Management of Healthcare Waste in Pakistan Maryam S. Abbasi

1. INTRODUCTION

Healthcare waste is such waste which is generated from healthcare facilities, natal care,

treatment centers of human and animals. It mainly includes different types of wastes such as

sharps, infected syringes, animal and human tissues, drugs and medicines. There are different

health risks associated with each type of waste so their management is necessary.

1.1 Types of healthcare waste

There are different types of healthcare wastes generated as a result of different activities in

healthcare facilities. According to World Health Organization (WHO) following are different

components of healthcare waste shown in the figures; 1

Figure 1: Components of healthcare waste

Among healthcare waste 10% consists of infectious waste, 85% is non-hazardous healthcare

waste and 5% chemical and radioactive waste.

Following are different types of healthcare wastes according to WHO;

a) Sharp waste

In healthcare facilities different types of items are used like blades, needles, scalpels, infusion

sets and pipettes. These items are considered highly infectious because they can cause wounds,

cuts and can transmit many infectious diseases. They may be dreadful and cause death when

absorbed through blood stream. Such items need to be handled with great care.

b) Infectious waste

Infectious waste is such waste which can cause infectious diseases if waste is not treated

according to standard procedures. This waste usually consists of harmful bacteria, viruses,

parasites and fungi. Such waste can cause diseases in susceptible hosts.

c) Pathological waste

Major part of this waste comes from surgery and consists of human and animal tissues, body

parts, body fluids and other waste. This waste is also infectious if tissues of human and animals

are infected with some diseases.

d) Pharmaceutical waste

In healthcare facilities different types of drugs, medicines, and vaccines are used for treatment. If

these products are expired and mismanaged then they become infectious. This waste also include

different items used during treatment like bottles, boxes containing pharmaceutical residues,

gloves, masks and connecting tubes.

e) Chemical waste

Different chemicals are used in healthcare facilities and wasted products include solid, liquid and

gaseous chemicals. They come from diagnostic and experimental work at hospitals and clinics.

Chemical waste may be hazardous, corrosive, flammable, radioactive and oxidizing.

f) Radioactive waste

This waste is generated of diagnosis of body tissues, internal organ imaging and tumor

localization. They also come from X-ray units and they should be highly protective to avoid

health hazardous because such waste is contaminated with radionuclides.

1.2 Sources of healthcare waste

Hospitals

Clinics

Emergency services

Research laboratories

Animal research laboratories

Blood bank

1.3 HEALTHCARE WASTE MANAGEMENT (HCWM) IN PAKISTAN

Management of healthcare waste is very necessary to avoid health hazards. Many countries are

facing problems of healthcare waste. Pakistan is also one of them. There will be very few

hospitals where hospital waste is managed. There are open pits and grounds full of waste. This

type of waste has bad impacts on health and it contaminates air, land and water.

According to one of the estimate Pakistan generates 2.0kg of waste per bed per day. This waste

includes used syringes, blades, used gloves, chemicals and drugs etc. 2

1.3.1 Status of Healthcare Waste Management

1.3.1.1 Introduction/ Background

A survey was carried out in May 2007 in four provinces Azad Jammu and Kashmir and Federal

capital area. This survey was done by Health Services Academy, Islamabad in collaboration with

Federal Ministry of Health, Provincial Health Departments, Ministry of Environment and World

Health Organization. This survey was to analyze the hospital waste management.

1.3.1.2 Methodology and sampling area

From each province under study fourteen healthcare establishments were selected. In this

survey 78 healthcare facilities were included and its waste management was analyzed on visit to

each facility. There were three types of hospitals under studies. First category was of large

hospital with more than 100 beds. Second category is of medium sized hospitals with 50-100

beds and last category was small size hospitals with less than 50 beds. Out of 78 hospitals 34%

were having out patients department, 24% facilities were tertiary care hospitals and 27% were

secondary care hospitals. Primary care hospitals were 41%. In this survey public and private

sectors were included.

1.3.1.3 Results and discussion

Out of 78 hospitals 30% were having Health Care Waste Management (HCWM) teams or

Infection Control Teams in place. Those hospitals which were having internal rules and

regulations for healthcare waste management were 41% while 27% were planning to manage for

healthcare waste. Regular training was given to 23% hospitals regarding hospital waste

management. 33 % staff was unaware from the health risk of healthcare waste management and

its associated risk factors. Reporting system was also very poor in most of the health care

facilities under study.

