CHALLENGES OF MEDICAL WASTE MANAGEMENT @ N. O. H, DALA-KANO Presenters: Ja’afar Isah, & Mustapha Abubakar Public Health & Sanitation Dept. National Orthopaedic Hospital, Dala-Kano June 24th, 2015

INTRODUCTION Medical Waste arises from a number of sources, including hospitals, medical and dental surgeries, veterinary practices, medical teaching establishments, medical research laboratories, and nursing homes. Medical waste is potentially dangerous because it may contain infectious materials and sharps such as needles, surgical blade, etc.

In addition Medical waste containing human organs and body parts which may be offensive in nature. It is therefore important to exercise special caution in the handling and management in order to minimize its potential danger to public health or pollution to the environment regardless of whether it is potentially infectious or not. (A Stanbul. Waste manage 2007 & wasman. 2008)

CONCEPT OF MEDICAL WASTE The medical Waste Tracking Act of (1988) defines medical waste as "any solid waste that is generated in the diagnosis, treatment, or immunization of human beings or animals, and researches.

It also described as any discarded biologic product such as blood or tissue removed from operating rooms, morgues, laboratories, or other medical facilities. The term may also be applied to bedding, bandages, syringes, and similar materials that have been used in treating patients and to animal carcasses or body parts used in research. (Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.)

TYPES OF MEDICAL WASTE An alternative classification scheme comes from The World Health Organization. (WHO 1992) classified medical waste into the following categories Sharp waste (used or unused) which are generally defined as objects that can puncture or lacerate the skin, include Hypodermic needles, scalpels, Broken glass, and other discarded surgical instruments, such items whether infected or not are usually considered as highly hazardous medical waste.

Infectious waste describes waste that has the possibility of causing infections to humans. It can include human or animal tissue (blood or other body parts), blood-soaked bandages, discarded surgical gloves, cultures, stocks, or swabs to inoculate cultures. Much of this category, including human or animal tissue, can also be labeled as pathological waste.

Pathological waste: It consists of human tissues, body parts, human foetus, placenta, and other similar waste from surgeries, animal carcasses, and organs infected with pathogens.

Hazardous waste: Describes waste that has the possibility to affect humans in non-infectious ways, but which meets federal guidelines for hazardous waste under the Resource Conservation and Recovery Act.

Genotoxic waste: Is a highly hazardous waste and may contain mutagenic, teratogenic, or carcinogenic properties. It raises serious safety problems, both inside hospitals and after disposal, and should be given special attention. genotoxic waste may include certain cytostatic drugs, vomit, urine, or faeces from patients treated with cytostatic drugs, chemicals, and radioactive material.

Radioactive waste: Any solid, liquid, or pathological waste contaminated with radioactive isotopes of any kind.

Pharmaceutical waste: It consist pharmaceutical products, drugs, vaccines, and sera that are no longer required and need to be disposed of appropriately. The category also includes discarded items used in the handling of pharmaceuticals, such as bottles, gloves, masks, connecting tubing, and drug vials.

Chemical waste: This type comprised solid, liquid, or gaseous such as solvent, reagent, firm den hyper, ethylene, and other chemicals that may be toxic, corrosive, explosive or carcinogenic.

General waste: Makes up at least 79% of all waste generated at medical facilities, and is no different from general household or office waste, and includes paper, plastics, liquids and any other materials that do not fit into the previous others.

MANAGEMENT OF MEDICAL WASTE Management of medical waste simply refers to collection or containment, transportation, treatment, and disposal of medical waste.

