Hospital Waste Management 2005-05-25

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Survey Report

Hospital Waste Management in Dhaka City

Executive Summary

Hospital wastes are highly infectious and hazardous. They may carry the germs of

dreadful diseases like hepatitis B and C (jaundice), and HIV/AIDS. The present

practice of improper handling of generated hospital wastes in Dhaka city is playing a

contributing role in spreading out the Hepatitis and HIV diseases. Hospital waste

accounts for a very small fraction of the total waste generated in a city. Mixed with

the ordinary waste, they make the entire municipal solid waste stream a great public

health hazard. The liquid and solid wastes containing hazardous materials are simplydumped into the nearest drain or garbage heap respectively where they are prone to

contaminate the rag-pickers that sift through the garbage dumps. The prevalence of

diseases that may be transmitted by hospital waste is alarming in Bangladesh.

Hospitals and other Health Care Establishments (HCE) have a duty of care for the

environment and for public health, and have particular responsibilities in relation to

the waste they produce. The responsibility is on such establishments to ensure that

there are no adverse health and environmental consequences of their waste handling,

treatment, and disposal activities.

Considering the experience of PRISM Bangladesh for successful Hospital Waste

Management (HWM) in Khulna, the World Health Organization (WHO) and the

Water and Sanitation Program (WSP) initiated a Hospital waste Management

Programme (HWMP) for Dhaka City under the WHO guidelines. A Memorandum of

Understanding (MOU) has signed between WHO and PRISM Bangladesh to prepare

a design of HWM in Dhaka city.

Providing orientation and training participating hospital staff on good practices of

HWM is an aim of this project. The project explores the amount of solid wastes

generated by each HCE; investigates the handling practice of waste within the

hospital premises; identifies storage, collection, transportation and disposal practices;

and assesses the needs of training for hospital waste management. Some 59 HCE from

Ward 49 of the Dhaka City Corporation (DCC) and the Dhaka Medical College

Hospital (DMCH) in Ward 56 and Samorita Hospital in Ward 51 were selected for

this pilot project.

The methodology for this project included empirical field observation and field level

data collection through inventory, questionnaire survey and interviews with formal

and non-formal ways. The relevant secondary data for this project were mainly

collected from the published and unpublished sources. The data were analyzed to

address the central issues of hospital waste management with relation to the

Survey Report on HMW in Dhaka City PRISM Bangladesh1


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generation of wastes in different sources. Statistical and spatial techniques apart from

the qualitative modes of analyses were also deployed for this purpose.

The survey reveals the existing scenario of different types of clinical wastes along

side the domestic wastes. The collected field data showed that all the surveyed HCE

generate pathological wastes, used syringes, broken bottles and glass, textile stained

with blood and papers. They generate about 6.4 tons/day (6392 kg/day) of wastes, of

which only about 5.2 tons/day (80.77%) are non-infectious wastes and about 1.2

tons/day (19.23%) are infectious wastes. The average waste generation rate for the

surveyed HCE is 2.63 kg:bed/day. The DMCH alone generates more than half (58%)

of the total wastes generated in the surveyed HCE. The DMCH itself generates about

2976 kg/day (46.55%) of non-infectious waste and 733 kg/day (11.46%) of infectious

waste.

The study reveals that there is no proper and systematic management of this waste

except a few private HCE that segregate their infectious wastes. All the HCEsurveyed dispose of their domestic waste at the same site as the civic waste. Some

cleaners were found to be engaged to mishandle the generated wastes. They

segregated the used sharps instruments (mainly the syringe-needles), saline bags,

blood bags and test tubes from the kitchen and non-hazardous wastes for sale (resale)

or reuse.

The level of awareness on medical waste among the waste handlers is not good

enough to manage the waste systematically; while the nurses and staffs are aware

about the health impact of medical wastes. The survey also reveals that the concerned

staffs need to take practical training rather than the traditional theoretical training tohandle the waste. About two-third of the total respondents did not get any training on

waste management, while the rest of the one-third respondents got their training on

this issue but they are not able to manage the waste systematically since their are

lacking of systems, rules and regulations.

The report reveals the overall situation of waste management in different HCE in

Dhaka. All the surveyed HCE dispose of their domestic waste at the same site as the

civic waste. Some cleaners are engaged to mishandle the generated wastes. They

segregated the used sharps instruments (mainly the syringe-needles), saline bags,

blood bags and test tubes from the kitchen and non-hazardous wastes for sale (resale)or reuse. To improve the waste management system, it needs to formulate rules and

regulations, develop systems, and financial support. The HCE do not have any

budgetary provision to manage their generated waste systematically.

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Chapter I

Introduction

1.1 General Background

The problem of hospital waste disposal and other toxic hazardous wastes is growing

rapidly throughout the world as a direct result of rapid urbanisation and population

growth. Hospital waste or clinical waste, which poses serious threats to environmental

health, requires specialized treatment and management prior to its final disposal.

Simply disposing it into dustbins, drains, and canals or finally dumping it to the

outskirts of the city poses a serious public health hazard. Such disregard for protecting

public health occurs due to lack of awareness, skill of the people and institutions

engaged in hospital waste generation and disposal as well as due to lack of treatment

facilities and system in the city. The problem is getting worse with the increasing

number of hospitals, clinics, and diagnostic laboratories in the city.

The rapid increase of hospitals, clinics, diagnostic laboratories etc in Dhaka city

exerts a tremendous impact on human health ecology. More than 600 clinics and

hospitals exist in the DCC. These facilities generate an estimated 200 tons of waste a

day (Lawson, 2003). Only a few have the necessary means to dispose the wastesafely. It is reported that even body parts are dumped on the streets by these HCE.

The present practice of improper handling of generated hospital wastes in Dhaka city

is playing a contributing role in spreading out the Hepatitis and HIV diseases. The

liquid and solid wastes containing hazardous materials are simply dumped into the

nearest drain or garbage heap respectively where they are prone to contaminate the

rag-pickers that sift through the garbage dumps. The chances of infection are very

high to the cleaners, concerned people in the HCE and to the general population. The

improvement of waste management for the HCE in Bangladesh will have significant

long-term impact on keeping the spread of infectious diseases to a minimum and

result in a cleaner and healthy environment.

Unlike the ordinary household waste, medical wastes are highly infectious and

hazardous. They may carry germs of dreadful diseases like hepatitis B, C and

HIV/AIDS. Mixing with the household wastes, they make the entire pile a great

public health hazard. To make the matter worse, poor scavengers (tokai) rummage

through the pile, earnestly searching for saleable items like syringes. These are

collected, washed, repacked and resold to the public. Thus, the vicious cycle of

transmission continues.



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The prevalence of diseases that may be transmitted by hospital wastes is alarming in

Bangladesh. There is evidence of hepatitis B infection among 10 percent of children

(5-10 age group) and 30 percent adults. About 5 per cent of the total population in

Bangladesh is thought to suffer from chronic hepatitis B infection. Although cases of

HIV/AIDS is low in Bangladesh (about 13,000 cases estimated in 2001) incomparison to neighbouring countries, nevertheless the numbers are rising (Waste

Concern, 2003). It is noted here that much of the clinical wastes (e.g. syringes,

needles, saline drips, discarded food, gauze, vials, and ampoules) are collected by

women and children who re-sell it despite of the deadly health risks.

It is estimated that hospital wastes account for a very small fraction, notably, only

about 1 percent of the total solid wastes generated in Bangladesh. In a report from the

World Bank (2003), only 10-25 percent of the hospital wastes are infectious or

hazardous. The amount of such hazardous waste is quite small in figure and until

recently this is not handled properly (WHO, 2001). Mixing with the domestic solid

wastes, the total waste steam becomes potentially hazardous.

1.2 Project Background

1.2.1 Genesis of the project

In 1997, the Water and Sanitation Programme (WSP) with financial assistance from

the Swiss Development Corporation (SDC) launched a community based Solid WasteManagement Project (SWMP) in Khulna City. The project was locally implemented

by Prodipan, a national NGO in collaboration with the local communities, Khulna

City Corporation (KCC) and local NGOs. Under this project, a house-to-house

garbage collection system ran by the local communities and NGOs, and the KCC

provided the transport services in collecting waste from the KCC bins for final

disposal at certain places.

