ADDIS ABABA UNIVERSITY GRADUATE PROGRAMS CENTER FOR ENVIRONMENTAL SCIENCE
Healthcare Waste Generation Rate, Composition and Its Management System: The case of Selected Governmental Hospitals in Addis Ababa, Ethiopia
A Thesis Submitted to the School of Graduate Studies of Addis Ababa
University, In Partial Fulfillment of the Requirement for the Degree of Masters
of Science in Environmental Science
By AzebTayework
Main Advisors
SeyoumLeta (PhD)
Co-Advisors
Eshetu Lemma (MSc)
June, 2016
i ADDIS ABABA UNIVERSITY SCHOOL OF GRADUATE STUDIES
Healthcare Waste Generation Rate, Composition, and Its Management System: The Case of Selected Governmental Hospitals in Addis Ababa, Ethiopia
By Name Signature Date
AzebTayework ______
I the under signed, declare that this is my original work and that all sources of materials used for the thesis have been correctly acknowledged.
Department of Environmental Science Addis Ababa University
The thesis has been approved for submission by:
Name Signature Date
SeyoumLeta (PhD) ______
Eshetu Lemma (MSc) ______
ii Acknowledgements
For the success of this work many individuals and institutions has contributed a lot. First, I would like to thank my advisor SeyoumLeta (PhD) and EshetuLemma (MSc) for unreserved comments, advice, and contributions of ideas as well as sharing of time to read the earlier drafts of this paper.
For various data and information I received; my foremost thank goes to Black Lion Specialized Teaching Hospital, Yekatit 12 Memorial Hospital, Gandhi Memorial Hospital and People in the study area also deserve acknowledgements for their kindness and hospitability during my actual collection and measurement in field work and also want to acknowledge the data collector and supervisor.
Finally, my heartfelt thank go to all my families for assisting me both in ideas and in materials to accomplish this paper.
AzebTayework
June, 2016
iii Acronyms
AAS Atomic Absorption Spectrometer AZT Azidothymidine CSA Central Statistics Authority EIA Environmental Impact Assessment EPA Environmental Protection Agency HCW Health Care Waste HCWM Health Care Waste Management HWM Hospital Waste Management MOE Ministry of Environment MOH Ministry of Health MSW Municipal Solid Waste OPD Outpatient Door IPD Inpatient Door TEPA Taiwan Environmental Protection Administration WHO World Health Organization SPSS StatisticalPackage For Social Science
iv Table of content
Contents Acknowledgements...... iii
Acronyms...... iv
Table of content...... v
List of table...... viii
List of Figure...... ix
Abstract...... xi
1. Introduction...... 11
1.1. Background of the Study...... 11
1.2. Statement of research problem...... 3
1.3. Objectives of the Study...... 4
1.3.1. General objective of the study;...... 4
1.3.2. Specific objectives of the study;...... 5
1.4. Delineation of the study...... 5
1.5. Research question...... 5
1.5.1. Main research question...... 5
1.5.2. Specific research questions...... 5
1.6. Scope of the Study...... 5
1.7. Organization of the Study...... 6
1.8. Clarification of basic terms and concepts...... 6
2. Review of related literature...... 7
2.1. Healthcare waste definitions...... 7
2.1.1. Healthcare waste generation rate...... 8
v 2.1.2. Classification of healthcare waste...... 9
2.2. Healthcare waste management...... 12
2.3. Public health of healthcare waste management...... 14
2.3.1. Effect of infectious waste and sharps...... 16
2.4. Conceptual structure of the study...... 17
2.5. Bottom ashes heavy metals...... 18
3. Materials and Methodology...... 20
3.1. Materials...... 20
3.2. Description of the study area...... 21
3.2.1. Geographic location...... 21
3.2.2. Climate...... 22
3.2.3. Temperature...... 23
3.2.4. Demography of the Study Area:-...... 24
3.3. Sampling techniques...... 25
3.4. Data collection...... 25
3.4.1. Data procedure and analysis technique:...... 26
3.5. Heavy metal determination...... 27
3.6. Data management and statistical analysis...... 28
3.7. Data quality assurance mechanisms...... 29
3.8. A tabular summary of the methods applied in this study...... 29
4. Results and Discussion...... 30
4.1. Healthcare wastes composition and generation rate...... 30
4.1.1. Healthcare waste composition:...... 30
4.1.2. Healthcare waste generation rate...... 33
4.2. Heavy metal concentration...... 37
vi 4.3. The practice of healthcare waste management...... 38
4.3.1. Healthcare waste segregation practice...... 42
4.3.2. Temporary storage of hospital healthcare waste practice on point of source...... 43
4.3.3. Collection and transportation of healthcare waste...... 44
4.4. Hospital healthcare waste treatment and disposal practice...... 44
4.5. Hospital healthcare waste reuse and recycling practice...... 45
5. Conclusion and Recommendations...... 46
5.1. Conclusions...... 46
5.2. Recommendations...... 47
References...... 48
Annex...... 52
vii List of table
Contents
Table 1, Types of heavy metals and their sources from healthcare institutions...... 19
Table 2, Mean monthly rainfall of Addis Ababa...... 23
Table 3, Min and Max Monthly Temperature of Addis Ababa in(C°)...... 24
Table 4, Population distribution by sub city...... 24
Table 5, Limit of detection for sample heavy metals...... 28
Table 6, Summary of methods based on the objectives of the study...... 30
Table 7, The mean composition of healthcare waste in the study hospital, 2016...... 31
viii List of Figure
Contents
Figure 1, Conceptual structure of healthcare waste generation rate, 2016...... 18
Figure 2, Map of the study area (Source: CSA, 2007)...... 22
Figure 3, mean composition of healthcare waste in the Yekatit 12 Memorial Hospital, 2016 ...... 31
Figure 4, mean composition of healthcare waste in the Gandhi Memorial Hospital, 2016... 32
Figure 5, mean composition of healthcare waste in the Black Lion Specialized Teaching Hospital, 2016...... 33
Figure 6, patient flow of in the studied hospitals per day, 2016...... 34
Figure 7, generation rate of healthcare waste per 8 day in the Y hospital 2016...... 35
Figure 8, generation rate of healthcare waste per 8 day in the G hospital, 2016...... 36
Figure 9, generation rate of healthcare waste per 8 day in the B hospital, 2016...... 36
Figure 10, the mean generation rate of healthcare waste kg/day/patient in the study hospitals, 2016...... 37
Figure 11, average concentration of heavy metals in the studied hospital, 2016...... 38
Figure 12, Photo shows, the incinerator instrument in Y hospital (Photo: Azeb Tayework, October 11, 2016)...... 39
Figure 13, Photo shows, the incinerator instrument in B hospital (Photo: Azeb Tayework, October 10, 2016)...... 41
Figure 14, Photo shows, the incinerator instrument in G hospital (Photo: Azeb Tayework, October 10, 2016)...... 41
Figure 15, Photo shows, HCW segregation practice storage in the studied hospital (Photo: Azeb Tayework, March 17, 2016)...... 42
ix Figure 16, Photo shows, hospital HCW temporal storage at the point of sources in the studied hospital (Photo: Azeb Tayework, March 17, 2016)...... 43
Figure 17, Photo shows, hospital HCW transportation in the studied hospital (Photo: Azeb Tayework, March 17, 2016)...... 44
Figure 18, Photo shows, hospital reuse mechanism in the studied hospital (Photo: Azeb Tayework, March 17, 2016)...... 45
x Abstract Healthcareprovide services likecontrolling and preventing of communicable andnon- communicable diseases. In the process of performing these activities, health facilities generally generate hazardous waste. The number of inpatient and outpatient are one of the factor that affect the generation rate of healthcare waste and it is different from hospital to hospital because of their specialization. The generation rate of hazardous and non-hazardous of solid healthcare waste has an environmental risk to the patient, healthcare worker and the environment at large. The general purpose of this study was to assess solid healthcare waste generation rate, composition, concentration of heavy metals and its management system in selected governmental hospital in Addis Ababa, Ethiopia. The study was conducted using cross-sectional, longitudinal and experimental method. The sample size was determined using simple random sampling technique. The generation rate and composition were collected using waste collecting andmeasuring equipment.Heavy metalin incinerated ash were analyzed using Atomic Absorption Spectrometer for the selected hospitals. The Data was analyzed using Microsoft excel version 2010 and SPSS version 20. The mean healthcare waste generation rate was 0.96kg/day/patient of which 0.46kg/day/patient (47.82%) was non-infectious waste and0.5kg/day/patient (52.18%) was infectious. The overall heavy metals concentration were found high concentration in copper and low concentration in cadmium and the descending order was Copper>lead>Cadmium>Chromium. A wide variation in trace concentration of several toxic elements has also been seen due to variation in initial waste composition, design of the incineration, the level of hospital and operating conditions.