Collection of Medical Waste: Collection of medical waste involve waste bins liners with appropriately colored plastic bin liners. It is very important that both providers and waste handlers understand the colour-coding system and handle waste accordingly. See table below:

Red Radioactive waste Radioactive symbol Noninfectious waste Category of waste Example of waste Colour of bin liners to be use Noninfectious waste Paper, packaging materials, plastic bottles, and cartons etc.  Black Infectious waste Gloves, dressing bandage, blood, body fluid, and used specimen containers etc.  Yellow Highly infectious waste Anatomical or pathological waste Red Chemical waste Formaldehyde, batteries, photographic chemical, solvent, organic chemical, and inorganic chemical  Brown Radioactive waste Any solid, liquid, or pathological waste, contaminated with radioactive materials Radioactive symbol Radioactive Symbol

Handling and storage: This refers to collection, weighing and storing of waste. Protective clothing should be worn by waste handlers when working with healthcare waste. This include apron, heavy duty long sleep, hand gloves, foot wear, goggle, and face mask. This clothing should take off when work with waste is completed.

Hand should always be washed with soap and running water. After removal of gloves kept in a good condition, protective clothing must be clean after each use and be kept at healthcare facility, protective clothing must never be taken to home.

Weighing: Quantifying waste by volume or weight, labeling as to its source, and recording. Full safety boxes should also be recorded. This information can be used to advocate for funds of waste management.

Storage: Placing waste in a secure place until it can be disposed, the ideal storage area should be designated (for waste only) secure (only authorized person should have access) kept clean, dry, pest free. Healthcare waste should be stored not longer than 2-3 days depending on whether condition.

Organic waste should be disposed of daily, Segregation must be maintained throughout until final disposal.

Transportation of medical waste: Simply means movement of waste from one place to another, either on-site or off-site

On-site: Is the movement of medical waste from one point to another within the healthcare facility. Waste should be moved in a designated trolley or wheel barrow.

Off-site: The movement of waste outside the health facility Off-site: The movement of waste outside the health facility. Bins/bags/safety boxes must be kept upright secure, dry (it protected against vermin) and of waste out of direct contact with other supplies. The person responsible for waste disposal must be aware of the schedule for pick-up and delivery of waste. It is preferable that the vehicle should be designated for waste transport only.

It’s also preferable to have a covered vehicle It’s also preferable to have a covered vehicle. The vehicle must be clean and sanitized at the end of each day. Sodeyama, T. et al. (1993)

Pictorial view of off-site transportation

Treatment of medical waste: Medical waste is treated to render it non-hazardous. Noninfectious waste does not need to be treated. Treatment of waste could be achieve through the use of this option for the enumerated forms of waste stated below;

Type of waste Recommended treatment Recommended procedure Microbiological waste, e.g. culture, vaccines, and specimen Autoclave As per instruction with machine Pathological waste, e.g. tissue, organs, blood, and body fluid Liming Dig pit, place lime, add waste, more lime add soil

Other ways for achieving appropriate treatment include; Incineration is simply high temperature burning. It reduces the volume of waste and eliminate pathogens, large scale incinerator that can reach very high temperature are preferred to small- scale lower temperature incinerators.

Medical waste may not burn easily, especially, if you do not add kerosene to make the fire hot enough to burn all waste. Be sure to add the kerosene before starting the fire. Adding kerosene after the fire has started might cause an explosion, open burning (outside of a pit, on the ground) should not be practiced.

Use of Bar or Barless incinerator: Bar or Barless incinerators are designed purposely for the treatment or burning of highly infectious medical waste such as blood, body fluid, or others potentially infectious materials. This incinerators are designed or fitted with pollution control and potentially toxic chemicals that previously ended up in emissions now remain in the ash.

Pictorial view of Bar or Barless incinerators

Pictorial view of Bar or Barless incinerators

BURIAL PIT Use of Burial Pit: A burial pit be dug at least 2.5 meters wide and 2.5 meters deep. But should be at least 1.5 meter above the water table. The water table be measured during the second half of rainy season. The pit be fenced to restrict unauthorized access and be located away from public areas.

BURIAL PIT

The area must be drained, and be located downhill. The area should be at least 50 meters away from any water source to prevent contamination of the water source.

Keep waste covered. Every time waste is add to the pit, cover it 10—30cm layer of soil. When the level of waste reaches to within 30—50 cm to the surface of the ground, fill the pit with soil and another one be dug.

