposal of healthcare waste poses health risks to health workers who may be directly exposed and to people near health facilities, particularly children and scavengers who may become exposed to infectious wastes and a higher risk of diseases like hepatitis and HIV/AIDS (Adegbita et al., 2010; Coker et al., 2009, PATH, 2009; Oke, 2008; WHO, 2002, 1999). The World Health Organization estimates that each year there are about 8 to 16 million new cases of Hepatitis B virus (HBV), 2.3 to 4.7 million cases of Hepatitis C virus (HCV) and 80,000 to 160,000 cases of human immune deficiency virus (HIV) due to unsafe injections and mostly due to very poor waste management systems (WHO, 1999; Townend and Cheeseman, 2005). In developing countries like Nigeria, where many health concerns are competing for limited resources, it is not surprising that the management of healthcare wastes has received less attention and the priority it deserves. Unfortunately, practical information on this important aspect of healthcare management is inadequate and research on the public health implications of inadequate management of healthcare wastes are few and limited in scope. Although reliable records of the quantity and nature of healthcare wastes and the management techniques to adequately dispose of these wastes has remained a challenge in many developing countries of the world, it is believed that several hundreds of tones of healthcare waste are deposited openly in waste dumps and surrounding environments, often alongside with non-hazardous solid waste (Alagoz and Kocasay, 2007; Abah and Ohimain, 2010). A near total absence of institutional arrangements for HCW in Nigeria has been reported by others (Coker et al., 1998). Various methodologies have been used all over the world to assess and quantify HCW. They include the use of physical observation, questionnaire administration and quantification (Adegbita et al., 2010; Olubukola, 2009; Phengxay et al., 2005), as well as checklists (Townend and Cheeseman, 2005) and private and public records (Coker et al., 2009). Recent studies in Nigeria has estimated waste generation of between 0.562 to 0.670 kg/bed/day (Longe and Williams, 2006) and as high as 1.68 kg/bed/day (Olubunmi, 2009). As reported in the literature, there may not be much of a difference in the way and manner wastes generated in various health care institutions are managed in Nigeria. A good example is given by the findings of the study in Lagos by Olubukola which reported the similarity in waste data and HCW management practices in two General hospitals, characterized by a lack of waste minimization or waste reduction strategies, poor waste segregation practices, lack of instructive posters on waste segregation and disposal of HCW with general waste (Olubukola, 2009). The mismanagement of healthcare waste poses health risks to people and the environment by contaminating the air, soil and water resources. Hospitals and healthcare units are supposed to safeguard the health of the community. However, healthcare wastes if not properly managed can pose an even greater threat than the original diseases themselves (PATH, 2009). There are a reasonable range of treatment technologies available for healthcare wastes that may be appropriate for third world countries, however, it is pertinent that before any of these options are adopted, hospitals and medical facilities will need to assess the problem and put forward a management strategy that is suitable to their economic circumstances and that can be sustained based on local technology. The aim of this research therefore is to identify the gaps in current practices of healthcare waste in Nigeria compared with international best practice and recommend ways of bridging this gap considering the current economic and technological realities in the country. Using a tertiary health institution (Teaching Hospital) in Southern Nigerian state of Edo as a case study, this paper therefore sets out to:
1. Assess the current waste management practices in terms of type of wastes and quantities of waste generated in the various units of a tertiary level healthcare facility and the waste handling and disposal practices. 2. Assess the level of awareness of health workers regarding HCW management. 3. Assess the level of compliance with recommended best practices for the sustainable management of healthcare wastes based on the United Nations Environmental Programme/World Health Organization (UNEP/WHO, 2005) and the Townend and Cheeseman (2005) guidelines.
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This study was carried out between June and September 2008 as a cross sectional descriptive study at a tertiary healthcare facility (Teaching Hospital) in Nigeria based on the modified methods of Townend and Cheeseman (2005) and UNEP/WHO (2005). The health facility selected is a major hospital with over 350 bed capacity and providing emergency, surgical and maternal and child health services. An inventory of the waste generated in each of the following sections of the hospital: Operation theatres, Pharmacy, Laboratories, In-patient wards, Out- patient units, Radiology unit and the Mortuary were obtained over a period of seven days using an inventory form (UNEP/WHO 2005). The different types of waste generated in the out -patient and in-patient were collected separately and weighed daily for a period of one week. Since the waste were not segregated, at each of the aforementioned unit, the entire quantity of waste generated was weighed together each day (using a weighing balance) prior to disposal and recorded in the inventory form. The quantity of the different categories of waste was deduced by estimation while the type of waste was identified through direct observation. In addition, the pharmacists and nurses were interviewed with a view to obtaining an accurate estimation of the number of sharps items used every day. Calculations of average quantity of waste per bed per day were then carried out by dividing the quantity of waste by the number of beds in the unit (UNEP/WHO, 2005; WHO, 2002). The wastes were classified according to the scheme presented in Figure 1.
