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Effects of improper
hospital-waste management on
occupational health and safety
S. V. Manyele
TANZANIA

Introduction for hospital waste are still poor. There waste’ is a subset of ‘hospital waste’, and
are neither proper methods of treated ‘regulated medical waste’, which is syn-
The improper management of medical
waste disposal nor written contingency onymous with ‘infectious waste’ from a
waste causes serious environmental
plans. regulatory perspective, is a subset of
problems in terms of air, water and land
Safeguarding the health care work- ‘medical waste’.
pollution. The nature of pollutants can
force against occupational health risks As stated, infectious waste is waste
be classified as biological, chemical and
arising from hospital-waste management that is capable of producing an infec-
radioactive. Environment problems can
calls for effective infectious waste con- tious disease; chances of this are higher
arise from the mere generation of med-
trol measures. In addition to protecting within hospitals than outside (2, 3, 4).
ical waste and from the process of han-
workers’ health, such control measures This definition requires consideration of
dling, treatment and disposal. This pa-
protect public health and the environ- the factors necessary for induction of
per analyses the effects of improper
ment from the hazards posed by hospi- disease, which include dose, host sus-
medical waste management and recom-
tal waste. Proper management ensures ceptibility, the presence of a pathogen,
mends proper means for safeguarding
that infectious waste is handled in ac- the virulence of a pathogen, and the most
health care workers.
cordance with established and accepta- commonly absent factor, a portal of en-
Mismanagement of hospital waste
ble procedures from the time of genera- try (2). Therefore, for waste to be infec-
implies a combination of improper han-
tion through treatment of the waste and tious, it must contain pathogens with
dling of waste during generation, col-
its ultimate disposal. sufficient virulence and quantity so that
lection, storage, transport and treatment.
The first issue is to define what is exposure to the waste by a susceptible
Improper handling comprises several
meant by hospital waste. The terms ‘hos- host could result in an infectious disease.
unsafe actions, such as handling with-
pital waste’, ‘medical waste’, ‘regulat- Other health care settings, such as
out personal protective equipment
ed medical waste’, and ‘infectious dental off ices and nursing homes,
(PPE), poor storage (e.g. high tempera-
waste’ remain poorly defined in the lit- present work environments similarly
ture conditions combined with pro-
erature (1). No standard, universally complicated as those in hospitals, where
longed storage times before treatment),
accepted definition for these terms ex- workers face a variety of occupational
manual transport for longer distances,
ists, and many definitions are in use by hazards. The hazards can be classified
use of uncovered containers instead of
practitioners and regulators. Given the in the following categories: biological
closed plastic bags, etc. Other examples
diversity of interest and scientific cre- or infectious hazards (bacteria, such as
include exposure times beyond accept-
dentials of persons, groups, and agen- tuberculosis, and viruses, such as HIV,
able limits, lack of worker and equip-
cies (e.g. physicians, health depart- hepatitis B and hepatitis C, which can
ment decontamination procedures, etc.,
ments, hospitals, environmentalists, be transmitted by contact with infected
all of which affect hospital workers in
trade unions, and state legislators) in- patients or contaminated body secre-
different ways.
volved in the medical waste issue, these tions/fluids); chemical hazards (medica-
In Tanzania, hospital waste was large-
differences should be expected. How- tions, solutions, or gases, such as ethyl-
ly mismanaged in the past, mainly be-
ever, adoption of a definition by a regu- ene oxide, formaldehyde, glutaralde-
cause the sector did not know what to
latory agency has serious ramifications hyde, waste anaesthetic gases, nitrous
do with the waste. The procedures for
because it dictates all the terms. oxide, chemotherapeutic agents, laser
safe waste handling were not adhered
‘Hospital waste’ (or solid waste) re- smoke and aerosolized medications such
to; for example, there were deficiencies
fers to all waste, biological or non-bio- as Pentamidine); and physical hazards
in designation and identification of in-
logical, that is discarded and not intend- (ionizing radiation, lasers, noise and
fectious waste, segregation, packaging
ed for further use. ‘Medical waste’ re- electricity).
and storage, as well as in transport pro-
fers to materials generated as a result of
cedures. Following countrywide train- Exposure routes for hospital
patient diagnosis, treatment, or the im-
ing of incinerator operators and health
officers in 2003, the management of
munization of human beings or animals. waste
‘Infectious waste’ refers to the portion
hospital waste is now taking a new The occupational health effects of med-
of medical waste that could transmit an
shape. However, treatment techniques ical and other hazardous wastes depend
infectious disease (2). Thus, ‘medical