Key words: Healthcare waste, generation rate, Composition, Hospitals, Hazardous waste, Non- hazardous waste, Atomic Absorption Spectrometer
1. Introduction
1.1. Background of the Study
xi Hospitals are health institutionsprovide diagnostic, therapeutic, research and rehabilitative services in an attempt to manage health problems and protect the public from different health risks. In the process of performing these activities, health facilities generally generate hazardous waste that could be potentially harmful to healthcare workers, the public, and the environment (Patil and Pokhrel, 2005). In the process of healthcare delivery, waste is generated which includes sharps, human tissues or body parts and other infectious materials (Bavejaet.al.,2000).HCW are defined to include all types of wastes produced by health facilities, such as general hospitals, health centers, clinics and dispensaries. However, such residues can potentially transmit diseases and present an additional risk to the staff of the healthcare facilities, patients, the community and affect the environment when the wastes are not managed properly (Silva et.al.,2005). Improper disposal of HCW including open dumping and uncontrolled burning for instance increases the risk of spreading infections and of exposure to toxic emissions from incomplete combustion. The characteristics of waste generation depends on number of factors such as established methods of waste management, type of healthcare establishment, degree of health facility specializations, proportion of reusable items employed in health care, seasonal variation and patient work load. In middle and low-income countries, healthcare waste generation is usually lower than that of high-income countries (MulukenAzage and AberaKumie, 2015). HCW may be classified into different types according to their source, type and risk factors associated with their handling, storage and ultimate disposal. The European Union has been making a special effort to standardize waste classification through the establishment of the Waste European Catalogue (Aivimet.al., 2005). Meanwhile, many different classifications still are being considered in legislation and in the literature (Aivim, 2005;Kgathi and Bolanee, 2001;Hardoy, 1992).
Throughout the world, the health sector is one area that has witnessed significant improvement. However, it seems that the fraction of waste generated at healthcare institutions has not attracted the same level of attention as other types of wastes, particularly in developing countries. Despite the fact that HCW is labeled as hazardous waste because it poses serious and direct threat to human health (Hardoy,1992; Coad, 1992; WHO,1999; Oweiset. al., 2005).
2 The publichealth impacts of HCW weredetermined by the overall waste management strategy adopted by the hospitals or health centers. HCWM involves management of a range of activities, which are mainly engineering functions such as collection, transportation, treatment of processing systems and disposal of waste. However, in most cases, initial segregation and storage activities are the direct responsibility of nursing personnel. If the infectious component gets mixed with the general non-infectious waste, the entire mass becomes potentially infectious. It is the responsibility of hospitals and other healthcare institutions to ensure that there are no adverse health and environmental consequences because of their waste handling, treatment, and disposal activities (Soncuyaet. al., 1997;Patil and Pokhrel, 2005). This present study focuses on the HCWM practices of a selected governmental hospital in Addis Ababa.
1.2. Statement of research problem Waste management has become a critical issue as it poses potential health risks and damage to the environment. An issue is taking central place in the national health policies of many countries.In developing countries, solid wastes have not received sufficient attention. This is because very often, health issues compete with other sectors of the economy for the limited resources available. Thus, management of HCW end up not getting the priority it deserves.
In many countries hazardous municipal and HCW are still handled and disposed together with domestic waste that posing a great health risk to municipal workers, the public and as well as the environment. HCW must be separate from municipal waste but in many parts of Africa, it tends to be collected along with the rest of the waste stream (Kgathi and Bolanee, 2001).
Forinstance in Ethiopia, HCW were seen as a mounting problem. In recent times, there have been numerous press statements about HCW being disposed of in an incorrect manner. This HCW has also caused much concern. Some studies have pointed out that incinerators have been associated with a wide variety of health problem in Ethiopia such as disrupting the body’s hormonal, immune system, and reproductive system, even cause cancers(FEPA, 2000).
HCW cannot be accounted for including that it is being illegally dumped, burnt in unknown locations, thus affecting the health of the people and the environment, the disposal of HCW constitutes a problem in other parts of the country(Groundwork, 2002).
3 Ethiopia as a country has not a capacity properly dispose of the huge amounts of HCW generated in the land. There have been numerous instances where HCW has been dumped in residential areas. The illegal removal of HCW in disadvantaged residential areas has resulted in situations where children’s has been found playing with HCW materials such as syringes. This problem is facing on black lion specialized teaching hospital, treated some children with Azidothymidine (AZT) after some were picked with needles and others ate potentially lethal pills they found in a field around the hospital. Waste from healthcare facilities poses a risk to healthcare workers, patients and the local communities in the area(reported in magazines news paper, September 2014).
Researches indicated that in the past,HCW has done much damage to the environment and to public health. One estimate shows that some 5.2 million people (including 4 million children) die each year from waste-related diseases. Evidence concerning health problems related to poor healthcare waste management indicate that, in 2003 the occurrence of a severe outbreak of acute respiratory syndrome in Taiwan enforced the authorities to take more serious steps in managing HCW (TEPA, 2003). Study indicates a clear association between exposure to incinerator emissions and ash increased adverse health impacts because of high amount of heavy metals. Studies conducted in Japan, Spain, and Germany show that incinerator workers or children and other residents living near incinerators have significantly higher blood or urine levels of dioxins, furans, and hydrocarbons compared to control groups or to national averages (Kumagaiet. al., 2005).
In Ethiopia there are some studies in the area using field observation and actual measurement, therefore in the light of all the above, these study was conducted based onlaboratory analysis. This study aims at examining the HCW generation rate, composition, theconcentration ofheavy metal, and its management system the case of selected government hospital in Addis Ababa.
1.3. Objectives of the Study
1.3.1. General objective of the study; The general purpose of this study was to assess solid healthcare waste generation rate, composition and its management system at selected government hospital in Addis Ababa.
4 1.3.2. Specific objectives of the study; To determine the solid healthcare waste generation rate and composition at selected government hospitals To determine the level of heavy metals content in solid healthcare waste at selected government hospitals To assess the practice of solid healthcare waste management at selected government hospitals
1.4. Delineation of the study This research was a case study and focuses on the selected governmental Hospital in Ethiopia. This study examines the HCWM practices with particular reference to the governmental Hospital.
1.5. Research question
1.5.1. Main research question Is itHCWMpracticable in selectedgovernmental hospitals?
1.5.2. Specific research questions Do storage, segregation, collection, transportation, treatment and disposal of HCW in selected government hospitals pose risk to human health and the environment? Is implementing segregation practice according to the categories reducing hospital hazardous waste generation rate? What is HCW generation rate in selected government hospitals?
1.6. Scope of the Study This study was conduct in Addis Ababa city administration. This Research focuses on solid HCW generation rate, composition,the level of heavy metals and its management system at selected government hospitals.Its scope of this study was delimited on the three selected hospitals; Black Lion Specialized Teaching Hospital, Yekatit 12 Memorial Hospital, and Gandhi Memorial Hospital.
5 1.6.1. Limitations of the study While carrying out this thesis, the researcher was encountered by several constraints such as financial related problems and shortage of time. The researcher does notconduct solid waste transfer station potential sites construction cost analysis. Also didnot see seasonal variation of healthcare generation rate with the available time.
1.7. Organization of the Study The study was organizing under five chapters:
Chapter one: is the introduction, it includes background of the study, statement of problem, objectives of the study,delineation of the Study, research question,scope of the study, limitations of the study, andorganization of the study. Chapter two: related literature available on medical waste management was reviewed. Chapter three: deals with material and methodology used in achieving the objectives of the study. Chapter four: covers the result and discussion of the study.Chapter five: the findings emerging from the analysis are summarized. Conclusions of the study were based on the findings and valid suggestions and recommendations in line with the objectives of the research are made.
1.8. Clarification of basic terms and concepts Healthcare waste is waste generated from health institutions. This includes both infectious waste and non-infectious waste materials. Healthcare waste is also referring to as medical waste, hospital waste or clinical waste (Soncuya et.al., 1997; WHO, 1999; WHO, 2005). Health institution or healthcare facility includes hospitals, medical or research laboratories, clinics, offices of physicians and dentists, veterinarians, long term care facilities (Soncuyaet.al., 1997; WHO,1999). Infectious waste includes infectious materials that can cause disease to humans (WHO, 2005). Infectious waste means healthcare risk waste which is suspect to contain pathogens and which normally causes or significantly contributes to the cause of increased morbidity or mortality of human beings and includes but is not limited to sharps waste and anatomical waste; but excludes babynappies and sanitary pads (Godey, 2003).
6 Hazardous waste means waste that may, by circumstances of use, quantity, concentration or inherent physical, chemical or infectious characteristics, cause ill health or increase mortality in humans, fauna and flora, or adversely affect the environment when improperly treated, stored, transported or disposed of (Godfrey, 2003). Healthcare waste management or healthcare waste management is a process that helps ensure proper hygiene in the health institution and safety of healthcare Workers and communities (SanitationConnection,2002) Waste disposalrefers to the final placement of treated waste (Johannessenet. al.,2000; WHO,2005). Treatment of wastesis mainly reducing direct exposure of waste to become less dangerous to humans, at recovering recyclable materials and at protecting the environment (Johannessenet.al.,2000). Waste minimization is the prevention of waste production and/or its reduction(WHO,2005).
