Yangon University of Economics Master of Development Studies Programme Awareness of Pharmaceutical Waste Handling Practice in Pr

YANGON UNIVERSITY OF ECONOMICS MASTER OF DEVELOPMENT STUDIES PROGRAMME

AWARENESS OF PHARMACEUTICAL WASTE HANDLING PRACTICE IN PRIVATE HOSPITALS (CASE STUDY ON CHAN AYE THAR ZAN TOWNSHIP, MANDALAY DISTRICT)

MAY THU THU TIN EMDevS - 20 (15th BATCH)

OCTOBER, 2019

YANGON UNIVERSITY OF ECONOMICS MASTER OF DEVELOPMENT STUDIES PROGRAMME

AWARENESS OF PHARMACEUTICAL WASTE HANDLING PRACTICE IN PRIVATE HOSPITALS (CASE STUDY ON CHAN AYE THAR ZAN TOWNSHIP, MANDALAY DISTRICT)

A thesis submitted in partial fulfillment of the requirements for the Master of Development Studies (MDevS) Degree

Supervised by Submitted by

Dr. Khin Thida Nyein May Thu Thu Tin Professor Roll No. 20 Department of Economics EMDevS 15th Batch Yangon University of Economics (2017 - 2019)

OCTOBER, 2019

YANGON UNIVERSITY OF ECONOMICS MASTER OF DEVELOPMENT STUDIES PROGRAMME

This is to certify that this thesis entitled “Awareness of Pharmaceutical Waste Handling Practice in Private Hospitals (Case Study on Chan Aye Thar Zan Township, Mandalay District)” submitted as a partial fulfillment of the requirements for the degree of Master of Development has been accepted by the Board of Examiners.

BOARD OF EXAMINERS

1. Dr. Tin Win Rector Yangon University of Economics (Chief Examiner)

2. Dr. Ni Lar Myint Htoo Pro-Rector Yangon University of Economics (Examiner)

3. Dr. Kyaw Min Htun Pro-Rector (Retired) Yangon University of Economics (Examiner)

4. Dr. Cho Cho Thein Professor and Head Department of Economics Yangon University of Economics (Examiner)

5. Dr. Tha Pye Nyo Professor Department of Economics Yangon University of Economics (Examiner)

OCTOBER, 2019 iii

ABSTRACT

The waste generated from the health care activities including the pharmaceutical waste carries a higher potential for infection and injury than any other type of waste. The knowledge and the handling practice of pharmaceutical waste is, therefore, essential for safe environment in our society. This study analyzes knowledge, attitude and practice of the respondents on pharmaceutical waste in 10 private hospitals of Chan Aye Thar Zan Township, Mandalay. The study was conducted by the descriptive method among the private hospitals in Mandalay. This study used primary data with structured questionnaires for knowledge, attitude and practice on handling of pharmaceutical waste. In this study, most of the respondents 80.9% revealed fair level of knowledge while 11.2% had poor knowledge and 7.9% had high level of knowledge on handling pharmaceutical waste. The respondents had positive attitude, 82.2% fairly, 6.6% on highly positive and only 11.2% revealed negative attitude on handling pharmaceutical waste. The practice was 73.0% fair, 13% revealed a high and 13% had poor. This study highlighted the practice was significantly associated with knowledge, attitude and training of the respondents.

ACKNOWLEDGEMENTS

First of all, I would like to express my sincere gratitude to Professor Dr. Tin Win, Rector of Yangon University of Economics, Professor Dr. Ni Lar Myint Htoo, Pro-Rector of Yangon University of Economics, Professor Dr. Cho Cho Thein, Programme Director of Master of Development Studies and Head of Department of Economics. I am sincerely and heartily grateful to my Supervisor, Professor Dr. Khin Thida Nyein, Department of Economics, Yangon University of Economics, for the support and guidance given to me throughout my thesis writing. It is a great pleasure to express my greatest gratitude to Dr. Hla Soe Tint, MBBS, DCOHC, DPH, MPH for helping me to conduct this study and for his valuable comments and advices. I am also grateful to all the faculty members of the Department of Development Studies, University of Economics, Yangon and all the guest lecturers from the other departments for their excellent lectures, guidance and encouragement throughout the post graduate course. I gave my heartfelt thanks to all the respondents of the field survey who gave invaluable input. They are highly appreciated for their willingness and patience in providing answers to all of the questions in the questionnaire. I would also like to extend my appreciation to all those who contributed in various ways to my thesis. Finally, it is my great pleasure to thank all of my friends who helped me throughout my difficult time during my Thesis. My thesis could not have been enriched with numerous data and information without help of World Health Organization (WHO) Office, Yangon, Myanmar. Last but not the least I would like to thank my parents, my family and relatives for their understanding, endurance, encouragement and great support to me overcome all the hardships throughout my post-graduate period. I would like to special appreciations is due to my beloved sisters, friends who are cheerfully provided unending emotional support and encourage during my thesis. Thanks are also due to all my colleagues of MSF-OCA for their understanding and moral support. However, I am the person most responsible for what I have prepared and presented in my thesis.

TABLE OF CONTENTS

Page ABSTRACT i ACKNOWLEDGEMENTS ii TABLE OF CONTENTS iii LIST OF TABLES v LIST OF FIGURE vii LIST OF ABBREVIATIONS viii

CHAPTER I INTRODUCTION 1.1 Rationale of the Study 1 1.2 Objective of the Study 4 1.3 Method of Study 4 1.4 Scope and Limitations of the Study 4 1.5 Organization of the Study 5

CHAPTER II LITERATURE REVIEW 2.1 Definition and Classification of Health Care Waste 6 2.2 Pharmaceutical Waste 7 2.3 Guiding Principle for Handling Practice of Pharmaceutical 9 Waste 2.4 Impacts of Pharmaceutical Waste in Society 14 2.5 Review on Previous Studies 16

CHAPTER III PHARMACEUTICAL WASTE HANDLING PRACTICE IN MANDALAY 3.1 National Policy Framework of Health Care 20 Waste Management 3.2 Current Handling Practice of Pharmaceutical Waste in 22 Mandalay 3.3 Hospitals in Mandalay 24

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CHAPTER IV ANALYSIS OF THE SURVEY 4.1 Survey Profile 27 4.2 Survey Design 27 4.3 Characteristics of Private Hospitals and Respondents 29 4.4 Survey Analysis 35

CHAPTER V CONCLUSION 5.1 Findings 52 5.2 Recommendations 56

REFERENCES APPENDICES

LIST OF TABLES

Table No. Title Page 2.1 Typical Waste Composition in Health Care Facilities 6 2.2 Categories of Health Care Waste 7 3.1 Waste Composition in Medical Waste 23 3.2 List of Public Hospitals in Mandalay 25 3.3 List of Private Hospitals in Mandalay 26 4.1 Frequency Distribution of Socio-demographic Characteristics of 29 Private Hospital (n = 10) 4.2 Frequency Distribution of Compound, Ward inspection and 30 Instruction guide to use Waste Bins in private hospital (n=10) 4.3 Compound Inspection in Private Hospital 31 4.4 Ward Inspection in Private Hospital 31 4.5 Instruction Guide to Use Waste Bins in Private Hospital 32 4.6 Content Analysis of the Waste Bags 32 4.7 Frequency Distribution of Socio-demographic Characteristics of 33 Respondents (n=152) 4.8 Frequency Distribution of Socio-demographic Characteristics of 34 Respondents (n=152) 4.9 Frequency Distribution of Rank of Respondents (n=152) 34 4.10 Frequency Distribution of Education of Respondents (n=152) 35 4.11 Frequency Distribution of Experience of Respondents (n=152) 35 4.12 Knowledge Status of Respondents on Segregation of 36 Pharmaceutical Wastes (n=152) 4.13 Attitude Status of Respondents on Segregation of 37 Pharmaceutical Wastes (n=152) 4.14 Practice Status of Respondents on Segregation of 38 Pharmaceutical Wastes (n=152) 4.15 Knowledge Status of Respondents on Collection of 39 Pharmaceutical Wastes (n=152) 4.16 Attitude Status of Respondents on Collection of 40 Pharmaceutical Wastes (n=152)

4.17 Practice Status of Respondents on Collection of 41 Pharmaceutical Wastes (n=152) 4.18 Knowledge Status of Respondents on Storage of 42 Pharmaceutical Wastes (n=152) 4.19 Attitude Status of Respondents on Storage of 43 Pharmaceutical Wastes (n=152) 4.20 Practice Status of Respondents on Storage of 43 Pharmaceutical Wastes (n=152) 4.21 Knowledge Status of Respondents on Transportation of 44 Pharmaceutical Wastes (n=152) 4.22 Attitude Status of Respondents on Transportation of 45 Pharmaceutical Wastes (n=152) 4.23 Practice Status of Respondents on Transportation of 45 Pharmaceutical Wastes (n=152) 4.24 Overall Knowledge Level of Respondents on Handling 46 Pharmaceutical Wastes 4.25 Overall Attitude Level of Respondents on Handling 47 Pharmaceutical Wastes 4.26 Overall Practice Level of Respondents on Handling 48 Pharmaceutical Wastes 4.27 Frequency Distribution of Barrier on Handling Practice of 48 Pharmaceutical Waste Management of Respondents 4.28 Frequency Distribution of Barrier on Handling Practice of 49 Pharmaceutical Waste Management of Respondents 4.29 Associations Model between Knowledge, Attitude and Practice 50

LIST OF FIGURE

Figure No. Title Page 2.1 The Steps of HCW Streams and Keys Points 10

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LIST OF ABBREVIATIONS

AT Attitude Total CCET IGES Center Collaborating with UN Environment on Environmental Technologies DoPH Department of Public Health ECD Environmental Conservation Department ENT Ear, Nose and Throat EQM Environmental Quality Management Company Limited GP General Practitioner HBV Hepatitis B Virus HCFs Health Care Facilities HCV Hepatitis C Virus HCWM Health Care Waste Management HCWs Health Care Wastes HIV Human Immunodeficiency Virus IGES Institute for Global Environmental Strategies IV Intravenous KAP Knowledge, Attitude and Practice KT Knowledge Total MCDC Mandalay City Development Council MoHS Ministry of Health Service PPE Personal Protective Equipment PT Practice Total RHC Rural Health Clinic SOP Standard Operating Procedure UNEP United Nations Environmental Program UNSDGS United Nation’s Sustainable Development Goals WHO World Health Organization YCDC Yangon City Development Council

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CHAPTER I INTRODUCTION

1.1 Rationale of the Study Health care means not only for protecting health, providing treatment and saving lives but also reducing risks that can provoke further health-related issues such as infection, trauma and chemical exposure. As a consequent, medical waste management became one of the important factors to control in every country. Under the medical waste management, pharmaceutical waste management is equally important for unwanted materials those can eventually lead to be harmful to humans and environments. While pharmaceutical wastes are existing in many different forms such as strips, expired products and management wastes, it also come from various sectors of health care systems such as manufactures, hospitals, individual physicians and etc. Each country in the world has different regulatory to prevent pharmaceutical wastes which are involved in waste management and waste management strategies. According to World Health Organization statistics report in 2013, pharmaceuticals enter the environment via a number of pathways but mostly from patient excretion or the disposal of unwanted pharmaceuticals. The size of the issue is brought into context when one considers that the global pharmaceuticals market is worth US$300 billion a year, a figure expected to rise to US$400 billion within three years (WHO, 2013). Moreover, BMI Research’s Q3 2018 Pharmaceuticals and Health Care Report shows that while health spending is forecasted to grow from USD 1.476 billion in 2017 to USD 2.364 billion in 2022, health spending as a percent of GDP likely continue to drop through to 2022, as economic growth is set to outpace the annual increase in health expenditure (EUROCHARM, 2018).According to that report, the health spending is forecasted to grow and the waste from the health sector can be increased. (Premakumara, Hengesbaugh, Onogawa, & Hlaing, 2017)

Meanwhile the United Nations’ Sustainable Development Goals (UNSDGs) also highlighted the needs of effective waste management such as ensuring health lives and promote well-being for all at all ages which is followed by the target of sustainability reduce the number of deaths and illness from hazardous chemical and air, water and soil pollution and contamination by 2030. It is also called for more research and development, increased health financing and strengthened capacity of all countries in health risk reduction and management. Health care waste management is one of the issue that has been persistently under-recognized and under-resourced, with enormous knock-on efforts for workers, patients and the community. Health care wastes are all wastes generated by health care and health research facilities and associated laboratories, hospitals, clinics and pharmacy stores. In Myanmar, though there is incomplete information on the current levels of medical waste generations in the country, Yangon City Development Council (YCDC) and Mandalay City Development Council (MCDC) estimate that an average the medical waste that is generated comprises 280 and 779 tons per year, respectively. A significant portion of this (over 70%) is infectious waste (Premakumara, Hengesbaugh, Onogawa, & Hlaing, 2017) Moreover, the recent policy reforms that promotes economic liberalization triggered the country to receive more foreign direct investment that can foster Myanmar economic growth in all sector. In the meantime, there are other challenges followed by those positives outcomes. One of the challenges included the medical and pharmaceutical waste management especially in the private sector. Meanwhile the previous researches about the waste management in Myanmar mainly focused in the challenges, regulations and recommendations, this paper will examine how the private hospitals in Mandalay manage for its daily waste management in order to provide the recommendations to the regional and national government. In Mandalay, there are an estimated 10 public hospitals and over 30 private hospitals. Economic growth and development require the production of goods and services that improve the quality of life. Sustainable growth and development require minimizing the natural resources and toxic materials used, and the waste and pollutants generated, throughout the entire production and consumption process. Sustainable procurement is also required: almost all hospital waste has come in the front door as a product. Health care needs to leverage its buying power to ensure that

