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• Volume 12, Issue 3
• Medical waste management-related factors affecting health and experiences of health risks among medical waste handlers in low and middle-income countries: a systematic review protocol of qualitative studies
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• http://orcid.org/0000-0001-7048-1266 Md Nazmul Huda 1 , 2 ,
• Tewodros Getachew Hailemariam 3 ,
• Syeda Zakia Hossain 4 ,
• James Sujit Malo 5 ,
• Sajedul Khan 6 ,
• Setho Hadisuyatmana 7 ,
• Afsana Ferdous 8 ,
• Blessing Akombi-Inyang 9 ,
• Rakibul M Islam 10 , 11 ,
• Andre M N Renzaho 12
• 1 School of Liberal Arts and Social Sciences (SLASS) , Independent University , Dhaka , Bangladesh
• 2 School of Health Sciences , Western Sydney University , Campbeltown , New South Wales , Australia
• 3 School of Public Health , Wolaita Sodo University , Sodo , Ethiopia
• 4 Faculty of Medicine and Health , The University of Sydney , Sydney , New South Wales , Australia
• 5 The Leprosy Mission International Bangladesh , Dhaka , Bangladesh
• 6 School of Social Work , Massey University , Auckland , New Zealand
• 7 Faculty of Nursing , Universitas Airlangga , Surabaya , Jawa Timur , Indonesia
• 8 Department of Political Science , University of Dhaka , Dhaka , Bangladesh
• 9 UNSW , Sydney , New South Wales , Australia
• 10 School of Public Health & Preventive Medicine , Monash University , Clayton , Victoria , Australia
• 11 South Asian Institute for Social Transformation , Dhaka , Bangladesh
• 12 Translational Health Research Institute, School of Medicine , Western Sydney University , Penrith , New South Wales , Australia
• Correspondence to Dr Md Nazmul Huda; hudasoc2020{at}gmail.com

Introduction Medical waste management (MWM)-related factors affecting the health of medical waste handlers (MWHs) and their health risks in low and middle-income countries (LMICs) are an important public health concern. Although studies of MWM-related factors and health risks among MWHs in LMICs are available, literature remains undersynthesised and knowledge fragmented. This systematic review will provide a comprehensive synthesis of evidence regarding the individual, system and policy-level MWM-related factors that affect MWHs’ health and their experiences of health risks in LMICs.

Methods and analysis All qualitative studies published in peer-reviewed journals between 1 July 2011 and 30 June 2021 with full texts available and accessible will be included in the review. Seven specific electronic databases (eg, Scopus, Ovid MEDLINE, EMBASE, Global Health, CINAHL, ProQuest and PsycINFO) will be searched. Two authors will review the citations and full texts, extract data and complete the quality appraisal independently. A third reviewer will check discrepancies when a consensus cannot be reached on differences between the two reviewers. Data extraction will be conducted using the Joanna Briggs Institute standardised data extraction form for qualitative research. The quality of articles will be assessed using a Critical Appraisal Skills Programme checklist. Results from eligible articles will be synthesised into a set of findings using the thematic framework analysis approach and will be reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research statement.

Ethics and dissemination This review is based on published articles, which does not require ethical approval because there is no collection of primary data. Findings from this review will be published in a peer-reviewed journal and presented at relevant public health conferences. This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO).

PROSPERO registration number CRD42020226851.

• health & safety
• public health
• occupational & industrial medicine
• risk management
• infection control

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2021-056037

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Strengths and limitations of this study

The primary strength of the systematic review is that it will bring together the current knowledge in the area of medical waste management (MWM)-related factors affecting the health of medical waste handlers (MWHs) and their experiences of health risks in low and middle-income countries (LMICs). This review will develop a context-specific comprehensive understanding of the individual, system and policy-level MWM-related factors that affect the health of MWHs, and their experiences of health risks.

To the best of our knowledge, this review will be the first evidence synthesis of the individual, system and policy-level MWM-related factors that affect MWHs’ health, and their experiences of health risks in LMICs using a systematic approach.

This review will only include studies published in the English language. Excluding studies published in languages other than English may produce publication bias and impact generalisability.

The healthcare sector in low and middle-income countries (LMICs) is growing fast 1 due to rapid population growth, and concomitant increased use of medical services 2 generates increased medical wastes (MW). 3 Low-income countries are those with a gross national income (GNI) per capita, calculated using the World Bank Atlas method, of $1045 or less in 2020. Lower middle and upper middle-income countries are those with a GNI per capita from $1046 to $4095 and $4096 to $12 695, respectively. 4 According to the WHO, 5 MWs refer to wastes and by-products generated by healthcare and medical research settings, including medical or diagnostic centres and hospitals. While most MWs are not hazardous, around 15% of them are considered dangerous wastes. 3 6 These hazardous MWs may be infectious (contaminated blood, cultures and stocks of contagious agents), sharps (syringes, needles, disposable, etc), cytotoxic (eg, wastes comprising cytostatic drugs—commonly used in cancer therapy, genotoxic chemicals), radioactive (eg, unused liquids from radiotherapy or laboratory research, contaminated glassware, packages or absorbent paper; urine and excreta from patients treated), chemical (disinfectants, sterilants, heavy metals, etc) or pharmaceutical (expired, unused and contaminated drugs and vaccines). 5–8 These wastes contain pathogenic micro-organisms that may enter into human bodies, especially in medical waste handlers (MWHs) in LMICs, through various routes, including punctures, abrasions or cuts in the skin, inhalation and ingestion. 3 Thus, MW constituents have the potential for injury and infection.

Health risk can be characterised as the probability of a situation or an event and its consequences related to infectious diseases (hepatitis B and C, HIV and COVID-19) and other health complications (eg, respiratory disorders, cancer, burn and skin irritation) of individuals’ (eg, waste handlers) health. 9 MWHs, particularly those in LMICs, 10 are potentially at a higher health risk to various injuries and infections due to the manual sorting of dangerous materials at waste disposal sites. 3 Compared with high-income countries, medical waste management (MWM) in LMICs is not well equipped with the resources and capability to reduce health risks of MWHs. Additionally, the good MWM practices are not followed by waste handlers due to inadequate education and training. 11 Furthermore, the emergence of the COVID-19 pandemic has resulted in increased dangerous MWs from increased use of personal protective equipment 12 such as gloves, surgical masks, goggles or face shields, gowns, respirators (ie, KN95 or FFP2) and aprons. 13 Improper management of these used infectious MWs, especially in LMICs, may increase the risk of injuries and infections, including the COVID-19, hepatitis B and C and sharps-inflicted injuries, among MWHs. 14 15

Although studies of the individual, system and policy-level MWM-related factors affecting the health of MWHs and their health risks in LMICs are available, 16–18 the findings of these studies were not systematically synthesised. Systematically identifying, collating, synthesising and appraising available literature will provide a comprehensive understanding of the individual, system and policy-level MWM-related factors affecting the health of MWHs in LMICs and their health risks and help inform future health policy and practices related to MWM in LMICs. Furthermore, systematically synthesising various findings of available studies may help LMICs, which may not follow the best available MWM practices and can learn from similar settings, thus improving their MWM. This sets a strong rationale for synthesising available evidence and understanding gaps through this review and suggests recommendations for improving MWM and reducing health risks. Therefore, this systematic review will identify, appraise and synthesise qualitative evidence on the individual, system and policy-level MWM-related factors that affect MWHs’ health in LMICs and explore common health risks experienced by them in LMICs. The review will answer the following questions: (1) what are the individual, system and policy-level MWM-related factors affecting the health of MWHs in LMICs? and (2) what are common health risks experienced by MWHs in LMICs?

This protocol is informed by the standard Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols reporting guidelines 19 (see online supplemental file 1 ). This review will use the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement to report the thematic synthesis of qualitative studies. 20 21 The ENTREQ statement aids investigators in reporting the phases most usually related to the synthesis of qualitative health research, including searching and selecting qualitative studies, quality appraisal and methods for synthesising qualitative findings. 20

Supplemental material

Patient and public involvement.

No patient was involved.

Search strategy

In this review, the following seven electronic databases will be searched for relevant studies in the past 10 years: Scopus, Ovid MEDLINE, EMBASE, Global Health, CINAHL, ProQuest and PsycINFO. In the case of relevant publications which might have been missed during the initial search, a further search of the bibliographical references of all eligible publications, complemented by citation tracking using Google Scholar, will be conducted. A search strategy will be developed on MEDLINE and adapted to other databases as shown in online supplemental file 2 . The search will apply truncations (*) and Boolean operators (‘AND’, ‘OR’ and ‘NOT’) depending on the specifications of the databases. A research librarian will be consulted to finalise the search strategy. A search log will be kept for accountability and transparency. Two authors (MNH and TGH) will identify relevant literature, run a screening using titles and review abstracts during the literature search. Final selection will be accomplished by reviewing full texts and applying eligibility criteria to include studies aligned with the research objectives. Database searches will be rerun prior to the final analysis to ensure any recent publications are included in the review. The search will be limited to English literature only since we have limited or no financial and logistical capacity to retrieve and translate articles published in languages other than English.

The search strategy will include all possible search terms, keywords and phrases relevant to the topic. As per a database of interest to conduct the search, we will apply a multipurpose (.mp) search across several fields, including title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word and unique identifier, to have efficient search outputs. The search strategy will use the following key terms: ‘medical waste’, ‘waste management’, ‘training’, ‘knowledge’, ‘technology provision’, ‘infrastructure’, ‘policy’, ‘regulation’, ‘medical waste handlers’, ‘health risks’, ‘infectious disease’, ‘health complications’, ‘low and middle-income countries’, ‘developing countries’ and ‘resource-limited countries’. Along with these key concepts for search criteria, specific diseases (including COVID-19/coronavirus, HIV/AIDs, hepatitis B and C, cancer) and health complications (eg, respiratory disorders, cancer, burn and skin irritation) will be searched to find relevant articles.

Inclusion and exclusion criteria

Types of studies.

All qualitative studies published in peer-reviewed journals (1) between 1 July 2011 and 30 June 2021 with full texts available and accessible will be included in the review. Qualitative literature will be chosen because the review’s interest is to understand better the experiences of MWHs’ health risks. Studies that (2) apply established qualitative data collection techniques (such as semistructured and unstructured interviews, focus group discussions, direct observations or semistructured questionnaires that permit free texts); (3) highlight the health risks experienced by MWHs; (4) focus on factors affecting MWHs’ health risks in LMICs; and (5) are published in English will be included in the analysis.

Studies will be excluded if they (1) use statistical analysis and do not provide accounts/quotes of study participants, or (2) apply mixed methods which lack accounts or quotes of study participants, and (3) are study protocols, reviews, editorials, letters to editors, commentaries, conference abstract, posters and opinion pieces.

Participants/populations

Participants will include MWHs, defined as all workers (eg, waste cleaners, waste pickers, collectors, recycling waste operators, scavengers, landfill workers, garbage workers) who are directly involved in MW collection and final disposal at waste disposal sites (city corporation bins and general landfill sites), medical research institutes and healthcare facilities (public and private hospitals/clinics) as recommended by the WHO. 8 The participants will include: (1) MWHs of all age groups, including children from 10 years and above; (2) both male and female garbage workers; (3) waste pickers who search MWs before or after the final disposal; and (4) scavengers who search MWs before or after the final disposal. However, this review will exclude MWHs having severe pre-existing health risks before they became involved in MWM.

Type of setting

We will include studies from LMICs where MW workers are engaged in collecting MW from waste disposal sites, medical research institutes and healthcare facilities, and disposing of waste at disposal sites.

Table 1 summarises the inclusion and exclusion criteria for this systematic review.

• View inline

The inclusion and exclusion criteria for this study

This review’s primary outcome will consist of the individual, system and policy-level MWM-related factors affecting MWHs’ health in LMICs. The secondary outcome will be the health risks experienced by the MWHs in LMICs.

Data collection and analysis

Study selection.

All studies identified in the search will be exported into the reference manager EndNote library. A three-step screening process will be applied to screen and select eligible studies. The first step will involve assessing the titles for relevance, in which case clearly irrelevant titles will be excluded. After that, abstract screening for eligibility and relevance will be conducted, and studies that do not meet the inclusion criteria will be excluded. In the final step, the full text of the retained studies will be further screened for inclusion in the review. Final studies selected from the full-text screening will be recorded. Two reviewers (MNH and TGH) will independently perform the study selection, and any disagreements will be resolved by a third reviewer (SH).

Data extraction and management

Data will be independently extracted by two review authors (MNH and TGH) from eligible studies onto the Joanna Briggs Institute standardised data extraction form for qualitative research 22 (see online supplemental file 3 ) and populated with variables pertaining to the study population and phenomena of interest. If there are disagreements between the two authors, a third author (SH) will double-check and verify the differences. Study characteristics that will be extracted will include the first author’s name and publication year, data collection period and country in which the study was conducted. Then, descriptive data will be captured, including the study design, study population, sample size, sampling procedures and data collection procedures. The main findings and accounts of participants that explain the individual, system and policy-level MWM-related factors affecting MWHs’ health in LMICs and the common health risks experienced by MWHs will be systematically extracted.

Quality appraisal

Studies included in this review will be assessed for methodological quality and risk of bias 23 using the Critical Appraisal Skills Programme (CASP) quality assessment tool for qualitative studies. 24 The CASP tool consists of 10 questions: 9 addressing ‘quality’ and 1 addressing ‘value’ (contribution to existing literature). All included studies will be appraised as high, medium or low quality, and the Grading of Recommendations Assessment, Development and Evaluation approach 25 will be used to assess the overall quality of the studies included in this review. Two reviewers (MNH and TGH) will independently score the quality appraisal assessment. We will apply both scoring methods and discussion to arrive at a consensus on quality. A third author (BA-I) will adjudicate should no agreement be reached between the two reviewers.

In line with other qualitative reviews, 26 27 this review will not exclude studies on the basis of quality. Instead, a further understanding of the contributions of the included studies will be provided at a later stage of this review. Regardless of the quality appraisal score, all studies relevant to the review questions will undergo data extraction and synthesis to assess and compare the findings. The results of the quality appraisal will be reported in a narrative form and a table.

Data synthesis and analysis

In accordance with the existing systematic reviews, 28 29 we will adopt the thematic framework analysis approach to identify the individual, system and policy-level MWM-related factors affecting MWHs’ health in LMICs and their common health risks from the narratives of critical findings in selected studies. 30 The thematic framework analysis is one of the approaches recommended by the Cochrane Qualitative Review Methods Group 31 to perform syntheses of qualitative studies. 32 Thematic synthesis is appropriate where the evidence is likely to be mainly descriptive 28 and will enrich our understanding of the individual, system and policy-level MWM-related factors that can affect MWHs’ health in LMICs and their experiences of health risks. We will follow the five stages of the thematic framework analysis to synthesise the data 28 33 (see below).

Familiarisation with the data

The first author (MNH) will begin with familiarising the data against the review aims and documenting recurrent themes across the studies.

Identifying a thematic framework

Given our interest in identifying a priori themes (individual, system and policy-level MWM-related factors affecting MWHs’ health and their experiences of common health risks), we will use a predetermined thematic framework which was developed using literature (see online supplemental file 4 ) to guide the thematic analysis instead of developing our own a priori framework. We will also explore emergent issues (including author, country, research focus, etc) related to review objectives. This thematic framework provides a detailed list of individual, system and policy-level MWM-related factors affecting MWHs’ health and their experiences of health risk in LMICs.

The two authors (MNH and TGH) will independently read the extracted information to search for themes according to a predetermined thematic framework and additional emergent themes. The framework will be revised as new themes emerge. All studies will be read until there are no new emerging themes. The data will be coded based on the themes identified in the data. Each primary study will be indexed using the codes related to the themes of the framework. Where appropriate, parts of the studies may be indexed with one or more codes. All agreements and disparities between the coders will be resolved through discussion and consensus among all authors.

We will group the data into descriptive themes that capture and describe patterns in the data across studies and present the themes in the form of an analysis table (chart). The columns and rows of the table will reflect the studies and related themes and enable us to compare the findings of the studies across different themes and subthemes.

Mapping and interpretation

We will use charts to define the identified concepts and map the range and nature of the phenomena. This systematic review will explore relationships between the themes to help clarify the findings. We will synthesise the findings across studies and interpret their meanings concerning the review research questions and emerging themes.

Investigation of heterogeneity

We will assess heterogeneity of findings by conducting subgroup analyses according to: MWHs at various settings (healthcare facilities, incineration and waste disposal facilities, public and private healthcare facilities), ages (children vs adults), types of hazardous MWs (infectious, sharp, cytotoxic, radioactive, chemical and pharmaceutical) and health risks (infectious vs non-infectious). We will also consider other axes that can emerge as essential when synthesising the evidence, such as settings (low-income vs middle-income countries) and waste management in urban and rural areas.

Globally, most LMICs have inadequate and inappropriate MWM practices, and various factors contribute to exacerbating MWM-induced health risks among MWHs. 11 34 MWHs’ vulnerability to health risks and the necessity for improving MWM in LMICs highlight a research and policy priority. A substantial pool of literature exists on the subject matter but remains undersynthesised. The considerable body of literature supports the necessity for a review to provide a robust summary of evidence that could be drawn on to optimise policies and planning related to MWM and health risks experienced by MWHs in LMICs. By analysing the accounts of participants across their exposure settings, and demography, this review could provide a direction where possible future interventions or research should focus on reducing the risks and long-term effects on MWHs. The results of this systematic review could be used to understand the individual, system and policy-level MWM-related factors affecting MWHs’ health in LMICs and their experiences of common health risks. The review findings will inform and guide healthcare authorities in developing MWM-related interventions to improve MWHs’ health in LMICs and reduce their health risks.

Ethics and dissemination

This review is based on published studies, which does not require ethical approval, because there is no collection of primary data. Findings from this review will be published in a reputable peer-reviewed journal and presented at a relevant public health conference. The protocol has been registered with the International Prospective Register of Systematic Reviews.

Ethics statements

Patient consent for publication.

Not required.

• Jakovljevic M ,
• Torkashvand J ,
• Pasalari H ,
• Jonidi-Jafari A , et al
• Padmanabhan K ,
• ↵ WHO. health-care waste , 2021 . Available: https://www.who.int/topics/medical_waste/en/
• Mugivhisa LL ,
• Dlamini N ,
• Rahman MM ,
• Bodrud-Doza M ,
• Griffiths MD , et al
• Khan AA , et al
• Patrício Silva AL ,
• Walker TR , et al
• Sharma HB ,
• Vanapalli KR ,
• Cheela VRS , et al
• Patwary MA ,
• O’Hare WT ,
• Shaikh BT ,
• Somrongthong R , et al
• Sapkota S ,
• Karki J , et al
• Shamseer L ,
• Clarke M , et al
• Flemming K ,
• McInnes E , et al
• Swennen MHJ ,
• van der Heijden GJMG ,
• Boeije HR , et al
• Aromataris E ,
• Henderson J ,
• Alderdice F
• Critical Appraisal Skills Programme
• Guyatt GH ,
• Vist GE , et al
• Vaughn VM ,
• Krein SL , et al
• Lambrechts F ,
• Simons P , et al
• Glenton C ,
• Colvin CJ ,
• Ballini L ,
• Maltoni S , et al
• Papaioannou D
• Dixon-Woods M
• Young T , et al
• Chaudhry N , et al

Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1
• Data supplement 2
• Data supplement 3
• Data supplement 4

Twitter @nazmul_bakhtiar, @BlessingAkombi

Contributors MNH, SK and AF conceptualised the idea and designed the review. MNH, JSM, SK, SH and AF drafted the initial protocol. MNH and SK developed the search strategy. MNH interpreted, analysed and revised the manuscript with intellectual input from TGH, SZH, BA-I, RMI and AMNR. All authors read and approved the manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• Open access
• Published: 07 July 2021

Current practices of waste management in teaching hospitals and presence of incinerators in densely populated areas

• Salma Khalid 1 ,
• Najibul Haq 2 ,
• Zia-ul-Ain Sabiha 3 ,
• Abdul Latif 1 ,
• Muhammad Amjad Khan 4 ,
• Javaid Iqbal 4 &
• Nowsher Yousaf 4  

BMC Public Health volume  21 , Article number:  1340 ( 2021 ) Cite this article

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Metrics details

Hospital waste management (HWM) practices are the core need to run a proper health care facility. This study encompasses the HWM practices in teaching hospitals of Peshawar, Pakistan and examine the enforcement of Pak HWM (2005) rules and risks through transmission of pathogens via blood fluids, air pollution during waste incineration and injuries occurring in conjunction with open burning and dumping.

A questionnaire based on World Health Organization (WHO) recommendations was used to survey the selected private and public teaching hospital ( n  = 16). Site visits and personnel observations were also included in the data. It was spatio-statistically analyzed using descriptive statistics, Krushkal-wallis and Fisher’s exact tests.

The findings revealed that the lack of HWM practices in all surveyed hospitals ( p  > 0.05), besides statistical difference ( p  < 0.017) in waste generation/day. No proper segregation of waste from generation point to final disposal was practiced. However, the performance of private teaching hospitals (50%) was found better in terms of HWM personnel and practices. In surveyed hospitals, only nine hospitals (56.3%) were found with the incinerator facility while rest of the hospitals (43.7%) practiced open dumping. Moreover, operational parameters of the incinerators were not found satisfactory and located in densely populated areas and emitting hazardous gases.

Proper HWM practices are not being followed in the light of WHO guidelines. Hospital waste impose serious menace to healthcare workers and to nearby population. WHO issued documents for improving HWM practices but triggered no change in Pakistan. To improve the situation, insights in this context is need for enforcement of rules.

Peer Review reports

Globally, inadequate and improper handling of hospital’s waste is a major concern in many developing countries [ 1 ]. The effect of waste mismanagement is considerable and far-reaching in terms of serious public health consequences and has significant impacts on the environment [ 1 , 2 , 3 ]. Main contributing factors for increased ratio of hospital waste generation are high population growth rate, increase in number of healthcare facilities, easy access of population to the health care facilities and use of the disposable medical products [ 4 , 5 ].

Worldwide, published literature on medical waste management reported poor handling, treatment and disposal of biomedical waste in many health care facilities. Hospital waste includes hazardous or risk waste and non-risk waste [ 1 , 6 ]. A total of 15–20% healthcare waste is infectious, while 80–85% is non-infectious [ 1 ]. Waste produced in the hospitals either in large or small quantities carries high potential of infections and injuries [ 1 ]. The study of Almuneef et al., [ 7 ] has pointed out a strong probability that blood transmitted diseases such as AIDS, hepatitis B, hepatitis C and tuberculosis could be transferred to sanitary staff through poor handling of the hospital waste. In many low and middle income countries, hospital and municipal wastes are collected and disposed- off jointly, exposing municipal workers and public to major health risks [ 8 , 9 , 10 ]. According to a survey conducted by WHO (2005) in 22 developing countries including Pakistan for hospital waste management (HWM) practices, approximately 18–64% of waste disposal methods in practice were found unsuitable.

Studies in Pakistan showed that around 2 kg of waste/bed/day is produced, out of which 0.1–0.5 kg can be categorized as risk waste and their mismanagement occurs at all levels, from segregation through collection to its final disposal [ 11 ]. Despite of waste mishandling in the site of generation; its open dumping without incineration becomes the source of collection for scavengers. They collected used medical products which are recycled and re-sold in the markets [ 12 , 13 ].

In many developing countries, including Pakistan, incinerators consist of primary and secondary combustion chambers for treatment of medical wastes [ 14 ], while the WHO recommended standard is a multi-chambered incinerator. In these incinerators, an absorption combination wet cyclone ensures the removal of gaseous particles, [ 15 ] whereas other low weighted air particles are preferably removed by lowering the temperature up to 200 °C [ 16 ]. In general, these incinerators work on high temperature and gas retention time frames and therefore require a huge quantity of fossil fuels to reach the desired temperature in their combustion chambers [ 17 ]. Worldwide, hospitals are setting up incineration systems based on sophisticated technology for hazardous medical wastes with lower combustion costs [ 18 ]. Although incineration is one of the final treatment option, [ 19 ] but un-regulated incineration leads to harmful effects on health including effects on sex ratio in child birth, congenital anomalies and cancer among population living nearby to an incineration plant [ 20 , 21 ]. Studies on biomarkers support this: populations exposed to emissions more than others have higher biological levels of released substances [ 22 , 23 ].

Likewise, several studies address various reasons, such as lack of awareness of hospital staff as well as the administration to enforce the rules, assessment of hospital waste compositions, unsafe and malpractices of hospital waste and their impacts on human health and environment [ 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ], but in published literature, limited studies exist at the management status of hospital waste, current practices, and issues responsible for the gaps in the teaching hospitals of Pakistan. The present study is based to evaluate and compare the current practices of hospital waste management being undertaken by public and private teaching hospitals in Peshawar, along with structural and operational parameters of incinerators in relation to Pak HWM (2005) rules [ 34 ] based on WHO guidelines [ 35 ]. The Pak HWM rules 2005 specify structure for HWM policy including a waste management team, a waste management plan and weekly record for quantities of generated waste. It is believed that this study will not only evaluate and unveil the differences that lie in management procedures, but also would be helpful to improve the current practices of HWM, which in turn enable the concerned authorities to set directions and implement strategies under the WHO guidelines and appropriate regulatory enforcement.

The present study has been conducted in Peshawar, Khyber Pakhtunkhwa. Peshawar is located between 33° 44′ N to 34° 15′ N latitudes and 71° 22′ E to 71° 42′ E longitudes. The concerned area cover is of 1257 sq.km and has been considered a historical city due to its geostrategic and socio-economic significance. According to 2017 population census, Peshawar possesses a total population 4,269,079 along with 3.99% average annual population growth rate.

Study design

The present research is a descriptive, cross-sectional study on HWM in selected public and private hospitals in Peshawar. A comprehensive study was conducted from February to March, 2019 in three government tertiary care hospitals, three government non-tertiary hospitals and ten private teaching hospitals in Peshawar. Only teaching hospitals from public and private sectors with bed capacities of more than 250 beds were selected (Table  1 ). All the surveyed hospitals are mostly located in residential areas with an average distance of 3.3 km from each other, approximately.

Data collection and analysis

For this research study, data were collected from the mentioned hospitals after getting the necessary approval from the concerned authorities i.e. Environmental Protection Agency (EPA) and Water and Sanitation Services Peshawar (WSSP) and ethical approval from Institutional Medical Ethics Committee. Data were collected through pretested structured questionnaire based on recommendations by the WHO for evaluation of HWM in developing countries [ 36 ]. It consisted of four parts, general information, waste management practices, presence and functional parameters of the incinerator and final disposal of the incinerator bottom ash. Site observations through checklist for the reliability of given information were also included in the survey. The questionnaire was filled during site visits, using information from personnel who were directly related to medical waste management (e.g. administrative officer, facility manager, waste collectors, incinerator operator, engineer and environmental health officer). Questionnaire attached as supplementary material in Additional file 1 . The collected data were analysed through SPSS software 25, for the descriptive statistics as well as Kruskal-wallis test for computing statistically significant difference with 95% Cl among public and private sector hospitals for waste generation and fisher’s exact test for hospital waste management practices.