2. Review of related literature
2.1. Healthcare waste definitions Waste is a material discharged and discarded from each stage of daily human life activities, which leads to adverse impacts on human health and the environment (Bringi,2007). Whereas,Hospitals produce a tremendous amount of HCW that is defined as any solid waste
7 which is generated as a result during patient diagnosis, treatment, or immunization of humans or animals.
According to WHO, the waste produced by hospitals carries a higher potential for infection and injury than any other kind of waste (WHO, 2005).HCW is a major problem in most developing countries of the world due to its growing and endless generation coupled with poor management (Alagozand Kocasoy, 2008).
The process of storing, collecting, transporting, treating and disposing waste material is known as waste management (Farzadkiaet. al., 2009). The aim is to clean up the surrounding environmentand realize that the waste does not have a detrimental effect on our health. Nowadays, waste management has gone a step further not only planning proper disposal but also attempting to see whether can reuse and recycle certain materials from waste matter (Harhayet. al.,2009.). The safe and effective disposal of HCW starts with a healthcare practitioner. There is a real need to reduce both the cost and environmental impact arising from the generation and disposal of waste in healthcare settings (Royal, 2009).
2.1.1. Healthcare waste generation rate Healthcare activities lead to the production of waste. The generation rate varies across the different types of hospitals. There exists different generation rate that does not only vary from country to country, but also within a country (AlagozandKocasoy, 2008).Based on WHO 2013 report; factors affecting HCW generation are:
established waste management methods, type of healthcare establishment, hospital specializations, proportion of reusable itemsemployed in healthcare, and proportion of patients treated on a day care basis
In addition, the research confirmed that HCW generation rate depends on thelevel of economic development of a country, reimbursement payment by National health insurance, location of healthcare establishment, proportion of disposable substance used in healthcare activities and
8 season of the year. This seasonal variation may be becauseof change in season the nature of illness of patients being admitted to hospitals also changes (Katoch and Kumar, 2007).
The generation rate of middle-income countries compared to low-income countries indicates that lower in low-income countries. However, the range of values for countries of similar income level is probably as wide in high-income countries as in less wealthy countries (WHO, 2005).
The WHO assessment of HCW generation rate indicated that 80% general HCW, 15% pathological and infectious waste, 1% sharps waste, 3% chemical or pharmaceutical waste, and less than 1% special waste, such as radioactive or cytostatic waste, pressurized containers or broken thermometers and used batteries (WHO, 2013).
According to the study of EsubalewTesfahun, 2015 the compositions of healthcare waste in public hospitals were 46.4%, 34.3%, 3.8%, 9.1%, 6.2% and 0.2% for general, infectious, sharps, pharmaceutical, pathological and radioactive wastes respectively. The compositions of healthcare waste in private hospitals were 45.3%, 29.7%, 6.7%, 17.3%, 0.5% and 0.5% for general, infectious, sharps, pharmaceutical, pathological and radioactive wastes respectively (EsubalewTesfahun, 2015).
According to the study of MulukenAzage and AberaKumie the HCW generation rate indicated that 52% were general waste and 48% were hazardous waste (MulukenAzage and AberaKumie, 2007).
2.1.2. Classification of healthcare waste The WHO classifies medical or healthcare waste into common waste or general waste and special waste. Common or general waste is all solid waste not including infectious, chemical, or radioactive waste. This waste stream can include items such as pack ageing materials, bedding,
9 office supplies, and other substances that do not pose special handling problem hazard to human health or the environment (WHO, 1999).
Special waste consists of several different subcategories:
Chemical waste: Consists of discarded solid, liquid, and gaseous chemicals, for example from diagnostic and experimental work and from cleaning, housekeeping, and disinfecting procedures. Chemical waste from healthcare may be hazardous or nonhazardous; in the context of protecting health. it is considered to be hazardous if it has at least one of the following properties:
toxic; corrosive (e.g. acids of pH<2 and bases of pH>12); flammable; reactive(explosive, water-reactive, shock-sensitive); genotoxic (e.g. cytostatic drugs)
Non-hazardous chemical waste consists of chemicals with none of the above properties, such as sugars, amino acids, and certain organic and inorganic salts (WHO, 1999)
General waste: Is all solid waste not including infectious, chemical, or radioactive waste. This waste stream can include items such as packaging materials and office supplies. Generally, this stream can be disposed of in a communal landfill or other such arrangement. Segregation of materials which are able to be reused or recycled will greatly reduce the impact burden of this waste stream(WHO, 1999).
Geno-toxicwaste:is highly hazardous and may have mutagenic, teratogenic, or carcinogenic properties. It raises serious safety problems from both inside hospitals and after disposal, which should be give special attention. Genotoxic waste may include certain cytostatic drugs, vomit, urine, or faeces from patients treated with cytostatic drugs, chemicals, and radioactive material. Cytotoxic drugs, the principal substances in this category, have the ability to kill or stop the growth of certain living cells, and are uses in chemotherapy of cancer. They play an important role in the therapy of various neoplastic conditions but there is also finding wider application as immune suppressive agent sin organ Tran’s plantation, and in treating various diseases with an
10 immunological basis. Cytotoxic drugs are most often used in specialized departments such as oncology and radiotherapy units, whose main role is cancer treatment; however, their use in other hospital departments is increasing and they may be used outside the hospital setting (WHO, 1999).
Hazardous waste: This has multiple sources in a Facility and includes both chemically hazardous materials, infectious and radioactive materialsand capable of causing disease in human being, animals, plants and environment (WHO, 1999).
Heavy metals waste: content fall under hazardous chemical waste, and are usually highly toxic. Mercury wastes are typically generating from spillage from broken clinical equipment but their volume is decreasing with the substitution of solid-state electronic sensing instruments (thermometers, blood-pressure gauges, etc.). Whenever possible, spilled drops of mercury should be recover. Residues from dentistry have high mercury content. Cadmium waste comes mainly from discarded batteries. Certain "reinforced wood panels" containing lead is still used in radiation proofing of X-ray and diagnostic departments. A number of drugs container arsenic, but these are treated here as pharmaceutical waste (WHO, 1999).
Infectious waste: contains pathogens (bacteria, viruses, parasites, or fungi) in sufficient concentration or quantity to cause disease in susceptible hosts. This category includes cultures and stock of infectious agents from laboratory work, waste from surgery and autopsies on patients with infectious diseases.Wastefrom infected patients in isolation wards, waste that has been in contact with infected patients undergoing home dialysis (e.g. dialysis equipment such as tubing and filters, disposable towels, gown sand aprons, gloves and laboratory coats) and waste that has been in contact with animals inoculated with an infectious agent or suffering from an infectious disease (WHO, 1999).
Pathological waste: Consists of tissues, organs, body parts, human fetuses and animal carcasses, blood, and body fluids. Within this category, recognizable human or animal body parts are also called anatomical waste. This category should be considered as a subcategory of infectious waste, even though it may also include healthy body parts(WHO, 1999).
Pharmaceutical waste: include pharmaceutical products, drugs, and chemicals that have been return from wards, have been spilled, are out date decontaminated, or are to be discarded because
11 they are no longer required. These also include discarded items used in the handling of pharmaceuticals, such as bottles or boxes with residues, gloves, masks, connecting tubing, and drug vials (WHO, 1999).
Radioactive materials: are wastes containing radioactive substances. These include solid, liquid, and gaseous waste contaminated with radionuclides generated from vitro analysis of body tissues and fluids, in vivo body organ imaging, tumor localization, and therapeutic procedures (WHO, 1999).
Sharps: Theseare items that could cause cuts or puncture wounds, including needles, hypodermic needles, scalpel and other blades, knives, infusion sets, saws, broken glass, and nails. Whether or not they are infected, such items were usually considered as highly hazardous healthcare waste(WHO, 1999).
2.2. Healthcare waste management Based on theWHO, the standard practice in each component of HCWM areHCW should be segregated based on their potential hazard characteristics, treatment requirement, and disposal route, by the person who produces each waste item (WHO, 2005). Separate labeled color code containers (infectious waste yellow, chemical, and pharmaceutical waste brown, general waste black) should be available for each medical area for each category ofHCW. Closed color-coded labeled containers are kept away from patient indoors for interim or short-term storage (depending upon the type of waste not more than 12 hours) of HCW in each medical room. Waste bags and sharp containers should be filled with not more than three quarters full (WHO, 2004).
