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Survey Report

Hospital Waste Management in Dhaka City

Executive Summary

Hospital wastes are highly infectious and hazardous. They may carry the germs of dreadful diseases like hepatitis B and C (jaundice), and HIV/AIDS. The present practice of improper handling of generated hospital wastes in Dhaka city is playing a contributing role in spreading out the Hepatitis and HIV diseases. Hospital waste accounts for a very small fraction of the total waste generated in a city. Mixed with the ordinary waste, they make the entire municipal solid waste stream a great public health hazard. The liquid and solid wastes containing hazardous materials are simply dumped into the nearest drain or garbage heap respectively where they are prone to contaminate the rag-pickers that sift through the garbage dumps. The prevalence of diseases that may be transmitted by hospital waste is alarming in Bangladesh. Hospitals and other Health Care Establishments (HCE) have a duty of care for the environment and for public health, and have particular responsibilities in relation to the waste they produce. The responsibility is on such establishments to ensure that there are no adverse health and environmental consequences of their waste handling, treatment, and disposal activities. Considering the experience of PRISM Bangladesh for successful Hospital Waste Management (HWM) in Khulna, the World Health Organization (WHO) and the Water and Sanitation Program (WSP) initiated a Hospital waste Management Programme (HWMP) for Dhaka City under the WHO guidelines. A Memorandum of Understanding (MOU) has signed between WHO and PRISM Bangladesh to prepare a design of HWM in Dhaka city. Providing orientation and training participating hospital staff on good practices of HWM is an aim of this project. The project explores the amount of solid wastes generated by each HCE; investigates the handling practice of waste within the hospital premises; identifies storage, collection, transportation and disposal practices; and assesses the needs of training for hospital waste management. Some 59 HCE from Ward 49 of the Dhaka City Corporation (DCC) and the Dhaka Medical College Hospital (DMCH) in Ward 56 and Samorita Hospital in Ward 51 were selected for this pilot project. The methodology for this project included empirical field observation and field level data collection through inventory, questionnaire survey and interviews with formal and non-formal ways. The relevant secondary data for this project were mainly collected from the published and unpublished sources. The data were analyzed to address the central issues of hospital waste management with relation to the

Survey Report on HMW in Dhaka City

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generation of wastes in different sources. Statistical and spatial techniques apart from the qualitative modes of analyses were also deployed for this purpose. The survey reveals the existing scenario of different types of clinical wastes along side the domestic wastes. The collected field data showed that all the surveyed HCE generate pathological wastes, used syringes, broken bottles and glass, textile stained with blood and papers. They generate about 6.4 tons/day (6392 kg/day) of wastes, of which only about 5.2 tons/day (80.77%) are non-infectious wastes and about 1.2 tons/day (19.23%) are infectious wastes. The average waste generation rate for the surveyed HCE is 2.63 kg:bed/day. The DMCH alone generates more than half (58%) of the total wastes generated in the surveyed HCE. The DMCH itself generates about 2976 kg/day (46.55%) of non-infectious waste and 733 kg/day (11.46%) of infectious waste. The study reveals that there is no proper and systematic management of this waste except a few private HCE that segregate their infectious wastes. All the HCE surveyed dispose of their domestic waste at the same site as the civic waste. Some cleaners were found to be engaged to mishandle the generated wastes. They segregated the used sharps instruments (mainly the syringe-needles), saline bags, blood bags and test tubes from the kitchen and non-hazardous wastes for sale (resale) or reuse. The level of awareness on medical waste among the waste handlers is not good enough to manage the waste systematically; while the nurses and staffs are aware about the health impact of medical wastes. The survey also reveals that the concerned staffs need to take practical training rather than the traditional theoretical training to handle the waste. About two-third of the total respondents did not get any training on waste management, while the rest of the one-third respondents got their training on this issue but they are not able to manage the waste systematically since their are lacking of systems, rules and regulations. The report reveals the overall situation of waste management in different HCE in Dhaka. All the surveyed HCE dispose of their domestic waste at the same site as the civic waste. Some cleaners are engaged to mishandle the generated wastes. They segregated the used sharps instruments (mainly the syringe-needles), saline bags, blood bags and test tubes from the kitchen and non-hazardous wastes for sale (resale) or reuse. To improve the waste management system, it needs to formulate rules and regulations, develop systems, and financial support. The HCE do not have any budgetary provision to manage their generated waste systematically.

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Survey Report on HMW in Dhaka City

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Chapter I

Introduction

1.1

General Background The problem of hospital waste disposal and other toxic hazardous wastes is growing rapidly throughout the world as a direct result of rapid urbanisation and population growth. Hospital waste or clinical waste, which poses serious threats to environmental health, requires specialized treatment and management prior to its final disposal. Simply disposing it into dustbins, drains, and canals or finally dumping it to the outskirts of the city poses a serious public health hazard. Such disregard for protecting public health occurs due to lack of awareness, skill of the people and institutions engaged in hospital waste generation and disposal as well as due to lack of treatment facilities and system in the city. The problem is getting worse with the increasing number of hospitals, clinics, and diagnostic laboratories in the city. The rapid increase of hospitals, clinics, diagnostic laboratories etc in Dhaka city exerts a tremendous impact on human health ecology. More than 600 clinics and hospitals exist in the DCC. These facilities generate an estimated 200 tons of waste a day (Lawson, 2003). Only a few have the necessary means to dispose the waste safely. It is reported that even body parts are dumped on the streets by these HCE. The present practice of improper handling of generated hospital wastes in Dhaka city is playing a contributing role in spreading out the Hepatitis and HIV diseases. The liquid and solid wastes containing hazardous materials are simply dumped into the nearest drain or garbage heap respectively where they are prone to contaminate the rag-pickers that sift through the garbage dumps. The chances of infection are very high to the cleaners, concerned people in the HCE and to the general population. The improvement of waste management for the HCE in Bangladesh will have significant long-term impact on keeping the spread of infectious diseases to a minimum and result in a cleaner and healthy environment. Unlike the ordinary household waste, medical wastes are highly infectious and hazardous. They may carry germs of dreadful diseases like hepatitis B, C and HIV/AIDS. Mixing with the household wastes, they make the entire pile a great public health hazard. To make the matter worse, poor scavengers (tokai) rummage through the pile, earnestly searching for saleable items like syringes. These are collected, washed, repacked and resold to the public. Thus, the vicious cycle of transmission continues.

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The prevalence of diseases that may be transmitted by hospital wastes is alarming in Bangladesh. There is evidence of hepatitis B infection among 10 percent of children (5-10 age group) and 30 percent adults. About 5 per cent of the total population in Bangladesh is thought to suffer from chronic hepatitis B infection. Although cases of HIV/AIDS is low in Bangladesh (about 13,000 cases estimated in 2001) in comparison to neighbouring countries, nevertheless the numbers are rising (Waste Concern, 2003). It is noted here that much of the clinical wastes (e.g. syringes, needles, saline drips, discarded food, gauze, vials, and ampoules) are collected by women and children who re-sell it despite of the deadly health risks. It is estimated that hospital wastes account for a very small fraction, notably, only about 1 percent of the total solid wastes generated in Bangladesh. In a report from the World Bank (2003), only 10-25 percent of the hospital wastes are infectious or hazardous. The amount of such hazardous waste is quite small in figure and until recently this is not handled properly (WHO, 2001). Mixing with the domestic solid wastes, the total waste steam becomes potentially hazardous.

1.2

Project Background 1.2.1 Genesis of the project

In 1997, the Water and Sanitation Programme (WSP) with financial assistance from the Swiss Development Corporation (SDC) launched a community based Solid Waste Management Project (SWMP) in Khulna City. The project was locally implemented by Prodipan, a national NGO in collaboration with the local communities, Khulna City Corporation (KCC) and local NGOs. Under this project, a house-to-house garbage collection system ran by the local communities and NGOs, and the KCC provided the transport services in collecting waste from the KCC bins for final disposal at certain places. In conducting the above work, the project workers noticed the presence of hospital wastes on the streets and into dustbins. The WSP and Prodipan took the matter seriously and discussed it with the KCC. The KCC then arranged a dialogue with the Bangladesh Medical Association (BMA), the Clinics Owners Association, and some progressive doctors in Khulna City. A number of workshops, seminars and roundtable discussions were held for building up of consensus. All the concerned parties finally agreed to participate in the programme and there were a disagreement in payment of service charge. The Mayor of the KCC then came forward and explained the necessity of the programme to protect public health. The concerned hospitals, clinics, and pathological laboratories then agreed to pay service charge in accordance with the volume of waste they generated. Therefore, the HWMP was launched in Khulna in 2000 with the participation of 20 private clinics, hospitals and pathological laboratories.
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1.2.2

PRISM Intervention

After completion of the project in December 2001 by Prodipan, PRISM Bangladesh came forward to continue the project from 2002 under a community based urban waste water treatment project with wider purposes. The project was then run under the Sustainable Environment Management Programme (SEMP) of Ministry of Environment and Forest (MOEF) with the financial assistance of the UNDP. The project is now providing all health care facilities within the Khulna city area. The number of participating HCE facilities has increased from 20 to 46 including the Khulna Sadar Hospital. Each of the HCE provides a monthly service charge between Tk 100.00 and Tk 600.00 depending on the volume of wastes they generate. Considering the experience of successful Hospital Waste Management (HWM) in Khulna, PRISM extended its support to make city wide coverage under the SEMP. The activities of HWM in Khulna were presented to the WHO and the WSP and they felt the emergent need to initiate a HWMP for Dhaka City what would be accepted under the WHO guidelines. A Memorandum of Understanding (MOU) has signed between WHO and PRISM Bangladesh to prepare a design of hospital waste management in Dhaka city.