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31

on the duration of exposure and the dose

Photo by ILO / M. Crozet


of toxic components that enters the
worker’s body from the waste. Unman-
aged hospital waste constitutes a haz-
ard to the personnel because it contains
toxic chemicals and pathogens ready to
enter the human body through different
routes of exposure (4).
The routes of health care workers’
exposure to hazardous substances con-
tained in hospital waste include inges-
tion (swallowed material), inhalation
(airborne chemicals and pathogens), and
dermal absorption or through skin open-
ings (3, 4). Due to the structure of the
human lung, the body’s retention capac-
ity for airborne particulates that carry
toxic chemicals and pathogens is high-
ly dependent on particle size. Dermal
absorption can be enhanced by
scratched, broken, roughened or abrad-
ed surfaces of the skin on the ankles, Mismanagement of hospital waste implies a combination of improper handling of waste
during generation, collection, storage, transport and treatment.
hands, neck or facial areas. The work- (People in the photo are not related to this article).
er’s face or hands are the most affected
skin areas. Water-soluble toxic chemi-
cals can be absorbed throughout the sharps (medical equipment used to pen- exhaust system is not available, an acti-
body since the human metabolism op- etrate skin and muscles like needles, vated carbon trapping device may be
erates on a water-based chemistry. blades, etc.) (2). When waste that has used, which requires maintenance of the
Drinking and eating in hospitals must not been pretreated is being transported trap and monitoring of the off-gas; this,
be done in well-controlled areas. This outside the hospital, or dumped openly, in turn, is a question of workers’ expo-
issue is not well managed in most Tan- pathogens can enter the atmosphere. sure (1, 5).
zanian hospitals and health centres. These pathogens can find their way to Indoor air pollution due to biological
The chemical poisons in hospital drinking water, foodstuffs, soil, etc., or agents can be reduced by covering the
waste can affect different parts of the they can remain in the ambient air. waste properly, routing the waste so that
body: for instance, hepatoxic agents Chemical pollutants that cause out- the shortest distance is used and sensi-
(e.g. carbon tetrachloride, tetrachlo- door air pollution have two major sourc- tive areas are avoided. Segregation of
roethane) affect the liver; nephrotoxic es: open burning and incinerators. The waste, pretreatment at the source, etc.,
agents (e.g. halogenated hydrocarbons) presence of plastics and hazardous ma- can also reduce this problem to a great
affect the kidneys; haematopoietic tox- terials in the waste will generate harm- extent. Sterilizing the rooms will also
ins (benzene, phenols) affect blood; and ful gases – such as oxides of sulphur, help to minimize the occupational health
neurotoxic agents (e.g. methanol, met- oxides of nitrogen, carbon dioxide, etc. risks posed by air pollutants from bio-
als, organometallics) and anaesthetic – and suspended particulate matter logical agents. Indoor air pollution can
agents (e.g. ethyl ether, esters, acetylene which may contain heavy metals. These also result from poor ventilation; thus
hydrocarbons) affect nerve systems and when inhaled can cause respiratory dis- the building design plays an important
consciousness, respectively (4). eases. Certain organic gases, such as role in maintaining proper ventilation.
dioxins and furans, are carcinogenic The health hazards due to improper
Occupational health hazards whose effects have longer latency peri- waste management affect not only hos-
from improper medical waste ods. Open burning of medical waste is pital occupants; they can also spread in
practised in many Tanzanian hospitals. the vicinity of a hospital. Occupational
management This should be strictly avoided. Air pol- health concerns exist for janitorial and
Pathogens present in waste can enter, lution control devices should be used for laundry workers, nurses, emergency
and remain in the air within the hospital waste combustion technologies which medical personnel, and waste handlers.
for a long period, in the form of spores produce toxic emissions. Such units ex- Injuries from sharps and exposure to
or as pathogens themselves (5). This can ist now in Tanzania, designed at the harmful chemical waste and radioactive
result in hospital-acquired infections University of Dar es Salaam. waste can also pose health hazards to
(nosocomial infections) or occupation- Research and radio-immunoassay ac- workers. The problem of occupational
al health hazards. Patients and their at- tivities may generate small quantities of health hazards arising from medical
tendants also have a chance of contract- radioactive gas. The clinical application waste is not well publicized as there is a
ing infections caused by airborne path- of 85Kr and 133Xe is the principal lack of information.
ogens or spores. However, there are very source of gaseous radioactive waste The general public’s health can also
limited statistics available relating oc- material requiring special disposal prac- be adversely affected by medical waste.
cupational health with workers’ hospi- tices (1, 5). Gaseous radioactive mate- Improper practices, such as dumping of
tal-acquired infections. This topic re- rial should be evacuated directly to the medical waste in municipal dustbins,
quires more research. The only publi- outside. For the workers’ safety, such open spaces, water bodies, etc., can lead
cized health hazard to workers is the gaseous radioactive waste should not be to the spread of diseases. Emissions
spread of disease from contaminated mixed with the indoor air. If a special from incinerators and open burning can

