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EVALUATING THE KNOWLEDGE OF MEDICAL
WASTE MANAGEMENT WITHIN MEDICAL
STAFF AT BIEN HOA HOSPITAL IN PROVINCE of
DONG NAI

研 研 研研Pham Thi Kim Hoa
研研研研研Yung-Yu Su, PhD.

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EVALUATING THE KNOWLEDGE OF MEDICAL
WASTE MANAGEMENT WITHIN MEDICAL
STAFF AT BIEN HOA HOSPITAL IN PROVINCE of
DONG NAI

Graduate student:研Pham Thi Kim Hoa
Supervisor研Yung-Yu Su, PhD.

Meiho University
Graduate Institute of Health care
Thesis
A thesis submitted to the Graduate Institute of Health Care of
Meiho University
In partial fulfillment of the requirement for the degree of

Master of Health Care

July 2014


Abstract
Health-care waste (HCW) is now not a problem of developed countries but
also developing countries. Along with the large extent of health care system, the
authorities of developing countries have to solve the puzzle in managing of increasing
HCW. Vietnam also follows this trend in which HCWs are generated uncontrollably
year by year. Poor management of HCW can threaten public health due to the fact that
HCW cause a variety of bad impacts on health conditions of health-care staff who
directly deal with HCW, patients, and general population and on surrounding
environment as well.
HCW management in Vietnam faces a variety of difficulties. Many health-care
facilities throughout the country still collect and dispose of HCW together with
domestic wastes. Moreover, the knowledge of HCW management that has a crucial
impact on practice of HCW among health-care workers may not high as expected.
Hence, the aim of the present study is to investigate the knowledge about HCW
management among health-care staff working in Bien Hoa General Hospital, Bien
Hoa Health Center and 30 health stations in Dong Nai province. To achieve this aim,
the following objectives are described: (1) To identify the knowledge about existence
of HCW management document, segregation and collection of HCW, transportation of
HCW, treatment and disposal of HCW among health-care staff dealing directly to
HCW management; (2) To examine the associations between the knowledge and
characteristics of health-care staff dealing directly to HCW management.
The study had achieved its main aim exploring the knowledge of health staff
about HCW management. There were 393 health staff including doctors, nurses and
hospital orderlies enrolled and five aspects of knowledge of HCW management
including classification, segregation, collect, transportation and storage, and treatment
and disposal of HCW evaluated in the present study.

For the knowledge of classification of HCW, the overall proportion of
participants knew the knowledge was 84.48%. Similarly, the knowledge of
segregation of HCW had reached the percentage equal of 77.35%. The knowledge of
transportation and storage of HCW was 78.88%. The remaining knowledge including
collection and treatment and disposal of HCW had gained a low percentage, yielding
65.39% and 41.22%.



Acknowledgements
First of all, I would like to express my deepest gratitude to my supervisor, Dr.
Yung-Yu Su and other professors, who spent valuable time in instructing me to
complete this thesis. I could not fulfil my thesis without profound knowledge,
invaluable advices and supports from my professors. All of these made me put more
efforts to finish my thesis.
I am also grateful to acknowledge Professor, Dr. Chung, Tiech-Chi, the chairman
of graduate committee, for his consultancy, encouragement, motivation and inspiration
throughout my study in Nursing Department.
Many special thanks were also sent to the Board of Directors of Nguyen Tat
Thanh University for supporting me during my study. I will always remember all
university officers for their help, cooperation and kindness during my study period in
Viet Nam as well as in Taiwan.
I would like to thank the Management Board of II Postgraduate Program in Dong
Nai province, the Directorate and the staff of the Department of Science and
Technology in Dong Nai province who have supported me from the beginning to the
end of my study. I would like to thank the Director of Bien Hoa General Hospital, Dr.
Trang Vo Tan, the Director of Bien Hoa Health Center, and Dr. Nguyen Xuân Hung
who have allowed and facilitated me in collecting data for this research. I won’t forget
Dr. Mai Van Dan, the Head of External Division of Bien Hoa General Hospital, for his
encouragement and supports.

I would like to send my special thanks to health-care staff in departments of Bien
Hoa General Hospital, Bien Hoa Health Center, 30 commune health stations and the
Department of Environmental Health of Public Health Institute at Ho Chi Minh City
who has provided precious documents used as reference in my study.
My great gratitude was also given to officers, librarians, staff of dormitory of
Meiho Institute of Technology for their help and sharing as close friends during my
time of studying in Taiwan.
I express my deep gratitude to Mrs. Nguyen Thi Minh Chau, lecturer of Pham
Ngoc Thach Medical University, and Mrs. Katrina, lecturer of Nguyen Tat Thanh
University who have spent precious time to help me to improve my English.


I would like to express my thankfulness to all participants who had no hesitation
in giving help and useful information during the data collection of the study process.
Finally, I am eternally indebted to my family who have always behind me in my
career advancement and without their helps and concerns I could not complete my
thesis.