1.3

Aims and Objectives To conduct a baseline survey of all health care facilities in Ward 49, the DMCH in Ward 56, and Samorita Hospital in Ward 51. Providing the orientation and train-up participating hospital staff on good practices of hospital waste management is an aim of this project. These are the initial activities of the pilot project on HWM in Dhaka city. The main objectives of the project are: (a) To make an inventory of HCE in terms of government hospitals, private hospitals, private clinics, and pathological diagnostic centres in Dhaka city, specifically in Wards 49 and 56 (mainly the DMCH); To quantify the amount of solid wastes generated by each HCE; To identify the current solid waste handling practice (e.g. storage, collection, transportation and disposal) within the hospital premises; To assess the needs of training for hospital waste management; and To suggest remedial measures for better management of medical wastes in the surveyed hospitals.

(b) (c)

(d) (e)

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1.4

Project Site A joint team comprising of WHO, Water and sanitation Programme (WSP) and PRISM Bangladesh organized a series of meetings with the authorities of DCC, Clinic Owners Association and other stakeholders to initiate a hospital waste management programme. Considering the present demand, DCC allocated one acre of land at Matuail dumpsite to install a treatment plant. It was decided to initiate the management service for wards 49 and 56 and on review of success of the program, the hospital waste of other wards will be managed under this project. It is noted here that before the agreement of the project, the DCC provided us with the information about the location of DMCH in Ward 57. During our field survey and GIS mapping, we investigated the DMCH is in ward 56. Since our target is to investigate the DMCH in order to fulfill the objectives, with the consultation of the WSP, we are agreed to use Ward 56 in place of Ward 57. The clinic owners association also agreed upon to participate in this hospital waste management programme. A series of meetings have been organized by the team (WHO, WSP and PRISM) with the clinic owners association and finally they assured us to collaborate with the initiatives of hospital waste management on every aspect (Figure 1.1).

Dhanmondi, once was a residential area given permission for the commercial establishment by the RAJUK (Rajdhani Unnayan Katripakkha) is found to increasing hospitals, clinics and diagnostic centres creating threats to human health and environment. Many poor children and people salvage saline bottles and bags from the

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pedestrian area have been indiscriminately dumped by hospitals. Reports claim that Dhanmondi, Ward 49 is badly affecting with the clinical waste and the DMCH in Ward 56 and Samorita Hospital in Ward 51 were selected for this project. It is also noted here that Dhanmondi is densely populated and the number of HCE in Dhanmondi is also highest in any Ward in Dhaka City. The DMCH is the biggest in Bangladesh and the lion share of the wastes are generated from the DMCH. Therefore, Dhanmondi and the DMCH were selected to investigate the situation of generating clinical waste and the existing management.

1.5

Concluding Remarks This chapter has mainly focussed on the basic issues about medical waste and its impact on human health, aims and objectives, and the sample project site. Medical waste and its problem are growing rapidly as a direct result of rapid urbanisation and population growth. Medical waste poses serious threats to environmental health, requires specialized treatment and management prior to its final disposal. The problem is getting worse with the increasing number of hospitals, clinics, and diagnostic laboratories in the city. The present practice of handling of generated hospital wastes in Dhaka city is playing a contributing role in spreading out the Hepatitis and HIV diseases. The improvement of waste management for the HCE in Bangladesh will have significant long-term impact on keeping the spread of infectious diseases to a minimum and result in a cleaner and healthy environment.

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Survey Report on HMW in Dhaka City

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Chapter II

Review of Literature and Research Gap

2.1

General Background With the recent rapid growth of private health sector, the need of safe and proper medical waste disposal is becoming important. Hospital waste is frequently described to be an environmental pollutant as well as presenting a serious health concern. The problem arises if the unsafe disposal of hospital wastes resulting in hepatitis B and C (jaundice), and HIV/AIDS. The materials presented in this chapter are aimed at providing an overview of medical waste issues in terms of medical waste types, its sources, and management. Finally, the last section makes some concluding remarks on the overall chapter.

2.2

Relevant Literature Generally, hospital waste is defined as the discarded or unwanted material or garbage or solid waste which is generated from the diagnosis, treatment, or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals (Lee, 1989). These have the potential to cause disease and are a health risk. It is a by-product of health care that includes sharps, non-sharps, blood, body parts, chemicals, pharmaceuticals, medical devices and radioactive materials (WHO, 2002). The HCE are one of the major producers of solid wastes which are hazardous in nature. Poor management of clinical wastes exposes health workers, waste handlers and the community to infections, toxic effects and injuries (Ecoaccess, 2004). 2.2.1 Medical Waste Types and Sources Medical wastes are mainly categorised into non-hazardous and hazardous wastes (Figure 2.1). The non-hazardous waste includes wool, kitchen wastes, etc. that do not pose any special handling problem, hazard to health or the environment and is generated in the patients ward areas, out-patient-department (OPD), kitchens, offices, etc (Mato and Kaseva, 1999). The hazardous waste includes pathological, infectious, sharps and chemical wastes and are normally produced in labour wards, operation theatres, laboratories, etc (Mato and Kaseva, 1999; Or and Akgill, 1994). Some

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definitions of hazardous wastes are (Henry and Heinke, 1996; Mato and Kaseva, 1999): (a) (b) Pathological wastes consist mainly of tissues, organs, placentas, blood, etc. Infectious wastes contain pathogens in sufficient concentrations or quantity that, when exposed to it, can result in diseases. Examples are, waste from surgeries with infectious diseases, contaminated plastic items, etc. Sharps include needles, syringes, broken glass, blades and any other items that could cause a cut or puncture. Chemical wastes comprise of expired medicine, discarded chemicals usually from cleaning and disinfecting activities.

(c)

(d)

The characteristics of waste from hospitals are almost similar in all countries except for amounts generated due to standard procedures executed in the medical field. Legislation on the safe disposal of medical wastes may vary from country to another (Henry and Heinke, 1996). There are a number of literatures on the types of medical wastes and its generation, mainly the sources of the wastes in HCE. Askarian et al, (2004) explain the type and nature of hospital wastes generated from private hospitals in Fars province in Iran and also describe the existing management systems of the generated wastes in hospitals. Da Silva et al, (2004) focused on types of medical wastes from the hospitals in Rio Grande do Sul of Brazil and illustrated the waste management pattern. Surveying a total of 91 healthcare facilities, they provide information about the management, segregation, generation, storage and disposal of medical wastes. The results about management aspects indicate that practices in most healthcare facilities do not comply with the principles stated in Brazilian legislation.

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2.2.2

Medical Waste Management

Mato and Kassenga (1997) pointed out the problems of management of medical solid wastes in Tanzania. They also described different measures for the management of medical wastes. Mato and Kaseva (1999) in their paper on Critical review of industrial and medical waste practices in Dar es Salaam City focused on the disposal of both the industrial and medical waste practices in Tanzania. There is a serious inadequacy in handling medical solid wastes in Dar es Salaam of Tanzania and improper waste deposition is increasingly becoming a potential public health risk and an environmental burden in Tanzania. It has long been known that the re-use of syringes can cause the spread of infections such as HIV and hepatitis. Tamplin et al, (2004) in their Issues and options for the safe destruction and disposal of used injection materials showed from their study in the developing countries that contaminated medical wastes find their way into municipal garbage poses obvious health risks, both in terms of direct exposure and environmental contamination. Their study suggests that holistic approaches to syringe use and clinical waste disposal need to be utilized in addressing the situation outlined. The clinical waste may also damage the environment. The collection of disposable medical equipment (particularly syringes), its re-sale and potential re-use without sterilization could cause an important burden of disease (WHO, 2002). Medical waste management is the focal issue to minimize the health risk developed from HCE. Patil and Pokhrel (2004) described the biomedical solid waste management in an Indian hospital. They assessed the waste handling and treatment system of hospital bio-medical solid waste and its mandatory compliance with Regulatory Notifications for Bio-medical Waste (Management and Handling) Rules, 1998, under the Ministry of Environment and Forestry, Govt. of India. They quantify the amount of non-infectious and infectious waste (ratio 5:1) generated in different wards/sections (about 2.31 kg per day per bed, gross weight comprising both infectious and noninfectious waste). They also focus their opinion in favour of incineration. Karademir (2004) provides a report on the health risk assessment of PCDD/F emissions from a hazardous and medical waste incinerator in Turkey. A few literatures focus on environmentally sound management of bio-medical and health-care waste. The WHO (2002) mainly focused on six different steps for the development of a healthcare waste management plan: (a) designate a responsible person; (b) conduct an HCWM survey and invite suggestions; (c) recommend HCWM improvements and prepare a set of arrangements for their implementation; (d) draft the HCWM plan; (e) approve the HCWM plan and start implementation; and (f) review the HCWM plan. The UNEP (2003) formulates some technical guidelines on the environmentally sound management of bio-medical and health-care waste.
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2.2.3