The Collection should be fixed and appropriate to the quantity of waste, but not more than a day. The collection of HCW must follow specific routes through the hospitals in order to reduce the passage of loaded carts through wards and other clean area. The unusable waste materials shouldbe preferably was treated to reduce their potential health or environmental hazard and volume, with remaining residues sent for land disposal to a suitably constructed site.
In all HCW systems, the removal of the remaining HCW materials after minimization or treatment will require access to land for final disposal. Desirable features of a landfill are restricted access to prevent scavenging, daily soil cover to prevent odors and regular
12 compactionand isolation of waste to prevent contamination of groundwater and surrounding areas (WHO, 2013).
It is to be noted that no single technology is ideal for all kinds of HCW and for all scales of operation. Commonly used technologies are incineration, land filling, burning, autoclaving and chemical treatment. Moreover, microwave disinfections, plasma touch technique, detoxification, and advanced wet oxidation are some emerging technologies. In addition, a new solar treatment technology was developed in India (Mohee, 2005).
If a country decided to use incineration as a HCW treatment options it should be the national governments might utilize emission limits and other requirements to ensure effective waste treatment, minimize emissions, and decrease exposure and risks to workers and the community (Shahjahanet. al.,2006).
There have been enhancements in the management of HCW in the last decade and developing countries have been drown lessons from India’s experience. Since 1995, India has made great progress in managingHCW, notwithstanding delays caused by weaknesses in the country’s legal and institutional framework for healthcare waste management (Katoch and Kumar, 2007).
The National Government of Nigeria has formulated HCW Rules, prepared national guidelines, and implemented a national training program. Countries have devised their own HCWM strategies and guidelines and provided assistance togovernment hospitals to implement HCWM initiatives. Non-Governmental Organizations (NGOs) have played a major role in bringing the HCWM agenda to the attention of government officials, creating public awareness of HCW issues and training healthcare facility personnel (Stephen and Elijan,2010).
WHO in 2004 prepared a policy paper calling on developing countries and countries in transition to develop national policies, guidance manuals, and implementationplans for sound management of HCW (WHO, 2005).
The managementof HCW in many developing countries has been often poor and it raises concerns about inappropriate HCWM methods employed in such states. Inappropriate treatment and final disposal of HCW leads to an adverse impact on public health, occupational health and safety and the environment (Chenet. al., 2003).
13 A study done in South Africa showed that incineration was a dominant option for treatment technology of HCW with most of the incinerators situated on the healthcare facility sites. Similar to many first world countries, however, non-incineration technologies are rapidly becoming the dominant treatment technologies, primarily due to increased costs associated with raised air emission control standards required for incineration facilities (Kobus and John, 2008). The study conducted in developing countries reviled that the commonest method of HCW treatment was done by poor design and construction incinerators have low combustion capacity (Israel Deneke,et.al., 2011).
A study done in Addis Ababa, Ethiopia HCW management includes all activities involved in waste generation, segregation, transportation, storage, generated in the HCFs. Healthcare waste handling is a hazardous activity which requires a high standard of training. It calls for specific training that depends on the nature of the work in the hospital, the hazards and possibility of worker exposure, and the responsibilities of individual workers treatment and final disposal of all types of waste. The study was found that the management of health care waste at hospitals in Addis Ababa city was poor (MesfinKoteet.al., 2011).
2.3. Public health of healthcare waste management In Ethiopia, there is no specific legislation directly to HCWM. However, there are policies and legislations with provisions for the management of healthcare waste (MOH, 2008). But it has lack of enforcement & unsatisfactory implementation.
According to the Ethiopia Public Health Proclamation No.200/2000 says the following bans and restrictions about healthcare waste “Any solid, liquid and other wastes generated from hospitals should be handled with special care and their disposal procedures should meet the standards set by the public health authorities”. The proclamation says on Article 4-sub article, 12,12.3, waste handling and disposal of any solid and other wastes generate from hospitals should be handled with special care and their disposal procedures should meet the standards set by the public health authorities.
According to Ethiopia Environmental Pollution Control Proclamation, No 300/2002, hazardous waste define as the following “an unwanted material that is believed to be deleterious to human safety or health or the environment pronounces the following prohibitions and restrictions in its
14 management”. Concerning the managementof hazardous waste, it states that the generation, keeping, storage, transportation, treatment or disposal of any hazardous waste without a permit from the Environmental Protection Authority or the respective Regional Environmental Agency is prohibited (Environmental Pollution Control Proclamation, No., 300/2002).
No person shall pollute or cause any other person to pollute the environment by violating the relevant environmental standards” (Article 3-sub article, 1). Any person engaged in any field of activity which is likely which is to cause pollution or any other environmental hazard shall, when the authority or the relevant regional environment agency so decides, install a sound technology that avoids or reduces, to the require minimum, the generation of waste and when feasible apply methods for the recycling of waste (Article 3-sub article, 3).
According to solid waste management Proclamation, No 513/2007 Solid waste management means “the collection ,transportation, storage ,recycling or disposal of solid waste the subsequent use of a disposal site that is no longer operational”. Urban administration shall ensure the participation of the lowest administrative levels and their respective local communities in designing and implementing their respective solid waste management plans.For management of hazardous waste of chemical and radioactive substance the proclamation says the generation, keeping, storage, transportation, treatment or disposal of any hazardous waste with out a permit from the authority or the relevant regional environmental agency is prohibited (Article 3-sub article, 4, 4.1).
Proclamation 661/2009 state promulgated to translate this to its executive organs. Article 4 indicates the Power and Duties of the Executive Organ and Sub article 18 states; The executive organ shall have the powers and duties to ensure that handling and disposal of trans regional solid and liquid wastes from different institutions are not harmful to public health.
According to Food, Medicine and Healthcare Administration and Control Council of Ministers Regulation 299/2013 describes waste handling and disposal on article 38 and 87 as it shall be prohibited to burn or dispose by any other means a poisonous or contagious waste without obtaining permit from appropriate organ.
The Environmental Impact Assessment Proclamation No.299/2002 requires proponents to undertake Environmental Impact Assessment (EIA) for those projects considered tohave
15 significant environmental impacts and listed as such in directives issued pursuant to this proclamation. According to the EIA guideline issued by the Federal Environmental Protection Authority (FEPA), large HCW incineration facilities, chemical treatment facilities and landfills for toxic, hazardous and dangerous wastes are among the list of projects considered to have adverse and significant environmental impacts and hence require full environmental impact assessment (Federal Environmental Protection Authority, 2000; EsubalewTesfahn, 2015).
2.3.1. Effect of infectious waste and sharps A study conducted in Addis Ababa 2011 revealed that almost in all of the hospitals there was no segregation of waste into infectious, pathological and pharmaceutical, and had no separate bins for the collection of infectious waste (MesfinKoteet.al., 2011).
Non-Hazardous HCW was often mixed with infectious waste. Four of the surveyed hospitals disposed of their waste on-site in their own incinerators and one hospital disposed of at both off- site (non-pathological waste) and on-site (pathological waste), while the remaining one hospital disposed of the waste at off-site (because the incinerator was not working at the time of data collection). Pre-treatment of highly infectious lab waste was not done in any of the hospitals (Debereet. al.,2013).
It is clear that there is much more to be achieved in HCWM, but ina developing country like Ethiopia the management of wastes produced in healthcarefacilitiescontinues to pose considerable problems for human health and the environment.Therefore, in developing countries still need a great effort to reduce public health and environmental impact related to poor healthcare waste management system.
A healthpolicyof Ethiopia emphasizes on the development of environmental health, the promotion of occupational health and safety, and on the prevention of environmental pollution with hazardous chemical waste as part of promote and preventive activities.
InEthiopia, there is no specific HCWM Legislation for the management of HCW (Health Policy of the Transitional Government of Ethiopia, 1993).But in Ethiopia currently there are two national guidelines and one voluntary code of practice formulated independently by the Federal Ministry of Health, Federal Environmental Protection Authority and Quality Standard Authority of Ethiopia that exclusively deal with HCWM (Ministry of Health; 2008; FEPA, 2004). Because
16 ofinadequate research data on the existing situation of HCWM in the country, the national guidelines hasbeen developed by considering the general situation in developing countries and basedon the biomedical and HCW guideline prepared by the United Nations Environment Program (Federal Environmental Protection Authority, 2004).
From the research conducted so far in different areas and time, we realize that appropriate HCWM canbe achieved by: the presenceNumber of the of responsible patients waste management team, preparing compressive plan, the waste handlers equipped with thelatest information, skill and practices, allocation of adequate financing, the estimation of the quantities and type of HCW, use of enforced codes of practice and guidelines, provision of regular training for staffs, and full participation of all staffs.
The research findings in Africa indicate that the current situation of HCWM cannot guarantee safety to healthcare establishment’s staff patients and general population. Instead, currentmismanagement constitutes a threat the public health and to the environment.
In Ethiopia, like other Africa Countries often, the level of safety in HCW handling and management is very low. The management of HCW is of great concern. Thus, there is an urgent need for the development of a HCWM intervention strategy that should be implemented consistently and universally in the study area.
