hospital waste management essay

Essay on Hospital Waste Management

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100 Words Essay on Hospital Waste Management

Introduction.

Hospital Waste Management involves the proper handling and disposal of waste produced in hospitals. This waste can be highly infectious and toxic, posing risks to health and the environment.

Types of Waste

Hospital waste includes general waste like paper and food, and hazardous waste like needles, chemicals, and body parts. Hazardous waste requires special treatment.

Proper waste management prevents diseases and protects the environment. It also complies with health regulations, ensuring hospitals are safe for patients and staff.

Methods include segregation, sterilization, and disposal. Waste is separated into categories, sterilized to kill germs, and safely disposed of.

Hospital Waste Management is vital for health and environmental protection. Everyone must contribute to ensure its success.

250 Words Essay on Hospital Waste Management

Hospital waste management is a critical aspect of health care that affects both public health and the environment. It involves the regulation, collection, treatment, and disposal of waste produced by healthcare facilities.

Significance of Hospital Waste Management

Hospital waste includes a wide variety of materials, from used needles and syringes to soiled dressings, body parts, diagnostic samples, blood, chemicals, pharmaceuticals, and even radioactive materials. Poor management of healthcare waste exposes healthcare workers, waste handlers, patients, and the community at large to infections, toxic effects, and injuries.

Methods of Hospital Waste Management

Effective hospital waste management involves segregation at the source, safe collection, and proper disposal. Waste should be separated into hazardous and non-hazardous, with hazardous waste further categorized into infectious, pathological, sharps, chemicals, and pharmaceuticals. Each category requires specific treatment and disposal methods, such as incineration, autoclaving, chemical treatment, or landfilling.

Challenges and Solutions

Despite its importance, hospital waste management is often overlooked due to lack of awareness, resources, and stringent regulations. Education and training of healthcare workers, adequate funding, and strict enforcement of waste management policies can help overcome these challenges. Furthermore, advancements in technology can provide innovative solutions, such as non-incineration technologies and waste minimization strategies.

In conclusion, effective hospital waste management is essential for safeguarding public health and the environment. By implementing comprehensive waste management strategies, hospitals can significantly reduce the risks associated with healthcare waste.

500 Words Essay on Hospital Waste Management

Hospital waste management is a critical aspect of healthcare facilities that ensures the safety and health of patients, staff, and the broader community. It involves the proper handling, storage, treatment, and disposal of waste produced in these facilities. Given the hazardous nature of some of these wastes, effective management is essential to mitigate potential health risks and environmental impacts.

The Importance of Hospital Waste Management

Hospital waste can be a significant source of pathogens, toxins, and other harmful substances. Improper handling and disposal of this waste can lead to the spread of diseases, environmental contamination, and even death. For instance, sharps waste, if not correctly disposed of, can lead to needle-stick injuries and the spread of bloodborne diseases. Chemical waste can contaminate water systems, while radioactive waste can pose long-term health risks. Hence, effective hospital waste management is crucial for public health and environmental safety.

Types of Hospital Waste

Hospital waste is broadly classified into general waste, infectious waste, hazardous waste, and radioactive waste. General waste, which makes up the majority, is similar to domestic waste and poses no particular risk. Infectious waste, on the other hand, contains pathogens that can cause disease. Hazardous waste includes chemical and pharmaceutical waste that can be toxic, while radioactive waste comes from radiology departments and poses radiation risks.

Best Practices in Hospital Waste Management

Effective hospital waste management involves several best practices. Segregation at the source is the first step, where waste is sorted into different categories based on their risk level. This practice prevents the mixing of hazardous and non-hazardous waste, reducing the volume of waste that requires special handling and treatment.

Storage and transportation of waste should also be done in a manner that minimizes the risk of exposure and environmental contamination. For hazardous waste, this often involves using secure containers and dedicated transportation.

Treatment and disposal methods vary based on the type of waste. For instance, infectious waste is often autoclaved or incinerated to kill pathogens, while hazardous waste might require specialized treatment facilities. In all cases, disposal should comply with local regulations and best practices to minimize environmental impact.

Challenges and Future Directions

Despite its importance, hospital waste management often faces several challenges. These include lack of awareness and training, inadequate resources, and insufficient regulatory oversight. Addressing these challenges requires concerted efforts from all stakeholders, including healthcare facilities, waste management companies, regulatory bodies, and the community at large.

In the future, more emphasis should be placed on waste reduction and recycling. For instance, hospitals can switch to reusable products where possible and implement programs to recycle non-hazardous waste. Moreover, advancements in technology can lead to more efficient and environmentally friendly waste treatment and disposal methods.

In conclusion, hospital waste management is a critical aspect of healthcare that requires careful attention. While challenges exist, adopting best practices and leveraging technology can significantly improve the safety and efficiency of waste management in hospitals. By doing so, healthcare facilities can protect public health and the environment while providing high-quality care to their patients.

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• Knowledge Center

Why Hospital Waste Management is Important

Each person working in a hospital setting can be impacted by hospital waste management – and each person should be provided with training and education on how healthcare waste handling and disposal processes directly impacts infection control. 

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In this blog we will be covering:

1 /   Hospital Waste Management Definition

2 /   Importance of Waste Management in Hospital

3 /  Hospital Waste Management Tips

4 /  Benefits of Modern Waste Management in Hospitals

5 /  Key Challenges in Hospital Waste Management and Employee Training

6 /  Ensuring Compliance: Your Key Responsibility in Hospital Waste Management  

Hospital waste management definition  

Hospital waste management is defined as the systematic handling, segregation, treatment, and disposal of waste generated in healthcare settings. This includes everything from general waste to more hazardous materials such as sharps, pharmaceuticals, and chemical waste. The goal is to ensure environmental safety, compliance with medical waste regulations, and the protection of healthcare workers and patients.

Importance of waste management in hospitals

Hospital waste management is not a one-size-fits-all solution.

The importance of medical waste management is not to be understated. This is because various types of healthcare waste are generated by every department in a hospital, from the janitorial and housekeeping staff to surgical suites, infectious disease units, and so forth. The same thing can be said about Skilled Nursing communities – each facility has unique needs that vary due to the amount of beds, the procedures performed, and the specialties of healthcare.

Daniels Health takes the time to observe your current processes and complete waste audits before proposing any changes. We meet you where you are and build an improvement plan from there. 

Hospital Waste Management Tips  

Begin with an “inside the four walls” approach.

We work directly with clinical staff to drive better healthcare waste management. Through training, container placement and process improvement within the four walls, we influence safety, alter segregation behaviors, enhance efficiencies and drive substantial cost benefits for our customers.

Our "Inside the Four Walls" approach, used for both acute and non-acute facilities across the US, centers around:

• Safety Infection and Risk Minimization
• Waste Optimization
• Compliance and Education
• Position and Movement
• Storage Optimization   

To learn more about our "Inside the Four Walls" approach, click here.

Education on Hospital Waste Management

We know that education is the key to awareness and proper implementation of healthcare waste segregation and disposal processes inside healthcare facilities. Notable initiatives include recognizing various healthcare waste stream sources and conducting regular healthcare waste audits. These practices are essential components of effective waste management in hospitals, ensuring both safety and compliance.

At Daniels Health, we want to work with you and your staff to ensure everyone feels confident in compliantly disposing of healthcare waste. We are your partner; not just another "bag and a box" medical waste disposal company.

Adopt Simplified Healthcare Waste Management Solutions

We make healthcare waste segregation easy by implementing our bold, reusable containment systems. They are color-coded and optimally placed to help you quickly and safely dispose of healthcare waste. 

Implementing our reusable solutions goes beyond education and enforcement of healthcare waste segregation – by choosing Daniels you are reducing the volume of single-use plastic medical waste or sharps containers going to landfills. You are choosing to move your hospital or healthcare facility in a more sustainable direction.

Benefits of Modern Waste Management in Hospital  

Minimizing touch in hospital waste management.

Nowadays, we are all hyper-aware of how much we are touching any and all surfaces. A modern hospital waste management plan includes solutions that minimize touch. Daniels Health reusable containment systems are either wall-mounted, or on a mobile cart for point-of-use disposal. Our systems should only be touched twice: once placing an empty container in its designated location and secondly when the container is full - permanently locking it to place in a soiled utility room or loading area.

Enhancing Safety 

Not only do we specialize in containers that reduce touch – they are Safety Engineered Devices. Our Sharpsmart alone is peer-reviewed to prevent the risk of container-associated sharps injuries by over 80%!

Healthcare personnel in the US experience over 300,000 needlestick and/or other sharps-related injuries every year. Today the focus is not only on minimizing environmental waste, but increasing worker safety.

Increased Efficiency and Compliance

We know change can be scary and vigilant healthcare waste segregation can feel time-consuming. Nevertheless, enhanced education and improved reporting procedures not only increases efficiency but ensures compliance to federal and state guidelines.

Key Challenger in Hospital Waste Management and Employee Training  

Proper training in waste segregation and effective on-site management of hazardous waste are among the most critical aspects of hospital waste management.

Are your employees confident in the difference between the variety of healthcare waste streams you generate? We're talking:

• Sharps waste
• Biohazard waste  

Are they confident in the safe disposal of medicinal and non medicinal sharps? Have they used point-of-use disposal systems before? Daniels Health emphasizes the “less touches equals less risk” approach. Do your hospital employees know how sharps waste is defined? Sharps don't just reference needles ( ISO standard 23907:2012 ), but include:

• Empty ampoules
• Razor blades
• Suture needles

• Culture slides and dishes

It is up to you to ensure that your Cradle to Grave responsibilities are upheld. As the waste generator, you are legally responsible to properly segregate and dispose of healthcare waste with a management partner of your choice. Daniels Health has proudly supported US healthcare with reliable service for over 30 years – giving many peace of mind that their waste been properly treated.

Improper waste segregation and an overall lack of awareness costs hospitals tens of thousands of dollars a year. This is because some throw away a bulk of their waste into their biohazardous waste stream – even if it's not biohazard waste. One New York City hospital started an aggressive medical waste reduction program and shaved nearly one million dollars annually off their waste disposal costs!

Know the healthcare waste streams

Hospitals, surgery centers, dentists – whatever your size – your facility must be able to follow the trail proper waste segregation to ensure all the streams you generate are treated correctly. This is one of the many reasons why choosing a healthcare partner you can trust is so important – they need to understand your waste at a deep level.

It's essential for hospitals to have policies and procedures in place that regulate the handling and implementation of healthcare waste and the volume and type of waste generated. Just because something is “disposable” doesn't mean that it doesn't have to be handled properly in regard to segregation.

If you are unsure where you can improve your facility's waste management plan – begin with a waste audit. This can be done in-house by your team or in partnership with your healthcare waste services partner. Waste audits are an integral part of healthcare waste management and aid hospitals in determining the difference between clinical waste and non-clinical waste, as well as the proper segregation of waste streams.

Every hospital should have a plan in place to deal with their medical waste. For example, hospitals around the country have implemented best-practices approaches to deal with medical waste. Some of the topics covered include: 

• Biomedical waste management

• Self-auditing for different medical waste streams  

Every department within the hospital - from administration to janitorial - are given specific guidelines and instructions. Washington State created their best-practices guide for medical waste years ago. For example, the anesthesia department is instructed to handle spent charcoal filters as dangerous waste. The clinical research department was mandated to manage their chemicals and waste properly through the use of closed, clearly labeled, and dated containers stored in secured areas.

They took it further and required that secondary containment before proper disposal was needed in certain scenarios. The housekeeping department was provided very specific guidelines on the segregation and storage of solid, biomedical, and dangerous waste as well as recyclables.

Ensuring Compliance: Your Key Responsibility in Hospital Waste Management

The responsibility of adhering to federal and state guidelines for healthcare waste management and disposal belongs to the waste generator. Penalties and fines can be incurred even after medical waste leaves your hospital. Until its final disposition, it's your responsibility.

With over 30 years of experience, we have the expertise to maintain your compliance and be a long-term partner. Our sustainable and efficient hospital waste management solutions put safety of employees and the environment first. Our Safety Engineered Devices are proven to reduce sharps injuries, lower your carbon footprint, and increase efficiency with disposal.

The ever-evolving needs of Hospital healthcare waste management can be daunting, but as your partner, we can tackle it together - and well! To speak to one of our team members about how Daniels can help your hospital, click here.

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With a little bit of knowledge about a lot of things and a quick wit, Megan was the recipient of the Daniels Pun-Master Award 2017 and is the go-to for fun analogies to explain healthcare waste.

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Medical Waste Disposal: Steps and Regulations Case Study

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Types of medical waste

Waste processing, steps of medical waste disposal.

Medical waste is “waste sufficiently capable of causing infection during handling and disposal.”

Biomedical waste, biohazardous waste, clinical waste, regulated medical waste (RMW), healthcare waste, infectious medical waste.

• Sharps – Needles, lancets, glass shards, razors, scalpels, and other objects that can pierce one’s skin.
• Infectious – Used swabs, equipment, lab cultures, tissues, and excreta.
• Radioactive – Radiotherapy and lab research liquids, including contaminated holding containers.
• Pathological – Contaminated animal carcasses, human tissue, body parts, blood, and other bodily fluids.
• Pharmaceuticals – Vaccines, antibiotics, pills, and injectables that are expired, unused, or contaminated.
• Chemical – Heavy metals for medical equipment (mercury), batteries, solvents, and disinfectants.
• Genotoxic – Highly dangerous waste that can be teratogenic, carcinogenic, or mutagenic (drugs for cancer treatment).
• General non-regulated – this type of waste is non-hazardous.

Healthcare providers must follow the national and state regulations, such as the Occupational Safety and Health Administration (OSHA). One must never dispose of waste in improper ways. For instance, prescription drugs should never be flushed down the drain or toilet unless specified on the label or patient information. These drugs can be disposed of through community pharmaceutical return programs or collection events.

To dispose of prescription drugs, one must take them out of their containers, mix them with an undesirable substance, put them in a disposal container with a lid, remove all personal information, and place the sealed container with this mixture trash.