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also lead to workers’ exposure to harm- Enforcement of medical waste Promote training in hospital-
ful gases which can cause cancer and management regulations waste management
respiratory diseases. Exposure to radi- There must be clearly stipulated rules Training of health care workers is the
oactive waste in the waste stream can that apply to all persons who generate, core of health care waste management
also pose serious health hazards to work- collect, receive, store, transport, treat, programmes (8). The sessions conduct-
ers. An often ignored area is the increase dispose of, or handle medical waste in ed by the Ministry of Health in 2003
of home-based health care activities. any form. This will help to maintain enabled workers to recognize health and
During the training sessions conducted occupational and public health. Those safety hazards, and to prevent further ex-
countrywide in 2003, this topic was ad- who generate medical waste must be posure to hazards posed by hospital
dressed as ‘home-based health care legally responsible. It shall be the duty waste. In reality, health care worker
waste management’. An increase in the of every generator of medical waste training programmes have increased the
number of diabetics who inject them- (which includes a hospital, nursing workers’ morale. However, the training
selves with insulin, home nurses taking home, clinic, dispensary, veterinary hos- focused only on those handling hospital
care of terminally ill patients etc., all pital, animal house, pathological labo- waste and health officers, while the
generate medical waste which can cause ratory, blood bank) to take all steps to waste generators (nurses and medical
health hazards. ensure that such waste is handled with- doctors) were not involved. For this rea-
out any adverse effect to workers and son, a comprehensive integrated health
Recommendations the environment (6, 7). and safety training programme has been
Observing exposure limits Medical waste shall not be mixed with developed at the University of Dar es
other wastes, and shall be segregated Salaam to provide a cost-effective
With respect to a wide variety of con- into well-labelled containers or bags at means of meeting health care waste man-
taminants related to management of hos- the point of generation prior to its stor- agement needs in Tanzania.
pital waste, certain exposure levels are age, transport, treatment and disposal. Hospital-waste handling is a hazard-
allowed by law. The most well-known Apart from the prescribed label, transit ous waste activity which requires a high
of allowable exposure standards are the containers containing medical waste standard of training. It calls for specific
threshold limit values (TLVs), which are shall also bear information on the date training that depends on the nature of
normally expressed at two levels: the of generation, the waste category/class/ the work in the hospital, the hazards and
time-weighted average (TWA) based on description, the sender’s/receiver’s possibility of worker exposure, and the
an eight-hour allowable average concen- name and address (phone/fax numbers) responsibilities of individual workers
tration, and the short-term exposure lev- and the contact person in case of emer- (8). The training must not only be con-
els (STEL), based on the maximum 15- gency. The label shall also be marked tinuous, but also comprehensive, inte-
minute average concentration to which with symbols, such as the universal bio- grated and structured with the necessary
a health care worker may be exposed. hazard or cytotoxic hazard symbol, and elements.
Currently, TWA and STEL have been warning signs, e.g. “handle with care” To reach the qualified stage, the train-
adopted as permissible exposure levels (7). ing must follow some of the following
(Peels), and are now legally enforcea- Untreated medical waste shall be steps: need analysis; training adminis-
ble levels of exposure in countries where transported only in a special vehicle tration; learning objectives development
environmental laws are in place. If such owned by a competent authority, as and lesson plans; site-specific training;
limits are observed, the occupational specified by the government. No un- task-specific training; and supervision.
health problems can be minimized in treated medical waste shall be kept or As hospital activities are similar, these
hospitals (4). stored beyond a period of 48 hours. The steps will be almost the same for differ-
Apply a hierarchy of controls municipal body of the area shall contin- ent hospitals, so that the training sessions
ue to pick up and transport segregated can be conducted for each worker cate-
Health care workers’ exposure to health
non-medical solid waste generated in gories. Factors to consider include train-
hazards can be prevented or reduced. hospitals and nursing health centres, as ers’ qualification, reprocity (e.g. the
The occupational hygiene hierarchy of well as duly treated medical wastes for Ministry of Health’s acceptance of
controls is a recognized method for pri-
disposal at a municipal dump site. course work offered by the University
mary prevention of occupational injury Every generator/occupier/operator of Dar es Salaam), equivalency (deter-
and disease. The following hierarchy is shall submit a report to the prescribed mination that previous experience, edu-
listed in order from the most to the least
authority every year, to include infor- cation or training is equivalent to a giv-
effective: elimination of hazardous ma- mation about the categories and quanti- en training course), and programme
terials and dangerous activities; substi- ties of medical wastes handled during evaluation (monitoring and revision of
tution of less hazardous materials (e.g.
the preceding year. The prescribed au- the training as a result of the comments
substitute oxidizing chemicals such as thority shall compile this information for received from participants, instructors
paracetic acid for glutaraldehyde, nitrile future reference. Meanwhile, every au- and supervisors) (8).
gloves for latex or vinyl gloves); engi-
thorized person shall maintain records
neering controls (e.g. lifting devices, related to the generation, collection, re- Environmentally preferable
safer needle devices, ventilation); ad- ception, storage, transport, treatment, purchasing
ministrative controls (such as policies Environmentally preferable purchasing
disposal and/or any form of handling of
that limit workers’ exposure to hazards); medical waste, in accordance with these (EPP) is the act of purchasing products
and appropriate allocation of personal rules and any guidelines issued. All and services that are less damaging to
protective equipment (e.g. gloves, res- occupational health and the environ-
records shall be subject to inspection
pirators and masks, goggles, gowns, and verification by the prescribed au- ment. Efforts to implement EPP are an
etc.). thority at any time (7). important component of a larger system
that supports the integrity of both busi-
ness and environmental decisions, for

