International Conference on Ecological, Environmental and Bio-Sciences (ICEEBS'2012) April 13-15, 2012 Pattaya

Medical Waste Management In Private Medical Clinics Taiping,

Chua Say Tiong, Puziah Abd.Latiff, Subramaniam a/l Karuppannan

Abstract—The proper management of medical waste II. LITERATURE REVIEW must be given priority and the medical waste generator has World Health Organization (WHO) defined medical to ensure the proper medical waste management involving waste as “any waste which consists wholly or partly of collection and disposal by private medical clinics with a human or animal tissue, blood or other bodily fluids, potential disposal mixing with municipal waste stream. The excretions, drugs or other pharmaceutical products, swabs study determined methods of medical waste management; or dressings, needles or other sharps; and any other waste and identified problems encountered and proposed measures arising from medical, nursing, dental, veterinary, for improvement. The study was carried out from January to pharmaceutical or similar practice, investigation, treatment, October 2008 in Taiping, ; where 19 of 72 private care, teaching or research, or the collection of blood for medical clinics (n=19) (26.4%) participated in the study. transfusion” [29]. WHO estimated 80% from total Data was collected through a self-administered healthcare waste is not infectious and only 20% is infectious questionnaire survey. The analysis showed private medical or poses risk of injury or hazardous to human beings [38] clinics who disposed of medical waste with general waste (Table 1). (n=3) (15.8%), with inappropriate types of containers for collecting. The main problem encountered by private TABLE I clinics was improper practices due to lack of awareness APPROXIMATE PERCENTAGE OF WASTE TYPE PER TOTAL WASTE IN PUBLIC (n=11) (57.9%). The charges imposed by DOE registered HEALTH CARE CENTRES contractor was not reasonable (n=2) (10.5%). The private Type of waste Quantity medical clinics did not engage the registered contractor Non-infectious waste 80% (n=3) (15.8%). Pathological waste and infectious waste 15% Sharps waste 1% Keywords – DOE - Department of Environment Chemical or pharmaceutical waste 3% Pressurized cylinders, broken thermometers etc. <1% I. INTRODUCTION Source: Management of Solid Healthcare Waste at Primary Healthcare Centres - A Decision-Making Guide [38] EDICAL waste is of environmental concern because Mof its infectious nature that can spread diseases and Private Healthcare Facilities and Services Act 1998 and cause injury to human [23]. Management of medical waste Private Healthcare Facilities and Services (Private Medical must be given special attention because of the potential risk Clinics or Private Dental Clinics) Regulations 2006 are to health or pollution to the environment and should be enforced by Ministry of Health for the registration, licensing disposed of at a licensed disposal facility. The and operating of private medical clinics. responsibility of medical waste generator is to ensure proper Under Section 7(1) of the Act, a certificate of registration management of medical waste [13]. According to Malaysia to establish, maintain, operate or provide a private medical Environmental Quality Report 2006 published by the clinic may only be issued to a registered medical Department of Environment, the amount of clinical and practitioner [16]. pharmaceutical waste generated was 32,270.34 metric Under these Regulations, hazardous waste includes both tonnes which consists of 2.9% of the total scheduled waste infectious and non-infectious waste. Infectious waste in 2006. includes human, animal, biological waste or contaminated sharps and any items that may be contaminated with

Chua Say Tiong is with the Department of Environmental Health, pathogens, whereas non-infectious waste includes toxic Faculty of Health Sciences, University Technology MARA, Bertam chemicals, cytotoxic drugs, radioactive, flammable and Campus, , 13200 Kepala Batas, Penang, Malaysia (Author’s Phone: explosive waste. +6012-5650843; Fax: +604-5623575; e-mail: [email protected]). Under the same Regulations, the private practitioner or Puziah Abd. Latiff is with the Faculty of Environmental Studies, University Putra Malaysia, 43400 Serdang, , Malaysia. (e-mail: owner of the private medical clinic shall take the following [email protected]). actions: Subramaniam a/l Karuppannan is the Head of Department for (i) infectious and non-infectious waste shall be separated Environmental Health and Safety, Faculty of Health Sciences, University at the point of generation. Technology MARA, 42300 Puncak Alam, Selangor, Malaysia and formerly from the Department of Environment, Malaysia (e-mail: (ii) infectious waste shall be discarded into clearly [email protected]). identifiable containers or plastic bags that are leak- proof and puncture-resistant and the containers shall be marked with the universal symbol for biological hazards (three black crescents superimposed on a circle