Sharps are a health hazard for the public. Thus, they should be disposed of properly. One must not put shards in the waste bin without a specifically designed container. Removing an already tossed needle from the waste should not be attempted.

Medical centers can have onsite and offsite medical waste treatments. The former is expensive to maintain and manage and is used by large organizations. Smaller facilities can use offsite treatment by hiring third-party vendors that collect and dispose of waste by using mail or truck services.

Waste can be processed in the following ways:

• Incineration – Currently, the only method used for pathological waste. In 1997, the EPA regulations changed to restrict the use of burning as a primary type of waste disposal. Before this date, more than 90% of all waste was incinerated.
• Autoclaving – This method uses steam sterilization. It can make biohazardous waste non-infectious. After the procedure, the waste can be disposed of in standard ways.
• Microwaving – By microwaving waste, one can render it non-hazardous. Processed waste becomes non-infectious.
• Chemical – It is used for chemical waste primarily. Reactive chemicals neutralize some types of waste and make them inert.
• Biological – This method is used for infectious organisms. It uses enzymes and is highly experimental.

Knowing the laws is crucial for healthcare workers to classify and dispose of medical waste. The following steps should be remembered:

• Separate waste by type – The types are mentioned above.
• Use proper containers – One must use approved containers for each waste type.
• Prepare containers – All containers must be taped and packaged following the Department of Transportation (DOT) weight restrictions. All containers must be labeled and stored in a secure area before shipping.
• Include documentation – Proper documentation can protect the healthcare provider and the hired firm and be included with every container.
• Use a color code – Sharps go in red puncture-proof containers. Biohazard waste goes in red containers/bags. Chemical waste goes in yellow containers. Pharmaceutical waste goes in black (hazardous) or blue (non-hazardous) containers. Radioactive waste should be stored in shielded containers with a radioactive symbol.
• Hire a reliable waste disposal company.
• Bloodborne Infections Among Medical Practitioners
• Controlling the Offsite Storage
• "Kaleidoscope" Diversity in the United States
• The Urgent Care: Patient Satisfaction and Cost Reduction
• Disciplinary Actions in the Medical Establishments
• Ambulatory Surgery Center's Business Plan
• How Doctors Die and Why It's Different
• The Oregon Health Plan
• Chicago (A-D)
• Chicago (N-B)

IvyPanda. (2020, September 3). Medical Waste Disposal: Steps and Regulations. https://ivypanda.com/essays/medical-waste-disposal-steps-and-regulations/

"Medical Waste Disposal: Steps and Regulations." IvyPanda , 3 Sept. 2020, ivypanda.com/essays/medical-waste-disposal-steps-and-regulations/.

IvyPanda . (2020) 'Medical Waste Disposal: Steps and Regulations'. 3 September.

IvyPanda . 2020. "Medical Waste Disposal: Steps and Regulations." September 3, 2020. https://ivypanda.com/essays/medical-waste-disposal-steps-and-regulations/.

1. IvyPanda . "Medical Waste Disposal: Steps and Regulations." September 3, 2020. https://ivypanda.com/essays/medical-waste-disposal-steps-and-regulations/.

Bibliography

IvyPanda . "Medical Waste Disposal: Steps and Regulations." September 3, 2020. https://ivypanda.com/essays/medical-waste-disposal-steps-and-regulations/.

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Home > Books > Current Topics in Public Health

Health Care Waste Management – Public Health Benefits, and the Need for Effective Environmental Regulatory Surveillance in Federal Republic of Nigeria

Submitted: 09 May 2012 Published: 15 May 2013

DOI: 10.5772/53196

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Current Topics in Public Health

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Author Information

Nkechi chuks nwachukwu *.

• Department of Microbiology, Faculty of Biological and Physical Sciences, Abia State University, Uturu, Abia State, Nigeria

Frank Anayo Orji *

• Enzymes and Genetics Division, Department of Biotechnology, Federal Institute of Industrial Research, Oshodi, Lagos State, Nigeria

Ositadinma Chinyere Ugbogu *

*Address all correspondence to:

1. Introduction

Waste generated by health care activities includes 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 (WHO, 2011).

Poor management of health care waste potentially exposes health care workers, waste handlers, patients and the community at large to infection, toxic effects and injuries, and risks polluting the environment. It is essential that all medical waste materials are segregated at the point of generation, appropriately treated and disposed of safely(WHO, 2011). Healthcare waste (HCW) is a by-product of healthcare that includes sharps, non-sharps, blood, body parts, chemicals, pharmaceuticals, medical devices and radioactive materials.

WHO Programme activities include developing technical guidance materials for assessing the quantities and types of waste produced in different facilities, creating national action plans, developing national healthcare waste management (HCWM) guidelines and building capacity at national level to enhance the way HCW is dealt with in low-income countries (LICs).

Classification of Health Care wastes shows that

Of the total amount of waste generated by health-care activities, about 80% is general waste.

The remaining 20% is considered hazardous material that may be infectious, toxic or radioactive.

Every year an estimated 16 000 million injections are administered worldwide, but not all of the needles and syringes are properly disposed of afterwards.

Health-care waste contains potentially harmful micro organisms which can infect hospital patients, health-care workers and the general public.

Health-care activities protect and restore health and save lives. But what about the wastes and by-products they generate

Types of waste

Waste and by-products cover a diverse range of materials, as the following list illustrates (percentages are approximate values):

Infectious waste : waste contaminated with blood and its by-products, cultures and stocks of infectious agents, waste from patients in isolation wards, discarded diagnostic samples containing blood and body fluids, infected animals from laboratories, and contaminated materials (swabs, bandages) and equipment (such as disposable medical devices); are considered as infectious waste, all wastes that are susceptible to contain pathogens (or their toxins) in sufficient concentration to cause diseases to a potential host. Examples of infectious waste include discarded materials or equipment, used for the diagnosis, treatment and prevention of disease that has been in contact with body fluids (dressings, swabs, nappies, blood bags…). This category also includes liquid waste such as faeces, urine, blood or other body secretions (such as sputum or lung secretions).

Pathological waste : recognizable body parts and contaminated animal carcasses; Pathological waste consists of organs, tissues, body parts or fluids such as blood. Even if pathological waste may contain healthy body parts, it has to be considered as infectious waste for precautionary reasons.

Anatomical waste is a sub-group of pathological waste and consists in recognisable human body parts, whether they may be infected or not. Following the precautionary principles, anatomical waste is always considered as potential infectious waste.

Pharmaceutical wastes : expired, unused, and contaminated drugs; vaccines and sera; Pharmaceutical waste includes expired, unused, spilt and contaminated pharmaceutical products, drugs and vaccines. In this category are also included discarded items used in the handling of pharmaceuticals like bottles, vials, connecting tubing. Since various ministries of health or their equivalents usually put in place specific measures that will reduce the the wastage of drugs, Health care facilities should deal only with small quantities of pharmaceutical wastes. This category also includes all the drugs and equipment used for the mixing and administration of cytotoxic drugs. Cytotoxic drugs or genotoxic drugs are drugs that have the ability to reduce/stop the growth of certain living cells and are used in chemotherapy for cancer. Cytotoxic waste is dealt with under a separate heading.

Genotoxic waste : highly hazardous, mutagenic, teratogenic or carcinogenic, such as cytotoxic drugs used in cancer treatment and their metabolites; Genotoxic waste derives from drugs generally used in oncology or radiotherapy units that have a high hazardous mutagenic or cytotoxic effect. Faeces, vomit or urine from patients treated with cytotoxic drugs or chemicals should be considered as genotoxic. In specialised cancer hospitals, their proper treatment or disposal raises serious safety problems.

Radioactive waste : such as glassware contaminated with radioactive diagnostic material or radiotherapeutic materials; Radioactive waste includes liquids, gas and solids contaminated with radionuclides whose ionizing radiations have genotoxic effects. The ionizing radiations of interest in medicine include X- and g-rays as well as a- and b- particles. An important difference between these types of radiations is that X-rays are emitted from X-ray tubes only when generating equipment is switched on whereas g-rays, α- and β- particles emit radiations continuously.

The type of radioactive material used in HCF results in low level radioactive waste. It concerns mainly therapeutic and imaging investigation activities where Cobalt 60Co, Technetium 99mTc, Iodine 131I and Iridium 192Ir are most commonly used.

With the noticeable exception of Cobalt 60Co, their half-life is reasonably short (6 hours for 99mTc, 8 days for 131I and 74 days for 192Ir) and the concentrations used remain low. A proper storage with an appropriate retention time is sufficient to prevent radioactivity spillage in the environment.

Infectious and anatomic wastes together represent the majority of the hazardous waste, up to 15% of the total waste from health-care activities. Sharps represent about 1% of the total waste but they are a major source of disease transmission if not properly managed. Chemicals and pharmaceuticals account for about 3% of waste from health-care activities while genotoxic waste, radioactive matter and heavy metal content account for around 1% of the total health-care waste.

The major sources of health-care waste are:

hospitals and other health-care establishments

laboratories and research centres

mortuary and autopsy centres

animal research and testing laboratories

blood banks and collection services

Nursing homes for the elderly.

High-income countries generate on average up to 0.5 kg of hazardous waste per bed per day; while low-income countries generate on average 0.2 kg of hazardous waste per hospital bed per day. However, health-care waste is often not separated into hazardous or non-hazardous wastes in low-income countries making the real quantity of hazardous waste much higher.

Laboratory waste : This is also high risk category waste. This includes chemicals used in the pathological laboratory, microbial cultures and clinical specimens, slide, culture dish, needle, syringes, as well as radioactive waste such as Iodine-125, iodine -131.

Health impact

Health-care waste contains potentially harmful micro-organisms which can infect hospital patients, health-care workers and the general public. Other potential infectious risks may include the spread of drug-resistant micro-organisms from health-care establishments into the environment.

Waste and by-products can also cause injuries, for example:

radiation burns;

sharps-inflicted injuries;

poisoning and pollution through the release of pharmaceutical products, in particular, antibiotics and cytotoxic drugs;

poisoning and pollution through waste water; and

Poisoning and pollution by toxic elements or compounds, such as mercury or dioxins that are released during incineration.

WHO estimates that, in 2000, injections with contaminated syringes caused 21 million hepatitis B virus (HBV) infections, two million hepatitis C virus infections and 260 000 HIV infections worldwide. Many of these infections were avoidable if the syringes had been disposed of safely. The re-use of disposable syringes and needles for injections is particularly common in certain African, Asian and Central and Eastern European countries.

In developing countries, additional hazards occur from scavenging at waste disposal sites and the manual sorting of hazardous waste from health-care establishments. These practices are common in many regions of the world. The waste handlers are at immediate risk of needle-stick injuries and exposure to toxic or infectious materials.

Vaccine waste

In June 2000 six children were diagnosed with a mild form of smallpox (vaccinia virus) after having played with glass ampoules containing expired smallpox vaccine at a garbage dump in Vladivostok (Russia). Although the infections were not life-threatening, the vaccine ampoules should have been treated before being discarded.

Radioactive waste

The use of radiation sources in medical and other applications is widespread throughout the world. Occasionally, the public is exposed to radioactive waste, which originates from radiotherapy treatment, which has not been disposed of properly. Serious accidents have been documented in Brazil in 1988 (where four people died and 28 had serious radiation burns), Mexico and Morocco in 1983, Algeria in 1978 and Mexico in 1962.

Boxes for sharps disposal (AIHPPRP, 2007)

Risks associated with other types of health-care waste, in particular blood waste and chemicals, may be significant but have not been fully assessed. In the meantime, precautionary measures should be taken.

Risks associated with waste disposal

Although treatment and disposal of health-care waste reduces risks, indirect health risks may occur through the release of toxic pollutants into the environment through treatment or disposal.

Landfills can contaminate drinking-water if they are not properly constructed. Occupational risks exist at disposal facilities that are not well designed, run, or maintained.

Incineration of waste has been widely practised but inadequate incineration or the incineration of unsuitable materials results in the release of pollutants into the air and of ash residue. Incinerated materials containing chlorine can generate dioxins and furans, which are human carcinogens and have been associated with a range of adverse health effects. Incineration of heavy metals or materials with high metal content (in particular lead, mercury and cadmium) can lead to the spread of toxic metals in the environment. Dioxins, furans and metals are persistent and bio-accumulate in the environment. Materials containing chlorine or metal should therefore not be incinerated.

Only modern incinerators operating at 850-1100 °C and fitted with special gas-cleaning equipment are able to comply with the international emission standards for dioxins and furans.

Alternatives to incineration are now available, such as autoclaving, microwaving, steam treatment integrated with internal mixing, and chemical treatment.

Waste management: reasons for failure

Lack of awareness about the health hazards related to health-care waste, inadequate training in proper waste management, absence of waste management and disposal systems, insufficient financial and human resources and the low priority given to the topic are the most common problems connected with health-care waste. Many countries either do not have appropriate regulations, or do not enforce them. An essential issue is the clear attribution of responsibility for the handling and disposal of waste. According to the 'polluter pays' principle, the responsibility lies with the waste producer, usually the health-care provider, or the establishment involved in related activities. To achieve the safe and sustainable management of health-care waste, financial analyses should include all the costs of disposal.

Steps towards improvement

Improvements in health-care waste management rely on the following key elements:

building a comprehensive system, addressing responsibilities, resource allocation, handling and disposal. This is a long-term process, sustained by gradual improvements;

raising awareness of the risks related to health-care waste, and of safe and sound practices;

selecting safe and environmentally-friendly management options, to protect people from hazards when collecting, handling, storing, transporting, treating or disposing of waste.

Government commitment and support is needed for universal, long-term improvement, although immediate action can be taken locally.

World Health Organisation response

The first global and comprehensive guidance document, Safe management of wastes from health-care activities , originally released by WHO in 1999 , addresses aspects such as regulatory framework, planning issues, waste minimization and recycling, handling, storage and transportation, treatment and disposal options, and training.