Figure 1. Classification of HCW (UNEP/WHO, 2005).
Using a list obtained from the personnel department of the hospital, a total of 52 healthcare staff including doctors and nurses were randomly selected for questionnaire administration, comprising of 1 administrator, 18 doctors, 26 nurses and 7 ward attendants. The questionnaires were administered by medical students in their 5th year of training and consist of questions on their knowledge and practice of HCW; knowledge of existing HCW management practices; knowledge and practice of waste handling, segregation and treatment and injuries related to HCW (Phengxay et al., 2005; WHO, 1999). To understand the overall healthcare waste management of the hospital, the principal researchers also interviewed the head of the hospital’s administration face to face (key informant interview). The main questions asked were:
(a) Hospital waste management policy. (b) Special budget for waste management. (c) Training of waste handling staff.
Data for the analysis were then extracted from the inventory form and personal interviews conducted by the researchers. The waste management performance of the hospital was assessed using a checklist consisting of six characteristic waste management descriptors and 27 indicators of healthcare waste management, presented in Table 1, namely:
(i) General management strategy. (ii) Waste collection. (iii) Waste segregation. (iv) Waste recycling. (v) Waste storage. (vi) Offsite disposal.
An overall performance rating was then assigned using the approach outlined in the guidelines suggested by Townend and Cheeseman (2005). This guideline uses a simple table format that links performance with a set of criteria to assess the level of sustainable development associated with the healthcare facility. Based on this guideline, healthcare facilities can be grouped into 4 different levels of sustainable practice based on the characteristics described in Table 2.
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The results of the HCW quantification and current management practices are presented in Tables 3 and 4, respectively. The average amount of HCW was 0.62 kg/person/day at the outpatient units and 0.81 kg/bed/day in the in-patient wards. The labour ward had the highest diversity of wastes, most of which are classified as either infectious (C series) or HCW requiring special attention (B series). The key findings on the current situation of HCW management practice are summarized in Table 4 and presented under the following sub-headings.
Overall responsibility for managing waste
Through face to face interview (key informant interview) of the hospital head of administration it was revealed that there was no focal person or waste manager responsible for HCW management, rather sanitation in the hospital is overseen by a committee. The hospital had thus retained the services of 2 environmental officers directly responsible for maintaining sanitation in the hospital. There were also a number of cleaners assigned to each ward and unit who are responsible for the day to day cleaning of the wards and emptying of waste bins. The overall responsibility for HCW management is not clearly defined.
Table 1. HCW management description and the indicators used in the assessment of waste management performance at the healthcare facility.
HCW management manual and instructive posters
Interviews of key informants and observations by the researcher reveal that the hospital does not have a HCW management manual. It was also observed that instructive posters on waste segregation were not on display anywhere in the health facility.
Waste collection, segregation and storage
Direct observation revealed that waste was collected in different types of receptacles. Out of 63 bins inspected, 41 (76.2%) did not have a lid. There was no form of color coding to indicate the type of waste to be deposited in a particular waste bin. There was no provision of weighing scales for measuring the weight of wastes generated at any of the wards or locations that waste were collected. As a result it is impossible to determine precisely the quantity of waste generated in the health facility. Sharp waste segregation was done in the wards. No other form of waste segregation occurs at any level and no strategy is in place for waste minimization. Temporal storage of waste occurs in the receiving receptacles or waste bins which are emptied daily or more frequently depending on the filling rate. Waste is collected daily by ward attendants and cleaners for dumping directly from storage receptacles or bins.
Waste re-cycling and re-use
Direct observations and face to face interviews of key informants revealed that no form of waste re-cycling or re-use exist or is planned for the near future at the health facility.
Table 2. Guidelines for the assessment of level of sustainable waste management practice.
Source: Modified from Townend and Cheeseman (2005).