Medical waste and Bangladesh issue

The pattern of storage and disposal of these wastes is to be a serious environmental threat in Dhaka. There has been a few project works on the medical waste issues in Bangladesh with the financial assistance of different donor agencies and stakeholders. PRISM Bangladesh is continuing their activities on medical waste management in Khulna City starting from 2000. The Initiative for Peoples Development (IPD) conducted a project on the medical waste management action plan in Dhaka city started on 2000 funded by the UNDP through the Project management Unit (PMU). The IPD surveyed 24 clinics through a questionnaire method. They provided training for awareness campaigning. They developed handouts regarding the waste and its management for the nurses, waste handlers, ward boys, and so on. The project lasted for about eight months and finished in 2001. The Local Initiative Facility for the Urban Environment (LIFE) carried out a project on In-house Hospital waste management in aiming the waste management of 11 clinics in Dhaka City with the financial assistance of the UNDP released by the global sources. The project started on 2002 and finished by 2003. It is noted here that the project ran with the collaboration of the IPD. After a short break due to the financial constraints, the UNDP agreed to provide funds through its global financial sources to run the project from 2004. The project is still running at the Mohammadpur and Lalmatia area. In 1997, the BCAS in collaboration with Asia Foundation undertook a study on Hospital Environmental Management with the aiming of investigation and improvement of safe handling and disposal of hospital waste in the country (BCAS, 1997). The study reveals the unhygienic waste disposal systems as it is being disposed in the DCC dustbin and formulates some measures for safe handling and disposal of hospital waste. The BCAS in the following year (1998) produced a report on Hospital Environment Management in Dhaka to create awareness among the professional and workers working in the hospitals and clinics in order to improve the hospital management as well as urban environment. In 2003, the World Bank produced a report on Health Facility Waste management Study in Bangladesh where the report focussed on the present status of health care facility waste management in Bangladesh for the informed decision-making process regarding appropriate future legislation, policies and programme activities that will significantly improve the present situation. The study also assessed in details the existing legislation, especially, the Bangladesh Environmental Conservative Act, 1995, and the Environment Conservation Rules, 1997. The recent progress report on Clean Dhaka Master Plan conducted by the Japan International Cooperation Agency (JICA) explains about the management pattern of
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solid waste in Dhaka City (JICA, 2004). The JICA study team focuses the problems of handling and mismanagement of existing system of solid waste transportation and dumping. In addition, they formulate a master plan regarding the solid waste management in Dhaka City with the target year of 2015 covering (a) collection, transportation, disposal and final disposal of solid wastes; (b) administration organization, institutional building, and public participation; and (c) planning of facility and material maintenance, maintenance management, and financial management. BRAC (2004) conducted a pilot project work between January 2004 and August 2004 on medical waste management. They mainly focused on the Dhaka Shishu Hospital, Institute of Child Health, and one upgraded BRAC SUSHASTO KENDRA (a medical centre). They are now trying to replicate their activities regarding to this issue. MOHFW (2004) produced an action plan for improved health care waste management in Bangladesh for the period of 2004-2010. The action plan focuses mainly to initiate a concentrated effort to improve the health care waste management to reduce the negative impact of waste on: (a) environment; (b) public health; and (c) safety at health care facilities. HLSP, a consulting farm is working on the medical waste issues under the guidance of Hospital Improvement Initiative. The project has been continuing since January 2000. It is noted here that although the project would finish by December 2003, but it is still running for implementing the policies for proper medical waste management. They are working in Chittagong Medical College Hospital and the Sylhet Medical College Hospital along with other 11 Government hospital in both the Chittagong and Sylhet divisions. Unfortunately, there is a little effort in properly disposing hospital waste in Bangladesh. Hospital waste is generally disposed of in the same way as ordinary domestic wastes. The Khulna City, however, is an exception to this practice. Khulna stands apart as the only city in the country with a Hospital Waste Management Programme (HWMP) running for over three years.

2.3

Concluding Remarks This chapter is inspired by the current scientific interest in medical waste poisoning on environmental risk, adverse health and public policy in Bangladesh. This chapter has explored the literature on medical waste issues in different aspects, which have provided insights into the nature of the existing pattern of medical waste research. In reviewing the literature, it has been found a research-focus on medical waste in the form of health problems at different levels of hepatitis B and C (jaundice), and HIV/AIDS, but little research on the proper management of medical waste to save urban environment.
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There has been an increasing interest in medical waste research over the last few years. Many empirical studies have been undertaken to explore the sources of wastes, their types and management and these provide a framework for discussing mainly the toxic nature of medical waste, its impact on human health and medical waste management system.

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Chapter III

Data and Methods

3.1

General Background The methodology for this project includes empirical field observation and field level data collection through inventory, questionnaire survey and interviews in formal and non-formal ways. The relevant secondary data for this project were mainly collected from the published and unpublished sources. The data were analyzed to address the central issues of hospital waste management with relation to the generation of wastes in different sources. In order to fulfil the aims and objectives, the project tasks were structured as data collection and data analysis (Figure 3.1).

3.2

Field Survey Design The field survey for this project was based on the aims and objectives. The investigation of medical wastes employed multiple methods. This strategy provided a mix of both quantitative and qualitative data, with the extensive questionnaire survey providing breadth of coverage, while the interviews with nurses in hospitals and indepth interviews with different respondents allow a greater depth of understanding of the waste management system within each hospitals and clinics as well as human responses to it. The design was composed mainly of qualitative and quantitative data collection procedures and manipulation, data analysis and interpretation. A GIS-based analysis was also deployed for this output.

3.3

Data collection planning A number of formal and informal approaches were adopted in order to gather data. Before entering into hospitals or clinics the project authority arranged a number of formal meetings with the concerned authority of each hospital, clinics, and diagnostic centres. After getting a green signal from different HCE, we started our fieldwork, which first began from DMCH. Before starting our fieldwork, we had an idea that it could be a difficult job to collect information from the DMCH. A series of talks with the Director of the DMCH started to melt the ice and this helped us to gather information smoothly. During our data collection phase in DMCH, each day we would spend our time with Ward Master of DMCH for building up a rapport. This broke the ice and conversation often turned to matters of relevance and importance for the project. Again we learned

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a lot from these encounters and found generally that we could understand much of the background of the DMCH concerning to the waste generation and management. In collecting our data questionnaire survey and in-depth interviews were adopted. Apart from this, the dialectic approach was used to confirm the credibility of stories and examine the cross-case themes (Brown and Gilligan, 1992) that we gathered from in-depth interviews.

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3.4

Mapping In order to facilitate the use of spatial information in a GIS, various geographically referenced maps were used to prepare our base map for Wards 49 and 56. Besides plotting the HCE locations and visualising different map features, a base map with detailed information was essential. The base map was mainly collected from the Department of Land Records and Survey (DLRS) of Bangladesh (RF 1:792). The DLRS is the only government organisation having the authorisation to prepare and sell maps. Since the project covers a whole Administrative Ward (WD 49) and part of Ward 56 (showing the location of DMCH), we needed to collect the relevant maps from the DLRS. It is mentioned here that GIS mapping would be of great help in spatial decision-making planning for waste management. In addition, the Ward Maps from the DCC were also collected as JPEG format. Since these maps were unable to use properly, we collected the relevant maps from the DLRS and inserted them into a GIS digital format. All the features in terms of roads, lakes, settlement areas, infrastructures etc; and some socio-economic characteristics were collected from other map sources. The collected map information were categorised into different point, line and polygon layers and finally appended on to the main coverage in developing a complete base map for this project.

3.5

Selection of Enumerators and Training Before conducting the questionnaire survey, we recruited 10 enumerators from different universities were conducted mainly the field survey (Figure 3.2). We selected the enumerators following their previous experience regarding the field level data collection. It is noted here that almost all the enumerators have already got their training on different environmental aspects. They were put together into five groups with gender differences. PRISM Bangladesh provided them with the daylong intensive training about the questionnaire. The training was mainly focused on the procedures of data collection and ethical issues concerning to the survey. It is also noted here that we provided them our previous experience concerning to the possible problems they would be faced and how to tackle the issue. After getting the training they went to the DMCH and other HCE in Ward 49 for collecting the information.