List of tables
Page
Table 4.1. Demographic characteristics of health-care staff.........................................45
Table 4.2. Knowledge about existence of and access to HCW management documents
......................................................................................................................................47
Table 4.3. The proportions of health-care staff knowing about types of waste............47
Table 4.4. Knowledge about classification of health-care waste..................................49
Table 4.5. Knowledge about segregation of health-care waste.....................................50
Table 4.6. Knowledge about collection of health-care waste.......................................52
Table 4.7. Knowledge about transportation and storage of health-care waste..............53
Table 4.8. Knowledge about treatment and disposal of health-care waste...................55

Table 4.9. Knowledge about classification of health-care waste and characteristics of
health-care staff.............................................................................................................57
Table 4.10. Knowledge about segregation of health-care waste and characteristics of
health-care staff.............................................................................................................59
Table 4.11. Knowledge about collection of health-care waste and characteristics of
health-care staff.............................................................................................................60
Table 4.12. Knowledge about transportation and storage of health-care waste and
characteristics of health-care staff................................................................................61
Table 4.13. Knowledge about treatment and disposal of health-care waste and
characteristics of health-care staff................................................................................63


Contents
Page
Abstract...............................................................................................................................i
Acknowledgements...........................................................................................................ii
List of tables.....................................................................................................................iii
Chapter 1. Introduction...................................................................................................1
1.1. Statement of this research....................................................................................1
1.2 Significance of this research.................................................................................2
1.3. The aim of the study............................................................................................3
1.4. Chapter summary.................................................................................................4
Chapter 2. Literature Review.........................................................................................5
2.1. Introduction..........................................................................................................5
2.2. Definition of health-care waste............................................................................6
2.3. Classification of health-care waste......................................................................6
2.4. Practices of health-care waste management worldwide....................................13
2.5. Current international normative framework for HCW management.................16
2.6. Current situation of health-care waste management in Vietnam.......................19
2.7. Contents of Decision No.43/2007/QD-BYT.....................................................26

2.8. Relevant studies on knowledge of health-care waste management...................34
2.9. Chapter summary...............................................................................................39
Chapter 3. Research Methodology...............................................................................41
3.1. Introduction........................................................................................................41
3.2. Research design.................................................................................................41
3.3. Research framework and hypotheses.................................................................41
3.4. Sampling issues..................................................................................................42
3.5. Data management and data analysis strategy....................................................43
3.6. Ethic issues........................................................................................................44
3.7. Chapter summary...............................................................................................44
Chapter 4. Results..........................................................................................................45
4.1. Introduction........................................................................................................45
4.2. Demographic characteristic of health-care staff................................................45
4.3. Knowledge about existence of and access to health-care waste management
documents.................................................................................................................46


4.4. Knowledge about classification of health-care waste........................................47
4.5. Knowledge about segregation of health-care waste..........................................50
4.6. Knowledge about collection of health-care waste.............................................52
4.7. Knowledge about transportation and storage of health-care waste...................53
4.8. Knowledge about treatment and disposal of health-care waste.........................54
4.9. The relationships between knowledge and characteristics of health-care staff. 57
4.10. Summary..........................................................................................................64
Chapter 5. Discussion.....................................................................................................65
5.1. Introduction........................................................................................................65
5.2. Discussing the significance results of findings..................................................65
5.3. The principal research findings..........................................................................79
5.4. Contributions and implications..........................................................................80
5.5. Limitations.........................................................................................................81

5.6. Recommendation for further research...............................................................81
5.7. Conclusion.........................................................................................................82
References
Appendix 1. Commentation from nursing ethic committee for scientific study of
Bien Hoa General Hospital
Appendix 2. The self-administered questionnaire


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Chapter 1. Introduction
1.1. Statement of this research
Today health-care waste (HCW) is a crucial public health and environmental issue
for all countries over the world. In United States, HCW is the third largest source of
waste, with hospitals discarding more than 2 million tons of waste annually (Everson,
2010). For developing countries, the problem draws more concern due to the
increasing development of health care services in those countries . Every year, over
0.33 million tons of HCW is generated in India (A. D. Patil & Shekdarf, 2001). It is
also estimated that there is about 0.25 million tons of HCW generated annually in
Pakistan (Government of Pakistan, 2005). High-income countries generate an average
up to 0.5 kg of hazardous waste per bed per day; while low-income countries generate
an average 0.2 kg of hazardous waste per bed per day (WHO, 2011b). However, HCW
is often not separated into hazardous and non-hazardous wastes in low-income
countries making the real quantity of hazardous waste much higher (WHO, 2011b).
HCW with poor management could have negative health impacts on health care
workers, waste handlers, patients and the community (WHO, 2013). Occasionally, the
public is exposed to radioactive waste, which originates from radiotherapy treatment
and is disposed of improperly. Serious accidents have been documented in Brazil in
1988 (where four people died and 28 had serious radiation burns) (IAEA, 1988),
Mexico and Morocco in 1983, Algeria in 1978 and Mexico in 1962 (WHO, 2007a). In