It is aimed at managers of hospitals and other health-care establishments, policy makers, public health professionals and managers involved in waste management. It is accompanied by a Teacher's guide , which contains material for a three-day workshop aimed at the same audience.

Additionally, WHO guidance documents on health-care waste are now available including:

a monitoring tool

a cost assessment tool

a rapid assessment tool

a policy paper

guidance to develop national plans

management of waste from injection activities

management of waste at primary health care centres

management of waste from mass immunization activities

Management of waste in emergencies.

Poor management of health care waste potentially exposes health care workers, waste handlers, patients and the community at large to infection, toxic effects and injuries, and risks polluting the environment. It is essential that all medical waste materials are segregated at the point of generation, appropriately treated and disposed of safely.

However in most countries including Nigeria, such wastes are not given appropriate treatment, thus it is impacting negatively on the environment.

2. Medical and pharmaceutical waste in Europe and America

In Europe, wastes are defined by their European Waste Catalogue (EWC) Codes. EWC Codes are 6 digits long, with the first two digits defining the overarching category of waste, the next two defining the sub-category, and the last two defining the precise waste stream. Clinical waste comes under the "18" codes, for example: "18 01 01" corresponds to healthcare waste (18), from humans (01), that is sharp and not infectious [01].

United Kingdom

In the UK, clinical waste and the way it is to be handled is closely regulated Applicable legislation includes the Environmental Protection Act 1990 (Part II), Waste Management Licencing Regulations 1994, and the Hazardous Waste Regulations (England & Wales) 2005, as well as the Special Waste Regulations in Scotland.

United States

In 1988 the Federal government passed The Medical Waste Tracking Act which set the standards for governmental regulation of medical waste. After the Act was repealed in 1991, States were given the responsibility to regulate and pass laws concerning the disposal of medical waste. All fifty states vary in their regulations from no regulations to very strict. Disposal of this waste is an environmental concern, as many medical wastes are classified as infectious or biohazardous and could potentially lead to the spread of infectious disease. Examples of infectious waste include blood, potentially contaminated "sharps" such as needles and scalpels, and identifiable body parts. Sharps include used needles, lancets, and other devices capable of penetrating skin. Infectious waste is often incinerated. The most common method of sterilization is an autoclave. The autoclave uses steam and pressure to sterilize the waste. Additionally, medical facilities produce a variety of hazardous chemicals, including radioactive materials. While such wastes are normally not infectious, they may be classified as hazardous wastes, and require proper disposal.

In the United States, there are three main methods for medical waste generators to dispose of their waste: On-site, truck service, and mail-back disposal. On-site treatment involves the use of very expensive equipment, and is generally only used by very large hospitals and major universities who have the means to afford such equipment. Truck service involves hiring of a medical waste disposal service whose employees are trained to collect and haul away medical waste in special containers (usually cardboard boxes, or reusable plastic bins) for treatment at a facility designed to handle large amounts of medical waste. Mail-back medical waste disposal is similar, except that the waste is shipped through the U.S. postal service instead of by private hauler. Although currently available in all 50 U.S. states, mail-back medical waste disposal is limited to very strict postal regulations (collection and shipping containers must be approved by the postal service for use) and only available by a handful of companies.

3. Health care waste in Nigeria

In developing countries like Nigeria, where many health concerns are competing for limited resources, it is not surprising that the management of healthcare wastes has received less attention and the priority it deserves ( Abah and Ohimain, 2010 ). Unfortunately, practical information on this important aspect of healthcare management is inadequate and research on the public health implications of inadequate management of healthcare wastes are few and limited in scope ( Abah and Ohimain, 2010 ). Although reliable records of the quantity and nature of healthcare wastes and the management techniques to adequately dispose of these wastes has remained a challenge in many developing countries of the world, it is believed that several hundreds of tones of healthcare waste are deposited openly in waste dumps and surrounding environments, often alongside with non hazardous solid waste ( Alagoz and Kocasay, 2007 ; Abah and Ohimain, 2010 ).

A near total absence of institutional arrangements for HCW in Nigeria has been reported by others (Coker et al., 1998). Various methodologies have been used all over the world to assess and quantify HCW. They include the use of physical observation, questionnaire administration and quantification ( Adegbita et al., 2010 ; Olubukola, 2009 ; Phengxay et al., 2005 ), as well as checklists (Townend and Cheeseman, 2005) and private and public records ( Coker et al., 2009 ). Recent studies in Nigeria has estimated waste generation of between 0.562 to 0.670 kg/bed/day ( Abah and Ohimain, 2011 ) and as high as 1.68 kg/bed/day ( Abah and Ohimain, 2011 ). As reported in the literature, there may not be much of a difference in the way and manner wastes generated in various health care institutions are managed in Nigeria. A good example is given by the findings of the study in Lagos by Olubukola which reported the similarity in waste data and HCW management practices in two General hospitals, characterized by a lack of waste minimization or waste reduction strategies, poor waste segregation practices, lack of instructive posters on waste segregation and disposal of HCW with general waste ( Olubukola, 2009 ). The mismanagement of healthcare waste poses health risks to people and the environment by contaminating the air, soil and water resources. Hospitals and healthcare units are supposed to safeguard the health of the community. However, healthcare wastes if not properly managed can pose an even greater threat than the original diseases themselves ( PATH, 2009 ).

A study of Health Care Waste management in Jos Metropolis, Nigeria has demonstrated that the waste management options in the hospitals did not meet the standard practices ( Ngwuluka et al., 2009 ). Waste management with safe and environmentally sound methods cannot be over-emphasized. The hospital management board and the hospitals should make a conscious and deliberate effort to ensure they do not contribute to the present and future threats to human health and the environment by poor waste management practices. In order to execute standard waste management, an understudy of a healthcare establishment with standard waste management practices in or outside the country may be the first practical step to undertake ( Ngwuluka et al., 2009 ). A waste management team should be constituted which will prepare waste management plan, policy documents and technical guidelines and in addition supervise waste management activities ( Ngwuluka et al., 2009 ).

In another study in Port-Harcourt metropolis, Nigeria carried out to assess hospitals waste management practice ( Ogbonna, 2011 ). The study enquired into waste generation rates and various waste disposal options by different categories of hospital. It was further evident in this study that hospital waste management issues and problems are not peculiar to Port Harcourt metropolis alone. Solid waste disposal methods indicated that open dump sites is most preferred while incineration was non existent in the hospitals, clinics. Most other hospitals do not segregate wastes into marked or colour coded containers for the different waste streams neither do they keep records of waste generation and disposal ( Ogbonna, 2011 ). In addition, the survey revealed that both hospital waste generators and handlers treat hospital wastes as a usual domestic waste ( Ogbonna, 2011 ).

Domestic Waste Dump Site at LSUTH-Ayinke House (AIHPPRP, 2007)

Therefore disposal of ashes containing toxic metals from Hospital waste incineration can be done through solidification-stabilization of fly and bottom ash with cement because it appears to be the best method to render ash less toxic. Similarly, the concentration of toxic heavy metals in the ash of hospital waste incinerator can be avoided to some extent through segregation of the waste prior to incineration. Lack of relevant training and protective equipment for waste handlers was a common feature in the survey. Generally, Port Harcourt, as a fast growing city in Nigeria, like most developing countries, lacked the infrastructure, as well as institutional capacity necessary to effectively manage medical wastes as part of the effort to enhance protection of human life and the environment from health hazards arising from improper management of hazardous waste ( Ogbonna, 2011 ).

It was further observed that open dump sites are not even engineered or treated, thus expose the entire public to risks of infection. Ogbonna (2011 ) reported that except for the oil company clinics such as the SPDC, all the other hospitals sampled do not have any unit or department responsible for waste management. Knowledge, attitude and practices towards environmental issues are relatively low among the various actors in the tasks of hospital waste management.

Temporary storage area at NOH, Igbobi (AIHPPRP, 2007)

4. Microorganisms associated with health care waste

The following groups of persons are at the risk of health care waste Medical staff: doctors, nurses, sanitary staff and hospital maintenance personnel; In and out-patients receiving treatment in healthcare facilities as well as their visitors. Workers in support services linked to healthcare facilities such as laundries, waste handling and transportation services; Workers in waste disposal facilities and the general public. Presence of various microorganisms such as pathogenic viruses and bacteria have been investigated by both cultivation and by (RT)-PCR assays. A number of (opportunistic) pathogenic bacteria, including Pseudomonas spp., Lactobacillus spp., S taphylococcus spp., Micrococcus spp., Kocuria spp., Brevibacillus spp., Microbacterium oxydans , and Propionibacterium acnes , were identified and reported from the various medical wastes. In addition, pathogenic viruses such as noroviruses and hepatitis B virus have been also detected in human tissue wastes. Commonly identified bacterial and viral pathogens such as Pseudomonas spp., Corynebacterium diphtheriae, Escherichia coli, Staphylococcus spp., and respiratory synctial virus (RSV) have been reported to be part of the medical wastes. Medical waste should be carefully controlled and monitored to prevent nosocomial infection associated with the exposure to these wastes ( Nascimento et al., 2009 )

Health service waste gives rise to controversy regarding its importance for human, animal and environmental health ( Nascimento et al., 2009 ). Occurrences of clinically relevant bacteria in piles of health service waste in a sanitary landfill and their antimicrobial susceptibility profile have been previously studied by Nascimento et al., 2009 . Nascimento et al., 2009 reported that aliquots of leachate from health care waste in Brazil contained pathogenic strains of Staphylococcus sp, Gram-negative rods of the Enterobacteriaceae family and non-fermenters. Bacterial resistance to all the antimicrobials tested was observed in all microbial groups, including resistance to more than one drug. This makes it possible to suggest that viable bacteria in health service waste represent risks to human and animal health. Furthermore, occurrences of multi-resistant strains support the hypothesis that health service waste acts as a reservoir for resistance markers, with an environmental impact. The lack of regional legislation concerning segregation, treatment and final disposal of waste may expose different populations to risks of transmission of infectious diseases associated with multi-resistant microorganisms.

Microbial diseases associated with health care waste ( Akter, 2010 )

5. Dangers of improper disposal of health care waste

Transmission of disease through infectious waste is the greatest and most immediate threat from healthcare waste.

If waste is not treated in a way that destroys the pathogenic organisms, dangerous quantities of microscopic disease-causing agents—viruses, bacteria, parasites or fungi—will be present in the waste. These agents can enter the body through punctures and other breaks in the skin, mucous membranes in the mouth, by being inhaled into the lungs, being swallowed, or being transmitted by a vector organism (World Health Organization, 1992).People who come in direct contact with the waste are at greatest risk. Examples include healthcare workers, cleaning staff, patients, visitors, waste collectors, disposal site staff, waste pickers, drug addicts and those who knowingly or unknowingly use “recycled” contaminated syringes and needles. Although sharps pose an inherent physical hazard of cuts and punctures, the much greater threat comes from sharps that are also infectious waste. Again, healthcare workers, waste handlers, waste pickers, drug addicts and others who handle sharps can, and have, become infected with HIV/AIDS and hepatitis B and C viruses through pricks or reuse of syringes/needles. These infections may be fatal ( Johannessen, 2000 ). Contamination of water supply from untreated healthcare waste can also have devastating effects. If infectious stools or bodily fluids are not treated before being disposed of, they can create and extend epidemics, since sewage treatment in Africa is almost nonexistent.

For example, the absence of proper sterilization procedures is believed to have increased the severity and size of cholera epidemics in most parts of Africa during the last decade.

Chemical and toxic threats

Chemical and pharmaceutical wastes, especially large quantities, can be health and environmental threats. Since hazardous chemical wastes may be toxic, corrosive, flammable, reactive, and/or explosive, they can poison, burn or damage the skin and flesh of people who touch, inhale or are in close proximity to them. If burned, they may explode or produce toxic fumes. Some pharmaceuticals are toxic as well ( Johannessen, 2000 ).

When chemical and pharmaceutical waste is disposed of in unlined landfills, especially unlined pits, these wastes may contaminate ground and surface water—particularly when large quantities are disposed of. This can threaten people who use the water for drinking, bathing and cooking, and damaging plants and animals in the local ecosystem. Burning or incinerating healthcare waste, while often a better option than disposal in an unlined pit, may create additional problems. Burning or incineration of healthcare waste may produce toxic air pollutants such as Nitrogen Oxides (NOx), particulates, dioxins and heavy metals and distribute them over a wide area. Dioxins and heavy metals are of particular concern ( Prüss and Townend, 1998 ). Dioxins believed to be potent cancer-causing agents, do not biodegrade, and accumulate in progressively higher concentrations as they move up the food chain ( WHO, 1999 ).

Heavy metals such as mercury and cadmium are toxic and/or cause birth defects in small quantities and can also concentrate in the food chain.

Disposable pressurized containers pose another hazard for incineration, as they can explode if burned.

In fact, disposal of large quantities of hazardous chemicals and pharmaceuticals is a serious problem. In most of Africa, no methods are available to small-scale facilities that are safe and affordable ( Prüss and Townend, 1998 ).

Improvised incinerator at UCH, Ibadan

Medical waste storage area at LUTH, Lagos, Nigeria without proper symbols to differentiate wstes into categories (AIHPPRP, 2007)

Antibiotic resistance spread in the Environment through improperly disposed Health Care Wastes

Antimicrobial resistance (AMR) is resistance of a microorganism to an antimicrobial medicine to which it was previously sensitive. Resistant organisms (they include bacteria, viruses and some parasites) are able to withstand attack by antimicrobial medicines, such as antibiotics, antivirals, and anti-malarials, so that standard treatments become ineffective and infections persist and may spread to others. AMR is a consequence of the use, particularly the misuse, of antimicrobial medicines and develops when a microorganism mutates or acquires a resistance gene ( WHO, 2012 ). In places like Nigeria most families become financially distressed after hospitalization of members of their families. Many infectious diseases risk becoming uncontrollable and could derail the progress made towards reaching the targets of the health-related United Nations Millennium Development Goals set for 2015. When infections become resistant to first-line medicines, more expensive therapies must be used. The longer duration of illness and treatment, often in hospitals, increases health-care costs and the financial burden to families and societies ( WHO, 2012 ). Multidrug resistance is described as a phenomenon where a microbial pathogen resists at least three groups of antibiotics (CDC, 2005). Healthcare liquid wastes are the reservoirs of harmful infectious agents such as the pathogens and multiple drug resistant microorganisms ( Sharma et al., 2010 ). Potential infectious risks include the spread of infectious diseases and microbial resistance from health-care establishments into the environment and thereby posing risks of getting infections and antibiotic resistance in the communities ( Sharma et al., 2010 ).