In conducting the above work, the project workers noticed the presence of hospital

wastes on the streets and into dustbins. The WSP and Prodipan took the matter

seriously and discussed it with the KCC. The KCC then arranged a dialogue with the

Bangladesh Medical Association (BMA), the Clinics Owners Association, and some

progressive doctors in Khulna City. A number of workshops, seminars and roundtable

discussions were held for building up of consensus. All the concerned parties finally

agreed to participate in the programme and there were a disagreement in payment of

service charge. The Mayor of the KCC then came forward and explained the necessity

of the programme to protect public health. The concerned hospitals, clinics, and

pathological laboratories then agreed to pay service charge in accordance with the

volume of waste they generated. Therefore, the HWMP was launched in Khulna in

2000 with the participation of 20 private clinics, hospitals and pathological

laboratories.



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1.2.2 PRISM Intervention

After completion of the project in December 2001 by Prodipan, PRISM Bangladesh

came forward to continue the project from 2002 under a community based urban

waste water treatment project with wider purposes. The project was then run under the

Sustainable Environment Management Programme (SEMP) of Ministry of

Environment and Forest (MOEF) with the financial assistance of the UNDP. The

project is now providing all health care facilities within the Khulna city area. The

number of participating HCE facilities has increased from 20 to 46 including the

Khulna Sadar Hospital. Each of the HCE provides a monthly service charge between

Tk 100.00 and Tk 600.00 depending on the volume of wastes they generate.

Considering the experience of successful Hospital Waste Management (HWM) in

Khulna, PRISM extended its support to make city wide coverage under the SEMP.

The activities of HWM in Khulna were presented to the WHO and the WSP and theyfelt the emergent need to initiate a HWMP for Dhaka City what would be accepted

under the WHO guidelines. A Memorandum of Understanding (MOU) has signed

between WHO and PRISM Bangladesh to prepare a design of hospital waste

management in Dhaka city.

1.3 Aims and Objectives

To conduct a baseline survey of all health care facilities in Ward 49, the DMCH inWard 56, and Samorita Hospital in Ward 51. Providing the orientation and train-up

participating hospital staff on good practices of hospital waste management is an aim

of this project. These are the initial activities of the pilot project on HWM in Dhaka

city. The main objectives of the project are:

(a) To make an inventory of HCE in terms of government hospitals, privatehospitals, private clinics, and pathological diagnostic centres in Dhaka

city, specifically in Wards 49 and 56 (mainly the DMCH);

(b) To quantify the amount of solid wastes generated by each HCE;(c) To identify the current solid waste handling practice (e.g. storage,

collection, transportation and disposal) within the hospital premises;

(d) To assess the needs of training for hospital waste management; and(e) To suggest remedial measures for better management of medical wastes in

the surveyed hospitals.



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1.4 Project Site

A joint team comprising of WHO, Water and sanitation Programme (WSP) and

PRISM Bangladesh organized a series of meetings with the authorities of DCC, Clinic

Owners Association and other stakeholders to initiate a hospital waste management

programme. Considering the present demand, DCC allocated one acre of land at

Matuail dumpsite to install a treatment plant. It was decided to initiate the

management service for wards 49 and 56 and on review of success of the program, the

hospital waste of other wards will be managed under this project.

It is noted here that before the agreement of the project, the DCC provided us with the

information about the location of DMCH in Ward 57. During our field survey and

GIS mapping, we investigated the DMCH is in ward 56. Since our target is to

investigate the DMCH in order to fulfill the objectives, with the consultation of the

WSP, we are agreed to use Ward 56 in place of Ward 57.

The clinic owners association also agreed upon to participate in this hospital waste

management programme. A series of meetings have been organized by the team

(WHO, WSP and PRISM) with the clinic owners association and finally they assured

us to collaborate with the initiatives of hospital waste management on every aspect

(Figure 1.1).

Dhanmondi, once was a residential area given permission for the commercial

establishment by the RAJUK (Rajdhani Unnayan Katripakkha) is found to increasing

hospitals, clinics and diagnostic centres creating threats to human health and

environment. Many poor children and people salvage saline bottles and bags from the



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pedestrian area have been indiscriminately dumped by hospitals. Reports claim that

Dhanmondi, Ward 49 is badly affecting with the clinical waste and the DMCH in

Ward 56 and Samorita Hospital in Ward 51 were selected for this project. It is also

noted here that Dhanmondi is densely populated and the number of HCE in

Dhanmondi is also highest in any Ward in Dhaka City. The DMCH is the biggest inBangladesh and the lion share of the wastes are generated from the DMCH.

Therefore, Dhanmondi and the DMCH were selected to investigate the situation of

generating clinical waste and the existing management.

1.5 Concluding Remarks

This chapter has mainly focussed on the basic issues about medical waste and its

impact on human health, aims and objectives, and the sample project site. Medicalwaste and its problem are growing rapidly as a direct result of rapid urbanisation and

population growth. Medical waste poses serious threats to environmental health,

requires specialized treatment and management prior to its final disposal. The

problem is getting worse with the increasing number of hospitals, clinics, and

diagnostic laboratories in the city.

The present practice of handling of generated hospital wastes in Dhaka city is playing

a contributing role in spreading out the Hepatitis and HIV diseases. The improvement

of waste management for the HCE in Bangladesh will have significant long-term

impact on keeping the spread of infectious diseases to a minimum and result in a

cleaner and healthy environment.

*****



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Chapter II

Review of Literature and Research Gap


With the recent rapid growth of private health sector, the need of safe and proper

medical waste disposal is becoming important. Hospital waste is frequently described

to be an environmental pollutant as well as presenting a serious health concern. The

problem arises if the unsafe disposal of hospital wastes resulting in hepatitis B and C

(jaundice), and HIV/AIDS. The materials presented in this chapter are aimed at

providing an overview of medical waste issues in terms of medical waste types, itssources, and management. Finally, the last section makes some concluding remarks

on the overall chapter.

2.2 Relevant Literature

Generally, hospital waste is defined as the discarded or unwanted material or garbage

or solid waste which is generated from the diagnosis, treatment, or immunization of

human beings or animals, in research pertaining thereto, or in the production or

testing of biologicals (Lee, 1989). These have the potential to cause disease and are a

health risk. It is a by-product of health care that includes sharps, non-sharps, blood,

body parts, chemicals, pharmaceuticals, medical devices and radioactive materials

(WHO, 2002). The HCE are one of the major producers of solid wastes which are

hazardous in nature. Poor management of clinical wastes exposes health workers,

waste handlers and the community to infections, toxic effects and injuries (Ecoaccess,

2004).

2.2.1 Medical Waste Types and Sources

Medical wastes are mainly categorised into non-hazardous and hazardous wastes

(Figure 2.1). The non-hazardous waste includes wool, kitchen wastes, etc. that do not

pose any special handling problem, hazard to health or the environment and is

generated in the patients ward areas, out-patient-department (OPD), kitchens, offices,

etc (Mato and Kaseva, 1999). The hazardous waste includes pathological, infectious,

sharps and chemical wastes and are normally produced in labour wards, operation

theatres, laboratories, etc (Mato and Kaseva, 1999; Or and Akgill, 1994). Some



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definitions of hazardous wastes are (Henry and Heinke, 1996; Mato and Kaseva,

1999):

(a) Pathological wastesconsist mainly of tissues, organs, placentas, blood, etc.(b) Infectious wastescontain pathogens in sufficient concentrations or quantity

that, when exposed to it, can result in diseases. Examples are, waste from

surgeries with infectious diseases, contaminated plastic items, etc.

(c) Sharpsinclude needles, syringes, broken glass, blades and any other itemsthat could cause a cut or puncture.

(d) Chemical wastes comprise of expired medicine, discarded chemicals -usually from cleaning and disinfecting activities.

The characteristics of waste from hospitals are almost similar in all countries except

for amounts generated due to standard procedures executed in the medical field.

Legislation on the safe disposal of medical wastes may vary from country to another

(Henry and Heinke, 1996).

There are a number of literatures on the types of medical wastes and its generation,

mainly the sources of the wastes in HCE. Askarian et al, (2004) explain the type and

nature of hospital wastes generated from private hospitals in Fars province in Iran and

also describe the existing management systems of the generated wastes in hospitals.