19% hospitals were not having any segregation system for the hospital waste while in

27% hospitals only sharps were segregated and at 21% sites infectious waste were separated

from healthcare waste. Other types of waste such as pharmaceutical, anatomical, radioactive and

chemical waste were separated from 3-11% hospitals. There were very few hospitals (32%) were

having properly labeled containers and 48% hospitals were using separate containers for

infectious and non-infectious waste. Color coding was observed in 5% wards, 8% operation

theaters separately and 31% overall in theaters and wards and 1% was seen in OPDs. So overall

condition was not good enough for the health of patients and doctors and general public.

According to survey 18% were not having much knowledge for response but 67%, a

major portion, were not having knowledge of healthcare waste. Highly infectious waste from

laboratories were segregated and handled separately from 30% facilities. There were 74%

facilities which were using needle removers and needle cutters in 74% facilities.

As far as use of different containers is concerned minimal concept for the segregation

of healthcare waste exists. 47% healthcare facilities were using simple plastic boxes for the

separation of sharps while 5% used yellow color coded system is used. 28% facilities throw

sharps in ordinary dustbins while 5% use card board boxes, 33% used dustbins and 6% used steel

containers but 22% didn’t use any kind of container for the segregation of healthcare waste.

There were 37% healthcare facilities using dedicated trolleys for internal transportation of HCW

bags. As far as protective material and clothing is concerned with the waste handlers only 46%

healthcare facilities were provided.

When concerned to the temporary storage areas within the healthcare facilities, 45%

had temporary storage areas while 46% had central storage area. For the separation of general

and hazardous waste 31% were separating in central storage areas whereas 33% facilities were

segregating the waste from temporary storage areas. In 35% of the facilities, central storage

areas were having closed doors and 27% were having ceiling. 6% facilities were refrigerated but

30% were washed periodically. 41% facilities were having easy access to central storage areas.

Trolleys were used for the onsite transportation of waste in 36% facilities and two wheel bin

containers in 22%. Municipality vehicles were used in 50% vehicles and 18% vehicles were

using 18% facilities for off-site transportation.

There was no treatment of hospital waste for onsite waste in 60% of the facilities. 17%

were using direct fire system, 18% incineration and only 1% used chemical disinfection. The

majority of waste is disposed of in municipal dumping sites. Even bags were thrown without

proper burial. There were 11% facilities keeping arrangements of disposal system.

1.3.1.4 Conclusion

The above said survey concludes that the knowledge, attitude and practices of hospital waste

management are not up to the required standard in most of the private and public hospitals.

These pose serious health impacts to the visitors to the healthcare facilities so they need serious

attention for its standard management.

1.3.2 Healthcare waste management in Karachi

According to one of the survey by Pakistan Medical Research Council (PMRC) showed that

there was lack of knowledge among 137 personnel involved in hospital waste management of 68

randomly selected healthcare sites in city of Karachi. The study showed that workers dispose of

infectious and non-infectious waste in open bins without proper segregation of waste. Workers

directly deal with waste without protective clothes, gloves etc. Majority of the workers were not

interested in medical checkup. They were not having any protective equipment. There is no

education given to the safe disposal of healthcare facilities waste. Workers were doing jobs for

the sake of earning only. 3

1.3.3 Healthcare waste management in Lahore

According to one of the study conducted at Lahore, showed that majority of sweepers were

aware of the fact that their job is harmful for them but they were doing for economic purposes.

More than 70% workers didn’t use protective equipment because they believe that only rich

nations can take such measures. Most of workers don’t understand the meaning of training so

they are unawareness for the health impacts of health care waste. Majority of the hospital waste

is thrown into the waste bins and some hospitals treat waste with incineration and recycled. The

disposal system in not efficient and workforce involved in its disposal is ignorant of risk

involved. 4

1.3.4 Healthcare waste management in Rawalpindi

According to one of the study done by Maryam S. Abbasi with her group (un-published), 2010,

showed that the hospitals in Rawalpindi and Islamabad most of the facilities don’t follow

procedures for the management of waste. In one of the governmental hospital in Rawalpindi

condition was worse. Staff wasn’t using separate containers for the segregation of waste.