June 2000 six children were diagnosed with a mild form of smallpox (vaccinia virus)
after having played with glass ampoules containing expired smallpox vaccine at a
garbage dump in Vladivostok, Russia . Also in 2000, World Health Organization
(WHO) estimates that injections with contaminated syringes caused 21 million
hepatitis B virus (HBV) infections, 2 million hepatitis C virus infections and 260,000
HIV infections worldwide. In addition, waste and by-products can also cause injuries
such as radiation burns, and sharps-inflicted injuries (WHO, 2011b).
Many materials utilized in health-care facilities can also result in the release of
hazardous substances into environment (Laustsen, 2007). Incinerated materials
containing chlorine can form dioxins and furans (Emmanuel et al., 2001), which are
human carcinogens and can pose a variety of adverse health effects. Incineration of


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heavy metals or materials with high metallic content (in particular lead, mercury and
cadmium) can lead to the spread of toxic metals in the environment (WHO, 2011b).
In accordance with increasing development of health care facilities, HCW
management is now a great concern of Vietnamese government. According to a survey
of Department of Therapy, Ministry of Health, between 2009 and 2010 the total of
HCW in the whole country was approximately 100-140 tons/day, of which 16-30
tons/day was hazardous HCW. The HCW average was 0.86 kg/bed/day, of which
hazardous HCW constitutes 0,14-0,2 kg/bed/day (MOH, 2011). Recognized the
problem, in 2011 the "Prime Minister Decision No: 798/QĐ-TTg on the approval of
the solid waste treatment investment program for the period 2011 to 2020" was issued
(Prime Minister Decision, 2011). The target for the first phase (2011–2015) is the safe
management and treatment of 85% of the total HCW and within the second phase
(2016–2020), 100% of the total non-hazardous and hazardous HCW will be collected
and treated according to the existing standards.
HCW management in Vietnam, however, engages a variety of difficulties. Many

health-care facilities throughout the country still collect and dispose of HCW together
with domestic wastes (Acid Deposition and Oxidant Research Center, 2001). There is
of 63.6% hospitals used PE or PP bags, those are not recommended in national
regulations, to collect HCW (IOMD., 2006). The collection efficiency is 40–67% of
generated HCW in big cities and 2–40% in small towns, while the average collection
rate is only about 53.4% (Asian Productivity Organization, 2007). There is still
inconsistency in the technology for collection and transportation of HCW, with a mix
of different forms (Asian Productivity Organization, 2007). For treatment and disposal
of HCW, various problems have also been identified such as lack of investment for
HCW management, lack of incinerators for hazardous HCW, and environmental
pollution resulting from HCW treatment activities etc.

1.2 Significance of this research
Bien Hoa City is one of the largest cities of Dong Nai province with a complete
health care system. The health care system includes one general hospital (Bien Hoa
General Hospital) which is responsible for clinical treatment, one Health Center and
30 health stations responsible for preventive health care. During their operations, the
health-care facilities have discharged a large number of HCW including both non-


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hazardous and hazardous waste. In the first six months of 2013, the total amount of
infectious waste originated from Bien Hoa General Hospital is approximately 1.4 tons
and the figure will increase in the next decades (Dong Nai Health Service, 2013).
Regarding to response to this urgent issue, each of health-care facility has made great
efforts to reduce HCW. Nevertheless, many difficulties still exist that lead to less
effectiveness of HCW management in the whole health care system. Many health-care
facilities, especially those at commune level, do not have good practices in segregation
and collection of HCW. In addition, lack of equipments for segregation and collection

of HCW, poor quality of waste containers, open storage areas, and lack of incinerators
for hazardous HCW have been addressed but not resolved yet.
There is a variety of causes that lead to the mentioned difficulties, but inadequate
knowledge of HCW management of health-care staff could be the most important one.
With inadequate knowledge, health-care staff could perform wrong practices of HCW
management that in turn could result in negative impacts on their health and public,
and even the surrounding environment. Investigation knowledge of HCW
management of health-care staff therefore is necessary for health-care facilities to
improve practices of HCW. In 2013, a preliminary study conducted in Bien Hoa
General Hospital and Bien Hoa Health Center showed that the overall knowledge of
health-care staff was relatively high (T. K. H. Pham, 2013). However, with the hope of
depicting more detailed knowledge of health-care staff in the whole health care system
in Bien Hoa city, the present study was carried out. The findings of the study were
used as database to point out the gaps on knowledge of HCW management among
health-care workers in Bien Hoa city and suggest solutions to fulfil these gaps.

1.3. The aim of the study
The aim of the present study is to investigate the knowledge about HCW
management among health-care staff. To achieve this aim, the following objectives are
described:
1. To identify the knowledge about existence of HCW management documents,
segregation and collection of HCW, transportation of HCW, treatment and disposal
of HCW among health-care staff dealing directly to HCW management.
2. To examine the associations between the knowledge and characteristics of healthcare staff dealing directly to HCW management.