87 International Conference on Ecological, Environmental and Bio-Sciences (ICEEBS'2012) April 13-15, 2012 Pattaya

with white background and the word “INFECTIOUS According to the Malaysian Auditor General’s Report SUBSTANCES (WASTE)” at the bottom). 2007 on the appalling methods used to dispose of clinical (iii) non-infectious waste shall be handled in accordance waste at hospitals and clinics, the government has paid with good safety practice and any written law relating RM131,400,000 to the concession companies for the to handling of such waste. management of medical waste in 140 government healthcare (iv) all hazardous waste shall be packaged, transferred and facilities. The total quantity of medical waste handled for disposed of in a manner accepted by the relevant the year 2005 to 2007 was 203,529 metric tonnes. The authority to protect both the persons and the findings revealed in the report were of clinical waste environment. contained and dumped in drums labeled ‘domestic waste’. A person who commits an offence under these The findings noted that needles and sharp objects were not Regulations shall be liable on conviction to a fine not segregated from other waste and were not disposed of in exceeding five thousand ringgit or to imprisonment for a ‘sharp containers’ as required. term not exceeding one month or to both [18]. The control General waste was disposed of together with medical of hazardous waste including medical waste in the private waste, thus increased the quantity of medical waste and medical clinics is included under the licensing procedures of incurred extra cost. ‘Sharp containers’ that contained Ministry of Health. needles and sharp objects were kept for too long before The concessionaire agreements for medical or clinical disposal. ‘Sharp containers’ were badly maintained and waste management in government healthcare facilities was almost never washed. The medical wastes were transported signed between Ministry of Health and three concession from health clinics to hospitals using ambulances, vans or companies in October 1996 whereby all medical or clinical four-wheeled drive vehicles which did not have approval waste generated in all government hospitals and clinics are from the DOE. The waste water was allowed to flow into managed and disposed of by three concession companies common public drains without first being treated [3]. which are Faber Medi-Serve Sdn Bhd for states of , Medical waste is potentially dangerous since it can spread , Penang, Perak, and ; Radicare (M) disease because of the infectious nature of some waste, Sdn Bhd for Wilayah Persekutuan and and/or cause injury through the presence of sharps such as Putrajaya, Selangor, , and , and needles and scalpels. It is important to safeguard the health Pantai Medivest Sdn Bhd for , Melaka and and safety of the public, patient and healthcare staff against . The management of medical waste in all government the risk posed by medical waste. hospitals and clinics are well organized and systematic. The method of medical waste segregation, storage, Unfortunately the medical waste management in private collection and disposal in private medical clinics is not fully medical clinics is not well established and not standardized implemented and not standardized. This could be due to the because not all the private clinics engage the services from quantity of medical waste generated is too small and cost of the above mentioned companies. collection and disposal is too high especially for small The Malaysia Medical Association (MMA), Department private medical clinics. of Environment (DOE), Ministry of Health, and the three Illegal disposal of medical waste in open ground, in companies held a meeting in Putrajaya on 25th February landfill site or in open municipal bins, renders them freely 2002 to discuss the matter of medical waste management in accessible to drug addicts, rag pickers, scavengers, and private medical clinics. This meeting was a follow-up of the children, thereby increasing the risk of transmission of first meeting held on 9th November 2001 on the same issue, infections. There is potential of disposing medical waste whereby, the DOE had given the MMA a deadline until 1st into the municipal general waste bins or landfills due to the March 2002 to seek the services of these companies. high cost and lack of enforcement from the authority. The The MMA were facing problems of costs and services number of private medical clinics is too many and scattered offered by the companies. It was agreed that private throughout the country, hence it is not easy to carry out the medical clinics must follow the practice of the small health enforcement effectively and also the difficulties in centre of the Ministry of Health that is to send the clinical collection and disposal of medical waste by a registered waste to the nearest service centre. The Director-General of contractor. DOE has agreed that clinics can group together and send This study is carried out to determine the method of their waste. Alternatively, they can also seek assistance of medical waste collection and disposal in private medical the nearest private laboratory or private hospital. Private clinics and to identify problems encountered in medical medical clinics must ensure that wastes are delivered to the waste management and to propose measures for improving allocated service centre that is run by the companies. the medical waste management. Service centre is a place where all medical waste that has Medical waste is potential to transmit infection such as been collected from hospitals or clinics is kept temporarily Hepatitis B virus (HBV), Hepatitis C virus (HCV) and before sending them to disposal site. Human Immunodeficiency virus (HIV) to human. In 2004, approximately 430,000 tonnes of scheduled Epidemiological studies indicated that a person who waste was generated in Malaysia. Approximately 18.8% experiences one needle stick injury from a needle used on was treated and disposed of in the toxic waste treatment and an infected source patient has risks of 30%, 1.8%, and 0.3% disposal facility in Bukit Nanas, Negeri Sembilan; 58.0% respectively of becoming infected with HBV, HCV and was recycled and recovered at licensed premises; 19.7% was HIV. Other risks include physical injury and adverse local treated and stored within the premises of generators; 0.7% or systemic effects through contact with potentially was exported for recycling and 2.7% was disposed of at hazardous pharmaceuticals that may also be present [37]. In clinical waste incinerators [24]. the past, the re-use of needles and syringes has caused the spread of infectious diseases such as HIV and hepatitis [33].