Da Silva et al, (2004) focused on types of medical wastes from the hospitals in RioGrande do Sul of Brazil and illustrated the waste management pattern. Surveying a

total of 91 healthcare facilities, they provide information about the management,

segregation, generation, storage and disposal of medical wastes. The results about

management aspects indicate that practices in most healthcare facilities do not comply

with the principles stated in Brazilian legislation.



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2.2.2 Medical Waste Management

Mato and Kassenga (1997) pointed out the problems of management of medical solid

wastes in Tanzania. They also described different measures for the management of

medical wastes. Mato and Kaseva (1999) in their paper on Critical review ofindustrial and medical waste practices in Dar es Salaam City focused on the disposal

of both the industrial and medical waste practices in Tanzania. There is a serious

inadequacy in handling medical solid wastes in Dar es Salaam of Tanzania and

improper waste deposition is increasingly becoming a potential public health risk and

an environmental burden in Tanzania.

It has long been known that the re-use of syringes can cause the spread of infections

such as HIV and hepatitis. Tamplin et al, (2004) in their Issues and options for the

safe destruction and disposal of used injection materials showed from their study inthe developing countries that contaminated medical wastes find their way into

municipal garbage poses obvious health risks, both in terms of direct exposure and

environmental contamination. Their study suggests that holistic approaches to syringe

use and clinical waste disposal need to be utilized in addressing the situation outlined.

The clinical waste may also damage the environment. The collection of disposable

medical equipment (particularly syringes), its re-sale and potential re-use without

sterilization could cause an important burden of disease (WHO, 2002).

Medical waste management is the focal issue to minimize the health risk developedfrom HCE. Patil and Pokhrel (2004) described the biomedical solid waste

management in an Indian hospital. They assessed the waste handling and treatment

system of hospital bio-medical solid waste and its mandatory compliance with

Regulatory Notifications for Bio-medical Waste (Management and Handling) Rules,

1998, under the Ministry of Environment and Forestry, Govt. of India. They quantify

the amount of non-infectious and infectious waste (ratio 5:1) generated in different

wards/sections (about 2.31 kg per day per bed, gross weight comprising both

infectious and noninfectious waste). They also focus their opinion in favour of

incineration. Karademir (2004) provides a report on the health risk assessment of

PCDD/F emissions from a hazardous and medical waste incinerator in Turkey.

A few literatures focus on environmentally sound management of bio-medical and

health-care waste. The WHO (2002) mainly focused on six different steps for the

development of a healthcare waste management plan: (a) designate a responsible

person; (b) conduct an HCWM survey and invite suggestions; (c) recommend HCWM

improvements and prepare a set of arrangements for their implementation; (d) draft

the HCWM plan; (e) approve the HCWM plan and start implementation; and (f)

review the HCWM plan. The UNEP (2003) formulates some technical guidelines on

the environmentally sound management of bio-medical and health-care waste.



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2.2.3 Medical waste and Bangladesh issue

The pattern of storage and disposal of these wastes is to be a serious environmental

threat in Dhaka. There has been a few project works on the medical waste issues in

Bangladesh with the financial assistance of different donor agencies and stakeholders.

PRISM Bangladesh is continuing their activities on medical waste management in

Khulna City starting from 2000.

The Initiative for Peoples Development (IPD) conducted a project on the medical

waste management action plan in Dhaka city started on 2000 funded by the UNDP

through the Project management Unit (PMU). The IPD surveyed 24 clinics through a

questionnaire method. They provided training for awareness campaigning. They

developed handouts regarding the waste and its management for the nurses, waste

handlers, ward boys, and so on. The project lasted for about eight months and finished

in 2001.

The Local Initiative Facility for the Urban Environment (LIFE) carried out a project

on In-house Hospital waste management in aiming the waste management of 11

clinics in Dhaka City with the financial assistance of the UNDP released by the global

sources. The project started on 2002 and finished by 2003. It is noted here that the

project ran with the collaboration of the IPD. After a short break due to the financial

constraints, the UNDP agreed to provide funds through its global financial sources to

run the project from 2004. The project is still running at the Mohammadpur and

Lalmatia area.

In 1997, the BCAS in collaboration with Asia Foundation undertook a study on

Hospital Environmental Management with the aiming of investigation and

improvement of safe handling and disposal of hospital waste in the country (BCAS,

1997). The study reveals the unhygienic waste disposal systems as it is being disposed

in the DCC dustbin and formulates some measures for safe handling and disposal of

hospital waste. The BCAS in the following year (1998) produced a report on

Hospital Environment Management in Dhaka to create awareness among the

professional and workers working in the hospitals and clinics in order to improve the

hospital management as well as urban environment.

In 2003, the World Bank produced a report on Health Facility Waste management

Study in Bangladesh where the report focussed on the present status of health care

facility waste management in Bangladesh for the informed decision-making process

regarding appropriate future legislation, policies and programme activities that will

significantly improve the present situation. The study also assessed in details the

existing legislation, especially, the Bangladesh Environmental Conservative Act,

1995, and the Environment Conservation Rules, 1997.

The recent progress report on Clean Dhaka Master Plan conducted by the Japan

International Cooperation Agency (JICA) explains about the management pattern of



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solid waste in Dhaka City (JICA, 2004). The JICA study team focuses the problems

of handling and mismanagement of existing system of solid waste transportation and

dumping. In addition, they formulate a master plan regarding the solid waste

management in Dhaka City with the target year of 2015 covering (a) collection,

transportation, disposal and final disposal of solid wastes; (b) administrationorganization, institutional building, and public participation; and (c) planning of

facility and material maintenance, maintenance management, and financial

management.

BRAC (2004) conducted a pilot project work between January 2004 and August 2004

on medical waste management. They mainly focused on the Dhaka Shishu Hospital,

Institute of Child Health, and one upgraded BRAC SUSHASTO KENDRA (a medical

centre). They are now trying to replicate their activities regarding to this issue.

MOHFW (2004) produced an action plan for improved health care waste management

in Bangladesh for the period of 2004-2010. The action plan focuses mainly to initiate

a concentrated effort to improve the health care waste management to reduce the

negative impact of waste on: (a) environment; (b) public health; and (c) safety at

health care facilities.

HLSP, a consulting farm is working on the medical waste issues under the guidance

of Hospital Improvement Initiative. The project has been continuing since January

2000. It is noted here that although the project would finish by December 2003, but it

is still running for implementing the policies for proper medical waste management.

They are working in Chittagong Medical College Hospital and the Sylhet MedicalCollege Hospital along with other 11 Government hospital in both the Chittagong and

Sylhet divisions.

Unfortunately, there is a little effort in properly disposing hospital waste in

Bangladesh. Hospital waste is generally disposed of in the same way as ordinary

domestic wastes. The Khulna City, however, is an exception to this practice. Khulna

stands apart as the only city in the country with a Hospital Waste Management

Programme (HWMP) running for over three years.


This chapter is inspired by the current scientific interest in medical waste poisoning

on environmental risk, adverse health and public policy in Bangladesh. This chapter

has explored the literature on medical waste issues in different aspects, which have

provided insights into the nature of the existing pattern of medical waste research. In

reviewing the literature, it has been found a research-focus on medical waste in the

form of health problems at different levels of hepatitis B and C (jaundice), and

HIV/AIDS, but little research on the proper management of medical waste to save

urban environment.



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There has been an increasing interest in medical waste research over the last few

years. Many empirical studies have been undertaken to explore the sources of wastes,

their types and management and these provide a framework for discussing mainly the

toxic nature of medical waste, its impact on human health and medical waste

management system.

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Chapter III

Data and Methods


The methodology for this project includes empirical field observation and field level

data collection through inventory, questionnaire survey and interviews in formal and

non-formal ways. The relevant secondary data for this project were mainly collected

from the published and unpublished sources. The data were analyzed to address the

central issues of hospital waste management with relation to the generation of wastes

in different sources. In order to fulfil the aims and objectives, the project tasks were

structured as data collection and data analysis (Figure 3.1).

3.2 Field Survey Design

The field survey for this project was based on the aims and objectives. The

investigation of medical wastes employed multiple methods. This strategy provided a

mix of both quantitative and qualitative data, with the extensive questionnaire survey

providing breadth of coverage, while the interviews with nurses in hospitals and in-

depth interviews with different respondents allow a greater depth of understanding of

the waste management system within each hospitals and clinics as well as humanresponses to it. The design was composed mainly of qualitative and quantitative data

collection procedures and manipulation, data analysis and interpretation. A GIS-based

analysis was also deployed for this output.