Therefore, even if the hospitals are discharging their healthcare liquid waste into Sewage system, it is mixed with the sewage and gets in surface water without proper treatment. If the hospital effluents are not treated, concentrated forms of infectious agents and antibiotic resistant microbes are shed into communities resulting in water borne diseases such as cholera, typhoid fever, dysentery and gastroenteritis. Antibiotics, disinfectants and bacteria resistant to them have been detected in the environmental compartments such as waste water, surface water, ground water, sediments and soils ( Kummerer, 2004 ). Studies have discovered trace level concentrations of antibiotics in waste water treatment plant effluents and surface waters ( Kolpin et al, 2002 ). Long term exposure of microorganisms to low concentrations of antibiotics in wastewater and surface water has the potential for the development of antibiotic resistance in these organisms (Smith et al., 1999).

The concerns about antimicrobial resistance are increasing. In a report by the United Kingdom, House of Lords, it is stated that the resistance to antibiotics and other anti-infective agents constitutes a major threat to public health and ought to be recognized (HLSCST, 1998). Input of resistant bacteria as well as of antibiotics can disturb the established well balanced and important interdependencies ( Hiraishi, 1998 ). The input of resistant bacteria into the environment seems to be an important source of resistance in the environment.

Therefore, the development of antibiotic resistance in bacteria and their dissemination in the environment is of serious public health concern because an individual patient can develop an antibiotic resistant infection by contacting a resistant organism and spread in the communities. Hospitals and public health care units must safeguard the health of the community. However, the waste produced by the health care centres if disposed of improperly, can pose an even greater threat than the original diseases themselves due to the presence of concentrated forms of numerous risks including pathogenic and antibiotic resistant microorganisms ( Sharma et al., 2010 ).

In Nepal, where several thousand die due to infectious diseases and several more, losing quality of lives, untreated hospital liquid waste discharge into surface water directly or indirectly must have been adding more problems. It is our common observation that majority of the healthcare facilities do not practice safe healthcare liquid waste treatment and disposal.

6. International agreements and principles on health care management

Basel convention

This convention is a global agreement, ratified by some 178 member countries to address the problems and challenges posed by hazardous waste. Nigeria is a signatory to this convention.

The Secretariat, based in Geneva (Switzerland) is administered by UNEP. It facilitates the implementation of the Convention and related agreements. It also provides assistance and guidelines on legal and technical issues and conducts training on the proper management of hazardous waste.

The key objectives of the Basel Convention are:

to minimize the generation of hazardous wastes in terms of quantity and hazardousness;

to dispose of them as close to the source of generation as possible;

to reduce the movement of hazardous wastes.

A central goal of the Basel Convention is “environmentally sound management” (ESM), the aim of which is to protect human health and the environment by minimizing hazardous waste production whenever possible. ESM means addressing the issue through an “integrated life-cycle approach”, which involves strong controls from the generation of a hazardous waste to its storage, transport, treatment, reuse, recycling, recovery and final disposal. Health Care Related Wastes (HCRW) is one of the categories of hazardous wastes covered by the Convention . It was adopted in 1989. During its first decade, the Convention’s principal focus was the elaboration of controls on the “transboundary” movement of hazardous wastes that is the movement of such wastes across international frontiers and the development of criteria for environmentally sound management of the wastes. More recently the work of the Convention has emphasized full implementation of treaty commitments, promotion of the environmentally sound management of hazardous wastes, a lifecycle approach, and minimization of hazardous waste, generation. The Convention entered into force 5 May 1992. (HCWC, 2007).

The Basel Convention (Article 4) requires each Party to minimize waste generation and to ensure, to the extent possible, the availability of disposal facilities within its own territory. The Conference of the

Parties at its sixth meeting in December 2002 adopted a Strategic Plan for the implementation of the Basel Declaration to 2010 building on and using the framework of the 1999 Ministerial Basel Declaration on Environmentally Sound Management. The Basel Convention covers wastes that are listed in Annex I, if they display the hazardous characteristics listed in Annex III. Hazardous wastes are those wastes that are: explosive, flammable, poisonous, infectious, corrosive, toxic, or ecotoxic.

The Stockholm convention on persistent organic pollutants

This Convention is a global treaty to protect human health and the environment from persistent organic pollutants (POPs). POPs are chemicals that remain intact in the environment for long periods, become widely distributed geographically, accumulate in the fatty tissue of living organisms and are toxic to humans and wildlife. Persistent Organic Pollutants (POPs) circulate globally and can cause damage wherever they travel. In implementing the Convention, Governments will take measures to eliminate or reduce the release of POPs into the environment. The countries that have signed these conventions are Afghanistan, Albania, Algeria, Andorra, Angola, Antigua and Barbuda Argentina, Armenia, Australia, Austria, Azerbaijan, Bahamas, Bahrain, Bangladesh, Barbados, Belarus, Belgium, Belize, Benin, Bhutan, Bolivia, Bosnia, and Herzegovina, Botswana, Brazil, Brunei, Darussalam, Bulgaria, Burkina Faso, Burundi, Cambodia, Cameroon, Canada, Cape Verde, Central African Rep, Chad, Chile, China, Colombia, Comoros, Congo, Costa Rica, Cote d'Ivoire, Croatia, Cuba Cyprus, Czech Republic, Dem. Rep. of Korea, Dem. Rep. of the Congo, Denmark, Niger, Nigeria and many more other countries.

The Stockholm Convention was adopted in 2001. POPs are chemicals that are highly toxic, persistent, bio-accumulate and move long distance in the environment. The Convention seeks the elimination or restriction of production and use of all intentionally produced POPs (i.e. industrial chemicals and pesticides). It also seeks the continuing minimization and, where feasible, ultimate elimination of the release of unintentionally produced POPs such as dioxins and furans. The Convention entered into force17 May 2004 (HCWC, 2007).

The Rotterdam convention

The Rotterdam Convention was adopted in 1998. In the 1980s, UNEP and FAO developed voluntary codes of conduct and information exchange systems, culminating in the Prior Informed Consent (PIC) procedure introduced in 1989. The Convention replaces this arrangement with a mandatory PIC procedure and information exchange mechanism on hazardous chemicals and pesticides. The Convention entered into force 24 February 2004.

The Rotterdam Convention (Article 5), obliges Parties to notify the secretariat of final regulatory actions taken in respect of banned or severely restricted chemicals, for the information of other Parties and possible listing under the Convention. Developing countries and countries with economies in transition may also propose the listing of severely hazardous pesticide formulations (Article 6).

The Rotterdam Convention apply to any chemical that is banned or severely restricted by a Party. The Prior Informed Consent procedure applies to the following 28 hazardous pesticides: 2,4,5-T, aldrin, binapacryl, captafol, chlordane, chlordimeform, chlorobenzilate, DDT, 1,2- dibromoethane (EDB), dieldrin, dinoseb, DNOC and its salts, ethylene dichloride, ethylene oxide, fluoroacetamide, HCH, heptachlor, hexachlorobenzene, lindane, mercury compounds, monocrotophos, parathion, pentachlorophenol and toxaphene, plus certain formulations of methamidophos, methyl-parathion, monocrotophos, parathion, phosphamidon and a combination of benomyl, carbofuran and thiram. It also covers 11 industrial chemicals: asbestos (actinolite, anthophyllite, amosite, crocidolite, tremolite), polybrominated biphenyls (PBBs), polychlorinatedbiphenyls (PCBs), polychlorinated terphenyls (PCTs), tris (2,3 dibromopropyl) phosphate and tetraethyl lead (TEL) and tetramethyl lead (TML).

World conventions and Principles of Health Care Waste management

1. Duty of care principle

This principle stipulates that any organisation that generates waste has a duty to dispose of the waste safely . Therefore it is the HCF that has ultimate responsibility for how waste is containerized, handled on-site and off-site and finally disposed of.

2. Polluter pays principle

According to this principle all waste producers are legally and financially responsible for the safe handling and environmentally sound disposal of the waste they produce . In case of an accidental pollution, the organisation is liable for the costs of cleaning it up. Therefore if pollution results from poor management of health-care waste then the HCF is responsible. However, if the pollution results because of poor standards at the treatment facility then the HCF is likely to be held jointly accountable for the pollution with the treatment facility. Likewise this could happen with the service provider. The fact that the polluters should pay for the costs they impose on the environment is seen as an efficient incentive to produce less and segregate well.

3. Precautionary principle

Following this principle one must always assume that waste is hazardous until shown to be safe . This means that where it is unknown what the hazard may be, it is important to take all the necessary precautions.

4. Proximity principle

This principle recommends that treatment and disposal of hazardous waste take place at the closest possible location to its source in order to minimize the risks involved in its transport. According to a similar principle, any community should recycle or dispose of the waste it produces, inside its own territorial limits.

Five fundamental principles for handling health care wastes

These principles include Minimization and Recycling, Sorting receptacles and handling, Collection and Storage, Transportation, and Treatment and Disposal ( ICRC, 2011 ).

Minimization and recycling

The reduction of waste generation must be encouraged by the following practices: Reducing the amount of waste at source, Choosing products that generate less waste: less wrapping material, for example, Choosing suppliers who take back empty containers for refilling (cleaning products); returning gas cylinders to the supplier for refilling, Preventing wastage: in the course of care, for example, or of cleaning activities, Choosing equipment that can be reused such as tableware that can be washed rather than disposable tableware ( Bassey et al., 2006 ; ICRC, 2011 ).

Sorting receptacles and handling

Sorting consists of clearly identifying the various types of waste and how they can be collected separately. There are two important principles that must be followed. The simplest way to identify the different types of waste and to encourage people to sort them is to collect the various types of waste in separate containers or plastic bags that are colour-coded and/or marked with a symbol ( ICRC, 2011 ).

Waste sorting must always be the responsibility of the entity that produces them. It must be done as close as possible to the site where the wastes are produced. There is no point in sorting wastes that undergo the same treatment process, with the exception of sharps, which must at all times be separated at source from other wastes ( Longe and Williams, 2006 ).

Collection and storage

Waste must be collected regularly - at least once a day. It must never be allowed to accumulate where it is produced. A daily collection programme and collection round must be planned. Each type of waste must be collected and stored separately with different known signs on the containers ( Longe and Williams, 2006 ).

Infectious wastes must never be stored in places that are open to the public.

The personnel in charge of collecting and transporting wastes must be informed to collect only those yellow bags and sharps containers which the care staff have closed. They must wear gloves. The bags that have been collected must be replaced immediately with new bags ( Longe and Williams, 2006 ).

Transportation

This means of conveyance must meet the following requirements: they must be easy to load and unload; they must not have any sharp corners or edges that might tear the bags or damage the containers; they must be easy to clean; (with a 5% active chlorine solution); they must be clearly marked.

Furthermore, off-site means of transport must meet the following requirements: they must be closed in order to avoid any spilling on the road; they must be equipped with a safe loading system (to prevent any spilling inside or outside the vehicle); they must be marked according to the legislation in force if the load exceeds 333 kg (for some countries). The entity producing the waste is responsible for packaging and labelling the waste to be transported outside the hospital. Packaging and labelling must be in conformity with national legislation on the transport of dangerous substances and with the Basel Convention in the case of cross-border transport. If there is no national legislation on the subject, the [United Nations] Recommendations on the Transport of Dangerous Goods1312or the European Agreement on the International Carriage of Dangerous Goods by Road (ADR) 1413 should be referred to. If a vehicle is carrying less than 333 kg of medical waste entailing the risk of contamination (UN 3291), it is not required to be marked. Otherwise it must bear sign plates

Treatment and disposal

Choices of treatment and disposal technique depend on a number of parameters ( Bassey et al., 2006 ). These include the quantity and type of waste produced, availability of waste treatment site near the waste generating facility, availability of reliable means of transport, availability of National legislation on health care waste management, climate conditions, groundwater level, regular supply of electricity in the area etc. The handling and treatment of waste entails health risks for staff throughout the chain. The purpose of protective measures is seriously recommended. The purpose of protective measures is to reduce the risks of accident/exposure or the consequences (Sharma et al., 2006; Longe and Williams, 2006 ).

7. Environmental regulatory agencies in Nigeria with health care wastes related mandates

Federal Ministry of Environment (FMENV)

The need to protect the environment in Nigeria started with the pronouncement prohibiting water pollution through the colonial hygiene of public health inspectors. In 1975, a Division was created in the Federal Ministry of Economic Development to deal with pollution and other industrial matters. Lack of effective implementation of its mandate led to the relocation of the Division from one Ministry to another ( Rain Forest, 2012 ; FMenv, 2012)

The discovery of six ship loads of toxic waste of Italian origin in Koko, Delta State in 1988, exposed the need for stringent environmental laws and its effective enforcement with monitoring mechanism put in place. The Federal Government promulgated the Harmful Wastes Criminal Provision Decree 42 of 1988, which made it a criminal offence to import or trade in toxic waste. The Federal Environmental Protection Agency (FEPA) was created by Decree 58 of 1988 as a parastatal of the Ministry of Works and Housing. The agency authority was strengthened through Decree 59 of 1992 and October 12th, 1999 saw the creation of the Federal Ministry of Environment (FMEnv) (FMenv, 2012 ). The Federal Ministry of Environment is charged with the overall responsibility of protecting the Nigerian environment including biodiversity, conservation and sustainable development of natural resources ( Rain Forest, 2012 ).