Pathological waste was thrown on open ground adjacent to Gynecology ward. There was no

concept of segregation of sharps. It was collected by workers from open bins and they were

infected via cuts and wounds. Bed sheets were contaminated with blood of patients and not

changed regularly. The worse condition was that staff was unaware of the fact that they can be

infected with infectious diseases. Expired solid medicines and drugs were thrown in same bins

and those bins were observed open in the entire hospital.

On the other hand, condition of the facility of Islamabad was comparatively better. They were

having separate bins and color coded bins for the segregation of waste. Workers were equipped

with protective equipment and they use trolley for the transportation of waste. They use

incineration process for handling of waste and incinerator was within that facility but away from

treatment areas. They had closed pit to dispose off waste after incineration process. But there is

lack of the proper management of nuclear waste. There is no system for the control of flue gases

which are released as a result of incineration. There is no mechanism for the medical check- up

of workers dealing with waste.

1.4 WHO guidelines for management of healthcare waste

Healthcare waste should be managed properly so that infectious diseases can be controlled and

environment could be contaminant free from healthcare waste. Following are the principals for

the disposal of healthcare waste; 5

Segregation

Collection

Interim storage

Transportation

1.4.1 Segregation

Wastes are segregated at their place of production to reduce the health risk from the infectious

factions. Labeling of waste containers is used to identify the source, record the type and

quantities of waste produced in each area, and allow problems with waste segregation to be

traced back to a medical area. A simple approach is to attach a label to each filled container with

the details of the medical area, date and time of closure of the container, and the name of the

person filling out the label. Using an international hazard symbol on each waste container is also

recommended. Few symbols are as follows;

Corrosive Highly flammable Toxic Harmful

Explosive Irritant Extremely flammable Very toxic

Oxidizing Dangerous for environment (N)

1.4.2 Collection

General waste and infectious health-care waste is collected separately and at least once a day.

Collection is at regular times and is reliable.

Waste bags and sharps containers should be filled to no more than three quarters full. Once this

level is reached, they should be sealed ready for collection. Plastic bags should never be stapled

but may be tied or sealed with a plastic bag or tie. Replacement bags or containers should be

available at each waste-collection location so that full ones can immediately be replaced.

Waste bags and containers should be labeled with the date, type of waste and point of generation

to allow them to be tracked through to disposal. Where possible, weight should also be routinely

recorded. Anomalies between departments with similar medical services or over time at one

location can show up differences in recycling opportunities, or problems such as poor

segregation and diversion of waste for unauthorized reuse.

1.4.3 Interim storage

Where possible, hazardous waste generated in medical areas should be stored in utility rooms,

which are designated for cleaning equipment, dirty linen and waste. From here, the waste can be

kept away from patients before removal, then collected conveniently and transported to a central

storage facility. This is known as interim or short-term storage.

Infectious waste, general waste and used sharps waste are stored in separate colour-coded

containers and locations within medical areas, and subsequently at a central storage site at a

health-care facility. Central storage area(s) are fenced, lockable and isolated from patients and

the public. Maximum storage times before treatment or disposal of infectious waste are not

longer than

Temperate climate: 72 hours in winter and 48 hours in summer

Warm climate: 48 hours during the cooler season and 24 hours during the hot season.

Staff receives instruction on three-bin waste segregation and safe handling and storage of

health-care wastes.

Staff is aware of how to protect themselves from injuries and infection from waste.

Waste containers and storage areas are cleaned regularly.

1.4.4 Transportation

Waste containers and onsite transport trolleys are closed with lids to isolate wastes from patients

and the public. Where wastes are transported offsite for disposal, the vehicle is able to carry

wastes in a closed or covered container, and the driver knows what to do if there is an accident or

incident during transportation on public roads. Transport vehicle should be labelled with

symbols. It should be noticed that the climate is very necessary for the disposal of waste. It

shouldn’t be raining because during transportation liquid chemical waste as well as solid waste

may leach onto roads and can be addition to ground water ultimately which may cause havoc.

Transport staff is vaccinated at least against hepatitis A and B, polio and tetanus. Transport

vehicle should be cleaned after disposal of waste. Documentation should be maintained and

checked by respective authorities.