3.3 Data collection planning

A number of formal and informal approaches were adopted in order to gather data.

Before entering into hospitals or clinics the project authority arranged a number offormal meetings with the concerned authority of each hospital, clinics, and diagnostic

centres. After getting a green signal from different HCE, we started our fieldwork,

which first began from DMCH. Before starting our fieldwork, we had an idea that it

could be a difficult job to collect information from the DMCH. A series of talks with

the Director of the DMCH started to melt the ice and this helped us to gather

information smoothly.

During our data collection phase in DMCH, each day we would spend our time with

Ward Master of DMCH for building up a rapport. This broke the ice and conversation

often turned to matters of relevance and importance for the project. Again we learned



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a lot from these encounters and found generally that we could understand much of the

background of the DMCH concerning to the waste generation and management. In

collecting our data questionnaire survey and in-depth interviews were adopted. Apart

from this, the dialectic approach was used to confirm the credibility of stories and

examine the cross-case themes (Brown and Gilligan, 1992) that we gathered fromin-depth interviews.



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3.4 Mapping

In order to facilitate the use of spatial information in a GIS, various geographically

referenced maps were used to prepare our base map for Wards 49 and 56. Besides

plotting the HCE locations and visualising different map features, a base map with

detailed information was essential. The base map was mainly collected from the

Department of Land Records and Survey (DLRS) of Bangladesh (RF 1:792). The

DLRS is the only government organisation having the authorisation to prepare and

sell maps. Since the project covers a whole Administrative Ward (WD 49) and part of

Ward 56 (showing the location of DMCH), we needed to collect the relevant maps

from the DLRS. It is mentioned here that GIS mapping would be of great help in

spatial decision-making planning for waste management.

In addition, the Ward Maps from the DCC were also collected as JPEG format. Since

these maps were unable to use properly, we collected the relevant maps from theDLRS and inserted them into a GIS digital format. All the features in terms of roads,

lakes, settlement areas, infrastructures etc; and some socio-economic characteristics

were collected from other map sources. The collected map information were

categorised into different point, line and polygon layers and finally appended on to the

main coverage in developing a complete base map for this project.

3.5 Selection of Enumerators and Training

Before conducting the questionnaire survey, we recruited 10 enumerators from

different universities were conducted mainly the field survey (Figure 3.2). We

selected the enumerators following their previous experience regarding the field level

data collection. It is noted here that almost all the enumerators have already got their

training on different environmental aspects. They were put together into five groups

with gender differences. PRISM Bangladesh provided them with the daylong

intensive training about the questionnaire. The training was mainly focused on the

procedures of data collection and ethical issues concerning to the survey. It is also

noted here that we provided them our previous experience concerning to the possible

problems they would be faced and how to tackle the issue. After getting the training

they went to the DMCH and other HCE in Ward 49 for collecting the information.

3.6 Questionnaire survey for quantitative data

The quantitative data for this project were collected through the questionnaire survey

(Appendix-A). The questionnaire survey produces causal determinations, predictions,

and findings by using quantitative measurements and by the application of statistical

and mathematical analysis. The questionnaire was designed following the objectivesof this project.



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It is noted here that before entering into the DMCH and other HCE in conducting our

survey, we hold talks with the relevant authorised persons for providing us

cooperation to arrange every opportunity for a successful survey.

We spent nine days to complete our surveys in the DMCH. After collecting our data

from the DMCH, we arranged a series of meetings for appointments to enter different

HCE for the data. In this stage, we got experience with some problems - the

respective HCE authorities, at the initial stage, were not interested to provide us any

time slot. But, finally we were successful to manage half of the total HCE in Ward 49

(Dhanmondi). We got information from 59 HCE out of 131 existing HCE from this

Ward.

A total of 144 questionnaire surveys, of which 59 from Ward 49, 61 from the DMCH,

19 from BMCH (Bangladesh Medical College Hospital) and 5 from Samorita

Hospital were conducted (Table 3.1). The questionnaire mainly addressed the issues

of (a) types of wastes; (b) sources of wastes; (c) amount of wastes generated; (d)

existing waste management; and (e) qualitative aspects for management views. In

addition, a questionnaire for the management section apart from the staff section was

administered for this project. Moreover, informal interviews with different patients

were also employed. It is noted here that we faced a number of problems when we

were engaging to gather our data from patients of different private hospitals.

A total of 61 respondents from the DMCH were interviewed for this project. The

respondents were selected from all the Wards (n = 41), Operation Theatres (n = 11)

and outdoor, emergency and other departments (n = 9). Among the interviewees of

the DMCH, some 49 (80.33%) were female and some 12 (19.67%) were male

respondents. It is noted here that all the female respondents were nurses, and the rest



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were doctors, medical technicians, and cleaners. The average age of the respondents

was about 42 years and the average length of service was about 20 years (Table 3.1).

The BMCH is the largest private hospital in Bangladesh located in Ward 49. Some 19

respondents from the BMCH were interviewed, of which 11 (about 58%) were female

(nurses) and 8 (42%) were male (3 doctors and 5 technicians). The average age of the

respondents was 32 years and their average service length was 7 years (Table 3.1). In

Samorita, 5 respondents were provided us information through our questionnaire

survey. Of them 4 were female and 1 was male and their average age and service

length were 32 and 12 years respectively (Table 3.1). It is noted here that the Senior

Vice-President of the Bangladesh Clinical Owners Association is conducting his

medical practices at Samorita. To get a green signal to collect data from all the private

HCE, we selected this hospital.

Apart from the individual hospitals (DMCH, BMCH and Samorita), 59 respondents

from 59 HCE in terms of general hospitals, private clinics, and diagnostic laboratories



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provided us the relevant information concerning to the generated wastes and the

system of waste management. Some 56 (95%) were male and 3 (5%) were female.

The average age and service length of the respondents were 39 and 6 years

respectively (Table 3.1). Among these 59 respondents, 5 (8.47%) completed their

Higher-Secondary School Certificate (HSC) program, 41 (69.49%) completed eithertheir Graduation or Masters, 13 (22.03%) completed their MBBS and/or higher

medical training (Table 3.1).

3.7 Spatial data for GIS mapping

For spatial analysis and mapping, GIS supporting data were collected during the field

survey. The data used here for the compilation of a GIS are for spatial distribution of

HCE. The spatial data address the point, line and polygon information of HCE andrelated parameters. The spatial data were collected from primary and secondary

sources. All the point (X and Y coordinate values for a HCE), line (string of X and Y

coordinate values for a road) and polygon (identical X and Y coordinate values for the

beginning and ending points for a lake) features in terms of settlement areas, ponds,

road networks etc in the project sites were plotted on maps having the RF of 1:792.

The collected spatial data were digitised and entered into a GIS format (ArcGIS). The

attribute data of map features were also imported into the GIS environment.

3.8 Qualitative data

Qualitative research is especially useful for the exploration and discovery of inherent

issues. It is an umbrella term for various philosophical approaches to interpretive

research (Eisner, 1991; Glesne and Peshkin, 1992). Generally, qualitative research

may be defined as an attempt to obtain an in-depth understanding of the meanings and

definitions of the situation (Powell and Single, 1996; Rich and Ginsburg, 1999;

Wainwright, 1997) presented by informants, rather than the quantification (Strauss

and Corbin, 1998) of their characteristics. Qualitative analysis was used to uncover

and understand what lies behind waste management in which little is yet known, forinstance, the intricate details of phenomena that are difficult to convey with

quantitative methods (Strauss and Corbin, 1998). The in-depth interview was adopted

in collecting our qualitative data.

In-depth interviews were arranged to get a greater depth of understanding of the

existing management system of generated clinical wastes. In-depth interviewing is

defined as . . . a social relationship . . . a short-term, secondary social interaction

between two strangers with the explicit purpose of one person obtaining specific

information from the other (Neuman, 1994). In qualitative approach, interviewing is

a highly personal process where meanings are created through personal interaction



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(Chen and Hinton, 1999; Holstein and Gubrium, 1995). Where quantitative research is

uncooperative or depth required, the in-depth interview becomes one of a small range

of tools available to the researcher (Chen and Hinton, 1999). Different questions were

asked of individuals (Appendix-A) for getting their understanding about the issue

addressed on medical waste management.