HCW generation rate andcomposition are not known, which makes it difficult to plan and develop an appropriate intervention strategy in order to provide better HCWM. Therefore, there was a need to do an investigation of HCWM practices and determining generation rate in selected governmental hospitals found in the study area.
2.4. Conceptual structureof the study Based on the review literature HCW generation rate were affected by both the number of inpatients and outpatients, and the solid waste management practice of the hospitals. These are briefly expressed in the following conceptual framework.Conceptual framework of factors determining hospital waste generation rate
17 Disease out break Season of the year
Healthcare activities
(healthcare specialization)
Healthcare waste generation rate Figure 1, Conceptual structure of healthcare waste generation rate, 2016
2.5. Bottom ashes heavy metals Incinerator emissions are a major source of fine particulates, of toxic metals and of more than Healthcare waste 200 organic chemicals, including known carcinogens, mutagens, and hormone disrupters. managementpractice Emissions also contain other unidentified compounds whose potential for harm is yet unknown, as was once the case with dioxins. Since the nature of waste is continually changing, so is the chemical nature of the incinerator emissions and therefore the potential for adverse health effects (Jeremy and Honor, 2008).
18 Heavy metals have been found in both bottom and fly ashes produced by incinerators used for treating healthcare waste(Shamset. al., 2012).Studiedheavy metals in bottom ash from healthcare incinerators were reported that the concentration of Cu, Cr and Pb all exceeded the tolerable level except the concentration of Cd. (Racho, 2002).
There are different Sources of heavy metals in healthcare waste. Some of the are listed in tables 1
No Heavy metals Sources 1 Mercury Thermometers Sphygmomanometers Monitoring device Fluorescent bulbs Mercury switches Batteries 2 Lead Autoclave indicator tape Radiation shields (Lead boxes and foil packets Aprons) 3 Chromium X-ray developer Glassware Tank cleaners Waste water X-ray cleaners 4 Silver Imaging X-ray Fixer 5 Cadmium Pigment/colorant Incineration 6 Copper Tissue Source: (Laura et. al., 2005)
Table 1, Types of heavy metals and their sources from healthcare institutions
19 Atomic Absorption Spectrometry (AAS) is an analytical technique that measures the concentrations of elements. Atomic absorption spectroscopy can be usedto analyze the concentration of over 62 different metals in a solution and is so sensitive that it can measure down to parts per million of a gram in a sample. An analytical method for the determination of the heavy metals is composed of three steps; it depends on analyses of interest and consists in acidification (e.g. Fe3+ in waters), acid digestion (e.g. Zn2+ in sediments), and filtration in order to remove coarse particles to preserve the analytical instrumentation (Ward, 1969).
3. Materials and Methodology
3.1. Materials
20 Various kinds of software’s, equipment, and maps were used for the specific research. These different materials and tools which were used for the research are listed below categorized into the following parts:- for data analysis and documentationMicrosoft Office (MS-word, MS-excel)Software’swere usedand also SPSS software were used to analyze the variance.
For this study different equipment were used those areDigital beam balance, Mortar and Pestle (grinder), scientific sieve of 200 micron-mesh size, Camera for field works, oven used for drying samples, AAS to determine the concentration of heavy metals, Hot plate to digest the sample, 25 and 50 ml volumetric flask, Crucible.
And the chemicalswere used3 normal hydrochloric acid, 6 normal hydrochloric acid and nitric acid
3.2. Description of the study area
3.2.1. Geographic location Addis Ababa, founded in 1886, is the political and economic capital of the country located at 90 1’ 48’’N and 380 44’ 24’’ E, It has an area of about 540.1 km2 with an altitude range from its lowest point of 2,326 meters around bole airport to its highest point of around 3000 meters at EntotoMountains. Its population has been increasing at an alarming rate reaching around 3 million according to 2007 population census.
Addis Ababa is the capital city of Ethiopia, with the total population of 2,917,295 (1,389,817 males and1,527,478 females) exponentially increase by 2.5%. The city has three layers of
21 administration; the City Administration at the top, 10 Sub cities Administration in the middle and 116 Woreda at the bottom Each sub city administration has the estimated population of 300,000 and each Woreda administration has the population of 30,000 (CSA, 2007).
Location map of the study area:
Figure 2,Map of the study area (Source: CSA, 2007)
3.2.2. Climate Addis Ababa is located in a tropical zone but it is influenced by the altitude, from 2000 to 3200 meters, which tempers the temperature. This climate is characterized by a wet season, from June to the end of September, dry season specially from December to the end of February and the rest of the month have little amount of rain. But temperature depending on the altitude, decrease from the south (Akaki) to the north (Gulele, Yeka) (Tamiru , 2003).
The main rainfall season in the study area is from June to September, but there is relatively small rainfall during the month of March and April. The most beneficial rain is essentially of
22 orographic type, produced from condensation of vapors driven by winds against marginal escarpment on the plateau. In summer, mainly Jun to September, the rain is very heavy with sporadic thunderstorm causing high runoff. Where as in autumn, (late September, October and November) and spring (March, April and May) the rain has less intensity. During winter (from December to February), it is sunny and dry with a very little or no rain fall. The meteorological data shows the total rainfall of Addis Ababa is about 1076.6mm per year, with the high rainfall occurring in July to August , While in April , Jun and September moderate concentration of rainfall, In march and May small concentration and the remaining months (January, February, October, November And December) Are dry months (Tamiruet.al., 2003).
Month Jan Feb Mar April May Jun Jul Aug Sep Oct Nov Dec total Amount of 15.8 37.3 68 88.6 77.3 118.1 250.4 238.8 137.6 32.9 6.2 5.6 1076.6 rainfall F(mm)
Source: Ethiopia Metrological Agency, 2015 Dry season Rain season
Table 2, Mean monthly rainfall of Addis Ababa
3.2.3. Temperature The minimum mean monthly temperature of the Addis Ababa ranges between 7.50c in December to 11.70C In May, while the maximum mean monthly temperature varies between 20.10C In August to 24.60C in March, throughout the year in the last ten years.
Jan Feb Mar April may Jun Jul Aug Sep Oct Nov Dec Total Month Max(Tco) 24 24.1 24.6 23.9 24.6 22.9 20.3 20.1 22.4 22.6 22.6 22.8 22.8 Min(Tco) 10.3 9.5 10.9 11.5 11.7 10.8 10.8 10.8 10.5 9.2 7.9 7.5 10.1 Source: Ethiopia Metrological Agency Annual Report, 2015.
23 Table 3, Min and Max Monthly Temperature of Addis Ababa in(C°)
3.2.4. Demography of the Study Area:- The first census in Addis Ababa was made by the Central Statistics Authority (CSA) of Ethiopia in 1984. The population of the city was estimated to 1.4 million inhabitants (Central Statistical Authority, 1984). According to the last census of CSA 2007, the population of Addis Ababa were enumerate as 2.7 million inhabitants. The population nearly doubled in 23 years (Central Statistical Authority 2007). Since Addis Ababa is a center of national and international organizations, the current estimated population is over 3million inhabitants, with annual demographic growth rate of 2.6% (Central Statistical Authority, 2008).
No Sub city name Area in (ha) Population Percentage Population size (%) density/Km2 1 Addis ketema 898 255,092 9.3 28,407 2 Akakikalty 12614 181,202 6.7 1,437 3 Arada 1156 212,009 7.78 18,340 4 Bole 12094 308714 11.2 2,553 5 Gulele 3273 267,381 9.76 8,169 6 Kirkos 1626 220,991 8 13,591 7 Kolfekeraneo 6510 428,654 15.6 6,585 8 Ledeta 1240 201,613 7.4 16,259 9 Nifas silk 6359 316,108 11.5 4,971 10 Yeka 8230 346,484 12.6 4,210 Total 54,000 2,738,251 100 5,071 (Source: CSA, 2007)
Table 4, Population distribution by sub city From the above table 3, there is a disparity in Sub City population distribution which shows uneven distribution. The majority of the city population lives in KolfeKeranyo (15.6%), Yeka(12.6%), and Nefas silk Lafto (11.5%) whereas; Arada and Kality have the smallest share from the City’s total population. Regarding density, Addis Ketema has the highest (28,407
24 persons/ km²) followed by Arada (18,340 persons/ km²) and Lideta (16,259 persons/ km²) while, AkakiKality (1,437 persons/ km²) is the most sparsely populated Sub City of Addis Ababa.
3.3. Sampling techniques The study area was conduct in the manner of following schema, the hospitals are selected by using simple random sampling (lottery) technique.
Addis Ababa city Administration health bureau and ministry of health
10 sub city
(9 hospitals)
Simple random or lottery method
Gandhi Memorial Black Lion Specialized Yekatit 12 Memorial
Hospital Teaching Hospital Hospital
3.4. Data collection Three hospitals in Addis Ababa were selected using simple random method as a representative of the government hospitals in the study area. Sampling wasconductfor a period of one month to determine the solid HCW generation rate and effectivenessof HCWM practices.