3.6

Questionnaire survey for quantitative data The quantitative data for this project were collected through the questionnaire survey (Appendix-A). The questionnaire survey produces causal determinations, predictions, and findings by using quantitative measurements and by the application of statistical and mathematical analysis. The questionnaire was designed following the objectives of this project.
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It is noted here that before entering into the DMCH and other HCE in conducting our survey, we hold talks with the relevant authorised persons for providing us cooperation to arrange every opportunity for a successful survey. We spent nine days to complete our surveys in the DMCH. After collecting our data from the DMCH, we arranged a series of meetings for appointments to enter different HCE for the data. In this stage, we got experience with some problems - the respective HCE authorities, at the initial stage, were not interested to provide us any time slot. But, finally we were successful to manage half of the total HCE in Ward 49 (Dhanmondi). We got information from 59 HCE out of 131 existing HCE from this Ward.

A total of 144 questionnaire surveys, of which 59 from Ward 49, 61 from the DMCH, 19 from BMCH (Bangladesh Medical College Hospital) and 5 from Samorita Hospital were conducted (Table 3.1). The questionnaire mainly addressed the issues of (a) types of wastes; (b) sources of wastes; (c) amount of wastes generated; (d) existing waste management; and (e) qualitative aspects for management views. In addition, a questionnaire for the management section apart from the staff section was administered for this project. Moreover, informal interviews with different patients were also employed. It is noted here that we faced a number of problems when we were engaging to gather our data from patients of different private hospitals. A total of 61 respondents from the DMCH were interviewed for this project. The respondents were selected from all the Wards (n = 41), Operation Theatres (n = 11) and outdoor, emergency and other departments (n = 9). Among the interviewees of the DMCH, some 49 (80.33%) were female and some 12 (19.67%) were male respondents. It is noted here that all the female respondents were nurses, and the rest

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were doctors, medical technicians, and cleaners. The average age of the respondents was about 42 years and the average length of service was about 20 years (Table 3.1). The BMCH is the largest private hospital in Bangladesh located in Ward 49. Some 19 respondents from the BMCH were interviewed, of which 11 (about 58%) were female (nurses) and 8 (42%) were male (3 doctors and 5 technicians). The average age of the respondents was 32 years and their average service length was 7 years (Table 3.1). In Samorita, 5 respondents were provided us information through our questionnaire survey. Of them 4 were female and 1 was male and their average age and service length were 32 and 12 years respectively (Table 3.1). It is noted here that the Senior Vice-President of the Bangladesh Clinical Owners Association is conducting his medical practices at Samorita. To get a green signal to collect data from all the private HCE, we selected this hospital.

Apart from the individual hospitals (DMCH, BMCH and Samorita), 59 respondents from 59 HCE in terms of general hospitals, private clinics, and diagnostic laboratories

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provided us the relevant information concerning to the generated wastes and the system of waste management. Some 56 (95%) were male and 3 (5%) were female. The average age and service length of the respondents were 39 and 6 years respectively (Table 3.1). Among these 59 respondents, 5 (8.47%) completed their Higher-Secondary School Certificate (HSC) program, 41 (69.49%) completed either their Graduation or Masters, 13 (22.03%) completed their MBBS and/or higher medical training (Table 3.1).

3.7

Spatial data for GIS mapping For spatial analysis and mapping, GIS supporting data were collected during the field survey. The data used here for the compilation of a GIS are for spatial distribution of HCE. The spatial data address the point, line and polygon information of HCE and related parameters. The spatial data were collected from primary and secondary sources. All the point (X and Y coordinate values for a HCE), line (string of X and Y coordinate values for a road) and polygon (identical X and Y coordinate values for the beginning and ending points for a lake) features in terms of settlement areas, ponds, road networks etc in the project sites were plotted on maps having the RF of 1:792. The collected spatial data were digitised and entered into a GIS format (ArcGIS). The attribute data of map features were also imported into the GIS environment.

3.8

Qualitative data Qualitative research is especially useful for the exploration and discovery of inherent issues. It is an umbrella term for various philosophical approaches to interpretive research (Eisner, 1991; Glesne and Peshkin, 1992). Generally, qualitative research may be defined as an attempt to obtain an in-depth understanding of the meanings and definitions of the situation (Powell and Single, 1996; Rich and Ginsburg, 1999; Wainwright, 1997) presented by informants, rather than the quantification (Strauss and Corbin, 1998) of their characteristics. Qualitative analysis was used to uncover and understand what lies behind waste management in which little is yet known, for instance, the intricate details of phenomena that are difficult to convey with quantitative methods (Strauss and Corbin, 1998). The in-depth interview was adopted in collecting our qualitative data. In-depth interviews were arranged to get a greater depth of understanding of the existing management system of generated clinical wastes. In-depth interviewing is defined as . . . a social relationship . . . a short-term, secondary social interaction between two strangers with the explicit purpose of one person obtaining specific information from the other (Neuman, 1994). In qualitative approach, interviewing is a highly personal process where meanings are created through personal interaction

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(Chen and Hinton, 1999; Holstein and Gubrium, 1995). Where quantitative research is uncooperative or depth required, the in-depth interview becomes one of a small range of tools available to the researcher (Chen and Hinton, 1999). Different questions were asked of individuals (Appendix-A) for getting their understanding about the issue addressed on medical waste management.

3.9

Data Analysis This section presents the different analytical methods of collected data for this project. The analysis of data consists of four linked processes (Silverman, 1993): (a) data reduction; (b) data display; (c) conclusion drawing; and (d) verification. The collected quantitative and qualitative data were analysed by different techniques. The quantitative data analyses were based on both statistical and spatial operations; while the qualitative modes of analyses were mainly ethnography, thick description, discourse analysis, and narrative analysis. 3.9.1 Quantitative analysis

The collected data for this study with the questionnaire were analysed following different statistical techniques. The deviation, frequency distribution, central tendency and correlation coefficient methods were employed in this project to analyse the information to address the aims and objectives. In addition, a number of statistical graphs in terms of histogram, pie diagram, bar chart, etc, were used to clearly focus the situation. 3.9.2 Qualitative analysis

The qualitative modes of analysis were also deployed for this project. Qualitative modes of analysis recognise the primacy of the subject of inquiry (Rich and Ginsburg, 1999). The qualitative analysis for this project is based on the interpretation of text and observations. The qualitative data are analysed from multiple perspectives using different analytical methods (Miles and Huberman, 1994; Silverman, 1993; and Wolcott, 1994). The mode of thick description consider the data to be present without interpretation and abstraction (Geertz, 1973); and the ethnography considers to creating a rich descriptive narrative (Strauss and Corbin, 1998) and vivid presentation of new understanding. This report aims to combine these approaches for exploring and presenting rich descriptive narratives by developing new concepts of medical waste management.

3.10

Concluding Remarks

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This chapter has mainly focussed on the multi-methods of data collection procedures and data analysis techniques under the framework of field survey and research design. The methodology adopted here is a combination of both the quantitative and qualitative approach, which are helpful in describing medical waste issues in a realistic manner. The quantitative data cover the statistical analysis for quantification of medical waste generation and the qualitative approach is for analysing the verbatim data for level of awareness, training need assessment and about the in-house management situation. Qualitative data were used to understand the complexities of existing management system. The qualitative techniques for both data collection and analytical procedures include in-depth interviews, formal and in-formal discussion etc.

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Chapter IV

Hospital Waste: Sources, Types and Generation

4.1

General Background Hospital waste poses, due to its contents of infectious materials and other hazardous substances, special risks compared to municipal waste and the risks are not only connected to the handling of the waste, but also to the treatment and disposal of the waste (MOHFW, 2004). The HCE also generate domestic or municipal waste including food waste and packaging from kitchen, food waste and packaging from patient, packaging materials from treatment of patients, paper and packaging from administrative functions (MOHFW, 2004). Apart from the DMCH, some 60 HCE including the BMCH were selected for the project. It has been found from our field survey that all the surveyed HCE generate pathological wastes, used syringes, broken bottles and glass, textile stained with blood and papers. They generate about 6.4 tons/day (6392 kg/day) of wastes, of which only about 5.2 tons/day (80.77%) are non-infectious wastes and about 1.2 tons/day (19.23%) are infectious wastes. The materials presented in this chapter are aimed at providing the sources and types of medical wastes from our recent field survey. Section 4.2 focuses the generation of medical wastes; section 4.3 describes the inventory of the HCE; section 4.4 concentrates the sources of medical waste; and section 4.5 discloses the quantification of medical wastes generation. Finally, the last section makes some concluding remarks on the overall chapter.