1.5 Treatment methods of healthcare waste

Incineration is the most popular method of choice in most of the countries. The choice of method

should be on the following basis; 6-7

Disinfection efficiency

Health and environmental considerations

volume and mass reduction

Occupational health and safety considerations

Quantity of wastes for treatment and disposal/capacity of the system;

Types of waste for treatment and disposal;

infrastructure requirements

locally available treatment options and technologies

options available for final disposal

training requirements for operation of the method

Operation and maintenance considerations

Available space

Location and surroundings of the treatment site and disposal facility

investment and operating costs

Public acceptability

Regulatory requirements

1.5.1 Incineration

Incineration is a high-temperature dry oxidation process that reduces organic and combustible

waste to inorganic, incombustible matter and results in a very significant reduction of waste

volume and weight. This process is usually selected to treat wastes that cannot be recycled,

reused, or disposed of in a landfill site.

Incineration has drawbacks as well. Though it reduced waste volume but its emissions into

environment are very harmful. During incineration process poisonous gases are release into

environment. The solution is the modification to the incinerator. It should be equipped with such

system which can collect flue gases and can be re-cycled and re-used.

Figure 2: Simplified diagram of incineration process

The process of incineration is made environmental friendly to control environmentally hazardous

emissions.

1.5.2 Autoclaving

Autoclaving is an efficient wet thermal disinfection process. Mostly, autoclaves are used in

hospitals for the sterilization medical equipment so that it can be reused. Autoclaves are used

only for highly infectious waste, such as microbial cultures or sharps because of their low

capacity. It is recommended that all general hospitals, even those with limited resources, be

equipped with autoclaves to sterilize equipment.

Minimum contact times and temperatures depend on several factors such as the moisture content

of the waste and ease of penetration of the steam. Research has shown that effective inactivation

of all vegetative microorganisms and most bacterial spores in a small amount of waste (about 5–

8kg) requires a 60-minute cycle at 121°C (minimum) and 1 bar (100kPa); this allows for full

steam penetration of the waste material.

1.5.3 Microwave irradiation

Most microorganisms are killed by the action of microwaves of a frequency of about 2450 MHz

and a wavelength of 12.24cm. The water contained within the wastes is rapidly heated by the

microwaves and the infectious components are irradiated by heat conduction process.

1.5.4 Land disposal

If healthcare facility lacks the means to treat wastes before disposal, the use of landfill has to be

regarded as an acceptable disposal route. Allowing health-care waste to accumulate at hospitals

or elsewhere constitutes a far higher risk of the transmission of infection, to cause infectious

diseases, than careful disposal in a municipal landfill, even if the site is not designed to the

standard used in higher-income countries. The primary objections to landfill disposal of

hazardous health-care waste, especially untreated waste, may be cultural or religious or based on

a perceived risk of the release of pathogens to air and water or on the risk of access by

scavengers.

The landfill site must be closed to avoid the contamination of the environment. It must be far

apart from population. Landfill sites should be designed according to waste type. It also depends

upon the geology of that disposal site.

1.5.5 Inertization

The process of “inertization” involves mixing waste with cement and other substances before

disposal in order to minimize the risk of toxic substances contained in the waste transferring into

surface water or groundwater. It is especially suitable, for pharmaceuticals and for incineration

products with a high metal content (in this case the process is also called “stabilization”). For the

inertization of pharmaceutical waste, the packaging should be removed, the pharmaceuticals

ground, and a mixture of water, lime, and cement added. A homogeneous mass is formed and got

small solid shapes are produced on site and then can be transported to a suitable storage site.

Alternatively, the homogeneous mixture can be transported in liquid state to a landfill and

poured into municipal waste. The following are typical proportions for the mixture:

65% pharmaceutical waste

15% limes

15% cement

5% water

1.6 HEALTH RISKS DUE TO HEALTH CARE WASTE

Healthcare waste is quite dangerous for health especially waste containing sharps, syringes and

body tissues. Such waste is harmful, not only, for the health of patients but also for medical and

paramedical staff. Cleanliness staff especially sweepers are more prone to such waste because

they directly deal with drugs, syringes and pathological waste. Direct contact with skin causes

several diseases.

According to World Health Organization, in 2000, contaminated syringes caused8:

21 million population suffered from hepatitis B virus (HBV) infections

2 million suffered from hepatitis C virus (HCV) infections

Population of 260 000 suffered from HIV infections

Based on general observation, healthcare facilities in Pakistan don’t follow standard guidelines

for the management of healthcare waste. But there is need to conduct studies for the monitoring

of health of workers dealing with healthcare waste.