2 the materials it purchases generate as little waste as possible that is toxic, non- repairable, non- recyclable or simply unnecessary. Pharmaceutical waste is a category of health care waste that belongs to the hazardous health care waste stream. Hospital generate daily pharmaceutical and cytostatic waste during the provision of health care services to patients (Verica, Jelena, Dragomir, Branislava, & Nela., 2016). Therefore, the implementation of safe health care waste management practices is also important. In many countries, hazardous and medical waste are still handled and disposed together with domestic wastes that creating a great health risk to health workers, the public and the environment (Mania, Andrew, & Caroline, 2016). The key to effective management of health care waste is segregation at point of generation (Asadullah, Karthik, & Dharmappa, 2013). Segregation means placing the various categories of waste into different color-coded bins. Despite the necessity of segregation in health care waste management, some countries either lack proper rules and regulations on HCW segregation or do not impose them; hence the health care waste management systems are insufficient (Nwachukwu, Orji, & Ugbogu, 2013). In 2014, World Health Organization set up the minimum approach to overall management of health care waste contains waste minimization, segregation, special handling, collection and transport, storage, treatment and disposal arrangement. The management of health care waste requires intense devotion and diligence because, if poorly managed, it may cause risk to health care workers, waste handlers, patients, and the entire community (WHO, 2014). The poor management on handling practice of pharmaceutical waste can cause the various health and environmental risks that is one of the public health concern. The improper disposal may be hazardous if it leads to contamination of water supplies or local sources used by nearby communities (Atual Kadam, 2016). Adequate knowledge about the health hazard of hospital waste, proper technique and methods of handling the waste, and practice of safety measures can go a long way toward the safe disposal of hazardous hospital waste and protect the community from various adverse effects of the hazardous waste (Suwarna Madhukumar, 2012). Up to now, there has not been any published study regarding with the awareness of the pharmaceutical waste handling practice in Myanmar. There are only published studies about the hospital waste management. So, this study compares the status of

3 knowledge, attitude and practice in awareness of pharmaceutical waste handling practice and the current situation of private hospital of Chan Aye Thar Zan Township, Mandalay. Moreover, the finding in this study will be expected to use as a part of information in the development of national standard operation guidelines for health care waste management.

1.2 Objectives of the Study The objectives of the study are: (1) To access the knowledge, attitude and the current handling practice of the responsible person on pharmaceutical waste handling in private hospital in Chan Aye Thar Zan Township. (2) To find out the associations between knowledge, attitude and practice of pharmaceutical waste handling.

1.3 Method of Study The study used the random sampling technique and the descriptive method. The study participants included doctors, nurses, pharmacist and general health workers concern with pharmaceutical waste management in selected private hospitals in Chan Aye Thar Zan Township. This study based on the knowledge, attitude and practices (KAP) survey. This study used the primary data with predefined questions formatted in structured questionnaires. The secondary data from publication, reports and articles will be used in this study. This study also based on the quantitative and qualitative survey through interviews.

1.4 Scope and Limitations of the Study The study conducted the awareness on pharmaceutical waste handling practice in 10 randomly selected private hospitals covering area of Chan Aye Thar Zan Township only in Mandalay. There are total 20 private hospitals in this township; the data are collected from 50% of the total private hospital; 10 selected private hospitals and 152 people including doctors, nurses, pharmacists, and general workers that will be surveyed in handling practice of pharmaceutical waste. This survey studied awareness of pharmaceutical waste handling practices in the private hospital especially segregation at source, collection, storage within the

4 private hospital and regular collection from MCDC. This survey was not identified the medical waste management process. This survey found out the knowledge, attitude and awareness in handling practice of pharmaceutical waste. This survey analyzed and evaluated the present status of pharmaceutical waste handling practices in the light of medical waste control regulations recommended by WHO and the other countries.

1.5 Organization of the Study This study includes 5 chapters based on the facts and data collected in area of Chan Aye Thar Zan Township. Firstly, the chapter one presents the introductory aspect of the study which captures the rationale, objective, scope, methodology of the study and organization of the study. Chapter two includes the reviewed literatures which shows the awareness of the pharmaceutical waste handling practice and the chapter three contains the Pharmaceutical waste practice in Mandalay. Chapter four presents the research methodology, the analysis of the survey and the analysis result gathered. The final one, chapter five provides the findings and recommendations of the study.

CHAPTER II LITERATURE REVIEW

2.1 Definition and Classification of Health Care Waste There are many definitions for health care waste. The term health care waste includes all the waste generated within health care facilities, research centers and laboratories related to medical procedures. It includes the waste produced from the health care undertaken in the home. The health care provider produced the domestic waste that usually called “general health care waste” or “non-hazardous waste” between 75% and 90%. This includes the administrative, kitchen and housekeeping functions at health care activities and also includes packaging waste. The remaining 10% to 25% of health care waste are noticed as hazardous and may pose a variety of environmental and health risks. The table (2.1) represented the typical waste compositions in health care facilities. (WHO, 2014)

Table (2.1) Typical Waste Composition in Health Care Facilities Type of Wastes Composition (%) General 85% (non-hazardous health care waste) Infectious 10% (harzardous health care waste) Chemical/ ardioactive 5% (harzardous health care waste) Source: Safe management of waste from healthcare activities: WHO 2014

According to the safe management of waste from health care activities: WHO second edition, there are non-hazardous or general health care waste and hazardous health care waste. The non-hazardous or general health care waste includes all the wastes that has not been infected like packaging and they are similar to normal household waste. A classification of hazardous health care waste is summarized in Table (2.2).

Table (2.2) Categories of Health Care Waste Waste Category Descriptions and Examples Hazardous Health Care Waste Used or unused sharps (e.g. hypodermic, intravenous or other Sharp wastes needles: auto-disable syringes; syringes with attached needles; infusion sets; scalpels; pipettes; knives; blades; broken glass; Waste suspected to contain pathogens and that poses a risk of disease transmission (e.g. waste contaminated with blood and other body fluids; laboratory cultures and microbiological Infectious wastes stocks; waste including excreta and other materials that have been in contact with patients infected with highly infectious diseases in isolation wards) Pathological Human tissues, organs or fluids; body parts; fetuses; unused wastes blood products Pharmaceuticals that are expired or no longer needed; items Pharmaceutical contaminated by or containing pharmaceuticals waste, cytotoxic Cytotoxic waste containing substances with genotoxic waste properties (e.g. waste containing cytostatic drugs – often used in cancer therapy; genotoxic chemicals) Waste containing chemical substances (e.g. laboratory reagents; film developer; disinfectants that are expired or no Chemical waste longer needed; solvents; waste with high content of heavy metals, e.g. batteries; broken thermometers and blood-pressure gauges) Waste containing radioactive substances (e.g. unused liquids from radiotherapy or laboratory research; contaminated Radioactive waste glassware, packages or absorbent paper; urine and excreta from patients treated or tested with unsealed radionuclides; sealed sources) Non-hazardous or general health care waste - Waste that does not pose any particular biological, chemical, radioactive or physical hazard Source: Safe management of waste from healthcare activities: WHO 2014

2.2 Pharmaceutical Waste The term "pharmaceuticals" embraces a multitude of active ingredients and types of preparations. The spectrum ranges from teas through heavy metal containing disinfectants to highly specific medicines. Waste management therefore requires the use of a differentiated approach. This category of waste comprises expired pharmaceuticals or pharmaceuticals that are unusable for other reasons (e.g. call-back campaign). Pharmaceutical wastes are divided into three classes. Their management

7 occurs in a class-specific manner.  Non-hazardous pharmaceutical waste - This class includes pharmaceuticals such as chamomile tea or cough syrup that pose no hazard during collection, intermediate storage and waste management. They are not considered hazardous wastes and should be managed jointly with municipal waste.  Potentially hazardous pharmaceutical waste - This class embraces pharmaceuticals that pose a potential hazard when used improperly by unauthorized persons. They are considered as hazardous wastes and their management must take place in an appropriate waste disposal facility.  Hazardous pharmaceutical waste - The pharmaceutical waste comprises heavy metal containing and unidentifiable pharmaceuticals as well as heavy metal containing disinfectants, which owing to their composition require special management. They must be considered as hazardous wastes and their management must take place in an appropriate waste disposal facility.

Cytotoxic pharmaceutical waste - Cytotoxic pharmaceutical wastes are wastes that can arise by use (administration to patients), manufacture and preparation of pharmaceuticals with a cytotoxic (antineoplastic) effect. These chemical substances can be subdivided into six main groups: alkylated substances, antimetabolites, antibiotics, plant alkaloids, hormones, and others. A potential health risk to persons who handle cytotoxic pharmaceuticals results above all from the mutagenic, carcinogenic and teratogenic properties of these substances. Consequently, these wastes pose a hazard, and the measures to be taken must also include those required by occupational health and safety provisions. (e.g., Discernible liquid residues of cytotoxic concentrates, post-expiration-date cytotoxic pharmaceuticals and materials proven to be visibly contaminated by cytotoxic pharmaceuticals must be disposed of as cytotoxic pharmaceutical waste (WHO, 2005). As mentioned above, there are three classes of pharmaceutical wastes. Among them, the potentially hazardous and hazardous are important to handle with proper waste management. It includes expired, unused, spilt and contaminated pharmaceutical products, prescribed and proprietary drugs, vaccines and sear that are no longer required, and, due to their chemical or biological nature, need to be disposed of carefully. It also includes discarded items heavily contaminated during the handling of pharmaceuticals, such as bottles, vials and boxes containing

8 pharmaceutical residues, gloves, masks and connection tubing. It includes the items containing genotoxic waste which include cytostatic (used in chemotherapy of cancer) drugs (WHO, 2005).

2.3 Guiding Principle for Handling Practice of Pharmaceutical Waste World Health Organization (WHO) release the guideline for handling practice of disposal waste management for all of the health care waste. Most of the country release their own guideline and procedure based on WHO guidelines. In Myanmar, the health care waste management is not specific mentioned but it is in the process of developing SOPs and guidelines in Department of Public Health (WHO, Regional Office for South-East Asia, 2017) According to the safe management of waste from health care activities, WHO 2014, the health care waste should follow an appropriate and well-identified stream from their point of generation until their final disposal. This stream is composed of several steps that include waste minimization, generation, segregation collection and on-site transportation, on-site storage, offsite transportation (optional), treatment and disposal of the HCW. The steps of HCW streams and keys points are illustrated in figure (2.1).

Figure (2.1) The Steps of HCW Streams and Keys Points

Health Care Waste Stream Key Points

Stock Management Waste Minimization Centralized purchasing of hazardous chemicals Generation One of the most important step to reduce risk and Segregation at amount of hazardous waste source Protective equipment; sealed Collection + On-site Transport containers; specific easy to wash trolleys

Lockable easy to clean On-site Storage storage room; limited storage time of 24-48 hours

On-site Treatment / Disposal Adequate storage room; limited time of max 48 hours

Off-site Transport Appropriate vehicle and consignment note

Off-site Treatment / Disposal Appropriate vehicle and consignment note

Source: Safe management of waste from health care activities: WHO 2014

2.3.1 Waste Minimization of Pharmaceutical Waste The most efficient measure for waste minimization or reduction lies in the careful stock management of medical stocks in the hospital pharmacies. The reduction in purchasing amount of the product with hazardous waste lead to reduce in the amount of waste generated. The more frequent ordering of relatively small quantities rather than large amounts at one time cause the reduction of the quantities used. Using the oldest batch of a product first and checking of the expiry date of all products at the time of delivery and refusal to accept the short-dated items from the supplier is one of the stock management in the hospital pharmacies. In waste-minimization process,

10 there are the potential responsible partners; they are the suppliers of pharmaceutical products who can provide the rapid delivery of small orders, who can accept the return of un-opened stock and who offer offsite waste-management facilities of hazardous wastes (WHO, 2014).