Afr Newslett on Occup Health and Safety 2004;14:30–33


33

the benefit of workers’ health (9). must be well documented in the hospi- environmental.htm
Five areas have been identified as fo- tal’s health and safety plan (HASP), 6. http://kspcb.kar.nic.in/BMW/Laws.htm
cal points for EPP (9). They include: communicated to workers and imple- 7. US Federal Register, US – Environmental
Protection Agency, 40 CFR Part 60, Stand-
products containing mercury; products mented before workers enter hazardous ards of Performance for New Stationary
containing polyvinyl chloride (PVC); areas. Sources and Emission Guidelines for Exist-
reprocessed and reusable products; ing Sources: Medical Waste Incinerators;
green building products; and safer prod- Medical surveillance Proposed Rule, February, 1995.
ucts for workers. In addition, waste min- programmes for health care 8. Handbook for Occupational Health and
imization practices implemented by pur- workers Safety During Hazardous Waste Activities,
chasing products with reduced packag- Office of Enviornmnetal Management, US
Medical surveillance programmes must
Department of Energy, June, 1996.
ing and the procurement of items that be designed to accomplish the follow- 9. http://www.cehca.org/SHEA6_Occup
are readily recyclable and/or made of ing goals: to demonstrate that workers Safety.pdf
recycled content are highly recommend- are fit to perform their jobs safely and
ed. reliably; to provide ongoing assurance
that access and hazard controls limit
Proper worker and equipment worker exposure; and to comply with Dr. Samwel V. Manyele
decontamination occupational health regulations. A com- Waste Management Research
Anything that enters a hazardous waste prehensive medical surveillance pro- Department of Chemical &
exclusion zone (radiological area, or gramme should be designed and imple- Process Engineering
airborne radioactivity area) is assumed mented by an experienced and qualified University of Dar es Salaam
to be contaminated. If not removed, con- occupational health physician or exam- P.O. Box 35131
taminants eventually penetrate the PPE, iner with inputs provided by workers, Dar es Salaam, Tanzania
tools, instruments, and other equipment industrial hygienist, as well as health and smanyele@cpe.udsm.ac.tz
in use at the worksite, and may be trans- safety professionals. Based on the pres-
ferred into clean areas (1). Improper ence of such hazards as lead, asbestos,
management occurs when such items are and carcinogens, special types of medi-
not decontaminated (i.e. removing or cal surveillance are required. The occu-
neutralizing chemicals, radiological, pational health physician responsible for
biological or mixed waste contaminants) the medical surveillance programme CCOHS has released a new
and hazardous material accumulates on should work with the rest of the medi- web design of Occupational
personnel and equipment while work is cal surveillance team to determine which Health and Safety
being performed (1,8). forms of surveillance are applicable for
Factors affecting contaminant perme- activities at each worksite (1,8).
Encyclopaedia
ation of PPE and other equipment in- Analysis of surveillance data should The Canadian Centre for Occupational
clude contact time, concentration, tem- include at least the following elements Health and Safety (CCOHS) has re-
perature, chemical characteristics, and on each infection, in order to detect clus- leased a new design of the web version