Waste treatment and disposal
Waste is collected at a central open dumpsite and burnt periodically. Occasionally, the wastes are buried by covering with a layer of earth. No prior treatment takes place. Human body parts such as placenta and amputated limbs are either disposed with the general waste or returned to the patient for disposal. Used swabs and dressings as well as pharmaceutical wastes are disposed with general waste. Sharps are collected separately in sharp proof containers and disposed by burying.
Training, knowledge and practice of doctors and nurses
The proportion of respondents who had received specific training in management of HCW was 11.5% (6/52). The number who understood the importance of HCW management in the provision of safety to the public was 46% (24/52). Only 8% (4/52) responded that they had seen instructive posters on waste segregation. None of the respondents knew the focal person responsible for HCW management in their unit and the hospital strategy for managing HCW. About 69% (36/52) of the respondents reported that the waste generated in their unit of the hospital was disposed of by open burning or burying on facility site (Figure 2).
Table 3. Type and average quantity of HCW generated.
Rating of HCW management practice
The HCW management practices adopted at the study site was rated using the guidelines proposed by Townend and Cheeseman (2005). Results of the ratings are presented in Table 5, which show that the level of waste management is 0 for all the criteria considered; indicating that the waste management practices at the studied health facility is unsustainable.
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Management and commitment
This study has revealed significant problems with HCW management at the tertiary facility studied. These include lack of management commitment, poor waste handling practices, inadequate training on HCW, nonexistent segregation of HCW and risky disposal practices. Although some form of segregation of sharps (needle and syringes) takes place at the facility, which has reduced the incidence of needle prick injuries, the overall practice of HCW management is still problematic. HCW management is a management and technical issue (WHO, 1999) requiring urgent attention. Sustainable HCW management practice depends on the commitment of all healthcare facility staff, particularly commitment from the hospital leadership. The current management approach to HCW found in this study mirrors waste management at the national level in a number of ways. For instance, national legislation and policy specific to HCW management is yet to be implemented at any level despite the existence of Draft Nigeria National HCW (2007) and the fact that Nigeria is a signatory to several multilateral environmental agreements including the Basel convention; municipal waste management is ongoing problem in many states and the absence of functional landfills in the country has further compounded the problem. Other factors contributing to poor health care waste management in the country include the general situation of infrastructure such as poor roads, intermittent electricity, lack of health vehicles (thus making transportation of waste unsafe) and the absence of effective municipal waste disposal system. These constraints not withstanding it is possible to demonstrate management commitment in a number of other simple but effective ways such as training and creating awareness of the health risks from the inadequate management of medical waste, provision of simple institutional guidelines, provision of adequate personal protective equipment for waste workers and a focus on implementation of solutions that are currently affordable and available. The findings from this study has shown clearly the critical need for management to provide institutional support and guidance aimed at ensuring that health workers follow a standard procedure in the management of HCW waste at the institutional level. Without a clear policy from management there is likely to be very little attempt at waste segregation, waste minimization and adequate treatment and disposal. Another major issue confronting the management of healthcare waste is perhaps the fact that it is generally viewed mainly from an environmental and less from a public health perspective. As a result gaps exist in visions and understanding, particularly as it relates to the much desired robust integration of the Environment ministry and the Health ministry at both the state and National levels of Governance. In Nigeria, liability for any pollution occurring as a result of unauthorized waste management activities rests with the waste generator in accordance with Article 20(1) of Decree No. 58/88. The Public Health Act 1958 and various state edicts on environmental sanitation also provide regulations on the management of solid waste, particularly non hazardous, general (municipal) waste. These laws however do not adequately address the important aspects of healthcare waste. A mechanism to regulate and enforce sustainable management of wastes generated from health cares as an integral part of the existing environmental protection framework should be considered. The 1992 Earth Summit in Rio de Janeiro called for action to establish national policy, national guidelines and a training program for HCW management in all countries in the world (UNCED, 1992). In Nigeria, the Government response to the conference has yet to result in a national policy on HCW management. The current national action plans for waste management (as published in Daily Trust Newspapers of 17 September, 2008) does not include participation from the health sector. It is thus not surprising that healthcare waste management centers are generally lacking at any level of health care. The establishment of specific policies and strategic plans on HCW at the national level, particularly given the limited budget available to the health sector is a crucial initial step towards the achievement of a minimum level of HCW management practice in a developing economy like Nigeria.
Table 4. Characteristic of HCW management at the study site.