Initially, hospital waste generation per day and management plan were evaluated. All teaching hospitals have records of the waste generated from their respective institutions. Overall (87.5%), hospitals have plans a hospital waste management committee, sanitary staff and clearly defined procedures for the collection and handling of wastes from specified units (Table  2 ). Training for HWM team was provided in hospitals (62.5%), while records about trainings was found almost negligible in all surveyed hospitals (Table 2 ).

Furthermore, no recorded data for the quantity of waste generated per bed and its composition per day, both at institutional level as well as in total, were found. General wastes were found to be mixed with health care or infectious waste in all teaching hospitals.

Government tertiary care hospitals produced more waste approximately on average of (900 kg/day) with mean rank of (15), government non-teaching hospitals (166.7 kg/day) with mean rank of (9.67) and private teaching hospitals produced (78.6 kg/day) with mean rank of (6.20) without any segregation at generation point (Fig.  1 ).

Waste generation in kg/day in surveyed teaching hospitals of the study area

Overall, when the mean ranks of public hospitals were compared with those of private hospitals, significant increased ( p  < 0.017) in waste generation were found in public hospitals due to their more than 1200 patient bed capacity and higher outdoor patient flow and visitors. The summary statistics for pair wise comparison is presented in (Table 3 ) in which government tertiary hospitals waste generation rate was found statistically different across the private teaching hospitals ( p  < 0.014).

Current practices of HWM were observed during the site visits and verified through checklist (Tables  4 and 5 ). It was found that segregation of waste at the generation point was not properly followed in all public teaching hospitals due to patient overload, while only (60%) of private teaching hospitals comply as per WHO guidelines. Hospital staff was not fully aware of proper segregation at the point of generation and collection. Overall percentage was found (37.5%) with no statistical difference between public and private teaching hospitals ( p  > 0.098). The study further states that there is no proper dedicated staff for the segregation of waste. However, the percentage of identified staff was found more (68.75%) as compared to dedicated staff (31.25%) in all of the surveyed hospitals.

Waste collecting bins were observed in all public sector hospitals (100%) and in private teaching hospitals (60%) with proper labels and color codes. All the government tertiary care hospitals were not maintaining appropriate shifting of wastes from smaller bins to larger containers at disposal point. Most often, in both sectors, the waste was being collected in shopping bags/bins once filled (56.3%) carried out by waste handler (50%) to the temporary storage point. As such no proper availability of trolleys and wheel barrowers for waste transportation were observed in public hospitals (0%). Statistically, no significant difference was observed in both public and private sector hospitals ( p  > 0.05) in terms of required facilities for waste collection from generation point to temporary storage area.

However, about (50%) in private teaching hospitals, waste collection was done by means of trolleys or wheel barrowers for on-site transportation of hospital waste and is not used for other purpose. Site survey also revealed that only (50%) private teaching hospitals have temporary storage area within the hospital premises with color coded labeled containers (50%) for waste segregation, whereas rest of the hospitals dumped waste in open area. Staff in the hospitals was handling the waste without using proper protection measures except gloves (100%) and were not aware of the potential hazards. In all surveyed hospitals, none of the observed waste handler and staff wore face masks, aprons or protective shoes. No record for vaccination against hepatitis A & B and Tetanus were found for the protection of workers who are in daily contact with waste handling and collection (Table 4 ).

Overall, (56.3%) of the hospitals had been equipped with incinerator, out of which (100%) in government tertiary care hospitals, no incinerator in govt. non tertiary hospitals and (60%) in private teaching hospitals. Observed incinerators were locally made and found not environmentally friendly as they used old technology and operations were not up to the minimum standards like temperature range and chimney height etc., as shown in the (Table 4 ). Approximately (33.33%) incinerators were found single chamber, (44.4%) double chamber and (22.22%) multi-chamber in private and public sector hospitals respectively.

Coal and sometimes diesel/kerosene are used as fuel in the incinerator due to shortage of natural gas, which is a potential source of toxic air pollutants. Availability of an incinerator operational manual was also checked and found (66.67%) in hospitals (Table  5 ).

Those hospitals which have no incinerator facility (43.75%) were mostly practicing open dumping/burning of the waste in the vicinities. They have 3 or 5 years contracts with private companies other than WSSP for ash burial/open dumping of waste in their own lands or fields without realizing the hazardous effects of the waste on health and environment.

Ash generated at the incinerator was not being buried deeply in the 4 or 5 ft cemented pits/trench. Only (11.11%) hospitals including (16.67%) private teaching hospitals have cemented pits arrangement for final disposal of ash, while (88.89%) hospitals used container including (100%) government tertiary care hospital and (83.33%) private teaching hospitals. No documentation record for incinerated waste was found in all hospitals. In the present study, as such, no HWM practices were observed for Government non-tertiary hospitals.

Comparing the present results with other studies around the world, as well as some studies conducted in major cities of Pakistan, clearly indicates that there was no proper, systematic management of hospital waste practiced [ 24 , 29 , 37 , 38 , 39 , 40 , 41 , 42 ]. Although, (87.5%) surveyed hospitals have HWM plan and team with specified responsibilities. In addition to this study, the study of Harhay et al., [ 43 ] showed that six countries including China, India, Brazil, Pakistan, Bangladesh and Nigeria, the top ten most populous countries in the world, were found to be facing inadequate HWM problems.

These poor management practices are not only due to the lack of interest from the hospital management team or lack of awareness concerning health risks, but also due to the economic issues in implementation of healthcare policy from the government [ 8 ].

Although 20 years ago, WHO issued documents assessing in improving the waste management from hospitals but unfortunately did not trigger any change in Pakistan.

The study of Zeeshan et al., [ 42 ] about HWM polices in Pakistan revealed partial presence of HWM plans, poor record keeping of waste produced and lack of dedicated budget for HWM. In this context, Pak HWM- 2005 rules still need positive improvement and additional provision to become in alignment with the WHO standard guidelines [ 37 ]. The better hospital waste management can be perceived through effective legislation of healthcare waste management and can be witnessed in Kingdom of Bahrain; where proper management of the healthcare waste practices showed positive signs of improvement due to amendments and revisions for improvement in national healthcare waste management legislation [ 44 ].

In the present study, as such no significant difference were found in hospital waste management practices except waste generation per day which was found comparatively higher in tertiary care hospitals ( p  < 0.017) than private teaching hospitals. This may be attributed due to high in patient flow, provision of services and greater bed capacity, but required more attention and efforts to train the hospital waste management team so as to prevent the infections stemming from the waste.

However, there was found no documented/maintained record of waste by type at the point of generation per bed in the studied hospitals.

Usually, private teaching hospitals were witnessed better than the public ones in some fields of waste management. Findings of the present study are similar to a study conducted in Islamabad which revealed that the practices of hospital wastes are better in private hospital than the public one [ 45 ]. Similarly, in other study conducted by Khan et al., [ 40 ] in four tertiary care hospitals of Peshawar, i.e. two hospitals from public and two from private sectors revealed that private hospitals performed well practices for waste management as compared to public hospitals. Although private hospitals may charge more and hence have less patients but may be more inclined to follow better HWM practices in comparison to public hospitals where the conditions are just reversed. The most prominent reasons for relatively better practice of waste management in the private teaching hospitals are waste segregation, storage, training and awareness and staff availability etc., but are unable to fully implement and practice the HWM rules- 2005.

Generally, the segregation of waste at the generation source is considered as one of the crucial components for efficient HWM practices but unfortunately, it is not followed properly as per WHO guidelines which recommend that “hospital waste be separated in distinct groups with regard to the requirements of disposal and treatment”. Improper segregation could convert rest of the general waste into hazardous waste and poses a potential threat to all the stakeholders including healthcare providers, patients, visitors and surrounding communities [ 46 ]. Studies from other developing countries were also in lined, that there was found no proper segregation of waste into different groups at generation point for proper disposal. Mostly, hospital waste collected from different units was dumped along with general waste for further disposal [ 10 , 47 ]. Likewise, (75%) surveyed hospitals had color code and labeled containers but in fact, there was seemed no proper supervision from HWM team/administration for waste segregation at the generation point. Apart from this, (31.25%) of studied hospitals used the color code and labeled containers at temporary storage area. About (68.75%) of surveyed hospitals had no temporary storage area for waste and practiced open dumping. As per HWM [ 34 ] rules, waste needs to be collected at least once daily in accordance with the schedule specified in waste management plan. The removed waste bags and containers need to be replaced with new ones of same type, but unfortunately the present conditions are most horrible. Mahwish et al., [ 48 ] in their study revealed the same conditions in both public and private hospitals of Islamabad, Karachi, Lahore, and Khyber Pakhtunkhwa of Pakistan.

In (50%) hospitals, on site transportation of waste was mostly done manually, using plastic bags, while off- site transportation was undertaken with the use of trucks, by had contracts with different government and private authorities. Highlighting the hazardous nature and involving high risks of waste handler in terms of getting injury or contact with disease causing pathogen, Johnson et al., [ 49 ] in their study described that off-site transportation of hospital waste on roads must be carried out by trained staff in a dedicated vehicles with closed containers. Similarly, Patil et al., [ 50 ] in their study illustrate that “management of hospital care waste depends on the input from the administration and active participation by trained staff in segregation, storage, collection, transportation, treatment and disposal”.

Furthermore, in surveyed hospitals, the identified staff/waste handler as well as HWM staff did not use all the required PPE (i.e. plastic gloves, face mask, apron, protective shoes and shades) except wearing gloves; such staff handled and transported the waste without realizing the high risks in case of injury and accidently being in contact with disease causing pathogens [ 19 ]. A study conducted by [ 51 ] in Karachi among health care workers reported high prevalence of hepatitis B infection, among 20% sweepers of a medical center due to unsafe disposal of hospital waste. Similar results have been reported in various studies, highlighting the importance of PPE for waste handlers, while dealing with potentially dangerous waste particularly sharps, blood and blood contaminated fluids [ 52 , 53 , 54 ]. Also no maintained record of vaccination for protection against from hepatitis A & B and Tetanus were found for HWM team.

Currently, three kinds of methods are being used for disposal of waste, i.e. incineration, landfills, and open dumping. Neither a single landfill is constructed on scientific lines nor do the installed incinerators at various places have proper structure and operational parameters. The most prevalent type of waste treatment was observed as incineration and open burning and finally the waste disposed together with general waste in the open disposal site. Besides, in the studied hospitals, 9 out of 16 hospitals have incineration facility for final disposal of waste in which 5 private teaching hospitals uses single chamber incinerator built of brick. Several problems have been reported with single chamber brick-made incinerators, including emission of toxic substances (SOx, NOx, HC1, smoke, furans and dioxin gases) into the environment that are a risk to public health [ 10 , 19 , 21 ]. Moreover, partial and incomplete burning in locally made incinerator increase the risks of hazards by contaminating the land and water resources on disposal [ 55 ]. They are mostly situated in densely populated areas with an average distance of 3.3 km. Though in WHO [ 56 ] guidelines, it is clearly mentioned that off-site treatment can be more easily ensured in one centralized facility than in several plants.

The rest of the hospitals practicing open dumping of waste or have did 3 or 5 years contracts with government and some private authorities for off-site waste transportation and dumping in their own lands without realizing the deteriorating effects on the environment as well as residents in the surrounding. This indicates a void in implementation of the HWM [ 34 ] rules for the adequate management and treatment of hospital waste.

Conclusion and recommendations

This study was conducted to evaluate the HWM practices in teaching hospitals of Peshawar in connection with implementation of WHO recommended guidelines. The overall findings of the present study indicated, lack of HWM practices in all surveyed hospitals. However, waste generation capacity of public sector hospitals was found significantly high ( p  < 0.017) as compared to private teaching hospitals. In all studied hospitals, only nine hospitals have had their functional incinerator for hospitals waste combustion, while the rest of the hospitals were practicing open dumping of waste or off-site transportation. Functional incinerators were locally built, not up to the standard as recommended by WHO, and located in densely populated areas of Peshawar. Similarly, awareness regarding proper waste management practices remains low in the absence of training for hospital staff. Further, waste handler operates without the provision of safety equipment or immunization. It is concluded that HWM across the Peshawar faces several challenges and require sustainable waste management practices on long way in reducing the harmful effects of hospital wastes both at institutional as well as at community level. Therefore this study offers the following recommendations;

Basic training and capacity building program for HWM staff with regard to use of PPE, maintain daily record of waste generation/bed and ensure proper segregation to final disposal of waste should be arranged on regular basis by concerned authorities along with the provision of reinforcement training material.

The Government concerned authorities should create /develop inspection teams for regular monitoring and continuous supervision of HWM staff and effective implementation of HWM practices in hospitals.

The inspection team also strictly enforced the national HWM 2005 rules in all hospitals and penalties to be imposed in case of contravention.

Open dumping of waste should be avoided and a specific place should be declared and designed as temporary storage from where proper transportation and disposal of waste be ensured.

A common hospital waste treatment facility/a centralized incinerator equipped with new technologies should be installed in outside of the / away from the residential area which can efficiently cater all the HWM needs of the hospitals. This facility will not only minimize the risks of deteriorating the air quality of the residential areas and ill effects but also will be helpful to save the cost associated with waste disposal via incinerator.

Availability of data and materials

The authors confirm that the summary of data supporting the findings of this study is available within the article. However, detailed data of this study are available from the corresponding author upon request.

Chartier Y. Safe management of wastes from health-care activities: World Health Organization; 2014.

Google Scholar  

Ross DE. Safeguarding public health, the core reason for solid waste management. England: Sage Publications; 2011.

Book   Google Scholar  

Ali M, Wang W, Chaudhry N. Management of wastes from hospitals: A case study in Pakistan. Waste Manag Res. 2016;34(1):87–90.

Article   Google Scholar  

Arab M, Baghbani RA, Tajvar M, Pourreza A, Omrani G, Mahmoudi M. Report: the assessment of hospital waste management: a case study in Tehran. Waste Manag Res. 2008;26(3):304–8. https://doi.org/10.1177/0734242X08093598 .

Article   PubMed   Google Scholar  

Taghipour, Mosaferi. The challenge of medical waste management: a case study in Northwest Iran-Tabriz. Waste Manag Res. 2009;27(4):328–35. https://doi.org/10.1177/0734242X08104132 .

WHO. Health-care waste. Fact sheet. 2018.

Almuneef M, Memish ZA. Effective medical waste management: it can be done. Am J Infect Control. 2003;31(3):188–92. https://doi.org/10.1067/mic.2003.43 .

Da Silva C, Hoppe A, Ravanello M, Mello N. Medical wastes management in the south of Brazil. Waste Manag. 2005;25(6):600–5. https://doi.org/10.1016/j.wasman.2004.03.002 .

Article   CAS   PubMed   Google Scholar  

Ganguly R, Vasistha P, Gupta AK. Design of an incinerator to treat combined biomedical wastes generated from four major hospitals in Chandigarh and Shimla City, India; 2017.

Hayleeyesus SF, Cherinete W. Healthcare waste generation and management in public healthcare facilities in Adama, Ethiopia. J HealthPollut. 2016;6(10):64–73. https://doi.org/10.5696/2156-9614-6-10.64 .

Hashmi S, Shahab S. Hospital and biomedical waste management. Community medicine and public health. 4th ed. Karachi: Time Publishers; 2003. p. 426–37.

Khan, Fareedi F, Rashid B. Techno-economic disposal of hospital wastes in Pakistan. Pak J Med Res. 2006;45(2):41–5.

Imdad S, Anwar S, Shoukat MS. Healthcare waste: evaluation of its generation rate and management practices in tertiary care hospitals of Lahore. Ann King Edward Med Univ. 2013;19(4):274.

Van HT, Pham QH, Trinh MV, Bui HM. Treatment of medical solid waste using an air flow controlled incinerator. Pol J Chem Technol. 2020;22(1):29–34.

Liu F, Liu H-Q, Wei G-X, Zhang R, Liu G-S, Zhou J-H, et al. Detoxification of medical waste incinerator fly ash through successive flotation. Sep Sci Technol. 2019;54(1):163–72. https://doi.org/10.1080/01496395.2018.1481091 .

Article   CAS   Google Scholar  

Shen H-M, Wang Y-F, Chyang C-S, Yang H-Y. Incineration of pelletized Fly ash in a bench-scale fluidized bed combustor. Aerosol Air Qual Res. 2019;19(9):2115–29.

Deng D, Qiao J, Liu M, Kołodyńska D, Zhang M, Dionysiou DD, et al. Detoxification of municipal solid waste incinerator (MSWI) fly ash by single-mode microwave (MW) irradiation: addition of urea on the degradation of dioxin and mechanism. J Hazard Mater. 2019;369:279–89. https://doi.org/10.1016/j.jhazmat.2019.01.001 .

Ma C-J, Gong-unn K. Chemical Property of the Fly Ash Collected at an Incinerator and its Effects on Near Ambient Particles. Asian J Atmospheric Environ (AJAE). 2019;13(2):136–43.

Vasistha P, Ganguly R, Gupta AK. Biomedical waste generation and management in public sector Hospital in Shimla City. Environmental Pollution: Springer; 2018. p. 225–32.

Porta D, Milani S, Lazzarino AI, Perucci CA, Forastiere F. Systematic review of epidemiological studies on health effects associated with management of solid waste. Environ Health. 2009;8(1):60. https://doi.org/10.1186/1476-069X-8-60 .

Article   PubMed   PubMed Central   Google Scholar  

Ashworth DC, Elliott P, Toledano MB. Waste incineration and adverse birth and neonatal outcomes: a systematic review. Environ Int. 2014;69:120–32. https://doi.org/10.1016/j.envint.2014.04.003 .

Gonzalez CA, Kogevinas M, Gadea E, Huici A, Bosch A, Bleda MJ, et al. Biomonitoring study of people living near or working at a municipal solid-waste incinerator before and after two years of operation. Arch Environ Health. 2000;55(4):259–67. https://doi.org/10.1080/00039890009603416 .

Reis MF, Sampaio C, Brantes A, Aniceto P, Melim M, Cardoso L, et al. Human exposure to heavy metals in the vicinity of Portuguese solid waste incinerators–part 1: biomonitoring of Pb, cd and hg in blood of the general population. Int J Hyg Environ Health. 2007;210(3–4):439–46. https://doi.org/10.1016/j.ijheh.2007.01.023 .

Kumar R, Somrongthong R, Ahmed J. Impact of waste management training intervention on knowledge, attitude and practices of teaching hospital workers in Pakistan. Pakistan J Med Sci. 2016;32(3):705–10. https://doi.org/10.12669/pjms.323.9903 .

Ali MU, Wang W, Chaudhry N, Geng Y, Ashraf U. Assessing knowledge, performance, and efficiency for hospital waste management—a comparison of government and private hospitals in Pakistan. Environ Monit Assess. 2017;189(4):181.

Khan HMA, Zafar B, Mehmod R, Mushtaq S. Knowledge, attitude and practices of health care staff regarding hospital waste handling in tertiary care hospitals of Muzaffarabad, AJK, Pakistan. Int J Sci Reports. 2017;3(7):220.

Komilis D, Fouki A, Papadopoulos D. Hazardous medical waste generation rates of different categories of health-care facilities. Waste Manag. 2012;32(7):1434–41. https://doi.org/10.1016/j.wasman.2012.02.015 .

Tesfahun E, Kumie A, Legesse W, Kloos H, Beyene A. Assessment of composition and generation rate of healthcare wastes in selected public and private hospitals of Ethiopia. Waste Manag Res. 2014;32(3):215–20. https://doi.org/10.1177/0734242X14521683 .

Ali S, Mahmood U, Malik AU, Aziz F, Naghman RB, et al. Current hospital waste management practices in Pakistan: case study and curative measures. Public Health Prevent Med. 2015;1(3):125–9.

Ansari S, Habiba U, Aslam F, Hussain A. Hospital waste management- tackling trash as a team. Waste Manag Res. 2013;31(7):733–8.

Arshad N, Nayyar S, Amin F, Mahmood KT. Hospital waste disposal: a review article. J Pharm Sci Res. 2011;3(8):1412.

Asante B, Yanful E, Yaokumah B. Healthcare Waste Management; Its Impact: A Case Study Of The Greater Accra Region, Ghana. Int J Sci Technol Res. 2014;3(3):106–12.

Mukhtar S, Khan H, Kiani Z, Nawaz S, Zulfiqar S, Tabassum N. Hospital waste management: execution in Pakistan and environmental concerns—a review. Environ Contam Rev (ECR). 2018;1(1):13–7.

Hospital waste management rules- Pakistan. Ministry of Environment, Government of Pakistan; 2005. 2005. http://wwwenvironmentgovpk/act-rules/rHWMRules2005PDF . Accessed 16 Jan 2018.

De Titto E, Savino AA, Townend WK. Healthcare waste management: the current issues in developing countries. London: SAGE Publications Sage UK; 2012.

Prüss-Üstün A, Townend W. Safe management of wastes from health-care activities: World Health Organization; 1999.

Ali M, Kuroiwa C. Status and challenges of hospital solid waste management: case studies from Thailand, Pakistan, and Mongolia. J Mater Cycles Waste Manag. 2009;11(3):251–7. https://doi.org/10.1007/s10163-009-0238-4 .

Sharma S, Chauhan S. Assessment of bio-medical waste management in three apex government hospitals of Agra. J Environ Biol. 2008;29(2):159–62.

PubMed   Google Scholar  

Munir S, Batool SA, Chaudhry MN. Characterization of hospital waste in Lahore, Pakistan. Chin Med J. 2014;127(9):1732–6.

Khan MI, Khan EA, Irfan S, Muhammad A. Wastes Management Practices in Selected Public And Private Hospitals Of Peshawar, Khyber Pakhtunkhwa. J Med Stud. 2016;2(1):5–11.

Rasheed S, Iqbal S, Baig LA, Mufti K. Hospital waste management in theTeaching hospitals of Karachi. JPMA. 2005;55:192.

Zeeshan MF, Ibad AA, Aziz A, Subhani A, Shah A, Khan T, et al. Practice and enforcement of national Hospital Waste Management 2005 rules in Pakistan. Eastern Mediterr Health J. 2018;24(5):443–50.

Harhay MO, Halpern SD, Harhay JS, Olliaro PL. Health care waste management: a neglected and growing public health problem worldwide. Tropical Med Int Health. 2009;14(11):1414–7. https://doi.org/10.1111/j.1365-3156.2009.02386.x .

Mohamed L, Ebrahim S, Al-Thukair A. Hazardous healthcare waste management in the Kingdom of Bahrain. Waste Manag. 2009;29(8):2404–9. https://doi.org/10.1016/j.wasman.2009.02.015 .

Ahmad I. Review of current waste management strategies at public and private sector hospitals of Islamabad; 2011.

WHO. Water, sanitation and hygiene in health care facilities: status in low and middle income countries and way forward. 2015 9241508477.

Hossain MS, Santhanam A, Norulaini NN, Omar AM. Clinical solid waste management practices and its impact on human health and environment–A review. Waste Manag. 2011;31(4):754–66. https://doi.org/10.1016/j.wasman.2010.11.008 .

Mahwish I, Khan KU, Alam B, Ahad MZ, Malahat F. Critical evaluation of hospital waste management system in Pakistan and how it could be improved; recommendation for Pakistan environmental protection agency. Int J Appl Sci Eng Technol. 2013;1(1):12–6.

Johnson KR, Braden CR, Cairns KL, Field KW, Colombel AC, Yang Z, et al. Transmission of mycobacterium tuberculosis from medical waste. Jama. 2000;284(13):1683–8. https://doi.org/10.1001/jama.284.13.1683 .

Patil A, Shekdar A. Health-care waste management in India. J Environ Manag. 2001;63(2):211–20. https://doi.org/10.1006/jema.2001.0453 .

Mujeeb Z, Lodi M. Prevalence of hepatitis B infection in health care workers. J Pak Med Assoc. 1994;44:265.

Camacho-Ortiz A, Díaz-Rodríguez X, Rodríguez-López JM, Martínez-Palomares M, Palomares-de la Rosa A, Garza-Gonzalez E. A 5-year surveillance of occupational exposure to bloodborne pathogens in a university teaching hospital in Monterrey, Mexico. Am J Infect Control. 2013;41(9):e85–e8. https://doi.org/10.1016/j.ajic.2013.01.008 .

Mol MP, Gonçalves JP, Silva EA, Scarponi CF, Greco DB, Cairncross S, et al. Seroprevalence of hepatitis B and C among domestic and healthcare waste handlers in Belo Horizonte, Brazil. Waste Manag Res. 2016;34(9):875–83. https://doi.org/10.1177/0734242X16649686 .

Shiferaw Y, Abebe T, Mihret A. Sharps injuries and exposure to blood and bloodstained body fluids involving medical waste handlers. Waste Manag Res. 2012;30(12):1299–305. https://doi.org/10.1177/0734242X12459550 .

Babanyara Y, Ibrahim D, Garba T, Bogoro A, Abubakar M. Poor medical waste management (MWM) practices and its risks to human health and the environment: a literature review. Int J Environ Ealth Sci Eng. 2013;11(7):1–8.

WHO. Fundamentals of health-care waste management. United Nations Environment Programme/SBC National Health-Care Waste Management Plan, Guidance Manual; 2003. p. 7–23.

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Acknowledgments

The authors are thankful to the Environmental Protection Agency (EPA) and Water and Sanitation Services, Peshawar (WSSP) for the permission and entire support in data collection. The authors are also grateful for the sincere participation and cooperation of the HWM staff during key respondent questionnaire survey and site visits of the studied hospitals.

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Salma Khalid & Abdul Latif

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Najibul Haq

Department of Community Health Sciences, Peshawar Medical College, Prime Foundation, Riphah International University, Islamabad, Pakistan

Zia-ul-Ain Sabiha

Department of Environmental Sciences, University of Peshawar, Peshawar, Pakistan

Muhammad Amjad Khan, Javaid Iqbal & Nowsher Yousaf

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Dr. Salma Khalid wrote the main manuscript with the support and feedback from all the authors. Prof. Dr. Najibul Haq conceived idea, designed the study and provide his technical input at every step. Dr. Zia ul Ain Sabiha and Dr. Abdul Latif helped in collection of data and did site visits. Dr. Muhammad Amjad did overall management of the article. Dr. Javaid Iqbal and Dr. Nowsher Yousaf did interpretation of results and presentation. All authors reviewed the manuscript and proof read the final draft. The author(s) read and approved the final manuscript.