2.3.2 Generation of Pharmaceutical Waste Pharmaceutical waste is potentially generated through a wide variety of activities in a health care facility, including but not limited to intravenous (IV) preparation, general compounding, spills/breakage, unused preparations, unused vials, syringes, discontinued, unused preparations, unused unit dose repacks, patient’s personal medications and outdated pharmaceuticals (Mangilal, Vijaya Kumari, & Kavitha, 2014). There are minor or major sources of pharmaceutical wastes depend on the different types of health care facilities and the quantities produced. The major sources of pharmaceutical wastes are well known, that hospitals (University hospital, General hospital, District hospital and Private Hospital). The other health care facilities as like emergency medical care services, health care centers and dispensaries, obstetric and maternity clinic, outpatient clinics, military medical services, prison hospitals or clinic and nursing homes for the elderly are also the major sources of pharmaceutical waste. The minor sources of pharmaceutical wastes are the small health care establishments (physician’s office and dental clinics) and specialized health care establishments and intuitions which low waste generation (psychiatric hospitals, disabled person’s institutions and home treatment. (WHO, 2014)

2.3.3 Segregation of Pharmaceutical Waste The health care wastes are generated in the medical area and segregation of the waste at the source is one of the most important step. Segregation should be carried out in place of waste generation in medical area such as at a bedside and in an operation theatre. The simplest waste segregation system is to separate all hazardous waste from the larger quantity of non-hazardous general waste. The segregation of general, non-hazardous waste, potentially infectious waste and used sharps into separate containers is referred to “three-bin system”. Many countries have national legislation that prescribes the waste segregation categories to be used and a system of color-coding for waste containers. Color coding makes it easier for medical staff and

11 hospital workers to put the waste items into the correct containers and to maintain segregation of the wastes during transport, storage, treatment and disposal and it also provides a visual indication of the potential risk posed by the waste in that container. The another recommendation is labelling with the international hazard symbol on each waste containers is used to identify the source, record the type and quantities of the waste produced in each area and allow problems with waste segregation to be traced back to a medical area. The segregation posters for medical and general workers help to raise knowledge about segregation practice and improve the quality of separated waste components. (WHO, 2014) Sorting should be done in a well ventilated, as close as possible to the stockpile in an orderly way, with all sorted material clearly labelled, and separated all the times. The expired pharmaceutical wastes should be sorted by active ingredient (special disposal needed) such as controlled substances: e.g., narcotic, psychotropic substances, anti-infective drugs, antineoplastic, cytotoxic-anti-cancer drugs, toxic drugs, antiseptics and disinfectants. It also should be sorted by dosage form solids, semi-solid and powders such as tablets, capsules, powders for injections, mixtures, creams, lotions, gels, suppositories, liquids such as solutions, suspensions, syrups, ampoules and aerosol canisters including propellant-driven sprays and inhalers. The staffs should be wear protective equipment (gloves, boots, overalls, dust masks, etc.) and should work under the direct supervision of a pharmacist and should receive the training on the sorting criteria. Once sorted, the pharmaceuticals should be carefully packed into steel drums or into containers such as sturdy cupboard boxes with the contents clearly indicated on the outside of the containers.

2.3.4 Collection and On-site Transport of Pharmaceutical Waste The collection time should be fixed and appropriate to the quantity of waste produced in each area. The general waste should not be collected at the same time or in the same trolleys as infectious or other hazardous wastes. In on-sites transports, the specific routes should be set to prevent exposure to staff and patients and to minimize the passage of loaded carts through patient care and other clean areas. Regular transport routes and collection times should be fixed and reliable. Transport staff should wear adequate personal protective equipment, gloves, strong and closed shoes, overalls and masks. Hazardous and non-hazardous waste should always be transported separately. The transport staff are vaccinated at least against Hepatitis A, B, polio and tetanus. (WHO, 2014)

2.3.5 Storage of Pharmaceutical Waste The storage areas should be sized according to the quantities of waste generated and the frequency of collection. The areas must be totally enclosed and separate from supply rooms or food preparation areas. The areas should be labelled in accordance with the hazard level of the stored areas and its access should always be limited to authorized personnel. It should also be easy to clean, lockable, have good ventilation and lighting. A maximum storage should not exceed 24 hours. Non risk health care waste should always be stored in the separate location from the hazardous health care waste in order to avoid cross-contamination. Pharmaceutical waste should be stored from other wastes and local regulations followed for final disposal. In general, pharmaceutical waste can be hazardous or non- hazardous and liquids or solid in nature, and each should be handled differently. The pharmaceutical waste streams that are listed below can be distinguished (WHO, 1999): Pharmaceutical waste with non-hazardous characteristics that can be stored in a non hazardous storage area  Ampoules with non-hazardous content  Fluids with non-hazardous content  Solids or semi-solids, such as tablets, capsules, granules, powders for injection, mixtures, creams, lotions, gels and suppositories  Aerosol cans including propellant-driven sprays and inhalers. Hazardous waste that should be stored in accordance with their chemical characteristics (e.g. genotoxic drugs) or specific requirements for disposal (e.g. controlled drugs or antibiotics)  Controlled drugs (should be stored under government supervision)  Disinfectants and antiseptics  Anti-infective drugs (e.g. antibiotics)  Genotoxic drugs  Ampoules with antibiotics Cytotoxic pharmaceutical waste may also carry a risk of infection. Genotoxic waste is highly toxic and should be carefully away from the other health care waste in a designated secured location. (WHO, 2014)

2.3.6 Off-site Transport of Pharmaceutical Waste The off-site transportation is required when hazardous health care waste is treated outside. Before sending hazardous health care wastes offsite, transport documentation (commonly called a “consignment note” or “waste tracking note”) should be prepared and carried by the driver. All vehicles should carry a consignment notes from the point of collection to the treatment facility. On completion of a journey, the transporter should complete a consignment note and return it to the waste producer. The vehicles used for the collection of hazardous health care waste should not be used for other purposes. They shall be free of sharp edge, easy to load and unload by hand, easy to clean/disinfectant and fully enclosed to prevent any spillage in the hospital premises or on the road during transportation. (WHO, 2014)

2.3.7 On-site and Off-site Treatment of Pharmaceutical Waste The on-site treatment facilities are particularly appropriate in areas where hospitals are situated far from each other and the road system is poor. The treatment cost may be high and the extra technical staff may be required to operate and maintain the facilities and it may be difficult for the relevant authorities to monitor the performance of many small facilities. The advantages of on-site treatment facility include convenience and minimization of risk to public health and the environment by confinement of hazardous/ infectious healthcare waste to the health care premises. The healthcare waste can be treated off-site when the centralized regional facilities exist. Although the off-site treatment increases dependency on an external actor and requires a fine tuned transportation system, it provide the advantages such as the greater cost effectiveness for large units and it will be easier for the relevant government agencies to supervise and monitor the facilities. (WHO, 2014)

2.4 Impacts of Pharmaceutical Waste in Society Globalization encourages the world as a village where the information flows rapidly and the living standard of the people change in every day. The consequences of the globalization are varied in both negative and positive ways. However, one of the most obvious problem nowadays is related to the environmental impacts. Among them, the waste management become a crucial factor that can harmful the society. Among the negative environmental impacts, the pharmaceutical waste is one the most important and can give harmful effect to our society if not properly managed.

Treatment and disposal of healthcare waste may pose health risks directly through the release of pathogens and toxic pollutants into the environment. Excreted pharmaceuticals from patients do find their way into waterways, which can contribute to potentially serious environmental effects, including toxicity to wildlife and the generation of antibiotic resistance in bacteria (Guardabassi, Petersen, Olsen, & Dalsgaard, 1998). Pharmaceutical waste is not only an environmental issue, like other waste management, it is part of many peoples’ working conditions in respect to how it is handled, contained and disposed of. When the materials entail a serious hazard, it requires special handling to ensure safety. The staff who involved in the handling of pharmaceutical waste may be at risk of respiratory or dermal diseases caused by exposure to pharmaceuticals and chemicals (Mangilal, Vijaya Kumari, & Kavitha, 2014). During handling of wastes, the sanitary labourers can be injured if the waste has not been packed safely. The labourers that worked with health care waste are more getting to chance the exposure of infected diseases such as HIV, HBV and HCV etc., Supporting the people from society in awareness of the waste handling practice of pharmaceutical waste to minimize the overall risks into the environment. Not only the medical staffs but also the people who are working with the health care product in society should know the process of how to handle the disposal waste in proper management. This will protect the health care worker and the population and minimize indirect impacts from environmental exposure to health care waste. Meanwhile there has been growing awareness of the need for handling practice in safe management of health care waste not only all over the world but also all over Myanmar. Hospitals have different practices concerning pharmaceutical and cytostatic waste management due to the different level of education of the staff and there is a need for strengthening the education of hospital staff concerning proper pharmaceutical waste management in Serbia (Verica, Jelena, Dragomir, Branislava, & Nela., 2016). Even the health care provider has adequate knowledge but the practices are inappropriate due to lack of proper facilities and interest of individual it is therefore imperative to evaluate practice on medical waste management in Kenya (Mania, Andrew, & Caroline, 2016). In Brazil, the health care waste contained pathogenic strains of Staphylococcus species, Gram-negative rods of the Enterobacteriaceae family and non-fermenters. Bacterial resistance to all the antimicrobials tested was observed in all microbial

15 groups, including resistance to more than one drug. This makes it possible to suggest that viable bacteria in health care waste represent risks to human and animal health. Furthermore, occurrences of multi-resistant strains support the hypothesis that health care waste acts as a reservoir for resistance markers, with an environmental impact. The lack of regional legislation concerning segregation, treatment and final disposal of waste may expose different populations to risks of transmission of infectious diseases associated with multi-resistant microorganisms. Potential infectious risks include the spread of infectious diseases and microbial resistance from health care establishments into the environment and thereby posing risks of getting infections and antibiotic resistance in the communities (Sharma, Pradhan, & Mishra, 2010). The health care waste including pharmaceutical waste management practices are substandard although there is basic awareness at all levels about the importance of protecting health workers and communities living within the vicinity of health care waste. Respective townships and city development committees are responsible for collecting medical waste. Both YCDC and MCDC collect medical waste from large hospitals and special clinics on a daily basis while collection service is provided to smaller facilities once a week or on an on-call basis (Premakumara, Hengesbaugh, Onogawa, & Hlaing, 2017). The economic growth due to Myanmar reform policies, there will be changing in consumption and production patterns that lead to increase in waste generation as well as the proliferation of emerging waste streams such as industrial, medical, and hazardous waste. Therefore, the awareness on pharmaceutical waste handling practice will be important role in our society and it creating the challenges for national, state/regional and township governments with regard to handling practice and waste management.

2.5 Review on Previous Studies Yangon General Hospital generates an average 1439.62kg of non-hazardous and 46.27kg of hazardous health care waste per day. The annual generation rate of health care waste was 525.46 tons per year. 25.77% of manpower was shortage in hospital service and 31.9% of manpower was shortage in menial worker show that the waste handling process has not enough worker. Then, 88% of menial workers are not educated and they do not have right awareness on health care waste management. This indicate a clear evidence to enforce the strong management of health care wastes

16 handling in Yangon General Hospital to be achieved not only for safety environment but also for the public health promotion. (SoeHlaing, 2012) A knowledge, attitude and practice study of health care workers on health care waste disposal was assessed in Mandalay General Hospital. There were 146 respondents in operational level, 80 respondents in managerial level. Most of respondents were knowledgeable. In operational level, only 0.7% of respondents had negative attitude and 99.3% of respondents had positive attitude. In managerial level, there were 8.8% of respondents with negative attitude and 91.2% of respondents with positive attitude. Regarding the Practice, 84.1% had good practice. There were a number of problems on health care waste management. These are lack of discipline, lack of knowledge on health care waste and its effect on health and environment, lack of support for necessary equipment, lack of supervision for proper disposal of waste (Phyu Pyar Kyaw Swe, 2011) A cross sectional descriptive study was conducted at North Oakkalapa General Hospital, Yangon Region from September to December, 2015. In summarization of knowledge score, 53.6% were poor knowledge and 46.4% were good knowledge on health care waste management. Number of health care providers with good attitude is higher than those with poor attitude, having 59.6% and 40.4% respectively. Regarding the practice on health care waste management, 48.8% of respondents had poor practice and 51.2% had good practice (Kaung Myat Wyunn, 2015). G.Seng Taung, 2010 studies on Environmental Health situation in Health Setting (General Practitioner Clinics) at Lashio. It is a cross-sectional descriptive study conducted in 52 general practitioners clinic in Shan State. About 87% of the studied clinics separated their health care waste but only 20% emphasized on both sharps and infectious waste. Only 6% of the clinics are practicing in color coding and labelling practice. Regarding waste storage practice, 83% stored more than 72 hours. Concerning final disposal methods used by the studied clinics, 73% relied on municipal operating system and 10% used opened burning method. Han Min Than, 2017 studies on Knowledge, Attitude and Practice on healthcare waste management among general practitioner in North Okkalapa Township, Yangon. The summarization of the study in knowledge score, 56% were good and 44% were poor on health waste management. Regarding the practice on healthcare waste management, 76% of respondents had poor practice and only 24% had good practice.