Table 5. Summary result of the application of the Townend and Cheeseman guidelines for the sustainable management of HCW at the studied healthcare facilities.
* 0 = unsustainable level of HCW management.
Figure 2. Training, knowledge and practice regarding HCW.
Waste generation, segregation, treatment and disposal
Our study has shown that generally the quantity of waste generated in the out-patient units is less than that in the in-patient units. This may be because a large proportion of the wastes generated by patients in the in-patient wards are similar to general waste such as packaging and food waste, and thus there may be no real difference in the actual quantity of general waste. In-patients on the other hand are more likely to generate infectious wastes, pharmaceutical wastes and pathodological wastes. Good segregation practice will ensure a reduction in the quantity of medical waste which is more expensive to manage. The absence of waste segregation at the health facility imply that the estimates of the various categories of waste may not be precise, nonetheless it provides a useful guide for the assessment of the different waste streams generated many of which are hazardous in nature requiring special handling to avoid health consequences. The World Health Organization recommends the segregation of HCW waste preferably at the source of production and provides guidelines for the safe and sound management of medical waste in developing countries (WHO, 1994, 1995). From this study, it is obvious that the WHO guidelines have not been followed in the HCW management of the hospital. The WHO recommends the following color coding of waste receptacles to facilitate the segregation of HCW at the source of generation (and to keep them separated from each other):
Red for highly infectious waste, yellow for other infectious waste, yellow marked ‘‘SHARPS’’ for sharp waste, brown for pharmaceutical waste, lead box labeled with radioactive symbol for radioactive waste and black for general or non-infectious waste (Pruss et al., 1999).
It must be emphasized that in addition to the color, special sharp proof containers are required for sharps waste. Segregation of HCW serves many important public health functions: segregation reduces medical waste and thus reducing the health impacts on the general public (after dumping); reduction of medical waste impacts positively on the budget required for HCW disposal. Phengxay et al. (2005) have reported a reduction in cost of up to US$2938/year in the Vientiane municipality if perfect segregation practices are applied. The use of instructive posters and color coded bins are important to achieve effective segregation of waste. Hagen et al. (2001) in their study of infectious wastes in a Saudi Arabian hospital have also reported the importance of providing instructive posters as tool to promote effective segregation of HCW. In this study, the lack of HCW management manual and hospital policy on HCW management are likely to be responsible for the low awareness of health workers on HCW management. This finding is consistent with the outcome from other studies (Askarian et al., 2004). A lack of sufficient health budget means that waste management is probably not a priority issue amongst competing needs in the health facility and may be a factor in the non provision of standard waste bins of desired size and make, such as bins with foot operated lid. To overcome these limitations the health facility should consider the use of inexpensive locally available containers which can be modified to make them suitable and then inserting colored labels. This is can be used as a short term measure. A medium to long term measure will be the proper allocation of financial resources for the provision of appropriate storage bags and containers, construction of temporal storage facility, training of operational staff and other health workers and the investment in appropriate technology for waste treatment and disposal. The provision of instructive posters is also not expensive and can be achieved in the short term within available resources. The current disposal method adopted by the health facility, which is dumping and open burning at the facility premises poses health risks to patients and people residing close to healthcare facilities (Kuroiwa et al., 2004). The HCW may also contain a large proportion of plastics. When burnt, dioxin is a major air pollutant of concern from chlorinated polymer as reported by the World Health Organization (WHO, 2004). Hazardous healthcare Waste poses potential risk of injury or infection to all those exposed to it, including;
(i) Medical staff: doctors, nurses, sanitary staff and hospital maintenance personnel. (ii) In- and out-patients receiving treatment in health-care facilities as well as their visitors. (iii) Workers in support services linked to health-care facilities such as laundries, waste handling and transportation services. (iv) Workers in waste disposal facilities, including scavengers. (v) The general public and especially the children, who play with items scavenged from open waste dumps.