Toassess the HCWM in terms of segregation, storage, collection, and treatment observational checklist and key informant interview guide were used. Standard weighing scale;heuer, Lot No:5295, Mfg date November 13, GST Corporation Ltd.(India) was used to quantify the generation rate of HCW. The frequency of daily new patients and those who had some other health services at the time the study duration were taken from OPD registers and total patients number in monthly and annually were taken from annual reports of hospitals.
25 The number of new OPD was used to calculate the daily waste generation. Reviewed article onHCW generation often considered the denominator of new outpatients who were handled by ambulatory health facilities
3.4.1. Data procedure and analysis technique: First, a transient walk through inspection in each hospitals was done in order to identify the type of generated waste. The transient observations were done on different department of the hospitals. To ensure reliability during data collection, selected strategies were employs. First, the measuring instruments were calibrates. Second, professionals were selected for data enumerators and third, supervisor on site during the actual measurements.
HCW was collected and measured daily for eight consecutive days from March 4, 2016 – April 1, 2016 were done in three hospitals. First, the measurement had done in Gandhi Memorial Hospitals from March 04, 2016 - March 11, 2016 then Yekatit 12 Memorial Hospitals from March 16, 2016 – March 23, 2016 and finally Black Lion Specialized Teaching Hospitals from March 25, 2016 – April 1, 2016. Data were collect using prepared data entry sheet for the daily measurement of the amount of healthcare waste rate.
Data were collected for 24 hours from each sampling unit in different coded and labeled polyethylene bags. Empty plastic bins of standard colorsare black color for general waste, green color for pharmaceutical waste and yellow color used for infectious waste and pathological waste were used to different section of the hospitals.
Plastic bags with different colors (black plastic bags for general waste and yellow plastic bags for infectious waste and pathological waste) were kept inside the bins. The bins and plastic bags were label to indicate the different categories of HCW, the place of generation, date of collection andsample number. Waste weighting and recording station was arranged in convenient site within the compound of the hospitals. On the next day, collected wastes in plastic bagswere removed every morning and the weight was measured at 3:00 am (local time) using weighing scale (Baby scale, capacity range 15 kg & model 4 capacity range 20 kg)
Then the data captured were entered in the Microsoft Excel program. Most of quantitative data were analyzed using Microsoft Excel program and IBM SPSS VERSION 20 software.
26 The parameters developed include:
Waste generation rates: Waste generation per day, Wd, is defined as the total weight of waste (in kg) generated per day and was calculate by this formula:
Wd=
The total waste generation rate per day per patient was calculated Wpd;
Wpd =
The healthcare waste collection efficiency, Ec:Wdc as total waste collected per day per patient for different category, then, collection efficiency was determined as
Ec,i =
3.5. Heavy metal determination Bottom ash samples were collect from the incinerators that were properly mixesfrom thethree hospitals;during data collection, abouthalf kg of ash was collect.First all the visible metals and glass objects were removed; ash samples were then crushed and passed throughmesh sieve.
The concentration of Chromium(Cr),Cadmium(Cd), Lead(Pb),and Copper(Cu), were analyzed by Atomic AbsorptionSpectrophotometer equipped with Hydride Vapor Generator.
The metal contents was calculated by using the formula;
Metal content (mg/100g)
Where,
W = weight of the sample (g) V = volume of extract (ml) A = concentration of sample solution (g/ml)
27 B = concentration of blank solution (g/ml) The limits of detection for each element are given in Table-4; linearitycoefficient R2 was >0.998. Metals Chromium (Cr), Cadmium (Cd), Lead( Pb) Copper (Cu) Detection 0.05 0.05 0.02 0.05 limit
Table 5, Limit of detection for sample heavy metals
And 2.5gm of ash from each sample was taken used for double hot digestion, after dry ashes was treated with 5ml of 6 Normal HCL to wet it completely and carefully dried on a low temperature hot plate. 7ml of 3 Normal HCL were added and the dish was heated on the hot plate until the solution just boils. Then, it has been cool and filtered through a filter paper in to a 50ml volumetric flask. Again, 7ml of 3 Normal HCL was added to the dish and heated on the hot plate until the solution just boils. Finally cooled and filtered into the volumetric flask. For the determination of heavy metals, lanthanum chloride was added to both standards and samples to suppress interference from phosphorus. Using AAS calibration curve was prepared by plotting the absorption or emission values against the metal concentration in mg/100g. Reading was taken from the graph, which depicted the metal concentrations that correspond to the absorption or emission values of the sample and the blank.
3.6. Data management and statistical analysis To address the current practices of solid healthcare waste management, data from interviews and observation were analyzed by theme. Data was conducted a thematic analysis physically, by sorting and organizing information according to thematic similarities and differences. Then, data was categorized and studied to understand relationships in the overall context of the thesis.
Thedata was analyzed by using IBM SPSS statistical version 20 software for analysis entry. The analysis was performed separately for each of the three hospitals; Data description was made using minimum, maximum, mean, Standard Deviation (SD) and mean ± Standard Deviation (SD).
28 In order to see the effect of the parameters and their confidence levels on the waste generation rate in healthcare services, analysis of variance was performed to compare the rate by the type of hospitals. The data quality was maintained by calibrating the instruments used for measurement.
3.7. Data quality assurance mechanisms In order to improve validity all questions and checklist were logically related to the variables measured, and to the overall study aims. In addition, the instrument was designed to measure all components of the variables and also use an existing instrument that was already tested in other studies and calibration/standardization of the measuring instrument were helped to improve the validity of the study.
3.8. A tabular summary of the methods applied in this study
No Objectives Study design Method of analysis 1 To determine the solid Longitudinal Descriptive statistics and Analysis of healthcare waste generation variance rate, and composition was performed to compare the rate by the numbers of patients 2 To determine the level of Experimental Descriptive statistics such as mean heavy metals content in solid and healthcare waste STDEV and comparison of two proportions. 3 To assess the practice of Cross-sectional Descriptive analysis of the data by waste management theme. Information organized according to thematic similarities and Differences
29 Table 6, Summary of methods based on the objectives of the study
4. Results and Discussion
4.1. Healthcare wastes composition andgeneration rate
4.1.1. Healthcare waste composition: The composition of HCW in the study hospitals wascategorized as infectious, non-infectious, pathological, sharp and radioactive wastes. Infectious waste were include lab work, Wastes from surgery and autopsies, Wastes from infected patients and any matrials having been in contact with infected patients. Non-Infectious waste were include papers and card board packaging, food wastes and aerosols. Pathological waste includes tissues, organs, body parts, fetuses, blood and body fluids. Sharps wastes were include the following whether infected or not needles, syringes, scalpels, infusion sets, saws and knives, blades, broken glass and any other items that cut or puncture. Radioactive wastes were includes liquid, solid and gaseous wastes contaminated with radionuclide’s generated from in vitro analysis of the body tissue/fluids in vitro body organs imaging and tumors localization and investigation and therapeutic procedures
total Code Infectious Non infectious pathological sharp radioactive Of Hospital kg/day B 602.19 ± 80.90 598.39± 79.08 26.85 ± 4.28 19.13 ± 7.99
30 0.98 ± 1.39 1247.53±136.04 Y 252.26 ± 33.32 248.36 ± 36.11 25.73 ±2.99 12.20 ± 7.33 - 538.55±46.82 G 116.09 ± 19.69 103.49 ± 11.15 22.18 ± 5.01 3.61 ± 0.99 - 245.36±26.38
Table 7, The mean composition of healthcare waste in the study hospital, 2016
Figure 3, mean composition of healthcare waste in the Yekatit 12 Memorial Hospital, 2016 Its composition varied as shown in Figure 3. Non-infectious wastewas the highest about (47.25%), followed by infectious waste (45.25%), pathological waste (5.31%), sharp waste (2.19%).
31 Figure 4, mean composition of healthcare waste in the Gandhi Memorial Hospital, 2016 Its composition varied as shown in Figure 4. Non-infectious waste was the highest about (41.91%), followed by infectious waste (47.01%), pathological waste (9.62%), sharp waste (1.46%).
32 Figure 5, mean composition of healthcare waste in the Black Lion Specialized Teaching Hospital, 2016. Its composition varied as shown in Figure 5. Non-infectious waste was the highest about (48.53%), followed by infectious waste (47.85%), pathological waste (1.89%), sharp waste (1.51%), and radioactive waste (0.21%).
Comparison of HCWs composition within in the study hospitals
The mean compositions of solid HCW in all studied hospital were almost similar except radioactive waste. The radioactive waste were found only in B hospital, because hospitals B has nuclear medicine and radiotherapy centers other not have.