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Khalid, S., Haq, N., Sabiha, ZuA. et al. Current practices of waste management in teaching hospitals and presence of incinerators in densely populated areas. BMC Public Health 21 , 1340 (2021). https://doi.org/10.1186/s12889-021-11389-1

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Research Article

Awareness and practice of medical waste management among healthcare providers in National Referral Hospital

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Software, Supervision, Writing – original draft

* E-mail: [email protected]

Affiliation Medical Education and Research Unit, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan

Roles Conceptualization, Investigation, Methodology, Supervision, Validation, Writing – original draft, Writing – review & editing

Affiliation Department of Pathology and Laboratory Medicine, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan

Roles Conceptualization, Funding acquisition, Investigation

Affiliation Department of Nursing, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan

Roles Data curation, Formal analysis, Investigation, Methodology

Roles Data curation, Formal analysis

• Zimba Letho, 
• Tshering Yangdon, 
• Chhimi Lhamo, 
• Chandra Bdr Limbu, 
• Sonam Yoezer, 
• Thinley Jamtsho, 
• Puja Chhetri, 
• Dawa Tshering

• Published: January 6, 2021
• https://doi.org/10.1371/journal.pone.0243817
• Peer Review
• Reader Comments

Introduction

The management and treatment of Medical Waste (MW) are of great concern owing to its potential hazard to human health and the environment, particularly in developing countries. In Bhutan, although guidelines exist on the prevention and management of wastes, the implementation is still hampered by technological, economic, social difficulties and inadequate training of staff responsible for handling these waste. The study aimed at assessing the awareness and practice of medical waste management among health care providers and support staff at the National Referral Hospital and its compliance with the existing National guidelines and policies.

Materials and methods

An observational cross-sectional study was conducted from March to April 2019. Three research instruments were developed and used; (i) Demographic questionnaire, (ii) Awareness questions, and (iii) the Observational checklist. The data was coded and double entered into Epi data version 3.1 and SPSS version 18 was used for analysis. Descriptive statistics were used to present the findings of the study.

The majority of the respondents were female (54.1%) with a mean age of 32.2 (±7.67) years, most of whom have not received any waste management related training/education (56.8%). About 74.4% are aware of medical waste management and 98.2% are aware on the importance of using proper personal protective equipment. Only 37.6% knew about the maximum time limit for medical waste to be kept in hospital premises is 48 hours. About 61.3% of the observed units/wards/departments correctly segregated the waste in accordance to the national guidelines. However, half of the Hospital wastes are not being correctly transported based on correct segregation process with 58% of waste not segregated into infectious and general wastes.

The awareness and practice of medical waste management among healthcare workers is often limited with inadequate sensitization and lack of proper implementation of the existing National guidelines at the study site. Therefore, timely and effective monitoring is required with regular training for healthcare workers and support staff. Furthermore, strengthening the waste management system at National Referral Hospital would provide beneficial impact in enhancing safety measures of patients.

Citation: Letho Z, Yangdon T, Lhamo C, Limbu CB, Yoezer S, Jamtsho T, et al. (2021) Awareness and practice of medical waste management among healthcare providers in National Referral Hospital. PLoS ONE 16(1): e0243817. https://doi.org/10.1371/journal.pone.0243817

Editor: Itamar Ashkenazi, Technion - Israel Institute of Technology, ISRAEL

Received: March 31, 2020; Accepted: November 27, 2020; Published: January 6, 2021

Copyright: © 2021 Letho et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The Jigme Dorji Wangchuck National Referral Hospital provided material support for this study but had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

A health care facility inevitably produces medical wastes (MW) that may be hazardous to health [ 1 – 3 ]. MW refers to all categories of waste generated from health facilities, clinics, animal husbandries, veterinary hospitals and other clinical laboratories, and home-based treatment of patients [ 3 ]. Although the MW is classified broadly, in general, it is categorized as Sharps, Infectious, Pathological, Pharmaceutical, cytotoxic, pressurized containers, chemical, radioactive and non-hazardous or general waste [ 1 – 4 ]. Hazardous MW is referred to any wastes which have the potential to cause harmful effects to human or environment if poorly managed [ 3 ]. Fig 1 provides the types of hazardous wastes, waste bin, and color code and biohazard symbols [ 5 ].

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https://doi.org/10.1371/journal.pone.0243817.g001

Although MW management practices differ from hospital to hospital, the implementation of MW management still poses a challenge. For the MW management, WHO has prepared various biomedical waste management guidelines to ensure the safe management of the wastes from healthcare facilities.

In Bhutan, the Government with various initiatives developed guidelines on proper management of healthcare waste including developing environmental code of practice for hazardous waste management 2002, waste prevention and management act of Bhutan 2009, Guideline for Infection Control and healthcare waste management in health facilities 2006 and National Infection Control and Medical Waste Management guidelines 2018 [ 3 , 5 , 6 ] however, implementation is still hampered by technological, economic, social difficulties and inadequate training of staff responsible for the handling of these waste [ 3 , 7 ].

Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), the apex Hospital of the capital city Thimphu, Bhutan caters to the healthcare services delivery for the population residing in Thimphu as well as to the patients referred from district hospitals. Being the only tertiary care hospital, large number of patients and referral samples are received at JDWNRH leading to increase medical waste generations. For the management of the waste generated, JDWNRH consist of infection control focal team headed by deputy nursing superintendent who supervises the overall monitoring of the infection control and waste management by conducting annual monitoring system in all the departments (Annual report 2018).

This study was conducted at JDWNRH which is also the teaching hospital affiliated to Khesar Gyelpo Medical University of Bhutan (KGUMSB). JDWNRH is 350 bedded hospital situated in Thimphu consisting of 1300 staff with an annual turnout of 5, 26,491 patients in OPD and 17,468 patients in IPD (Annual Report, 2017). This study targeted the staff and supporting staff working at National referral hospital on their awareness and practice on MW management practice.

The appropriate MW management process includes vital steps: Collection, segregation, storage, transportation, treatment, and disposal [ 2 ]. Table 1 show the procedure for collection, transportation, treatment of MW according to the National guideline [ 5 ].

https://doi.org/10.1371/journal.pone.0243817.t001

Segregation is based on color-coding of the non-infectious and infectious wastes [ 4 ]. The segregated waste are stored in designated storage area within the units/wards/departments and storage duration is 24–48 hours (summer time) and 24–72 hours (winter time). The waste is collected every morning from the all the wards/unit/department and transported to the waste treatment unit. The infectious waste is treated by autoclaving and disposed off along with the general waste. The waste like cardboard box, pet bottles are sold to the vendor to reduce the waste going to the land fill and the food waste are used to prepare organic compost for fertilizer.

In an audit report by Royal Audit Authority (RAA) on Medical Waste Management conducted in 2008, it was found that the support staff handling MW of JDWNRH lacked awareness and knowledge on proper handling and management. Also, the waste handlers were seen handling the MW without protective gear such as utility gloves, apron, gumboots and mask [ 8 ]. Therefore, this study aimed at assessing the awareness and practice of health care providers on the management of medical wastes and implementation of the existing national guidelines.

An observational cross-sectional study was conducted to describe the awareness and current practice of medical waste management at JDWNRH. All Bhutanese citizenship health workers registered with Bhutan Medical and Health Council BMHC) and working permanently fulltime in JDWNRH were interviewed including the supporting staff who handles the MW.

The convenience sampling method was used to collect data from all 18 departments of JDWNRH. The 18 departments were Clinical Departments (n = 15), Community Health Department (n = 1) and Diagnostic Departments (n = 2).

Sample size

S = required sample size

X = Z value (e.g. 1.96 for 95% confidence level)

N = population size

P = population proportion [expressed as decimal, assumed to be .5 (50%)]

d = degree of accuracy (5%), expressed as a proportion (.05); it is a marginal of error

In this study, 350 participants were recruited to target maximum number of participants from healthcare workers and supporting staff.

Research instrument

Three research instruments were used in this study according to WHO standards (1) viz. i) Demographic questionnaire, (ii) Awareness questions, and (iii) the Observational checklist. All the research instruments were pilot tested and validated by the researchers prior to using on the participants.

PART I: The demographic questionnaire

This part of the questionnaire was developed by the researcher which include all demographic variables (as given in the questionnaire) ( S1 File ).

PART 2: Awareness questionnaire

This tool consists of 15 questions to test the awareness of medical waste management. Face to face interview was carried out to collect the data. The correct response was coded as 1 and incorrect as 0 respectively ( S2 File ).

PART 3: Observational checklist

This checklist consist of assessing the process and practice on handling the MW by the healthcare workers and supporting staff by visual observation at the work station on the disposal method. The observation was coded as; 1 for Yes, 0 for No and 9 for Not applicable ( S3 File ).

Data collection and analysis

Data were collected from March to April 2019. Head of Departments were explained on the objective of the study and the written informed consent were obtained from all the volunteer participants. Ethical clearance was sought from Research Ethic Board (REBH), Ministry of Health (Ref. No. REBH/PO/2019/012). Ethical waive was granted since there was no clinical intervention and the protocol fulfilled the criteria for ethical exemption from REBH.

The data was coded and double entered into Epi data version 3.1 and SPSS version 18 was used for analysis. Descriptive statistics were used to present the findings of the study. The current practice and awareness of medical waste management among health care providers in JDWNRH was described in terms of frequency, percentage, mean ( M ), and standard deviation ( SD ).

Part 1: Demographic characteristics of participants

Table 2 shows the demographic characteristics of health care providers. A majority of the respondents were female (54.1%) as compared to males. The mean age of the health care providers was 32.2 years (SD = 7.35) with a minimum and maximum age of 20 and 55 years respectively. The age range of most health care providers was between 26 and 30 years (33.8%). Most of them (32.9%) had a Diploma followed by a Certificate degree (30.9%) and a bachelor's degree (18.8%). The average years of experience of the health care providers were 8.48 years (SD = 7.67) and 37.6% had an experience of fewer than 4 years. It also revealed that the highest respondents were nurses (44.1%) followed by technicians (23.5%) and least were health assistants (3.2%). Most of them had not received any waste management related training/education (56.8%). It is worth to note that 82.9% of health care providers have been vaccinated against Hepatitis B virus which is provided as mandatory vaccination for all healthcare providers and support staff.

https://doi.org/10.1371/journal.pone.0243817.t002

Part 2: Awareness questionnaire

Table 3 describes awareness about biomedical waste management among health care providers in JDWNRH. Almost all (98.5%) heard about medical waste and 69.7% are aware of regulation on medical waste management. About 74.4% of health care providers are aware of the biohazard symbol and only 45.3% knew about eight categories of medical waste.

https://doi.org/10.1371/journal.pone.0243817.t003

It's encouraging to note that 83.5% and 88.2% of the respondents are aware that HIV/AIDS and Hepatitis B & C can be transmitted through medical waste respectively. Also, the majority (98.2%) are aware that personal protective measures are necessary while handling medical waste. 90.0% believe that the disinfection of medical waste is necessary and 72.9% are aware that a bleaching solution of 0.5% is used for the disinfection of infectious medical waste. However, only 37.6% are aware that the maximum time for medical waste to be kept in hospital premises is 48 hours.

Part 3: Observational checklist

Table 4 describes the observation of the current practice on medical waste management for four categories; a) condition of waste receptacles, b). Segregation of waste, c) Transportation of medical waste, d) Appropriate use of PPE. The observation was carried out by visiting the department/unit/wards and visually observing whether the waste disposal process was followed in accordance to National guidelines on infection control (3).

https://doi.org/10.1371/journal.pone.0243817.t004

On an average, 93.5% of the waste bins were appropriately available in the required color-coded bins (83.85%), however, the availability of blue-colored waste bin was minimum (45.2%). Only 58.1% of the waste bins were covered with 74.2% being foot-operated. The biohazard symbol was imprinted in the majority of the waste bin (90.3%) with 67.7% user posters displayed in waste bins.

About 61.3% of the observed units/wards/departments have correctly segregated the waste accordingly. Only 48% of the waste generated is transported in accordance with the transportation guideline with 58% of the waste not segregated into infectious and general wastes. Only 35.4% was found to be using appropriate PPE with 32.3% not complying and 32.3% not applicable.

The majority of the respondent were nurses which are concurrent with the highest number of health workers at JDWNRH being nurses followed by paramedical staff. Of these, the respondents were mostly in the age group of 26–30 years old and having a diploma course certificate. Less than half of the health care workers (43.2%) attended training on medical waste management which was a similar finding from the study conducted in 2015 [ 10 ]. However, it is noteworthy that the majority of the health care workers were vaccinated against Hepatitis B virus which is mandatory for all healthcare providers and support staff. Although most of them were aware of the regulations on medical waste management, the failure to adhere to these guidelines may be due to a lack of inspection from the authorities and the absence of strict rules and regulations. Therefore framing rules and regulations followed by proper and timely reminders of the importance of adhering to the rules and regulations are important by hospital infection control team.

There was satisfactory knowledge of color coding of wastes which is an essential factor for proper segregation of waste (80%) which was similar to the study conducted in Nigeria with 81.9% [ 11 ]. Our study revealed that the majority of the waste bins were color-coded (83.85%) which indicates the understanding of the respondents on the management of medical waste into infectious and non-infectious waste.

The waste generated is required to be transported by following the national guideline [ 3 , 5 ]. Such wastes are collected and transported using a trolley, wheeled barrow, trucks, etc. Data from this study revealed that the waste is transported in trolleys and supporting staff loads it into the trucks by hand which could be dangerous. Although WHO stipulates that different trolleys should be used in transporting the different categories of wastes, this requirement does not adhere to 58% of wastes not segregated at source. Indeed, all the wastes generated are carried with the same trolley and this could also lead to cross-contamination [ 12 ].

As important as protective equipment is to anybody who handles medical wastes, only 35.4% complied with the use of appropriate PPE which is not consistent with the recommended standard of WHO which requires the use of heavy-duty gloves, boots, and apron [ 11 ]. There is a need to properly equipped and educate those in charge of on-site transportation of wastes, given the great danger associated with this task.

Although national regulations exist on medical waste management, adherence to the practice is often limited due to inadequate sensitization amongst the health care workers and support staff. Most notably, the use of appropriate PPE while handling waste is often neglected causing potential risk. Therefore, timely and effective monitoring from the authorities should be implemented and regular training sessions to be provided for the healthcare workers and support staff.

Our findings suggest that although many of the respondents are aware of the National guideline on infection control and waste management, the practice is limited due to lack of proper training and sensitization on medical waste management process. Even though the hospital infection control team performs the assessment on waste management bi-annually, the findings and corrective action implementation needs to be strengthened by regular follow-up on action plan and providing incentives for the best medical management practice in the units/wards/departments.

Supporting information

S1 file. demographic questionnaire..

https://doi.org/10.1371/journal.pone.0243817.s001

S2 File. Awareness questions.

https://doi.org/10.1371/journal.pone.0243817.s002

S3 File. Observational checklist.

https://doi.org/10.1371/journal.pone.0243817.s003

Acknowledgments

Authors would like to thank the Department of Nursing and JDWNRH administration and all the health care provides who were involved in the study and provided their immense support.

• 1. World Health Organization (WHO). (2014). Safe management of wastes from health-care activities—edited by CHARTIER Yves et al. World Health Organization, 329.
• 2. WHO: Basic Steps in the Preparation of Health Care Waste Management Plans for Health Care Establishments Amman: World Health Organization; 2002.
• View Article
• Google Scholar
• 4. World Health Organization (WHO). (2017). Report on health-care waste management status in countries of the South-East Asia Region, (April), 128.
• 5. Waste prevention and management regulation, Royal Government of Bhutan (RGOB), 2012
• 6. National Guideline of Infection Control and Medical Waste management, Healthcare and Diagnostic Division, Department of Medical Services, Ministry of Health, Bhutan 2018.
• PubMed/NCBI
• 10. Choden, N. N. (2015). Medical Waste Management at Jigme Dorji Wangchuck National Referral Hospital, Thimphu.

COMMUNITY CASE STUDY article

A whole systems approach to hospital waste management in rural uganda.

• 1 Bwindi Community Hospital, Kanungu, Uganda
• 2 College of Life and Environmental Science, University of Exeter, Exeter, United Kingdom
• 3 Institute of Medicine, University of Chester, Chester, United Kingdom

Introduction: Safe waste management protects hospital staff, the public, and the local environment. The handling of hospital waste in Bwindi Community Hospital did not appear to conform to the hospital waste management plan, exhibiting poor waste segregation, transportation, storage, and disposal which could lead to environmental and occupational risks.

Methods: We undertook a mixed-methods study. We used semi-structured interviews to assess the awareness of clinical and non-clinical staff of waste types, risks, good practice, and concerns about hospital waste management. We quantified waste production by five departments for 1 month. We assessed the standard of practice in segregation, onsite transportation, use of personal protective equipment, onsite storage of solid waste, and disposal of compostable waste and chemicals.

Results: Clinical staff had good awareness of waste (types, risk) overall, but the knowledge of non-clinical staff was much poorer. There was a general lack of insight into correct personal or departmental practice, resulting in incorrect segregation of clinical and compostable waste at source (>93% of time), and incorrect onsite transportation (94% of time). In 1 month the five departments produced 5,398 kg of hazardous and non-hazardous waste (12; 88%, respectively). Good practice included the correct use of sharps and vial boxes and keeping the clinical area clear of litter (90% of the time); placentae buried immediately (>80% of the time); gloves were worn everyday by waste handlers, but correct heavy-duty gloves <33% of the time, reflecting the variable use of other personal protective equipment. Chemical waste drained to underground soakaways, but tracking further disposal was not possible. Correct segregation of clinical and compostable waste at source, and correct onsite transportation, only occurred 6% of the time.

Conclusion: Waste management was generally below the required WHO standards. This exposes people and the wider environment, including the nearby world heritage site, home to the endangered mountain gorilla, to unnecessary risks. It is likely that the same is true in similar situations elsewhere. Precautions, protection, and dynamic policy making should be prioritized in these hospital settings and developing countries.

Introduction

Health care waste management is a global concern. All health care activities generate waste, which when poorly managed can affect the environment, the community, and domestic and wild animals. It is an issue of growing concern as the number of health care facilities is increasing while population growth reduces space for waste disposal ( 1 ). Waste generated by human activities and changes associated with lifestyles threatens both human beings and natural resources ( 1 – 3 ).

The World Health Organization (WHO) defines medical waste as waste generated by health care activities including a broad range of materials, from used needles and syringes to soiled dressings, body parts, diagnostic samples, blood, chemicals, pharmaceuticals, medical devices, and radioactive materials ( 4 ).

Health care waste is defined as all types of waste produced in health facilities such as hospitals, health centers, and pharmaceutical shops ( 2 ). The majority (85%) of the waste is non-hazardous, compostable/biodegradable, and non-compostable, which does not require specialist disposal. The remainder is hazardous waste: 10% infectious and highly infectious, and 5% is toxic chemicals, radioactive, and pharmaceuticals ( 5 , 6 ), all of which requires special care and processing. Placentae are classed as highly infectious in settings such as Uganda, where blood-borne viruses are common, and need to be handled carefully ( 7 ).

Waste from health care activities can have a long-lasting impact on human health, including people handling the waste and the public in general ( 7 – 10 ) and the environment can be contaminated through underground water sources polluted by untreated medical waste buried in, or drained into, the ground ( www.who.int/water_sanitation_health/medicalwaste/020to030.pdf ).

People can be infected either through direct contact with contaminated waste or infected people, or indirectly via contamination of soil, ground water, surface water or air, or through affected animals. Direct or indirect exposure through environmental contamination by pharmaceutical and laboratory waste can also lead to disease, both in the human and animal populations ( 11 – 14 ).

Twenty-three percent of global deaths and 22% of global disability adjusted life years (DALYs) were attributable to environmental factors in 2012, including, but not limited to waste ( 15 ). Blood borne diseases like HIV and viral hepatitis B can be acquired through mismanagement of hazardous hospital waste.

In some industrialized countries, institutions that generate lots of waste, including health care waste, have a legal responsibility to manage such waste. As a result, they monitor the amount of hazardous waste generated and there are clearly organized structures for handling every type of waste. Different expensive and highly technical waste management methods are used, including solidification, elementary neutralization, carbon absorption, separation, filtration, and evaporation. This is as a result of considerable investment by authorities and organizations in waste handling and management, but these methods are not available in resource-poor countries. In these countries other, cheaper, but reasonably effective, methods like incineration, land filling, and composting are used to manage health care waste ( 16 , 17 ).

Background and Rationale

In low- and middle-income countries, health care waste management receives little attention as the health sector competes with other sectors of the economy for very limited resources. In most of these countries, health care waste is still handled and disposed of as domestic waste, with the resulting appreciable threat to the waste workers, the public, and the environment ( 5 , 7 , 18 ).

The literature about a whole systems approach to hospital waste management, from segregation of waste to disposal, that was relevant to rural, privately-funded hospitals in resource-poor countries, was limited ( 19 ). In a published paper from Uganda, waste generation rates in a public and a private hospital in Kampala, the capital city vary according to patients' circumstances (type and state of condition, number of people nursing a patient, number of visitors to a patient, items carried into ward) ( 8 ), but there is no clear mention of rural hospitals in a recent review across the developing world ( 1 ). The review concluded that the issue of health care waste management has received little attention and needs highlighting to create greater awareness.

In Uganda there is no legal framework requiring health facilities to take any special care with their waste disposal, and very limited finance available to address any such issues, either within the budgets of these facilities or from the government or other funding agencies. It is, therefore, possible that staff working in health facilities and people living nearby may be exposed to unnecessary risks, including possible environmental contamination ( 7 , 15 ).

Bwindi Community Hospital, in southwest Uganda, has had its own waste management program since its inception in 2004 as part of its wide-ranging community health program. It generates heath care waste internally across departments, and externally during outreach health activities. The waste includes pathological, infectious, sharps, pharmaceutical, chemical, tissue, as well as non-infectious waste. The waste generated was thought to be systematically managed through a series of activities (including segregation at source, regular departmental collection, safe transport, storage, and disposal), to reduce the risk of any adverse outcome.

The hospital is located in a low land surrounded by forested hills of the impenetrable national park, a mile away, and several small water bodies, including one that generates hydro power that is supplied to the nearby trading center with a growing urban population in a radius of two kilometers. This is the first Uganda study in a rural hospital and such studies are still infrequent globally. Improper health care waste management can compromise health, safety and puts the environment at risk for all stakeholders in this community setting ( 1 , 9 ).

This study evaluated the knowledge of clinical and non-clinical staff at Bwindi Community Hospital and assessed the current management of health care waste (hazardous waste—sharps, infectious, chemical, and pathological—and non-hazardous waste—compostable and non-compostable) during the month of October 2017.

Specifically, we (a) assessed the knowledge and practice of health care waste management by clinical staff and non-clinical staff, (b) measured the weight of waste generated and assess the effectiveness of the segregation of hazardous and non-hazardous waste in different clinical departments, (c) assessed the appropriate use of personal protective equipment by the porters, (d) reviewed the methods of on-site waste transportation, storage, and disposal of all waste, and (e) described the arrangements for offsite disposal of the hospital waste.

Description of Case

Staff are trained when first employed to segregate waste at the point of generation by using color-coded bins with matched color-coded liners. Waste is collected daily from each department, except in two departments (Surgery and Sexual Reproductive Health) that produce a high volume of hazardous waste. In these two departments, waste is removed several times a day, after procedures have been carried out. Non-hazardous waste is separated into bins for compostable and non-compostable waste at the point of generation in the hospital.

Collection, including ensuring that all bin liners are securely closed, and transportation of waste to the storage site, is done by hospital porters, who should use appropriate personal protective equipment (gumboots, surgical face masks, heavy duty gloves, and plastic aprons).

The estates manager (SK) was aware of some shortcomings in the waste management system. Given the hospital vision, “ a healthy community free from preventable disease, and accessible health care for all,” he realized that there could be wider implications in addition to the risk to hospital staff. It was therefore imperative to assess how the hospital waste was being managed and see if more could be done to ensure safe waste management, so as to mitigate the risks from pollution and infection.

Study Design

The study was a mixed-methods design, with a quantitative, descriptive, cross sectional study of waste management, with simultaneous qualitative in-depth interviews. This design was used to increase the breadth and depth of understanding of health care waste management.

Uganda is a land locked country in East Africa, bordering the Democratic Republic of Congo, Rwanda, Tanzania, Kenya, and South Sudan. It has a population of 39 million people, half of whom are under 18 years. It is classed as a low-income country and 70% of the population are subsistence farmers ( 20 ). There are 165 hospitals in Uganda, with 40% government, 43% private not-for-profit, and 17% private for-profit ( 21 ).

Bwindi Community Hospital is a rural private not-for-profit hospital run by the Church of Uganda in Kanungu District, South-Western Uganda, with a large community health program, as reflected in the hospital vision. It is located over 500 kilometers from the capital city Kampala, and borders the Bwindi Impenetrable Forest National Park and the Democratic Republic of Congo. There is a poor road network, and no reliable source of power, or nearby facilities that can handle health care waste or recycling.

The community health program of the hospital includes health promotion, prevention, immunization, mental health, and support to over 500 community health volunteers. The volunteers are supported by 12 health centers and the hospital. The hospital provides general surgery, orthopedics, pediatrics, sexual, and reproductive health, adult inpatient and outpatient care.

Study Population

The quantitative study population was hospital departments that generate waste. The qualitative study population was purposefully selected clinical and non-clinical staff directly involved in health care waste management.

Data Variables and Sources

We assessed the knowledge and practice of health care waste management by clinical staff and non-clinical staff through semi-structured interviews. These in-depth interviews were conducted with purposive selection of staff (clinical and non-clinical) to elicit responses on the broad themes: segregation, collection and transport, disposal, risk, and concerns. Interviews were conducted by the principal investigator and another researcher, both experienced in qualitative methods, after obtaining written informed consent. An interview guide with open-ended questions was used. Interview questions focused on (a) types of waste generated (b) color coding for waste bins, (c) hazards posed by improper waste handling, (d) waste transportation, (e) storage and disposal, (f) concerns on waste handling (g) risk to population, and environment. All interviews were recorded with permission. Saturation was reached.

The quantitative data variables were each measured over 31 days, in October 2017, and included (a) the weight of each type of waste produced, and adequacy of its segregation by each clinical area, (b) if there was correct use of personal protective equipment by porters transporting the waste, (c) how waste bags were transported to the storage site, (d) if there was safe on-site storage and off-site removal of waste, (e) if the use of compost pits was appropriate, (f) if the disposal of laboratory and X-Ray chemicals was safe, and (g) if the burial of placentae and still-borne infants was appropriate and safe.