4

1.4. Chapter summary
HCW is now not a problem of developed countries but also developing countries.

Along with the lager extent of health care system, the authorities of developing
countries have to solve the puzzle in managing of increasing HCW. Vietnam also
follows this trend in which HCWs are generated uncontrollably year by year. Poor
management of HCW can threaten public health due to the fact that HCW cause a
variety of bad impacts on health conditions of health-care staff who directly deal with
HCW, patients, general population and surrounding environment as well.
There are many warning reports indicating HCW is now a big problem of Bien
Hoa city (one of largest cities of Dong Nai province), since the amount of HCWs is
raising but the management of HCW is still limited and ineffectively. One of
underlying causes of the poor management of HCW is the lack of knowledge of HCW
management among health-care staff working at health-care facilities located in the
city. The studying of knowledge of HCW management of health-care workers is
important but to date there are not any comprehensive studies conducted yet.
Therefore the aim of the study is to identify the knowledge about HCW management
of health-care staff dealing directly to HCW management.


5

Chapter 2. Literature Review
2.1. Introduction
Health-care activities are a means of protecting health, curing patients and saving
lives. However they also produce waste with 20% of which posing risks either of
infection, of trauma or of chemical or radiation exposure (WHO, 2011b). Although the
risks in accompany with hazardous HCW and measures of HCW management are well
documented in international guidelines and many studies, the practices of HCW
management globally are still big problems that many governments have to deal with
these days, especially developing countries where technical and financial resources
and a legal framework are still limited.
This chapter describes a variety of aspects concerning to the study from

definition of HCW to studies on knowledge of HCW management of health-care staff
worldwide. Firstly, the definition of HCW is provided so that the audience have a clear
concept of HCW used in this study. Five defined types of HCW including infectious,
sharp, anatomical, chemical and radioactive waste and their impacts on public health
are also mentioned. In the next section the audience could find a summary of global
practices of HCW management that depicts increasing difficulties in each stage of
HCW processing. To deal with global problems of HCW, international organizations
have made many efforts to develop standardized guidelines on HCW management but
unfortunately that has not yet been done.
The second part of this chapter largely focuses on the situation of HCW
management in Vietnam. The Vietnamese health care system with more than 13,000
health facilities at all level takes care of the increasing quantity of patients, so the
amount of HCW generated each day increases as well. It could be said that HCW
management in Vietnam is ineffective with enormous problems existing from
segregation to disposal of HCW. The government has published many official papers
such as law, decrees, and decisions to form a national framework of waste
management, and Decision No 43/2007/QD-BYT is the most updated paper involving
in HCW management. To end this chapter, a summary of studies on knowledge of
HCW management among health-care staff is added.


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2.2. Definition of health-care waste
HCW although is defined by 2013 WHO guideline shows a variation in definition
depending on practical settings of different countries. WHO defines HCW as all
wastes generated within health-care facilities, research centres and laboratories related
to medical procedures. In addition, it includes the same types of waste originating
from minor and scattered sources, including waste produced in the course of health
care undertaken in the home (e.g. home dialysis, self-administration of insulin,

recuperative care) (WHO, 2013). However, by the guideline of HCW management of
Tanzania, HCW is defined as any solid waste generated in diagnosis, treatment or
immunization of human beings or animals, in related research, production or testing of
biological from all type of healthcare institutions, including hospital, clinics, doctor,
offices, and medical labs (Manyele, 2004). In Decision No. 43/2007/QĐ-BYT
approved by Vietnamese government, HCWs are defined in a simple concept as solid,
liquid or gas wastes generated from health-care facilities including hazardous and nonhazardous HCW (Ministry of Health-Socialist Republic of Vietnam, 2007).

2.3. Classification of health-care waste
It is known that not all HCW is hazardous for human health. Indeed, most of
HCW (approximately 75 to 90 per cent of the total amount of waste) is general HCW
(non-hazardous HCW) that does not pose any particular risk to human health or the
environment (Rutala et al., 1998; WHO, 2013). It comes mostly from the
administrative, kitchen and housekeeping functions at health-care facilities and may
also include packaging waste and waste generated during maintenance of health-care
building. The remaining 10-25% of HCWs is regarded as "hazardous" and may create
a variety of health risks if not managed and disposed of in an appropriate manner
(Rutala, et al., 1998; WHO, 2013).
For hazardous HCW, it may be classified into different types of waste according
to the source, type and risk factors associated with its handling, storage, transport and
disposal. These include (a) infectious waste; (b) sharps waste; (c) anatomical and
pathological waste; (d) chemical and pharmaceutical waste; and (e) radioactive waste.

2.3.1. Infectious waste


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Infectious waste, accounting for 10% of all HCW, is material containing
pathogens such as bacteria, viruses, parasites or fungi in a sufficient concentration that

