assessment of health care waste management in some medical ... · s.j. moja. council of geoscience,...

Assessment of health care waste management in some medical facilities in Pretoria, South Africa

K. Semenya. School of Environmental Sciences, University of South Africa, South [email protected]. Moja. Council of Geoscience, South Africa. [email protected]

ABSTRACT In the process of health care delivery, waste is generated which includes sharps, human tissues or body parts and other infectious material. The mismanagement of health care waste has been a problem all over the world. In many countries, health care waste is still handled and disposed together with domestic wastes, thus creating a great health risk to municipal workers, the public and the environment. The treatment of health care waste through incineration gives rise to secondary waste such as hazardous ash residue and emissions of persistent organic pollutants. Health care waste incinerators result in incomplete waste destruction, hazardous ash problems and emissions of persistent organic pollutants. Success in medical waste management may be achieved at in-house training in hospitals instructed by sufficiently knowledgeable managers who have grasped the importance of the subject. This study was conducted to assess management of health care waste in some private medical facilities around Pretoria. The adoption and implementation of the recommendations of the study will lead to the improvement of managing health care waste.

1. INTRODUCTION

Generally, health care waste is waste arising from diagnosis; monitoring and preventive; curative or palliative activities in the field of veterinary and human medicine (Pruss et al., 1999). Broadly, it is defined as any solid or liquid generated in the diagnosis, treatment or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals (BAN & HCWH, 1999). Health care waste can be separated into a number of categories that identify the major hazard or risk that they pose to human health and the environment, i.e. infectious; chemical; radioactive and general waste.

This waste is a growing problem worldwide, jeopardizing the health of the staff, patients, disposal workers, local communities and the environment. The city of Pretoria is also facing similar problems. Due to poor screening and management, health care waste is often mixed with municipal waste and collected in the same collection bins and disposed of the same way. Some waste is simply buried without any appropriate consideration. Some patients, who routinely use syringes at home, do not know how to dispose them off properly.

Exposure to health care waste can have serious consequences, for instance, if children pick up and play with improperly disposed waste items and accidentally get pricked by used syringe or injure themselves. Infectious waste can cause diseases like Hepatitis C Virus (HCV), Hepatitis B Virus (HBV), Human Immune Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS), Typhoid, Boils etc.(Yimer, 2005). Hepatitis C is rapidly spreading among young garbage scavengers, as they pick up used syringes and other clinical waste from different sources within the city for recycling (Yimer, 2005). Many drug addicts also reuse the syringes that can cause HIV/AIDS and other dangerous and contagious diseases (Pruss et al., 1999). If the infectious component mixes with the general non-infectious waste, the entire mass becomes infectious. It is therefore, the responsibility of hospitals and other health care institutions to ensure that there are no adverse health and environmental consequences as a result of their waste handling, treatment and disposal activities (Patil & Pokhrel, 2005).

Most of the health care waste treatment companies are located within big cities like Pretoria, Johannesburg and Cape Town. Health care waste is thus transported to Gauteng Province for treatment and proper disposal. Sometime these facilities are overwhelmed and unscrupulous dealers will dump the waste improperly. Other times, waste would be dumped off illegally at inappropriate sites near residential areas which impact negatively on human health and the environment.

The irresponsible and illegal dumping of hazardous health care waste in South Africa, as intermittently reported in the media, is a matter of serious concern. It also places an unacceptable high financial and human resources burden on health authorities to manage the problem.

Proceedings of the 23rd WasteCon Conference 17-21 October 2016,Emperors Palace, Johannesburg, South Africa

309 Institute of Waste Management of Southern Africa

mailto:[email protected]