3.9 Data Analysis

This section presents the different analytical methods of collected data for this project.

The analysis of data consists of four linked processes (Silverman, 1993): (a) data

reduction; (b) data display; (c) conclusion drawing; and (d) verification. The collected

quantitative and qualitative data were analysed by different techniques. The

quantitative data analyses were based on both statistical and spatial operations; while

the qualitative modes of analyses were mainly ethnography, thick description,

discourse analysis, and narrative analysis.

3.9.1 Quantitative analysisThe collected data for this study with the questionnaire were analysed following

different statistical techniques. The deviation, frequency distribution, central tendency

and correlation coefficient methods were employed in this project to analyse the

information to address the aims and objectives. In addition, a number of statistical

graphs in terms of histogram, pie diagram, bar chart, etc, were used to clearly focus

the situation.

3.9.2 Qualitative analysis

The qualitative modes of analysis were also deployed for this project. Qualitative

modes of analysis recognise the primacy of the subject of inquiry (Rich and Ginsburg,

1999). The qualitative analysis for this project is based on the interpretation of text

and observations. The qualitative data are analysed from multiple perspectives using

different analytical methods (Miles and Huberman, 1994; Silverman, 1993; and

Wolcott, 1994). The mode of thick description consider the data to be presentwithout interpretation and abstraction (Geertz, 1973); and the ethnography

considers to creating a rich descriptive narrative (Strauss and Corbin, 1998) and

vivid presentation of new understanding. This report aims to combine these

approaches for exploring and presenting rich descriptive narratives by developing new

concepts of medical waste management.




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This chapter has mainly focussed on the multi-methods of data collection procedures

and data analysis techniques under the framework of field survey and research design.

The methodology adopted here is a combination of both the quantitative and

qualitative approach, which are helpful in describing medical waste issues in a

realistic manner.

The quantitative data cover the statistical analysis for quantification of medical waste

generation and the qualitative approach is for analysing the verbatim data for level of

awareness, training need assessment and about the in-house management situation.

Qualitative data were used to understand the complexities of existing management

system. The qualitative techniques for both data collection and analytical procedures

include in-depth interviews, formal and in-formal discussion etc.

*****



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Chapter IV

Hospital Waste: Sources, Types and Generation


Hospital waste poses, due to its contents of infectious materials and other hazardous

substances, special risks compared to municipal waste and the risks are not only

connected to the handling of the waste, but also to the treatment and disposal of the

waste (MOHFW, 2004). The HCE also generate domestic or municipal waste

including food waste and packaging from kitchen, food waste and packaging from

patient, packaging materials from treatment of patients, paper and packaging from

administrative functions (MOHFW, 2004).

Apart from the DMCH, some 60 HCE including the BMCH were selected for the

project. It has been found from our field survey that all the surveyed HCE generate

pathological wastes, used syringes, broken bottles and glass, textile stained with blood

and papers. They generate about 6.4 tons/day (6392 kg/day) of wastes, of which only

about 5.2 tons/day (80.77%) are non-infectious wastes and about 1.2 tons/day

(19.23%) are infectious wastes.

The materials presented in this chapter are aimed at providing the sources and types of

medical wastes from our recent field survey. Section 4.2 focuses the generation ofmedical wastes; section 4.3 describes the inventory of the HCE; section 4.4

concentrates the sources of medical waste; and section 4.5 discloses the quantification

of medical wastes generation. Finally, the last section makes some concluding

remarks on the overall chapter.

4.2 Hospital wastes generation

This section deals with the present situation of generating different types of clinicalwastes from different sources (Figure 4.1). Wastes, which are produced in hospitals,

have variable hazard. The medical wastes are toxic and infectious diseases like

HIV/AIDS, hepatitis B and C etc, could be communicated by contaminated medical

waste. Exploring the existing waste management system in different hospital, clinics,

diagnostic centres, and pathology departments is the main objective of this project.

In HCE, two types of wastes are generated: non-hazardous and hazardous. The first

group contains the domestic wastes in terms of paper, kitchen wastes, food wastes and

others from hospital services. The second group includes wastes, which are produced

in laboratories, operating rooms, consulting rooms and hospital units. This later groupof wastes is needed to be treated because of thread of infection.



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4.3 Inventory of HCE

It is mentioned here that more than 600 clinics and hospitals existing in the DCC aregenerating an estimated 200 tons of waste a day (Lawson, 2003). It has been observed

that 131 HCE are located in Wards 49 and 56. Some 60 HCE including the BMCH

were selected from Ward 49 for the project. It is noted here that the HCE in Ward 49

were not selected through any sampling procedure - those who were willing to

provide us information were selected for this survey (Appendix B). The selected

HCE includes General Hospitals (GH) (30, 50.85%), Private Clinics (PC) (15,

25.42%), and Diagnostic Centres (DC) (14, 23.73%).

It is noted here that there is no government owned hospital in Ward 49. The DMCH is

the biggest government owned hospital in Bangladesh. The DMCH provides medical

facilities for about 2000 resident patients per day. The BMCH located in Ward 49 is

the biggest private General Hospital in Bangladesh and offers medical treatment for

about 300 resident patients and the Samorita offers for about 100 resident patients

(Table 4.1).

The recent survey reveals that the Central Hospital and the Ibn Sina Hospital in

combination provide treatment facilities to about almost half of the total patients

admitted to different surveyed general hospitals located in Ward 49 (Table 4.1). Out

of 1743 outpatients, the Ibn Sina D-Lab and the Ibn Sina Consultation centre incombination provide outdoor services to about one-third of the patients. It is noted



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here that the Central Hospital and the Ibn Sina provide most of the medical facilities

to their patients other than the BMCH located in Ward 49.

It is calculated from our data that out of 119 resident patients, about 30% get their

services from the Crescent Gastro liver. The survey also reveals that slightly more

than 1800 patients take the diagnostic services per day from surveyed 14 DC in Ward

49 (Table 4.1) and three-fifth (61%) and one-fifth (20%) of the patients take their

services from the Popular Diagnostic Centre and the Ibn Sina Trust respectively.

4.4 Sources of hospital waste

Hospital waste is produced from the various activities performed in the hospitals.

General waste produced at the hospital is related mainly to food preparation and

administrative departments and this type of waste is similar to household waste and

city waste (Askarian et al, 2004). During the field survey, it was observed that the

surveyed hospitals generated pathological wastes, textile stained with blood, cotton

pads, used syringes, broken bottles and glass, paper, cans and other metals,

vegetable/rubbish and sharp instruments (syringe-needles, surgical blades and blood

lancets). Some of the wastes are blood stained. All the surveyed HCE produce used

syringes, broken bottles and glass, textile stained with blood and papers (Figure 4.2).

Pathological wastes are generally produced in hospitals conducting surgeries. These

wastes are infectious and demand careful handling.



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Medical wastes arise from various activities. These include general medical treatment,

clinical investigation, food preparations and ward activities. The quantities of medical

wastes generated among other factors depend on the status of the hospital, level of

instrumentation and sometimes location of medical facilities (Mato and Kassenga,

1997). The composition of medical wastes is often characteristic of the type of source.

Different units within a hospital and clinic would generate different wastes. Inaddition, some scattered sources may produce some medical wastes in categories

similar to hospital waste (WHO, 2001).

(a) Medical wards: mainly infectious waste such as dressings, bandages,sticking plaster, gloves, disposable medical items, used hypodermic

needles and intravenous sets, body fluids and excreta, contaminated

packaging, and meal scraps.

(b) Operating theatres and surgical wards: mainly anatomical waste suchas tissues, organs, fetuses, and body parts, other infectious waste, andsharps.

(c) Health-care units: mostly general waste with a small percentage ofinfectious waste.

(d) Laboratories: mainly pathological (including some anatomical), highlyinfectious waste (small pieces of tissue, microbiological cultures, stocks

of infectious agents, infected animal carcasses, blood and other body

fluids), and sharps, plus some radioactive and chemical waste.



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(e) Pharmaceutical and chemical stores:small quantities of pharmaceuticaland chemical wastes, mainly packaging (containing only residues if stores

are well managed), and general waste.