the physical state of the contaminants. ters and trends: type of infection; date of the ILO Encyclopaedia of Occupa-
Decontamination by physical means can of onset; location in the facility; and tional Health and Safety.
be used for loose contaminants (dusts, appropriate culture information. Infec- Users can search the ILO Encyclopae-
aerosols), adhering contaminants, ad- tion rates should be calculated periodi- dia on its own, or together with the CIS-
sorbed or permeated contaminants or cally, recorded, analysed, and reported ILO database.
volatile contaminants. Decontamination to the administration and the infections The Fourth Edition of the Encyclo-
using solutions, chemicals or other ma- control committee. Tables, graphs, and paedia of Occupational Health and
terials must follow physical decontami- charts may be used, to facilitate educa- Safety, published by the International
nation. Decontamination materials can tion of the personnel. Surveillance data Labour Office of the United Nations,
also be applied directly to chemical or should be used for planning infection consists of more than 100 chapters with
radiological contaminants. Cleaning control efforts, detecting epidemics, di- over 1,000 separate articles containing
solutions can involve one or more of the recting continuing education, and iden- essential safety information gathered by
following methods: dissolving contam- tifying individual resident problems for health and safety experts around the
inants; surfactants; solidification; rins- intervention (8). world. Its comprehensive coverage of
ing; or disinfection/sterilization. It must occupational health and safety topics
be stressed that decontaminations dif- References will assist anyone concerned about
fer from sanitation in that the former is 1. Blackman WC. “Basic Hazardous Waste these issues, including non-specialists
Management”, Lewis Publishers, Inc., such as lawyers, physicians, nurses,
conducted either in the contamination
Michigan, USA, 2nd Edition, 1996.
reduction zone or radiological buffer engineers, as well as occupational hy-
2. Rutala WA, Mayhall CG. “Medical Waste”,
zone at the worksite, whereas sanitation in Infectious Control and Hospital Epidemi- gienists, toxicologists, regulators and
functions are performed either in the ology, vol. 13(1), January 1992, pp. 38–48. other safety professionals.
support zone or outside the boundaries 3. Manyele SV. “Medical/hazardous Waste For more information or to sub-
of the hazardous waste activities work- Management for Practitioners”, Course notes scribe to the web version of the Fourth
site after decontamination has been for the BICO Professional Development Pro- Edition of the ILO Encyclopaedia of
gram, Prospective College of Engineering Occupational Health and Safety,
completed (1,8).
and Technology, University of Dar es Sa-
For this reason, the time required for laam, January 2004.
contact CCOHS’ Client Services at
decontamination must be incorporated 4. Griffin RD. “Principles of Hazardous Mate- clientservices@ccohs.ca
in work plans and schedules. By con- rials Management”, Lewis Publishers, Inc., or
trast, contamination control and decon- Michigan, USA, 1990. visit us on the web at the address
tamination strategies and procedures 5. h t t p : / / k s p c b . k a r . n i c . i n / B M W / http://www.ccohs.ca.

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