The WHO (2002) estimates that over 20 million infections of Hepatitis B, C and HIV occur yearly due to unsafe injection practices (reuse of syringes and needles in the absence of sterilization). Improperly disposed hazardous HCW also poses indirect risks to humans through direct environmental effects by contaminating soils and ground water. During open burning or incineration, air pollutants are released into the atmosphere causing respiratory illnesses to nearby populations. Immediate improvements in the waste disposal system can be achieved through a combination of waste segregation and a simple high temperature system. It is generally acknowledged that the items of waste corresponding to the category of “non risk or general waste” constitute about 80 to 85% of HCW (WHO, 1999; Adegbita et al., 2010) which can be disposed through the regular municipal waste disposal system. The hazardous component can be disinfected or autoclaved. Although incineration has the advantage of being able to handle most types of medical waste and of achieving volume reduction, it has a number of significant disadvantages. It is a relatively costly technology requiring frequent maintenance, and limited life span. In addition environmental concerns arising from emissions of green house gases and dioxins to the atmosphere and the impacts of the residual ash make incineration a less acceptable technology. Advanced pollution control mechanisms for dioxin emission now exist in many developed countries and involve the injection of activated carbon and calcium hydroxide into the flue gases emerging from the furnace and collecting the resultant particulate in a fabric filter. It is however doubtful if many hospitals in developing countries can afford this expensive air pollution control equipment (APC). Unfortunately it is not enough to have incinerators fitted with APC, it is also critically important to have professsionally trained personnel to operate it (Connett, 1997). The present study is of the view that incineration will not solve the problem of medical waste in developing countries. Other simple technologies worth considering are autoclaving, shredding followed by chemical disinfection or microwaving, inertization and encapsulation.
Improving current HCW management practices
Significant improvements in the current practice of HCW management can be achieved through a number of simple steps. A clear policy on medical waste management must be put in place both at the institutional and national levels. Health workers must then be trained to follow a simple but systematic procedure that is based on the policy. To achieve this, healthcare institutions must utilize the most practical options to achieve acceptable standards and practices for HCW management using available technologies. New technologies used in advanced economies, although desirable may not be appropriate on account of cost, power requirements, maintenance capabilities and availability. The choice of waste treatment technology should be tailored to urban or rural health facility as well as the availability and affordability of the technology in the context of long term sustainability. Waste segregation is a critical beginning step to achieve waste minimization, cost reduction and sustainable waste management practice. It offers the health facility the ability to make more accurate assessment of their waste composition and also positions the facility for practical HCW management strategies (Shaner 1993; Going, 2001). Improving the standard of healthcare waste management in Nigeria will serve several useful public health purposes:
(i) Protecting the health and safety of healthcare workers, patients and visitors at healthcare facilities. (ii) Improving occupational health and safety conditions of those responsible for handling healthcare waste. (iii) Improving environmental protection. (iv) Saving costs through segregation, salvaging and re-use. (v) Improving the service delivery of the healthcare sector, particularly in terms of compliance with the ‘duty of care’ principle (which requires that any person who generates, transports, treats or disposes of waste must ensure that there is no unauthorised transfer or escape of waste from her/his control. Such a person must retain documentation describing both the waste and any related transaction. In this way, he retains responsibility for the waste generated or handled). (vi) Boosting the morale of healthcare workers.
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The current management practices for healthcare wastes generated at the health facility studied is unsustainable and cannot be relied upon to protect human health and environmental integrity. There is no existing policy or plan and no systems in place for sustainable management of HCW. There is thus urgent need to take practical steps aimed at ensuring the ‘duty of care’ and safeguarding the environment for current and future generations. Although, the findings of the present study is important for the management of HCW in Nigeria and other developing countries, the widespread application of these findings may be limited because of the small sample size, the narrow scope of study and the short duration of the study. It will be useful to consider the waste management practices at lower levels of health care practice, such as Primary Health Care Centres, in future research. The authors recommend the following directions as a way forward towards attaining sustainable HCW management:
1. Management commitment to the sustainable management of HCW through:
(i) Formulation of hospital waste operational procedure (HCW Management plan). (ii) Allocation of appropriate resources. (iii) Adequate staff training and capacity building. (iv) Technology transfer. (v) Information and awareness of HCW management plan to all hospital staff and their patients.
2. Formulation of appropriate institutional and national policies on HCW and initiating monitoring activities relating to HCW in Nigeria. Tertiary health institutions should apply the principle of ‘‘waste to wealth”. Over 75% of HCW is general non hazardous waste. Materials such as paper, glass and plastics can be safely and easily re-cycled. Not only is the market readily available, the process can also be used as a powerful economic tool to improve the financial resources available to the hospital, given the current poor funding of health care in Nigeria. 3. The current levels of HCW management in tertiary health facilities need to be given more attention through improved funding and research to protect the health of the public and the environment.
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