HAZARD ASSOCIATED WITH MEDICAL WASTE Exposure to hazardous medical waste can result in disease or injury, the hazardous nature of medical waste may be due to one or more of the following characteristics: It contains infectious agents It is genotoxic It contains toxic or hazardous chemicals or pharmaceuticals It is radioactive It contains sharps

Hazards from infectious waste and sharps Infectious waste may contain any of a great variety of pathogenic microorganisms; Pathogens in infectious waste may enter the human body by a number of routes. Through a puncture, abrasion, or cut in the skin Through the mucous membranes By inhalation By ingestion.

There is particular concern about infection with (HIV Aids) and infective hepatitis viruses B and C, for which there is strong evidence of transmission via medical waste. These viruses are generally transmitted through injuries from syringe needles contaminated by human blood. A pilot study. Waste management 2007)

Hazards from chemical and pharmaceutical waste: Many of the chemicals and pharmaceuticals used in health-care establishments are hazardous (e.g. toxic, genotoxic, corrosive, flammable, reactive, explosive, shock-sensitive). These substances are commonly present in small quantities in health-care waste; larger quantities may be found when unwanted or outdated chemicals and pharmaceuticals are disposed of.

They may cause intoxication, either by acute or by chronic exposure, and injuries, including burns. Intoxication can result from absorption of a chemical or pharmaceutical through the skin or the mucous membranes, or from inhalation or ingestion. Injuries to the skin, the eyes, or the mucous membranes of the airways can be caused by contact with flammable, corrosive, or reactive chemicals e.g. formaldehyde and other volatile substances.

The most common injuries are Burns. (Lee MG (1988) The environmental risks associated with the use and disposal of pharmaceuticals in hospitals.

Hazards from genotoxic waste: The severity of the hazards for health-care workers responsible for the handling or disposal of genotoxic waste is governed by a combination of the substance toxicity itself and the extent and duration of exposure. Exposure to genotoxic substances in health care may also occur during the preparation of or treatment with particular drugs or chemicals.

The main pathways of exposure are inhalation of dust or aerosols, absorption through the skin, ingestion of food accidentally contaminated with cytotoxic drugs, chemicals, or waste, and ingestion as a result of bad practice, such as mouth pipetting. Exposure may also occur through contact with the bodily fluids and secretions of patients undergoing chemotherapy. (Monographs on the evaluation of carcinogenic risk of chemicals to humans 1991).

Hazards from radioactive waste: The type of disease caused by radioactive waste is determined by the type and extent of exposure. It can range from headache, dizziness, and vomiting to much more serious problems. Because radioactive waste, like certain pharmaceutical waste, is genotoxic, it may also affect genetic material. Handling of highly active sources, e.g. certain sealed sources from diagnostic instruments, may cause much more severe injuries (such as destruction of tissue, necessitating amputation of body parts) and should therefore be undertaken with the utmost care.

The hazards of low-activity waste may arise from contamination of external surfaces of containers or improper mode or duration of waste storage. Health-care workers or waste-handling or cleaning personnel exposed to this radioactivity are at risk. (Selavan, S.G. et al. (1985). A study of occupational exposure to antineoplastic drugs and fetal loss in nurses.

Persons at risk: Medical doctors, nurses, health-care auxiliaries, and hospital maintenance Personnel. Patients in healthcare establishments or receiving home care; Visitors to healthcare establishments; Workers in support services allied to health-care establishments, such as laundries, waste handling, and transportation.

Workers in waste disposal facilities (such as landfills or incinerators), including scavengers. (WHO 1992 Technical Report Series, No. 819)

SAFETY AND PRECAUTIONARY MEASURES IN MEDICAL WASTE MANAGEMENT Every hospital must have a plan programme of awareness and adequate training for all category of personnel including Administrators in issues like infection risk, mode of transmission, sign and symptom, and mode of prevention of diseases that could be transmitted through medical waste.