4.5 Quantification of Hospital Waste Generation

The wastes generation rates in the surveyed hospitals were obtained by actual

measurements and through assessment of the storage facilities emptying frequencies

and degree of filling of the refuse receptacles. It has been found from the field survey

that all the surveyed HCE generates about 6.4 tons/day (6392 kg/day) of wastes, of

which only about 5.2 tons/day (80.77%) are non-infectious wastes and about 1.2

tons/day (19.23%) are infectious wastes (Figure 4.3 and Table 4.1).

The survey shows the average waste generation rate for the surveyed HCE is 2.63

kg/bed/day (Table 4.2). The results compare with solid waste generation rates

reported in USA hospitals of 4.5-9.1 kg/bed/day, of which about 10% is thought to be

infectious or disease causing (Henry and Heinke, 1996). The improper management

of the infectious wastes are reported be hazardous for human health and environment.

The kitchen wastes are found to be highest generated in the HCE and the net volume

covers for about half (49.10%) of the generated wastes followed by cotton bandage

(11.68%), vial-ampoule (9.69%), placenta (7.86%), sharp instrument (4.05%) and so

on (Table 4.2).



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The survey reveals that the medical waste0 generation rate ranges between 0.17 and

0.74 kg/patient/day having an average of 0.56 kg/patient/day (Table 4.3). The study

revealed that hospitals with modern medical facilities and good services were found to

have higher waste generation rates. For example, BMCH and the Samorita Hospitals

has a waste generation rate of 0.73 and 0.74 kg/patient/day respectively. Moreover,

the average waste generation rate in the surveyed HCE is estimated at 2.63 kg/bed/day

(Table 4.3).

In different studies, the waste generation rate was reported to be 2.71 kg/bed/day in

hospitals of Tehran (Iran), (Mohammadi Baghaee, 2000) and the waste generation

rate in Dar es Salaam (Tanzania) hospitals was reported to be between 0.84 and 5.8kg/bed/day (Mato and Kassenga, 1997). The WHO report regarding the waste



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generation shows the rate in general and university hospitals, which are 4.2-21.1 and

4.1-8.7 kg/bed/day, respectively (Prss et al, 1999).

In the hospitals, different kinds of therapeutic procedures such as cobalt therapy,

chemotherapy, dialysis, surgery, delivery, resection of gangrenous organs, autopsy,

biopsy, para-clinical exams, injections etc. are carried out and result in the production

of infectious wastes, sharp objects contaminated with patients blood and secretions,

radioactive wastes and chemical materials which are considered to be the hazardous

wastes (Prss et al, 1999). The amount of waste generated in the hospitals depends

upon various factors such as the number of beds, types of health services provided,

economic, social and cultural status of the patients and the general condition of the

area where the hospital is situated (Askarian et al, 2004).

It is noted here that the DMCH, BMCH and Samorita hospitals were taken especially

for this project. The DMCH is the largest govt medical college hospital, the BMCH isthe largest private medical college hospital, and the Samorita is the large private

hospital in Bangladesh.

4.5.1 DMCH and waste situation

The DMCH is the largest government owned hospital in Bangladesh having almost all

the health-care facilities (e.g. pathology, radiology and imaging, microbiology,

surgery, pharmacology and therapeutics, gynaecology and so on). Apart from the

facilities of health-care, outdoor, emergency, OT, etc are in the DMCH. The free

wards for the poor are at the ground floor and paid wards are at the second floor.

The DMCH has the capacity for 1400 beds and about 500 floor patients. The hospital

provides emergency treatment to about 250-300 patients daily, surgical treatment

(major and minor operations) to about 3900-4000 patients per day from various

departments and wards, and outdoor advice to about 1000-1200 in a day (Ahmed,

2000).

The survey reveals that the DMCH alone generates more than half (58%) of the total

wastes generated in the surveyed HCE (Table 4.2). The DMCH itself generates about

2976 kg/day (80.2%) of non-infectious waste and 733 kg/day (19.8%) of infectious

waste. The net generation of non-infectious and infectious wastes from the DMCH are

calculated to be 46.55% and 11.46% respectively (Table 4.2). It is found from the

fieldwork that more than half (51%) of the generated wastes in DMCH is kitchen

wastes followed by cotton bandage (12%), vial-ampoule (11%), placenta (7%), saline

bags (4%), sharp instruments (4%), body fluids (3%) and others (Figure 4.4).

The wastes generated in the DMCH are mainly from the kitchen, pathology

department, gynaecology, OT and emergency section. The DMCH produces the

average waste generation rate of 2.65 kg/day or 0.67 kg/patient/day (Table 4.3).



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4.5.2 BMCH and waste situation

The BMCH is the largest private hospital in Bangladesh having most of the health-

care facilities (e.g. pathology, surgery, gynaecology etc). Apart from the facilities of

health-care, outdoor, emergency, OT, etc are available in the BMCH. The BMCH has

the capacity for 300 beds for resident patients. The hospital provides emergency

treatment facilities for about 50 patients daily and outdoor facilities for 600-800

patients in a day.

It has been estimated from the survey that the BMCH generates about one-eight

(12.53%) of the total wastes generated in the surveyed HCE (Table 4.2). The BMCH

produces 640 kg/day (10.01%) of non-infectious waste and 161 kg/day (2.51%) of

infectious waste totalling of 801 kg/day of wastes (Table 4.2). Almost half (47%) of

the generated waste in BMCH is kitchen wastes followed by placenta (15%), vial-

ampoule (9%), cotton bandage (8%), saline bags (5%), sharp instruments (3%), body

fluids (3%) and others (Figure 4.5).



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The wastes generated in the BMCH are mainly from the kitchen, emergency, OT

pathology, and gynaecology department. The BMCH produces the average waste

generation rate of 2.67 kg/day or 0.73 kg/patient/day, a slightly more than the wastes

generated in DMCH (Table 4.3).

4.5.3 Samorita and waste situation

The Samorita is one of the largest private hospitals in Bangladesh having the modern

health-care facilities. Apart from the general health-care facilities, outdoor,

emergency, OT, etc are available in the Samorita Hospital. It is noted here that due to

the high treatment cost, poor people generally do not get facilities from this hospital.

The Samorita has the capacity for 100 beds resident patients. The hospital provides

emergency treatment facilities for 20-50 patients daily and outdoor facilities for 200-

300 patients in a day. It has been estimated from the survey that the Samorita Hospital

generates slightly more than 4% of the total wastes generated in the surveyed HCE(Figure 4.6 andTable 4.2).

The net generation of the wastes from Samorita Hospital is 4.05%, of which 3.41% is

non-infectious waste and 0.64% of infectious waste having 218 kg/day of non-

infectious waste and 41 kg/day of infectious waste totalling of 259 kg/day of wastes

(Table 4.2). Some two-third (40%) of the generated waste in Samorita is kitchen

wastes followed by placenta (21%), cotton bandage (12%), vial-ampoule (7%), saline

bags (7%), body fluids (3%), sharp instruments (3%), and others (Figure 4.6).

The wastes generated in the Samorita are mainly from the kitchen, pathology,

gynaecology, OT and emergency. The hospital produces the average waste generation

rate of 2.59 kg/day or 0.74 kg/patient/day. The amount of kg/day waste generation

rate is lower than that of the DMCH, but the kg/patient/day rate is higher than that of

the DMCHand BMCH (Table 4.3).



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4.5.4 General Hospitals in Ward 49

Some 30 GH were classified from our surveyed HCE in Ward 49. The selected GH

has the capacity for about 600 beds for resident patients and provides outdoor

facilities for about 1750 patients daily. It has been estimated from the survey that all

the 30 GH in combination produce 14.51% of wastes generated in the surveyed HCE

for this project (Table 4.2). Some 757 kg/day (11.84%) of non-infectious wastes and

171 kg/day (2.67%) of infectious wastes totalling of 928 kg/day of waste are being

generated from the surveyed GH selected in the project site.

All the GH themselves in the project site generate about two-third (41%) of the

kitchen wastes followed by cotton bandage (16%), saline bags (13%), vial-ampoule

(7%), placenta (5%), blood and urine bags (5%), sharp instruments (5%), and others

(Figure 4.7).

The wastes generated in the GH are mainly from the kitchen, pathology, gynaecology,

OT and emergency. The GH produces the average waste generation rate of 1.57

kg/day or 0.40 kg/patient/day, much lower than those of the DMCH, BMCH and

Samorita (Table 4.3). Ibn Sina produces and the Bangladesh Heart and Chest Hospital

produce the highest and lowest waste in this category with 2.97 kg/bed/day and 1.09

kg:bed/day respectively.