Healthcare waste also contains micro-organisms which can infect hospital patients, workers and

general public. Following are health hazards according to waste type; 9

1.6.1 Health impacts from infectious waste

Infectious waste consists of a lot of harmful micro-organisms which can enter into human body

inhalation, ingestion and direct skin contact. This transmission is because of contaminated

needles with human blood. Needles and sharps can not only cause cut but also transmit harmful

viruses which cause vomit, eye and genital secretions, pus, skin secretions, cerebrospinal fluid,

blood and faeces.

1.6.2 Health impacts from chemical and pharmaceutical waste

This type of waste causes several diseases when come into contact. When it is absorbed into skin

or mucous membrane then it causes intoxication and even injuries to the skin and eyes. When

drugs, heavy metals like mercury in dentistry etc are thrown into sewerage system, ultimately

seeps into ground water and causes several diseases.

1.6.3 Health impacts from genotoxic waste

This waste comes out when particular drug is made or open for specific treatment. Its exposure

may be via inhalation, skin contact or infected food. These drugs are usually carcinogenic and

mutagenic. Cytotoxic drugs cause dizziness, nausea, headache or dermatitis. These should be

handled according to standard procedures and wasted items should be handled according to

WHO guidelines.

1.6.4 Health impacts from radioactive waste

Type of disease from radioactive waste depends on its rate of exposure. It can cause headache,

dizziness and vomiting. Most of the radioactive waste is genotoxic and it can alter genetic

material. It can also cause destruction of tissue so it should be undertaken with the utmost care.

The hazards of low-activity waste may arise from contamination of external surfaces of

containers or improper mode or duration of waste storage. Health-care workers or waste-

handling or cleaning personnel exposed to this radioactivity are at risk.

1.7 Conclusion and suggestions

Healthcare waste is of several types and its exposure to public, nurses, cleanliness staff, patients

and paramedical staff is from several routes like inhalation, ingestion and skin contact. Once it

gets entry into environment it causes several health impacts which may lead to death. There are

guidelines and treatment systems in Pakistan for the treatment of healthcare waste but since there

is no system of check and balance so condition is worse here. Most of the diseases are caused

from the exposure to different types of healthcare waste. So there is need to treat this waste

according to WHO guidelines before its final disposal into environment.

Government and associated departments should step in to control the situation. There is

serious need of handling of waste specially sharps and syringes, pathological waste and

infectious waste.

Hospitals, which are major part of healthcare waste, must be charged if they don’t handle

waste properly.

Workers should be given trainings for the awareness of health hazardous of healthcare

waste.

There should be strict rules and regulations for the use of protective equipment such as

gloves and masks and special dress for the collection and disposal of waste.

Above all, there should be proper system for the segregation, collection, storage and

transportation of waste.

Storage area must be separate and away from healthcare facility so that it cannot affect

health of workers.

There should be regular check-up for the workers involved in handling of healthcare

waste specially who are involved in handling of infectious waste.

References

1. P.Annette , E. Jorge , R. Philip, Z. Raki , S. Ruth, P. Ute ,K. William, W. Susan and

C. Yves, 2013, “Safe management of wastes from healthcare activities”, World

Health Organization, Second edition, viewed date; 17-9-13.

2. Pakistan Environment. Fact Sheet. http://www.wwfpak.org/ factsheets _hwf.php

3. S. Habibullah, A. Salahuddin, 2007, Waste disposal of government health care

facilities in urban area of Karachi. PJMR; 46: 1-4

4. MR Khan, F. Fareedi, B. Rashid, 2006, Techno-economic disposal of hospital wastes

in Pakistan. PJMR; 45: 41-45

5. P.Annette , E. Jorge , R. Philip, Z. Raki , S. Ruth, P. Ute ,K. William, W. Susan and

C. Yves, 2013, “Safe management of wastes from healthcare activities”, World

Health Organization, Second edition, viewed date; 17-9-13.

6. Brunner CPE (1989). Handbook of hazardous waste incineration. Blue Ridge

Summit, PA, TAB Books 7. Bartone C (1998). Municipal solid waste management. In: Brazil: managing pollution

problems—the brown environmental agenda. Washington, DC, World Bank (Report

No. 16635). 8. World Health Organization (WHO), Health Impacts of Healthcare waste,

http://www.who.int/water_sanitation_health/medicalwaste/020to030.pdf

9. World Health Organization (WHO), 2000,

http://www.who.int/water_sanitation_health/medicalwaste/hcwmpolicy/en/