We also described the arrangements for offsite disposal of the hospital waste.

Operational Definitions as Used in the Hospital

Correct waste management practices.

Acting according to hospital waste management guidelines: source segregation at generation points, proper transportation, and storage and disposal waste.

Segregation of Waste

The recognition and division of waste into the correct waste receptor.

Compostable Waste

Non-hazardous waste that will break down, safely, and relatively quickly, by biological decomposition.

Clinical Waste

Waste containing human tissue, blood, other body fluids, pharmaceutical products, or any items used directly in providing health services, unless rendered safe.

Hazardous Waste

Waste that poses any biological, chemical, radioactive or physical hazard.

Infectious Waste

Waste from patients with infections.

Highly Infectious Waste

Material used in patient care that is heavily contaminated by blood.

Interviews were recorded and transcribed and evaluated by two independent investigators to reduce bias and increase interpretive credibility. Any difference between the two was resolved by discussion to arrive at a consensus. A thematic network method, as described by Attride-Stirling, was used to analyze the data employing a global theme, organizing themes, and basic themes ( 20 ).

We undertook descriptive analysis of all quantitative data.

In total, over five tons (5,398 kg) of health care waste were produced by five departments of Bwindi Community Hospital in the study month. Of this, 12% (662 kg) was classed as hazardous and 88% (4,735 kg) as non-hazardous ( Table 1 ).

Table 1 . Type and weight of waste produced by clinical departments of Bwindi Community Hospital, Uganda, October 2017.

The Sexual and Reproductive Health department produced over a third (35%) of the total waste in the study ( Table 1 ). Adult Inpatients generated a quarter (26%) while Pediatrics produced a fifth (22%). HIV and Outpatients departments produced about 8% each.

Compostable waste, from food preparation by patients and their relatives, constituted nearly three quarters (3,902 kg, 72%) of the waste collected. This came particularly from the Sexual and Reproductive Health and Adult Inpatients.

Hazardous waste (highly infectious + infectious) made up 12% of all the waste in the study. The largest amount of hazardous waste was produced by the Sexual Reproductive Health and HIV departments.

In-depth interviews were conducted with 15 clinical staff (nurses, midwives, clinical officers, lab staff, and medical doctors) and 6 non-clinical staff (administrators and porters). All interviewees had some knowledge about hospital waste types and gave examples. They knew the basics about hospital waste and the reasons why handling such waste is important. We report the findings under the organizing themes (segregation, transport, disposal, risk, and concerns) found through analysis of the interviews ( Figure 1 ).

Figure 1 . Thematic network showing the global theme (lozenge), organizing themes (ovals), and basic themes (rectangles) found through analyzing the qualitative interviews.

Segregation

Waste should be collected in color-coded waste bins, with matching bin liners. There were sufficient waste-collecting bins throughout the hospital, but the correctly colored bin liners were often not available to order and so were not supplied consistently to the hospital wards. Staff used the available waste bins inconsistently. It was not clear if this was just them using the nearest available bin, expecting others to correctly segregate the waste later, or due to not being able to easily distinguish different bins ( Table 2 ). A non-clinical staff member said, “ Training is one thing. Doing another.” Segregation of waste was seen by some clinical staff as the job of the porters who transport the waste. “ If waste segregation is improved, the rest would be at rest ,” said a clinical staff member.

Table 2 . Percentage of days with correct waste management practices by clinical departments in Bwindi Community Hospital, Uganda, October 2017.

However, the use of sharps and vial boxes and keeping clinical areas clean of litter showed good practice on most days ( Table 2 ).

One clinical officer noted that there were no brown bin liners for pharmaceutical waste. This affects waste collection since pharmaceutical waste may be put in the wrong bins and may end up in the wrong disposal route. “ Supply [of brown bins] would put us at the level of people who handle waste very well .

Clinical waste (393 kg) was largely carried incorrectly by hand rather while non-clinical waste (3,903 kg) was transported within the hospital in a wheelbarrow. A clinical officer was concerned about the nature of waste transportation by porters: “ Waste is transported by porters on their backs .” One non-clinical staff member said that he would like each department to have their own wheelbarrow for transporting waste because there is only one wheelbarrow in the hospital and most times it is in use, taking too long to become available.

Transportation to the storage facility was carried out incorrectly on most days ( Table 2 ). The use of personal protective equipment by porters varied by equipment and between departments (porters are largely assigned to one department). While gloves were worn every day, the type of gloves worn were largely incorrect. Face masks were only used about a third of the time. The practice of wearing protective aprons varied by departments ( Table 3 ).

Table 3 . Percentage of days with correct use of personal protective equipment (PPE) by porters in Bwindi Community Hospital, Uganda, October 2017.

Bwindi Community Hospital has a secure waste storage site that is ventilated and well fenced, preventing entry by domestic animals, pets, pests including marabou storks ( Leptoptilos crumenifer ), and unauthorized humans. The hospital waste was, at the time of the conception of the study, disposed of by incineration, burying, placenta pit, and open burning, according to the different waste types.

At the time of the study, compostable waste was transported to compost pits within the hospital land, and placentae were buried in a dedicated pit. Inspection of the compost pits showed the same lack of segregation of compost and non-compost waste as was seen in all the departments, with paper and plastics being the most common contaminant, although no hazardous waste was seen.

Placentae were usually quickly disposed of correctly after deliveries and did not remain on the ward. The only still birth in the month of study was taken for burial by the family ( Table 4 ).

Table 4 . Disposal of placentae and still born infants in Sexual and Reproductive Health department of Bwindi Community Hospital, Uganda, October 2017.

In October 2017, hospital waste was not disposed of on-site, as previously (incineration, and open burning). Instead, such waste was transported from the storage site to a processing plant in Eastern Uganda by an internationally funded health care waste handling company in a dedicated refrigerated vehicle. This new arrangement has been running since July 2016, after the study was conceived.

The collection and off-site transportation of the non-compostable and hazardous waste by the national contractor was irregular. The hospital understood that waste would be collected every 5 days; however, this was not adhered to. During the month of the study, waste was collected four times out of an anticipated six. The intervals between collections varied between three and seven days. Despite the inconsistency in timing of waste collections, on all occasions all stored waste was removed from the hospital.

But not everyone on the hospital staff thought that such transport was appropriate. “ We should dispose of our waste, not send it away,” said a clinical staff member.

One non-clinical staff member was concerned about the indiscriminate disposal of clinical waste that arises from incorrect segregation. He said, “ You find blood stained gauze mixed with empty intravenous fluid bottles and urine bags .”

Ionizing radiation in x-ray waste was a concern as identified by a senior clinical officer, who said, “ There seems to be no clear way of handling ionizing waste .” It proved impossible to quantify the laboratory and X-ray chemical waste, since the fluids were disposed of directly down the drains. These drains run into deep soakaways under grassed areas and were separate from other drainage systems. It was not known how the continued use of such soakaways over years had contaminated the local groundwater, which drains into the river, which in turn is used as a water supply by humans and animals.

The respondents correctly identified a number of risks that include cross infection (“ waste that is infectious contains pathogens” clinical officer ) , occupational hazards, and direct injury (“ can cause harm to health care workers and patients ” clinical staff), pollution of the environment (“ leads to environmental pollution” clinical staff; “ minimize contamination of water… reduce air pollution” non-clinical staff). These risks can affect people immediately or in the future, directly or indirectly.

A non-clinical staff member said that safe handling of hazardous waste is of medium priority because of the limitation of funds availed for such activities, but was quick to note that this topic should be highly prioritized because of the risks involved. This recognizes that there is a degree of risk for all staff who are involved in hazardous waste management.

Surprisingly, a few staff had no concerns about the waste management of their department or the hospital. “ I don't have any concerns,” commented a clinical staff member, while another said, “ Hazardous waste is handled very well”. One non-clinical staff member had an understanding of the size of the issue the hospital faces: “[The] issue is not hazardous waste, but the issue is [all] waste .”

However, many of the concerns expressed centered on the porters. Their knowledge about waste management, especially waste handling was seen as not adequate, confirming other findings in this study ( Table 3 ). One clinical officer said, “ The porters are not aware of the dangers of poor waste handling .” Another said, “ Porters need a refresher about waste management .” A third commented that, “ [I'm] not sure about the immunization status of porters against Hepatitis B .” The porters were mainly using soft medical disposable gloves, which concerned a clinical officer who emphasized that porters should be given heavy duty gloves.

Some of those who expressed concern about the porters were less aware of their own responsibility to segregate waste properly at source.

Summary of the Findings

Over five tons of health care waste was produced in the month observed. Only 28% was clinical waste, while the remainder was compostable waste from food preparation by patients or their relatives. Clinical staff had a good awareness about health care waste management. Unfortunately, this did not translate into proper segregation of waste into the different categories at the point of generation. Non-clinical staff involved in health care waste management had limited awareness of the risks involved in their roles. Their incorrect use of personal protective equipment while transporting the waste put them at risk of infection as well as occupationally-induced issues such as back problems. Disposal of chemicals directly into the ground posed a potential risk to water sources.

Strengths of the Study

Strengths of the study include following the complete waste disposal process within the hospital from waste generation to removal from the site for disposal. We also assessed staff awareness and practice about waste management. Data was collected for a whole month.

A weakness was that only five out of eight hospital departments were assessed and no other health centers or service delivery points were included. Details of quantities and kinds of waste fluids disposed of by pouring down drains and where the soak-away may drain to were not available, so the safety of fluid waste disposal could not be effectively assessed. This needs further work.

Reasons for Findings

The considerable amount of compostable waste from the Sexual and Reproductive Department (SRD) and adult inpatients was generated by relatives providing meals for the large number of in-patients, including 28 beds reserved for the use of pregnant women living in the hospital while awaiting delivery. The food waste includes bulky plantain skins from preparation of the local staple, bananas (matooke).

The relatively large amount of hazardous (highly infectious + infectious) produced by SRD (including maternity) were due to placentae and blood-contaminated materials from deliveries. The placentae not removed at the time of inspection indicate the on-going nature of deliveries, not the inadequacy of removal ( Table 4 ).

A large percentage of the hazardous waste from the HIV department was from items contaminated by body fluids during patient investigations.

Poor segregation of waste unnecessarily increased the amounts of apparently hazardous waste, and therefore the cost of disposal, whether to the hospital directly, or as at present to the private internationally funded waste company. The issue of incorrect segregation means that waste can be disposed of incorrectly. This is still true now that both non-compostable and hazardous waste are transported from the storage site to the processing plant in Eastern Uganda.

Comparison of Findings

The proportions of hazardous (12%) and non-hazardous waste (87%) was similar to that reported in other low- and middle-income countries ( 22 , 23 ). Segregation was incorrect across all departments; this is a common problem reported in other studies ( 24 , 25 ). From the interviews it was clear that clinical staff did not entirely apply the knowledge they had during segregation of waste in all departmental generation points, as found elsewhere ( 26 – 28 ). This is complicated by the lack of supply of the correctly colored bin liners to BCH.

The poor segregation and handling of waste increased the risk of infection to staff, patients, and visitors ( 9 ). Cross infection was taken seriously in both the hospital and the community health centers, with a dedicated infection control committee which is ready to act on conclusions of the study ( 28 ).

Overall, in our clinical areas, sharps were well handled, although globally sharps contribute the biggest morbidity of the waste ( 29 ).

Transportation within the hospital to the storage area was done manually by porters who did not use personal protective equipment correctly. This practice increases the risk of direct contact with contaminated waste and of injuries from sharps and also of spills of waste from the bin liners to the pathways and the compound. It is of note that the porters' basic knowledge about all aspects of proper waste handling was severely limited ( 30 ).

Water source contamination by chemicals from laboratory and X-ray has also been described in Haiti ( 31 ). Contamination of water sources may affect livestock and humans directly through drinking, and farming fields through irrigation, which is very important because the local community largely depends on agriculture for its livelihood. In Bwindi Community Hospital, while we do not know the existence or extent of any water contamination, the study has highlighted the need to investigate this in the future.

Human to animal spread of infection has been documented many times [reviewed in Chartier ( 16 )]. Cross contamination leading to transmission of infection in the catchment area of the hospital and community project could lead on to exposure, directly, or indirectly through intermediary species, not only of the human population but of the gorilla ( Gorilla beringei beringei ) population in the adjacent world heritage site ( 13 ). Environmental degradation, particularly deforestation ( 14 ), enhanced by waste pollution, may further endanger the nearby gorilla population, a responsibility the hospital is taking increasingly seriously.

Lessons Learnt

Knowledge of clinical staff is largely adequate with regard to the importance of recognizing the different waste types. Unfortunately, except for sharps and vials, this is not applied in the practical management of waste in the hospital.

Non-clinical staff involved in waste handling show little understanding of the resultant risks leading to possible adverse occupational outcomes and hospital contamination. As a result of this study, the hospital management more clearly recognized the risks to the health of the wider community, the natural environment, including contamination of water sources, and even possibly cross infection to local wild animals.

Implications

There is a need for the hospital to develop systematic methods to improve waste management for the benefit of staff, patients, and the wider community. This could be achieved through three approaches: education, audit, and review of the drain design.

• Continuous education for all hospital staff about safe and proper waste management with emphasis on segregation at point source, PPE, transport, storage, and disposal. Staff need to realize that they are the primary stake holders in ensuring that a clean and safe working environment. Clinical and non-clinical staff should contain a regular component on waste management.

• Waste audits should become more regular and consistent. Collection by the waste handling company for offsite management should be monitored to ensure consistency to avoid prolonged stay of waste which would lead to scavenging by rodents. Periodic close monitoring and evaluation of waste management would impart a sense of security against occupational health risks, increasing the moral among hospital workers.

• The procedures for disposal of potentially hazardous liquid waste draining into the ground should be reviewed. Liquid waste could be treated by dilution and liquid treatment before disposal. The hospital may need some investment to re-engineer the waste flow.

The hospital should prioritize health care waste management with dedicated budget line allocations. Over three tons of compostable waste was produced in 1 month. How this could be better managed to support the local agricultural community requires further work. Subsequent monitoring and auditing of the waste management protocols and policies will improve resources and ensure a cleaner and safer health care institution and the surrounding environment.

Health care waste management at Bwindi Community Hospital still faces many challenges and does not meet WHO standards that would ensure safety for staffs, clients, and the surrounding environment from hospital-related infections. The five departments in the study produced over 5,000 kg of waste in 1 month, a large amount that needs to be properly managed to minimize infections, water source contamination, and environmental pollution.

The hospital should arrange sufficient on-going training programs for clinical and non-clinical staff, and use of personal protective equipment by porters should be emphasized. Efforts should be made to improve the minimization of waste at source. Audit of waste management across the hospital, as well as re-engineering for the chemical wastes, is needed to ensure the lessons learned in this study are not lost but built into BCH's waste management policy and practice.

Data Availability

All datasets generated for this study are included in the manuscript and/or the supplementary files.

Ethics Statement

Ethics approval was obtained from the Bwindi Community Hospital Health and Scientific Committee local Ethics Committee, and also from the Ethics Advisory Group of International Union Against Tuberculosis and Chronic Lung Disease, Paris, France.

Author Contributions

SK conceived the study. SK, EW, AS, AD, and BM designed the study protocol and all authors read and approved the study protocol. SK collected the data. All authors contributed to analyzing and interpreting the data. SK and AS drafted the manuscript and all authors critically revised the manuscript for intellectual content. All authors read and approved the final manuscript. SK and BM are guarantors of the paper.

The program was funded by personal sources. The United Kingdom's Department for International Development (DFID) and The Union supported travel costs for some of the overseas mentors. The Special Programme for Research and Training in Tropical Diseases at the World Health Organization (WHO/TDR) supported the costs for open access publication. The external funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We acknowledge the contributions of Sheila Asimwe, research assistant, and the clinical and non-clinical staff of Bwindi Community Hospital. This research was conducted through the Structured Operational Research and Training Initiative (SORT IT), a global partnership led by the Special Programme for Research, and Training in Tropical Diseases at the World Health Organization (WHO/TDR). The training model is based on a course developed jointly by the International Union Against Tuberculosis and Lung Disease (The Union) and Medécins sans Frontières (MSF). The specific SORT IT program and the mentorship and coordination of the three SORT IT Workshops which resulted in this publication were implemented by authors affiliated with: Bwindi Community Hospital, Bwindi, Uganda; The University of Chester, Chester, UK; University of Exeter, Exeter, UK; and The Union, Paris, France.

1. Ali M, Wang W, Chaudhry N, Geng Y. Hospital waste management in developing countries: a mini review. Waste Manag Res. (2017) 35:581–92. doi: 10.1177/0734242X17691344

PubMed Abstract | CrossRef Full Text | Google Scholar

2. Hossain MS, Santhanam A, Norulaini NN, Omar AM. Clinical solid waste management practices and its impact on human health and environment–A review. Waste Manag. (2011) 31:754–66. doi: 10.1016/j.wasman.2010.11.008

3. Harhay MO, Halpern SD, Harhay JS, Olliaro PL. Health care waste management: a neglected and growing public health problem worldwide. Trop Med Int Health. (2009) 14:1414–7. doi: 10.1111/j.1365-3156.2009.02386.x

4. World Health Organization India. Medical Waste . (2018). Available online at: http://www.searo.who.int/india/topics/medical_waste/en/ (accessed December 19, 2018).

5. Aseweh Abor P, Bouwer A. Medical waste management practices in a Southern African hospital. Int J Health Care Qual Assur. (2008) 21:356–64. doi: 10.1108/09526860810880153

6. Uddin MN, Islam MR, Yesmin K. Knowledge on hospital waste management among senior staff nurses working in a selected medical college hospital of Bangladesh. J Waste Manag. (2014) 2014:573069. doi: 10.1155/2014/573069

CrossRef Full Text | Google Scholar

7. Muhwezi L, Kaweesa P, Kiberu F, Eyoku EL. Health care waste management in uganda-a case study of soroti regional referral hospital. Int J Waste Manag Technol. (2014) 2:1–2. Available online at: http://www.ijwmt.com/Vol. 2, No. 2, April 2014.php

Google Scholar

8. Ssempebwa JC, Tumwesigye NM, Van Vliet B, Adedimeji A. Healthcare waste management in Uganda: management and generation rates in public and private hospitals in Kampala. J Public Health. (2012) 20:245–51. doi: 10.1007/s10389-011-0459-6

9. Akulume M, Kiwanuka SN. Health care waste segregation behavior among health workers in Uganda: an application of the theory of planned behavior. J Environ Public Health. (2016) 2016:8132306. doi: 10.1155/2016/8132306

10. Kumar R, Shaikh BT, Somrongthong R, Chapman RS. Practices and challenges of infectious waste management: a qualitative descriptive study from tertiary care hospitals in Pakistan. Pak J Med Sci. (2015) 31:795. doi: 10.12669/pjms.314.7988

11. Prüss-Ustün A, Wolf J, Corvalán C, Neville T, Bos R, Neira M. Diseases due to unhealthy environments: an updated estimate of the global burden of disease attributable to environmental determinants of health. J Public Health . (2017) 39:464–75. doi: 10.1093/pubmed/fdw085

12. Chapman CA, Lawes MJ, Eeley HA. What hope for African primate diversity? Afr J Ecol. (2006) 44:116–33. doi: 10.1111/j.1365-2028.2006.00636.x

13. Ryan SJ, Walsh PD. Consequences of non-intervention for infectious disease in African great apes. PLoS ONE . (2011) 6:e29030. doi: 10.1371/journal.pone.0029030

14. Messenger AM, Barnes AN, Gray GC. Reverse zoonotic disease transmission (zooanthroponosis): a systematic review of seldom-documented human biological threats to animals. PLoS ONE . (2014) 9:e89055. doi: 10.1371/journal.pone.0089055

15. Bu K, Freile D, Cizdziel JV, Richards J, Sidhu V, Duzgoren-Aydin NS. Geochemical characteristics of soils on Ellis Island, New York-New Jersey, sixty years after the abandonment of the hospital complex. Geosciences. (2018) 8:13. doi: 10.3390/geosciences8010013

16. Chartier Y, Emmanuel J, Pieper U, Prüss A, Rushbrook P, Stringer R, et al. (eds.). Safe Management of Wastes From Health-care Activities . Geneva: World Health Organization (2014).

17. Ruoyan G, Lingzhong X, Huijuan L, Chengchao Z, Jiangjiang H, Yoshihisa S, et al. Investigation of health care waste management in Binzhou District, China. Waste Manag. (2010) 30:246–50. doi: 10.1016/j.wasman.2008.08.023

18. Njagi AN, Oloo AM, Kithinji J, Kithinji JM. Knowledge, attitude and practice of health-care waste management and associated health risks in the two teaching and referral hospitals in Kenya. J Commun Health. (2012) 37:1172–7. doi: 10.1007/s10900-012-9580-x

19. World Health Organization. Water, Sanitation, Hygiene [Internet]. WHO, United Nations' Children's Fund 2018. Water, Sanitation and Hygiene in Health Care Facilities: Status in Low and Middle Income Countries and Way Forward . Available online at: https://www.who.int/water_sanitation_health/publications/wash-health-care-facilities/en/ (accessed December 20, 2018).

20. The World Bank. Population, Total [Internet]. World Bank Group . (2018). Population, total. Available online at: https://data.worldbank.org/indicator/SP.POP.TOTL?locations=UG (accessed December 20, 2018).

21. Uganda Bureau of Statistics. The National Population and Housing Census 2014. Main Report (2016) (Kampala).

22. Attride-Stirling J. Thematic networks: an analytic tool for qualitative research. Qual Res. (2001) 1:385–405. doi: 10.1177/146879410100100307

23. Ali M, Wang W, Chaudhry N. Management of wastes from hospitals: a case study in Pakistan. Waste Manag Res. (2016) 34:87–90. doi: 10.1177/0734242X15616474

24. El-Salam MM. Hospital waste management in El-Beheira Governorate, Egypt. J Environ Manag. (2010) 91:618–29. doi: 10.1016/j.jenvman.2009.08.012

25. Nemathaga F, Maringa S, Chimuka L. Hospital solid waste management practices in Limpopo Province, South Africa: a case study of two hospitals. Waste Manag. (2008) 28:1236–45. doi: 10.1016/j.wasman.2007.03.033

26. Shinn HK, Hwang Y, Kim BG, Yang C, Na W, Song JH, et al. Segregation for reduction of regulated medical waste in the operating room: a case report. Korean J Anesthesiol. (2017) 70:100–4. doi: 10.4097/kjae.2017.70.1.100

27. Bhagawati G, Nandwani S, Singhal S. Awareness and practices regarding bio-medical waste management among health care workers in a tertiary care hospital in Delhi. Indian J Med Microbiol. (2015) 33:580. doi: 10.4103/0255-0857.167323

28. Anozie OB, Lawani LO, Eze JN, Mamah EJ, Onoh RC, Ogah EO, et al. Knowledge, attitude and practice of healthcare managers to medical waste management and occupational safety practices: findings from southeast nigeria. J Clin Diagn Res. (2017) 11:IC01. doi: 10.7860/JCDR/2017/24230.9527

29. Prüss-Üstün A, Rapiti E, Hutin Y. Estimation of the global burden of disease attributable to contaminated sharps injuries among health-care workers. Am J Ind Med. (2005) 48:482–90. doi: 10.1002/ajim.20230

30. Mbongwe B, Mmereki BT, Magashula A. Healthcare waste management: current practices in selected healthcare facilities, Botswana. Waste Manag. (2008) 28:226–33. doi: 10.1016/j.wasman.2006.12.019

31. Emmanuel E, Pierre MG, Perrodin Y. Groundwater contamination by microbiological and chemical substances released from hospital wastewater: health risk assessment for drinking water consumers. Environ Int. (2009) 35:718–26. doi: 10.1016/j.envint.2009.01.011

Keywords: hazardous waste, compostable waste, SORT IT, operational research, mixed methods, personal protective equipment, zoonoses

Citation: Kwikiriza S, Stewart AG, Mutahunga B, Dobson AE and Wilkinson E (2019) A Whole Systems Approach to Hospital Waste Management in Rural Uganda. Front. Public Health 7:136. doi: 10.3389/fpubh.2019.00136

Received: 15 February 2019; Accepted: 13 May 2019; Published: 06 June 2019.

Reviewed by:

Copyright © 2019 Kwikiriza, Stewart, Mutahunga, Dobson and Wilkinson. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Stuart Kwikiriza, kwikirizastuart6@gmail.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Research note
• Open access
• Published: 23 May 2019

Healthcare waste management current status and potential challenges in Ethiopia: a systematic review

• Teshiwal Deress Yazie   ORCID: orcid.org/0000-0002-1678-604X 1 ,
• Mekonnen Girma Tebeje 1 &
• Kasaw Adane Chufa 1  

BMC Research Notes volume  12 , Article number:  285 ( 2019 ) Cite this article

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During the healthcare delivery process, hazardous wastes can be generated from the health facilities. Improper healthcare waste management is responsible for the transmission of more than 30 dangerous bloodborne pathogens. The aim of this systematic review was to evaluate the healthcare waste management practice and potential challenges in Ethiopia.

Electronic databases and direct Google search yielded 1742 articles from which 17 studies met the inclusion criteria. The proportion of hazardous waste generated in Ethiopian healthcare facilities was unacceptably high which ranged from 21 to 70%. Most studies indicated the absence of proper waste segregation practice at the source of generation. Treatment of the healthcare waste using low combustion incinerator and/or open burning and open disposal of the incinerator ash were very common. Lack of awareness from the healthcare staff, appropriate waste management utilities and enforcement from the regulatory bodies were mainly identified as a common factor shared by most of the studies. The healthcare waste management practice in Ethiopian healthcare facilities was unsatisfactory. There should be close supervision of the waste disposal process by the regulatory bodies or other stakeholders.

Introduction

During the healthcare delivery process, healthcare facilities (HCFs) can generate wastes and by-products [ 1 ]. Currently, there are several terms used to explain the waste generated from the HCFs such as; health facility waste, clinical waste, healthcare waste, medical waste, and biomedical waste. However, healthcare waste (HCW) is most frequently used by the articles published so far [ 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ]. In this study, we used the term HCW to represent the total waste generated from the HCFs.

Healthcare waste is categorized as general and hazardous waste types [ 25 , 26 , 27 ]. General waste is the largest portion [ 26 ] which is originated from food preparation, administrative and housekeeping activities. Whereas, the hazardous waste is generated throughout the healthcare delivery process [ 19 ]. It includes laboratory wastes, pathological, body fluids, and sharp wastes [ 25 , 26 ]. According to the guidelines, six consecutive healthcare waste management (HCWM) steps should be implemented by the HCFs [ 26 , 28 , 29 , 30 , 31 ]. This successful management process includes segregation, collection, storage, transportation, treatment, and end up with final disposal [ 17 , 26 , 32 ] (Fig.  1 ).