Disposal of health care waste has emerged as a major problem worldwide. The most common method of treatment is incineration. Studies have shown that hydrogen chloride and heavy metals are emitted from medical waste incinerators causing environmental pollution (Acharya & Singh, 2000; Yimer, 2005; Blenkham, 2006). Incineration of health care waste produces toxic air pollutants such as Nitrogen Oxides, particulates and heavy metals which can be distributed over a large area (WHO, 1999). Incineration of health care waste is the main cause of mercury in the atmosphere which causes mercurial pollution (Abor, 2008). Health care waste entering the normal domestic waste stream will end up being disposed of in municipal landfill sites. When medical waste is placed in landfills contamination of groundwater may occur and may result in the spread of unacceptable microorganisms such as E-Coli (Acharya & Singh, 2000). Many smaller landfill sites are not fenced off and have poor security. This results in unwanted tip-face picking and scavenging. If health care waste is disposed on such a site, there is a risk of exposure to people scavenging on the site. The management of health care waste must occur from its cradle (the health care facility) to its grave (the disposal facility) where the waste itself or residues after treatment are disposed. Generally, health care waste is waste arising from diagnosis; monitoring and preventive; curative or palliative activities in the field of veterinary and human medicine (Pruss et al., 1999). Broadly, it is defined as any solid or liquid generated in the diagnosis, treatment or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals (BAN & HCWH, 1999). Health care waste can be separated into a number of categories that identify the major hazard or risk that they pose to human health and the environment, i.e. infectious; chemical; radioactive and general waste. This waste is a growing problem worldwide, jeopardizing the health of the staff, patients, disposal workers, local communities and the environment. The city of Pretoria is also facing similar problems. Due to poor screening and management, health care waste is often mixed with municipal waste and collected in the same collection bins and disposed of the same way. Some waste is simply buried without any appropriate consideration. Some patients, who routinely use syringes at home, do not know how to dispose them off properly. Exposure to health care waste can have serious consequences, for instance, if children pick up and play with improperly disposed waste items and accidentally get pricked by used syringe or injure themselves. Infectious waste can cause diseases like Hepatitis C Virus (HCV), Hepatitis B Virus (HBV), Human Immune Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS), Typhoid, Boils etc.(Yimer, 2005). Hepatitis C is rapidly spreading among young garbage scavengers, as they pick up used syringes and other clinical waste from different sources within the city for recycling (Yimer, 2005). Many drug addicts also reuse the syringes that can cause HIV/AIDS and other dangerous and contagious diseases (Pruss et al., 1999). If the infectious component mixes with the general non-infectious waste, the entire mass becomes infectious. It is therefore, the responsibility of hospitals and other health care institutions to ensure that there are no adverse health and environmental consequences as a result of their waste handling, treatment and disposal activities (Patil & Pokhrel, 2005). Most of the health care waste treatment companies are located within big cities like Pretoria, Johannesburg and Cape Town. Health care waste is thus transported to Gauteng Province for treatment and proper disposal. Sometime these facilities are overwhelmed and unscrupulous dealers will dump the waste improperly. Other times, waste would be dumped off illegally at inappropriate sites near residential areas, which impact negatively on human health and the environment. The irresponsible and illegal dumping of hazardous health care waste in South Africa, as intermittently reported in the media, is a matter of serious concern. It also places an unacceptable high financial and human resources burden on health authorities to manage the problem. Disposal of health care waste has emerged as a major problem worldwide. The most common method of treatment is incineration. Studies have shown that hydrogen chloride and heavy metals are emitted from medical waste incinerators causing environmental pollution (Acharya & Singh, 2000; Yimer, 2005; Blenkham, 2006). Incineration of health care waste produces toxic air pollutants such as Nitrogen Oxides, particulates and heavy metals which can be distributed over a large area (WHO, 1999). Incineration of health care waste is the main cause of mercury in the atmosphere which causes mercurial pollution (Abor, 2008). Health care waste entering the normal domestic waste stream will end up being disposed of in municipal landfill sites. When medical waste is placed in landfills contamination of groundwater may occur and may result in the spread of unacceptable microorganisms such as E-Coli (Acharya & Singh, 2000). Many smaller landfill sites are not fenced off and have poor security. This results in unwanted tip-face picking and scavenging. If health care waste is disposed on such a site, there is a risk of exposure to people scavenging