could result in infectious diseases (WHO, 2013). Infectious agents may enter the
human body through several routes including puncture, abrasion or cut in the skin,
mucous membranes, inhalation, and ingestion. Mia et al (2012) conducted a study to
investigate HCW management practices in many health facilities in Bangladesh and
they found that among 110 respondents being directly involved in HCW management,
63% were affected by one or more diseases such as diarrhoea, hepatitis B and C, and
skin diseases.
According to 2013 WHO guidelines, infectious waste includes waste
contaminated with blood or other body fluids, cultures and stocks of infectious agents
from laboratory work, and waste from infected patients in isolation wards (WHO,
2013). Waste contaminated with blood or other body fluids could be any material,
tools used in health-care settings and contaminated with patient’s blood or body fluid,
whereas laboratory cultures and stocks are highly infectious waste due to containing
highly infectious agents. Waste from infected patients in isolation wards includes
excreta, dressings from infected or surgical wounds, and clothes heavily soiled with
human blood or other body fluids (WHO, 2013). Waste from non-infective patients is
not considered as infectious waste and waste from non-isolation ward may be
classified either infectious or non-infectious waste based upon the practical setting of
each health-care facility.
Incineration and modern technologies such as autoclaving, microwave are often
the choices of disposal of infectious waste in health-care facilities (Cole, 2000). The
modern technologies are used with higher frequency in developed countries, while
incineration is an interim method that is used by most of hospitals in less developed
countries. Since most of incinerators often operate at low temperatures and do not
follow high standards, they pump into the environment toxic pollutants and hazardous
chemicals such as dioxins, furans which cause bad effects on human health.
2.3.2. Sharp waste
Sharps are items that could cause cuts or puncture wounds, including needles,
hypodermic needles, scalpels and other blades, knives, infusion sets, saws, broken
glass and pipettes (WHO, 2013). Since being able to contact with skin, blood and

other body fluids of patients, such items are usually considered highly hazardous
HCW.


8

Potential risks of sharp waste
Sharp waste may not only cause physical injuries (cuts and punctures) but also
exert infected wounds if it contains infectious agents. It is estimated that more than
two million health-care workers are exposed to percutaneous injuries with infected
sharps every year (Prüss-Üstün et al., 2005). Infected syringe needles in accordance
with unsafe injection practices could highly result in transmitting blood-borne
pathogens, including hepatitis B virus, hepatitis C virus and HIV. A 1999 report of the
Center for Disease Control and Prevention (CDC) showed that there were 191
American health-care workers had been acquired occupational HIV infection
(Beltrami et al., 2000). In the year 2000, WHO estimated that injections with
contaminated syringes caused 21 million cases of hepatitis B infection, 2 million cases
of hepatitis C infection and 260.000 cases of HIV infection among health-care workers
(WHO, 2011b). In 2009, 240 people in Indian state of Gujarat developed hepatitis B
due to injections with used syringes those were later discovered to have been bought
through a black market trade of unregulated health care waste (Solberg, 2009).
Sharp waste management
The basic principle for disposal of sharp waste is to collect sharps waste in
puncture-resistant containers that prevents sharp waste from causing injuries and
infections for waste handlers. After that, sharp waste could be disposed by different
methods such as incineration, autoclave, and burying in sharp pits (WHO, 2005c).
Regarding used syringes, plastic and needle portions must be treated separately
with proper processes. A study in Ukraine used mechanical needle cutters to divide
plastic and needle portions of syringes, treated both parts with autoclaves and then
remelted the plastics in recycling plants and buried or melted the needles in a foundry

(Laurent, 2005). The same process with a light difference has been applied in a pilot
study by the Swiss Red Cross in Kyrgyzstan in which after autoclaving, needles were
shredded in a locally made hammer-mill shredder, whereas plastics were sold to a
plastics manufacturer that remelted the plastics to make coat hangers, flower pots and
other commodities (Emmanuel, 2006). In Guyana, needle cutters were also used, but
the plastic portions were treated as infectious waste and the needle portions were
collected in a 45-gallon plastic barrel with an aluminium funnel (Furth, 2007).
2.3.3. Anatomical and pathological waste
By nature, pathological waste could be considered a subcategory of infectious


9

waste; however it is often classified separately due to the fact that special methods of
handling, treatment and disposal are used. Pathological waste consists of tissues,
organs, body parts, blood, body fluids and other waste from surgery and autopsies on
patients with infectious diseases. It also includes human fetuses and infected animal
carcasses (WHO, 2013). Recognizable human or animal body parts are sometimes
called anatomical waste. Most of anatomical and pathological wastes, do not
necessarily entail a health risk or risk for the environment but must be treated as
special wastes for ethical or cultural reasons (International Committee of the Red
Cross, 2011).
Pathological waste management
Two traditional methods of disposal of pathological waste that have been used
widely in many countries are interment in cemeteries or special burial sites and
burning in crematoria or specially designed incinerators (WHO, 2013). Several other
advanced technologies such as alkaline digestion and promession (a newer technology
designed especially for human cadavers) have been also utilized. In some countries,
placenta waste is composted or buried in placenta pits designed to facilitate natural
biological decomposition (WHO, 2013).