Healthcare waste management process

Proper disposal of the HCW has become a global concern due to its public health hazards [ 17 , 25 , 33 ]. According to the WHO estimation, 10–25% of the HCW is hazardous [ 26 ]. However, this proportion is varied from country to country which ranged between 16 and 75% [ 6 , 8 , 12 , 14 , 21 , 23 , 34 , 35 ]. Globally over two million healthcare workers are exposed to infections [ 26 ]. The HCW can transmit more than 30 dangerous bloodborne pathogens [ 36 ]. Poor HCWM is a problem particularly in most developing countries [ 5 , 12 , 37 , 38 , 39 , 40 ]. Several studies indicated that HCWM is still at infancy stage [ 3 , 7 , 15 , 16 ] and particularly it is a neglected activity in Ethiopia [ 31 ]. Therefore, the aim of this systematic review was to evaluate the HCWM practice and potential challenges in Ethiopia.

Ethiopia is a highly populated country in Africa. During 2012 the Ethiopian population was predicted to be 84,320,987 [ 41 ]. In parallel with the rapid population growth, the number of HCFs is increasing [ 13 , 42 ]. The healthcare management is categorized as primary, secondary and tertiary levels. During 2011 there were 125 hospitals, 2999 health centers, 15,668 health posts and more than 4000 private clinics in the country [ 43 ]. The health post, health center, and primary hospitals serve a population of 3000–5000, 40000 and 60,000–10,000, respectively. General and specialized hospitals serve 1 to 1.5 and 3.5–5.0 million population, respectively [ 44 ].

A qualitative research design was employed to develop this systematic review. The study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to ensure the inclusion of relevant information in the study [ 45 ]. Studies were eligible only if they were published in the English language in peer-reviewed journals, carried out in the Ethiopian context, and accessed in the full-text format.

Published articles were searched in PubMed and Google Scholar by two investigators (TD and MG). The search strategy was employed using a combination of keywords and Boolean functions; “healthcare waste” OR “medical waste” OR “clinical waste” OR “infectious waste” OR “hospital waste” OR “healthcare facility waste” OR hazardous waste” OR “biomedical waste” OR “medical waste” AND “Ethiopia”. In addition, a direct Google search was also employed. Then, the searched articles from the two investigators were compiled together and screened for duplication. Finally, reference lists cited by each eligible study were assessed to identify additional articles. We used an endnote X9 version citation manager software to manage the citation.

Two authors (TD and KA) independently extracted data using the predefined data extraction sheet. Inconsistent data between the two data abstracters were resolved by discussion and involvement of a third co-author (KA). Data were abstracted containing first author and year of publication, setting, key findings (availability of waste management utilities/devices, waste segregation practice, hazardous waste proportion, waste treatment, final disposal, potential challenges) and additional relevant findings were paraphrased.

Before starting data extraction, selection process of the relevant studies was explained under the characteristics of included studies using texts and graphical presentation. After data extraction, the findings were grouped together into three thematic areas ‘waste generation, segregation and use of proper waste management utilities’, ‘waste treatment and disposal practices’, and ‘potential challenges. Finally, data were presented using texts.

To ensure reliability, articles were searched systematically using a combination of key terms and Boolean functions by two authors independently. The quality of the data was assured through extracting by two authors independently using the predefined data extraction checklist. Any inconsistent data from the two data extractors were resolved by discussion and involvement of a third co-author (Kasaw). In addition, the review process was done using the PRISMA guidelines.

Characteristics of the included studies

This systematic review was conducted on published studies which were conducted among the Ethiopian healthcare facilities. An online electronic search was done using Google Scholar and PubMed databases and we identified 834 articles. In addition, from reference lists of the included studies and direct Google search, we identified 908 articles. From a total of 1742 articles, 1619 data files were removed due to duplication. Further, 123 articles were refined by their title and abstract and 104 studies were excluded due to short communication, lack of relevant data with respect to this systematic review, unpublished student thesis, studies conducted elsewhere in another country, a review article on the legal framework, and letters to editors. Nineteen full-text articles were reviewed and two of them were excluded due to lack of relevant information for this systematic review as one study was conducted on developing new models for HCWM and the other was conducted on the prevalence of injuries associated with the mismanagement of HCWs among the waste collectors. Finally, we included 17 full-text articles (Fig.  2 ).

Flowchart to describe the selection of articles for the systematic review

Waste generation, segregation and use of utilities

Most studies were obtained from the central and northwest regions of Ethiopia. Studies indicated no waste segregation practice [ 2 , 13 , 14 , 17 , 44 ]. In some cases; however, there was very limited segregation [ 5 , 6 , 8 , 18 , 20 , 21 , 46 ]. Due to this reason, the proportion of the hazardous waste generation rate becomes unacceptably high which range from 21 to 75% [ 2 , 6 , 9 , 12 , 14 , 17 , 21 , 23 ]. Privately owned HCFs generated a higher proportion of hazardous wastes than government-run facilities [ 23 ]. There was no use of proper color-coded bins for waste segregation [ 5 , 9 ]. General and infectious wastes were mixed together [ 9 ]. Plastic buckets were used to store the HCW temporarily [ 17 , 27 ]. Disinfection of waste storage and/or transporting utilities was uncommon [ 6 , 17 ].

Waste treatment and disposal practices

Low combustion incinerator was used to treat all the HCW types [ 2 , 8 , 9 , 12 , 14 , 21 , 46 ]. In other cases, studies indicated the use of incineration and open burning methods to treat hazardous and general wastes, respectively [ 5 , 6 , 8 , 14 , 17 , 20 , 27 ]. With respect to disposal of the treated waste by-products, some studies used burial pit [ 2 , 6 ] while other studies disposed of in an unsanitary way simply by open dumping [ 8 , 12 , 27 ].

Potential challenges

In the Ethiopian context, there was no separate regulation specific for the HCFs to enforce them for the proper management of the hazardous waste. Though currently they are not updated and lacked proper compliance on their implementation, there are three HCWM guidelines prepared by the Federal Ministry of Health (FMoH), Food, Medicine and Healthcare Administration and Control Authority (FMHACA), and Federal Environmental Protection Authority (FEPA) independently [ 29 , 30 , 46 ]. In addition, studies indicated lack of training, awareness, staff resistance, managerial poor commitment, lack of adequate resources, negligence, and unfavorable attitude of the healthcare staff were the main identified challenges [ 8 , 10 , 12 , 13 , 14 , 46 , 47 ]. Most studies measured the aforementioned potential factors either quantitatively or qualitatively that could affect HCFs to implement the proper waste management practices.

Currently, HCWM is a public health and environmental concern worldwide particularly in the developing countries [ 4 , 48 ]. Hazardous waste mismanagement affects all individuals particularly healthcare providers. The general and hazardous waste types should be properly segregated at their source of generation [ 25 , 49 , 50 , 51 ]. However, in this systematic review, studies mentioned the absence of waste segregation practices [ 2 , 5 , 12 , 14 , 17 , 20 , 21 , 32 , 44 ]. Probably this could be due to lack of the appropriate waste segregation utilities, lack of awareness or lack of enforcing laws and/or regulations. It is also a continent-wide problem by which a systematic review in the African region indicated that 47% of the studies mentioned the absence of waste segregation [ 52 ]. The proportion of hazardous HCW is varied in Ethiopia which ranged from 21 to 70% [ 14 , 44 ]. This proportion is higher than the hazardous waste threshold (10–25%) predicted by the WHO [ 26 ]. In one study, even the amount of hazardous waste was higher than the general waste [ 14 ]. This could be due to the fact that during the segregation process even a very small amount of hazardous waste is added to the general waste category, then the entire mass of the general waste can be unnecessarily polluted by the hazardous waste.

The segregated HCW types are required to be collected separately using waste collecting utilities designed for each type of HCW [ 26 , 31 ]; however, in this systematic review, studies indicated the aggregate collection of the different HCW types using a single container [ 9 , 17 , 21 ]. This could be due to the lack of awareness of the health hazards associated with the aggregate collection of all the HCW types by the waste collectors because in Ethiopian context waste collectors are mostly recruited from the low educational level and they might not provide adequate training as the healthcare professionals.

According to WHO guidelines, all hazardous HCW types generated from the HCFs should be stored in utility rooms prepared for cleaning equipment, dirty linen and waste storage [ 26 ]. If these facilities are not available, the HCW can be stored in other secured locations [ 31 , 53 ]. However, studies indicated hazardous waste storage practices using the primary waste segregation containers stationed around the corridors [ 27 , 44 ]. This unacceptable waste storage practice could probably due to the lack of sufficient and isolated waste storage spaces away from direct public access.

Incineration is the most widely used waste treatment method to treat hazardous HCW before the final disposal particularly in most developing countries. In Ethiopia, incineration and open burning are common treatment methods to treat hazardous and general waste types, respectively. However, incinerators are often operated under sub-optimal conditions mostly with untrained personnel [ 4 ]. Thus, due to inadequate incineration harmful substances can be released into the environment [ 27 ]. Regarding disposal of the HCW, incinerator ash is commonly disposed of in burial pit or open dumping. Most studies showed HCWM noncompliance with the requirements of the national and international guidelines [ 2 , 5 , 6 , 8 , 9 , 12 , 14 , 18 , 21 , 27 , 44 ]. This could be due to lack of the appropriate quantity and/or type of waste management utility supply, adequate financial allocation, specific laws, and regulations.

Healthcare waste management is a complex and challenging process and in this systematic review lack of training [ 2 , 5 ], accessible guideline [ 2 , 6 , 12 , 21 , 46 ], regular supervision, appropriate utility supply, management support, and specific rules/regulations are identified as a major challenge for having effective waste management system [ 5 , 13 , 17 , 23 , 24 , 27 , 44 , 46 ] that needs establishment of an immediate strategy to reduce the potential problems associated with the mismanagement of the hazardous wastes emanated from the healthcare establishments.

In conclusion, the HCW generation rate was high but its management very poor. Lack of accessible guideline, waste management utility, adequate training, financial constraint, and poor managerial supports were identified as the main challenges. There should be sufficient resource allocation, periodic training, and strict supervision by the stakeholders.

Limitations

In this systematic review, liquid waste management was not considered. In addition, recycling practices of the reusable materials from the HCWs were not considered.

Availability of data and materials

Not applicable.

Abbreviations

healthcare waste

healthcare facilities

healthcare waste management

Pinto VN, Joshi SM, Velankar DH, Mankar MJ, Bakshi H, Nalgundwar A. A comparative study of knowledge and attitudes regarding biomedical waste (BMW) management with a preliminary intervention in an academic hospital. Int J Med Public Health. 2014;4:91–5.

Article   Google Scholar  

Abebe S, Raju R, Berhanu G. Health care solid waste generation and its management in Hawassa Referral Hospital of Hawassa University, Southern, Ethiopia. Int J Innov Res Dev. 2017;6:126–32.

Google Scholar  

Alagoz AZ, Kocasoy G. Determination of the best appropriate management methods for the health-care wastes in Istanbul. Waste Manage. 2008;28:1227–35.

Asante OB, Yanful E, Yaokumah EB. Healthcare waste management; its impact: a case study of the greater Accra Region, Ghana. Int J Sci Technol Res. 2014;3:106–12.

Azage M. Healthcare waste management practices among healthcare workers in healthcare facilities of Gondar town, Northwest Ethiopia. Health Sci J. 2013;7:315–26.

Azage M, Kumie A. Healthcare waste generation and its management system: the case of health centers in West Gojjam Zone, Amhara Region, Ethiopia. Ethiop J Health Dev. 2010;24:119–26.

Bendjoudi Z, Taleb F, Abdelmalek F, Addou A. Healthcare waste management in Algeria and Mostaganem department. Waste Manag. 2009;29:1383–7.

Article   CAS   Google Scholar  

Debalkie D, Kumie A. Healthcare waste management: the current issue in Menellik II Referral Hospital, Ethiopia. Curr World Environ. 2017;12:42–52.

Debere MK, Gelaye KA, Alamdo AG, Trifa ZM. Assessment of the health care waste generation rates and its management system in hospitals of Addis Ababa, Ethiopia, 2011. BMC Public Health. 2013;13:28.

Doylo T, Alemayehu T, Baraki N. Knowledge and practice of health workers about healthcare waste management in public health facilities in Eastern Ethiopia. J Community Health. 2018;43:1–8.

Esubalew T. Assessment of health care waste generation rate and evaluation of health care waste management in Debre Birhan zonal hospital. M.Sc. Thesis, School of public health, Addis Ababa University, 12, 2007.

Haylamicheal ID, Dalvie MA, Yirsaw BD, Zegeye HA. Assessing the management of healthcare waste in Hawassa city, Ethiopia. Waste Manage Res. 2011;29:854–62.

Haylamicheal ID, Desalegne SA. A review of legal framework applicable for the management of healthcare waste and current management practices in Ethiopia. Waste Manage Res. 2012;30:607–18.

Hayleeyesus SF, Cherinete W. Healthcare waste generation and management in public healthcare facilities in Adama, Ethiopia. J Health Pollut. 2016;6:64–73.

Manga VE, Forton OT, Mofor LA, Woodard R. Healthcare waste management in Cameroon: a case study from the south-western region. Resour Conserv Recycl. 2011;57:108–16.

Mbongwe B, Mmereki BT, Magashula A. Healthcare waste management: current practices in selected healthcare facilities, Botswana. Waste Manage. 2008;28:226–33.

Meleko A, Adane A. Assessment of health care waste generation rate and evaluation of its management system in Mizan Tepi University Teaching Hospital (MTUTH), Bench Maji Zone, South West Ethiopia. Ann Rev Res. 2018;1:1–9.

Mesfin A, Worku W, Gizaw Z. Assessment of health care waste segregation practice and associated factors of health care workers in Gondar University Hospital, North West Ethiopia, 2013. Univ J Public Health. 2014;2:201–7.

Patil AD, Shekdar AV. Health-care waste management in India. J Environ Manage. 2001;63:211–20.

Sahiledengle B, Gebresilassie A, Hiko K, Getahun T. Healthcare waste segregation, treatment and disposal practice in governmental healthcare facilities in Addis Ababa, Ethiopia. Ethiop J Environ Stud Manage. 2018;11:73–85.

Tadesse ML, Kumie A. Healthcare waste generation and management practice in government health centers of Addis Ababa, Ethiopia. BMC Public Health. 2014;14:1221.

Tesfahun E, Kumie A, Beyene A. Developing models for the prediction of hospital healthcare waste generation rate. Waste Manage Res. 2016;34:75–80.

Tesfahun E, Kumie A, Legesse W, Kloos H, Beyene A. Assessment of composition and generation rate of healthcare wastes in selected public and private hospitals of Ethiopia. Waste Manage Res. 2014;32:215–20.

Yenesew MA, Moges HG, Woldeyohannes SM. A cross sectional study on factors associated with risk perception of healthcare workers toward healthcare waste management in healthcare facilities of Gondar Town, Northwest Ethiopia. Int J Infect Control. 2012;8:1–9.

Olufunsho A, Aishat AA, Azuka CO. Assessment of medical waste management in seven hospitals in Lagos, Nigeria. BMC Public Health. 2016;16:269.

Chartier Y, Emmanuel J, Pieper U, Prüss A, Rushbrook P, Stringer R, et al. Safe management of wastes from health-care activities. Geneva, Switzerland: World Health Organization; 2014.

Derso S, Taye G, Getachew T, Defar A, Teklie H, Amenu K. Biomedical waste disposal systems of health facilities in Ethiopia. Environ Health Eng Manage J. 2018;5:1–9.

Bokhoree C, Beeharry Y, Makoondlall CT, Doobah T, Soomary N. Assessment of environmental and health risks associated with the management of medical waste in mauritius. APCBEE Procedia. 2014;9:36–41.

The Federal Environmental Protection Authority (FEPA). Technical guidelines on the environmentally sound management of biomedical and healthcare wastes. Addis Ababa: The Federal Environmental Protection Authority (FEPA); 2004.

Food, Medicine and Healthcare Administration and Control Authority (FMHACA). Healthcare waste management directive. Addis Ababa: Food, Medicine and Healthcare Administration and Control Authority (FMHACA); 2005.

Federal Ministry of Health (FMoH). Healthcare waste management national guidelines, hygiene and environmental health development. Addis Ababa: Federal Ministry of Health (FMoH); 2008.

Manyele SV, Lyasenga TJ. Factors affecting medical waste management in low level health facilities in Tanzania. Afr J Environ Sci Technol. 2010;4:304–18.

Chakraborty S, Veeregowda B, Gowda L, Sannegowda SN, Tiwari R, Dhama K, et al. Biomedical waste management. Adv Anim Vet Sci. 2014;2:67–72.

Bassey BE, Benka-Coker MO, Aluyi HS. Characterization and management of solid medical wastes in the federal capital territory, Abuja Nigeria. Afr Health Sci. 2006;6:59–63.

Sarkar SK, Haque MA, Khan TA. Hospital waste management in Sylhet city. ARPN J Eng Appl Sci. 2006;1:32–40.

Sawalem M, Selic E. Hospital waste management in Libya: a case study. Waste Manage. 2009;29:1370–5.

Hossain MS, Santhanam A, Norulaini NN, Omar AM. Clinical solid waste management practices and its impact on human health and environment—a review. Waste Manage. 2011;31:754–66.

De Titto E, Savino AA, Townend WK. Healthcare waste management: the current issues in developing countries. Waste Manag Res. 2012;30:559–61.

Townend B, Vallini G. Healthcare waste management—the global paradox. Waste Manage Res. 2008;26:215–6.

Diaz LF, Fisher S. Management of healthcare wastes. Waste Manage. 2005;25:567–74.

Federeal Democratic Republic of Ethiopia Ministry of Health, Health and Health Related Indicators 2004 E.C 2011/12.

Eshetie S, Gizachew M, Dagnew M, Kumer G, Woldie H, Ambaw F, et al. Multidrug resistant tuberculosis in Ethiopian settings and its association with previous history of anti-tuberculosis treatment: a systematic review and meta-analysis. BMC Infect Dis. 2017;17:219.

Federal Democratic Republic of Ethiopia. Health and health related indicators. Ethiopia: Federal Democratic Republic of Ethiopia; 2011.

Abebe A. Study of hazardous biomedical waste management practices and development of hazardous biomedical waste management guidelines in Addis Ababa. Int J Sci Eng Sci. 2017;1:19–32.

Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097.

Demissie F. Hazardous waste management by healthcare institutions, Addis Ababa: implementation of laws and regulation. Ethiop J Environ Stud Manage. 2014;7:134–41.

Deress T, Hassen F, Adane K, Tsegaye A. Assessment of knowledge, attitude, and practice about biomedical waste management and associated factors among the healthcare professionals at Debre Markos Town Healthcare Facilities, Northwest Ethiopia. J Environ Public Health. 2018;2018:1–10.

Sabageh A, Adeomi A, Adediran O, Abodunrin O, Oladimeji O, Eunice F. Perception and practices of healthcare workers in Southwestern Nigeria towards healthcare waste management. Br J Med Health Res. 2015;2:19–26.

Longe E, Williams A. A preliminary study of medical waste management in Lagos metropolis, Nigeria. J Environ Health Sci Eng. 2006;3:133–9.

Ngwuluka N, Ochekpe N, Odumosu P, John SA. Waste management in healthcare establishments within Jos Metropolis, Nigeria. Afr J Environ Sci Technol. 2009;3:459–65.

Ola-Adisa EO, Mangden YE, Sati YC, Adisa JO. Knowledge, Attitudes/beliefs and practices in medical waste management—an appraisal of Jos North LGA, Plateau State, Nigeria. Int J. 2015;2:43–56.

Emilia A, Julius N, Gabriel G. Solid medical waste management in Africa. Afr J Environ Sci Technol. 2015;9:244–54.

Ruth S. Medical waste and human rights. Health care without harm; Submission to the UN human rights council special rapporteur. 2011.

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• Published: 09 February 2022

A deep learning approach for medical waste classification

• Haiying Zhou 1 ,
• Xiangyu Yu 4 ,
• Ahmad Alhaskawi 1 ,
• Yanzhao Dong 1 ,
• Zewei Wang 8 ,
• Qianjun Jin 1 ,
• Xianliang Hu 5 ,
• Zongyu Liu 5 ,
• Vishnu Goutham Kota 8 ,
• Mohamed Hasan Abdulla Hasan Abdulla 8 ,
• Sohaib Hasan Abdullah Ezzi 8 ,
• Binjie Qi 2 ,
• Juan Li 3 ,
• Bixian Wang 3 ,
• Jianyong Fang 6 &
• Hui Lu 1 , 7  

Scientific Reports volume  12 , Article number:  2159 ( 2022 ) Cite this article

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As the demand for health grows, the increase in medical waste generation is gradually outstripping the load. In this paper, we propose a deep learning approach for identification and classification of medical waste. Deep learning is currently the most popular technique in image classification, but its need for large amounts of data limits its usage. In this scenario, we propose a deep learning-based classification method, in which ResNeXt is a suitable deep neural network for practical implementation, followed by transfer learning methods to improve classification results. We pay special attention to the problem of medical waste classification, which needs to be solved urgently in the current environmental protection context. We applied the technique to 3480 images and succeeded in correctly identifying 8 kinds of medical waste with an accuracy of 97.2%; the average F1-score of five-fold cross-validation was 97.2%. This study provided a deep learning-based method for automatic detection and classification of 8 kinds of medical waste with high accuracy and average precision. We believe that the power of artificial intelligence could be harnessed in products that would facilitate medical waste classification and could become widely available throughout China.

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Introduction.

Medical waste (MW) refers to directly or indirectly infectious, toxic, or otherwise hazardous waste generated by medical institutions during medical or preventative care and related activities, and specifically includes infectious, pathological, damaging, pharmaceutical, and chemical waste 1 . These wastes contain a large amount of bacteria and viruses, and have the potential to cause space pollution, acute viral infection, and latent infection 2 . If they are not properly managed, they can contaminate the surrounding environment, where they pollute the land, water, plants, animals, and air, causing the spread of disease. MW also poses a great threat to the physical and mental health and the quality of life of medical staff and patients 3 .

Currently, MW in China is generally collected and processed centrally by a unified acquisition department, and faces challenges such as inadequate use of waste bins, lack of detailed classification of medical waste or even stacking randomly, and insufficient training of waste classification personnel 4 . High expenses are also one of the reasons for improper disposal of medical waste. Because more processing costs have to be paid to external agencies, the cost of medical waste disposal for hospitals has risen accordingly. The increase in expenditure has caused hospitals to deploy waste disposal facilities and human resources more casually, and in turn, hospitals’ medical waste disposal has steeply declined in quality, which greatly increases the potential for medical waste to contaminate the environment and harm the associated staffs, while reducing the chances of its recycling.

Since the classification of MW varies from country to country 5 , it becomes difficult to count which types of MW are most common. However, in most cases, textile materials, such as gauzes and bandages, occupy the central stage and account for about 83%-97% of overall MW 6 , 7 . This is followed by plastic products, which account for 39%-49%. Notably, medical plastic waste includes infusion bags, syringe, blood bags, tubing, gloves, labware, and medical packaging-related waste usually made of PVC plastic, and they will produce many toxic substances such as dioxins and furans after incineration, which is by far the most common means of medical waste disposal, thereby, the health of the residents and the atmosphere are at great risk 7 . Sharps such as needles, surgical blades, and broken glass, account for 12% of the total waste generated and are the main cause of injury and infection among medical workers and medical waste handlers 6 , 8 , 9 . In this case, the classification of hazardous and common MW is our main concern. Eight types of MW that comprised of textile materials, such as gauze; plastic materials, such as gloves, infusion bags, infusion apparatus, syringes; and sharp objects such as infusion bottles, tweezers, and needles, were selected as the objects of study in an attempt to improve the efficiency and safety of MW classification. Because of their different shapes, it is feasible to classify them by image analysis.

Deep learning-based algorithms have promoted significant advances in waste sorting and medical image analysis 10 , 11 . Convolutional neural networks (CNNs) are one of the most important network types in the field of deep learning. The most attractive feature of CNNs is that they can learn increasingly complex features from the input data. For example, the Alex Krizhevsky Network (AlexNet) won the ILSVRC competition in 2012, setting off the current craze of deep learning. Its innovations included the use of ReLU functions, dropout regularization, multi-GPU distributed computing, and data augmentation during training 12 . With the successful application of CNNs in the field of image recognition, Simonyan et al. proposed a simple and effective CNN architecture design principle. Their architecture, called VGG, popularized the idea of using smaller convolutional kernels and deeper network layers (VGG19 has up to 19 layers, AlexNet has up to seven) 13 . GoogLeNet (also known as Inception-V1GoogLeNet) won the 2014 ILSVRC contest, and contained multiple inception modules, each of which applied multiple filters of different sizes to the input; the network then concatenated the results. GoogLeNet also popularized the idea of using global average pooling instead of fully connected layers, thus significantly reducing the number of model parameters and solving the gradient loss problem posed by training deeper networks 14 . In 2015, He et al. proposed ResNet, adding skip connections to the standard path. ResNet retained information as the data passed through the layer. ResNet is 152 layers deep (20 times deeper than AlexNet and 8 times deeper than VGG), and won the 2015-ILSVRC championship 15 . Even with the increase in depth, ResNet's computational complexity is still lower than VGG's. ResNeXt is constructed by repeating a building block that aggregates a set of transformations with the same topology 16 . This simple design results in a homogeneous, multi-branch architecture that has only a few hyper-parameters to set.

Machine learning algorithms are widely used in supervised learning, and can solve many practical problems. However, in comparison, the deep neural network (DNN) model has more advantages in image processing and image classification, because deep learning algorithms are better at solving image problems. When people classify medical waste manually, it is done by visually judging the type of waste, which is actually done by image features. Therefore, it makes sense to use the deep learning model to classify medical waste (Figs. 1 , 2 ).

Examples of the medical waste. ( a ) Gauze, ( b ) Gloves, ( c ) Infusion bags and bottles, ( d ) Infusion apparatus and syringe, ( e ) Syringe needles, ( f ) Tweezers.

Deep MW: a overview of the deep learning framework.

To show the effectiveness of our approach, we conducted a five-fold crossover experiment on the data set. For each experiment we used 2784 images as the training set and 696 as the validation set. The results of the five cross-validation experiments are shown in Table 1 . Figures  3 and 4 show the change curves of the loss function and accuracy for each experiment.

History curves for train accuracy (blue line) and valid accuracy (yellow line).

History curves for train loss(blue line) and valid loss(yellow line).