on the site. The management of health care waste must occur from its cradle (the health care facility) to its grave (the disposal facility) where the waste itself or residues after treatment are disposed. 2. MATERIALS AND METHODS The study was conducted in Pretoria, the capital city of South Africa. The city of Pretoria is located about 60 km north of the city of Johannesburg within Gauteng Province. A national census in 2011 recorded the population of the city as 2,345,908 (Statistics South Africa, 2011). South Africa’s healthcare system is structured in four layers, namely: Primary healthcare (clinics), District hospitals, Regional hospitals and Tertiary (academic) hospitals (SAHCS, 2012). Academic hospitals are tertiary health care institutions rendering specialized services to patients who were referred hospitals in that by their local clinics. Only private health care facilities were contacted to request permission to undertake the study within their premises. These facilities are well equipped and well-staffed. Purposive sampling method was adopted for the study. This method was used because the researcher was targeting respondents who are knowledgeable and experienced in the management of health care waste. According to Bless and Smith (1995) purposive sampling is based on the judgement of a researcher regarding the characteristics of a representative sample. The study used mixed methods data collection strategies. Mixed method data collection strategies are those that are designed to combine elements of one method with elements of the other in either a sequential or simultaneous manner (Axinn & Pearce, 2006). Varying the data application approaches reduces non-sampling error by providing redundant information from multiple sources and ensures that a potential bias coming from one particular approach is not replicated in alternative approaches (Creswell, 2009). Using different sources of information gathering is also referred to as triangulation and it helps in minimising biases coming from the use of a single method (Howell et al., 2005). The researcher conducted an empirical research that is both quantitative and qualitative methods, which presented original research findings (Mouton, 2001). The selection of mixed method helped the researcher to gain special opportunities to the use of multiple sources of information from multiple approaches to gain new insights into the medical waste management dynamics in Pretoria. Data was collected from the doctors, nurses, cleaners and managers of the different medical facilities. Data collection methods used included the questionnaires, interviews, direct observation and literature review. A semi-structured questionnaire with closed and open-ended questions was used in the study. The design of the instrument was based on the recommendations of the world health organisation (WHO) for evaluation of hospital waste management in developing countries (WHO, 1999). Bryman and bell (2007) noted that the use of closed questions lead to: ease of processing answers; enhanced comparability of answers; easier to show relationship between variables; easier to make comparisons between variables and easier to make comparisons between respondents. These are easy to analyse statistically but they limit the respondent’s response (Jackson, 2009). Open ended questions lead to a greater variety of responses from participants but are difficult to analyse statistically because the data must be reduced in some manner. The questions were formulated to understand worker’s knowledge of medical waste in terms of constituents, hazards and diseases that could be transmitted through improper management of medical waste. The questionnaires were hand delivered to the respondents of each of the surveyed facilities. The respondents contacted the researcher telephonically and through emails if there were any follow up questions. The researcher collected the completed questionnaires personally from each facility after a week. A covering letter was attached to each questionnaire. The purpose of the covering letter was to explain the purpose and nature of the study, to assure the respondents of total confidentiality and anonymity to allay any fears that may arise regarding divulging information. The semi-structured interviews were directed to the waste managers. The interviews aimed to obtain descriptive data that helped the researcher to get more in-depth information about medical waste management (Maree, 2008). Direct observations also helped the researcher to gain some insight on the issues of interest concerning waste management, for example: how waste is managed, collected, stored, treated and transported. Both the interviews and walkthrough surveys were conducted during the same visits. During the walkthrough surveys photos of waste storage, containers and transportation vehicles were taken. Observations were made in line with the checklist items while at the same time questions were raised on issues that needed further clarification.



The field observations enabled the researcher to understand the exact nature of activities associated with the process (Maree, 2008). The researcher made several visits to the facilities observing how medical waste is managed from generation to disposal. Creswell (2009) finds self-administered questionnaires to be cheaper as compared to other modes of administration, and having an advantage or reaching a large sample size, cover wide geographical area and excellent for capturing sensitive topics. 3. RESULTS AND DISCUSSION It is the responsibility of the waste generator to ensure that the waste generated is handled, transported and disposed of in an environmentally and responsible manner. The generator of waste must also ensure that the applicable legislations, regulations and procedures are being adhered to (Hazardous Substance Act No 15, 1973). Healthcare waste management is the practice of identifying, minimising, separating, collecting, handling, treating, storing and disposing of healthcare waste per policy of the institution or of the government (Rao et al., 2004). It has been observed that almost all the cleaners are responsible to manage the waste generated, collecting it from the wards to the temporary storage area. It is also the cleaner’s responsibility to ensure that there are more empty bins to be placed once the used ones are full. Waste generation depends on a number of factors such as number of beds, type of health services provided, economic, social and cultural status of the patients and the general condition of the area where the facility is situated (Pruss et al., 1999). Healthcare facilities generate various kinds of wastes as a result of a variety of medical treatment and research (Akter et al., 2003). It has been found from the field survey that all of the surveyed facilities generate general waste, infectious, non-infectious, used syringes, broken bottles and glass, swabs and pharmaceuticalThe cleaners wore the protective clothing (that is: gloves, protective boots and masks) at all times. There are four keys to MWM, segregation, transportation, treatment and disposal (Crick, 2012). 3.1 Segregation The key to effective healthcare waste management is segregation and identification of waste (Rao et al., 2004). The first priority is to separate wastes at the nearest point of generation. Segregation involves the separation of waste into the designated categories of health care general waste and health care risk waste respectively. In terms of world health organisation’s proposal the health care facilities must provide plastic bags and strong plastic containers for infectious wastes. These bags and containers should be marked with biohazard symbol (Pruss et al, 1999). It has been observed that the segregation of waste in these facilities is done at the generation point. The waste is stored in designated colour coded bags and bins with identification labels as shown on the poster (Figure 2). General waste is stored in black bag or bin, Infectious waste in red, sharps in yellow and pharmaceutical in green. This minimizes the actual volume of the infectious waste and it also makes their storage and the disposal manageable. This makes it easier for staff members to know where to throw different waste. The segregation of medical waste into infectious and non-infectious is conducted according to definite rules and standards.