2.3.4. Chemical and pharmaceutical waste
Pharmaceutical waste includes expired, unused, spilt and contaminated
pharmaceutical products, prescribed and proprietary drugs, vaccines and sera that are
no longer required, and discarded items heavily contaminated during the handling of
pharmaceuticals, such as bottles, vials and boxes containing pharmaceutical residues,
gloves, masks and connecting tubing (WHO, 2013). Genotoxic waste, a subcategory
of pharmaceutical waste, is highly hazardous and may include certain cytostatic drugs
(alkylating agents, antimetabolites, and mitotic inhibitors), vomit, urine or faeces from
patients treated with cytostatic drugs, cytotoxic drugs, and chemicals and radioactive
material (WHO, 2013). In specialized oncological hospitals, genotoxic waste may
constitute as much as 1% of the total HCW (WHO, 2013).
Chemical waste consists of discarded solid, liquid and gaseous chemicals with
toxic, corrosive, flammable, reactive, and oxidizing properties produced from
diagnostic and experimental work and from cleaning and disinfecting procedures
(WHO, 2013). Some of common types of instrument or tool used for health-care
activities containing hazardous chemical waste are photographic fixing and
developing solutions, disinfecting and cleaning solutions, insecticides and


10

rodenticides, discarded batteries, mercury thermometers, reinforced wood panels in
radiation proofing in X-ray and diagnostic departments, pressurized cylinders,
cartridges and aerosol cans.
Potential risks of chemical and pharmaceutical waste
Genotoxic waste or more specifically cytostatic drugs may cause bad affects on
intracellular processes such as DNA synthesis and mitosis and that in turn leads to
carcinogenic or mutagenic conditions and secondary neoplasia occurring after the
original cancer has been eradicated by using chemotherapy (WHO, 2013). Many
cytotoxic drugs are extreme irritants and have harmful local effects after direct contact

with skin or eyes. Cytotoxic drugs may also cause dizziness, nausea, headache or
dermatitis (WHO, 2013).
To date, little data on the long-term health impacts of genotoxic waste is
documented due to the fact that it is hard to assess the human exposure of this type of
waste. Sorsa et al (1985) reported an excess of spontaneous abortions during
pregnancy and malformations in children of females who had been treated with
anticancer agents earlier. A later study in Canada also demonstrated that conclusion
(Valanis et al., 1999), while a meta-analysis found only significant association
between exposure to cytotoxic drugs and spontaneous abortion (Dranitsaris, 2005).
Chemical wastes may cause intoxication, either by acute or chronic exposure, or
physical injuries with the most common being chemical burns (WHO, 2013).
Intoxication can result from absorption of a chemical or pharmaceutical through the
skin or the mucous membranes, or from inhalation or ingestion. Injuries to the skin,
the eyes or the mucous membranes of the airways can occur by contact with
flammable, corrosive or reactive chemicals (WHO, 2013).
With the same reason like genotoxic waste, the impacts of chemical waste to
public health are difficult to be recorded and measured as well. However, WHO noted
that pharmacists, anaesthetists, and nursing, auxiliary and maintenance personnel may
be at risk of respiratory or dermal diseases caused by exposure to chemicals and
pharmaceuticals (WHO, 2013). Reduction of this type of occupational risk could be
done through substitution of hazardous chemical or pharmaceuticals whenever
possible and provision of protective equipments to all at risk personnel. Additionally,
personnel handling hazardous materials should be trained in preventive measures and
emergency care in case of accident (WHO, 2013).
Chemical and pharmaceutical waste management


11

For small quantities of pharmaceutical waste, the available methods of disposal

are return of expired pharmaceuticals to the donor or manufacturer, encapsulation and
burial in a sanitary landfill, chemical decomposition in accordance with the
manufacturer’s recommendations, dilution in large amounts of water and discharge
into a sewer for moderate quantities of relatively mild liquid or semi-liquid
pharmaceuticals (WHO, 2013). If the amount of pharmaceutical waste is huge, the
disposal options may include encapsulation and burial in a sanitary landfill,
incineration in kilns equipped with pollution-control devices designed for industrial
waste and that operate at high temperatures, dilution and sewer discharge for relatively
harmless liquids such as intravenous fluids (salts, amino acids, glucose) (WHO, 2013).
For cytotoxic waste, three options could be chosen for disposal including return
to the original supplier, incineration at high temperatures, chemical degradation in
accordance with manufacturers’ instructions (WHO, 2013). It should be noted that as
incineration is the choice the temperatures of incinerators must be up to 1200°C and a
minimum gas residence time of two seconds in the second chamber (WHO, 2013). If
these criteria could not be met, the incineration process may release hazardous
cytotoxic vapours into the atmosphere.
Because of the complexity of chemicals waste produced from health-care
sectors, the disposal of this category of waste needs a national strategy with an
infrastructure, cradle-to-grave legislation, competent regulatory authority and trained
personnel (WHO, 2013). The disposal method should be a combination of measures
and depend upon the nature of hazard presented in the waste. To health-care facilities
being lack of technical and financial resources, the most appropriate method may be
return chemical waste to the original supplier.
2.3.5. Radioactive waste
Radioactive wastes are materials contaminated with radionuclides and are
produced as a result of procedures such as in vitro analysis of body tissue and fluid, in
vivo organ imaging and tumour localization, and various investigative and therapeutic
practices (WHO, 2013). There are two sources of radionuclides including unsealed
sources and sealed sources. Unsealed sources are usually liquids that are utilized
directly, while sealed sources are radioactive substances contained in parts of

equipment or encapsulated in unbreakable or impervious objects, such as pins, “seeds”
or needles (WHO, 2013).
Potential risks of radioactive waste