4.2

Hospital wastes generation This section deals with the present situation of generating different types of clinical wastes from different sources (Figure 4.1). Wastes, which are produced in hospitals, have variable hazard. The medical wastes are toxic and infectious diseases like HIV/AIDS, hepatitis B and C etc, could be communicated by contaminated medical waste. Exploring the existing waste management system in different hospital, clinics, diagnostic centres, and pathology departments is the main objective of this project. In HCE, two types of wastes are generated: non-hazardous and hazardous. The first group contains the domestic wastes in terms of paper, kitchen wastes, food wastes and others from hospital services. The second group includes wastes, which are produced in laboratories, operating rooms, consulting rooms and hospital units. This later group of wastes is needed to be treated because of thread of infection.
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4.3

Inventory of HCE It is mentioned here that more than 600 clinics and hospitals existing in the DCC are generating an estimated 200 tons of waste a day (Lawson, 2003). It has been observed that 131 HCE are located in Wards 49 and 56. Some 60 HCE including the BMCH were selected from Ward 49 for the project. It is noted here that the HCE in Ward 49 were not selected through any sampling procedure - those who were willing to provide us information were selected for this survey (Appendix B). The selected HCE includes General Hospitals (GH) (30, 50.85%), Private Clinics (PC) (15, 25.42%), and Diagnostic Centres (DC) (14, 23.73%). It is noted here that there is no government owned hospital in Ward 49. The DMCH is the biggest government owned hospital in Bangladesh. The DMCH provides medical facilities for about 2000 resident patients per day. The BMCH located in Ward 49 is the biggest private General Hospital in Bangladesh and offers medical treatment for about 300 resident patients and the Samorita offers for about 100 resident patients (Table 4.1). The recent survey reveals that the Central Hospital and the Ibn Sina Hospital in combination provide treatment facilities to about almost half of the total patients admitted to different surveyed general hospitals located in Ward 49 (Table 4.1). Out of 1743 outpatients, the Ibn Sina D-Lab and the Ibn Sina Consultation centre in combination provide outdoor services to about one-third of the patients. It is noted

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here that the Central Hospital and the Ibn Sina provide most of the medical facilities to their patients other than the BMCH located in Ward 49.

It is calculated from our data that out of 119 resident patients, about 30% get their services from the Crescent Gastro liver. The survey also reveals that slightly more than 1800 patients take the diagnostic services per day from surveyed 14 DC in Ward 49 (Table 4.1) and three-fifth (61%) and one-fifth (20%) of the patients take their services from the Popular Diagnostic Centre and the Ibn Sina Trust respectively.

4.4

Sources of hospital waste Hospital waste is produced from the various activities performed in the hospitals. General waste produced at the hospital is related mainly to food preparation and administrative departments and this type of waste is similar to household waste and city waste (Askarian et al, 2004). During the field survey, it was observed that the surveyed hospitals generated pathological wastes, textile stained with blood, cotton pads, used syringes, broken bottles and glass, paper, cans and other metals, vegetable/rubbish and sharp instruments (syringe-needles, surgical blades and blood lancets). Some of the wastes are blood stained. All the surveyed HCE produce used syringes, broken bottles and glass, textile stained with blood and papers (Figure 4.2). Pathological wastes are generally produced in hospitals conducting surgeries. These wastes are infectious and demand careful handling.

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Medical wastes arise from various activities. These include general medical treatment, clinical investigation, food preparations and ward activities. The quantities of medical wastes generated among other factors depend on the status of the hospital, level of instrumentation and sometimes location of medical facilities (Mato and Kassenga, 1997). The composition of medical wastes is often characteristic of the type of source. Different units within a hospital and clinic would generate different wastes. In addition, some scattered sources may produce some medical wastes in categories similar to hospital waste (WHO, 2001). (a) Medical wards: mainly infectious waste such as dressings, bandages, sticking plaster, gloves, disposable medical items, used hypodermic needles and intravenous sets, body fluids and excreta, contaminated packaging, and meal scraps. Operating theatres and surgical wards: mainly anatomical waste such as tissues, organs, fetuses, and body parts, other infectious waste, and sharps. Health-care units: mostly general waste with a small percentage of infectious waste. Laboratories: mainly pathological (including some anatomical), highly infectious waste (small pieces of tissue, microbiological cultures, stocks of infectious agents, infected animal carcasses, blood and other body fluids), and sharps, plus some radioactive and chemical waste.

(b)

(c)

(d)

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(e)

Pharmaceutical and chemical stores: small quantities of pharmaceutical and chemical wastes, mainly packaging (containing only residues if stores are well managed), and general waste.

4.5

Quantification of Hospital Waste Generation The wastes generation rates in the surveyed hospitals were obtained by actual measurements and through assessment of the storage facilities emptying frequencies and degree of filling of the refuse receptacles. It has been found from the field survey that all the surveyed HCE generates about 6.4 tons/day (6392 kg/day) of wastes, of which only about 5.2 tons/day (80.77%) are non-infectious wastes and about 1.2 tons/day (19.23%) are infectious wastes (Figure 4.3 and Table 4.1).

The survey shows the average waste generation rate for the surveyed HCE is 2.63 kg/bed/day (Table 4.2). The results compare with solid waste generation rates reported in USA hospitals of 4.5-9.1 kg/bed/day, of which about 10% is thought to be infectious or disease causing (Henry and Heinke, 1996). The improper management of the infectious wastes are reported be hazardous for human health and environment. The kitchen wastes are found to be highest generated in the HCE and the net volume covers for about half (49.10%) of the generated wastes followed by cotton bandage (11.68%), vial-ampoule (9.69%), placenta (7.86%), sharp instrument (4.05%) and so on (Table 4.2).

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The survey reveals that the medical waste0 generation rate ranges between 0.17 and 0.74 kg/patient/day having an average of 0.56 kg/patient/day (Table 4.3). The study revealed that hospitals with modern medical facilities and good services were found to have higher waste generation rates. For example, BMCH and the Samorita Hospitals has a waste generation rate of 0.73 and 0.74 kg/patient/day respectively. Moreover, the average waste generation rate in the surveyed HCE is estimated at 2.63 kg/bed/day (Table 4.3).

In different studies, the waste generation rate was reported to be 2.71 kg/bed/day in hospitals of Tehran (Iran), (Mohammadi Baghaee, 2000) and the waste generation rate in Dar es Salaam (Tanzania) hospitals was reported to be between 0.84 and 5.8 kg/bed/day (Mato and Kassenga, 1997). The WHO report regarding the waste
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generation shows the rate in general and university hospitals, which are 4.2-21.1 and 4.1-8.7 kg/bed/day, respectively (Prss et al, 1999). In the hospitals, different kinds of therapeutic procedures such as cobalt therapy, chemotherapy, dialysis, surgery, delivery, resection of gangrenous organs, autopsy, biopsy, para-clinical exams, injections etc. are carried out and result in the production of infectious wastes, sharp objects contaminated with patients blood and secretions, radioactive wastes and chemical materials which are considered to be the hazardous wastes (Prss et al, 1999). The amount of waste generated in the hospitals depends upon various factors such as the number of beds, types of health services provided, economic, social and cultural status of the patients and the general condition of the area where the hospital is situated (Askarian et al, 2004). It is noted here that the DMCH, BMCH and Samorita hospitals were taken especially for this project. The DMCH is the largest govt medical college hospital, the BMCH is the largest private medical college hospital, and the Samorita is the large private hospital in Bangladesh. 4.5.1 DMCH and waste situation

The DMCH is the largest government owned hospital in Bangladesh having almost all the health-care facilities (e.g. pathology, radiology and imaging, microbiology, surgery, pharmacology and therapeutics, gynaecology and so on). Apart from the facilities of health-care, outdoor, emergency, OT, etc are in the DMCH. The free wards for the poor are at the ground floor and paid wards are at the second floor. The DMCH has the capacity for 1400 beds and about 500 floor patients. The hospital provides emergency treatment to about 250-300 patients daily, surgical treatment (major and minor operations) to about 3900-4000 patients per day from various departments and wards, and outdoor advice to about 1000-1200 in a day (Ahmed, 2000). The survey reveals that the DMCH alone generates more than half (58%) of the total wastes generated in the surveyed HCE (Table 4.2). The DMCH itself generates about 2976 kg/day (80.2%) of non-infectious waste and 733 kg/day (19.8%) of infectious waste. The net generation of non-infectious and infectious wastes from the DMCH are calculated to be 46.55% and 11.46% respectively (Table 4.2). It is found from the fieldwork that more than half (51%) of the generated wastes in DMCH is kitchen wastes followed by cotton bandage (12%), vial-ampoule (11%), placenta (7%), saline bags (4%), sharp instruments (4%), body fluids (3%) and others (Figure 4.4). The wastes generated in the DMCH are mainly from the kitchen, pathology department, gynaecology, OT and emergency section. The DMCH produces the average waste generation rate of 2.65 kg/day or 0.67 kg/patient/day (Table 4.3).

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4.5.2

BMCH and waste situation

The BMCH is the largest private hospital in Bangladesh having most of the healthcare facilities (e.g. pathology, surgery, gynaecology etc). Apart from the facilities of health-care, outdoor, emergency, OT, etc are available in the BMCH. The BMCH has the capacity for 300 beds for resident patients. The hospital provides emergency treatment facilities for about 50 patients daily and outdoor facilities for 600-800 patients in a day. It has been estimated from the survey that the BMCH generates about one-eight (12.53%) of the total wastes generated in the surveyed HCE (Table 4.2). The BMCH produces 640 kg/day (10.01%) of non-infectious waste and 161 kg/day (2.51%) of infectious waste totalling of 801 kg/day of wastes (Table 4.2). Almost half (47%) of the generated waste in BMCH is kitchen wastes followed by placenta (15%), vialampoule (9%), cotton bandage (8%), saline bags (5%), sharp instruments (3%), body fluids (3%) and others (Figure 4.5).