The National Environmental Protection (Pollution Abatement in Industries & Facilities Generating Waste) Regulation S. I 9 of 1991,

Prohibits the release of hazardous or toxic substances into the environment beyond the limits approved by the Agency,

Solid, liquid and gaseous discharge should be analyzed and reported to their nearest office,

The factory is required to submit yearly environmental audit report within 90 days of demand by the Agency( FMenv, 2012).

Waste Management and hazardous Waste Regulations of 1991,

Regulates the collection, treatment and disposal of solid and hazardous wastes from municipal and industrial sources (FMenv, 2012).

Guidelines and Standards for Environmental Pollution Control in Nigeria 1991,

Directs industries to improve the quality of the environment.

Serves more or less as recommended standards of environmentally good behaviour for industries.

The Federal Government of Nigeria also passed into law the Environmental Impact Assessment (EIA) Act No 86 of 1992, which is summarized below,

Requires the government, its agency and private enterprises to carry out EIA study of a proposed project,

The study also covers for proposed expansion of existing project or facility/ industry( FMenv, 2012).

In November 1989, the present Nigeria Environmental Policy was launched to guide environmental activities in Nigeria. The main objective of the policy is to achieve sustainable development which can be achieved by;

Securing for all Nigerians a quality of Environment adequate for their health and well being;

Conserving and using the natural resources for the benefit of the present and future generations;

Restoring, maintaining and enhancing the ecosystem and ecological process essential for the preservation of biological diversity;

Raising public awareness and promoting understanding of the essential linkages between environment and development;

Co-operation with other countries and international organizations and agencies to achieve the above specific goals, and prevent transboundary environmental pollution( FMenv, 2012)..

National Environmental Standards and Regulation Enforcement Agency (NESREA)

The basis of environmental policy in Nigeria is contained in the 1999 Constitution of the Federal Republic of Nigeria. Section 20 of the Constitution empowers the state to protect and improve the environment; and safeguard the water, air and land, forest and wildlife of Nigeria. Hitherto, various laws and regulations have been enacted to safeguard the Nigerian environment. These include:

National Environmental Protection (Effluent Limitation) Regulations;

National Environmental Protection (Pollution Abatement in Industries and Facilities Generating Wastes) Regulations; and

National Environmental Protection (Management of Solid and Hazardous Wastes) Regulations.

- National Environmental Health Practice Regulations 2007; and

- Nigerian Radioactive Waste Management Regulations 2006.

Environmental Impact Assessment Act of 1992 (EIA Act).

The Petroleum (Drilling and Production) Regulations 1969, made pursuant to The Petroleum Act.

Harmful Wastes (Special Criminal Provisions etc.) Act of 1988 (Harmful Wastes Act).

The National Oil Spill Detection and Response Agency (Establishment) Act 2006 (the NOSDRA Act).

Nigerian Radioactive Waste Management Regulations 2006 issued pursuant to the Nuclear Safety and Radiation Protection Act 1995

The National Environmental Standards and Regulations Agency 2007 (NESREA Act).

The NESREA Act was enacted on the 31st July, 2007 to provide for the establishment of the National Environmental Standards and Regulations Agency (NESREA). This Act repealed the Federal Environmental Protection Agency Act (the FEPA Act) pursuant to which the FEPA which was formerly charged with the protection and development of the environment in Nigeria was established. However all regulations, authorizations and directions made pursuant to the FEPA act and which were in force at the commencement of the NESREA Act shall continue to be in force and have effect as if made by the NESREA Act. The NESREA Act applies to the regulation and the protection and development of the environment in Nigeria with the exception of the oil and gas sector. The NESREA is responsible for the protection and development of environmental standards, regulations, rules, laws, policies and guidelines within Nigeria. The NESREA’s functions do not however include enforcement of environmental standards, regulations, policies and guidelines in the oil and gas sector of Nigeria. The NESREA Act give authorized officers of the NESREA powers to:

enter and search any land, building, vehicle, tent, vessel, floating craft or any inland water; for the purpose of conducting inspection, searching and taking samples for analysis which are reasonably believed to be carrying out activities or storing goods which contravene environmental standards or legislation

seize or detain for such a period as may be necessary articles which are reasonably believed to contravene provisions of the legislation or any of its regulations; and

Obtain an order of a court to suspend activities, seal and close down premises including land, vehicle, tent, vessel, floating craft or any inland water and other structure.

Functions of NESREA Act

Under the NESREA Act, the Minister charged with the responsibility of the environment is empowered by regulations to prescribe any specific removal methods and reporting obligations on the owners or operators of vessels discharging harmful substances and waste into the environment.

Public authorities are statutorily required to inform the public of Environment-related issues. The NESREA Act requires NESREA to enforce compliance with environmental regulations, to create public awareness, provide environmental education on sustainable environmental management and to publish data resulting from the performance of its functions.

The NESREA Act provides that a person who breaches the provisions of the Act commits an offence and shall on conviction be liable to a fine, or imprisonment, or both.

The NESREA Act also provides that where there has been a discharge of any hazardous substance in violation of environmental laws/permits, the person responsible for the discharge will bear the liability of the costs of removal and clean up.

In executing its functions, the NESREA is required to conduct environmental audits and establish a data bank on regulatory and enforcement standards.

The following are environmental impacts associated with the improper disposal of medical wastes:

Pollutants from medical waste (e.g. heavy metals and PCBs) are persistent in the environment

Accumulation of toxic chemicals within soil (proximity to agricultural fields, humans, soil organisms, wildlife, cattle) ground water contamination, decrease in water quality bio-accumulation in organism’s fat tissues, and biomagnify through the food chain

Repeated and indiscriminate application of chemicals over a long period of time has serious adverse effects on soil microbial population - reducing the rate of decomposition, and generally lowering the soil fertility.

Pathogens leads to long term accumulation of toxic substances in the soil specimens collected for analysis have the potential to cause disease and illness in man, either through direct contact or indirectly by contamination of soil, groundwater, surface water, and air wind blown dusts from indiscriminately dumping also have the potential to carry hazardous particulates with domestic animals being allowed to graze in open dumps, there is the added risk of reintroducing pathogenic micro-organisms into the food chain.

Public nuisance (e.g. odours, scenic view, block the walkway, aesthetics, etc.)

Improper sterilization of instruments used in labour room may cause infection to mother and child

Combination of both degradable and non-degradable waste increase the rate of habitat destruction due to the increasing number of sites necessary for disposal of wastes (degradation of habitat)

Plastic-bags, plastic containers, if not properly destroyed may contaminate the soil and also reduces the chance for water percolation into the soil during precipitation.

Open air burning does not guarantee proper incineration, and releases toxic fumes (dioxin) into the atmosphere from the burning of plastics i.e., PCB’s (Atkin, 2010).

Medical waste management has received very little attention in waste management process in Nigeria. Neither the government nor hospital authorities pay proper attention to its management. Unwholesome waste disposal by many hospitals, clinics and health centers in Abuja pose serious health hazard to the city dwellers in general and people living within the vicinity of the health care institutions in particular ( Bassey et al., 2006 ).

Almost all the health care institutions surveyed dispose every kind of waste generated into municipal dumpsites without pre-treatment, leading to an unhealthy and hazardous environment around the health institutions, affecting patients and staff ( Bassey et al., 2006 ).

Scavengers who collect waste from dustbins are at risk of injury from sharp instruments and direct contact with infectious materials. Liquid medical wastes are disposed directly into the municipal sewer system by all the institutions surveyed ( Bassey et al., 2006 ). Direct disposal of faces and urine of infectious patients in municipal sewer system may cause outbreak of epidemic diseases. The scavengers that engage in recycling operations are unaware of the harmful consequences of exposure to contaminate and hazardous waste ( Bassey et al., 2006 ).

Scavenging at Ojota dumpsite in Lagos, Nigeria

Infected carcasses gathered in a dump for burning (AIHPPRP, 2007)

Most at times, the absence of Environmental impact assessments before commencement of public health and pharmaceutical industry projects is responsible for the archive of challenges associated waste management in the developing worlds including Nigeria. Nigeria lacks both effective and adequate waste management facilities and an inadequate Government policy to guide health providers and punish offenders. There is great need to incorporate standard EIA processes into the Nigerian regulatory documents for Public health institutions and pharmaceutical industries. These regulatory bodies need to establish mitigatory measures especially on waste management during the EIA process of Health care facility in Nigeria.

Incidentally, lapses on these bodies have resulted in no or poor implementation of hazard/ risk/ waste management processes in health care institutions.

NESREA and FMEnv are required to follow-up medical laboratories, hospitals, Pharmaceutical companies springing up all over Nigeria on laboratory waste, and Industrial effluent treatment and disposal.

Without this strict implementation of impact mitigation and management of health care waste, Sustainable development is far from being attained.

Health care waste should be treated with utmost attention, since the wastes could be virulent, pathogenic, carcinogenic, mutagenic, and teratogenic. This shows that its impact on environment and human and plant’s health is greater than that of petroleum hydrocarbon spill.

8. Emerging issues of health care waste management

There is no proper waste management system in place in most developing countries. On-site incineration, autoclaving, and steam disinfection are a few processes currently in use for treating very small amounts of hazardous wastes.

Countries found to practice incineration are Brazil, Argentina, Peru, India, Pakistan and Bangladesh etc. Clinical waste incinerators, particularly in developing and poorer countries, often operate under sub-optimal conditions. Most of the cases the percentage of incinerators that were functioning poorly or not operational (HCWH, 1999). Most medical administrations usually focus on installing disposal technologies such as incinerators and do not implement a “practice” of waste management within the hospital. Over 6500 incinerators were installed in the US alone in the 1980s ( Agarwal, 1998 ). Chronic problems both relating to very high toxic levels as well as difficulties in operating a sophisticated engineering technology in a medical setting have given rise to a debate which attempts to define a clean technology for medical waste disposal. There are some techniques practiced by different countries all over the world such as: Incineration, Autoclave Disinfection, Microwave Disinfection, and Mechanical/Chemical Disinfection. Each of this technique has limitations in terms of technological aspect, environmental condition and waste composition. Burning and incineration of medical and municipal waste have been linked to severe public health threat and pollution resulting in the release of toxic dioxin as well as mercury and other toxic substances. These substances produce a remarkable variety of adverse affects in humans at extremely low doses (Basset et al., 2006). Putrefaction occurs in portions of refuse, which have not been fully burnt and add to air pollution through foul smells. Sanitary landfill can lead to pollution of ground water if not properly managed.

However, most of the developed countries have defined policy and regulations to handle and manage medical waste such as Germany, France, Canada, and USA. Unfortunately, health care waste management is not yet carried out with a satisfactory degree of safety in many parts of the globe especially in the underdeveloped world ( Stanley et al., 2011 ).

In Nigeria, the lack of will by policy makers and implementation groups to adopt current technology in Health Care Waste management is an emerging challenge towards HCW management. The Health Care system is not developed in Nigeria, and by extension Health Care Waste Management.

9. Environmental impact assessment for public health and pharmaceutical institutions

In Nigeria Health Care facilities are constructed and flagged off in terms of operations without due considerations to Environmental Impact Assessment (EIA). Its hazards are numerous to be counted. The regulatory agencies in Nigeria on the Environment such as NESREA, FMEnv etc must rise to the challenges of environmental pollution coming from health care facilities. Community engagement during the process of establishing Public health institutions and pharmaceutical companies is also advisable. This will ensure the development of robust Terms of Reference, EIA document, Environmental Management Plan (EMP). The EMP should address the issues or negative impacts of the health care facility on the bio-physical, social environment and health.

It is worthy to note that some health care facilities such as medical and Environmental Laboratories are small projects and may not require full blown EIA. However, the regulatory agencies should develop a module of monitoring their waste disposal to avoid pollution. The situation is bit different in developed countries, where there is integrated Health management system; medical laboratories are usually part of large health care facilities. It is good to state categorical that laboratory wastes are among the most infectious group of health care waste. They contain live virulent pathogens and mutagenic, teratogenic chemicals including dyes. Laboratories must be forced to have a standard waste tracking protocol, in line with the international convention called Polluters Pay Principles (PPP).

10. Conclusion

Federal Republic of Nigeria will gain a lot from the battery of Public health benefits of Health Care waste Management. It is still not well understood why Nigeria at its level of development, Health Care Waste management is not well legislated and thus proper attention has not been given to it by Environmental regulators and Health Care operators. The issues are to be treated as urgent and very critical by Government. Immediate interventions are also required. All hands including the National Orientation Agencies and communities must be on deck to get over this challenge.

11. Recommendation

There is great need for effective Environmental regulatory Surveillance in Nigeria. National laws on Health Care waste management should be established and be moved to an act.

This is the best time for Nigerian Government to establish a regulatory agency to effectively monitor medical wastes and its treatment in Nigeria. Otherwise, the FMEnv and NESREA are to be strengthened to establish a well funded unit (Finance and good Human Resources) for monitoring of Health Care Institutions over Health Care Wastes.

• 9. The Hazardous Chemicals and Wastes Conventions (HCWC) 2007 http://www.healthcarewaste.org/fileadmin/user_upload/resources/UNEP-3Conventions-2007-EN.pdf Accessed August 15, 2011)
• 31. House of Lords Select Committee on Science and Technology (HLSCST). 1998 7th Report of House of Lords (UK). London: The Stationery Office

© 2013 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3.0 License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Why health care waste management

Each and every hospital, large and small, rural and urban, can have a positive impact on the public and environmental health of their community through sustainable health care waste management.

As the global health care system expands, reaching more people and offering ever more sophisticated treatments, a silent and largely neglected crisis is unfolding. The ever growing amount of waste that is generated by these lifesaving advances is not being treated properly, causing enormous suffering, pollution, unnecessary carbon emission, and waste of resources.