12

The affect of radioactive waste on human health depends on the type and extent
of exposure to this type of waste. The consequences could be from headache, dizziness
and vomiting to much more serious problems such as severe injuries, tissue
destruction and even death (WHO, 2013). Massive impacts of radioactive waste on
communities have not been reported yet, except several accidents resulting from
improper disposal of radioactive waste. A tragedy related to radioactive waste
happened in Brazil in which a victim opened a radioactive sealed source; consequently
249 people were exposed to radioactive waste, of whom several died or suffered
severe health problems (International Atomic Energy Agency, 1988). Other recorded
accidents often involve exposure to ionizing radiations in health-care facilities as a
result of unsafe operation of X-ray apparatuses, improper handling of radiotherapy
solutions or inadequate control of doses of radiation during radiotherapy (WHO,
2013).
Radioactive waste management
In most cases, radioactive waste often has a short time of decay, so the waste
loses its radioactivity relatively quickly. The treatment needed for radioactive waste
therefore is segregation and storage for decay before further treatment to eliminate
biological hazards and/or release into the environment (WHO, 2013). Other options
for disposal of radioactive waste are return to supplier and long-term storage at an
authorized radioactive waste disposal site.
2.3.6. Non-hazardous general waste
Non-hazardous or general waste is waste that has not been in contact with
infectious agents, hazardous chemicals or radioactive substances and does not pose a

sharps hazard (WHO, 2013). It accounts for approximately 85% of all waste produced
from health-care facilities and has similar properties like municipal solid waste
(WHO, 2013). Some common types of general waste are paper, cardboard and
plastics, discarded food, metal, glass, textiles, plastics and wood.

2.4. Practices of health-care waste management worldwide
2.4.1. Health-care waste management planning in health-care facilities
Planning helps health-care facilities define the strategy for the implementation of


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improved waste management and the allocation of roles, responsibilities and
resources. A comprehensive plan describes the actions to be implemented by
authorities, health-care personnel and waste workers (WHO, 2013). However, in many
health-care facilities, a HCW management plan is often neglected by authorities due to
underestimation of its importance. A study in Nigeria showed that hospitals did not
have any inspective program of HCW management and no plan for treatment and
disposal of HCW in the hospitals (Longe 2006). Another study conducted in India by
WHO in three different level hospitals (general, divisional, and township hospitals)
showed that none of hospitals had a written waste management policy or plan, or
provided waste management training for employees. Furthermore, none of hospitals
had a coding system for waste segregation so that health care staff did not know how
to segregate and collect HCW (Cole, 2000). A study in South Africa investigated
HCW management in a hospital showed that there was no clear policy and plan in
place for managing medical waste. There is no definite policy or plan for purchasing
the necessary equipment and for providing the facilities for the correct management of
medical waste in the hospital. The hospital has a medical waste management guideline
prepared by the head of infection control but this is not strictly followed (Abor, 2007).
2.4.2. Health-care waste segregation, collection, storage and transportation

It is recommended that all health-care facilities should be segregated at source
separately HCW and general waste. However, the reality is not quite like what all
standard guidelines recommended. Some of bad practices of HCW segregation and
collection have been indicated in numerous studies and mainly found in developing
countries.
In developing countries, HCWs are often mixed together with general waste and
then disposed of in municipal waste facilities or dumped illegally (Harhay et al.,
2009). In Nigeria, HCWs are collected by municipal waste collection system and
disposed in open dumps (Longe, 2006). Weir (2002) and colleges investigated a
children’s hospital in Toronto and reported that HCW often mixed with general waste
and the hospital had to spend a sixteen time of expenditures more than usual to
resegregate the mixture of waste.
For segregation of HCW, health-care facilities do not segregate HCW into
different categories. A study in Zimbabwe found that HCW was not segregated and
stored according to its composition and that hazardous HCW and non-hazardous HCW
were largely collected and stored together (Taru & Kuvarega, 2005). A study


14

conducted in a hospital in South Africa showed that in the wards, doctors and nurses
who use sharps are required to drop them into different containers but this is not
diligently followed. The hospital does not label infectious waste with Biohazard
symbol in wast bags or bins (Abor, 2007). In Nepal most of health care facilities,
governmental or non-governmental have not done systematic segregation of HCW at
the place of generation (Joshi, 2013 ; Nepal Health Research Council, 2007).
Another bad practice of segregation that could be seen is the misclassification of
HCW due to colour coded system is not homogonous. In a cross-sectional study,
Longe (2006) found that there was not a consensus in colour code system for bags and
bins in investigated hospitals. In South Africa, a large survey of the Department of