For the classification problem, we selected the following indicators to evaluate the model results: f1 score, recall, and precision. These evaluation indicators were calculated by category. In the multi-classification problem, the accuracy of simple calculation was biased, so more detailed evaluation standards were needed to measure the performance of the model. At the same time, we drew a confusion matrix to visualize the classification effect of the five categories [Fig.  5 ].

Confusion matrix for the eight categories classification.

Practically, our calculation is performed within the deep learning framework named PyTorch, and for the reason of efficiency, the GPU version with cuDNN computational kernels is applied to accelerate the training procedure. As the traditional classification problem, the cross-entropy loss function is effective in this research, and some extensions on classical ResNeXt-50 are applied for our case: the output size of fully connected layer is fitted to 256, and a dropout layer paramered with 40 percents is applied subsequenty. Finally, the number of final output is set to the same with the categories of the waste. As for the training process, the learing rate is chosen as 1e-3 without decay, and the training process ended within no more than 100 steps. It is also worth to mention that all of the numerical results in this paper is obtained on our GPUs workstation equipped with NVIDIA Tesla V100.

Poor management of medical waste can lead to adverse environmental impacts and human health risk. According to the World Health Organization (WHO), of the total amount of medical waste, 25% of waste is regarded as hazardous and about 75% as non-hazardous. However, both of these types of waste are generally mixed and disposed of together 17 . When hidden in mixed waste, sharp objects such as needles and razor blades can cause injuries to cleaning staff, and waste contaminated with patient bodily fluids not only increases the risk of infection for medical staff, but its improper disposal can also significantly increase the potential for infection in the surrounding population 18 , 19 . In addition, mixing waste not only increases sanitation labor, but also the burden on environmental protection departments 20 . At present, mixed medical waste is sent to be incinerated, and the significant amount of soot and other emissions it produces pollutes the land and atmosphere 7 , 20 .

However, with the progress and development of society, people are more concerned about their health problems, causing the production of medical waste to increase rapidly 21 . In only 3 years, from 2013 to 2016, the annual growth rate of the production of medical waste in China was nearly 20% according to China's Ministry of Environmental Protection. The burden of sorting waste by manpower alone is too great, considering the large number of staff to be hired and the cost of managing and training them. Therefore, we used a CNN to develop Deep MW, an image recognition system for sorting medical waste, which can realize simpler, more efficient and accurate sorting and recycling of medical waste, as well as reduce the risk of occupational exposure for medical waste facility workers [Table S1 ]. There are other similar contributions, such as iWaste 22 , where for different class of medical waste are detected and classified. In the sense of accuracy of classification, DeepMW has better result and more convenient extending to more categories of objects.

The results presented in the previous section show that advanced AI solutions can be applied for automatic identification and classification of medical waste with a high accuracy, even with a limited imaging dataset. The primary goal of this study was to achieve the highest possible classification accuracy using a data set of only 3480 medical waste images and the developed AI algorithm. The main issue concerned here is to alleviate overfitting dut to the limited training data. To mitigate this problem, various image augmentation techniques are applied, such as rotation, rescaling, clipping and flipping. Noticing that the classical ResNeXt network is a effective and highly modularized architecture for classification tasks, a traditional technique is to repeat the building block with the same topology to formation a set of transformations, as well as used in our previous work 23 . This simple design results in a homogeneous, multi-branch architecture that requires only a few hyper-parameters. In a practical calculation, it is also effective to increase the cardinality instead of using deeper and wider structure. The current task is one of the fundamental tasks in the whole practical processing. In a practical using, It is always suggested to capture/detect the object from the video frames, which depend on a very efficient detection network to perform online detection. The classification task is the subsequently job after the image is captured and cropped from the video frames. In this stage, the accuracy is the concerned issue, while the speed is the main issue at the stage of detection. In this sense, we formulate the problem as a classification task.

The mixed packing of medical waste treats garbage as waste, whereas the separate packaging of garbage treats waste as a resource. For instance, plastics or polystyrene in medical waste can be widely recycled to produce secondary products such as accessories, packaging, cases, and containers. Recycling and reuse can save a remarkable amount of energy when compared with the virgin material 24 . For example, the air pollution and water pollution produced when waste paper is restored and recycled are much less than the pollution produced when the original natural fiber is used to make paper. The classification of medical waste can also bring certain economic benefits to the hospital. On the one hand, medical products currently in use usually have high-quality paper packaging, so paper recycling is very feasible. On the other hand, disposal of medical waste is very expensive. After sorting, this portion of the expenditure can be reduced and indirect economic benefits can be generated. Another reason to focus on medical waste identification is that it promotes safe disposal by taking simple steps to pack and separate garbage, as recyclable waste is distributed to various recycling departments, and does not pollute the soil and atmosphere. Classification of medical waste also helps improve the environmental protection awareness of staff. With the current goals of advocating environmental protection and creating a conservation-oriented society, if every employee in the operating room cares about environmental protection, saves resources, and contributes to environmental protection, they can establish a tradition of conservation and enhance the public image of the hospital. Therefore, medical waste classification can not only reduce medical harm, but also promote recycling, reduce consumption, and bring economic benefits to medical and health services providers.

In summary, we propose a deep learning-based method, Deep MW, for automatic detection and classification of medical waste based on images. Our results show that the method is capable of identifying the 8 main kinds of medical waste with high accuracy and average precision. The application of the method described in this paper to medical waste could prevent hazardous and DEA-regulated medications from being commingled with non-hazardous medications. This in turn would reduce the volume of medical waste generated by medical programs and the associated transportation and disposal costs.

Description of the dataset

For this research, we used a medical waste dataset from The First Affiliated Hospital, Zhejiang University, collected in 2019. This special dataset consists of labels, image data, and medical waste boarder for 3480 samples, which could be categories into eight kinds of medical waste. In this sense, the proposed deep learning approach is named with Deep MW (deep medical waste).

There was some abnormal data in the dataset, as shown in Fig.  1 . In addition, some images contained more than one category of waste. For example, the upper left corner of the gauze in Fig.  1 a contains gloves, an infusion bottle and infusion bag are both in Fig.  1 c, and infusion apparatus and syringe both appear in Fig.  1 d. This type of image had a lower degree of accuracy than classical images. The quality of the source image, such as size and background, could influence the performance of classification model siginificantly. In practical application, additional operation on the source image is nessary, such as local sampling 25 , cropping 26 , etc. We used data preprocessing to ensure sufficient data quality and consistent sample size.

Following the suggestions from medical experts, eight categories of medical waste are considered as the typical illustration in this research respectively were gauze, gloves, infusion bags, infusion bottles, infusion apparatus, syringe needles, tweezers and syringe. More specifically, the dataset classification and corresponding sample size are shown in Table 2 .

It is not difficult to see from the table that the sample size of the eight kinds of medical waste was basically balanced: sample gauze had the most images (508), and sample syringe the fewest (369). The sample size distribution was workable for algorithm classification.

Data augmentation

We augmented the training set by generating new medical waste images in order to balance the classes, and adjusted them using zoom, rotation, shear, translation, flipping, Gaussian noise, and stretching transformations. We applied these transformations to each image, with parameters chosen at random. We then included the new images in the training set, while images of the most favored class were excluded at random until the classes were balanced.

Dividing the dataset

First, we randomly (without repeated sampling) divided the dataset into ten parts, using nine of them in turn as training sets and one as the test set. Next, we augmented the training set as described above and conducted experiments. Finally, we averaged the results of ten experiments as an estimate of the overall accuracy of the algorithm.

We collected images of 8 kinds of typical medical waste: gauze, gloves, infusion bags, infusion bottles, infusion apparatus, syringe needles, tweezers, and syringe. Since the images for the sampling are collected by ourselves, the category balance is taken into account at this stage, in which the samples’ sizes are kept almost in the same level. The number of images of each type was: 508 of gauze, 440 of gloves, 443 of infusion bags, 433 of infusion bottles, 426 of infusion apparatus, 410 of syringe needles, 451 of tweezers, and 369 of syringe sets. The dataset includes all the image forms of each category collected so far, if there are samples of non-single medical waste images, adding them will help to improve the accuracy of the algorithm, can be considered enough in scope. The total number of training sets was 3480. For practical usage, the enrichment of the categories of the classification is simple to modify with the current framework. More categories could be appended by preparing more images for the interested objects.

Framework of the data flow

We packaged the training sets and tested them to generate PKL files. Then, we inputted the PKL files to the pre-training model, and the loss function was used to iteratively train the network to obtain the automatic classification model. After the model training was completed, the medical waste images were either predicted by the prediction script, or subjected to batch classification prediction using the verification script. For a better illustration, let us depicted the framework of proposed deep learning system, namely DeepMW, within the following Fig.  2 .

Setup of the deep neural network

ResNeXt follows the principle of concise design 16 . Multiple modules with the same structure are repeatedly divided, and each module aggregates the grouping transformation of the same topology. This simple design produces a homogeneous, multi-branch architecture, which requires only a few hyperparameters.

Each module of ResNeXt follows two simple rules: (i) if generating feature maps of the same size, the modules share the same hyperparameters (ii) each time the feature map is downsampled by 2 times, the width of the module is multiplied by 2 times. The second rule ensures that the calculation complexity of FLOP (floating-point operations, multiply–add operations) is approximately the same for all blocks. Using these two rules, we only need to design a template module to determine all modules in the network accordingly. Therefore, these two rules greatly reduce design complexity, allowing us to focus on some key factors.

A neuron is the basic unit of an artificial neural network. It mainly performs inner product operations, that is, nonlinear transformation completed by a fully connected layer and a convolutional layer. In simple terms, the inner product operation can be viewed as a combination of the three operations of splitting, transforming, and aggregating. (i) splitting: decompose the input vector x into low-dimensional embeddings. Generally, each low-dimensional embedding corresponds to a one-dimensional subspace x i . (ii) transforming: transform the low-dimensional embedding obtained by decomposition, that is, multiply the weight \({w}_{i}\) to get \({w}_{i}{x}_{i}\)

(iii) aggregating: the transformations in all embeddings are aggregated by \({\sum }_{i=1}^{D}\)

Formally, we present aggregated transformations as

where \({T}_{i}(x)\) can be an arbitrary function. In ResNeXt, it is best to use a network instead of the basic transformation ( \({w}_{i}{x}_{i}\) ). Broadly speaking, transformation is not limited only to a function; it can also be a network, that is, a “Network-in-Neuron” structure. Similar to a simple neuron, \({T}_{i}\) should project \(x\) into an (optionally low-dimensional) embedding and then transform it. C is the size of the transformation set to be aggregated, and we refer to C as cardinality. All \({T}_{i}\) have the same topology. We set each transformation \({T}_{i}\) as a bottleneck structure. Thus, the first 1*1 layer of each \({T}_{i}\) produces low-dimensional embedding.

We converted the aggregate transformation into a residual function

where y is the output.

The result of determining whether an item was medical waste was outputted in principal binary. The cross-entropy loss function for input was reasonable from the perspective of classification. Our label for medical waste showed whether the item was medical waste or not. The expression of the loss function was as follows.

where \({w}_{l(x)}\) corresponds to the weight of different labels and l(x) is the label type of pixel point x.

Transfer learning

Image or medical examination classification is one of the first fields where deep learning has made a significant contribution. In medical examination classification, one or more images are usually used as input, and a single diagnostic result is used as output (for example, whether there is a disease). In this scenario, each diagnosed case is a sample. Compared with data sets in the field of computer vision, data sets for medical examinations usually have a small sample size (hundreds vs. thousands and millions of samples). Transfer learning is required to meet the needs of deep learning for large data sets.

In practical applications, the following two transfer learning strategies are often used: (1) Using a pre-trained network without modification as a feature extractor. (2) Fine-tuning a network trained with medical data. The advantage of the former strategy is that there is no need to train a deep network and the extracted features are directly input into the existing image analysis process. Both strategies are popular and have been widely used. However, few authors have conducted the thorough investigations necessary to arrive at the best strategy. For more details of these strategyies, we are referred to a recenty survey 27 . These two studies pre-trained Google’s Inception v3 network on medical data and achieved performance comparable to human experts.

As far as the authors are aware, using only a pre-trained network as a feature extractor has not yet achieved similar results. In this study, we also used a pre-training strategy to implement our algorithm. Let us show some numerical results in the following Table 3 on the performance with or without fine-tune.

In the above experinments, the pretrained model is supplied by the deep learning framework directly, and it is pretrained in practice with the ImageNet dataset. While the Fine-tune model is archived by performing further training, through which the model parameters are adjusted accordingly for better accuracy on our destinating images. It is not difficult to find out from the numerical results that, the fine-tune model performs better on each category in consideration.

Actually, some kinds of medical wastes, such as tweezers and infusion bottle, are similar in some sense with certain common objects, and it does have some benefits to perform fine-tuning from such pretrained models. On the other hand, the accuracy of pretrained model is not satisfied on some soft object, such as gloves and bags. It may caused by the possibility of their folding shape.

Availability of data and materials

The dataset supporting the conclusions of this article is included with the article.

Abbreviations

Medical waste

Convolutional neural network

Alex Krizhevsky network

Deep medical waste

Floating point operations, multiply and add operations

Lo, W. H. Y. et al. Medical waste production at hospitals and associated factors. 29 , 440-444 (2009).

Kuo, H. W., Shu, S.-L., Wu, C.-C. & Lai, J.-S. Characteristics of Medical Waste in Taiwan. Water Air Soil Pollut. 114 , 413–421.

Johnson, K. R. et al. Transmission of Mycobacterium tuberculosis from medical waste. JAMA 284 , 1683–1688. https://doi.org/10.1001/jama.284.13.1683 (2000).

Article   CAS   PubMed   Google Scholar  

Chen, Y. et al. Application countermeasures of non-incineration technologies for medical waste treatment in China. Waste Manag. Res. J. Int. Solid Wastes Public Cleansing Assoc. Iswa 31 , 1237–1244.

Komilis, D. P. Issues on medical waste management research. Waste Manag. (New York, N.Y.) 48 , 1–2, doi: https://doi.org/10.1016/j.wasman.2015.12.020 (2016).

Hani Abu, Q., Atallah, R. & Abdulla, F. Characteristics of the medical waste generated at the Jordanian hospitals. Clean Technol. Environ. Policy 9 , 147–152, https://doi.org/10.1007/s10098-006-0077-0 (2007).

Jang, Y. C., Lee, C., Yoon, O. S. & Kim, H. Medical waste management in Korea. J. Environ. Manag. 80 , 107–115. https://doi.org/10.1016/j.jenvman.2005.08.018 (2006).

Article   Google Scholar  

Blenkharn, J. I. Sharps management and the disposal of clinical waste. Br. J. Nurs. (Mark Allen Publishing) 18 (860), 862–864. https://doi.org/10.12968/bjon.2009.18.14.43353 (2009).

Coker, A. et al. Medical waste management in Ibadan, Nigeria: obstacles and prospects. Waste Manag. (New York, N.Y.) 29 , 804–811, https://doi.org/10.1016/j.wasman.2008.06.040 (2009).

Ker, J., Wang, L., Rao, J. & Lim, T. Deep learning applications in medical image analysis. IEEE Access 6 , 9375–9389. https://doi.org/10.1109/access.2017.2788044 (2018).

Litjens, G. et al. A Survey on Deep Learning in Medical Image Analysis. 42 , 60–88 (2017).

Krizhevsky, A., Sutskever, I. & Hinton, G. J. A. i. n. i. p. s. ImageNet Classification with Deep Convolutional Neural Networks. 25 (2012).

Simonyan, K. & Zisserman, A. J. a. Very Deep Convolutional Networks for Large-Scale Image Recognition. (2014).

Szegedy, C. et al. Going Deeper with Convolutions. (2014).

He, K., Zhang, X., Ren, S. & Sun, J. in IEEE Conference on Computer Vision & Pattern Recognition.

Xie, S., Girshick, R., Dollár, P., Tu, Z. & He, K. (Cornell University Library, arXiv.org, Ithaca, 2017).

Organization, W. H. Safe Management of Wastes From Health-Care Activities: Second Edition . (2014).

Deress, T., Jemal, M., Girma, M. & Adane, K. Knowledge, attitude, and practice of waste handlers about medical waste management in Debre Markos town healthcare facilities, northwest Ethiopia. BMC. Res. Notes 12 , 146. https://doi.org/10.1186/s13104-019-4174-7 (2019).

Article   PubMed   PubMed Central   Google Scholar  

Oroei, M., Momeni, M., Palenik, C. J., Danaei, M. & Askarian, M. A qualitative study of the causes of improper segregation of infectious waste at Nemazee Hospital, Shiraz, Iran. J. Infect. Public Health 7 , 192–198. https://doi.org/10.1016/j.jiph.2014.01.005 (2014).

Article   PubMed   Google Scholar  

Almuneef, M. & Memish, Z. A. Effective medical waste management: it can be done. Am. J. Infect. Control 31 , 188–192. https://doi.org/10.1067/mic.2003.43 (2003).

Korkut, E. N. Estimations and analysis of medical waste amounts in the city of Istanbul and proposing a new approach for the estimation of future medical waste amounts. Waste Manag. (New York, N.Y.) 81 , 168–176, https://doi.org/10.1016/j.wasman.2018.10.004 (2018).

Chen, J., Mao, J., Thiel, C. & Wang, Y. iWaste: Video-Based Medical Waste Detection and Classification. Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual International Conference 2020 , 5794–5797, https://doi.org/10.1109/embc44109.2020.9175645 (2020).

Hu, X., Liu, Z., Zhou, H., Fang, J. & Lu, H. Deep HT: A deep neural network for diagnose on MR images of tumors of the hand. PLoS ONE 15 , e0237606. https://doi.org/10.1371/journal.pone.0237606 (2020).

Article   CAS   PubMed   PubMed Central   Google Scholar  

Garcia, J. M. & Robertson, M. L. The future of plastics recycling. Science 358 , 870–872.

Yuan, Y., Huang, J., Fang, J., Yuan, F. & Xiong, C. A self-adaptive sampling digital image correlation algorithm for accurate displacement measurement. Opt. Lasers Eng. 65 , 57–63 (2015).

Dong, J. et al. Mapping paddy rice planting area in northeastern Asia with Landsat 8 images, phenology-based algorithm and Google Earth Engine. Rem. Sens. Environ. , 142–154 (2016).

Pan, Sinno & Jialin. A Survey on Transfer Learning. IEEE Transactions on Knowledge & Data Engineering (2010).

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Acknowledgements

This work was supported by Alibaba Cloud.

The study was funded by the National Natural Science Foundation of China (the grant number 11805049), Alibaba Youth Studio Project (the grant number ZJU-032), Shanghai "Science and Technology Innovation Action Plan" Enterprise International Science and Technology Cooperation Project (the grant number 18510732000). The funding bodies had no role in the design of the study; in collection, analysis, and interpretation of data; and in drafting the manuscript.

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H.L. designed the study, Q.J.J., B.J.Q., J.L., V.G.K. and X.B.W. performed data collection, X.L.H., X.Y.Y., M.H.A.H.A., S.H.A.E. and J.Y.F. analyzed the results, and H.Y.Z., A.A., Y.Z.D., Z.W.W. and Z.Y.L. drafted the manuscript. The authors have read and approved the final manuscript.

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Zhou, H., Yu, X., Alhaskawi, A. et al. A deep learning approach for medical waste classification. Sci Rep 12 , 2159 (2022). https://doi.org/10.1038/s41598-022-06146-2

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An overview for biomedical waste management during pandemic like COVID-19

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Amid COVID-19, world has gone under environmental reformation in terms of clean rivers and blue skies, whereas, generation of biomedical waste management has emerged as a big threat for the whole world, especially in the developing nations. Appropriate biomedical waste management has become a prime concern worldwide in the pandemic era of COVID-19 as it may affect environment and living organisms up to a great extent. The problem has been increased many folds because of unexpected generations of hazardous biomedical waste which needs extraordinary attentions. In this paper, the impacts and future challenges of solid waste management especially the biomedical waste management on environment and human beings have been discussed amid COVID-19 pandemic. The paper also recommends some guidelines to manage the bulk of medical wastes for the protection of human health and environment. The paper summarizes better management practices for the wastes including optimizing the decision process, infrastructure, upgrading treatment methods and other activities related with the biological disasters like COVID-19. As achieved in the past for viral disinfection, use of UV- rays with proper precautions can also be explored for COVID-19 disinfection. For biomedical waste management, thermal treatment of waste can be an alternative, as it can generate energy along with reducing waste volume by 80–95%. The Asian Development Bank observed that additional biomedical waste was generated ranged from 154 to 280 tons/day during the peak of COVID-19 pandemic in Asian megacities such as Manila, Jakarta, Wuhan, Bangkok, Hanoi, Kuala Lumpur.

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Challenges and measures during management of mounting biomedical waste in COVID-19 pandemic: an Indian approach

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Introduction

COVID-19 (or Coronavirus disease 2019) originated from the animals (meat/fisheries market of the Wuhan city, China) can cause severe infections to the human respiration system (Cascella et al. 2020 ; Roujian et al. 2020 ; Zhu et al. 2020 ; Xu et al. 2020 ). Firstly, it was diagnosed in the end of December, 2019 in Wuhan city of China when like pneumonia symptoms were observed in the local residents of Wuhan (WHO 2020a ; Lokhandwala and Gautam 2020 ; Sohrabi et al. 2020 ). Other health problems were also got detected because of CIVID-19 infections including breath shortness, fever, pain in muscles and head (Huang et al. 2020 ). WHO declared worldwide human health emergency (pandemic) due to fast rate of COVID-19 infections as it took around 3 months durations only to reach in 100 nations. Moreover, 10 million people of the world got infected with COVID-19 till the last of May, 2020, whereas up to last week of June, 2020, COVID-19 infections reached in 216 countries (WHO 2020b ). Even top economic nations of the world (USA, Germany, France, Spain, Japan, Singapore, Italy etc.) were stuck in the raising COVID-19 infections among the community people (Amanat and Krammer 2020 ). However, USA was and still on the top in terms of highest numbers of both infections and deaths due this pandemic (CDC 2020 ). In Asia, India is on the top position reading deaths as well infections due to corona virus (MoHFW 2020 ). In the absence of vaccine, testing of COVID-19 has become very important to prevent its further infections and reverse-transcription polymerase chain reaction, medical imaging and computed tomography are the recommended methods of detection (Ardakani et al. 2020 ). Despite of infecting huge population, the fatality rate of COVID-19in India is less than Middle East respiratory syndrome (MERS, year 2012) and severe acute respiratory syndrome (SARS CoV-1 year 2003) and more than the Spanish flu (year 1918) as shown in Fig.  1 .

Source : Modified from Goel et al. 2020 )

Human fatality rates of different viral infections (

From Fig.  1 , it was observed that in year 2012, MERS had affected people of 27 countries of the world with maximum fatality rate of 34.3% followed by SARS CoV-1 in year 2003 with 15%. In 1918, the fatality rate of Spanish flu was rescored as 10% which is less than COVID-19 (12.3%) (Callaway et al. 2020 ; Goel et al. 2020 ). However, according to Gates ( 2020 ), it can kill only 1% of total infected persons including old aged people as well as adults, if they were already suffering with some serious health disorders. However, it can spread easily among the humans as compared to other illness (Goel et al. 2020 ). Because of this reason, initially, rate of infection was slow and later through community transmission; it has reached in every part of the world (Anderson et al. 2020 ; Shammi et al. 2020 ).

Factors responsible for the transmission of COVID-19

As per the studies, it has been found that several days are required for complete inactivation of COVID-19 virus (Casanova et al. 2009 ; Qu et al. 2020 ). It is quite evident corona virus is mostly spreading through physical contacts between the individuals knowingly or unknowingly. However, it can also infect the healthy people through the skin, mouth, nose and eyes of any COVID-19 patient after direct or indirect interactions. The virus can survive on the various types of surfaces (medical wastes, plastic etc.) or environment for a specific time (Weber et al. 2016 ; Qu et al. 2020 ). Further, the chances of viral infection may be governed by several factors including stability of virus containing aerosols in the air (usually 3 h is reported), active periods of the virus on the surfaces like steel (7 days), glasses and currency papers (4 days). Even after applying soap on the hands, additional five minutes are required to inactivate the virus. Hence, it is advisable that one should avoid touching any part of the face within 5 min of hand wash (Goel et al. 2020 ).Other factors of COVID-19 transmission may also be considered as sneezing, coughing, and talking with any infected person. In many studies, presence of COVID-19 virus has been diagnosed in the excreta, tear, urine and other body secretions of the infected people (Zhang et al. 2020 ; Xia et al. 2020 ; Peng et al. 2020 ). In Japan, a study has shown that COVID-19 transmission is also possible through the lighter water droplets containing virus. As lighter water droplets (or aerosols) when come in the contact of any COVID-19 infected person and thereafter it can transmit into healthy people. However, this type of airborne infection depends upon the local weather conditions (wet or dry) (Chin and Poon 2020 ; Wölfel et al. 2020 ). Moreover, a theory of asymptomatic or oligosymptomatic infections are also reported in the literatures (Wölfel et al. 2020 ). There are different types of which can trigger in the transmission of the COVID-19 (Fig. 2 ).

Responsible factors for the human transmission of COVID-19

Most importantly, poor people (may be due to insanitary practices), elderly persons, workers of waste management authorities are in high risk zone of COVID-19 infection. However, their restricted movement can reduce the chance of pandemic outbreak (United Nations 2020 ). Because of this reason, in USA and Singapore, recycling of waste materials has been discontinued or carried out with less frequency to reduce the risk of further transmission of COVID-19 among the sanitary workers (Zambrano-Monserrate et al. 2020 ; National Environmental Agency, Singapore 2020 ). In developing world, situation has become very critical during this pandemic because of unemployment during lockdown and panic of infection among waste management people, and ultimately, it may affect the economy of the nations too (World Bank 2020 ). According to Nghiem et al. ( 2020 ) and Kulkarni and Anantharama ( 2020 ) it can be managed by adopting best practices of waste management to safeguard the health of these workers during handling of contagious wastes. Major objective of the present research paper is to explore the practices which can be helpful in the management of biomedical wastes during pandemic like COVID-19. Moreover, alternatives options and challenges of future have also been discussed.

Impacts of COVID-19 pandemic

(i) impact on the human health.

Human respiration system is the main target of this COVID-19 virus. Moreover, this has become more dangerous for the elderly people or the people who are suffering with sever diseases related with cardiac system, diabetes, cancer, or else (Dhama et al. 2020 ; Rodriguez-Morales et al. 2020 ; Mahajan and Kaushal 2020 ). However, it has also found that children are not a common victim of the COVID-19 virus (Huang et al. 2020 ) because usually they do not go outside the home as well as less travelling exercise (Lee et al. 2020 ). Chen et al. ( 2020 ) reported that only in China health recovery of the citizens was so better due to an improvement in air quality amid COVID-19 lockdown periods. Therefore, due to lockdown, the pollution load of environmental systems (atmosphere, hydrosphere and lithosphere) has decreased worldwide and this may be helpful for the protection of public health. Figure  3 shows the confirmed infections of COVID-19 in top ten countries as on Sept. 30, 2020.