Incinerator in East Africa

Globally, health care waste management is underfunded and poorly implemented. The combined toxic infectious and other hazardous properties of medical waste represent a significant environmental and public health threat. Scientists (1) have estimated that over half of the world’s population is at risk from environmental, occupational, or public health threats deriving from improperly treated health care waste. As centers of healing whose priority is to first, do no harm, preventing these risks to their community and environment is imperative for health care facilities.

Unlike many other hazardous wastes, there is currently no international convention that directly covers medical waste management, so categorization systems vary from country to country. However, waste is usually categorized according to the risk it carries. The majority of medical waste – around 75 to 85 percent -- is similar to normal municipal waste, and of low risk unless burned. The remainder is composed of more hazardous types of medical wastes, including infectious and sharps wastes, chemical and radioactive wastes, and hospital wastewaters.

Burning medical waste releases many hazardous gases and compounds, including hydrochloric acid, dioxins and furans, as well as the toxic metals lead, cadmium, and mercury. It also releases large amounts of carbon dioxide, worsening climate change. The disposal of biodegradable waste produces greenhouse gas emissions, including methane, which has a bigger impact on the climate than any other gas than carbon dioxide (2). In many countries, the lack of recycling and disposal infrastructure means that waste- including a large percentage of plastic- is dumped, joining the millions of tonnes that annually pollute our lands and seas.

The good news is that solutions exist that can address these problems, and, in doing so, develop and popularise technologies, products and concepts that will help drive society forward to a zero waste, low carbon, toxics free, circular economy.

By reducing and segregating health care waste, health care facilities can reduce their operational costs, eliminate risks to their staff, enhance the local environment and improve community relations.

A large scale rotating autoclave

1. Harhay et al. 2009 Health care waste management: a neglected and growing public health problem worldwide. Tropical Medicine and International Health 14(11):1414-1417

2. IPCC 5th report Chapter 8, p677 https://www.ipcc.ch/pdf/assessment-report/ar5/wg1/WG1AR5_Chapter08_FINAL.pdf

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Effective Medical Waste Management for Sustainable Green Healthcare

Sang m. lee.

1 College of Business, University of Nebraska-Lincoln, Lincoln, NE 68588, USA

2 College of Business Administration, Inha University, Incheon 22212, Korea

Associated Data

The data presented in this study are available on request from the corresponding author.

This study examines the importance of medical waste management activities for developing a sustainable green healthcare environment. This study applied a multiple methodological approach as follows. A thorough review of the literature was performed to delineate the factors that have been explored for reducing medical waste; hospital staff who handle medical waste were surveyed to obtain their opinions on these factors; the analytic hierarchy process (AHP) was applied to determine the priorities among the identified key factors; and experts’ opinions were consulted to assess the actual applicability of the results derived by the AHP. The study identified the following factors as the most important: medical waste management (26.6%), operational management issues (21.7%), training for medical waste management procedures (17.8%), raising awareness (17.5%), and environmental assessment (16.4%). This study analyzed the contributing factors to the generation of medical waste based on the data collected from medical staff and the AHP for developing a sustainable green healthcare environment. The study results provide theoretical and practical implications for implementing effective medical waste management toward a sustainable green healthcare environment.

1. Introduction

The impacts of the global COVID-19 pandemic on people’s daily life, the society, economy, and the environment involve trade-offs in many aspects. Technological innovations (e.g., rapid testing, tracking infected persons, online-based remote work and education, etc.) have been effective in preventing the spread of the pandemic. On the other hand, they also have drawbacks, such as waste treatment issues with the increased use of disposable products and inequalities due to social and digital divides. In particular, the increased volume of plastic waste due to COVID-19-related practices has significant ramifications that pose challenges with respect to ensuring a sustainable environment [ 1 , 2 ].

Penga et al. [ 3 ] predicted that 193 countries worldwide would generate an additional 8.4 million tons of plastic waste due to COVID-19-related activities, a 10% increase from the baseline since the World Health Organization (WHO) declared the disease a global pandemic in March 2020. Of the additional plastic waste generated during the pandemic, approximately 87.4% was discharged from healthcare institutions, including personal protective equipment (such as masks, sanitary gloves, and face shields), online packaging materials (due to increased online shopping), and virus test kits, accounting for 7.6%, 4.7%, and 0.3%, respectively. Geographically, waste generation was the highest in Asia (46.3%), followed by Europe (23.8%), South America (16.4%), Africa (7.9%), and North America (5.6%) [ 3 ]. In a simulation study of the dynamics of COVID-19-related plastic waste, Peng et al. [ 3 ] predicted that 3800 to 25,900 tons of debris have been released into the sea. With approximately 280 million confirmed COVID-19 cases at the end of 2021, the volume of medical waste is likely to be approximately 11 million tons, with about 34,000 tons being released into the sea [ 4 ].

In South Korea, medical waste generated due to COVID-19 is classified as “quarantine medical waste” according to the “Wastes Control Act” of 1999, and includes most items used by healthcare workers in COVID-19 treatment institutions, such as screening clinics [ 5 ]. With the rapidly increasing volume of medical waste during the pandemic, waste treatment facilities in South Korea have struggled despite operating at full capacity [ 5 ]. Furthermore, because massive amounts of medical waste are routinely incinerated, its environmental impact is not tomorrow’s problem, but an urgent current issue. In addition, the consequences of delays in collecting and/or disposing of medical waste could threaten the health of patients, guardians, healthcare workers in hospitals, and community residents. Therefore, joint efforts of healthcare providers and local communities are necessary to develop an environmentally sustainable healthcare system. As climate change, air pollution, plastic waste, and medical waste threaten human health and environmental sustainability, establishing an eco-friendly medical system can provide a better ecosystem and potentially offer long-term benefits to human health [ 2 , 6 ].

Considering infectious diseases caused by environmental pollution, there is an urgent need to develop a healthier ecosystem. Healthcare institutions generally use disposable products to minimize infection while treating patients. This strategy seems logical to prevent the spread of COVID-19. However, only 15% of all medical waste is considered “hazardous waste” which may be infectious or toxic, whereas 85% of the hospital-generated waste is general and non-hazardous waste, comprising food containers, packaging, and medical supplies (i.e., gloves and masks, among others) used in the screening process for patients without contagious diseases [ 6 , 7 ]. Different and more cost-effective approaches can be used to reduce medical waste from healthcare institutions, such as appropriately sorting the discharged waste and promoting the use of systems that employ high-temperature/pressure and chemical processes to sterilize medical equipment and materials. Great Ormond Street Hospital in London saved approximately USD 120,000 in expenses by eliminating 21 tons of plastic waste through training employees on the use of disposable plastic gloves [ 6 ].

Several initiatives and studies have investigated various aspects of medical waste, including the Medical Wastes Act [ 8 ]; treatment methods and the current status of waste management [ 9 , 10 , 11 , 12 , 13 , 14 ]; knowledge, attitudes, and practices of medical staff with respect to medical waste e.g., [ 1 , 15 , 16 ]; and COVID-19-related medical waste e.g., [ 3 , 6 , 17 ]. However, limited research is available on the sources of medical waste (e.g., healthcare institutions). Environmental protection and cost reduction through medical waste reduction depend on the activities and actions of related organizations and medical staff on the front lines of medical waste discharge. In addition, developing plans to initiate a change through healthcare workers can help establish a foundation for creating an eco-friendly healthcare environment.

The purpose of this study is to propose an operational plan for the effective management and treatment of medical waste generated in hospitals. Irrespective of how optimal a system or policy may be, an effective medical waste management program should address the following: (1) identify activities that can be implemented by employees who are generating medical waste; (2) determine the priority among these various activities; and (3) define the support needed at the organizational level to implement these activities.

To accomplish the study objectives, a thorough review was undertaken on relevant previous studies on the approaches and factors that were explored for reducing and managing medical waste. Second, to apply the AHP to determine the importance of the identified key factors, a survey of 16 hospital staff with more than 3 years of experience in handling medical waste was conducted to obtain their opinions on these factors for a pairwise analysis. Third, the AHP was applied to determine the priorities among the identified factors. Finally, three experts in medical waste management were interviewed to gain additional insights about the results of AHP and their actual application feasibilities. The study results can be used as a framework for developing a sustainable green healthcare ecosystem.

This paper is organized as follows. Section 2 reviews the relevant literature on medical waste and sustainable medical waste management. In Section 3 , research design is presented for identifying and assessing the importance of the key factors that contribute to the generation of medical waste. Section 4 provides the AHP results and the opinions of experts on application feasibility of the AHP results. Section 5 summarizes the results of the study, implications, limitations, and suggestions for future research.

2. Literature Review

2.1. medical waste.

Healthcare services enrich and prolong people’s lives through health promotion and disease prevention and treatment. However, healthcare services generate a large amount of medical waste in the process; 20% of such waste poses health risks, such as infection and exposure to hazardous chemicals or radiation [ 18 ].

The World Health Organization [ 19 ] provided the guidelines for medical waste management in its report “Safe management of waste from healthcare activities”. In these guidelines, the WHO defined healthcare waste as “all the waste generated by healthcare facilities, medical laboratories, and biomedical research facilities, as well as waste from minor or scattered sources”. ICRC [ 18 ] added that “medical waste covers all wastes produced in healthcare or diagnostic activities”. The United States Environmental Protection Agency (US EPA) [ 20 ] defined medical waste as “a subset of wastes generated at healthcare facilities, such as hospitals, physicians’ offices, dental practices, blood banks, and veterinary hospitals/clinics, as well as medical research facilities and laboratories”. In Article 2, No. 5, of the “Wastes Control Act” of South Korea, medical wastes are defined as “wastes discharged from public health and medical institutions, veterinary clinics, testing and inspection institutions, and other similar institutions, such as parts and extracts of human bodies and carcasses of laboratory animals, which may cause harm to human bodies by infection or otherwise and need to be specially controlled for public health and environmental conservation”. Although international agencies present diverse definitions of medical waste, their guidelines commonly include “waste generated from healthcare facilities” [ 18 , 19 , 20 ]. Hossain et al. [ 11 ] defined health care waste as “all types of waste produced in health facilities such as hospitals, health centers, and pharmaceutical shops”. In this study, medical waste refers to the waste generated during patient treatment processes (see Table 1 ).

Medical waste can be classified as hazardous or non-hazardous (general) waste. While non-hazardous medical waste does not pose a specific hazard, hazardous medical waste can cause diseases and environmental hazards [ 19 , 21 ]. The WHO [ 7 ] classifies medical waste into eight categories: ‘infectious waste, pathological waste, sharps waste, chemical waste, pharmaceutical waste, cytotoxic waste, radioactive waste, and non-hazardous or general waste’. As listed in Table 1 , although the definition of medical waste differs slightly between institutions and countries, its classifications and contents are similar. Table 1 provides a detailed summary of the separation and treatment of infectious medical waste by organizations, countries, and date.

Medical waste classifications and related details.

2.2. Medical Waste Management for a Sustainable Healthcare Environment

According to the WHO [ 7 ], 15% of all medical waste generated is hazardous. In high-income countries, 0.5 kg of hazardous medical waste is generated per hospital bed every day, whereas it is 0.2 kg in low-income countries. During the COVID-19 pandemic, medical waste generation has accelerated. According to the United Nations Environment Program [ 26 ], the volume of medical waste generated from medical facilities related to COVID-19 is 3.4 kg per person and approximately 2.5 kg per hospital bed each day worldwide. During the pandemic, China generated approximately 469 tons of medical waste per day [ 3 ]. Japan, India, and Indonesia generated 876, 608, and 290 tons per day, respectively [ 26 ], while South Korea generated 476 tons per day [ 27 ].

Hassan et al. [ 10 ] argued that medical waste problems are caused because of the lack of awareness and willingness on the part of healthcare employees and ambiguous policies and laws about proper management of medical waste. Hossain et al. [ 11 ] emphasized that inappropriate behavior of employees and improper disposal methods of medical waste in hospitals can increase serious health risks and environmental pollution due to the contagious nature of the waste. Therefore, healthcare institutions require an operational strategy to train stakeholders involved in medical waste generation to manage this critical problem.

Although previous research on medical waste management focused primarily on the treatment of hazardous waste, the emphasis has recently shifted to operational strategies on managing the disposal of all types of medical waste. The reason for this trend is that the safe handling and disposal of all medical waste is a key step to preventing potential hazards (disease or injury) and pollution of the environment [ 9 ]. Although the transmission of blood-borne viruses and respiratory and other infections through inappropriate medical waste disposal has yet to be explored completely [ 19 ], the potential risks to human health and the environmental issue are obviously high [ 15 ]. Thus, medical waste management is now regarded as a critical component of high-quality medical services [ 28 ]. This change is a result of reports which have demonstrated how environmental pollutants generated during waste treatment are threatening the in which we live ecosystem and human health. Penga et al. [ 3 ] claimed that over eight million tons of COVID-19-pandemic-related plastic waste had been generated globally, with more than 25,000 tons discharged into the sea. This could cause adverse long-term effects on the marine environment.

Windfeld and Brooks [ 8 ] suggested the need for a standardized classification method to educate medical workers in the efficient management of medical waste. Thakur et al. ([ 29 ], p. 357) presented six dimensions of medical waste management practices as ‘experience, relationship, environmental factors, technology and qualification, economic factors, and firm’s capabilities.’ Healthcare institutions should develop medical waste management plans which include the daily collection, processing, separation, and packaging of medical waste, as well as the implementation of regular monitoring and training programs [ 11 , 15 , 30 , 31 ]. The effective operation and maintenance of medical equipment and facilities can help prevent the frequent generation of medical waste. For example, the life cycle of medical equipment can be extended through proper maintenance. Therefore, the appropriate operation and maintenance require continuous management activities, such as personnel training and supply of appropriate materials and spare parts.