4.5.5 Private Clinics in Ward 49Some 15 Private Clinics (PC) were classified from our surveyed HCE in Ward 49.

The selected PC has the capacity for about 312 beds for resident patients and by

definition, there are no outdoor facilities. It has been estimated from the survey that

all the 15 PC in combination produce 6.02% of wastes generated in the surveyed HCE

for this project (Table 4.2). Some 309 kg/day (4.83%) of non-infectious wastes and 76

kg/day (1.18%) of infectious wastes totalling of 385 kg/day of waste are being



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generating from the surveyed PC selected in Ward 49. All of the PC themselves in the

project site generate about one-third (39%) of the kitchen wastes followed by cotton

bandage (12%), placenta (10%), saline bags (10%), vial-ampoule (10%), sharp

instruments (5%), blood and urine bags (5%), and others (Figure 4.8).

The PC produces the average waste generation rate of 1.23 kg/day, much lower than

those of the previously described HCE (Table 4.3). The Crescent Gastroliver and

General Hospital Ltd produces the highest and Justice Amin Mohammad Charity

Clinic produces the lowest waste in this category with 2.01 kg/bed/day and 0.93

kg/bed/day respectively.4.5.6 Diagnostic Centres in Ward 49A number of 14 Diagnostic Centres (DC) were identified from our surveyed HCE in

Ward 49. Since there is no opportunity of resident facilities, all of the DC provides

diagnostic facilities for 1802 patients daily. It has been estimated from the survey that

all the DC in combination produce 4.84% of wastes generated in the surveyed HCE

for this project (Table 4.2 and Figure 4.9).



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Some 273 kg/day (4.27%) of non-infectious wastes and 37 kg/day (0.57%) of

infectious wastes totalling of 310 kg/day of waste are being generated from the

surveyed DC selected in Ward 49. All the DC themselves in the project site generate

more than two-third (70%) of the kitchen wastes followed by cotton bandage (10%),

vial-ampoule (5%), saline bags (4%), sharp instruments (2%), blood and urine bags(2%), and others (Figure 4.9).The wastes generated in the DC are mainly from the kitchen and pathology. The DC

produces the average waste generation rate of 0.17 kg/patient/day, average lowest in

all the HCE in the project site (Table 4.3). The Popular Diagnostic Centre and the

Reliable Diagnostic Centre produce the highest and lowest waste in this category with

0.61 kg/patient/day and 0.14 kg/patient/day respectively.


This chapter attempted the quantification of different medical wastes generated from

different HCE in the project site. The collected field data showed that all the surveyed

HCE generate pathological wastes, used syringes, broken bottles and glass, textile

stained with blood and papers. They generate about 6.4 tons/day (6392 kg/day) of

wastes, of which only about 5.2 tons/day (80.77%) are non-infectious wastes and

about 1.2 tons/day (19.23%) are infectious wastes. The average waste generation rate

for the surveyed HCE is 2.63 kg/bed/day and the results compare with solid waste

generation rates reported in USA hospitals of 4.5-9.1 kg/bed/day.

The DMCH alone generates more than half (58%) of the total wastes generated in the

surveyed HCE. The DMCH itself generates about 2976 kg/day (46.55%) of non-

infectious waste and 733 kg/day (11.46%) of infectious waste. The BMCH generates

about one-eight (12.53%) of the total wastes generated in the surveyed HCE. The

BMCH produces 640 kg/day (10.01%) of non-infectious waste and 161 kg/day

(2.51%) of infectious waste totalling of 801 kg/day of wastes. The net generation of

the wastes from Samorita Hospital are 3.41% for non-infectious waste and 0.64% of

infectious waste having 218 kg/day of non-infectious waste and 41 kg/day ofinfectious waste totalling of 259 kg/day of wastes.

The outcome from this chapter will be of helpful for the researchers and policy

makers to think about the hazardous medical waste situation in Bangladesh and to

formulate policies in this regard.

*****



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Chapter V

Hospital Waste Management in Surveyed HCE


Generally the existing hospital waste management in Bangladesh in the form of an

environmental point of view is taking place with an improper procedure. Only a very

few HCE are exceptional in this regard. Almost all the HCE do not segregate the

generated wastes. This chapter seeks to explore the existing waste management

system to formulate recommendations to manage the generated waste properly.

The materials presented in this chapter are aimed at providing the existing practice of

waste management in terms of in-house management (segregation, temporary storage,

disposal system), off-site transport, and final disposal. The following section focuses

the management of wastes; section 5.3 describes the in-house waste management;

section 5.4 concentrates the off-site transport and final disposal; section 5.5 discloses

the segregation of waste in the DCC bin; and section 5.6 focuses the existing waste

management practice in different surveyed HCE. Finally, the last section makes some

concluding remarks on the overall chapter.

5.2 Waste management

It has been found from the survey that almost all the cleaners (Aayah) are responsible

to clean and manage the generated waste. Some cleaners were found to be engaged to

mishandle the generated wastes. They segregated the used sharps instruments (mainly

the syringe-needles), saline bags, blood bags and test tubes from the kitchen and non-

hazardous wastes for sale (resale) or reuse. They are continuing this practice probably

with the full knowledge of the nurses and ward master. Figure 5.1 shows the

segregation pattern of generated wastes in a HCE.

5.2.1 In-house waste management

In some HCE, radioactive, infectious, and sharp wastes are separated from the non-

infectious waste stream at the site of production and they are not stored in similar

containers and are disposed together. In all hospitals, pharmaceutical waste and

pressurized containers are disposed along with the general waste. Liquid

pharmaceutical waste is poured into the drains along with liquid chemical waste.

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



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as the domestic wastes, and no control measures exist for the management of these

wastes. Most of the HCE do not have plastic bags and strong plastic containers for

infectious waste in accordance with the WHO guideline. In general, in most of the

HCE, plastic and aluminium made containers are used. Intermingling of dangerous

wastes with general waste in the hospitals is due to the lack of comprehensive stafftraining and to a lesser extent due to the lack of facilities.

There is no segregation system for infectious and non-infectious waste stream at the

site of production almost in all the HCE. The field survey shows that only four-fifth

(81.4%) of the surveyed HCE do not have any systematic waste collection procedure,

while the rest one-fifth (18.6%) of the HCE collect their in-house waste

systematically (Table 5.1). Some five private HCE in Ward 49, say, Medinova, Ibn

Sina, Popular Diagnostic centre, Central Hospital, and Dr Salahuddin Hospital

segregate their sharp instruments and infectious wastes in separate bins and sent off to

the ICDDRB for incineration at the rate of Tk 50 per kg of waste. It is noted here that

all the HCE in the project site other than these 5 HCE directly dispose their

intermingled infectious and non-infectious wastes in the roadside Dhaka City

Corporation (DCC) Dustbin.



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The survey reveals that only 8.47% HCE in Ward 49 segregate their waste in separate

bins (3 HCE), in safety boxes (1 HCE), and in separate buckets (1 HCE). A total of

91.53% do not segregate the waste, but they have special storage before disposing

them into the roadside DCC bin. The survey also reveals that all the HCE in the

project site finally dispose their wastes into the DCC bin. The DMCH, BMCH, andSamorita dispose their wastes into the DCC bin without segregating them. This poses

serious health risks to the personnel handling the waste and to the scavengers at the

dumpsite and the public at the large site. The consequences of this practice extend to

the possibility of polluting both surface water and the groundwater resource in the

vicinity of the dumpsite (Mato and Kaseva, 1997). Figure 5.2 shows the usual

situation of in-house segregation of waste in many HCE.

Cleaners appointed in the HCE are responsible for cleaning and managing the wastegenerated in the HCE. They collected the waste from different Wards, OT, Pathology

Department and other in-house sources and dispose it to the hospital bins before

disposing them into the DCC bin. In the DMCH, we found some cleaners to be

segregating syringe-needles, saline bags, empty water bottles, tubes etc for sale and

reuse (Figure 5.3).