Total COVID-19 infections in top 10 mostly affected countries (WHO 2020b ) (assessed on the 30.09.2020)

From Fig.  3 , it appears that till Sept. 30, most affected countries with COVID-19 infections are USA, Indian, Brazil, Russia and Columbia. Similar problems have been observed in the Bangladesh during lockdown periods amid COVID-19 pandemic (Hopman et al. 2020 ). Transmission of corona virus through air is also reported (Bourouiba 2020 ) and can be prevented by using face mask at crowded places (Klemeš et al. 2020 ). Moreover, during the crisis maintaining employment opportunities along with public health protection has become top priorities of the government authorities. For public health protection, there are many issues should be handles with due care like advancement of medical standards, easy availability of testing facility, revisions of policies for local public etc. (WHO 2020b ; Sharma et al. 2020 ). In addition to these, many psychological disorders have been observed especially among patients due to this pandemic as studied in United Kingdom (Ford et al. 2020 ; Holmes et al. 2020 ). Figure  4 summarises the diverse types of impacts observed during the COVID-19 outbreak.

Impact of COVID-19 on the environment and human beings

Elderly people are found at the larger risks of COVID-19 and during quarantine period, there is a great chance of developing mental disorders (for example, anxiety, guiltiness, dementia, depression etc.) because of loneliness (Armitage and Nellums 2020 ; Holmes et al. 2020 ; Ahorsu et al. 2020 ; Shammi et al. 2020 ).These mental problems may be responsible for the increase in number of suicide cases in the society (Duan and Zhu 2020 ). However, few medicines are recommended in case of emergency situation for COVID-19 patients (Singh et al. 2020 ). Recently, Goel et al. ( 2020 ) reported that silver coated grapheme oxide sheets and chiral gold nanohybrids for the inhibition as well as detection of the different types of viruses including corona virus. According to Chan ( 2020 ) application of different types of nano-materials should also be explored against the coronavirus. Because of unavailability of proper medication, “social lockdown” or “social distancing” has been imposed to stop the transmission of COVID-19 virus across the world (Paital et al. 2020 ; Zambrano-Monserrate et al. 2020 ; Lokhandwala and Gautam 2020 ; Somani et al. 2020 ). During lockdown, restrictions were imposed on every type of public meetings, industries and automobiles to maintain social distancing. Due to shutdown of factories and vehicles many positive changes have been observed in the cosmopolitan environment.

(ii) Impact on the environmental systems

In twenty-first century, there are many challenges for whole world including severe environmental quality diminution (Chakraborty and Maity 2020 ) due to over industrialization as well as unorganized fast urbanization as it requires huge demand of natural resources. Because of overexploitation of resources, ecological systems have been deteriorated which includes air pollution, water quality degradation, soil contamination, global warming, threat to the biodiversity, human health problems etc. (Bremer et al. 2019 ). Amid COVID-19 pandemic, world has gone into complete lockdown except essential commodities which imposed ban on the opening of industries as well as movement of the vehicles. Hence, during lockdown periods emission of harmful gases and wastewater discharges were decreased significantly and considerable environmental healing was observed across the world (Australia, China, France, Germany, India, Italy, Iran, Spain, South Korea, Taiwan, Turkey, United Kingdom and USA) since March 2020 (Chakraborty and Maity 2020 ; Elavarasan and Pugazhendhi 2020 ; Atalan 2020 ). As it has been observed that air pollution is responsible for > 7 million human deaths in whole world and out of it, 1.2 million deaths were reported in only in India (WHO 2018 ; Polk 2019 ). Significant reduction in the concentration of air pollutants (particulate matters and greenhouse gases) was reported from the various parts of the world like Kazakhstan (Kerimray et al. 2020 ), India (Mahato et al. 2020 ) and Brazil (Dantas et al. 2020 ). Besides, industries and automobiles, operations of aeroplanes were also affected during lockdown and it was also helped in the reduction of greenhouse gases in the atmosphere (Corletta et al. 2020 ). However, level of indoor air pollutants (including black carbon of smoke) was increased amid lockdown as most of the people were got stuck inside their homes (NASA 2020 ). Availability of adequate natural ventilation (not any artificial systems like air conditioner etc.) inside the homes could dilute the concentrations of indoor air pollutants (Bhatia and Bhaskar 2020 ; Somani et al. 2020 ). Moreover, concentrations of greenhouse gases were also remarkably decreased during lockdown periods, for example 2600 metric tons of carbon dioxide was decreased across the global amid COVID-19 pandemic (Global Climate Report 2019 ) due to less energy demand as around 64% of total electrical energy is getting produced from the natural gas and coals (Somani et al. 2020 ). In India, the carbon dioxide emission was decreased in between 15 and 30% during March to April, 2020 (Myllavirta and Dahiya 2020 ). Similarly, due to closure of machines and restricted vehicle movements, level of noise also got decreased as reported in many countries such as China (19%), USA (36%) and United Kingdom (54%) (Somani et al. 2020 ). Moreover, decrease in oceanic noise levels were also observed during lockdown due to limited waterways traffic and it could have provided a better environment for aquatic lives (Ian Randall 2020 ). In India, around 40–75% noise level reductions were reported from the various states or cities (for example, Karnataka, Delhi, Bengaluru, Kolkata ) due to non-movements of the trains (Somani et al. 2020 ) as trains and other vehicles are the principal causes of noise pollution in megacities of India (Mishra et al. 2010 ). Furthermore, biodiversity conservation via revival of natural shelters for marine organisms (turtles), other aquatic lives, birds, wild life animals were found to be very rapid due to less movement of human beings (Corletta et al. 2020 ; Zambrano-Monserrate et al. 2020 ) as the reports were published in the countries like Mexico, Spain, India as well as Ecuador (Zambrano-Monserrate et al. 2020 ; Somani et al. 2020 ). Self-purification capacities of many rivers/lakes increased amid lockdown because of less wastewater discharge as most of the pollution in surface water reservoirs is due to the raw sewage mixing into them (Sinha et al. 2016 ; CPCB 2020a ; Corletta et al. 2020 ; Zambrano-Monserrate et al. 2020 ). In India, amid lockdown, water quality of rivers Ganga and Yamuna were improved for bathing and aquaculture purpose as observed by the Central Pollution Control Board (CPCB) than previous years (CPCB 2020a ). Most importantly, Uttarakhand Pollution Control Board of India stated that Ganga river water at Haridwar (location: Har-ki-Pauri) was improved for drinking purpose after more than 30 years (Katariya 2020 ). Similarly, (Yunus et al. 2020 ) reported ~ 15.6% water pollution reduction in the Venbanad Lake of Kerala province of India. These improvements were observed in many Indian states ( Uttrakhand, UttarPradesh, West Bengal, Karnataka, Tamilnadu ) because of very less number of visitors, drastic decrease in the volume of the untreated effluents (~ 500%) during lockdown periods (Somani et al. 2020 ).

Challenges of biomedical waste generation and its proper management amid COVID-19 pandemic

Apart from some environmental benefits, great negative impacts will be observed across the globe due to COVID-19 pandemic including public health crisis (WHO 2020a ) including hurdles in the recycling of the wastes (Calma 2020 ), economical emergency and unemployment (Atalan 2020 ), proper management and disposal of hospital wastes and need of extra disinfectants (Zambrano-Monserrate et al. 2020 ). Certainly, COVID-19 pandemic is one of the greatest challenges for everyone such as the scientists, industrialists, doctors, paramedical staffs, police, municipal authorities, government authorities as well as local public of the world. Since its beginning in 2019 from China, researchers of the world are working 24 h a day to develop effective medication/or vaccine against it. However, no any solution is reported till now against this virus (Vellingiri et al. 2020 ). Because of high mutagenic characters and continuous morphological changes in the COVID-19, development of its vaccine is facing difficulties (American Society of Microbiology 2020 ). Therefore, governments of most of the nations have imposed compulsory national lockdowns to keep safe their citizens except essential supplies of the goods and medicines. Apart from it, individual physical distancing and self-quarantine were also recommended for each person to ensure wellbeing (Balachandar et al. 2020 ). On the other hand, because of the lockdown, worldwide huge economical loss is expected in near future (Somani et al. 2020 ) due to closure of industries and manufacturing units (United Nations Industrial Development Organization 2020 ). Because of shutting industries, product supply chain of goods has been ruined (Kahlert and Bening 2020 ; Kulkarni and Anantharama 2020 ). In addition to huge economical loss, health workers and hospitals of the world (both developed and developing countries) are under tremendous pressure due to exponential rate of COVID-19 infections. Moreover, critical patients are not getting proper care due to unavailability of intensive care units in most of the hospitals. Health workers are using personal protective equipments (for example, face mask, transparent face shield, gloves etc.) to protect themselves from this virus and providing these safety devices are also a challenge for the authorities (Dargaville et al. 2020 ). Some misconceptions have been spread into the society that intake of lemon beverages, wine etc. can be used as medications against Coronavirus (Shammi et al. 2020 ). Moreover, in most of the countries, numbers of unemployed personas have been increased due to the pandemic (Kulkarni and Anantharama 2020 ). In order to handle these challenges, many governments are planning effective strategies for the sustainable development of the world after COVID-19 era (Rosenbloom and Markard 2020 ).

Owing to lockdown amid COVID-19 pandemic, world has gone under environmental reformation in terms of clean rivers and blue skies, whereas, this pandemic has created lots of problems in the management of solid waste (Gardiner 2020 ). Appropriate solid waste management has been a big challenge for the world especially to the developing nations. COVID-19 pandemic has boosted this problem many folds because of unexpected generations of waste materials (especially biomedical waste: a type of hazardous waste). It needs to be given extraordinary attentions by the waste management authorities and governments (Ferronato and Torretta 2019 ; Kaufman and Chasan 2020 ) as the compositions and volumes of the waste materials has been changed (Mallapur 2020 ). Moreover, Fan et al. ( 2021 ) reported that during COVID-19 pandemic many challenges have been emerged while managing waste materials because of changes observed in the volume, types, composition, disposal rate, frequency of collection, availability of treatment options, funds availability etc. as shown in Fig.  5 .

modified from Fan et al. 2021 )

Common challenges of infected waste management during pandemic (

In order to prevent transmission of COVID-19, lockdown was imposed in many countries which increased online shopping for the household products especially in developed countries. This panic situation has created a big concern of proper waste management in terms of collection, recycle, treatment as well as disposal (Zambrano-Monserrate et al. 2020 ; Nghiem et al. 2020 ). Moreover, Rahman et al. ( 2020 ) observed that hospital waste can cause severe environmental as well as public health problems as 5.2 million people of the world are dying annually due to mismanagement of hospital waste materials. During the pandemic, the composition of medical waste has changed drastically as it contains huge quantities of discarded masks, gloves, PPE kits etc. (UNEP 2020 ; Somani et al. 2020 ) and it could be dangerous for the society (especially workers of waste management authorities) in terms of increasing transmission due to mishandling of such types of infected wastes (Sharma et al. 2020 ). Similar, concern was also expressed by Occupational Safety and Health Administration (OSHA) regarding further infections among the workers of waste management authorities (OSHA 2020 ). Further, wastage of plastic waste also got increased across the world which is being used by pharmaceutical industries for packaging purpose (WHO 2020d ). Therefore, World Health Organization, Central Pollution Control Board (India), OSHA and other prestigious international organizations have developed new guidelines to manage the waste materials (especially hospital wastes) during COVID-19 (Somani et al. 2020 ; Kulkarni and Anantharama 2020 ). According to WHO, > 80% wastes of the hospitals were found in the category of noncontiguous wastes which can be treated and managed similar as municipal waste materials (WHO 2020d ). Normally, biomedical wastes are waste generated from the hospitals and veterinary medical premises including syringe, pathological materials, pharmaceutics etc. (Sharma et al. 2020 ; Somani et al. 2020 ). Due to COVID-19 pandemic, huge mass of plastic wastes has been increased across the world as it is being used in personal protection kits (for example, gloves, masks, face shield, ventilator etc.) (Klemeš et al. 2020 ). In India, waste management authorities are in more trouble due to fear of infection as safety measures are not good in the comparison of developed countries. During, lockdown in India, the bulk of biomedical waste was found to be greater than the municipal solid wastes (Somani et al. 2020 ). Significant reduction in municipal solid waste quantity was attributed to the shutdown of markets, shops, hotels, commercial premises, offices, transport etc. (Somani et al. 2020 ), whereas, huge amount of biomedical waste was generated probably because of high numbers of the COVID-19 infected persons admitted in the hospitals. In USA, huge quantities of food waste were generated during lockdown as most of the commercial institutes (like hotels, restaurants, mess etc.) had already purchased the raw materials (Kulkarni and Anantharama 2020 ). During lockdown, similar observations of change in the quantity and composition of waste materials have been reported from North America (SWANA 2020 ) and China (Klemeš et al. 2020 ). According to Klemeš et al. ( 2020 ), only in Hubei (China), around 370% increase in biomedical waste after COVID-19 infections. However, the quantity of municipal solid waste was generated less than 30% during pandemic. Nghiem et al. ( 2020 ) and Zambrano-Monserrate et al. ( 2020 ) have also studied the change in the waste composition (and quantity) along with their negative impacts of change in waste generation on the environment and health workers. They found that transmission of virus in community has significantly affected waste recycling facilities around the world. For instance, in United Kingdom, 46% material recovery process was stopped due to lockdown amid COVID-19 pandemic and similarly 31% recycling units of USA were also closed in the similar situations (Somani et al. 2020 ).

Contagious biomedical wastes can spread disease in living organisms and their mishandling may also be responsible for soil contamination, water pollution (both groundwater and surface water), injuries and death of ecofriendly microbes (Datta et al. 2018 ). Incineration is one of the preferred options for the waste management especially biomedical (or infectious) wastes in developed countries as shown in Fig.  6 .

Proportion of incineration for energy recovery in developed countries before COVID-19 pandemic

From the above figure, it is visible that Japan used to treat municipal solid waste through 74% incineration, 17% recycling and only 3% as landfill disposal before the pandemic (Mollica and Balestieri 2020 ). In Wuhan (China), normally 40 tons of biomedical waste was generated every day and after COVID-19 infections, it was reached up to 240 tons/day. Therefore, the increase in infectious wastes was around 6 times more as compared to normal days. This huge bulk of medical waste created big challenge to the management authorities as Wuhan administration could incinerate only 49 tons (maximum) of waste every day. Moreover, this will not be economical for any country as the costs of incineration for hazardous and municipal solid wastes in China were calculated as 281.7–422.6 USD/tons and 14.1 USD/tons, respectively (Tang 2020 ; Klemeš et al. 2020 ). According to WHO ( 2017 ), usually, 85% biomedical wastes are not hazardous in nature, rest 10% may be infectious along with 5% radioactive wastes. Before pandemic, except USA (12.7% only) (United States Environmental Protection Agency 2017 ), many developed countries incinerate their waste materials to recover energy such as 50% municipal waste incinerated in Denmark, Finland, Norway and Sweden (Istrate et al. 2020 ); 40% in Austria (Kyriakis et al. 2019 ); 76% in United Kingdom (DEFRA Government of UK 2020 ). However, recycling of the waste reported 32% in Austria (including composting) (Kyriakis et al. 2019 ); 45% in United Kingdom (DEFRA Government of UK 2020 ), and 35.2% in USA (both recycling and composting) (United States Environmental Protection Agency 2017 ). Therefore, it can be seen from the above results that collection and recycling of waste materials has been disturbed due COVID-19 pandemic. Moreover, pandemic has caused huge economical losses by many ways to the affected countries along with an unseen fear of its infections. Datta et al. ( 2018 ) studied that in India by the year 2017, 500 MT/day biomedical wastes were generated and infrastructure of managing biomedical waste is not good. Hence, based on the data of biomedical waste generated in Wuhan (> 6 times) during pandemic, India this situation is expected. However, till now biomedical waste generation data is not available for whole India (Somani et al. 2020 ). Further, according to one Indian leading newspaper in Gurugram (India), only in 2 months of pandemic, the quantity of biomedical wastes has increased around 40 times as compared to normal months. Similarly, before pandemic 550–600 kg biomedical waste was generated every day in Ahmadabad. Now, it has already increased up to 1000 kg/day during pandemic with an expectation of reaching up to 3000 kg/day especially in the red zones (COVID-19 containment zones (TOI 2020 ; Somani et al. 2020 ). Tables 1 and 2 shows the biomedical waste generation in some Asian cities and Indian cities/states.

From Table 1 , it can be seen that around every Asian city, the quantity of biomedical wastes has been increased many folds during the outbreak of COVID-19 in the community. In terms of maximum additional biomedical waste was generated in the capital of Philippines, i.e., Manila followed by Jakarta (Indonesia). In, Wuhan (China) and Bangkok (Thailand), 210 tons of additional biomedical waste was generated amid COVID-19 pandemic (ADB 2020 ). Improper medical waste handling may increase the number of COVID-19 infections in the community (Peng et al. 2020 ) due to presence of pathogenic microbes (Windfeld and Brooks 2015 ). Due to airborne infections of the COVID-19 virus in healthy people, use of masks, gloves, face cover etc. has been also increased up to dangerous levels in the world (Bourouiba 2020 ). At global level, 89 million masks and 76 million gloves are required against the protection from COVID-19 infection (WHO 2020c ). According to UNEP ( 2020 ), appropriate management of extra waste materials generated during COVID-19 pandemic has become a major concern for the countries. Therefore, medical wastes from the COVID-19 affected zones/hospitals need to be disinfected with careful handling. Treatment of medical waste can be carried out by using thermal techniques such as autoclaving, incineration, microwave and plasma method. However, selection above processes of waste treatment will be governed by many factors like economic feasibility, easy and safe handling, eco-friendly nature as well as harmless to the society (Liu et al. 2015 ). In order to reduce the chance of infection in the community, effective medical waste (or infectious waste) management should be adapted. Apart from collection and transport, trained manpower should be involved in this activity and disinfection of infectious waste should be compulsory (Klemeš et al. 2020 ).

The waste management as well as waste recycling process of the developed nations has been disturbed due to this COVID-19 outbreak. Figure  7 shows the waste management practices adapted by developed countries.

Management practices for solid wastes in some developed countries (ACRPlus 2020 ; Nghiem et al. 2020 ; Kulkarni and Anantharama 2020 ). (Reprinted from Kulkarni and Anantharama 2020 with permission from Elsevier)

From Fig.  7 , it can be seen that in developed countries waste management practice involves segregation of the waste at the source of generation followed by their effective collection, transpiration, treatment and disposal. However, during COVID-19 outbreak, the waste collection guidelines were changed as segregation and collection of the wastes from the infected area is carried out after a waiting period of 72 h (ACRPlus 2020 ; Nghiem et al. 2020 ). In most of the Asian countries like Bangladesh, India, Indonesia, Malaysia, Myanmar and Thailand, municipal solid wastes are getting managed by land-filling (Yadav and Samadder 2018 ). Integrated solid waste management system can be a good alternative for the recycling of wastes and also producing energy from the waste materials (Ramachandra et al. 2018 ). Lack of scientific designing of land-fill sites for waste disposal may lead several environmental problems such as air pollution, water pollution, soil pollution, marine pollution and vector borne-diseases among humans (Pujara et al. 2019 ). Therefore, mishandling of the biomedical wastes will be more dangerous as it may cause infections in the living organisms.

Biomedical waste management is a big challenge for every country especially during this pandemic time. According to the WHO, most of the developing countries do not have advanced systems for the management of biomedical wastes (Chartier et al. 2014 ). Chartier et al. ( 2014 ) proposed a close pit (as shown in Fig.  8 a) which should have a dimension of 2 m and 3 m and can be made by clay or geo-synthetic materials used at the base. This arrangement can be used for the safe management of biomedical wastes in emergency situations such as COVId-19 pandemic.

a Layout of a pit for onsite disposal of biomedical wastes in low-income countries during COVID-19 like emergency situation (Chartier et al. 2014 ; Sharma et al. 2020 ). (Reprinted from Sharma et al. 2020 with permission from Elsevier). b COVID-19 infected waste handling procedure for low income countries

Figure  8 a gives a temporary arrangement for the effective and safe disposal of biomedical wastes in low-income countries (Chartier et al. 2014 ; Sharma et al. 2020 ). Further, Fig.  8 b can be adopted during the handling infected hospital wastes.

Figure  8 b gives a detail outline for the management of infected wastes generated during the pandemic like COVID-19. In this diagram, it can be seen that disinfection of hospital waste has become very important as recommended by many government authorities of the world. For disinfection, autoclaving and sterilization of the tools can be carried out at the temperature ranged between 121 and 149 °C or with the spraying of 0.1% of NaClO. After, disinfection processes, the medical wastes can be shredded and incinerated (~ 1000 °C temperature) followed by ultimate disposal in landfills. Further, incineration has been considered as the best method for the treatment of hazardous wastes (e.g. medical wastes) as it will condense the weight along with volume of the wastes (Rajor et al. 2012 ). Even, US Environmental Protection Agency (USEPA 2020 ) issued special guidelines for managing food wastes of residential colonies and other commercial buildings during pandemic. Similarly, Government of India issued guidelines for the management of waste products generated during sudden lockdown. These wastes included perishable agricultural products as well (FAO 2020 ). According to Klemeš et al. ( 2020 ), environment and human health can be protected well after appropriate waste management. Hospital or infectious wastes can be managed effectively through proper collection, transport, treatment and final disposal. It also requires trained health workers who should be aware about the proper disinfection process along with self-protection too. Wasted PPE kits volume can also be decreased, if these materials (like antiviral masks, face shields etc.) can be reused after disinfections (Goel et al. 2020 ).Previously, viral disinfection was achieved by using UV-C rays (at 254 nm) in 40 min (Darnell et al. 2004 ), but in case of COVID-19, it is a matter of exploration. Moreover, it was also reported that UV-C rays can lead skin and eye disorders. Therefore, it must be examined before suggesting the application of UV-C rays as a disinfectant (Goel et al. 2020 ).Thermal treatment of waste can be an alternative for their management as it will generate energy along with reducing waste volume by 80–95%, and mineralization etc. (Singh et al. 2011 ; Brunner and Rechberger 2015 ; World Bank 2018 ). Implementation of these technologies were successful in some developed and developing countries and land-filling has become a rare practice in the developed nations because of land scarcity or/and environmental pollutions. Further, due to high investments, in developing countries it is still inaccessible (Mayer et al. 2019 ). Apart from the above advantages, incineration generates the ash residues which may contain toxic metals etc. Similarly, groundwater contamination may happen due to the disposal of such residues in the landfills (Rajor et al. 2012 ). Dargaville et al. ( 2020 ) recommended some steps to reduce the wastage of PPE kits which includes:

To explore the possibility of recycling of PPE kits (gloves, mask, face shield etc.);

Disinfection should be ensured before recycling

One of the best disinfection methods should be shared with everyone (especially medical workers)

Material’s properties should be examined before recycling

Fix the guidelines for their number of recycling

Exchange of recycled materials should not be allowed

Time to time expert’s (material science, clinical doctors, virologist etc.) guidelines should be shared.

These are the general guidelines to be followed everywhere to reduce the quantity of medical wastes along with the human health and environmental protections (Dargaville et al. 2020 ).According to WHO, thermal treatment and/or application of conventional biocidal materials can be integrated with waste treatment systems for inactivating Coronavirus before the disposal of biomedical wastes (Kampf et al. 2020 ). Apart from these options of biomedical waste management; some extra efforts are needed to upgrade the existing waste management systems so that it can deal with emergency situations like this pandemic (COVID-19).

Some challenges observed as wastes are also generated from the mildly infected or asymptomatic people that may have viral infections. COVID-19 virus can be present in active form for different time periods (few hours to days) on the cardboards, plastic materials and metallic objects (Kampf et al. 2020 ; Doremalen et al. 2020 ; Nghiem et al. 2020 ). Somani et al. ( 2020 ) observed other waste materials which may be considered as infectious in nature, if not treated properly. These wastes are syringe, needles, masks, gloves, medicines, discarded materials from the home quarantine patients etc. Mishandling of these wastes may trigger the chance of more infections in public as well as health workers (Sharma et al. 2020 ; Kulkarni and Anantharama 2020 ).Further studies have shown that in between 21 and 23 °C temperature in presence of 40% relative humidity, the survival time of Coronavirus was 7 days. However, in atmosphere, with 65% relative humidity the activation time was drastically reduced up to 3 h with same temperature range (Doremalen et al. 2020 ). Kampf et al. ( 2020 ) reported 9 days active period of Coronavirus on the metal, glass or plastic. Further, Chin et al. ( 2020 ) found that at 70 °C, COVID-19 virus did not survive more than 5 min. National Biodefense Analysis and Countermeasures Centre, USA found in the initial studies that direct sunlight can be very effective to inactivate the Coronavirus within minutes from the many surfaces (Goel et al. 2020 ). Better management of the wastes can be carried out by optimizing the decision process, infrastructure, upgrading treatment methods and other activities related with the biological disasters like COVID-19 (Klemeš et al. 2020 ).

Provisions for biomedical waste management in India amid COVID-19

According to Bio-Medical Waste Management Rules, 2016 passed by Indian parliament data of biomedical waste generation should be updated on daily basis by the health care service providers and also, they must expose monthly information on their website (BMWM 2016 ). These rules were amended at time to time as per the need of the hour to make the effective biomedical waste management in the country. Amid COVID-19 pandemic, like other countries, Indian government has also taken many initiations for the purpose of quarantine, isolation, sampling, laboratory works etc. These initiatives were in agreement with the guidelines of various international (WHO, CDC etc.) and national agencies (MoH&FW, ICMR, CPCB etc.) such as application of separate colour storage basket or double layered bags with proper labelling, separate collection for biomedical wastes etc. During COVID-19 pandemic, some activities were recommended for the rapid and effective waste management by the Indian government to reduce the chance of further infections such as use PPE kits especially by the health workers/waste management people, providing training for their safety, record maintenance, extra working times for treatment facilities etc. (Soni 2020 ). CPCB has developed a mobile app, i.e., ‘COVID19BWM’ for the daily updation of the generation of biomedical wastes from COVID-19 related places. Moreover, 0.5% chlorine solution was recommended for the disinfection purpose where the patients wards. However, COVID-19 waste and their storage places should be disinfected with 1% sodium hypochlorite solution on daily basis (CPCB 2020b ). These guidelines were revised again (on July 17, 2020) and some significant amendments were carried out to fight with the COVID-19 virus such as rail coaches can also be used as isolation wards the materials used by COVID-19 patients included in the category of biomedical waste and their treatment should be mandatory as per the guidelines provided by CPCB and yellow bags can be used for their collection. It was mandatory that do not mix the municipal solid wastes with the waste generated from the COVID-19 infected places/homes (CPCB 2020c ). There, it can be said that despite of being a developing nation, Indian authorities are also doing lots of efforts to reduce the numbers of COVID-19 infections in the community.