Figure 1:Different waste bags



3.2 On-site transportation This is the removal of waste from different wards to temporary storage area. The movement mean must meet the following standards WHO [14]:

• Easy loading and unloading; • The absence of sharp edges, which can cause severe damage to the waste bags or containers

during loading and offloading. • Easy cleaning and must be cleaned and sterilised daily using appropriate purgatory. All bags must

be tightly closed and the end of transport operations.

Figure 2:Onsite trolley The waste generated is collected and transported to a temporary storage area by the cleaners. Wheeled trolleys indicated above are used to transport waste, fig. 2. This is well handled and they follow the WHO’s standards as stated above. 3.3 Temporary storage area This is the area where waste is stored prior to off-site transportation, fig.3. This area is sanitised and secured and only accessed by authorised persons (Pruss et al [1]. The prescribed storage time of waste within the temporary area should be less than 72 hours in winter and less than 48 hours in summer. In hot regions, it should however be kept for less than 48 hours in winter and less than 24 hours in summer WHO [14]. The results indicate that all health care facilities wastes are collected on a daily basis.



Figure 3:Temporary storage area 3. 4 Off-site transportation and final disposal A private waste management company collects the waste on a daily basis. The final disposal of the medical waste is therefore the responsibility of this company. These facilities receive disposal certificates of medical waste as a substantive proof of ultimate disposal as required in section 28 of NEMA (DEAT, 2000). The health care waste is incinerated as the final disposal method. Dioxins, furans and other toxic air pollutants are produced as emissions (Acharya & Singh, 2000). Incineration of waste has been widely practised, but inadequate incineration or the incineration of unsuitable materials results in the release of pollutants into the air and of ash residue. Incinerated materials containing chlorine can generate dioxins and furans, which are human carcinogens and have been associated with a range of adverse health effects (Yimer, 2005). Incineration of heavy metals or materials with high metal content (in particular lead, mercury and cadmium) can lead to the spread of toxic metals in the environment ((Acharya & Singh, 2000). 4. CONCLUSION The health care facilities visited were found to be well managed and maintained. The management of waste is practised to a satisfactory extent, that is, according to South African national and local guidelines as well as WHO’s recommended standards. These facilities are doing their best not to expose their patients, visitors, society and the environment to the dangers of medical waste. The studied facilities, however, to not measure the waste and generated. A private company using incineration does the final disposal. 5. RECOMMENDATIONS The researcher being the resident of South Africa has noticed that there is a constant rise in electricity demand and lack of additional power generation capacity which has led to electricity shortages. There is therefore a need for more efficient use of energy on the demand side. Transferring MW to energy or fuels can be a solution for this country. This process is termed gasification Energy [16]. This process undergoes high energy and high temperature cracking by means of plasma stream where the remaining molecular chains are cracked into isolated and inactive molecules CMD [17]. This process has the following advantages fabtanks [18]:



• It produces no toxic by-products. • No ash residue. • All slag is vitrified due to the high temperature and the end product (tiny vitreous pebbles) can be

used in road construction. • No reactive or residual toxins for landfilling • The process is designed with an energy transformation focus. • The process is a conservational and green approach to the MW and waste in general.