Saw Lwin, 2018 studies on Assessment of Health Care Waste Management of Private Clinic in Mandalay. Only 53.64% of GPs had good knowledge and 43.64% had positive attitude on health care waste management. None of GP was good at labelling and disinfection practice. Almost all of GPs accepted lack of instruction or guideline as barrier to proper health care waste management. s In a study of 1800-bedded tertiary care hospital in Mumbai, it was found that waste segregation was less than satisfactory in 40.3% of areas in spite of continuous monitoring and informal counseling of HCWs (Nataraj, et al., 2008). In another study conducted in 1300-bedded Government College and Hospital and 50-bedded private hospital of a south Indian city (Rao, 2009), it was found that waste segregation was not proper. In Poland, the significantly portion of respondents do not know or follow the rules for the proper disposal of expired pharmaceuticals. The female has more awareness in practice of pharmaceutical disposal method than male in their household. The respondents dispose of their pharmaceutical in their household rubbish or into the sewage system because they did not aware of the harmful impacts of pharmaceutical waste on the environment. This study used ‘snow ball’ method of survey sample selection, the survey was sent to a random selection of populations and asked them to complete the questionnaire and to forward copies of the blank questionnaires to other people on their own contact lists who might also take part. The 2 survey are taken: 1 for the use of pharmaceutical and disposal method and 2 for disposal of expired household pharmaceuticals by persons visiting pharmacies. This study recommended that the general population need to educate on environmental impacts of pharmaceutical waste in society and awareness of it. (Rogowska, Zimmermann, Muszynska, Ratajczyk, & Wolska, 2019) In the studies on Knowledge, Awareness and Disposal Practice for Unused Medications among the students of Private University of Bangladesh indicated that there are no standard mediation disposal protocols and none of people even the pharmacists know about the protocols, hence they fail to follow them. This study was an educational and cross-sectional survey involving with respondents on a structured and multiple choice questions and the objectives is to assess the knowledge, awareness and practice to develop about harmful effects of medication’s waste. This study highlighted that gender equal on distribution of knowledge and lack in unused medication disposal practice. The increasing environmental awareness in the

18 community of Bangladesh are highly recommended. The suggestion of developing public awareness and education on medical waste issue via the campaign are found. (Zubair Khalid, Mir Md. Adullah, Md, Harun-or-Rashid, & Krishanu, 2013) In the Assessment of pharmaceutical waste management at 5 selected hospitals and homes in Ghana, there is no specific legislation, regulations for the health care waste management and the training of waste management process. The unused or expired medications are kept at home is becoming common practice and a quarter of the respondents (44.6%, out of total 83 respondents) did not know the environmental impacts of pharmaceutical waste. The more than three quarters of the respondents disposed the pharmaceutical waste in the waste bins. This study is the simple descriptive analysis and SPSS was used for analysis. This study highlighted that the most hospitals were not obeying the color coding systems and container as prescribed by MOH for the collection of pharmaceutical waste. There is a policy or guidelines for handling practice of pharmaceutical waste management, during the study, the reality is different. The education or awareness on the proper handling practice of pharmaceutical waste to the patients, doctors, pharmacists and the health care staff within and outside the hospital are recommended. (Sasu, Kummerer, & Kranert, 2011) The study in assessment of knowledge, attitude and practice towards disposal of unused and expired pharmaceuticals among community in Harar city of Eastern Ethiopia, the guidelines on safe disposal of unused and expired pharmaceuticals waste management are needed and awareness about that guidelines among the public should be created. This was descriptive cross-sectional study of 695 residents in Kabele 16 (Ward) of Jinela Woreda (District). The data were entered into episdata analyzed by using SPSS version 20 software. 86% of the respondents had improper disposal of unused and expired medicine had harmful effects on the environment. 53.2% respondents were disposed the unused and expired pharmaceuticals in waste bins, 15.5% did not know about the practice of expired medication disposal. This study highlighted that the lack of awareness on proper pharmaceutical waste disposal and the poor involvement of health care professional in generating awareness and guiding the consumers on proper disposal practices. (Ayele & Mamu, 2018)

CHAPTER III PHARMACEUTICAL WASTE HANDLING PRACTICE IN MANDALAY

3.1 National Policy Framework of Healthcare Waste Management According to the report on health care waste management status in Countries of the South-East Asia Region, 2017, Myanmar is in the process of streamlining their policies and would need to enhance the capacity to manage the health care waste. Capacity-building of stake holders and providing infrastructure would be the major focal points for the country. The two policies; 1972 Public Health Law and 1993 National Health Policy mentioned definitely about the health and environmental protection. However, there is no separate legislation or policy on health care management and there is a plan to develop them in future. (WHO, Regional Office for South-East Asia, 2017) The Department of Medical Services have the two existing general policies: Hospital Infection Control and Hospital Management Manual (2011). In these two policies, the healthcare waste management is not specific mentioned but it is in the process of developing SOPs and guidelines in Department of Public Health (DoPH). The Ministry of Health Services (MoHS) is responsible for not only framing the guidelines but also implementing at both the national and state levels. Myanmar also effort in place for greening the health care sector, the reduction and minimizing waste and becoming zero waste remains a priority as well as to focus on non-burn options for waste management. There is no provision of submission of annual reports by the health care facilities. (WHO, Regional Office for South-East Asia, 2017) According to the hospital management manual of 2011, each hospital should have a hospital waste management committee chaired by the medical superintendent with a microbiologist or pathologists as secretary and members as follow: ward in charge, pharmacist, hospital engineer and sister in charge. Nearly 100% of hospitals

20 have a hospital waste management committee, which is in charge of developing a management plan; assigning roles and responsibilities; categorizing waste; providing personal protective equipment (PPE); providing immunization; providing training to staff; and conducting monitoring and evaluation. (WHO, Regional Office for South- East Asia, 2017) Regarding with segregation, the current practice is to segregate in three color- coded bins- general waste in a black bin, infectious waste in a yellow bin and highly infectious waste in red bin. Infectious wastes are incinerated; sharps, syringes and needles are buried in deep concrete wells; and general waste are disposed with municipal wastes. 100% of hospitals follow segregation in the following manners; general waste (black); infectious waste (yellow); highly infectious waste including sharps (red). (WHO, Regional Office for South-East Asia, 2017) In the collection and transportation, the workers collect waste on a daily basis by using trolleys which are covered and some are opened. There are no separate lifts/chutes for waste collection, and the trolleys are not marked with a hazardous symbol. Municipalities collect waste from township HCFs, but regional health cares and sub-centers are not covered by them. The waste collection is at regular intervals. The municipalities transport this waste to disposal sites using separate vehicles for hazardous waste. Approval for these vehicles is given by municipalities and there is no private licensing. There is no approved responsible body if and accident occurs. (WHO, Regional Office for South-East Asia, 2017) For the storage of healthcare waste, The Hospital Management Manual (2011) rules are to be followed. These rules lay the minimum requirements for area, space, building and barrier specifications. For the treatment technologies, WHO Guidelines are followed, however, there is no approval from government body for ensuring technology standards/validation and inclusion of new technologies. Waste is treated both onsite and offsite. The recommendation method for infectious waste is incineration and autoclaving for infectious specimens in labs. Only some central hospitals have provision of a captive/onsite treatment facility for the treatment of medical waste. The infrastructure for waste treatment is highly insufficient. (WHO, Regional Office for South-East Asia, 2017) In Myanmar, both onsite and offsite treatment for waste are not adequate to cover waste generated from all the health care facilities. The government has not specified operation standards for installed treatment technology and emission and

21 effluent standards. Incineration, open burning or deep burial is the end disposal methodology. At the central and state/regional levels, waste is collected by the municipality and at the district/township levels and RHC and sub-RHC levels, open burning and burial methods are followed. There is no testing on regular basis of the treatment technologies. (WHO, Regional Office for South-East Asia, 2017) While handling waste, about 50% of the overall staff uses personal protective equipment (PPE). All of the staff are not administered in Hepatitis B vaccination. At the central level, pharmaceutical waste is collected by the municipality and some items are incinerated and some are deep buried. There is no enforcement in the public sector. In private hospitals, it is in accordance with the clinic law. (WHO, Regional Office for South-East Asia, 2017) In the country’s policy/rule/guideline, there is no outline for training of healthcare staff for the management of health care waste. The required guideline is in the process of developing under the Occupational and Environmental Health (OEH) Division of the DoPH. The division is developing not only for a national level training module for staff but also for incorporation into the medical, nursing and health assistant curricula. There is no data available on awareness levels of health care staff. (WHO, Regional Office for South-East Asia, 2017)

3.2 Current Handling Practice of Pharmaceutical Waste in Mandalay Mandalay Regional Government is carrying out tasks with the objective of making Mandalay into a clean, green and smart city. It is the former capital of Myanmar, is widely recognized for its numerous opportunities for economic development and its rich cultural background (MCDC, 2017). The industrialization, economic growth and changes in consumption patterns have been accompanied by immense challenges in managing the city’s solid waste. The waste collection and disposal have been the responsibilities of Mandalay City Development Committees (MCDC). The health care waste management practices in Myanmar are substandard although there is basic awareness in the communities living within the environment of health care waste, the importance of protecting health workers and the visitors to health care facilities. MCDC collect medical waste from large hospitals and special clinics on a daily basis while collection service is provided to smaller facilities once a week or on an on-call basis. For waste management, the infectious waste is incinerated or burned in cemeteries

22 while sharp wastes are buried underground in landfills. Other waste is treated as domestic waste. Due to lack of an effective management system, hazardous wastes are collected together with household wastes and disposed of in landfill sites. Thus, MCDC confront an enormous challenge in identifying and implementing the proper waste disposal methods. Perhaps what makes it more difficult and complicated is the lack of sufficient awareness about the seriousness of medical waste that has led to poor application of waste management systems properly. MCDC estimate that current landfill sites are set to reach the end of their lifecycle in another 2-4 years and the city administration is having trouble in locating suitable replacement land sites within city limits. (Premakumara, Hengesbaugh, Onogawa, & Hlaing, 2017) Through there is incomplete information on the current levels of medical waste generation in Myanmar, MCDC estimate that an average the medical waste is generated 779 tons per year and among them over 70% is infectious waste. The total waste generation of hospital waste is 2 tons per day, among them infectious waste is 83%, sharps waste is 1% and miscellaneous is 16% (Premakumara, Hengesbaugh, Onogawa, & Hlaing, 2017)

Table (3.1) Waste Composition in Medical Waste Type of Wastes Composition (%) Infectious waste 83% Sharp Waste 1% Miscellaneous 16% Source: Waste Management in Myanmar, 2017

3.2.1 Waste Management Strategy and Action Plan for Mandalay City (2017-2030) Mandalay is one of the first cities to have received technical assistance from the Institute for Global Environmental Strategies (IGES) Centre collaborating with United Nations Environmental Program (UNEP) on Environmental Technologies (CCET) for the development of a City Waste Management Strategy and Action Plan based on the National Waste Management Strategy and Action Plan of the Government of Myanmar. The City Waste Management Strategy and Action Plan is intended to programs, approaches and local policies to maximize proper collection

23 and treatment of industrial, medical and other types of waste through institutional strengthening, capacity building, awareness raising, monitoring and improvement. (MCDC, 2017) The City Waste Management Strategy and Action Plan has 6 strategic goals with key targets and objectives. Among them the strategic goal C is intended to maximize proper waste collection and treatment of industrial and other special types of wastes (hazardous, medical, mining, e-waste, construction and demolition waste etc.). Currently, the medical waste collected from city hospitals and private clinics is burned directly in a ground pit dug in a cemetery neighboring the city’s northern landfill. Therefore, managing industrial and hazardous medical waste separately from municipal waste has been identified as one of the goals of the strategy. MCDC agreed to provide technical and financial support such as establishment of incinerator, capacity building and training from external party to improve industrial and hazardous medical waste management in the city. (MCDC, 2017) The strategic goal E is capacity development, awareness raising and advocacy. Environmental education and information campaigns are critical in raising public awareness about the importance of waste management. However, lack of awareness about proper waste practices such as segregation as well as low motivation of the general public impedes efficient integration of waste management. The local policymakers, practitioners and stakeholders require capacity building on good waste management practice and planning. Therefore, in order to capacitate local governments more effectively, knowledge and information sharing should be widely promoted, in addition to supporting education and training of public, private and civil society partners. MCDC can leverage the experience and assistance of IGES in developing environmental education and training modules to support the successful implementation of this goal.

3.3 Hospitals in Mandalay Mandalay region is located in the center of the country, bordered by Irrawaddy (Ayeyarwady) River on western side and the highland of Shan State in the east. Mandalay is the third largest city of Myanmar and the regional capital is Mandalay. The total area of the city is 315 km2 (or 121.5 miles2) and consists of 6 townships, further divided into 96 wards, 42 village tracts and 170 villages. The 6 townships are Aung Mye Thar Zan, Chan Aye Thar Zan, Chan Mya Thar Zi, Maha Aung Mye,

Pyigyi Dagun and Ama Ra Pura. Among them Chan Aye Tha Zan township is the oldest and second densest township of the city, the population is 212,540. Mandalay is “Dry Zone” area of Myanmar and the one of the most climate- sensitive and low annual rainfall regions. The dry season lasts from November to April and December to March being with almost totally dry. The hottest month is April, average maximum temperature - 38.8 ˙C and the coldest is January, average minimum temperature - 13.5 ˙C. The primary health care specialized hospitals of both public and private are located in Mandalay. The major specialist hospitals including Children’s hospital, Women’s hospitals, Eye’s hospitals and ENT (Ear, Nose and Throat) hospitals of the public are also located in Mandalay. The general hospitals with specialist services available in both public and private hospitals. People still offers traditional herbal medicines alongside modern therapeutic practices; the traditional medical services are also available. The private hospitals, polyclinics and pharmacies also play primarily as ambulatory health care facilities in Mandalay. The private hospitals and specialist clinics have become a popular alternative venue for seeking immediate medical treatment. The public hospitals are categorized into general hospitals (up to 2000 beds), specialist hospitals and teaching hospitals (100-1200 beds), regional/state hospitals and district hospitals (200-500 beds) and township hospitals (25-100 beds). In rural areas, sub- township hospitals and station hospitals (16-25 beds), rural health care center (RHC) (no beds), and sub-rural health centers (no beds) provide health services, including public health services. The number of the public hospitals in each township are shown in Table (3.2).