Amid COVID-19, world has gone under environmental reformation in terms of clean rivers and blue skies, whereas, this pandemic has hurdled the appropriate solid waste management process and the same has emerged as a big threat for the world especially to the developing nations. Researchers have suggested some steps to reduce the wastage of biomedical waste and explored the mechanisms of safe and hygienic recycling. As advised by the WHO, developing countries, who are deficient of advanced systems for the management of biomedical wastes should follow the temporary solution of a close pit with a dimension of 2 m and 3 m and can be made by clay or geo-synthetic materials used at the base and the same arrangement can be used for the safe management of biomedical wastes in emergency situations such as COVId-19 pandemic wastes in emergency situations. The paper summarizes that better management of the wastes can be carried out by optimizing the decision process, infrastructure, upgrading treatment methods and other activities related with the biological disasters like COVID-19. National Biodefense Analysis and Countermeasures Centre, USA found in the initial studies that direct sunlight can be very effective to inactivate the Coronavirus within minutes from the many surfaces. Hospital or infectious wastes can be managed effectively through proper collection, transport, treatment and final disposal. The health workers must be trained enough and should be aware about the proper disinfection process along with self-protection too. Wasted PPE kits volume can also be decreased by reusing the same after disinfections. As achieved in the past for viral disinfection, the use of UV-C rays with proper precautions can also be explored for COVID-19 disinfection. Waste management especially for biomedical waste management, thermal treatment of waste can be an alternative, as it can generate energy along with reducing waste volume by 80–95%.

ACRPlus-Association of Cities and Regions for Sustainable Resource Management (2020) Municipal waste management and COVID-19. https://www.acrplus.org/en/municipal-waste-management-covid-19 . Accessed 4 May 2020

ADB (2020) Asian Development Bank. Managing infectious medical waste during the COVID-19 pandemic. https://www.adb.org/sites/default/files/publication/578771/managingmedical-waste-covid19.pdf . accessed 4 May 2020

Ahorsu DK, Lin CY, Imani V, Saffari M, Griffiths MD, Pakpour AH (2020) The fear of COVID-19 scale: development and initial validation. Int J Ment Health Addict. https://doi.org/10.1007/s11469-020-00270-8

Article   Google Scholar  

Amanat F, Krammer F (2020) SARS-CoV-2 vaccines: status report. Immunity 52(4):83–589. https://doi.org/10.1016/j.immuni.2020.03.007

Article   CAS   Google Scholar  

American Society of Microbiology (2020). https://asm.org/PressReleases/2020/COVID-19 . Accessed Aug 10 2021

Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD (2020) How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet 395(10228):931–934

Ardakani AA, Kanafi AR, Acharya UR, Khadem N, Mohammadi A (2020) Application of deep learning technique to manage COVID-19 in routine clinical practice using CT images: results of 10 convolutional neural networks. Comput Biol Med 30:103795

Armitage R, Nellums LB (2020) COVID-19 and the consequences of isolating the elderly. Lancet Public Health 5(5):e256. https://doi.org/10.1016/S2468-2667(20)30061-X

Atalan A (2020) Perspective—Is the lockdown important to prevent the COVID-19 pandemic? Effects on psychology, environment and economy-perspective. Ann Med Surg 56:38–42

Balachandar V, Kaavya J, Mahalaxmi I, Arul N, Vivekanandhan G, Bupesh G, Singaravelu G, Anila V, Dhivya V, Harsha G, Kamarajan R (2020) COVID-19: a promising cure for the global panic. Sci Total Environ 725:138277

Bhatia A, Bhaskar S (2020) Coronavirus outbreak explained: are air conditioners safe to use during the COVID-19 pandemic. NDTV. https://swachhindia.ndtv.com

BMWM (2016) Bio-medical waste management rules, 2016. Ministry of Environment, Forest & Climate Change, Delhi – 110032, India. Dated 19 Feb 2020

Bourouiba L (2020) Turbulent gas clouds and respiratory pathogen emissions. Potential implications for reducing transmission of COVID-19. J Am Med Assoc. https://doi.org/10.1001/jama.2020.4756

Bremer S, Schneider P, Glavovic B (2019) Climate change and amplified representations of natural hazards in institutional cultures. Oxf Res Encycl Nat Hazard Sci. https://doi.org/10.1093/acrefore/9780199389407.013.354

Brunner PH, Rechberger H (2015) Waste to energy—key element for sustainable waste management. Waste Manag 37:3–12. https://doi.org/10.1016/j.wasman.2014.02.003

Callaway E, Cyranoski D, Mallapaty S, Stoye E, Tollefson J (2020) Coronavirus by the numbers. Nature 579:482

Calma J (2020) https://www.theverge.com/2020/3/26/21194647/the-covid-19-pandemic-is-generating-tons-of-medical-waste

Casanova L, Rutala WA, Weber DJ, Sobsey MD (2009) Survival of surrogate coronaviruses in water. Water Res 43(7):1893–1898

Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Napoli RD (2020) Features, evaluation and treatment Corona Virus (COVID-19), NCBI Bookshelf. StatPearls Publishing, Treasure Island, FL

Google Scholar  

CDC (2020) https://www.ecdc.europa.eu/sites/default/files/documents/RRA-sixth-updateOutbreak-of-novel-coronavirus-disease-2019-COVID-19.pdf . Accessed 5 July 2020

Chakraborty I, Maity P (2020) COVID-19 outbreak: migration, effects on society, global environment and prevention. Sci Total Environ 728:138882

Chan WC (2020) Nano research for COVID-19. ACS Nano 14(4):3719–3720. https://doi.org/10.1021/acsnano.0c02540

Chartier Y, Emmanuel J, Pieper Ute PA, Philip R, Ruth S, William T, Wilburn S, Zghondi R (2014) Safe management of wastes from health-care activities. WHO, Geneva

Chen K, Wang M, Huang C, Kinney PL, Anastas PT (2020) Air pollution reduction and mortality benefit during the COVID-19 outbreak in China. Lancet Planet Health 4(6):e210–e212

Chin AW, Chu JT, Perera MR, Hui KP, Yen HL, Chan MC, Peiris M, Poon LL (2020) Stability of SARS-CoV-2 in different environmental conditions. Lancet Microbe 1(1):10

Corletta RT, Primack RB, Devictor V, Maasd B, Goswami VR, Bates AE, Koh LP, Regani TJ, Loyolaj R, Pakemanl RJ, Cummingm GS, Pidgeon A, Johns D, Roth R (2020) Impacts of the coronavirus pandemic on biodiversity conservation. Biol Conserv 246:108571

CPCB (2020a) Report on assessment of impact of lock down on water quality of river Yamuna- Delhi stretch. Central Pollution Control Board, Ministry of Environment, Forests and Climate Change, Delhi – 110032

CPCB (2020b) Guidelines for handling, treatment, and disposal of waste generated during treatment/diagnosis/quarantine of COVID-19 patients—Rev. 3, dated 10 June 2020b. Central Pollution Control Board, (Ministry of Environment, Forest & Climate Change), Delhi – 110032, India

CPCB (2020c) Guidelines for handling, treatment and disposal of waste generated during treatment/diagnosis/quarantine of COVID-19 patients—Rev. 4, dated 17 July 2020c. Central Pollution Control Board, (Ministry of Environment, Forest & Climate Change), Delhi – 110032, India

Dantas G, Siciliano B, França BB, da Silva CM, Arbilla G (2020) The impact of COVID-19 partial lockdown on the air quality of the city of Rio de Janeiro, Brazil. Sci Total Environ. https://doi.org/10.1016/j.scitotenv.2020.139085

Dargaville T, Spann K, Celina M (2020) Opinion to address a potential personal protective equipment shortage in the global community during the COVID-19 outbreak. Polymer Degrad Stab 176:109162

Darnell ME, Subbarao K, Feinstone SM, Taylor DR (2004) Inactivation of the coronavirus that induces severe acute respiratory syndrome, SARS-CoV. J Virol Methods 121(1):85–91

Datta P, Mohi GK, Chander J (2018) Biomedical waste management in India: critical appraisal. J Lab Physicians 10(1):6–14

DEFRA-Department for Environment Food & Rural Affairs, Government of UK (2020) UK statistics on waste. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/874265/UK_Statistics_on_Waste_statistical_notice_March_2020_accessible_FINAL_rev_v0.5.pdf

Dhama K, Sharun K, Tiwari R et al (2020) Coronavirus disease 2019—COVID-19. Preprints. https://doi.org/10.20944/preprints202003.0001.v1

Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, Tamin A, Harcourt JL, Thornburg NJ, Gerber SI, Lloyd-Smith JO, Wit E, Munster VJ (2020) Aerosol and surface stability of HCoV-19 (SARS-CoV-2) compared to SARS-CoV-1. N Engl J Med. https://doi.org/10.1101/2020.03.09.20033217

Duan L, Zhu G (2020) Psychological interventions for people affected by the COVID-19 epidemic. Lancet Psychol 7(4):300–302

Elavarasan RM, Pugazhendhi R (2020) Restructured society and environment: a review on potential technological strategies to control the COVID-19 pandemic. Sci Total Environ 725:138858

EPCA (2020) The Environment Pollution (Prevention and Control) Authority (EPCA). https://www.epca.org.in/EPCA-Reports1999-1917/EPCA-reportno-112.pdf . Accessed on 17 Dec 2020

Fan VY, Jiang P, Hemzal M, Klemeš JJ (2021) An update of COVID-19 influence on waste management. Sci Total Environ 754:142014

FAO (2020) Food and Agriculture Organization of the United Nations. Local food systems and COVID-19; a glimpse on India's responses. http://www.fao.org/in-action/foodfor-cities-programme/news/detail/en/c/1272232/

Ferronato N, Torretta V (2019) Waste mismanagement in developing countries: a review of global issues. Int J Environ Res Public Health 16(6):1060

Ford T, Vizard T, Sadler K et al (2020) Data resource profile: the mental health of children and young people surveys (MHCYP). Int J Epidemiol. https://doi.org/10.1093/ije/dyz259

Gardiner B (2020) Pollution made COVID-19 worse. Now, lockdowns are clearing the air. National Geographic. https://www.nationalgeographic.com/science/2020/04/pollution-made-the-pandemic-worse-but-lockdowns-clean-the-sky/ . Accessed 15 May 2020

Gates B (2020) Responding to Covid-19—a once-in-a-century pandemic? N Engl J Med 382(18):1677–1679

Global Climate report (2019) https://www.ncdc.noaa.gov/sotc/global/201913

Goel S, Hawi S, Goel G, Thakur VK, Agrawal A, Hoskins C, Pearce O, Hussain T, Upadhyaya HM, Cross G, Barber AH (2020) Resilient and agile engineering solutions to address societal challenges such as coronavirus pandemic. Mater Today Chem 17:100300

Holmes EA, O’Connor RC, Perry VH, Tracey I, Wessely S, Arseneault L, Ballard C, Christensen H, Silver RC, Everall I, Ford T (2020) Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. Lancet Psychiatry 7:547–560. https://doi.org/10.1016/S2215-0366(20)30168-1

Hopman J, Allegranzi B, Mehtar S (2020) Managing COVID-19 in low-and middle-income countries. JAMA 323(16):1549–1550

Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z (2020) Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet 395(10223):497–506

Istrate I-R, Iribarren D, Galvez-Martos J-L, Dufour J (2020) Review of life-cycle environmental consequences of waste-to-energy solutions on the municipal solid waste management system. Resour Conser Recov 157:104778. https://doi.org/10.1016/j.resconrec.2020.104778

Kahlert S, Bening CR (2020) Plastic recycling after the global pandemic: resurgence or regression? Resour Conserv Recycl 160:104948. https://doi.org/10.1016/j.resconrec.2020.104948

Kampf G, Todt D, Pfaender S, Steinmann E (2020) Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect 104:246–251. https://doi.org/10.1016/j.jhin.2020.01.022

Katariya M (2020) 10 Things that have happened for the first time in years during the coronavirus lockdown. Scoopwhoop, https://www.scoopwhoop.com/news/things-that-have-happened-for-the-first-time-inyearsduring-coronavirus-lockdown/

Kaufman L, Chasan E (2020) Cities wonder whether recycling counts as essential during the virus. Bloomberg Green. https://www.bloomberg.com/news/articles/2020-03-27/cities-wonder-whether-recycling-counts-as-essential-during-the-virus . Accessed 26 April 2020

Kerimray A, Baimatova N, Ibragimova OP, Bukenov B, Kenessov B, Plotitsyn P, Karaca F (2020) Assessing air quality changes in large cities during COVID-19 lockdowns: the impacts of traffic-free urban conditions in Almaty, Kazakhstan. Sci Total Environ 730:139179. https://doi.org/10.1016/j.scitotenv.2020.139179

Klemeš JJ, Van Fan Y, Tan RR, Jiang P (2020) Minimising the present and future plastic waste, energy and environmental footprints related to COVID-19. Renew Sustain Energy Rev 127:109883

Kulkarni BN, Anantharama V (2020) Repercussions of COVID-19 pandemic on municipal solid waste management: challenges and opportunities. Sci Total Environ 743:140693

Kyriakis E, Psomopoulos C, Kalkanis K (2019) Investigating the correlation of purchase power parity with the adopted waste management method in EU28. J Soc Sci 8:162. https://doi.org/10.3390/socsci8050162

Lee PI, Hu YL, Chen PY, Huang YC, Hsueh PR (2020) Are children less susceptible to COVID-19? J Microbiol Immunol Infect. https://doi.org/10.1016/j.jmii.2020.02.011

Liu HC, You JX, Lu C, Chen YZ (2015) Evaluating health-care waste treatment technologies using a hybrid multi-criteria decision making model. Renew Sustain Energy Rev 41:932–942

Lokhandwala S, Gautam P (2020) Indirect impact of COVID-19 on environment: a brief study in Indian context. Environ Res 188:109807

Mahajan P, Kaushal J (2020) Epidemic trend of COVID-19 transmission in India during lockdown-1 phase. J Commun Health. https://doi.org/10.1007/s10900-020-00863-3

Mahato S, Pal S, Ghosh KG (2020) Effect of lockdown amid COVID-19 pandemic on air quality of the megacity Delhi, India. Sci Total Environ 730:139086. https://doi.org/10.1016/j.scitotenv.2020.139086

Mallapur C (2020) Sanitation workers at risk from discarded medical waste related to COVID-19. IndiaSpend. https://www.indiaspend.com/sanitation-workersat-risk-from-discarded-medical-waste-related-tocovid-19/

Mayer F, Bhandari R, Gath S (2019) Critical review on life cycle assessment of conventional and innovative waste-to-energy technologies. Sci Total Environ 672:708–721. https://doi.org/10.1016/j.scitotenv.2019.03.449

Ministry of Health and Family Welfares (MoHFW), Government of India (2020) COVID-19 INDIA. https://www.mohfw.gov.in/

Mishra RK, Parida M, Rangnekar S (2010) Evaluation and analysis of traffic noise along bus rapid transit system corridor. Int J Environ Sci Technol 7(4):737–750. https://doi.org/10.1007/BF03326183

Mollica GJG, Balestieri JAP (2020) Is it worth generating energy with garbage? Defining a carbon tax to encourage waste-to-energy cycles. Appl Therm Eng 173:115195. https://doi.org/10.1016/j.applthermaleng.2020.115195

Myllavirta L, Dahiya S (2020) Analysis: India's CO2 emissions fall for first time in four decades amid coronavirus. Carbon Brief, https://www.carbonbrief.org/analysis-indias-co2-emissions-fall-for-first-time-in-four-decades-amidcoronavirus#

National Aeronautics and Space Administration (NASA) (2020) Airborne particle levels plummet in Northern India. Retrieved on 11 May 2020 from https://earthobservatory.nasa.gov/images/146596/airborne-particle-levels-plummet-innorthern-india

National Environment Agency Singapore (2020)Waste management-public waste collection services during circuit breaker. https://www.nea.gov.sg/our-services/wastemanagement/overview .

Nghiem LD, Morgan B, Donner E, Short MD (2020) The COVID-19 pandemic: considerations for the waste and wastewater services sector. Case Stud Chem Environ Eng. https://doi.org/10.1016/j.cscee.2020.100006

Occupational Safety and Health Administration (OSHA) (2020) Guidance on Preparing Workplaces for COVID-19

Paital B, Das K, Parida SK (2020) Review-Inter nation social lockdown versus medical care against COVID-19, a mild environmental insight with special reference to India. Sci Total Environ 728:138914

Peng L, Liu J, Xu W, Luo Q, Chen D, Lei Z, Huang Z, Li X, Deng K, Lin B, Gao Z (2020) SARS-CoV-2 can be detected in urine, blood, anal swabs, and oropharyngeal swabs specimens. J Med Virol. https://doi.org/10.1002/jmv.25936

Polk HS (2019) State of global air 2019: a special report on global exposure to air pollution and its disease burden. Health Effects Institute, Boston, MA

Pujara Y, Pathak P, Sharma A, Govani J (2019) Review on Indian Municipal Solid Waste Management practices for reduction of environmental impacts to achieve sustainable development goals. J Environ Manage 248:109238

Qu G, Li X, Hu L, Jiang G (2020) An imperative need for research on the role of environmental factors in transmission of novel coronavirus (COVID-19). Environ Sci Technol 54:3730–3732

Rahman MM, Bodrud-Doza M, Griffiths MD, Mamun MA (2020) Biomedical waste amid COVID-19: perspectives from Bangladesh. Lancet Glob Health 8(10):e1262

Rajor A, Xaxa M, Mehta R (2012) An overview on characterization, utilization and leachate analysis of biomedical waste incinerator ash. J Environ Manage 108:36–41

Ramachandra TV, Bharath HA, Kulkarni G, Han SS (2018) Municipal solid waste: generation, composition and GHG emissions in Bangalore, India. Renew Sustain Energy Rev 82:1122–1136. https://doi.org/10.1016/j.rser.2017.09.085

Randall I (2020) Sound of the sea: underwater noise pollution from ships plummets during the coronavirus lockdown offering respite for 'stressed' whales and other marine life. The Daily Mail. https://mol.im/a/8262147

Rodriguez-Morales A, Tiwari R, Sah R, Dhama K (2020) COVID-19, an emerging coronavirus infection: current scenario and recent developments—an overview. J Pure Appl Microbiol 14:6150

Rosenbloom D, Markard J (2020) A COVID-19 recovery for climate. Science 368(6490):447. https://doi.org/10.1126/science.abc4887

Roujian L, Xian Z, Juan L et al (2020) Genomic characterization and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. Lancet 395:565–574

Shammi M, Bodrud-Doza M, Islam ARMT, Rahman MM (2020) COVID-19 pandemic, socioeconomic crisis and human stress in resource-limited settings: a case from Bangladesh. Heliyon 6:e04063

Sharma HB, Vanapalli KR, Cheela VS, Ranjan VP, Jaglan AK, Dubey B, Goel S, Bhattacharya J (2020) Challenges, opportunities, and innovations for effective solid waste management during and post COVID-19 pandemic. Resour Conser Recycl 162:105052

Singh RP, Tyagi VV, Allen T, Ibrahim M, Kothari R (2011) An overview of exploring the possibilities of energy generation from municipal solid waste (MSW) in Indian scenario. Renew Sustain Energy Rev 15:4797–4808. https://doi.org/10.1016/j.rser.2011.07.071

Singh AK, Singh A, Shaikh A, Singh R, Misra A (2020) Chloroquine and hydroxychloroquine in the treatment of COVID-19 with or without diabetes: a systematic search and a narrative review with a special reference to India and other developing countries. Diab Metab Syndr Clin Res Rev 14:241–246

Sinha SN, Paul D, Biswas K (2016) Effects of Moringaoleifera Lam. and Azadirachtaindica A. Juss. leaf extract in treatment of tannery effluent. Our Nat 14:47–53

Sohrabi C, Alsafi Z, O’Neill N, Khan M, Kerwan A, Al-Jabir A, Iosifidis C, Agha R (2020) Review- World Health Organization declares global emergency: a review of the 2019 novel coronavirus (COVID-19). Int J Surg 76:71–76

Somani M, Srivastava AN, Gummadivalli SK, Sharma A (2020) Indirect implications of COVID-19 towards sustainable environment: an investigation in Indian context. Bioresour Technol Rep 11:100491

Soni DK (2020) Regulatory interventions in Covid-19 waste management in India. Natl J Life Sci 17(1):5–7

SWANA - Solid Waste Association of North America article (2020) SWANA reminds all state and local governments that solid waste management is an essential public service. https://swana.org/news/swana-news/article/2020/03/19/swana-reminds-allstate-and-localgovernments-that-solid-waste-management-is-an-essential-publicservice

Tang W (2020) The medical waste related to COVID-2019 is cleaned up every day—the medical waste treatment market needs to be standardised. 21st Century Business Herald; 2020. www.21jingji.com/2020/3-12/xNMDEzODFfMTU0MjIxNQ.html

Times of India (TOI) (2020) 350 Tonnes of trash disappear from streets of Ahmedabad. http://timesofindia.indiatimes.com/articleshow/75039037.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst

UNEP (2020) BASEL: waste management an essential public service in the fight to beat COVID-19. The United Nations Environment Programme (UNEP) and The Basel Convention. http://www.basel.int/Implementation/PublicAwareness/PressReleases/WastemanagementandCOVID19/tabid/8376/Default.aspx

United Nations Industrial Development Organization (UNIDO) (2020) India's manufacturing reels from the impact of COVID-19. https://www.unido.org/stories/indias-manufacturingreelsimpact-covid-19

United Nations (2020) The Social Impact of COVID-19. Department of Economics and Social Affairs. https://www.un.org/development/desa/dspd/2020/04/social-impact-ofcovid-19

United States Environmental Protection Agency (2020) Recycling and sustainable management of food during COVID-19 public health emergency. https://www.epa.gov/coronavirus/recycling-and-sustainable-management-food-duringcoronaviruscovid-19-public-health

United States Environmental Protection Agency (2017) National overview: facts and figures on materials, wastes and recycling. https://www.epa.gov/facts-and-figuresabout-materials-waste-and-recycling/national-overview-facts-and-figures-materials . Accessed 10 May 2020.

Vellingiri B, Jayaramayya K, Iyer M, Narayanasamy A, Govindasamy V, Giridharan B, Ganesan S, Venugopal A, Venkatesan D, Ganesan H, Rajagopalan K (2020) COVID-19: a promising cure for the global panic. Sci Total Environ 725:138277

Weber DJ, Rutala WA, Fischer WA, Kanamori H, Sickbert-Bennett EE (2016) Emerging infectious diseases: focus on infection control issues for novel coronaviruses (Severe Acute Respiratory Syndrome-CoV and Middle East Respiratory Syndrome-CoV), hemorrhagic fever viruses (Lassa and Ebola), and highly pathogenic avian influenza viruses, A(H5N1) and A(H7N9). Am J Infect Control 44(5):E91–E100

WHO (2017) Report on health-care waste management (HCWM) status in Countries of the South-East Asia Region (SEA-EH-593). The World Health Organization. https://apps.who.int/iris/handle/10665/258761 .

WHO (2018) World Health Organization. Global status report on alcohol and health. https://www.who.int/substance_abuse/publications/global_alcohol_report/en/ .

WHO, 2020a. Pneumonia of unknown cause- China. World Health Organization.

WHO (2020b) Coronavirus Disease (COVID-2019) Situation Reports-67. World Health Organization

WHO (2020c) World Health Organization. WHO-Director-general-s-opening-remarks-at-the-media briefing-on-covid-19. www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19

WHO (2020d) Water, sanitation, hygiene, and Waste Management For the COVID-19 virus: interim guidance, 23 April 2020d (No. WHO/2019-nCoV/IPC_WASH/2020.3).WorldHealth Organization URL. https://apps.who.int/iris/bitstream/handle/10665/331846/WHO-2019-nCoV-IPC_WASH-2020.3-eng.pdf . Accessed 30 April 2020.

Windfeld ES, Brooks MS-L (2015) Medical waste management—a review. J Environ Manag 163:98–108

Wölfel R, Corman VM, Guggemos W, Seilmaier M, Zange S, Müller MA, Niemeyer D, Jones TC, Vollmar P, Rothe C, Hoelscher M (2020) Virological assessment of hospitalized patients with COVID-2019. Nature 581(7809):465–469

World Bank Urban Development Series (2018) Decision Maker’s Guides for Solid Waste Management Technologies.

World Bank (2020) Waste workers are protecting our communities during COVID-19. https://blogs.worldbank.org/sustainablecities/waste-workers-are-protecting-ourcommunitiesduring-covid-19 . Accessed 11 May 2020.

Xia J, Tong J, Liu M, Shen Y, Guo D (2020) Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection. J Med Virol 92(6):589–594

Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, Liu S, Zhao P, Liu H, Zhu L (2020) Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Resp Med 8(4):420–422

Yadav P, Samadder SR (2018) A critical review of the life cycle assessment studies on solid waste management in Asian countries. J Clean Prod 185:492–515. https://doi.org/10.1016/j.jclepro.2018.02.298

Yunus AP, Masago Y, Hijioka Y (2020) COVID-19 and surface water quality: improved lake water quality during the lockdown. Sci Total Environ 731:139012. https://doi.org/10.1016/j.scitotenv.2020.139012

Zambrano-Monserrate MA, Ruano MA, Sanchez-Alcalde L (2020) Indirect effects of COVID-19 on the environment. Sci Total Environ 728:138813. https://doi.org/10.1016/j.scitotenv.2020.138813

Zhang W, Du RH, Li B, Zheng XS, Yang XL, Hu B, Wang YY, Xiao GF, Yan B, Shi ZL, Zhou P (2020) Molecular and serological investigation of 2019-nCoV infected patients: implication of multiple shedding routes. Emerg Microbes Infect 9(1):386–389

Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, Huang B, Shi W, Lu R, Niu P (2020) A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 382:727–733

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Kanwar, V.S., Sharma, A., Rinku et al. An overview for biomedical waste management during pandemic like COVID-19. Int. J. Environ. Sci. Technol. 20 , 8025–8040 (2023). https://doi.org/10.1007/s13762-022-04287-5

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Received : 20 September 2021

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Published : 06 June 2022

Issue Date : July 2023

DOI : https://doi.org/10.1007/s13762-022-04287-5

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