Personal protective Equipment (PPE) such as hand glove, apron, face mask, long sleep (trouser and shirt) boot and goggles must appropriately be used while at work to reduce the risk of workers exposure to infection. The employer must ensure that the workers or employees use the protective device as well as ensure sustainable supply of the device throughout the exposures.

Hepatitis B vaccine and Tetanus toxoid vaccination are frequently given to the employees to ensure their protection against Hepatitis B and tetanus. This in particular is needed for those expose to the risk of infection. All efforts should be made to limit the length of exposure subjecting the staff to adequate shifting to reduce the length of exposure.

If an exposure incident occurs employees should immediately report exposure incidents. The employer is responsible for establishing the procedure for evaluating. (Handling and management of medical waste Rule 1996).

CHALLENGES IN MEDICAL WASTE MANAGEMENT The task of collection, storing or containment, transportation, treatment and disposal has always become a serious task. Even though, medical waste constitute a smaller portion of entire healthcare waste. Nonetheless, the cost of its management and the desire attention is quite challenging due to it associated risk or hazards to human population.

The following are some of the major challenges that could be encountered when handling medical waste in institution: Medical waste generators, (Medical Doctor, Nurses, Health Attendants, Pharmacist, and Workers in waste management, etc.) They contribute some major challenges, for example, segregation is the essence of medical waste management and should be done at source of generation.

The responsibility of segregation should be with the generators, but in most cases, you may find many needles, razor-blade, and other surgical instrument into dustbin, instead of safety boxes this may help in the spread of disease, most especially HIV Aids, and infective Hepatitis, etc.

Sustainable supply of bin liners that could be used for the collection or containment of medical waste. These include the color coded bin liner such as yellow bin liner for the collection of infectious waste and red for collection of highly infectious waste. It also include the safety boxes commonly used for collection of sharps medical waste.

Constant Supply of Personal Protective Equipment (PPE), such as rain boots, face masks, aprons, and hand-gloves to protect the workers from direct handling of pathogenic waste while at work is very difficult.

Provision of facility for treatment of medical waste other than sharps such as expired blood, specimen and similar other medical waste. The facility are Bar or Barless incinerator and waste pit or Ditch which are often used for the treatment of pathological waste are lacking.

The cost of diesel, maintenance and repairs of Hospital incinerator for the treatment of sharps medical waste has been a very expensive matters, as such when an institution runs short of finance the incinerator tend to be locked out of use or impracticable.

Inadequate trained personnel that could manage the medical waste in the hospital often led to shabby handling of medical waste thereby promoting unethical practice in waste management e.g. dumping medical waste in a wrong place or manner.

Seasonal Geographical variable such as rain, or high humidity often affect the successful treatment of medical waste. This is because if waste pit is use, laterite that are used in covering the waste may not be easily accessible. More so, Rain and high humidity may make the burning of waste very difficult as the waste submerge in water, thereby making it impossible to burn completely.

CONCLUSION Going by presentation we can understand that there should not be compromise of standard in matters to do with medical waste management in hospital if the health and well-being of peoples to be protected against likely infection that are transmitted through pathological waste.

RECOMMENDATION Considering the issues, and challenges in medical waste management in Hospital setting The following Recommendation are pertinent to help us succeed in the system: The hospital management having done so much in area of Staffing, repairs, and provision of equipment should equally extend the same gesture by providing of other facilities such as Ditch, Bar/barless incinerator which are often use for the treatment and disposal of other medical waste other than sharps.

Bulk purchase of working material such as color coded bins and bin liners for the collection of highly infectious waste, safety boxes for the collection of sharps and personal protective equipment (PPE) for the safety of workers be made available at all times. Regular maintenance and repairs of hospital incinerator in order to work continuously without long break for the urgent treatment of medical waste.

Adequate training of staff to improve their skills and knowledge will go a long way in improving their abilities to handle the waste appropriately. Much of the facilities that are needed for the management of medical waste should be sited at a landed area made available for the treatment and disposal of medical including the disposal of amputated body parts.

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