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The wastes generated in the BMCH are mainly from the kitchen, emergency, OT pathology, and gynaecology department. The BMCH produces the average waste generation rate of 2.67 kg/day or 0.73 kg/patient/day, a slightly more than the wastes generated in DMCH (Table 4.3). 4.5.3 Samorita and waste situation

The Samorita is one of the largest private hospitals in Bangladesh having the modern health-care facilities. Apart from the general health-care facilities, outdoor, emergency, OT, etc are available in the Samorita Hospital. It is noted here that due to the high treatment cost, poor people generally do not get facilities from this hospital. The Samorita has the capacity for 100 beds resident patients. The hospital provides emergency treatment facilities for 20-50 patients daily and outdoor facilities for 200300 patients in a day. It has been estimated from the survey that the Samorita Hospital generates slightly more than 4% of the total wastes generated in the surveyed HCE (Figure 4.6 and Table 4.2).

The net generation of the wastes from Samorita Hospital is 4.05%, of which 3.41% is non-infectious waste and 0.64% of infectious waste having 218 kg/day of noninfectious waste and 41 kg/day of infectious waste totalling of 259 kg/day of wastes (Table 4.2). Some two-third (40%) of the generated waste in Samorita is kitchen wastes followed by placenta (21%), cotton bandage (12%), vial-ampoule (7%), saline bags (7%), body fluids (3%), sharp instruments (3%), and others (Figure 4.6). The wastes generated in the Samorita are mainly from the kitchen, pathology, gynaecology, OT and emergency. The hospital produces the average waste generation rate of 2.59 kg/day or 0.74 kg/patient/day. The amount of kg/day waste generation rate is lower than that of the DMCH, but the kg/patient/day rate is higher than that of the DMCH and BMCH (Table 4.3).

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4.5.4

General Hospitals in Ward 49

Some 30 GH were classified from our surveyed HCE in Ward 49. The selected GH has the capacity for about 600 beds for resident patients and provides outdoor facilities for about 1750 patients daily. It has been estimated from the survey that all the 30 GH in combination produce 14.51% of wastes generated in the surveyed HCE for this project (Table 4.2). Some 757 kg/day (11.84%) of non-infectious wastes and 171 kg/day (2.67%) of infectious wastes totalling of 928 kg/day of waste are being generated from the surveyed GH selected in the project site. All the GH themselves in the project site generate about two-third (41%) of the kitchen wastes followed by cotton bandage (16%), saline bags (13%), vial-ampoule (7%), placenta (5%), blood and urine bags (5%), sharp instruments (5%), and others (Figure 4.7).

The wastes generated in the GH are mainly from the kitchen, pathology, gynaecology, OT and emergency. The GH produces the average waste generation rate of 1.57 kg/day or 0.40 kg/patient/day, much lower than those of the DMCH, BMCH and Samorita (Table 4.3). Ibn Sina produces and the Bangladesh Heart and Chest Hospital produce the highest and lowest waste in this category with 2.97 kg/bed/day and 1.09 kg:bed/day respectively. 4.5.5 Private Clinics in Ward 49 Some 15 Private Clinics (PC) were classified from our surveyed HCE in Ward 49. The selected PC has the capacity for about 312 beds for resident patients and by definition, there are no outdoor facilities. It has been estimated from the survey that all the 15 PC in combination produce 6.02% of wastes generated in the surveyed HCE for this project (Table 4.2). Some 309 kg/day (4.83%) of non-infectious wastes and 76 kg/day (1.18%) of infectious wastes totalling of 385 kg/day of waste are being

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generating from the surveyed PC selected in Ward 49. All of the PC themselves in the project site generate about one-third (39%) of the kitchen wastes followed by cotton bandage (12%), placenta (10%), saline bags (10%), vial-ampoule (10%), sharp instruments (5%), blood and urine bags (5%), and others (Figure 4.8).

The PC produces the average waste generation rate of 1.23 kg/day, much lower than those of the previously described HCE (Table 4.3). The Crescent Gastroliver and General Hospital Ltd produces the highest and Justice Amin Mohammad Charity Clinic produces the lowest waste in this category with 2.01 kg/bed/day and 0.93 kg/bed/day respectively. 4.5.6 Diagnostic Centres in Ward 49

A number of 14 Diagnostic Centres (DC) were identified from our surveyed HCE in Ward 49. Since there is no opportunity of resident facilities, all of the DC provides diagnostic facilities for 1802 patients daily. It has been estimated from the survey that all the DC in combination produce 4.84% of wastes generated in the surveyed HCE for this project (Table 4.2 and Figure 4.9).

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Some 273 kg/day (4.27%) of non-infectious wastes and 37 kg/day (0.57%) of infectious wastes totalling of 310 kg/day of waste are being generated from the surveyed DC selected in Ward 49. All the DC themselves in the project site generate more than two-third (70%) of the kitchen wastes followed by cotton bandage (10%), vial-ampoule (5%), saline bags (4%), sharp instruments (2%), blood and urine bags (2%), and others (Figure 4.9). The wastes generated in the DC are mainly from the kitchen and pathology. The DC produces the average waste generation rate of 0.17 kg/patient/day, average lowest in all the HCE in the project site (Table 4.3). The Popular Diagnostic Centre and the Reliable Diagnostic Centre produce the highest and lowest waste in this category with 0.61 kg/patient/day and 0.14 kg/patient/day respectively.

4.6

Concluding Remarks This chapter attempted the quantification of different medical wastes generated from different HCE in the project site. The collected field data showed that all the surveyed HCE generate pathological wastes, used syringes, broken bottles and glass, textile stained with blood and papers. They generate about 6.4 tons/day (6392 kg/day) of wastes, of which only about 5.2 tons/day (80.77%) are non-infectious wastes and about 1.2 tons/day (19.23%) are infectious wastes. The average waste generation rate for the surveyed HCE is 2.63 kg/bed/day and the results compare with solid waste generation rates reported in USA hospitals of 4.5-9.1 kg/bed/day. The DMCH alone generates more than half (58%) of the total wastes generated in the surveyed HCE. The DMCH itself generates about 2976 kg/day (46.55%) of noninfectious waste and 733 kg/day (11.46%) of infectious waste. The BMCH generates about one-eight (12.53%) of the total wastes generated in the surveyed HCE. The BMCH produces 640 kg/day (10.01%) of non-infectious waste and 161 kg/day (2.51%) of infectious waste totalling of 801 kg/day of wastes. The net generation of the wastes from Samorita Hospital are 3.41% for non-infectious waste and 0.64% of infectious waste having 218 kg/day of non-infectious waste and 41 kg/day of infectious waste totalling of 259 kg/day of wastes. The outcome from this chapter will be of helpful for the researchers and policy makers to think about the hazardous medical waste situation in Bangladesh and to formulate policies in this regard.

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Chapter V

Hospital Waste Management in Surveyed HCE

5.1

General Background Generally the existing hospital waste management in Bangladesh in the form of an environmental point of view is taking place with an improper procedure. Only a very few HCE are exceptional in this regard. Almost all the HCE do not segregate the generated wastes. This chapter seeks to explore the existing waste management system to formulate recommendations to manage the generated waste properly. The materials presented in this chapter are aimed at providing the existing practice of waste management in terms of in-house management (segregation, temporary storage, disposal system), off-site transport, and final disposal. The following section focuses the management of wastes; section 5.3 describes the in-house waste management; section 5.4 concentrates the off-site transport and final disposal; section 5.5 discloses the segregation of waste in the DCC bin; and section 5.6 focuses the existing waste management practice in different surveyed HCE. Finally, the last section makes some concluding remarks on the overall chapter.

5.2

Waste management It has been found from the survey that almost all the cleaners (Aayah) are responsible to clean and manage the generated waste. Some cleaners were found to be engaged to mishandle the generated wastes. They segregated the used sharps instruments (mainly the syringe-needles), saline bags, blood bags and test tubes from the kitchen and nonhazardous wastes for sale (resale) or reuse. They are continuing this practice probably with the full knowledge of the nurses and ward master. Figure 5.1 shows the segregation pattern of generated wastes in a HCE. 5.2.1 In-house waste management

In some HCE, radioactive, infectious, and sharp wastes are separated from the noninfectious waste stream at the site of production and they are not stored in similar containers and are disposed together. In all hospitals, pharmaceutical waste and pressurized containers are disposed along with the general waste. Liquid pharmaceutical waste is poured into the drains along with liquid chemical waste. 5.2.2 Segregation

This study reveals that segregation of all wastes is not conducted according to definite rules and standards, some amount of infectious waste is stored in the same containers

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as the domestic wastes, and no control measures exist for the management of these wastes. Most of the HCE do not have plastic bags and strong plastic containers for infectious waste in accordance with the WHO guideline. In general, in most of the HCE, plastic and aluminium made containers are used. Intermingling of dangerous wastes with general waste in the hospitals is due to the lack of comprehensive staff training and to a lesser extent due to the lack of facilities.