Table (3.2) List of Public Hospitals in Mandalay

No. Township Number of Hospitals 1 Aung Mye Thar Zan 1 2 Chan Aye Thar Zan 5 3 Chan Mya Thar Zi 2 4 Maha Aung Mye 1 5 Pyigyi Dagun - 6 Ama Ra Pura 1 Total 10 Source: Mandalay Regional Public Health Department

There is no public hospital in Pyigyi Dagun township and people in this township mainly go to Ama Ra Pura public hospital which is near with it and private hospitals. In Chan Aye Thar Zan Township, the name of the public hospital are Mandalay General Hospital, Mandalay Children’s Hospital 300 bedded, Mandalay New Children’s Hospital 550 bedded, Mandalay Central Women Hospital and Mandalay Mental Health Hospital. Generally, the private hospitals have better in facilities than the public hospitals, so people mainly choose the private clinic and hospitals for minor diseases. There are total 30 private hospitals in Mandalay. Among them, there are 20 private hospitals in Chan Aye Thar Zan Township. The number of the private hospitals in Chan Aye Thar Zan townships are shown in Table (3.3).

Table (3.3) List of Private Hospitals in Mandalay No. Township Number of Hospitals 1 Aung Mye Thar Zan 2 2 Chan Aye Thar Zan 20 3 Chan Mya Thar Zi 3 4 Maha Aung Mye 1 5 Pyigyi Dagun 4 6 Ama Ra Pura 0 Total 30 Source: Mandalay Regional Public Health Department

CHAPTER IV ANALYSIS OF THE SURVEY

4.1 Survey Profile The survey area was the selected private hospitals of Chan Aye Thar Zan Township, Mandalay. There are total 20 private hospitals in this township. The data are collected from 50% of the total private hospitals. This study comprised of 10 health facilities which were private hospitals in Chan Aye Thar Zan Township, Mandalay and 152 respondents who were employees of those health facilities. Data was collected by using pre-tested self-administered structured questionnaires. Data entry was done by using Microsoft Excel. Data management and analysis was done by using SPSS software version 21 valid for individual students. Descriptive statistics were done to summarize the study population characteristics. Frequency and percentage was used to mention for categorical data and mean with standard deviation, medium and range for continuous data. The associations between some of the related factors of the private hospital and their knowledge, attitude and practice status were founded out by Chi-squared test, student t test and ANOVA test for multivariate analysis.

4.2 Survey Design The required sample size was calculated by the formula valid for prevalence studies (infinite population).

2 2 N = [(Z1-α/2) {p(1-p)}] / d Where, N = Required Minimal Sample Size

Z1-α/2 = 1.96 (for 95% CI) Z1-α/2 = Confidence Interval d = 5 (for 95% CI) d = Precision p = 10 p = Prevalence (at least one in every ten hospital staffs will have good practice.)

According to the sample size calculation, the required minimum sample size was 138 at (95%) confidence level (CI) and 5% margin of error. But in this study, 152 respondents are participated. After taking informed consent in Appendix (I), the respondent was explained about the questionnaires. A pretested, self-administered structured questionnaire was used as a data collection tool. This questionnaire developed from reviewing literatures and based on Safe management of wastes from health-care activities (WHO, 2014). After administering the questionnaires, the completeness was checked on site. There are 2 parts of questionnaires: first part for characteristics of the hospital and the second part for KAP of pharmaceutical waste practice. The first part, questionnaires include questions for characteristics of hospitals and the overall hospital waste management was assessed by observation checklist in Appendix (II) that was also based on the questionnaire of the previous study. Before data collection, pretest of questionnaires was done and the questions were revised as required for understandability and relevance. Related factors consist of number of hospitals, beds, employees, department of hospitals and inspection visit to the hospital The second part, questionnaires include questions for related factors, knowledge and attitude of the respondents. Pharmaceutical waste management of hospital was assessed by observation checklist that was also based on Safe management of wastes from health care activities (WHO, 2014). Before data collection, pretest of questionnaires was done and the questions were revised as required for understandability and relevance. Related factors consisted of socio- demographic characteristics and KAP on proper health care waste practice. Socio- demographic characteristics consisted of age, sex, job title, level of education, working experience. Regarding knowledge in health care waste management, 20 questions related to waste segregation, color coding, collection, storage, waste handling and transportation were used. Regarding attitude questionnaires, 20 questions related to segregation, color coding, burden, safe healthcare waste management and national guideline for health care waste management were used. The response was measured by modified 5 point Likert’s skills. Regarding attitude questionnaires, 25 questions related to segregation, color coding, burden, safe healthcare waste management, municipal healthcare waste collection system and attending were used. To get the real practice, observation checklist was used and

28 waste segregation, color coding, labeling, handling, storage, treatment and disposal methods were assessed.

4.3 Characteristics of Private Hospital and Respondents This study comprised the specific characteristics of 10 private hospitals in Chan Aye Thar Zan Township, Mandalay and 152 health workers who were employees of those health facilities.

4.3.1 Characteristics of Private Hospital The specific characteristics of private hospitals were described in the following table (4.1).

Table (4.1) Frequency Distribution of Socio-demographic Characteristics of Private Hospital (n = 10) Particular Frequency Percent Numbers of beds <50 beds 5 50.0 50-100 beds 3 30.0 >100 beds 2 20.0 Numbers of employees <300 4 40.0 300- 600 5 50.0 >600 1 10.0 Number of departments 5 1 10.0 6 6 60.0 7 1 10.0 8 2 20.0 Source: Survey data

In this study, half of the private hospitals were less than 50 bedded while 30.0% were 50-100 bedded and the remaining 20.0% were greater than 100 bedded hospitals. The majority of private hospitals were less than 50 bedded and it was followed by 50-100 bedded hospitals and greater than 100 bedded hospitals were minority.

The majority (50.0%) of the private hospitals employed 300 – 600 employees and 40.0% of the hospitals had less than 300 employees while the remaining 10.0% employed over 600 employees. The majority of health facilities employed 300 – 600 employees and it was followed by facilities with less than 300 employees. Only minority had greater than 600 employees. Most of the hospitals (60.0%) had 6 departments and it was followed by hospitals with 8 departments (20.0%). The number of hospitals with 5 and 7 departments accounted for 10.0% each in this study. The most of the health facilities possessed 6 departments and it was followed by facilities with 8 departments. The remaining facilities owned 5 or 7 departments at the time of study.

Table (4.2) Frequency Distribution of Compound, Ward inspection and Instruction guide to use Waste Bins in private hospital (n=10)

Particular Frequency Percent Is the compound clean? Unclean 4 40 Clean 6 60 Is the ward clean? Unclean 2 20 Clean 8 80 Are posters to guide users displayed near waste bins? No 7 73 Yes 3 30 Does black bag contain only general waste? Does red bag contain hazardous waste? Does yellow bag contain only soiled infected waste? Correct waste 1 10 Mixed 9 90 Source: Survey data

The sanitary statuses of the health facilities were investigated using the preformed checklist in Appendix (II). Among the total 10 private hospital investigated, 60% were clean while 40% were unclean at the time of visit. The majority of the hospital compounds were clean, however, about 40% of the hospital compounds were found to be unclean at the time of study. The cleanness of the hospital compound was visualized in the following table (4.3)

Table (4.3) Compound Inspection in Private Hospital Compound Inspection Frequency Percent

Unclean 4 40.0

Clean 6 60.0

Total 10 100.0 Source: Survey data After inspection of the hospital compound, the investigator entered into the selected ward of the hospital and inspected whether the ward was clean or not using the preformed check list in Appendix (II). Among the total 10 private hospital investigated, 80% of the selected wards were clean while only 20% were unclean at the time of study. Most of the selected wards were clean, however, only 20% of the wards were found to be unclean at the time of study. The cleanness of the selected wards was visualized in the following table (4.4).

Table (4.4) Ward Inspection in Private Hospital

Ward Inspection Frequency Percent

Unclean 2 20.0

Clean 8 80.0

Total 10 100.0 Source: Survey data

The presence or absence of instruction guides to use waste bins was also investigated in this study. The majority (70.0%) of the inspected private hospitals failed to display the instruction guide for user near waste bins. The instruction guides to use the waste bins were did not shown in the majority of the inspected private hospital. The following table (4.5) revealed the presence or absence of instruction guide near the waste bins in the health facilities.

Table (4.5) Instruction Guide to Use Waste Bins in Private Hospital

Instruction guide Frequency Percent

No 7 70.0

Yes 3 30.0

Total 10 100.0 Source: Survey data

In all of the private hospital included in this study, did not have a system for segregation of pharmaceutical waste from general waste. It was true, not only for the whole hospital, but also for the drug stores and pharmacy units. All kinds of waste bins including black, red and yellow colored bins, were available in all selected wards. However, most of the bags were not securely fitted with the bin. Bin covers were half opened in most of the waste bins. Only few were covered securely. Biohazard symbol imprinted waste bags were found in some waste bins of only one hospital. Most of the waste bags were filled with mixed items of wastes. According to theory, there were three types of waste bags; black bag contains only general waste, red bag contain only plastic waste and yellow bag contain only soiled infected waste. However, in practice, most of the waste bags (90%) contained mixed types of waste. The following table (4.6) revealed the content analysis results of waste bags. Most of the waste bags were found to have admixed types of waste inside regardless of the principle.

Table (4.6) Content Analysis of the Waste Bags

Content analysis Frequency Percent

Correct 1 10.0

Mixed 9 90.0

Total 10 100.0 Source: Survey data

4.3.2 Characteristics of Respondents The specific characteristics of private hospitals were described in the following table (4.7).

Table (4.7) Frequency Distribution of Socio-demographic Characteristics of Respondents (n=152) Age Group (years) Frequency Percent

<30 72 47.4

30 – 39 47 30.9

40 – 49 18 11.8

50 – 59 15 9.9

Total 152 100.0

Mean ± SD 33±9.3 Minimum 22 Maximum 57 Source: Survey data

The majority of the respondents were under 30 years of age (47.4%) and it was followed by 30 – 39 years age group (30.9%), 40 -49 years (11.8%) and 50 – 59 years (9.9%). Therefore, a gradual decrescendo number of respondents with age groups increment were observed among respondents. The older the age group, there was fewer the number of respondents. The minimum and the maximum ages of the respondents were 22 and 57 years with an average age of 33±9.3 years. The majority of the employees were relatively in younger age. The frequency of employees was gradually fewer with advancement in age.

Table (4.8) Frequency Distribution of Socio-demographic Characteristics of Respondents (n = 152)

Gender Frequency Percent

Male 52 34.2

Female 100 65.8

Male : Female Ratio 1:1.9 (p = 0.000) Source: Survey data

Among the respondents, 34.2% were male and the remaining 65.8% were female. Male to female ratio was 1:1.9 and it was highly significant at the p value of 0.001. Therefore, female preponderance was observed among the employees of studies private hospitals and male versus female percentages of 34.2% versus 65.8% respectively.

Table (4.9) Frequency Distribution of Rank of Respondents (n=152) Rank Frequency Percent Medical superintendence (MS) 10 6.6 Medical doctor 39 25.7 Matron 10 6.6 Nurse and Nurse-aid 60 39.5 Pharmacist 18 11.8 General worker 15 9.9 Source: Survey data

Most of the respondents were Nurse and Nurse-aid (39.5%) and it was followed by medical doctors (25.7%), Pharmacist (11.8%), general workers (9.9%), matrons (6.6%) and MS (6.6%).

Table (4.10) Frequency Distribution of Education of Respondents (n=152) Education Level Frequency Percent Primary 4 2.6 Middle 2 1.3 High 9 5.9 Diploma 10 6.6 Graduate 120 78.9 Master 7 4.6 Source: Survey data

Most of the respondents were graduates (78.9%) and it was followed by diploma holders (6.6%), high school (5.9%), master degree (4.6%), middle school (1.3%) and primary school (2.6%).

Table (4.11) Frequency Distribution of Experience of Respondents (n=152) Experience (Years) Frequency Percent 1.0 17 11.2 2.0 24 15.8 3.0 26 17.1 4.0 29 19.1 5.0 26 17.1 6.0 13 8.6 7.0 10 6.6 8.0 6 3.9 9.0 1 0.7 Source: Survey data

Most of the respondents had less than 5 years of work experience.

4.4 Survey Analysis The knowledge, attitude and practice status of the respondents on handling pharmaceutical wastes were assessed by face to face interview with employees. A total of 152 respondents were included in this study.

4.4.1 Knowledge, Attitude and Practice Status of the Respondents on Segregation of the Pharmaceutical Wastes The knowledge, attitude and practice status of employees on segregation of the pharmaceutical wastes was also assessed by using the knowledge, attitude and practice assessment questionnaire shown in Appendix (IV). The questionnaire included 7 in each knowledge, attitude and 6 in practice assessment questions. The area specific knowledge, attitude and practice status of employee were shown in the following table (4.12).