88 International Conference on Ecological, Environmental and Bio-Sciences (ICEEBS'2012) April 13-15, 2012 Pattaya

The introduction of disposable or single-used needles and Askarian M et al. (2004) carried out a survey in 15 syringes as a solution to control the spread of infectious private hospitals in Fars Province, Iran to determine the diseases has indirectly created unnecessary problem because amount of different types of waste produced and the current the disposable needles and syringes are being disposed of in situation of waste management. The results indicated that dumping ground and reused or recycled by irresponsible the waste generation rate is 4.45 kg/bed/day, which includes person. Furthermore, there is an increase in the quantity of 1830 kg (71.44%) of domestic waste, 712 kg (27.8%) of medical waste generated especially disposable or single-use infectious waste, and 19.6 kg (0.76%) of sharps. needles and syringes. The unsafe disposal of medical waste Segregation of the different types of waste is not carried out poses public health risks [37]. Failure to dispose of perfectly. Two (13.3%) of the hospitals used containers contaminated needles and syringes safely may lead to without lids for on-site transport of waste. In the hospitals dangerous recycling and repackaging which lead to unsafe under study, there are no training courses about hospital reuse. Contaminated injection equipment may be scavenged waste management and the hazards associated with them. from waste areas and dumping grounds and either is reused The training courses that are provided are either ineffective or sold to be used again. WHO estimated that, in year 2000, or unsuitable [2]. contaminated injections with contaminated syringes caused 21 million hepatitis B virus infections (32% of all new III. METHODOLOGY infections); 2 million hepatitis C virus infections (40% of all The methodology is the tool used to carry out a research new infections); and at least 260,000 HIV infections (5% of which includes why, where, what, who and how the all new infections) [37]. The negative health and research is done. The main topics covered are the study environmental impacts of medical waste may include the area, selection of private medical clinics, methods of study, transmission of disease by viruses and microorganisms, as data collection and data analysis. well as contamination of underground water tables by The selected study area is Taiping, Perak. Taiping is untreated medical waste in landfills. located at a longitude of 100o43’41.53” E and latitude of Some of the most common problems concerning medical 4o51’24.32” N. Total population of Taiping is 191,104 in waste in developing countries in Asia are separation of 2007. There are 72 private medical clinics in Taiping. infectious waste from general waste; reuse of disposable The study respondents selected were all private medical syringes and other untreated equipment; lack of awareness practitioners in Taiping (N=72). Questionnaires were sent and training for healthcare professionals; and inadequate to all the respondents. storage facilities, transportation and disposal equipment. The response from the private medical clinics was very Medical waste problem is often overlooked or simply poor, only 19 respondents or 26% of 72 private medical viewed as a solid waste issue. Therefore, in order to protect clinics