There is no segregation system for infectious and non-infectious waste stream at the site of production almost in all the HCE. The field survey shows that only four-fifth (81.4%) of the surveyed HCE do not have any systematic waste collection procedure, while the rest one-fifth (18.6%) of the HCE collect their in-house waste systematically (Table 5.1). Some five private HCE in Ward 49, say, Medinova, Ibn Sina, Popular Diagnostic centre, Central Hospital, and Dr Salahuddin Hospital segregate their sharp instruments and infectious wastes in separate bins and sent off to the ICDDRB for incineration at the rate of Tk 50 per kg of waste. It is noted here that all the HCE in the project site other than these 5 HCE directly dispose their intermingled infectious and non-infectious wastes in the roadside Dhaka City Corporation (DCC) Dustbin.

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The survey reveals that only 8.47% HCE in Ward 49 segregate their waste in separate bins (3 HCE), in safety boxes (1 HCE), and in separate buckets (1 HCE). A total of 91.53% do not segregate the waste, but they have special storage before disposing them into the roadside DCC bin. The survey also reveals that all the HCE in the project site finally dispose their wastes into the DCC bin. The DMCH, BMCH, and Samorita dispose their wastes into the DCC bin without segregating them. This poses serious health risks to the personnel handling the waste and to the scavengers at the dumpsite and the public at the large site. The consequences of this practice extend to the possibility of polluting both surface water and the groundwater resource in the vicinity of the dumpsite (Mato and Kaseva, 1997). Figure 5.2 shows the usual situation of in-house segregation of waste in many HCE.

Cleaners appointed in the HCE are responsible for cleaning and managing the waste generated in the HCE. They collected the waste from different Wards, OT, Pathology Department and other in-house sources and dispose it to the hospital bins before disposing them into the DCC bin. In the DMCH, we found some cleaners to be segregating syringe-needles, saline bags, empty water bottles, tubes etc for sale and reuse (Figure 5.3).

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It is noted here that infectious waste should be packaged for protecting (a) waste handlers and public from possible injury and disease that could result from exposure to the waste and (b) avoiding attraction to rodents and vermin (Patil and Pokhrel, 2004). The integrity of packaging can be preserved during handling, storage, transportation and treatment. It is noted here that in all the surveyed HCE, sharp instruments are generally stored in separate refuse receptacles. In some HCE small empty bottles are separated and used for storage of blood and urine specimens. In some hospitals offering delivery services placentas and bottle stained cotton pads are put in separate containers. Pathological wastes from theatre are treated in a similar manner, but most HCE do not do the same. 5.2.3 Temporary storage

The place/storage where the hospital waste is kept before transporting to the DCC bin is termed as a temporary waste storage. Some small HCE do not have any temporary storage and they simply disposed the waste into the DCC bin. Most of the HCE keep their waste in different designed bins located in the corner of the hospital yard until disposing into the DCC bin. In some HCE, the infectious and non-infectious wastes are kept in separate containers and are not mixed together in the hospitals own bin. It is noted here that all the wastes generated in the HCE finally intermingled when disposing them to the DCC bin. 5.2.4 Disposal system

The generated wastes are finally disposed into the DCC bin located close to any HCE. It can be done by each HCE, or NGO, or CBO. Almost 93% of the HCE from our project site collect and dispose their waste into the DCC bin (Table 5.2). A very few HCE surveyed receive services from some private company engaged in refuse collection services. Western Organisation, First Clean, RAKT, Nepcone etc, is involved in collecting and managing the generated wastes from different HCE. Western Organisation is engaged in cleaning and managing the waste from Medinova, a reputed diagnostic centre in Bangladesh located in Ward 49.

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At the end of each shift, hospital waste is collected and transported to a bin for temporary storage by hospital cleaners. In some HCE, closed containers are used for off-site transport of waste from the sites of production (different wards) to the DCC bin. The cleaners employed for handling waste in HCE do not use complete personal protective equipment (special dress-shirt and trousers along with gloves, mask, boots etc), but in very few cases, cleaners use only masks and gloves. Lacking of suitable and sufficient protective equipment and knowledge could expose them to serious health problems.

5.3

Off-site Transport and Final Disposal Medical waste should normally be collected everyday due to its hazardous nature. The DCC has the responsibility for off-site transport of the waste for final disposal or dumping. It is noted here that off-site transport to the roadside DCC bin is undertaken by the hospital itself. Every early morning, the collected waste is finally crudely dumped at different DCC waste disposal sites located outside the DCC boundary by the DCC itself. Crude dumping of medical waste is treated as a threat of both humans and environment. The bio-medical solid wastes are not stored for more than 18 hours off-site. The bins in the wards should strictly be placed away from patients and from the nursing station (Patil and Pokhrel, 2004). All the HCE surveyed dispose of their domestic waste at the same site as the civic waste. As the separation of hazardous waste from the domestic is not carried out properly, the domestic waste of the hospitals cannot be compared with the common city waste. Therefore, due to the intermingling of hazardous waste, these wastes should be considered infectious.

5.4

Segregation of Wastes in the DCC Bin It has been found a different story during our field survey. We have investigated the segregation of refused medical wastes in terms of sharp instruments, saline and blood bags, plastic materials, tube and so on from the domestic wastes. Some people are responsible in collecting, segregating and selling the used hazardous wastes. Figure 5.4 shows the segregation of some clinical wastes for selling. It is also noted here that the existing laws are generally outdated and characterised by low penalties and sometimes no penalties for offenders. Thus awareness towards this issue could be effective until formulating new laws to protect people and environment from deadly clinical waste.

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5.5

Existing Waste Management Practice Generally, in the DMCH, all types of waste are to be collected twice a day. Wastes from the Operation Theatre (OT) and Intensive Care Units (ICU) are collected more often, depending on the number of operations and cases attended in any particular day. Apart from the DMCH, almost all the HCE collect their wastes in different times depending on the amount of wastes are to be generated. In the Pathology Department (PD), the generated wastes, most importantly, syringes and the needles with which they take the blood samples are collected in a box after use. Then they hand it over to the sweepers and cleaners. They return those to the suppliers and bring new ones (Ahmed, 2000). It is noted here that patients who cannot afford it, they wash those syringes with plain water and take their samples. It is also noted here that they do not use any antiseptic. In the Gynaecology Department, the generated wastes are collected into the metal dustbin for disposing into the DCC bin. There were sanitary napkins, left over food, liquid wastes, placenta, disposable gloves etc. All the generated wastes go inside the same dustbin and nothing is segregated. Sweepers collect the syringes and saline

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bags from them. They return them to the supplier again. All other wards have the same procedure of disposing their waste. The Operation Theatres (OT) in HCE produce catheters, gauze, blood cottons, etc. The syringes and saline bags are kept separately with the HCE since they are returned again to the hospital suppliers. The bucket is collected by the sweepers on duty and disposed by them in the DCC bin. It is noted here that amputated body parts are mainly disposed in the DCC dustbin by the sweepers and cleaners as mentioned in Ahmed (2000). The amputated parts are hands, legs, gal bladder, uterus, tumour, aborted child and many others (Ahmed, 2000).

5.6

Concluding Remarks The chapter has focused on the existing medical waste management system in Bangladesh. Almost all the HCE do not segregate their generated wastes. All the HCE surveyed dispose of their domestic waste at the same site as the civic waste. As the separation of hazardous waste from the domestic is not carried out, the domestic waste of the hospitals cannot be compared with the common municipal waste. Therefore, due to the intermingling of hazardous waste, these wastes should be considered infectious. Almost all the cleaners are responsible to clean and manage the generated waste. Some cleaners were found to be engaged to mishandle the generated wastes. They segregated the used sharps instruments (mainly the syringe-needles), saline bags, blood bags and test tubes from the kitchen and non-hazardous wastes for sale (resale) or reuse.

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Chapter VI

Awareness and Training

6.1

General background The chapter mainly focuses the level of awareness of different related professionals on medical waste and its impact on occupational health as well as environmental issues. The chapter also discloses the opinions of authority and medical staffs regarding the needs of training about the proper management of generated wastes. The materials presented here are aimed at providing the level of awareness and training needs. The following section focuses the level of awareness of different respondents; section 6.3 describes the needs of training on in-house waste management generated in HCE; and section 6.4 concentrates the opinion of the respondents about existing in-house management. Finally, the last section makes some concluding remarks on the overall chapter.