Comparison with other similar works in the area
The composition of general (46.78%) and hazardous (53.22%) of HCW in this study was different in WHO report in hospital setting.General of HCWmust bein the range of 85% and hazardous must be 15% (WHO,2000). But this study does not full fill this report it is reversible.Thestudy done in Tanzanian district hospitals HCWs composition varied general waste was the highest about (33%), followed by infectious waste (27%), pathological waste (19%), sharp waste (14%), chemical waste (3%), pharmaceutical (2%), radioactive waste 1% and pressurized containers (1%). It was also different with the study done in Sylhetcity, Bangladesh in diagnosis center and higher clinics general waste accounted 63.97% and hazardous waste accounted 36.03% (Alam, 2006). These difference could be due to seasonal variation, availability of different facilities, geological location and the variation of denominators between hospitals and health centers.
4.1.2. Healthcare waste generation rate Patient flow: All studied hospitals showed higher values of occupy rates with a corresponding wide variation in this parameter, it shows that all hospital beds are occupied at all times of the day.
33 Figure 6, patient flow ofin the studied hospitals per day, 2016. OPD loads in the study hospitals per day in hospitals B were 818, in hospitals Y were 307, and hospitals G were 144 and IPD loads in hospitals B were 485, in hospitals Y were 278, and in hospitals G were 135 patients wanted some kind of health service in the study hospitals per day. The total mean patient flow per day in all sections of inpatients and outpatients for studied hospital was 299.33±175.97 and 423±351.65 patients, respectively.
Generation rate: the daily distribution of HCW generation rate was highest in week days and less in weekend days. This variation happen due toflow of patients special OPD has high contribution because in weekend days the governmental hospital does not give service for OPD patient unless emergency cases is come up. The variation of HCW generation was analyzed by categories. The result showed that at B, Y and G hospitals infectious waste has high frequency variations while other categories are evenly generated with less variations. These results give insight to hospital administrators that, high attention is required to infectious waste as its generation is not predictable, and thus a HCWM plan accommodating the situation revealed by the study is of vital importance.
34 The results indicate that in (fig.7,8, and 9)different categories of waste are not equally generated as somecategories such as general waste has high rate of generation while others such as sharp and radioactive wastes which are hard and cost to dispose have low generation rates, which is advantage to hospital administrators as general waste can easily and economically be disposed of using the normal technologies to lower the cost and help hospitals to concentrate with hazardous HCW which are dangerous and costly to handle.
Figure 7, generation rate of healthcare waste per 8 day in the Y hospital 2016.
35 Figure 8, generation rate of healthcare waste per 8 day in the G hospital, 2016.
Figure 9, generation rate of healthcare waste per 8 day in the B hospital, 2016.
The mean HCW generation rate in kg/day/hospitals in this study was 677.15 ± 515.26kg/day, It was higher than the studydone in Ethiopia 9.61±3.28kg/day in health centers (MenelikLegesse,2011).Andanother study in the Amhara national regional State were conduct and obtained 0.78 kg/bed/day and 0.49 + 0.2 kg/patient/day which is lower than with the present study. In addition study done in hospitals of Addis Ababa, the median waste generation rate was found to be varied from 0.361- 0.669 kg/patient/day (MesfinKote, 2011). The study done in Tanzanian district hospitals rate of medical waste generation was very high; about 2,250 kg/day in Amana and 2,500 kg/day in Ligula hospital (Kagonji,2011). and also Bangladesh in diagnosis center and higher clinics, the mean HCW generation rate was 0.041 kg/patient/day(Alam, 2006). This variation may be due to geographical location, social status of the patients (i.e. income, living standard, awareness about disease), HCWM and legislation of system of the country.
The meangeneration rate of HCW kg/day/patient in present was 0.962kg/day/patient, 0.93kg/day/patient, and 0.88kg/day/patientfor hospitals B,Y, and G respectively.
36 Figure 10, the mean generation rate of healthcare waste kg/day/patientin the study hospitals, 2016.
Result shows that Mean ±SD, 0.47± 0.023 had the maximumgeneration rate of infectious waste category and 0.002 had the minimum generation rate of radioactive waste from the studied hospital that shown in table 10this result was similar.
4.2. Heavy metal concentration The incineration of HCW is a important alternative way for disposal of hazardous of waste. Thus incineration has acknowledged much attention but relatively less attention has been given to bottom ash. Now bottom ash is dumped on the soil which mixes into the soil as diffused pollutant.In terms of heavy metal contamination bottom ash is generally considered to be safer than fly ash. However, the study results indicate that HCW bottom ash contains high levels of heavy metals.
37 Figure 11, average concentration of heavy metals in the studied hospital, 2016. Result shows that Mean ±SD, 134.43mg/100g±0.74 had the highest concentration of Cu and 1.48mg/100g±1.74 had the lowest concentration Cd among found in bottom ash around the incinerator. The descending order of heavy metal content Cu>Pb>Cr> Cd. The heavy metal concentration in all study hospital has high variation this is due to the initial waste composition, design of the incineration, the level of hospital and operating conditions.
This result shows the same as studied before heavy metals in bottom ash from healthcare incinerators concentration of Cu, Cr and Pb all exceeded the tolerable level except the concentration of Cd (Racho, 2002; Ranjan, et. al., 2004). The level of concentration of heavy metals were 64.43%, 14.77%, 1.12% and 19.68% respectively.
4.3. The practice of healthcare waste management All studied hospitals were have National Healthcare Waste Management Guideline prepared by FMoHin 2008;but not use it properly, except some department.
In all studied hospitals, during transportation of collected HCW from the source to the incinerator were mixed wastes used one plastic bin. The wastes were scattered on the surrounding treatment and disposal sites due to the use of sub-standard waste containers. This will also contribute to the risk of infections for healthcare providers, patients, visitors and
38 theneighboring community.After disposal in the incinerator area, the general waste of healthcare were stays some days and pollute the environment.
During burning of hazardous waste of healthcare, incinerators release air pollutants to the environment. Therefore, the current practices of HCW treatment in the hospitals could expose the whole community at high risk of accruing chronic and acute health problems (Jeremy and Honor, 2008). Especially in Black lion specialized Teaching Hospitals and Gandhi Memorial Hospital. But in Yekatit 12 Memorial Hospital the incinerator has no emission that can affect the environment.
Figure 12, Photo shows, the incinerator instrument in Y hospital (Photo: AzebTayework, October 11, 2016).
39 40 Figure 13, Photo shows, the incinerator instrument in B hospital (Photo: AzebTayework, October 10, 2016).
Figure 14, Photo shows, the incinerator instrument in G hospital (Photo: AzebTayework, October 10, 2016).
Intermediate storage takes place in a specially designed storage area in order to avoid biodegradation, odours, and the attraction of insects and rodents (Bdour, 2007). In all study hospitals mixed (infectious and non-infectious ) healthcare wastes were temporarily stored in open dust bins for unlimited time that could attract insects, rodents, cat , dogs and they were also prone to spill over; these could potentially contaminate the environment. There is a possibility that such mixed waste can contain harmful agents (microbiological pathogens, sharps, hazardous chemicals, and radioactive substance) that can cause disease and injury to those exposed to them (Lars et. al., 2000; Singh et. al., 2012).
41 4.3.1. Healthcare waste segregation practice In all study hospitals, segregation of sharp waste, infectious waste and general waste waspracticed. Placentas and blood stained cotton pads were kept in separate containers in three hospitals. The use of waste containers with a color code and labeling at the point of generation was implemented in all hospitals.
Figure 15, Photo shows, HCW segregation practice storage in the studied hospital (Photo: AzebTayework, March 17, 2016)
Black lion specialized Teaching Hospitals uses both color code and labeling at the point of waste generation. HCW was collected and transported to incineration facilities with using wheeled cart twice a day in the morning before 12:00am and in the noon day after 6:00 am by cleaning agency and visited by the supervisor of environmental department. Yekatit 12 Memorial Hospitals uses color code at the point of waste generation. Healthcare waste were collected and transported to incineration facilities with using wheeled cart in daytime only the hours not limited collected and transported by housekeeping personal and visited by the supervisor of environmental department. Gandhi Memorials Hospitals were uses labeling at the point of waste generation and visited by the supervisor of department. Healthcare waste were collected and transported to incineration
42 facilities with using wheeled cart twice a day in the morning before 12:00am local time and in the evening at 10:00pm local time by housekeeping personal.
4.3.2. Temporary storage of hospital healthcare waste practice on point of source The study hospitals temporarily stored all waste in open and substandard dust bins for about unlimited time (figure 11). Pathological and sharp wastes were stored in closed plastic containers and collected in till the safety boxes is filled. The sampled hospitals use non- standard storages, such as carton boxes that can be easily damaged or torn out. In all hospitals, lack of proper and purpose-built waste storage areas was apparent. In all hospitals, lack of proper and purpose-built waste storage areas was apparent
Figure 16, Photo shows, hospital HCW temporal storage at the point of sources in the studied hospital (Photo: AzebTayework, March 17, 2016).