Affairs and Tourism in 1997 showed that only 38% of hospitals applied colour coded
bags for collecting of HCW. Moreover, 46% of the hospitals were using plastic
containers collect sharps, a practice that was not recommended in HCW management
of South Africa policies (Department of Environmental Affairs and Tourism, 2000).
The storage and transportation of HCW also have its own problem. A study in
South Africa showed that HCWs were loaded directly into the pickup without putting
them first into closed containers. Given the small size of the pickups, the wastes were
usually heaped and they fall off on the roads during transportation (Abor, 2007). This
scenario is also be seen in India hospital where HCWs are collected in mixed forms,
and then transported in open carts that results in spillage of HCW (Athavale &
Dhumale, 2010). A study in Nepal found that HCWs have been collected in larger bins
loaded on a trolley in most of large health-care facilities, but HCWs were transported
either in plastic bags or in the waste collection bucket. In addition, locations of the
temporary storage in the facilities were not satisfactory and are close to the municipal
waste storage or near water bodies or premises of hospital (Joshi, 2013 ).
2.4.2. Health-care waste treatment
There are many methods of treatment that have been used widely to treat HCW,
including incineration, autoclave, microwave, chemical disinfection, and electron
beam gun technology. However, it appears that combustion or incineration of HCW is
the most frequent used disposal method in countries lack of finance and resources
(Abor, 2007). Along with emitting hazardous chemicals such as dioxin and furans that
are harmful for human health, incinerators also produce substances that pollute the
surrounding environment. Therefore, incineration cannot be regarded as the best
method of disposal of hazardous HCW.


15

Till now in most of health-care facilities, incinerators like small brick kilns have
low stack height and are operated at low temperatures that do not meet common

standards (Oke, 2008). In a survey in India 82% of the incinerators were burning
mixed waste (HCW and general waste) and 80% of the incinerators were not
maintaining the temperature norms. The temperature was found optimum for dioxins
and furans formation (190-4000C) (Singh, 2003).
2.4.3. Health-care waste disposal
of sharp waste, but a part of these used sharp instruments did not disposed
properly (13% of total syringes) (Vong et al., 2002). Logez et al (2005) carried out a
study in Burkina Faso and found that used syringes did not disposed properly in 46
among 52 In developing countries, HCW is often disposal of in improper manners. A
study in Cabodia showed that hospitals were overused injections that exerted a large
amount investigated health facilities (88%). A study in Bangladesh indicated that in all
studied hospitalms pharmaceutical waste and pressurized containers are disposed
along with general waste and liquid pharmaceutical waste is poured into the drains
along with liquid chemical waste (Mia, et al., 2012). In Nigeria, HCW was collected in
a temporary storage in the campus of the hospitals and then poured into the river
surrounding the hospitals (Longe, 2006). Infected wastes then flow down to the
ground water or to surface water, hence spreading infectious agents in the river
stream (A. D. Patil & Shekdarf, 2001). This eventually can contaminate the drinking
water system of nearby inhabitants. In South Africa, HCW often are dumped into
disadvantaged residential areas and children living in these areas had a high risk of
exposing to infectious agents from HCW as they play nearby these waste pills. A
example for this bad practice of disposal HCW was that a hospital in South Africa
treated 48 children with AZT after some were pricked with needles and others ate
potentially lethal pills they found in a waste field in Elsie’s River (Abor, 2007).
Reuse infected sharp instruments in the hospital is also popular in several
countries. A study in Bangladesh found that some cleaners after segregating syringeneedles, saline bags, empty water bottles or tubes will sell or reuse these used waste
for their own purposes (Mia, et al., 2012). In addition, scavengers (including street
children) picking recyclable materials from the uncovered waste at the dumpsite may
carry millions of pathogens with them and vulnerable to various diseases (Oke, 2008;
G. V. Patil & Pokhrel, 2005). They can also transmit infectious diseases to other

individuals as well.


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2.5. Current international normative framework for health care waste
management
Although well-known risks caused by HCW to human health and the
environment have been demonstrated through literature and data, there has not been
yet a consensus on comprehensive framework to regulate the handling, transport and
disposal of HCW. Several international environmental treaties such as the Basel
Convention on the Control of Transboundary Movements of Hazardous Wastes and
their Disposal and the Stockholm Convention on Persistent Organic Pollutants have
been introduced, but they did not addressed specific aspects of the management and
disposal of this particular type of waste. In this regard, several international
organizations, including WHO and IAEA, have elaborated a number of technical
guidance and documents to guide their members in implementing good practices of
HCW management within their countries.
2.5.1. Basel Convention
The Basel Convention on the Control of Trans-Boundary Movements of
Hazardous Wastes and their Disposal (the Basel Convention) is the most
comprehensive global environmental treaty with the aims to protect human health and
the environment against the adverse effects resulting from the generation,
management, trans-boundary movement and disposal of hazardous and other wastes
(WHO, 2013). It was adopted on 22 March 1989 and put in place on 5 May 1992. The
number of member countries today is 176.
The main regulations of the Basel Convention is that every transboundary
movements of hazardous and other wastes must have agreements both from exporting
and improting countries. Besides, each member state must establish its national or
domestic legislation to prevent and punish illegal traffic in hazardous and other

wastes. The convention also obliges its parties to ensure that hazardous and other
wastes are managed and disposed of in an environmentally sound manner. Exported
wastes should be labeled according to the UN recommended standards (UNEP, 1989).
The convention specifically refers to clinical wastes from medical care in hospitals,
medical centres and clinics, waste pharmaceuticals, drugs and medicines and
infectious substances as hazardous wastes and need to be prohibited among member
states.
Athough widely accepted by members, the Basel Convention in practice is rarely