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It is noted here that infectious waste should be packaged for protecting (a) waste

handlers and public from possible injury and disease that could result from exposure

to the waste and (b) avoiding attraction to rodents and vermin (Patil and Pokhrel,

2004). The integrity of packaging can be preserved during handling, storage,

transportation and treatment. It is noted here that in all the surveyed HCE, sharpinstruments are generally stored in separate refuse receptacles. In some HCE small

empty bottles are separated and used for storage of blood and urine specimens. In

some hospitals offering delivery services placentas and bottle stained cotton pads are

put in separate containers. Pathological wastes from theatre are treated in a similar

manner, but most HCE do not do the same.

5.2.3 Temporary storage

The place/storage where the hospital waste is kept before transporting to the DCC bin

is termed as a temporary waste storage. Some small HCE do not have any temporarystorage and they simply disposed the waste into the DCC bin. Most of the HCE keep

their waste in different designed bins located in the corner of the hospital yard until

disposing into the DCC bin. In some HCE, the infectious and non-infectious wastes

are kept in separate containers and are not mixed together in the hospitals own bin. It

is noted here that all the wastes generated in the HCE finally intermingled when

disposing them to the DCC bin.

5.2.4 Disposal system

The generated wastes are finally disposed into the DCC bin located close to any HCE.

It can be done by each HCE, or NGO, or CBO. Almost 93% of the HCE from our

project site collect and dispose their waste into the DCC bin (Table 5.2). A very few

HCE surveyed receive services from some private company engaged in refuse

collection services. Western Organisation, First Clean, RAKT, Nepcone etc, is

involved in collecting and managing the generated wastes from different HCE.

Western Organisation is engaged in cleaning and managing the waste from Medinova,

a reputed diagnostic centre in Bangladesh located in Ward 49.



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At the end of each shift, hospital waste is collected and transported to a bin for

temporary storage by hospital cleaners. In some HCE, closed containers are used for

off-site transport of waste from the sites of production (different wards) to the DCC

bin. The cleaners employed for handling waste in HCE do not use complete personal

protective equipment (special dress-shirt and trousers along with gloves, mask, bootsetc), but in very few cases, cleaners use only masks and gloves. Lacking of suitable

and sufficient protective equipment and knowledge could expose them to serious

health problems.

5.3 Off-site Transport and Final Disposal

Medical waste should normally be collected everyday due to its hazardous nature. The

DCC has the responsibility for off-site transport of the waste for final disposal ordumping. It is noted here that off-site transport to the roadside DCC bin is undertaken

by the hospital itself. Every early morning, the collected waste is finally crudely

dumped at different DCC waste disposal sites located outside the DCC boundary by

the DCC itself. Crude dumping of medical waste is treated as a threat of both humans

and environment. The bio-medical solid wastes are not stored for more than 18 hours

off-site. The bins in the wards should strictly be placed away from patients and from

the nursing station (Patil and Pokhrel, 2004).

All the HCE surveyed dispose of their domestic waste at the same site as the civic

waste. As the separation of hazardous waste from the domestic is not carried out

properly, the domestic waste of the hospitals cannot be compared with the common

city waste. Therefore, due to the intermingling of hazardous waste, these wastes

should be considered infectious.

5.4 Segregation of Wastes in the DCC Bin

It has been found a different story during our field survey. We have investigated the

segregation of refused medical wastes in terms of sharp instruments, saline and blood

bags, plastic materials, tube and so on from the domestic wastes. Some people are

responsible in collecting, segregating and selling the used hazardous wastes. Figure

5.4 shows the segregation of some clinical wastes for selling.

It is also noted here that the existing laws are generally outdated and characterised by

low penalties and sometimes no penalties for offenders. Thus awareness towards this

issue could be effective until formulating new laws to protect people and environment

from deadly clinical waste.



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5.5 Existing Waste Management Practice

Generally, in the DMCH, all types of waste are to be collected twice a day. Wastes

from the Operation Theatre (OT) and Intensive Care Units (ICU) are collected more

often, depending on the number of operations and cases attended in any particular

day. Apart from the DMCH, almost all the HCE collect their wastes in different times

depending on the amount of wastes are to be generated. In the Pathology

Department (PD), the generated wastes, most importantly, syringes and the needleswith which they take the blood samples are collected in a box after use. Then they

hand it over to the sweepers and cleaners. They return those to the suppliers and bring

new ones (Ahmed, 2000). It is noted here that patients who cannot afford it, they wash

those syringes with plain water and take their samples. It is also noted here that they

do not use any antiseptic.

In the Gynaecology Department, the generated wastes are collected into the metal

dustbin for disposing into the DCC bin. There were sanitary napkins, left over food,

liquid wastes, placenta, disposable gloves etc. All the generated wastes go inside the

same dustbin and nothing is segregated. Sweepers collect the syringes and saline



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bags from them. They return them to the supplier again. All other wards have the

same procedure of disposing their waste.

The Operation Theatres (OT) in HCE produce catheters, gauze, blood cottons, etc.

The syringes and saline bags are kept separately with the HCE since they are returned

again to the hospital suppliers. The bucket is collected by the sweepers on duty and

disposed by them in the DCC bin. It is noted here that amputated body parts are

mainly disposed in the DCC dustbin by the sweepers and cleaners as mentioned in

Ahmed (2000). The amputated parts are hands, legs, gal bladder, uterus, tumour,

aborted child and many others (Ahmed, 2000).


The chapter has focused on the existing medical waste management system in

Bangladesh. Almost all the HCE do not segregate their generated wastes. All the HCE

surveyed dispose of their domestic waste at the same site as the civic waste. As the

separation of hazardous waste from the domestic is not carried out, the domestic

waste of the hospitals cannot be compared with the common municipal waste.

Therefore, due to the intermingling of hazardous waste, these wastes should be

considered infectious.

Almost all the cleaners are responsible to clean and manage the generated waste.

Some cleaners were found to be engaged to mishandle the generated wastes. Theysegregated the used sharps instruments (mainly the syringe-needles), saline bags,

blood bags and test tubes from the kitchen and non-hazardous wastes for sale (resale)

or reuse.

*****



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Chapter VI

Awareness and Training

6.1 General background

The chapter mainly focuses the level of awareness of different related professionals

on medical waste and its impact on occupational health as well as environmental

issues. The chapter also discloses the opinions of authority and medical staffs

regarding the needs of training about the proper management of generated wastes.

The materials presented here are aimed at providing the level of awareness and

training needs. The following section focuses the level of awareness of different

respondents; section 6.3 describes the needs of training on in-house wastemanagement generated in HCE; and section 6.4 concentrates the opinion of the

respondents about existing in-house management. Finally, the last section makes

some concluding remarks on the overall chapter.

6.2 Level of Awareness

This survey indicated that training was not provided to doctors and other personnel

about hospital waste management and their potential hazards except for a few. Some

hospitals provide some training for the cleansing staff and in some nurses. Lack of

proper training in the hospitals poses serious risks to the personnel as far as the

hazards of hospital waste is concerned. The process of collection, segregation and

disposal of hospital waste is not performed according to recommended standards, and

hence patients, visitors, society and the environment are exposed to the dangers of

such waste. In developed countries, training programs and educational classes are

instituted repeatedly for all personnel and the content of these programs is specifically

designed to different personnel.

Some 67 (47%) among the interviewees were female and some 77 (53%) were malerespondents. It is noted here that all the female respondents were mainly the nurses,

and the rest were doctors, medical technicians, and cleaners. The average age of the

respondents was about 42 years and the average length of service was about 20 years

(Table 6.1). It is noted here that we have collected our information from the

respondents from all occupational segments in the HCE. Their opinions have been

considered for addressing the awareness and training needs.

The field survey shows different level of awareness from different respondents. The

management authority of HCE and doctors got ideas about the medical wastes and its

negative impacts. They pointed out that they are willing to manage the generated



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waste properly, but lacking of financial support and proper system, they are unable to

do it. Nurses got their training on medical waste as a part of their professional

training, but due to the lack of system, they are unable to apply their theoretical

knowledge they gathered from their training. Some nurses told us with little

frustration that they are on the brink of forgetting the waste management system. Inaddition, most of the technicians, cleaners and ward-boys are not aware properly

about the medical wastes and its risk issues.

In the GH, about one-third of the total respondents did not get any direct training

concerning to the waste management, while only 13.56% got training on this issue

mainly from the WHO (Table 6.2). Some 6.78% from the PC and 10.17% from the

DC got training in this regard. It is estimated t

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Hospital Waste Management 2005-05-25