Improving the Management of Solid Hospital Waste in A Nigerian Tertiary Hospital

Health care activities lead to the production of waste that can have adverse health effects on the health care provider, the recipient and the community if not properly managed. The objective of this study was to determine the current situation of waste management in a Nigerian tertiary health facility and proffer solutions to the observed inadequacies. A 42-day study period was conducted; wastes were sorted into categories and at the point of collection and weighed. Information on knowledge and practices on hospital waste management was obtained using structure questionnaire, and in depth interview of a cross section of staff, infection control officers, waste handlers and off site vehicle drivers. Average daily waste generated was 554kg/day (202.21tons/year). Average waste generation rate per bed per day is 1.68kg/bed/day. Generation by waste type is 4.5% pathological, 20% infectious, 1.6% were sharps, while 73.9% were non-infectious or general waste. The federal Government should enact laws guiding such category of waste and have special budget for same, encourage continuous training and capacity building for medical personnel and waste handlers, and public awareness through media advocacy.

IMPROVING THE MANAGEMENT OF SOLID HOSPITAL WASTE IN A NIGERIAN TERTIARY HOSPITAL



















Key words: Hospital, Waste Management, Nigeria

Running Title: Improving Management of Solid Hospital Waste in Nigeria


ABSTRACT

Health care activities lead to the production of waste that can have adverse health effects on the health care provider, the recipient and the community if not properly managed.
The objective of this study was to determine the current situation of waste management in a Nigerian tertiary health facility and proffer solutions to the observed inadequacies. A 42-day study period was conducted; wastes were sorted into categories and at the point of collection and weighed. Information on knowledge and practices on hospital waste management was obtained using structure questionnaire, and in depth interview of a cross section of staff, infection control officers, waste handlers and off site vehicle drivers. Average daily waste generated was 554kg/day (202.21tons/year). Average waste generation rate per bed per day is 1.68kg/bed/day. Generation by waste type is 4.5% pathological, 20% infectious, 1.6% were sharps, while 73.9% were non-infectious or general waste. The federal Government should enact laws guiding such category of waste and have special budget for same, encourage continuous training and capacity building for medical personnel and waste handlers, and public awareness through media advocacy.

INTRODUCTION
Health-care wastes are by-products of health care services, and these includes sharps, blood, body parts, chemicals, pharmaceuticals, radioactive materials and others. (SBC/WHO/FME 2002).
Hospital waste management is an essential part of healthcare delivery. Poorly managed hospital waste exposes healthcare workers, waste handlers, and the community to infections, toxic effects, and injuries and may damage the environment. (SBC/WHO/FME 2002). In addition, it may create opportunities for collection, resale and potential re-use without sterilization of disposable medical equipment (particularly syringes). This may further compound the burden of disease world-wide especially in a developing country like Nigeria. Inadequate hospital waste management reduces the overall benefits of medical care. (SBC/WHO/FME 2002).
Hospital waste management entails all units of operations involved in managing medical wastes from generation to disposal (HCWH. 2001). Effective management or disposal of hospital waste should include basically; storage in generating premises, effective collection, effective transportation and proper disposal. In Nigeria, as reported by Coker et al, (1998), there a is near-total absence of institutional arrangements for the management of medical waste and currently there are no regulations, legislation or special edicts on medical waste management in Nigeria.
About 75% and 90% of waste produced by health care providers is "non risk" or "general" health-care waste while the remaining 10 ? 25% of healthcare waste is regarded as hazardous and may create a variety of health risks (Pruss et al, 1999). Segregation of hospital wastes involves separating different types of waste at the point of generation and keeping them isolated from each other. It is the most important step in the entire process of hospital waste management. There is the need for special attention to be given to the relatively small quantities of infectious and hazardous waste, thereby reducing not only the risks but also the cost of handling, treatment and disposal. The most appropriate way of identifying the categories of health care waste is by sorting the waste into colour-coded plastic bags or containers.
WHO recommended colour coding for biomedical and healthcare waste are : red for highly infectious waste, yellow for other infectious waste, yellow marked "SHARPS" for sharps waste, brown for pharmaceutical waste, lead box labeled with radioactive symbol for radioactive waste, and black for general or non infectious waste(Pruss et al, 1999). Waste segregation is an important treatment option in the management of hazardous waste. (Bassey et al, 2006). It is universally accepted fact that segregation of hospital waste is and should be the responsibility of the generator of the waste. Lack of training and capacity building increases the risk. The hospital waste director must be trained in all the different aspects of waste management. (Askarian.et al 2004).
Storage of hospital waste in a warm country like Nigeria is 48 hours during cool season while 24 hours is recommended during hot season (Pruss et al, 1999).
On-site transportation of healthcare waste should be done by means of wheeled trolleys, containers or carts that are not used for any other purposes. Safe packaging and adequate labeling of waste are essential ingredients for off-site transportation. Hospital wastes are treated to render them non- hazardous and then disposed of into air, land or water (Yadav, 2001). Treatment methods include: incineration, thermal processes such as autoclaves, microwaves, plasma pyrolysis ,and chemical processes.
Ullah Shellab, 2003, reported from his analysis that all types of hazardous wastes can be treated by incineration.
This study was designed to determine the current situation of waste management in a Nigerian tertiary health facility and proffer solutions to the observed inadequacies.
METHODOLOGY
STUDY SITE
The study was conducted at the University of Ilorin teaching hospital,
located in Kwara state in the north central region of Nigeria. It is a 500 bed hospital with two major sites consisting of general and maternity wings.