6.2

Level of Awareness This survey indicated that training was not provided to doctors and other personnel about hospital waste management and their potential hazards except for a few. Some hospitals provide some training for the cleansing staff and in some nurses. Lack of proper training in the hospitals poses serious risks to the personnel as far as the hazards of hospital waste is concerned. The process of collection, segregation and disposal of hospital waste is not performed according to recommended standards, and hence patients, visitors, society and the environment are exposed to the dangers of such waste. In developed countries, training programs and educational classes are instituted repeatedly for all personnel and the content of these programs is specifically designed to different personnel. Some 67 (47%) among the interviewees were female and some 77 (53%) were male respondents. It is noted here that all the female respondents were mainly the nurses, and the rest were doctors, medical technicians, and cleaners. The average age of the respondents was about 42 years and the average length of service was about 20 years (Table 6.1). It is noted here that we have collected our information from the respondents from all occupational segments in the HCE. Their opinions have been considered for addressing the awareness and training needs. The field survey shows different level of awareness from different respondents. The management authority of HCE and doctors got ideas about the medical wastes and its negative impacts. They pointed out that they are willing to manage the generated

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waste properly, but lacking of financial support and proper system, they are unable to do it. Nurses got their training on medical waste as a part of their professional training, but due to the lack of system, they are unable to apply their theoretical knowledge they gathered from their training. Some nurses told us with little frustration that they are on the brink of forgetting the waste management system. In addition, most of the technicians, cleaners and ward-boys are not aware properly about the medical wastes and its risk issues.

In the GH, about one-third of the total respondents did not get any direct training concerning to the waste management, while only 13.56% got training on this issue mainly from the WHO (Table 6.2). Some 6.78% from the PC and 10.17% from the DC got training in this regard. It is estimated that about two-third (69.4%) of the total respondents from the surveyed HCE in ward 49 did not get any training on waste management, while the rest one-third (30.5%) of the respondents got their training on this issue but they are not able to manage the waste systematically since their are lacking of systems, rules and regulations.

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The field survey reveals that most of the HCE do not have any budgetary provision to manage their generated waste systematically. A small amount of budgetary provisions are allocated by their own in some PC and DC and they follow their own guideline in managing their waste. The DMCH has not any budgetary provision in this regard.

6.3

Training Needs It is also investigated from our field survey that almost all the respondents from all the surveyed HCE focussed their opinion in favour of training concerning to the waste management. Some respondents urged on practical training rather than the traditional theoretical training for proper waste management. In connection with the training methods, about two-thirds of the respondents (62.71%) showed their interest in video, followed by flipchart (20.0%), lecture (10.16%), and others (7.13%). It is noted here that some respondents focussed on multiple methods (Table 6.3).

The voices of the respondents were mainly confined to the in-house waste collection procedure, segregation, incineration and safety dumping. Moreover, some respondents urged for reinforcement and imposing waste related laws. The survey shows different voices from the hospital management authority on the needs of training with respect to financial constraints. Almost all the respondents from the DMCH mentioned about their willingness in participating waste related training if the PRISM or any other organisation would arrange it. There is no budgetary provision for arranging any training session concerning to the waste management issue. The BMCH authority showed their interest in the training if it would benefit them commercially. It is also noted here that almost all the nurses showed their willingness in participating the training programme if the authority provide the facilities.

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6.4

Opinion about existing in-house management Most of the respondents showed their negative opinion in the present in-house waste management systems. Only a very few respondents (7, 12.00%) mentioned the good in-house management of the waste segregation. It is noted here that some private HCE (as mentioned earlier) segregate the infectious waste for incineration from the ICDDRB (Field survey, 2004). It is also noted here that almost all the respondents except for a few focussed on the improper in-house management. They mentioned that infectious waste could cause HIV/AIDS and Hepatitis. Moreover, they are presently facing stink and afraid of contaminating diseases from the infectious waste. They also mentioned here some probable steps that could overcome the problems: (a) Use of apron, musk and gloves during handling the patients and segregating and disposal of waste; Use of WHO guided colour-coded bins for segregated wastes; Training for awareness could be of great help concerning to this issue; Formulating, amendment, and imposing the relevant laws could prevent the improper in-house and final management of clinical wastes.

(b) (c) (d)

6.6

Concluding Remarks The chapter mainly focused on the level of awareness of different related professionals on medical waste and also the opinions of the hospital authority and medical staffs regarding the needs of training about proper in-house management of wastes. The respondents from all the surveyed HCE focussed their opinion in favour of training concerning to the waste management. Some respondents urged on practical training rather than the traditional theoretical training for proper waste management. Almost all the respondents are aware about the health impact of medical wastes except a few. About two-third (69.4%) of the total respondents from the surveyed HCE in ward 49 did not get any training on waste management, while the rest onethird (30.5%) of the respondents got their training on this issue but they are not able to manage the waste systematically since their are lacking of systems, rules and regulations. The HCE do not have any budgetary provision to manage their generated waste systematically. A small amount of budgetary provisions are allocated by their own in some PC and DC.

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Chapter VII

Summary and Recommendation

7.1

Summary The collection, storage and disposal of medical wastes are of growing environmental problem in Bangladesh, which needs immediate attention before it goes out of hand. Until recently, the management of medical wastes has received little attention despite their potential environmental hazards and public health risks. The project focuses the existing management system of medical wastes in hospitals, clinics, and pathological laboratories in Dhaka City. The study reveals that medical wastes are not properly managed in almost all the HCE in the DCC area. The most important principles underlying effective programmes for the management of medical waste include the awareness, assignment of legal responsibility, developing the rules and regulations concerning to the medical waste management. It is noted here that everyone concerned by medical waste should understand that medical waste management is an integral part of health care, and that creating harm through inadequate waste management reduces the overall benefits of health care (WHO, 2002). Because of the communicable diseases such as the AIDS/HIV and hepatitis B and C viruses, people are increasingly concerned over the disposal of medical waste. Using both the quantitative and qualitative approach, the report has attempted to quantify different medical wastes generated from different HCE in the project site. The collected field data showed that all the surveyed HCE generate pathological wastes, used syringes, broken bottles and glass, textile stained with blood and papers. They generate about 6.4 tons/day (6392 kg/day) of wastes, of which only about 5.2 tons/day (80.77%) are non-infectious wastes and about 1.2 tons/day (19.23%) are infectious wastes. The average waste generation rate for the surveyed HCE is 2.63 kg/bed/day. The DMCH alone generates more than half (58%) of the total wastes generated in the surveyed HCE. The DMCH itself generates about 2976 kg/day (46.55%) of non-infectious waste and 733 kg/day (11.46%) of infectious waste. The report has also focused on the existing medical waste management system in HCE. Almost all the HCE do not segregate their generated wastes. All the HCE surveyed dispose of their domestic waste at the same site as the civic waste. Some cleaners were found to be engaged to mishandle the generated wastes. They segregated the used sharps instruments (mainly the syringe-needles), saline bags, blood bags and test tubes from the kitchen and non-hazardous wastes for sale (resale) or reuse.

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The level of awareness on medical waste is very high, but they are not able to manage the waste systematically since there are lacking of systems, rules and regulations, and financial support. The HCE do not have any budgetary provision to manage their generated waste systematically.

7.2

Recommendation In many countries the safe disposal of medical waste is considered very important and handled in a very professional manner. They have effective systems of tracking waste generators, and follow specified regulations for segregation, collection, treatment and disposal of medical waste. The staff and people are trained in the use of separate bins and bags for different types of medical waste. At the very generation point, the waste is segregated into bio-hazardous, non-bio-hazardous, sharps, toxins, pharmaceuticals, carcinogens and ordinary solid waste, etc. and stored in designated bags and bins with identification tags and or barcodes. This minimises the actual volume of potentially infectious or dangerous medical waste to almost one quarter and makes the disposal less costly and more effective. Unfortunately, there is little effort in properly disposing hospital (biomedical) waste in Bangladesh. Hospital waste is generally disposed of in the same way as ordinary domestic waste. In order to arrange a proper and systematic in-house waste management, the following recommendations should be considered: (a) To avoid the risk of health effect from the wastes, it needs to formulate proper policy regarding this issue. The fact is that there has not been any municipal waste treatment in Dhaka yet, and the generated wastes have been dumped on municipal dumping grounds by the DCC. It is essential to treat the infectious waste before dumping them into the DCC dumping grounds. The health care waste management issue is becoming critical in view of the growing amounts of health care risk waste and fast increasing HIV/AIDS incidence among certain groups. Arrangement of training regarding this issue could minimize the health risk. Moreover, the training could increase attention to blood safety, disposal of needles and syringes and other infectious waste. Medical wastes are needed to be segregated separately, according to its characteristics, at the point of generation (Prss et al, 1999). All the HCE should use the WHO permitted colour-coded, high-density polyethylene bags for easy identification and segregation of biomedical solid waste. Non-infectious and domestic type of waste should be collected in black polyethylene bags, placed in bins while the
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(b)

(c)

(d)

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infectious wastes should be collected in red, yellow and blue colourcoded polyethylene bags placed within blue high-density polyethylene bags labelled with a bio-hazardous infectious materials symbol in specific bins (Patil and Pokhrel, 2004). (e) The field data shows that the medical facilities are characterised by inadequate and inappropriate refuse storage facilities, lack of refuse collection services, improper disposal methods and inadequate and inappropriate protective gear for refuse handlers. A remedial measure with the installation of a commercial environment friendly incinerator in the city are suggested.

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