To create a sustainable medical environment through the reduction in and management of medical waste, an appropriate organizational culture must be developed, encouraging the participation of all stakeholders who partake in medical waste generation [ 1 ]. This also requires the involvement and cooperation of all stakeholders, including the various occupations/departments within the healthcare institution, as well as the collaboration of patients, guardians, subcontractors, and communities [ 32 ]. Healthcare institutions should develop an integrated approach for medical waste management [ 29 , 30 ]. Therefore, one specific department should not bear the complete responsibility for medical waste reduction; instead, these activities should be practiced by all hospital members throughout the course of their work. For instance, the department in charge of medical waste disposal should practice proper separation to prevent general waste from being included in medical waste. Healthcare departments should attempt to reduce emissions from infectious waste and single-use products. Through these general activities, healthcare institutions can reduce medical waste generation and related operating costs, thus developing a sustainable healthcare service environment.

2.3. Operational Strategies for Effective Medical Waste Management

A well-prepared action plan can reduce the amount of medical waste without decreasing the quality of medical services provided by healthcare workers. Kwikiriza et al. [ 16 ] emphasized that clinical staff need to be fully aware of their critical role in effective medical waste management, because they are the ones who sort the waste at the point of generation. They also suggested that non-clinical staff tend to have limited awareness and experience about the treatment, segregation, and/or knowledge of medical waste management. To implement appropriate measures or activities to reduce the generation of medical waste in their daily operations, healthcare providers should have accurate information about the volume of medical waste being generated by them. Reducing the volume of waste that requires treatment is an obvious approach to lower the cost of waste management and improve the operational efficiency of the organization. Efforts to identify and eliminate unnecessary waste generation sources can positively impact the efficacy of developing a sustainable healthcare ecosystem. Therefore, the efficiency of medical waste management can be improved through correct waste classification and sorting at the point of material use.

The Organization for Economic Co-operation and Development (OECD) introduced the sustainable materials management system, which promotes efficient resource management throughout the entire lifecycle of a resource based on existing waste-management-oriented policies [ 33 ]. The G7 Toyama Environment Ministers’ Meeting in 2016 introduced a resource efficiency policy for promoting the efficient use of resources for sustainable development [ 33 ]. To implement a resource recycling economy, Kim et al. [ 34 ] suggested the following approaches: (1) suppression of waste generation; (2) waste reuse; (3) promotion of waste recycling; (4) energy recovery; and (5) appropriate disposal. As these approaches imply, implementing the activities that can reduce medical waste should be focused on frontline healthcare workers. To identify in-hospital activities that can reduce medical waste generation, the flow of waste processing phases must first be examined. Table 2 shows the general flow of medical waste management implemented in healthcare institutions in South Korea, from the generation to the treatment process of medical waste.

Synopsis of the medical waste stream in Korean hospitals.

Source: ICRC [ 18 ].

As shown in Table 2 , after medicine and medical supplies are stocked in the purchasing department, goods are distributed at the request of each healthcare department. Medical waste is generated from this point onwards. For instance, medicine and medical supplies are purchased based on care departments’ needs for operations and patient treatment. These supplies become medical waste when they are used, disposed of, or their expiration dates are passed. Although expired medicine (i.e., drug ingredients) may be hazardous, medical supplies, such as syringes, surgical gloves, and gauze, are classified as general medical waste. However, even though such expired medical supplies, not in contact with patients, are considered general medical waste, they are often discharged as infectious medical waste or mixed with infectious medical waste for convenience, increasing the volume of generated infectious medical waste. Therefore, reducing unnecessary infectious medical waste is possible if healthcare workers, such as doctors and nurses, are aware of the value of proper waste classifications, separation processes, and emission reduction benefits for medical waste.

Johannessen et al. [ 30 ] suggested guidelines for evaluating and improving medical waste management based on the standard for >50-bed facilities and those with fewer than 50 beds with respect to the current medical service situation. The WHO [ 35 ], through its National Healthcare Waste Management Plan Guidance Manual, suggested a set of factors that should be considered prior to developing a medical waste management plan. The detailed contents of these factors can be summarized as follows. The medical industry and environmental protection are closely related [ 1 ]. For example, healthcare institutions that operate emergency and in-patient rooms emit greenhouse gases throughout the day. Medical waste is landfilled or incinerated, resulting in air pollutant emissions and water pollution due to landfill leaching, constantly raising concerns over environmental protection issues. Although hospitals are fully aware of the importance of medical waste management, they tend to assign the responsibility to a designated department. However, medical waste management cannot be achieved based solely on the role and efforts of the department in charge. Thus, medical waste management strategies should include operational standards and classification, as well as plans for potential waste disposal issues and operational implementation plans. Furthermore, relevant information about the effect of medical waste management on hospital operating costs should be disseminated to all organization members. In this perspective, medical waste treatment requires operational and management strategies.

Kwikiriza et al. [ 16 ] suggested that the incorrect use of personal protective equipment during the treatment/transport process of medical waste may cause infection risks as well as occupational hazard problems. Medical waste is often infectious; therefore, it must be stored safely for a certain period. Hossain et al. [ 11 ] indicated that although the safe handling and disposal of medical waste require a seamless process from the initial collection step to the final disposal stage, improper management practices are often prevalent. These problematic practices are caused by a lack of awareness, effective control, appropriate legislation, and specialized staff [ 11 , 16 ]. Thus, safety protocols should be established to continuously monitor the process to prevent leaks or other hazardous consequences.

The majority of medical waste can be classified as general waste; therefore, a classification policy or manual should be developed for implementation. Previous studies have provided convincing evidence that medical waste has a direct negative impact on the environment [ 9 , 10 , 16 ]. As such, every healthcare institution should endeavor to minimize environmental pollution by complying with the relevant policies and laws while providing a safe medical environment. In addition, because medical waste management involves social, legal, and financial issues, relevant authorities and associations should provide regular education to healthcare workers on new regulations, research findings, or new technologies [ 11 , 12 , 15 , 16 ]. Hospitals should provide education and training programs on the importance and impact of environmental management on organizational efficiency and community safety [ 31 ]. The prevention of possible problems that may arise in medical waste management is possible through effective training on the risks of erroneous waste classification and disposal, operational procedures, and responsibilities involved in medical waste management.

3. Methodology

3.1. analytic hierarchy process.

The analytic hierarchy process (AHP), a method developed by Saaty [ 36 ], is an effective decision-making tool for problems with multiple and conflicting evaluation factors and multiple alternatives solutions. In the AHP, after stratifying the evaluation factors for decision-making and reconstructing the primary factors into sub-items (secondary factors), the importance of each factor is determined through a pairwise comparison between factors prior to obtaining the final solution. The AHP approach is widely used because it allows flexible decision-making based on an intuitive perspective, including objective and subjective factors [ 37 ].

In this study, the AHP was applied because it is well suited to decision-making for medical waste management issues that involve complex and sometimes conflicting operational activities. The AHP is a subjective approach that focuses on a specific issue; therefore, the judgment of experts with practical experience is more appropriate than that of a large sample size [ 38 , 39 ]. Several previous studies used sample sizes between four and nine e.g., [ 40 , 41 ]. On the other hand, other researchers employed sample sizes greater than 30 [ 42 , 43 ]. In applying the AHP, the general suggested number of respondents ranges from 4 to 30. Medical waste occurs at the various medical service encounter points. Thus, in this study, we tried to involve personnel at many service encounter points, resulting in 30 participants.

3.2. Identification of Key Medical Waste Management Factors

To identify important factors in medical waste management and treatment processes in hospitals, this study analyzed the measures that can effectively reduce medical waste and develop a practical assessment method based on the input from managers of medical waste at tertiary healthcare institutions in South Korea.

A preliminary questionnaire was prepared to develop the measurement items that represent the operational and treatment activities of medical waste. As a pilot study, the questionnaire was distributed to staff who had sufficient experience in medical waste management activities in five Korean general hospitals. Based on the respondents’ suggestions, the measurement items were refined for clarity and accurate understanding. The identified measurement items of medical waste management for pairwise analysis are shown in Table 3 .

Measurement items for this study.

3.3. Data Acquisition Process

To ensure effective decision-making with the verified importance of factors by AHP, we executed several steps. First, the final questionnaire developed for pairwise comparison evaluations of measurement items used nine-point Likert scales to determine the importance of items [ 36 ]. Second, the AHP was applied to determine important factors for medical waste management. Third, three experts who were in charge of medical waste management in their hospitals were interviewed to discuss the AHP results and their practicality. In this paper, AHP was applied to perform the following: (1) simplification of the evaluation item structure, (2) comparison of evaluation results, and (3) presentation of operational efficiency measures through decision-making based on the evaluation results.

The ultimate goal of the application of AHP was to determine the priority of factors involved in medical waste management activities and treatment processes to secure a safe, waste-free environment. Figure 1 presents a schematic of the AHP framework employed in this study.

The analytic hierarchy process framework.

3.4. Data Collection

In this study, our survey respondents were restricted to healthcare workers with more than 3 years of experience in medical waste management activities (e.g., separating and disposing of wastes such as syringes, alcohol swabs, gloves, and general medical waste). Waste disposal workers at the hospital moved waste containers to a storage area first; then, they are transferred to an external treatment contractor.

For the AHP application, the survey was conducted during 10–25 January 2022, targeting 30 healthcare workers in hospitals with more than 500 beds. We received 23 responses (76.7%), although 7 were discarded due to incomplete items. Thus, the sample included 16 responses (69.6%). Table 4 presents the sample profile. Approximately 25.0% of respondents were from general wards, and the remaining 75.0% were from isolation wards, emergency rooms, intensive care units, and operating rooms in participating hospitals. The participants had knowledge related to medical waste at the following levels: high (50.0%), medium (37.5%), and low (12.5%). These results imply that the participants had a great deal of knowledge about medical waste. The proportion of respondents who participated in waste management training was high: 87.5%. The participants responded to the importance of medical waste management with the following activities (multiple responses): practice (100.0%), attitude (75.0%), and education training (25.0%).

Respondents’ demographic characteristics.

Total respondents: 16 (100.00%).

4.1. Consistency Test

To apply the AHP, a validity verification was first performed on survey items based on the consistency ratio (CR). Saaty [ 36 ] reported that a CR value of 0.1 or less is desirable, indicating that the probability of obtaining a logically impaired decision is less than 10%. When the CR value is ≤0.2, it indicates an acceptable range. In this study, the CR value was set to ≤0.2 based on the requirement of a pairwise comparison for each item [ 36 ]. The CR values for the five key items proposed in this study were all < 0.2; therefore, the criteria for decision-making in this study were satisfied. For the substitutability index, the opinions of respondents were not within the range of CR values due to the small sample size. A pairwise comparison matrix was analyzed using the geometric mean for the five factors that were considered most important in the management and treatment activities for reducing medical waste in healthcare institutions.

4.2. AHP Results

Table 5 shows the weights of five items and twenty detailed items used to prioritize important factors in managing medical waste based on the Expert Choice 2000 program. The results indicate that medical waste management (26.6%) is the most important factor for reducing medical waste generation, followed by operational management issues (21.7%), training for medical waste management procedures (17.8%), raising awareness (17.5%), and environmental assessment (16.4%). The interpretation of these analysis results is as follows.

Results of the pairwise comparison matrix.

First, medical waste management must be implemented safely with prescribed pro-cedures that should be executed by medical staff at contact points with medical waste to reduce its generation. The second priority factor to be considered is the operational issue of medical waste management (21.7%) such as standards and procedures. The third im-portant factor is training for medical waste management procedures (17.8%), indicating the need to provide a basic method easily accessible through education on medical waste management for healthcare workers or other organization members. Fourth is raising awareness (18.1%) about the impact of effective medical waste management. Reducing the volume of medical waste is only possible when the activities of the responsible depart-ments that generate waste are integrated into daily work activities, along with employee awareness of medical waste management. Finally, environmental assessments are neces-sary to understand the broad impact of medical waste on the medical environment.

First, medical waste management must be implemented safely with prescribed procedures that should be executed by medical staff at contact points with medical waste to reduce its generation. The second priority factor to be considered is the operational issue of medical waste management (21.7%) such as standards and procedures. The third important factor is training for medical waste management procedures (17.8%), indicating the need to provide a basic method easily accessible through education on medical waste management for healthcare workers or other organization members. Fourth is raising awareness (18.1%) about the impact of effective medical waste management. Reducing the volume of medical waste is only possible when the activities of the responsible departments that generate waste are integrated into daily work activities, along with employee awareness of medical waste management. Finally, environmental assessments are necessary to understand the broad impact of medical waste on the medical environment.

Table 5 also shows the results of the analysis on the local weights for each of the five evaluation items. Based on the analysis, for recognizing the importance of good healthcare waste management, raising awareness was the highest (31.8%), followed by setting up a waste management team with responsibility (25.7%), integration into daily operations (21.9%), and establishing a committee to develop a waste management plan (20.6%). These results indicate the importance of recognizing the significance of proper management and treatment activities for reducing medical waste generation.

For operational management issues, the items deemed important were in the following order: operational standards for medical waste items (35.2%), develop and implement a medical waste management plan (29.3%), medical waste management cost (23.1%), and plan for potential medical waste treatment problems (12.4%). The results show that the standards for medical waste management are most important among operational management issues. Thus, the establishment and execution of management plans are key factors.

For medical waste management, the following items were deemed most important: the safe storage of secure leak-proof and infectious medical waste (33.4%), policies or manuals on separation of medical waste by type (28.3%), simple-to-implement medical waste management for staff (including ancillary staff) (20.4%), and regular monitoring to ensure compliance with procedures (17.9%). Based on these analysis results, classification policies and manuals for each type of medical waste are imperative in medical waste management to reduce liability issues (criminal liability) after appropriate waste classification and disposal.

For environmental assessment, the important items were: a safe medical environment from medical waste (30.5%), environmental and health impact monitoring (29.3%), environmental management and training (22.7%), and policy, legal, and administrative frameworks (17.5%). Providing a safe medical environment is not only important for patients, but also for the members of the organization and local communities. From this perspective, a safe healthcare environment from medical waste was rated most important among the detailed items in the environmental evaluation. Infectious medical waste can cause secondary infections in hospitals, which might have also been reflected in the results. Regarding training for medical waste management procedures, the items deemed most important were: training on staff responsibilities and roles in managing medical waste (29.8%), training on waste separation operations (27.8%), education on the risks of incorrect medical waste management (23.5%), and technical training on the application of waste management practices (18.9%).