METHODS
Information on knowledge and practices on hospital waste management was obtained using structure questionnaire,and in depth interview of a cross section of staff, infection control officers, waste handlers and off site vehicle drivers. In addition all wastes generated in the 42-day study period were sorted into categories and at the point of collection and weighed .The total quantity of waste generated was tabulated according to the wards or units from which they were obtained.
RESULTS
Waste generation
Average daily waste generated was 554kg/day (202.21tons/year). table 1 shows average daily generated according to ward/building. Average waste generation rate per bed per day is 1.68kg/bed/day. Generation by waste type is 4.5% pathological, 20% infectious, 1.6% were sharps, while 73.9% were non-infectious or general waste.


TABLE 1
WARD AV. DAILY QUANTITY (KG/DAY)
Orthopedic 28
Nursery/children ward 70
Surgical wards 40
Theaters 45
Accident and emergency 37
Isolation 33
Out patient 17
Medical 38
Pharmacy 30
Clinics 38
Laboratories 33
Psychiatric 10
Intensive care 7
Labour ward 33
Ante and post natal 42
Medical records / Admin. 4
Gynae 13
Family planning 9
Mortuary 6
Physiotherapy 6
Renal and ultra sound 15
TOTAL 554




Waste segregation, treatment and containers used
Hospital wastes emanating from UITH does not undergo any type of treatment. Waste segregation is also never employed by the institution. Hospital Wastes of different categories are lumped together and dumped into basket bins and lumped together in large wheeled bins for on site transportation to collection point.
On/off-site transportation
Wastes are collected from wards and offices to big plastic bins with rollers, moved every morning to refuse vehicle set aside to carry waste for disposal outside the hospital premises. 8 waste carts of dimension 1200 x 600 x450 are used to convey big plastic bins whose tyres are removed or spoilt. The waste carts could carry 2 large bins at a time. (See plate 1).


PLATE 1: WASTE CART FOR ON SITE TRANSPORTATION

A well covered truck is used on daily basis to transport waste to the point of disposal. The vehicle is a tipping type, diesel engine, with dimension 3.8x2.3x1.5m in length, breadth and height respectively. The upper part is shaped half cylinder with slide having opening on both side of the truck through which the waste is poured. It has a rear door through which the wastes are emptied at the disposal site by tipping during disposal. The vehicle is owned and managed by UITH.


Final disposal
Hospital wastes from the hospital are dumped at designated field at the outskirt of the metropolis (about 5km away from the centre of town). The open space is managed by the Kwara State Government. The wastes are burnt openly and intermittently.
Capacity building
Training of personnel is organized by a committee set up by the management of the hospital in collaboration with an international NGO.
Out of the 930 medical staff of the hospital 548 had been trained (58.9%) while out of the 373 waste handlers/ cleaners 363 had been trained (97.3%). Tools required for segregation and proper treatment/disposal of wastes are yet to be acquired.
Rules and regulations on waste management
The hospital has a waste management plan which is yet to be put in place. There are no rules and regulations regarding waste management of the hospital and no reference to management of hospital waste is available on job description to hospital staff.
DISCUSSION
In a study performed in 2006 in five selected hospitals in the Federal capital territory, Abuja, the average amount of waste produced is 2.78kg/b/day of solid waste (Bassey et al, 2006). The waste generation rate at university hospitals of Fars Province Iran was found to be 3.93kg/b/d. (Askarian. et al, 2004).
A similar study carried out in Bangladesh yielded 1.16kg/b/d (Ullah Shellab, 2003). The results of this study are similar to the WHO report regarding waste generation according to source size (0.05 to 8.7kg/b/day) though data was sourced from high income countries (Pruss et al. 1999).
Open burning method is carried out by 30% of hospitals visited in Ibadan , Nigeria (Coker et al.1998) while 36.3% do same in Abuja, Nigeria, as reported by Bassey et al 2006. 5% of hospitals visited in Ibadan practice open dumping without regard for scavengers that pick from such dumpsites possibly for resale (Coker et al.1998).
At the UITH, waste segregation is not practiced. All waste categories are lumped together without pre-treatment of any type leading to an unhealthy and hazardous environment around the health institution and also at the dump site. This affects patients and staff and the populace. For instance cases of used hospital needle piercing into the foot of staff had been reported. Scavengers were seen at the dumpsite picking used needles, left over drugs etc., risking injury from sharps and direct contact with injection material. Direct disposal of faeces and urine of infectious patients in sample bottles to dumpsite may cause outbreak of epidemic disease (Bassey et al 2006). The sample bottles are emptied and rewashed by scavengers for resale.
According to scientific standards, infectious waste in tropical area ( Nigeria, country of study lie in the tropics) can be kept for 24hrs during the hot season and 48hrs during the cold season (Pruss et al.1999) UITH complies with this standard as it as does not store waste more than 24 hrs.
This study revealed that 26.1% of total waste generated from UITH are hazardous and therefore require special attention for their disposal. This is a little higher than WHO classification of 10-25%. A similar study carried out in Iran revealed 48.5 % hazardous (Askarian et al 2004), 15.5% in Bangladesh (Ullah Shellab, 2003), Denmark 25% and 28% for New York city ( Bassey at al, 2006).
This variation may be due to the ways in which solid wastes are segregated and categorized in different countries. Hospital personnel and the general public are at risk because they do not have enough information regarding this category of hospital waste, whereas specific rules and regulations are carried out at National, Regional and Hospital level in developed countries. This is not so in Nigeria. For example in Freiberg , Germany, hospitals must comply with no less than 36 rules at National Level, 5 at regional and 13 at hospital level, amounting to a total of 54 regulation codes about correct disposal of hospital waste (Askarian.et al 2004).
CONCLUSION
Wastes emanating from healthcare activities can have adverse effects. Some types of healthcare waste represent a higher risk to health; these include infectious waste (about 26.1% from this research) among which are sharps (1.6%).
Hospital waste management in Nigeria falls short of WHO standard. This poses danger to hospital workers, the patients, and to the community at large. However, the Healthcare Waste Management Technical working Group (HCWM TWG) has worked out National Healthcare Waste Management Plan and Guidelines awaiting validation by the country's law makers.