Waste generated should be measured in the facility in order to know what kind of waste is generated more than the other. 6. ACKNOWLEDGEMENTS University of South Africa (UNISA) for funding this study. Medical institutions that participated in this study by providing required information. Abor, P.A., Bouwer, A. (2008). Medical Waste Management Practices in a Southern African Hospital. International Journal of Health Care Quality Assurance, 21, 4; 356-357. Acharya, D.B. and Singh, M. (2000). The Book of Hospital Waste Management. 1stEd. New Delhi: Minera Press. BAN & HCWH. (1999). Medical Waste in Developing Countries: An analysis with a case study of India and critique of the Basel-TWG guidelines. Basel Action Network Bryman, A. and Bell, E. (2007). Business Research Methods. New York: Oxford University. Cresswell, J. W. (2009). Research design, qualitative, quantitative and mixed methods approaches. Thousand Oaks: Sage publications. Crick, N. (2012). Waste management. Environment Watch Botswana, 16, 12-15. Maree, K. (2008). First Steps in Research. Pretoria: Van Schaik Publishers. Pruss, A., Giroult, E. and Rushbrook, P. (1999). Safe Management of Wastes from Healthcare Activities: Handbook WHO, Geneva, Switzerland. Statistics South Africa, Census. (2011). Retrieved from: (http://www.statssa.gov.za) on April 3, 2012. ABES. (2000). Sanitary and Environmental Engineering Brazilian Association: Rio de Janeiro, RJ. Akbolat, M., Isk, O., Olede, C.and Cimen, M. (2011). Evaluation of Level of Knowledge of Healthcare Professionals about Medical Wastes: University of Acibadem Health Sciences Journal 2(3):131-140. Blenkharn, J.I. (2006). Standards of Clinical Waste Management in UK Hospitals: Journal of Hospital Infection 62, 300-303. Bless, C., Higson-Smith, C. (2006). Fundamentals of Social Research Methods: An African Perspective. 4th Ed. Cape Town: South Africa. Chaerul, M., Tanaka, M. and Shekdar, A.V. (2008). A System Dynamics Approach for Hospital Waste Management: Journal of Waste Management 28(2): 442-449. Energy (2013). Retrieved from (http://www.energy-inc.com/technology) on 01 September 2013. Environmental Protection Agency (EPA) (2000). Medical Waste Management in the United States: Retrieved from (http://www.epa.gov) on 3 June 2012 Fabtanks 2013. Retrieved from: (http://www.fabtanks.co.za) on 01 September 2013.



Independent (2010). Medical waste piles up. The government downplays Problem. Retrieved from: (http://www.egyptindependent.com/news/medical) on 08 March 2010. Integrated Strategy and Action Plans (ISAP) for Sustainable Health Care Risk Waste Management in Gauteng (2004). Retrieved from: (http://www.environment.gov.za) on 15 September 2012. Jackson, S.L. (2009). Research Methods and statistics: A Critical Thinking Approach.3rd Ed. Belmont: wads worth. Ngwuluka, N., Ochekpe, N., Odumuso, P. and John, S. A. (2009). Waste Management in Healthcare Establishments within Jos Metropolis, Nigeria: African Journal of environmental Science and Technology, 3(12), 459-465. Pruss, A., Giroult, E. and Rushbrook, P. (1999). Safe Management of Wastes from Healthcare Activities: Handbook WHO, Geneva, Switzerland. Rao, S.K.M., Ranyal, R.k and Sharm, V.R. (2004). Biomedical Waste Management: An infrastructural Survey of Hospital. MJAFI Silva, C .E., Hoppe, A .E., Ravanello, M. M. and Mello, N. (2005). Medical Waste Management in the South of Brazil, Waste Management Journal, 25, 600-605. South African Health Care System (SAHCS). Retrieved from: (http://www.pah.org.za) on April 15, 2012. World Health Organisation (WHO), 2004. fact sheets no 281. Geneva, Switzerland: World health Organisation. Retrieved from: (http://www.who.int.org) on 30 January 2012. World Health Organisation (WHO), 2005. Management of Solid Healthcare Waste at Primary Healthcare Centres, A decision-Making Guide. Geneva, Switzerland. Retrieved from: (http://www.who.int.org) on 30 January 2012.



assessment of health care waste management in some medical ... · s.j. moja. council of geoscience,...

Documents