replied and returned the questionnaires. In a study public health, proper medical waste management requires carried out in Croatia by Natalija Marinkovic et al. (2008), committed planning, training and tracking throughout the the questionnaire was sent to 75 state-owned health care medical waste collection, storage, treatment and disposal facilities and 76 private practices. The response from state- process. The problem faced in the management of medical owned health care centers institutions was very high (93%). waste is due to limited reliable information on the quantities However, only 18 (24%) private practices responded to the and characteristics of various types of medical waste survey [28]. generated in healthcare facilities [11]. Improper waste More than half of the medical clinics or 11 (57.9%) management is increasingly becoming a potential public generated less than 1 kg of human tissues/blood/fluids health risk and an environmental burden [4]. WHO waste per day and only 1 medical clinic generated 1-5 kg of recommended that healthcare waste management should put human tissues/blood/fluids waste per day. Seven into a systematic, comprehensive framework, and should respondents did not answer this question. In all the medical become an essential feature of healthcare services. WHO clinics that generated syringes/needles/other sharps waste, has advocated that medical waste should be treated as 17 (89.5%) generated less than 1 kg per day, 1 (5.3%) special waste. Medical waste may represent serious health generated 1-5 kg per day and 1 (5.3%) generated more than hazards to health personnel if not properly managed 20 kg per day. There were 13 (68.4%) medical clinics [27][30]. The management of medical waste in many generated less than 1 kg of expired drugs/vaccines waste per developing countries is often poor [27][29]. The day, while 6 (31.6%) respondents did not answer the management of medical waste is driven by concerns about question. health and environmental effects, uncertainty regarding Majority of the respondents provide only medical service regulations, and the negative perceptions by waste handlers which generate very small amount of medical waste. In this [4]. In many developing countries, hazardous and medical survey, the quantity of medical waste generated by majority waste are still handled and disposed together with domestic of the medical clinics was less than 1 kg per day which is waste, thus creating a great health risk to municipal very much different from bigger hospital and medical workers, the public and the environment [6]. centre. This would increase the possibility of disposing A.D. Patil and A.V. Shekdar (2001) in India, found in medical waste as general waste because the quantity of their study that smaller private nursing homes and clinics do medical waste is small. The types of medical waste are not take any precautions and often dispose of their gloves, mask, apron, gauzes, cotton wool, swabs, human healthcare waste in the municipal waste bins [1]. Safe tissues, blood, body fluids, syringes, needles, sharps, disposal of medical waste is an essential component to expired drugs and vaccine. Other domestic waste generated maintain standard of hygiene, safe working and reduction of by medical clinics includes food, paper, plastic, metal or risk [8]. aluminium and glass. The quantity of domestic waste was