REFERENCES
1. Askarian M, Vakili M, and Kabir G.(2004) Hospital waste management status in University Hospitals of the Fars province, Iran. International Journal of Environmental Health Research 14(4). Pgs 295-305.
2. Bassey B.E, Benka-Coker M.O, and Aluyi H.S.A,(2006). Characterization and management of solid medical wastes in the FCT, Abuja Nigeria. African Health Sciences; 6(1); pgs 58 ? 63.
3. Coker A.O and Sangodoyin A.Y (1999) Management of Urban Hospital Waste in Ibadan, Nigeria. http\\www.google.com\medicalwastemanagement.
4. Coker, A.O, Sangodoyin, A.Y, and Ogunlowo O.O (1998) Managing Hospital Wastes in Nigeria. Proceedings of 24th WEDC Conference, Islamabad, Pakistan. Pgs 70-72.
5. Do no harm (2006) Injection safety in the context of infection prevention and control trainers' guide. Federal ministry of health and John Snow Inc. / making medical injections safer/Nigeria.Pgs 79-96.
6. DuttaGupta S.C and Gupta N.S, (2003), Low cost biomedical waste management system ? A case study. Proceedings of 29th WEDC Conference, Abuja, Nigeria. Pgs 127 ? 129.
7. Hall, S.K. (1989). Infections Waste Management a multifaceted problem. J. of pollution engineering, 21 (8), 74 ? 78.
8. HCWM TWG, (2009). National Healthcare Waste Management Plan.
9. Health Care Without Harm (HCWH) (2001). Non- incineration medical waste treatment technologies. A resource for Hospital Administration, Facility Managers, Health Care Professionals, Environmental Advocates, and Community Members. HCWH 1755 S Street, N.W Suite 6B, Washington, DC 20009. www.noharm.org.
10. Ogunbiyi. A.A (2003), Engineering Infrastructures and Engineers in Nigerian Solid Waste Management Industry. Proceedings Annual conference, Nigerian Society of Engineers. Ibadan Nigeria. Pgs 112-117.
11. Pruss, A., Giroult, E and Rushbrook, D. (1999) Safe management of waste from healthcare activities. Geneva: World Health Organization.
12. Sangodoyin A.Y (1991) Ground and surface water pollution by open refuse dump in Ibadan, Nigeria. Discovery and Innovation, 3(1),pgs 37-43.
13. SBC/UNEP/WHO/FMOH (2002): Proceedings on "Inventory of Health-care waste in Nigeria" organized by the Secretariat of the Basel Convention of the United Nations Environment Program (SBC/UNEP) and the World Health Organization (WHO) in collaboration with the Federal Ministry of Environment, Nigeria.
14. Ullah Shelab M.D, (2003), Incineration ? A hospital waste treatment option for Dhaka city proceedings of 29th WEDC Conference, Abuja, Nigeria. Pg 447 ? 449.

Olubunmi Ajike Mokuolu.(nee Adelaja) B.Eng, M.Eng MNSE,MNICE, MASCE

A professional Civil Engineer with experience Spanning over two decades in management/maintenance of public building, Structural design/analysis, co-examiner (professional examinations), Staff management, computing, Project Supervisor and of recent Environmental Engineering with a bias in solid waste management. She is trained in the management of healthcare waste and had served as resource person and master trainer to training workshops.

Olubunmi recently brought about awareness of dangers attached to mismanagement and unscientific handling of Health Care Waste (HCW) as a result of which University of Ilorin Teaching Hospital is gradually becoming environmentally sound.