Table (4.12) Knowledge Status of Respondents on Segregation of Pharmaceutical Wastes (n=152) No. of Particular Percent Respondent According to WHO classification, there are three 90 60.5 classes of pharmaceutical waste. The pharmaceutical waste should be segregated. 105 69.1

The pharmaceutical waste should be segregated in the 75 49.3 one place. The pharmaceutical wastes are sorting into color- 119 78.3 coded and well-labelled bags or containers. The black color bags or containers use for sorting the 89 58.5 non-hazardous pharmaceutical waste. The yellow color bags or containers use for sorting the 95 62.5 potentially hazardous pharmaceutical waste. The red color bags or containers use for sorting the 81 53.3 hazardous pharmaceutical waste. Source: Survey Data

Regarding the knowledge status of employees on segregation of pharmaceutical wastes, 60.5% of the respondents (n=90) correctly identified the classes of pharmaceutical waste. The correct response on pharmaceutical waste segregation was 69.1% (n=105). However, only 49.3% (n=75) knew the pharmaceutical waste should be segregated in the one place. The proportion of respondents who correctly answered pharmaceutical wastes are sorting into color-coded and well-labelled bags or containers was 78.3% (n=119). The correct usages of black, yellow and red colored

36 containers were known by 58.5% (n=89), 62.5% (n=95) and 53.3% (n=81) of respondents respectively. Therefore, for the whole sample, 93.4±11.1% of the respondents have good level of knowledge on segregation of pharmaceutical wastes.

Table (4.13) Attitude Status of Respondents on Segregation of Pharmaceutical Wastes (n=152) Frequency n (%) Particular Strongly Strongly Disagree Neutral Agree Disagree Agree The pharmaceutical waste should be 0 (0.0) 0 (0.0) 17 (11.2) 75 (49.3) 60 (39.5) segregated. The segregating hazardous from non- hazardous waste will reduce greatly the 0 (0.0) 0 (0.0) 43 (28.3) 71 (46.7) 38 (25.0) risks of infecting workers handling the pharmaceutical waste. The different classes of pharmaceutical waste should be identified by sorting 0 (0.0) 0 (0.0) 30 (19.7) 80 (52.6) 42 (27.6) the waste into color-coded and well- labeled bags or containers. The procedure of the pharmaceutical waste segregation, packaging and 0 (0.0) 1 (0.7) 48 (31.6) 63 (41.4) 40 (26.3) labelling should be explained to the staff who handle the pharmaceutical waste. The color coding system should be 0 (0.0) 3 (2.0) 37 (24.3) 78 (51.3) 34 (22.4) simple and applied uniformly throughout the country. The hazardous pharmaceutical should be placed marked and indicated with 0 (0.0) 0 (0.0) 33 (21.7) 73 (48.0) 46 (30.3) the international biohazard symbol The awareness and the training for waste segregation and labelling to the 0 (0.0) 0 (0.0) 44 (28.9) 70 (46.1) 38 (25.0) medical staff and the person who involve in pharmaceutical waste handling should be ensured. Source: Survey Data

Based on the survey data, the questionnaire specific attitude status of employees on segregation of pharmaceutical wastes was shown in the above table. In all questionnaires, the majority of the respondents revealed good attitude in terms of either agree (41.4% to 52.6%) and strongly agree (22.4% to 39.5%). The neutralization was found up to a maximum of 31.6%. Only minority (0.7% to 2.0%) of the respondents revealed negative attitude in two specific areas (please see details on the above table).

Table (4.14) Practice Status of Respondents on Segregation of Pharmaceutical Wastes (n=152) Particular Frequency Percent The pharmaceutical wastes are segregated. 81 53.3 The pharmaceutical wastes are segregated in the one place. 64 42.1 The pharmaceutical wastes are sorted into color-coded and 129 84.9 well-labelled bags or containers. The non-hazardous pharmaceutical waste are sorted in black 147 96.7 bags or containers. The potentially hazardous pharmaceutical waste are sorted in 106 69.7 yellow bags or containers and marked with international biohazard symbol <> The hazardous pharmaceutical waste are sorted in red bags 101 66.4 or containers and marked with international biohazard symbol <>

Source: Survey Data

Regarding the practice status of employees on segregation of pharmaceutical wastes, 53.3% (n=81) of the pharmaceutical wastes were segregated. Moreover, 42.1% (n=64) of the pharmaceutical wastes are segregated in the one place and 84.9% (n=129) were sorted into color-coded and well-labelled bags or containers. Right contents were found in 96.7% (n=147) of black containers, 69.7% (n=106) of yellow containers and 66.4% (n= 101) of red containers. Therefore, for the whole sample, 104.7±22.7% of the respondents have good level of practice on segregation of pharmaceutical wastes.

4.4.2 Knowledge, Attitude and Practice Status of the Respondents on Collection of the Pharmaceutical Wastes Again, the knowledge, attitude and practice status of employees on collection of the pharmaceutical wastes was also assessed by using the knowledge, attitude and practice assessment questionnaire shown in Appendix (IV). The questionnaire included 6 in knowledge, 5 in attitude and 7 in practice assessment questions. The area specific knowledge, attitude and practice status of employee were shown in the following table (4.15).

Table (4.15) Knowledge Status of Respondents on Collection of Pharmaceutical Wastes (n=152) Particular Frequency Percent The pharmaceutical waste is collected and transported 102 67.1 separately. The pharmaceutical waste collection include the collection 79 52.0 points and routes of waste transport separately. There is a timetable of the frequency of collection. 92 60.5 The pharmaceutical waste collector should wear the heavy 137 90.1 duty gloves, industrial boots and apron. The waste containers are replaced immediately when they 95 62.5 are more than three-quarters full. The hazardous and non-hazardous pharmaceutical waste are 96 63.2 collected on separate trolleys. Source: Survey Data

According to the survey data, 67.1% (n=102) of the respondents knew that the pharmaceutical waste is collected and transported separately. Moreover, 52.0% (n=79) knew that the pharmaceutical waste collection includes the collection points and routes of waste transport separately. The timetable of the frequency of collection was correctly answered by 60.5% (n=92) of respondents. Use of heavy duty gloves, industrial boots and aprons were answered by 90.1% (n=137) of respondents. Replacement of waste containers immediately when they are more than three-quarters full was known by 62.5% (n=95) and use of separate trolleys for pharmaceutical wastes was answered by 63.2% (n=96) of the respondents. Therefore, for the whole sample, 100.2±12.9% of the respondents have good level of knowledge on collection of pharmaceutical wastes.

Table (4.16) Attitude Status of Respondents on Collection of Pharmaceutical Wastes (n=152)

Frequency Particular n (%) Strongly Strongly Disagree Neutral Agree Disagree Agree The sanitary staffs and cleaners should always wear protective 0 (0.0) 0 (0.0) 22 (14.5) 80 (52.6) 50 (32.9) clothing such as industrial aprons, boots and heavy duty gloves while handling the pharmaceutical wastes. There should be the pharmaceutical waste management plan including 0 (0.0) 0 (0.0) 73 (48.0) 65 (42.8) 14 (9.2) the collection points, the routes of transport and the timetable of the frequency of collection. The hazardous and non-hazardous pharmaceutical should be collected 0 (0.0) 0 (0.0) 60 (39.5) 67 (44.1) 25 (16.4) on separate trolleys which should be marked with the corresponding color (yellow/black) and washed regularly. The reasons for labelling the pharmaceutical waste bags or 0 (0.0) 0 (0.0) 45 (29.6) 63 (41.4) 44 (28.9) containers is that in case of an accident the content can be quickly identified. The vehicle used for the collection of hazardous pharmaceutical waste 0 (0.0) 20 (13.2) 54 (35.5) 62 (40.8) 16 (10.5) should not be used for any other purpose. Source: Survey Data The questionnaire specific attitude status of employees on collection of pharmaceutical wastes was shown in the above table. In all questionnaires, the majority of the respondents revealed good attitudes in terms of agree (40.8% to 52.6%) and strongly agree (9.2% to 32.9%). The neutralization was found up to a maximum of 48.0%. Negative attitude (13.2%) was revealed on use of vehicle for the collection of hazardous pharmaceutical waste for any other purpose.

Table (4.17) Practice Status of Respondents on Collection of Pharmaceutical Wastes (n=152) Particular Frequency Percent The pharmaceutical waste collection has a plan which 65 42.8 include the collection points and the routes of waste transport. There is a timetable of the frequency of collection. 91 59.9 The pharmaceutical waste collector are wearing the heavy 138 90.8 duty gloves, industrial boots and apron while collection process. The waste containers are replaced immediately when they 94 61.8 are no more than three-quarters full. The hazardous and non-hazardous pharmaceutical are 106 69.7 collected on separate trolleys. The documents or forms are used during collection from the 96 63.2 service. MCDC collect the pharmaceutical waste regularly. 117 77.0 Source: Survey Data

Regarding the practice status of employees on collection of pharmaceutical wastes, only 42.8% (n=65) had a plan which include the collection points and the routes of waste transport and 59.9% (n=91) had a timetable of the frequency of collection. Most 90.8% (n=138) of the pharmaceutical waste collector were wearing the heavy duty gloves, industrial boots and apron while collection process. Moreover, 61.8% (n=94) of the waste containers were replaced immediately when they are no more than three-quarters full. Meanwhile, 69.7% (n=106) of the hazardous and non- hazardous pharmaceutical are collected on separate trolleys, 63.2% (n=96) were using the documents or forms during collection and most of all, 77.0% (n=117) of the respondents confirmed that MCDC was collecting the pharmaceutical waste regularly. Therefore, for the whole sample, 101.0±16.6% of the respondents have good level of practice on collection of pharmaceutical wastes.

4.4.3 Knowledge, Attitude and Practice Status of the Respondents on Storage of the Pharmaceutical Wastes The knowledge, attitude and practice status of employees on storage of the pharmaceutical wastes was also assessed by using the knowledge, attitude and practice assessment questionnaire shown in Appendix (IV). The questionnaire included 4 in knowledge, 3 in each attitude and practice assessment questions. The area specific knowledge, attitude and practice status of employee were shown in the following table (4.18).

Table (4.18) Knowledge Status of Respondents on Storage of Pharmaceutical Wastes (n=152) Particular Frequency Percent The pharmaceutical waste is not stored for more than 24 109 71.7 hours before disposed of. The pharmaceutical waste should not be stored near with 137 90.1 food stored or food preparation. The authorized person only can access to the store room of 105 69.1 pharmaceutical waste. Source: Survey Data

Regarding the pharmaceutical waste storage, 71.7% (n=109) knew that the pharmaceutical waste is not stored for more than 24 hours before disposed of. Most of the respondents, 90.1% (n= 137) knew that the pharmaceutical waste should not be stored near with food stored or food preparation. Moreover, 69.1% (n=105) reported that the authorized person only can access to the store room of pharmaceutical waste. Therefore, for the whole sample, 117.0±13.3% of the respondents have good level of knowledge on storage of pharmaceutical wastes.

Table (4.19) Attitude Status of Respondents on Storage of Pharmaceutical Wastes (n=152) Frequency n (%) Particular Strongly Strongly Disagree Neutral Agree Disagree Agree The pharmaceutical waste should not be stored more than 24 hours 0 (0.0) 0 (0.0) 23 (15.1) 77 (50.7) 52 (34.2) before disposed of. The non hazardous pharmaceutical waste should always be stored in a 0 (0.0) 0 (0.0) 63 (41.4) 63 (41.4) 26 (17.1) separate location from the hazardous pharmaceutical waste to avoid cross-contamination. The authorized person only can access to the store room of 0 (0.0) 0 (0.0) 55 (36.2) 83 (54.6) 14 (9.2) pharmaceutical waste. Source: Survey Data

All of the respondents revealed positive attitude on storage of pharmaceutical waste with 15.1% to 41.4% of neutralization.

Table (4.20) Practice Status of Respondents on Storage of Pharmaceutical Wastes (n=152) Particular Frequency Percent The pharmaceutical waste is not stored for more than 24 84 55.3 hours before disposed of. The pharmaceutical waste are not stored near with food 146 96.1 stored or food preparation. The authorized person only can access to the store room 109 71.7 of pharmaceutical waste. Source: Survey Data

Regarding the storage practice, 55.3% (n=84) of respondents did not store the pharmaceutical wastes for more than 24 hours before disposed of. Most of the respondents, 96.1% (n=146) did not store the pharmaceutical wastes near with food stored or food preparation and 71.7% (n=109) allowed only authorized person to the store room of pharmaceutical waste. Therefore, for the whole sample, 113.0±22.0% of the respondents have good level of practice on storage of pharmaceutical wastes.

4.4.4 Knowledge, Attitude and Practice Status of the Respondents on Transportation of the Pharmaceutical Wastes The knowledge, attitude and practice status of employees on transportation of the pharmaceutical wastes was also assessed by using the knowledge, attitude and practice assessment questionnaire shown in Appendix (IV). The questionnaire included 4 in knowledge, 1 in attitude and 3 in practice assessment questions. The area specific knowledge, attitude and practice status of employee were shown in the following table (4.21).

Table (4.21) Knowledge Status of Respondents on Transportation of Pharmaceutical wastes (n=152) Particular Frequency Percent There is the proper labelling of the containers that are 114 75.0 transported. The transportation should be properly documented. 91 59.9

MCDC generally collect the pharmaceutical wastes. 105 69.1

The documents or forms are used during collection 95 62.5 from the service. Source: Survey Data

Approximately three-fourth, 75.0% (n=114) of the respondents knew that there is the proper labelling of the containers that are transported, 59.9% (n=91) knew that the transportation should be properly documented, 69.1% (n=105) knew which service generally collect the pharmaceutical wastes and 62.5% (n=95) knew that the documents or forms are used during collection from the service. Therefore, for the whole sample, 101.3±8.3% of the respondents have good level of knowledge on transportation of pharmaceutical wastes.