43 4.3.3. Collection and transportation of healthcare waste There was no structured collection and transportation system for general and hazardous waste in study hospitals. In two out of three hospitals used closed plastic container (capacity of 50 litters) were used to collect and transport mixed. Only sharps and pathological wastes were collected and transported separately. Mixed waste was collected and transported in carton or open plastic bins.
Figure 17, Photo shows, hospital HCW transportation in the studied hospital (Photo: AzebTayework, March 17, 2016).
4.4. Hospital healthcare waste treatment and disposal practice In all studied hospitals, several methods was used for infectious and sharp waste treatment, depending on the type of waste material generated. These treatment methodsinclude one of the following option or combination of option: steam sterilization, incineration, thermal inactivation, gas vapor sterilization, and chemicaldisinfection, sterilization by irradiation or electromagnetic radiation. After treatment the wastes or their ashes should disposed of by discharge into sanitary sewer systems. Except in B hospital the practice of pre-treatment for final disposal of highly infectious waste was not practiced.The study conducted in developing countries reviled
44 that the commonest method of healthcare waste treatment was done by poor design and construction incinerators have low combustion capacity (Israel Denekeet.al., 2011).
During HCW, incineration significantly produced high smoke emission except Y hospital. The partial burned healthcare waste was disposed in an open pit. In addition to incinerators, all studied hospitals had an open hand dug pit in their backyard that was used for the direct dumping and open burning of healthcare wastes.
4.5. Hospital healthcare waste reuse and recycling practice Healthcare waste recycling practice were totally absent in all study hospitals, except reusing in all studied hospital were collect separately, wash and sterilize (either thermally or chemically in accordance with the national infection prevention guidelines) surgical equipment’s and other reusable items which are designed for reuse and are resistant to the sterilization or disinfection process. Pressurized materials such as cylinders were returned to the suppliers for refilling and reuse.
Fi gure 18, Photo shows, hospital reuse mechanism in the studied hospital (Photo: AzebTayework, March 17, 2016).
45 5. Conclusion and Recommendations
5.1. Conclusions The HCWM requires special attention because of the risk posed by the presence of hazardous substances in the healthcare waste.
HCWM system had not been given enough attention in all hospitals. Segregation and treatment of healthcare waste were not well practiced. This study confirm that, the handling, storage and disposal method of solid wastes practiced by the hospitals were not proper to protect the environment from contamination and avoid public health risks. Even if, during transportation infectious HCW was mixed with the non-infectious waste.
The composition of wastes in B Hospital were the infectious waste 48.52%, non-infectious waste 47.97%, sharp waste 1.53%, radioactive waste 0.08%, and pathological waste 2.15%. In Y Hospital were the infectious waste 46.84%, non-infectious waste 46.12%, sharp waste 2.27%, and pathological waste 4.78%. G Hospital was the infectious waste 47.32%, non-infectious waste 42.18%, sharp waste 1.47%, and pathological waste 9.04% were accorded.
The mean HCW generation rate per hospitals was 0.96kg/day/patient in B hospital, 0.93 kg/day/ in Y hospital, and 0.88kg/day in G hospital. The overall findings of heavy metal concentration were high, Concentration of copper was found to be very high in comparison to other metals and the descending order was Cu>Pb>Cd>Cr. A wide variation in trace concentration of several toxic elements has also been seen due to variation in initial waste composition, design of the incineration, the level of hospital and operating conditions.
46 5.2. Recommendations
Based on the research findings the following recommendations have been made:
Further studies should consider seasonal variation in HCW generation in view of temporal variations in the occurrence of endemic diseases and hospital utilization by the population, especially in rural areas. Further studies should consider the contamination levels of fly ash from incineration to the atmospheric air inventory.
Systematic collection and use of standardized analytical methods of data on healthcare waste among representative hospitals in different administrative zone of Addis Ababa may form the basis for the development of feasible, environmentally safe and cost-effective healthcare waste management system.
Detail healthcare sampling in public and private health centers at different sub city, will help to determines accurate HCWs generation rate, composition and its management practices in the administration zone.
47 References
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51 Annex Patient flow
code of hospitals inpatient outpatient total patient B 485 818 1303 Y 278 377 655 G 135 44 179
patient flow
N Sum Maximum Minimum Mean Std. Variance Deviation inpatient 3 898 485 135 299.33 175.973 30966.333 outpatient 3 1269 818 144 423.00 351.655 123661.000 Total patient 3 2167 1303 279 722.33 525.632 276289.333
B INF Non inf pathological radioactive sharp total
day 1 657.50 571.50 23.30 1.00 20.00 1,273.30
day 2 560.00 494.00 20.40 1.00 15.60 1,091.00
day 3 496.00 480.00 31.00 1.00 32.20 1,040.20
day 4 561.00 587.60 28.00 1.00 8.60 1,186.20
day 5 623.00 676.00 26.00 1.00 19.60 1,345.60
52 day 6 549.00 663.00 34.00 0.80 9.10 1,255.90 day 7 756.00 637.00 25.00 1.00 22.50 1,441.50 day 8 615.00 678.00 27.10 1.00 25.40 1,346.50
mean of generation rate in B hospital
N Sum Maximu Minimu Mean Std. Variance m m Deviation infectious 8 4817.50 756.00 496.00 602.1875 80.08564 6413.710 noninfectious 8 4787.10 678.00 480.00 598.3875 79.08333 6254.173 pathological 8 214.80 34.00 20.40 26.8500 4.27752 18.297 sharp 8 153.00 32.20 8.60 19.1250 7.98584 63.774 radioactive 8 7.80 3.30 .00 .9750 1.39053 1.934 total 8 9980.20 1440.50 1039.20 1247.5250 136.04234 18507.519
Y INF Non inf pathological sharp total day 1 305.70 256.80 33..4 5.20 567.70 day 2 266.90 193.30 30.20 22.90 513.30 day 3 242.50 209.60 34.00 11.60 497.70 day 4 204.30 220.40 29.20 7.80 461.70 day 5 219.60 258.80 26.00 23.80 528.20 day 6 234.50 286.00 26.00 7.40 553.90
53 day 7 280.00 274.50 29.10 12.60 596.20 day 8 264.60 287.50 31.30 6.30 589.70 total 2,018.10 1,986.90 205.80 97.60 4,308.40
means of generation rate in Y hospital
N Sum Maximu Minimu Mean Std. Variance m m Deviation infectious 8 2018.10 305.70 204.30 252.2625 33.31550 1109.923 noninfectious 8 1986.90 287.50 193.30 248.3625 36.11082 1303.991 pathological 8 205.80 34.00 .00 25.7250 10.72364 114.996 sharp 8 97.60 23.80 5.20 12.2000 7.32686 53.683 total 8 4308.40 596.20 461.70 538.5500 46.81959 2192.074
G INF Non inf pathological sharp total day 1 84.10 97.40 23.30 3.40 208.20 day 2 96.60 91.50 20.40 2.60 211.10 day 3 139.00 101.50 31.00 3.80 275.30 day 4 127.00 106.00 19.20 3.00 255.20 day 5 16.00
54 134.00 110.00 3.00 263.00 day 6 110.50 127.00 28.00 2.90 268.40 day 7 106.50 95.50 19.10 4.90 226.00 day 8 131.00 99.00 20.40 5.30 255.70 total 928.70 827.90 177.40 28.90 1,962.90
means of generation rate in G hospital
N Sum Maximu Minimu Mean Std. Varianc m m Deviation e infectious 8 928.70 139.00 84.10 116.0875 19.68832 387.630 noninfectious 8 827.90 127.00 91.50 103.4875 11.14969 124.316 pathological 8 177.40 31.00 16.00 22.1750 5.01163 25.116 Sharp 8 28.90 5.30 2.60 3.6125 .99058 .981 Total 8 1962.90 275.30 208.20 245.3625 26.38067 695.940
Healthcare waste generation per day per patients per hospitals code of hospitals INF Non inf pathological sharp radioactive total
B 0.47 0.46 0.02 0.01 0.002 0.96
Y 0.43 0.43 0.04 0.02 - 0.93
G 0.42 0.37 0.08 0.01 - 0.88
55 code of hospitals Cu Cr Cd Pd B 134.43 8.045 1.48 25.87 Y 125.5 32.35 1.94 62.43 G 80.48 34.95 2.24 21.94
Heavy metal concentration code of N Sum Maximu Minimum Mean Std. Variance hospitals m Deviation copper 3 340.41 134.43 80.48 113.4700 28.91697 836.191 cadmium 3 4.06 1.94 .64 1.3533 .65919 .435 chromium 3 41.13 32.35 .73 13.7100 16.55243 273.983 lead 3 88.85 62.43 .55 29.6167 31.10967 967.812
56