89 International Conference on Ecological, Environmental and Bio-Sciences (ICEEBS'2012) April 13-15, 2012 Pattaya also less than 1 kg per day. Suwannee Adsavakulchai secure safety in handling the waste. If not they would not (2002) in her study on waste from hospitals and clinics in collect their waste. Phitsanulok, Thailand noted that the average daily medical Six (31.6%) respondents agreed that high cost of waste generated in clinic was 0.041 kg per patient [32]. The collection/disposal is the problem faced in medical waste findings of this study is quiet similar to the one done by management while 13 (68.4%) did not agree. The method Suwannee Adsavakulchai. Even though the quantity of of disposal is by thermal treatment that is using incinerator. medical waste is a small proportion, there is still cross Three (15.8%) respondents agreed that space limitation infection risk and potential danger for environment for keeping medical waste containers is the problem faced in associated with mismanaged waste. medical waste management while 16 (84.2%) respondents The survey tried to determine the respondent’s did not agree. knowledge on the type of containers to be used for storing Fifteen (78.9%) respondents agreed that the quantity of or collecting medical waste in their clinics. The type of medical waste generated is too small is the problem faced in containers were general waste bin, normal plastic bag, medical waste management while 4 respondents did not biohazard plastic bag, sharp bin and other containers such as agree. paper basket or keep in the store. The medical clinics (n=13) Two (10.5%) respondents agreed that the procedure is too used the correct containers for storing food waste while 6 complicated or tedious is the problem faced in medical respondents did not answer. Paper waste generated in waste management while 17 did not agree. medical clinics (n=15) are collected in general waste bin, normal plastic bag and other containers. Plastic waste is IV. CONCLUSION collected in general waste bin and normal plastic bag in This descriptive study has achieved its objective by medical clinics (n=13). A respondent collected plastic discovering the method of medical waste collection and waste in biohazard plastic bag. Five respondents did not disposal methods used in private medical clinics. The type answer this question. Ten respondents collected of container used and method of disposal for medical waste metal/aluminium waste in general waste bin, normal plastic was not appropriate. The problems encountered in medical bag and other containers. One 1 respondent collected them waste management were also identified. The in sharp bin, 8 respondents did not answer, 4 respondents recommendations were proposed to improve the medical collected glass waste in general waste bin, 2 in normal waste management in private medical clinics. plastic bag, 4 in sharp bin, 2 in other containers and 7 did Based on the data and information collected in the study, not answer. it can be concluded that the medical waste management in Gloves/mask/apron waste generated in 5 medical clinics private medical clinics is improper, inconsistent, are collected in general waste bin, 3 in normal plastic bag, 4 unsatisfactory and do not comply with the requirements in biohazard plastic bag, 1 in sharp bin and 6 did not under the Environmental Quality (Scheduled Waste) answer. Four medical clinics collected gauzes/cotton Regulations 2005. There is possibility that the medical wool/swabs waste in general waste bin, 4 in normal plastic waste generated by private medical clinics is mixed and bag, 7 in biohazard plastic bag, 1 in sharp bin and 3 did not handled together with general waste because lack of answer. One medical clinic collected human training, enforcement and responsibility or to save cost. tissues/blood/fluids waste in general waste bin, 1 in normal plastic bag, 7 in biohazard plastic bag, 1 in sharp bin and 8 ACKNOWLEDGMENT did not answer. One medical clinic collected syringes/needles/other sharps waste in normal plastic bag, 3 The process of completing the research needs assistance, in biohazard plastic bag, 14 in sharp bin and 1 did not guidance and support from various parties and individuals. answer. Two medical clinics collected expired Without their help, it is impossible to complete the research. drugs/vaccines waste in general waste bin, 2 in normal I take this opportunity to convey my appreciation and plastic bag, 4 in biohazard plastic bag, 4 in sharp bin, 1 in thanks to everyone who has contributed to the research. other containers and 6 did not answer. First of all, I would like to thank my supervisor, Dr Puziah About 63.2% or 12 of the medical clinics have bt Abdul Latiff who has given support, advice, guidance and collection/disposal schedule for their medical waste while critic from beginning until the research is completed. I 31.6% or 6 did not have and 1 did not answer. would like to thank all private medical practitioners in There was a medical clinic that disposed of medical waste Taiping who have involved in the research. Special thanks daily and another one every alternate day. Four medical to Dr Khaw and Dr Choong who have contributed clinics disposed of medical waste once a week, 3 once a tremendously in the research. I would like to thank Mr month and 9 clinics disposed of medical waste irregularly. Mahalingam, the Manager of Faber Medi-Serve Sdn Bhd in One respondent did not answer. The irregularity of disposal Taiping Hospital who has provided assistances and is due to the small amount of medical waste generated. information in the research. I would like to thank Mr Out of 19 medical clinics surveyed, 5 (26.3%) kept Subramaniam a/l Karuppannan who has guided me inventory or record of medical waste while 14 did not. throughout the research. Finally, I would like to thank my Fourteen (73.7%) respondents agreed that clinic owner is responsible for the management of medical waste in private beloved wife, Tan Poh Kwan and my children for their love, medical clinic while 5 (26.3%) respondents did not agree. care and support throughout the research. 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90 International Conference on Ecological, Environmental and Bio-Sciences (ICEEBS'2012) April 13-15, 2012 Pattaya

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