Table (4.22) Attitude Status of Respondents on Transportation of Pharmaceutical Wastes (n=152) Frequency n (%) Particular Strongly Strongly Disagree Neutral Agree Disagree Agree The transportation should 0 (0.0) 0 (0.0) 52(34.2) 77(50.7) 23 (15.1) be properly documented. Source: Survey Data

Among the respondents participated in the survey, all of them revealed a positive attitude on the statement “The transportation should be properly documented.” with a neutral rate of 34.2%.

Table (4.23) Practice Status of Respondents on Transportation of Pharmaceutical Wastes (n=152) Particular Frequency Percent There is the proper labelling of the containers that are 138 90.8 transported. The transportation should be properly documented. 91 59.9

MCDC generally collect the pharmaceutical wastes. 127 83.6

Source: Survey Data

Most (90.8%, n=138) of the survey data confirmed that there was proper labelling of the containers that are transported. Proper documentation was attached in 59.9% (n=91) and MCDC generally collect the pharmaceutical wastes of 83.6% (n=127). Therefore, for the whole sample, 118.7±18.4% of the respondents have good level of practice on transportation of pharmaceutical wastes.

4.4.5 Overall Knowledge, Attitude and Practice Level of Respondents on Handling Pharmaceutical Wastes The scoring system overwhelming the above areas – segregation, collection, storage and transportation – was developed to assess the overall knowledge, attitude and practice levels of respondents and presented in the forthcoming tables.

4.4.6 Overall Knowledge Level of Respondents on Handling Pharmaceutical Wastes The overall knowledge assessment questionnaire included 20 knowledge assessment questions. Therefore, maximum total scores of 20 will be obtained if all the answers were correct and the minimum scores will be 0 (zero) if there was no correct answer. The respondents who achieved above mean scores + 1 SD were regarded as “high” knowledge level, the respondents who achieved mean ± 1 SD were regarded as “fair” knowledge level and the respondents who achieved below mean scores - 1 SD were regarded as “poor” knowledge level. The results were shown in the following table (4.24).

Table (4.24) Overall Knowledge Level of Respondents on Handling Pharmaceutical Wastes

Knowledge Level Frequency Percent

Poor 17 11.2

Fair 123 80.9

High 12 7.9

Total 152 100.0

Mean ± SD 13.2 ± 4.9 Source: Survey data

Most of the respondents (80.9%) revealed fair level of knowledge while 11.2% had poor knowledge and 7.9% of respondents had high level of knowledge on handling pharmaceutical wastes.

4.4.7 Overall Attitude Levels of Respondents on Handling Pharmaceutical Wastes The attitude questionnaire included 20 attitude assessment questions with five levels of attitudes with a neutral point in the middle. The respondent got 1-score for strongly disagree, 2-scores for disagree, 3 scores for neutral, 4-scores for agree and 5- scores for strongly agree attitudes on handling pharmaceutical wastes. Therefore, maximum total scores of 100 obtained if all the answers were highly positive attitudes and the minimum scores of 20 was obtained if there were all highly negative attitudes.

The respondents who achieved above mean scores + 1 SD were regarded as “high” attitude level, the respondents who achieved mean ± 1 SD were regarded as “fair” attitude level and the respondents who achieved below mean scores - 1 SD were regarded as “low” attitude level. The results were shown in the following table (4.25).

Table (4.25) Overall Attitude Level of Respondents on Handling Pharmaceutical Wastes Attitude Frequency Percent Negative 17 11.2 Fairly positive 125 82.2 Highly positive 10 6.6 Total 152 100.0 Mean ± SD 18.1 ± 7.2 Source: Survey data Most of the respondents had positive attitude, either fairly (82.2%) or highly positive (6.6%). Only 11.2% of the respondents revealed negative attitude on handling pharmaceutical wastes.

4.4.8 Overall Practice Level of Respondents on Handling Pharmaceutical Wastes The practice questionnaire included 25 practice assessment questions. Therefore, maximum total scores of 25 will be obtained if all the answers were correct and the minimum scores will be 0 (zero) if there was no correct answer. The respondents who achieved above mean scores + 1 SD were regarded as “high” practice level, the respondents who achieved mean ± 1 SD were regarded as “fair” practice level and the respondents who achieved below mean scores - 1 SD were regarded as “poor” practice level. The results were shown in the following table (4.26).

Table (4.26) Overall Practice Level of Respondents on Handling Pharmaceutical Wastes Practice Level Frequency Percent Poor 20 13.2 Fair 111 73.0 High 21 13.8 Total 152 100.0 Mean ± SD 15.6 ± 2.7 Source: Survey data

The practice level of the respondents was mostly fair (73.0%). On the other hands, approximately 13% of the respondents revealed either high or poor practice level.

4.4.9 Barriers on Handling Practice of Pharmaceutical Waste The barriers on handling practice of pharmaceutical waste were also identified in this study. The area specific barriers were shown in the following table (4.27).

Table (4.27) Frequency Distribution of Barrier on Handling Practice of Pharmaceutical Waste Management of Respondents (n=152) Frequency n (%) Particular Strongly Strongly Disagree Neutral Agree Disagree Agree The pharmaceutical waste 0 (0.0) 0 (0.0) 34 (22.4) 76 (50.0) 42 (27.6) management is the team work. The safe management of 3 (2.0) 44 (28.9) 62 (40.8) 37 (24.3) 6 (3.9) pharmaceutical waste is an extra burden of work. All of the staff who include in the 0 (0.0) 0 (0.0) 37 (24.3) 66 (43.4) 49 (32.3) pharmaceutical waste management should be vaccinated of Hepatitis B and Tetanus. There should be available of 0 (0.0) 0 (0.0) 24 (15.8) 65 (42.8) 63 (41.4) national guideline for handling practice of pharmaceutical waste. Source: Survey data

Regarding the barriers on handling practice of pharmaceutical wastes, half of the respondents agreed the pharmaceutical waste management as a team work. However, a remarkable proportion (40.8%) responded neutral on the statement of “The safe management of pharmaceutical waste is an extra burden of work”. The 43.4% agreed vaccination of staff and 42.8% agreed on the statement “there should be available of national guideline for handling practice of pharmaceutical waste”.

Table (4.28) Frequency Distribution of Barrier on Handling Practice of Pharmaceutical Waste Management of Respondents (n=152) Particular Frequency Percent There is available and used of internal guidelines and 101 66.4 standard operation procedure (SOP) at hospital. There is incinerator in your hospital. 3 2.0 The medical staffs are available on training regarding 103 67.8 health care waste management. The staffs are trained on monitoring and supervising of 89 58.6 health care waste management.

There is available of monitoring regulations for health 47 30.9 care waste and monitored regularly by the relevant authorities. Source: Survey data

At the time of survey, 66.4% (n=101) is available and used of internal guidelines and standard operation procedure (SOP) at hospital. However, only 2.0% (n=3) had incinerator in their hospital and 67.8% (n=103) of the medical staffs are available on training regarding health care waste management. Moreover, 58.6% (n=89) of the staffs are trained on monitoring and supervising of health care waste management. Only 30.9% (n=47) was available of monitoring regulations for health care waste and monitored regularly by the relevant authorities.

4.4.10 Associations between Knowledge, Attitude and Practice on Handling Pharmaceutical Wastes A multivariate model was constructed to find out the associations between the knowledge, attitude and practice on handling pharmaceutical wastes. The total practice scores (PT) was regarded as dependent variable. The total knowledge scores (KT) and total attitude scores (AT) were regarded as independent variables. Age, gender, training, rank, education and experience were placed as background variables. Both independent and background variables were equally weighted and regarded as predictor variables. The best fit model was presented in the following tables (4.29).

Table (4.29) Associations Model between Knowledge, Attitude and Practice

Crude Adjusted Model Odds P value Odds Ratio 95% CI 95% CI Ration Overall 7.21 3.91- 11.92 6.98 3.84 – 11.28 0.000**

Age 0.51 0.03 – 1.85 0.49 0.01 – 1.99 0.131

Gender 0.20 0.11 – 9.19 0.21 0.09 – 8.87 .650

Training 1.19 1.11 – 5.05 1.16 1.10 -4.99 .020*

Education 0.07 0.04 – 2.41 0.61 0.02 – 2.31 .874

Experience 0.08 0.01 – 5.79 0.04 0.02 – 5.13 .517

KT 1.77 1.28 – 7.99 1.69 1.52 – 7.01 .025*

Rank 0.06 0.02 – 1.07 0.02 0.01 – 1.09 .956

AT 9.00 2.51 – 17.3 7.92 2.34 – 18.1 .000**

* Statistically significant, **Statistically highly significant Source: Survey data

In the above best fit model, the total practice scores (PT) was found to be significantly associated with predictor variables (model significant level p <0.000). Moreover, the practice (PT) was found to be significantly associated with knowledge (KT) at the p value of 0.025, attitude (AT) at the p value of 0.000 and training (at the p value of 0.020) of the respondents. The practice was not found to be associated with

50 the age, gender, education and experience. This indicates that poor knowledge is a root cause of poor practice. The being young and old, female and male, rank and experiences were not directly proportionate to one’s practice. However, the higher the knowledge level through training, the more chance to be good at practice on pharmaceutical waste management.

CHAPTER V CONCLUSION

5.1 Findings In this study, half of the private hospitals were less than <50 bedded while 30.0% were 50-100 bedded and the remaining 20.0% were more than 100 bedded hospitals. The majority (50.0%) of the private hospitals employed 300 – 600 employees and 40.0% of the hospitals had less than 300 employees while the remaining 10.0% employed over 600 employees. Most of the hospitals (60.0%) had 6 departments and it was followed by hospitals with 8 departments (20.0%). The number of hospitals with 5 and 7 departments accounted for 10.0% each in this study. Among the total 10 private hospital investigated, 60% were clean while 40% were unclean at the time of visit. Among the total 10 private hospital investigated, 80% of the selected wards were clean while only 20% were unclean at the time of study. The majority (70.0%) of the inspected private hospitals failed to display the instruction guide for user near waste bins. In literature, healthcare waste generation depends on the number of beds occupied by patients and also numbers of patients treated on a daily basis and it can influence health care waste management (WHO, 1999). Up to now, there was no similar study in Myanmar which studied the pharmaceutical waste handling practice in private hospitals. According to the hospital management manual of 2011, each hospital should have a hospital waste management committee chaired by the medical superintendent with a microbiologist or pathologists as secretary and members as follow: ward in charge, pharmacist, hospital engineer and sister in charge. In this study, all of the hospitals have a hospital waste management committee, which is in charge of developing a management plan; assigning roles and responsibilities; categorizing waste; providing personal protective equipment (PPE); providing immunization; providing training to staff; and conducting monitoring and evaluation. Regarding with segregation, the current practice is to segregate in three color- coded bins- general waste in a black bin, infectious waste in a yellow bin and highly

52 infectious waste in red bin. Infectious wastes are incinerated; sharps, syringes and needles are buried in deep concrete wells; and general waste are disposed with municipal wastes. 100% of hospitals follow segregation in the following manners; general waste (black); infectious waste (yellow); highly infectious waste including sharps (red). Actually, in all of the private hospitals included in this study, did not have a system for segregation of pharmaceutical waste from general waste. It was true, not only for the whole hospital, but also for the drug stores and pharmacy units. This finding was coincided with the report of a study conducted in (Bungau, et al., 2018) in Romania. They reported the lack of procedure and incomplete legislation for pharmaceutical waste management. They recommended a productive system for pharmaceutical waste disposal, with a specific and comprehensive legislation with clear responsibilities and a strong information and awareness campaign for both staff and the general public in Romania. In this study, all kinds of waste bins including black, red and yellow colored bins, were available in all selected wards. However, most of the bags were not securely fitted with the bin. Bin covers were half opened in most of the waste bins. Only few were covered securely. Biohazard symbol imprinted waste bags were found in some waste bins of only one hospital. Most of the waste bags were filled with mixed items of wastes. Similar finding was reported by Dr. Saw Lwin (Saw Lwin, 2018). In his study, majority of general clinics did not separate wastes according to the types of wastes and did not dispose into the correct containers. There was only one clinic separate infectious waste into strong-leak proof containers. In the collection and transportation, the workers collect waste on a daily basis by using trolleys which are covered and some are opened. There are no separate lifts/chutes for waste collection, and the trolleys are not marked with a hazardous symbol. Municipalities collect waste from township HCFs, but regional health cares and sub-centers are not covered by them. The waste collection is at regular intervals. The municipalities transport this waste to disposal sites using separate vehicles for hazardous waste. Approval for these vehicles is given by municipalities and there is no private licensing. There is no approved responsible body if and accident occurs. For the storage of healthcare waste, The Hospital Management Manual (2011) rules are to be followed. These rules lay the minimum requirements for area, space, building and barrier specifications. For the treatment technologies, WHO Guidelines are followed, however, there is no approval from government body for ensuring