Organization members often do not have opportunities to interact with those in other departments. However, medical waste management is a special task which offers a shared goal for the benefit of all members of the organization. Thus, general education and training of all employees, in addition to those who are directly involved with the task, would be imperative to engage everyone in this effort.

Based on the analysis results for the 20 global evaluation items, there was no significant difference among the items. Safe storage of secure leak-proof and infectious medical waste (9.1%) was the highest, followed by simple-to-implement medical waste management for staff, including ancillary staff (8.7%), and operational standards for medical waste (8.4%).

4.3. Experts’ Opinions on the AHP Results

After the AHP results were obtained based on the responses of 16 medical workers in tertiary hospitals, we conducted interviews with experts in the related fields to derive additional insights from the study results. These interviews provided insiders’ perspectives on developing an effective implementation plan for medical waste management activities at the operational level. The different activity plans can also be delineated between the department in charge of waste management and supporting departments based on the experts’ ideas.

The three experts invited for the interview were selected among team leaders with more than 5 years of relevant work experience at tertiary hospitals in South Korea. Although each hospital has its own unique characteristics (e.g., operational structure, number of beds and employees, care units, etc.), there was no significant difference in their medical waste management programs among the hospitals of the 23 survey respondents. Some hospitals had their own dedicated medical waste management programs, whereas others had outsourcing arrangements with the municipal sanitation department. The hospitals that relied on the municipal sanitation program for waste management moved medical waste bins/boxes from each treatment room to medical waste storage areas. The collected medical waste was then transported and disposed of by contracted external firms. The departments in charge of medical waste management at these hospitals (e.g., general affairs or facilities departments) perform all necessary administrative procedures.

Table 6 summarizes the common problems, causes, and solutions suggested by the three experts. Based on both the AHP results and the experts’ opinions, medical waste management stood out as the first priority item. However, there was a difference in the second priority item. In the AHP results, the operational management issues item was rated as the second priority item. However, the experts rated training for medical waste management procedures item as the second priority. This may be due to differences in perspectives among managers (“provide education and training to staff to ensure proper sorting”) and staff involved in waste generation, handling, and sorting (“developing a manual for proper sorting of waste”). There was no significant difference among the priorities for the remaining items.

Expert opinions on the analytic hierarchy process (AHP) results.

5. Conclusions

With the increasing concerns regarding contagious and infectious diseases, due to climate change as well as resistance to medications and treatments, the effective management of medical waste has become a strategic priority for healthcare providers. Packaging materials for medical devices are a recyclable resource. Medical waste, mainly incinerated for disposal, requires an eco-friendly treatment method to conserve the environment. Furthermore, healthcare institutions should properly classify and sort general hospital and medical waste in practice. The use of eco-friendly and low-risk containers is a constructive step in the classification and collection processes for medical waste.

This study analyzed the contributing factors to medical waste generation based on the data collected from medical staff and AHP for developing a sustainable green healthcare environment. The analysis results indicated the following priorities for the five key factors: medical waste management was rated the highest (26.6%), followed by operational management issues (21.7%), training for medical waste management procedures (17.8%), raising awareness (17.5%), and environmental assessment (16.4%). The analysis of local weights of the five factors revealed the following items as the most important: raising awareness—recognizing the importance of good healthcare waste management (31.8%); operational management issues—operational standards for medical waste (35.2%); medical waste management—safe storage of secure leak-proof and infectious medical waste (33.4%); environmental assessment—a safe medical environmental from medical waste (30.5%); and training regarding medical waste management procedures—training on staff responsibilities and roles in managing medical waste (29.8%).

5.1. Theoretical and Practical Implications

The results of this study have several important implications. First, practical medical waste management is the most important step in management and treatment activities for reducing the generation of medical waste. Medical waste is typically generated in each treatment unit and staff can discard it in the containers provided [ 10 , 16 ]. However, general waste, which does not require the same treatment as medical waste, is often misplaced into medical waste containers. Approximately 85% of medical waste is from general operations; hence, some of this may be reused or recycled [ 44 ]. Therefore, hospitals should implement action campaigns based on evaluations of what items can be reused or recycled to reduce medical waste generation.

Second, healthcare organizations should pursue qualitative improvements in the treatment of diseases for patients. From this perspective, hospitals are generally known as institutions that consume a high volume of single-use plastic products to minimize infections [ 45 , 46 ]. Different medicines and medical supplies are used in each department; therefore, detailed instructions or manuals on the handling of waste should be provided to healthcare workers for proper sorting and disposal to reduce the volume of generated waste.

Third, because awareness and education on medical waste management are important factors [ 10 , 11 , 16 ], all members of the hospital should be encouraged to participate in education on the value of medical waste management, especially resource circulation through the proper collection and separation of waste they generate daily. In other words, the generation of medical waste must be reduced to the greatest possible extent, minimizing the impact on the environment by reusing/recovering waste and establishing an eco-friendly green environment. In addition, medicines and supplies are used or become medical waste when their expiration dates are passed. Thus, it is important to manage inventories to avoid valuable medical supplies to become waste after the expiration dates. One way to reduce medical waste would be to include an effective inventory management program in employee education and training courses.

Fourth, medical waste management is subject to strict treatment regulations such as the Medical Service Act and environmental laws. For example, because legal sanctions are imposed on disposing infectious medical waste as general waste, hospital employees must appropriately classify medical waste during the sorting stage to curtail waste generation.

Fifth, the AHP results and the opinions of the three experts indicated a slight difference in the priorities of the five key factors. Thus, healthcare organizations should provide support to front-line employees so that they can freely express their opinions and ideas for performing their medical waste management tasks that are most appropriate for each hospital.

Today, eco-friendly resource management has become important for creating a sustainable green enterprise due to increasing air pollution, climate change, and plastic waste that threaten human health. The global medical waste management market is expected to grow from USD 7.2 billion in 2020 to USD 12.8 billion by 2030 [ 47 ]. Thus, anticipating problems that may arise from medical waste generation would be important to all healthcare organizations. The results of this study provide new insights to developing strategic plans for treatment processes and activities to reduce waste.

The theoretical and practical contributions of this study can be summarized as follows. First, our study has broadened the topic and scope of medical waste management by analyzing the priority items that can significantly reduce medical waste generation, unlike previous studies which primarily focused on waste treatment methods. Second, our research method can be applied to other industries that are concerned about reducing waste generation or recycling resources. Finally, the evaluation items identified and analyzed in this study can also be applied to related industries that are struggling to manage waste. Medical waste management approaches may differ among healthcare providers due to their specific characteristics. This study identified and evaluated priority items (factors) that generate medical waste; therefore, the presented results can be used as useful data for developing strategies and policies for medical waste management.

5.2. Limitations and Future Research Directions

This study has several limitations. First, due to the small sample size (16), statistical verification for the substitutability index could not be performed. Second, although the amount of data required for AHP was appropriate, the fact that we received only 16 valid responses indicates the difficulties involved in the pairwise comparison for medical staff. Therefore, conducting additional surveys, including a pre-survey training session for respondents, would help collect objective and valid data. Furthermore, future studies should consider broadening the population base, as this study focused only on medical staff at the point of contact in generating medical waste. Third, due to a lack of previous studies on management and treatment activities for reducing medical waste produced by healthcare workers, the evaluation items were developed with a focus on items suggested in waste management research in general and the opinions of healthcare workers in handling medical waste. Future studies should consider the more in-depth development of priority items based on a survey of a broader population of medical personnel. Fourth, the causes and solutions of the medical waste problem were examined by comparing the AHP results with the opinions of three experts. However, because this study selected three experts randomly, it may be prudent to select more objective and representative experts in future studies. Fifth, this study focused on the strategies and activities to minimize medical waste; however, it did not explore other important issues related to medical waste management. For example, optimal economic efficiency and management of medical waste activities are critical topics that need to be researched to secure a sustainable healthcare environment. These are key future research areas of medical waste management. Lastly, because this study was conducted in South Korea, its global generalizability is limited. Therefore, future studies should perform comparisons by analyzing cases from more countries in varying degrees of healthcare services.

Funding Statement

This work was supported by INHA UNIVERSITY Research Grant (INHA-68945-1).

Author Contributions

All authors have conceptualization, writing the manuscript. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

The Unique Burial of a Child of Early Scythian Time at the Cemetery of Saryg-Bulun (Tuva)

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Pages:  379-406

In 1988, the Tuvan Archaeological Expedition (led by M. E. Kilunovskaya and V. A. Semenov) discovered a unique burial of the early Iron Age at Saryg-Bulun in Central Tuva. There are two burial mounds of the Aldy-Bel culture dated by 7th century BC. Within the barrows, which adjoined one another, forming a figure-of-eight, there were discovered 7 burials, from which a representative collection of artifacts was recovered. Burial 5 was the most unique, it was found in a coffin made of a larch trunk, with a tightly closed lid. Due to the preservative properties of larch and lack of air access, the coffin contained a well-preserved mummy of a child with an accompanying set of grave goods. The interred individual retained the skin on his face and had a leather headdress painted with red pigment and a coat, sewn from jerboa fur. The coat was belted with a leather belt with bronze ornaments and buckles. Besides that, a leather quiver with arrows with the shafts decorated with painted ornaments, fully preserved battle pick and a bow were buried in the coffin. Unexpectedly, the full-genomic analysis, showed that the individual was female. This fact opens a new aspect in the study of the social history of the Scythian society and perhaps brings us back to the myth of the Amazons, discussed by Herodotus. Of course, this discovery is unique in its preservation for the Scythian culture of Tuva and requires careful study and conservation.

Keywords: Tuva, Early Iron Age, early Scythian period, Aldy-Bel culture, barrow, burial in the coffin, mummy, full genome sequencing, aDNA

Information about authors: Marina Kilunovskaya (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Vladimir Semenov (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Varvara Busova  (Moscow, Russian Federation).  (Saint Petersburg, Russian Federation). Institute for the History of Material Culture of the Russian Academy of Sciences.  Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail:  [email protected] Kharis Mustafin  (Moscow, Russian Federation). Candidate of Technical Sciences. Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected] Irina Alborova  (Moscow, Russian Federation). Candidate of Biological Sciences. Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected] Alina Matzvai  (Moscow, Russian Federation). Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected]

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Out of the Centre

Savvino-storozhevsky monastery and museum.

Zvenigorod's most famous sight is the Savvino-Storozhevsky Monastery, which was founded in 1398 by the monk Savva from the Troitse-Sergieva Lavra, at the invitation and with the support of Prince Yury Dmitrievich of Zvenigorod. Savva was later canonised as St Sabbas (Savva) of Storozhev. The monastery late flourished under the reign of Tsar Alexis, who chose the monastery as his family church and often went on pilgrimage there and made lots of donations to it. Most of the monastery’s buildings date from this time. The monastery is heavily fortified with thick walls and six towers, the most impressive of which is the Krasny Tower which also serves as the eastern entrance. The monastery was closed in 1918 and only reopened in 1995. In 1998 Patriarch Alexius II took part in a service to return the relics of St Sabbas to the monastery. Today the monastery has the status of a stauropegic monastery, which is second in status to a lavra. In addition to being a working monastery, it also holds the Zvenigorod Historical, Architectural and Art Museum.

Belfry and Neighbouring Churches

Located near the main entrance is the monastery's belfry which is perhaps the calling card of the monastery due to its uniqueness. It was built in the 1650s and the St Sergius of Radonezh’s Church was opened on the middle tier in the mid-17th century, although it was originally dedicated to the Trinity. The belfry's 35-tonne Great Bladgovestny Bell fell in 1941 and was only restored and returned in 2003. Attached to the belfry is a large refectory and the Transfiguration Church, both of which were built on the orders of Tsar Alexis in the 1650s.  

To the left of the belfry is another, smaller, refectory which is attached to the Trinity Gate-Church, which was also constructed in the 1650s on the orders of Tsar Alexis who made it his own family church. The church is elaborately decorated with colourful trims and underneath the archway is a beautiful 19th century fresco.

Nativity of Virgin Mary Cathedral

The Nativity of Virgin Mary Cathedral is the oldest building in the monastery and among the oldest buildings in the Moscow Region. It was built between 1404 and 1405 during the lifetime of St Sabbas and using the funds of Prince Yury of Zvenigorod. The white-stone cathedral is a standard four-pillar design with a single golden dome. After the death of St Sabbas he was interred in the cathedral and a new altar dedicated to him was added.

Under the reign of Tsar Alexis the cathedral was decorated with frescoes by Stepan Ryazanets, some of which remain today. Tsar Alexis also presented the cathedral with a five-tier iconostasis, the top row of icons have been preserved.

Tsaritsa's Chambers

The Nativity of Virgin Mary Cathedral is located between the Tsaritsa's Chambers of the left and the Palace of Tsar Alexis on the right. The Tsaritsa's Chambers were built in the mid-17th century for the wife of Tsar Alexey - Tsaritsa Maria Ilinichna Miloskavskaya. The design of the building is influenced by the ancient Russian architectural style. Is prettier than the Tsar's chambers opposite, being red in colour with elaborately decorated window frames and entrance.

At present the Tsaritsa's Chambers houses the Zvenigorod Historical, Architectural and Art Museum. Among its displays is an accurate recreation of the interior of a noble lady's chambers including furniture, decorations and a decorated tiled oven, and an exhibition on the history of Zvenigorod and the monastery.

Palace of Tsar Alexis

The Palace of Tsar Alexis was built in the 1650s and is now one of the best surviving examples of non-religious architecture of that era. It was built especially for Tsar Alexis who often visited the monastery on religious pilgrimages. Its most striking feature is its pretty row of nine chimney spouts which resemble towers.

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