53 technology standards/validation and inclusion of new technologies. Waste is treated both onsite and offsite. The recommendation method for infectious waste is incineration and autoclaving for infectious specimens in labs. Only some central hospitals have provision of a captive/onsite treatment facility for the treatment of medical waste. The infrastructure for waste treatment is highly insufficient. The knowledge, attitude and practice status of the employees on handling pharmaceutical wastes were assessed by face to face interview with employees. Most of the respondents (80.9%) revealed fair level of knowledge while 11.2% had poor knowledge and 7.9% of respondents had high level of knowledge on handling pharmaceutical wastes. This finding was comparable with the study done in Haryana (Gupta, Mohaparta, & Kumar, 2015) and the study conducted in Chennai (Dutta, et al., 2017). In Gupta’s study, 86% of doctors had good knowledge score on health care waste management. The knowledge score on health care waste management was 78.6% in Dutta’s study. Likewise, 86.2 % of medical practitioners had good knowledge score on biomedical waste managements (Goyal, et al., 2015). In (Mathur, Dwivedi, Hassan, & Misra, 2011), 90% of doctors could answer correctly about health care waste management. However, the result was more than that of (Han Min Than, 2017) and (Saw Lwin, 2018). In their reports, 53% and 56% of the general practitioners had good knowledge on health care waste management. It was also higher than some global reports from developing countries. The reported fair knowledge levels of healthcare managers in Southeast Nigeria (Anozie OB, Lawani LO, Eze JN, Mamah EJ, Onoh EO, Ogah EO, Umezurike DA, Anozie RO, 2017) and medical practitioners in Kanchipuram town, India (Selvaraj, et al., 2013) were 1.9% and 39% respectively. This discrepancy might be explained by several reasons such as different continuous education system and lack of instruction or guideline for proper hospital waste management in various parts of the world. Attitude goes a long way in deciding work practices. The positive attitude shapes into good output and the output will be reversed for the negative attitude. In this study, most of the employees had positive attitude, either fairly (82.2%) or highly positive (6.6%). Only 11.2% of the employees revealed negative attitude on handling pharmaceutical wastes. This result is similar to the reports of two studies, (Gupta, Mohaparta, & Kumar, 2015) and (Sharma, Pradhan, & Mishra, 2010). In Gupta’s study, all doctors had positive attitude and 89.3% of doctors had positive attitude in Sharma’s study. However, in (Saw Lwin, 2018)’s report, some GP doctors (6.4%) felt

54 that safe management of health care waste is an extra burden. About 7.7% of GP doctors thought health care waste should be exposed without segregation. Those different results might be due to poor knowledge of GP doctors on health care waste. Another possible reason could be that they were reluctant to do segregation. In this study, the practice level of the employees was mostly fair (73.0%). Approximately 13% of the respondents revealed a high level of practice while the remaining 13% had poor practice level. This finding was similar to a study conducted in 2014, 76% of doctors correctly disposed sharp wastes into safety boxes (Sarker, et al., 2014). Moreover, the overall practice level of this study was higher than good practice level of GP doctors (60%) in Lashio (G. Seng Taung, 2010) and 66% of doctors disposed sharp wastes into corrected container (Mathur, Dwivedi, Hassan, & Misra, 2011) The total practice scores (PT) was found to be significantly associated with knowledge (KT), attitude (AT) and training. Other predictor variables included in the model; attitudinal scores, age, gender, education, rank and experience showed no significant association with PT. In reality, being young and old, gender, rank and experience were not directly proportionate to one’s practice. However, the higher the knowledge level through training, the more chance to be good at practice on waste management. This finding was consistent with the study done in Kenya (Nkonge Njagi, Mayabi OlooA, Kithinji J, Magambo Kithinji J, 2012). In that study, knowledge on health and safety was received through formal professional training. Moreover, the effects of knowledge and attitude on specific practice areas were highlighted and the most easily transformable areas were also identified in this study. According to the results, the most easily transformable areas were; P11 - The waste containers are replaced immediately when they are no more than three-quarters full, P15 - The pharmaceutical waste is not stored for more than 24 hours before disposed of, P6 - The hazardous pharmaceutical wastes are sorted in red bags or containers and marked with international biohazard symbol etc. The present study highlighted the existing knowledge, attitude and practice on pharmaceutical waste management. Since the knowledge, attitude and training on pharmaceutical waste management for private hospital employees was associated, this study indicates that there is an urgent need to train the employees in order to achieve proper pharmaceutical waste management.

5.2 Recommendations Based on the findings of this study, the following suggestions are made to improve pharmaceutical waste management of private hospitals in Mandalay city. Training alone was found to be not enough to improve practice of pharmaceutical waste management. Training may improve the knowledge and may change the attitude of the hospital staff. However, availability of resources including separate colored waste bags and containers, availability of vehicles and assess to MCDC services would also be essentials. That logistics were also important parallel to adequate training. Regular refresher training by experts would be important at the private hospitals to maintain competence and learn about new developments in this field. Posters and pamphlets for color coding and segregation of pharmaceutical wastes should be displayed in private hospitals. There is needed to develop instruction or guideline and proper pharmaceutical waste management plan for health care waste management of private hospitals.

REFERENCES

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APPENDIX I

INFORMED CONSENT

Yangon University of Economics

Informed Consent This study aims to determine the knowledge, attitude and practice of health care providers on pharmaceutical waste management system. The findings from the study will be used in the perpetuation and enhancement of the pharmaceutical waste management system. The information collected will be kept confidential and will be used only for research purpose. The participation in this study is completely voluntary. There is no persuasion or threat. The participation is not under duress. You are free to withdraw from the study at anytime if you do not wish to participate any further. If you agree to participate in this research, you are required to sing below.

Participant Researcher

Signature ------Signature ------Name ------Name ------Address ------Address ------

APPENDIX II

CHECK LIST FOR PRACTICE OF PHARAMCEUTICAL WASTE MANAGEMENT

Yangon University of Economics

Check List form for practice of pharmaceutical waste management No. Parameters Yes No 1. Is the hospital clean? 2. Is the ward clean? 3. Is there segregation of pharmaceutical waste? 4. Is black colored waste bin available in ward? 5. Is red colored waste bin available in ward? 6. Is yellow colored waste bin available in ward? 7. Is black bag securely fitted with the bin? 8. Is red bag securely fitted with the bin? 9. Is yellow bag securely fitted with the bin? 10. Are waste bins covered? 11. Is the biohazard symbol imprinted over waste bags? 12. Are posters to guide users displayed near waste bins? 13. Does black bag contain only general waste? 14. Does red bag contain only hazardous waste? 15. Does yellow bag contain only soiled infected waste? 16 Is the incinerator use?

APPENDIX III

QUESSIONNAIRES FOR CHARACTERISTICS OF HOSPITALS

Yangon University of Economics

Part 1: Characteristics of Hospitals

1. Name of hospital ------2. Number of beds ------3. Number of employees ------ MS -  AMS -  AS -  Doctors -  Matron -  Sisters -  Staff Nurse -  Trained Nurse -  Nurse Aid -  General worker -  Other -

4. Department of hospital Surgery Pediatric Male Female Emergency Neonates

Intensive Care Unit Kidney Dialysis Maternity Orthopedic Support Departments and units Other 5. Which kind of wastes are generated in hospital? Domestic waste Sharps waste Infectious waste Pharmaceutical waste Chemical waste Pathological waste

APPENDIX IV

QUESSIONNAIRES FOR KNOWLEDGE, ATTITUDE AND PRACTICE ON HANDLING PRACTICE OF PHARMACEUTICAL WASTE

Yangon University of Economics

Part 1: Characteristics of Respondents 1. How old are you? ------years old

2. Gender  Male  Female

3. Position/Job Title ------

4. Educational status  Illiterate  Can read and write  Primary  Middle  High  Diploma  Graduate  Master  PhD  Other

5. Working Experience ------years

Part 2: Knowledge on handling practice of pharmaceutical waste

No. Question Yes No 1. Do you know that according to WHO classification, how many classes of pharmaceutical waste? 2. Do you know that the pharmaceutical waste should be segregated? 3. Do you know that the pharmaceutical waste should be segregated in the one place? 4. Do you know the pharmaceutical waste are sorting into color-coded and well-labelled bags or containers? 5. Which color bags or containers use for sorting the non hazardous pharmaceutical waste?  Black  Red  Yellow  White 6. Which color bags or containers use for the potentially hazardous pharmaceutical waste?  Black  Red  Yellow  White 7. Which color bags or containers use for sorting the hazardous pharmaceutical waste?  Black  Red  Yellow  White 8. Do you know that the pharmaceutical waste is collected and transported separately? 9. Do you know that the pharmaceutical waste collection include the collection points and routes of waste transport separately? 10. Do you know that there is a timetable of the frequency of collection? 11. Do you know that the pharmaceutical waste collector should wear the heavy duty gloves, industrial boots and apron? 12. Do you know that the waste containers are replaced immediately when they are more than three-quarters full? 13. Do you know that the hazardous and non-hazardous pharmaceutical are collected on separate trolleys? 14. Do you know that the pharmaceutical waste is not stored for more than 24 hours before disposed of?

No. Question Yes No 15. Do you know that the pharmaceutical waste should not be stored near with food stored or food preparation? 16. Do you know that the authorized person only can access to the store room of pharmaceutical waste? 17. Do you know that there is the proper labelling of the containers that are transported? 18. Do you know that the transportation should be properly documented? 19. Do you know which service generally collect the pharmaceutical wastes?

20. Do you know that the documents or forms are used during collection from the service?

Part 3: Attitude on handling practice of pharmaceutical waste

Strongly No. Question Agree Neutral Disagree Strongly Agree Disagree 1. The pharmaceutical waste should be segregated. 2. The segregating hazardous from non-hazardous waste will reduce greatly the risks of infecting workers handling the pharmaceutical waste. 3. The different classes of pharmaceutical waste should be identified by sorting the waste into color-coded and well-labelled bags or containers. 4. The procedure of the pharmaceutical waste segregation, packaging and labelling should be explained to the staff who handle the pharmaceutical waste. 5. The color coding system should be simple and applied uniformly throughout the country. 6. The hazardous pharmaceutical should be placed marked and indicated with the international biohazard symbol. 7. The awareness and the training for waste segregation and labelling to the medical staff and the person who involve in pharmaceutical waste handling should be ensured.

Strongly No. Question Agree Neutral Disagree Strongly Agree Disagree 8. The sanitary staffs and cleaners should always wear protective clothing such as industrial aprons, boots and heavy duty gloves while handling the pharmaceutical wastes. 9. There should be the pharmaceutical waste management plan including the collection points, the routes of transport and the timetable of the frequency of collection. 10. The hazardous and non-hazardous pharmaceutical should be collected on separate trolleys which should be marked with the corresponding color (yellow/black) and washed regularly. 11. The reasons for labelling the pharmaceutical waste bags or containers is that in case of an accident the content can be quickly identified. 12. The vehicle used for the collection of hazardous pharmaceutical waste should not be used for any other purpose. 13. The pharmaceutical waste should not be stored more than 24 hours before disposed of.

Strongly No. Question Agree Neutral Disagree Strongly Agree Disagree 14. The non hazardous pharmaceutical waste should always be stored in a separate location from the hazardous pharmaceutical waste to avoid cross-contamination. 15. The authorized person only can access to the store room of pharmaceutical waste. 16. The transportation should be properly documented. 17. The pharmaceutical waste management is the team work. 18. The safe management of pharmaceutical waste is an extra burden of work. 19. All of the staff who include in the pharmaceutical waste management should be vaccinated of Hepatitis B and Tetanus. 20. There should be available of national guideline for handling practice of pharmaceutical waste.

Part 3: Practice on handling practice of pharmaceutical waste No. Question Yes No 1. The pharmaceutical wastes are segregated. 2. The pharmaceutical wastes are segregated in the one place. 3. The pharmaceutical waste are sorted into color-coded and well-labelled bags or containers 4. The non hazardous pharmaceutical waste are sorted in black bags or containers 5. The potentially hazardous pharmaceutical waster are sorted in yellow bags or containers and marked with international biohazard symbol? << Danger! Hazardous infectious waste >> 6. The hazardous pharmaceutical wastes are sorted in red bags or containers and marked with international biohazard symbol? << Danger! To be discarded by authorized staff only >> 7. The pharmaceutical wastes are collected and transported separately. 8. The pharmaceutical waste collection has a plan which include collection points and the routes of wastes transports. 9. There is a timetable of the frequency of collection.

10. The pharmaceutical waste collectors are wearing the heavy duty gloves, industrial boots and apron while collection process. 11. The waste containers are replaced immediately when they are no more than three-quarters full. 12. The hazardous and non-hazardous pharmaceutical are collected on separate trolleys. 13. The documents or forms are used during collection from the service? 14. MCDC collect the pharmaceutical waste regularly.

No. Question Yes No 15. The pharmaceutical waste is not stored for more than 24 hours before disposed of. 16. The pharmaceutical wastes are not be stored near with food stored or food preparation. 17. The authorized person only can access to the store room of pharmaceutical waste. 18. There is the proper labelling of the containers that are transported? 19. The transportations are properly documented.

20. Does MCDC generally collect the pharmaceutical waste? 21. There is available and used of internal guidelines and standard operation procedure (SOP) at hospital If yes, please specify that guideline or SOP ------22. There is incinerator in your hospital. 23. The medical staffs are available on training regarding health care waste management. 24. The staffs are trained on monitoring and supervising of health care waste management. 25. There is available of monitoring regulations for health care waste and monitored regularly by the relevant authorities.