Medical waste management in China: A case study of Nanjing

Medical waste management is of great importance due to its infectious and hazardous nature that can cause undesirable effects on humans and the environment. The objective of this study was to analyze and evaluate the present status of medical waste management in the light of medical waste control regulations in Nanjing. A comprehensive inspection survey was conducted for 15 hospitals, 3 disposal companies and 200 patients. Field visits and a questionnaire survey method were implemented to collect information regarding different medical waste management aspects, including medical waste generation, segregation and collection, storage, training and education, transportation, disposal, and public awareness.The results indicated that the medical waste generation rate ranges from 0.5 to 0.8 kg/bed day with a weighted average of 0.68 kg/bed day. The segregated collection of various types of medical waste has been conducted in 73% of the hospitals, but 20% of the hospitals still use unqualified staff for medical waste collection, and 93.3% of the hospitals have temporary storage areas. Additionally, 93.3% of the hospitals have provided training for staff; however, only 20% of the hospitals have ongoing training and education. It was found that the centralized disposal system has been constructed based on incineration technology, and the disposal cost of medical waste is about 580 US$/ton. The results also suggested that there is not sufficient public understanding of medical waste management, and 77% of respondents think medical waste management is an important factor in selecting hospital services.The problematic areas of medical waste management in Nanjing are addressed by proposing some recommendations that will ensure that potential health and environmental risks of medical waste are minimized.     

Medical waste production at hospitals and associated factors

This study was conducted to evaluate the quantities of medical waste generated and the factors associated with the generation rate at medical establishments in Taiwan. Data on medical waste generation at 150 health care establishments were collected for analysis in 2003. General medical waste and infectious waste production at these establishments were examined statistically with the potential associated factors. These factors included the types of hospital and clinic, reimbursement payment by National Health Insurance, total number of beds, bed occupancy, number of infectious disease beds and outpatients per day. The average waste generation rates ranged from 2.41 to 3.26kg/bed/day for general medical wastes, and 0.19-0.88kg/bed/day for infectious wastes. The total average quantity of infectious wastes generated was the highest from medical centers, or 3.8 times higher than that from regional hospitals (267.8 vs. 70.3Tons/yr). The multivariate regression analysis was able to explain 92% of infectious wastes and 64% of general medical wastes, with the amount of insurance reimbursement and number of beds as significant prediction factors. This study suggests that large hospitals are the major source of medical waste in Taiwan. The fractions of medical waste treated as infectious at all levels of healthcare establishments are much greater than that recommended by the USCDC guidelines.     

Selection of infectious medical waste disposal firms by using the analytic hierarchy process and sensitivity analysis

While Taiwanese hospitals dispose of large amounts of medical waste to ensure sanitation and personal hygiene, doing so inefficiently creates potential environmental hazards and increases operational expenses. However, hospitals lack objective criteria to select the most appropriate waste disposal firm and evaluate its performance, instead relying on their own subjective judgment and previous experiences. Therefore, this work presents an analytic hierarchy process (AHP) method to objectively select medical waste disposal firms based on the results of interviews with experts in the field, thus reducing overhead costs and enhancing medical waste management. An appropriate weight criterion based on AHP is derived to assess the effectiveness of medical waste disposal firms. The proposed AHP-based method offers a more efficient and precise means of selecting medical waste firms than subjective assessment methods do, thus reducing the potential risks for hospitals. Analysis results indicate that the medical sector selects the most appropriate infectious medical waste disposal firm based on the following rank: matching degree, contractor's qualifications, contractor's service capability, contractor's equipment and economic factors. By providing hospitals with an effective means of evaluating medical waste disposal firms, the proposed AHP method can reduce overhead costs and enable medical waste management to understand the market demand in the health sector. Moreover, performed through use of Expert Choice software, sensitivity analysis can survey the criterion weight of the degree of influence with an alternative hierarchy.     

Site investigation on medical waste management practices in northern Jordan

This study investigated the medical waste management practices used by hospitals in northern Jordan. A comprehensive inspection survey was conducted for all 21 hospitals located in the study area. Field visits were conducted to provide information on the different medical waste management aspects. The results reported here focus on the level of medical waste segregation, treatment and disposal options practiced in the study area hospitals. The total number of beds in the hospitals was 2296, and the anticipated quantity of medical waste generated by these hospitals was about 1400 kg/day. The most frequently used treatment practice for solid medical waste was incineration. Of these hospitals, only 48% had incinerators, and none of these incinerators met the Ministry of Health (MoH) regulations. As for the liquid medical waste, the survey results indicated that 57% of surveyed hospitals were discharging it into the municipal sewer system, while the remaining hospitals were collecting their liquid waste in septic tanks. The results indicated that the medical waste generation rate ranges from approximately 0.5 to 2.2 kg/bed day, which is comprised of 90% of infectious waste and 10% sharps. The results also showed that segregation of various medical waste types in the hospitals has not been conducted properly. The study revealed the need for training and capacity building programs of all employees involved in the medical waste management.     

Optimal evaluation of infectious medical waste disposal companies using the fuzzy analytic hierarchy process

Ever since Taiwan’s National Health Insurance implemented the diagnosis-related groups payment system in January 2010, hospital income has declined. Therefore, to meet their medical waste disposal needs, hospitals seek suppliers that provide high-quality services at a low cost. The enactment of the Waste Disposal Act in 1974 had facilitated some improvement in the management of waste disposal. However, since the implementation of the National Health Insurance program, the amount of medical waste from disposable medical products has been increasing. Further, of all the hazardous waste types, the amount of infectious medical waste has increased at the fastest rate. This is because of the increase in the number of items considered as infectious waste by the Environmental Protection Administration. The present study used two important findings from previous studies to determine the critical evaluation criteria for selecting infectious medical waste disposal firms. It employed the fuzzy analytic hierarchy process to set the objective weights of the evaluation criteria and select the optimal infectious medical waste disposal firm through calculation and sorting. The aim was to propose a method of evaluation with which medical and health care institutions could objectively and systematically choose appropriate infectious medical waste disposal firms.     

Regional medical waste management in China: a case study of Shenyang

Medical waste management is of great importance due to its potential environmental and public health risks, especially in developing countries where both financial and technological resources on medical waste management are still lacking. Although many studies have focused on country-scaled medical waste management, few have paid close attention to regional (city-scale) management, particularly in China. This paper fills such a gap by employing a case study approach. Due to its representative nature, Shenyang was selected as the case study. After a review of China’s medical waste management, an empirical study in Shenyang was conducted in order to analyze the current state as well as identify key challenges on regional medical waste management. Based upon the local realities and aiming to better manage medical wastes, an integrated medical waste management framework is developed. Such a platform encourages the establishment of a specific medical waste management authority, a city scaled capacity building program on improving the general public’s awareness, an information platform, application of state-of-the-art technologies, as well as creation of an effective financial system. The combination of such initiatives can significantly improve the overall eco-efficiency of medical waste management at the regional level and should be promoted to other developing cities.     

Medical waste management in Trachea region of Turkey: suggested remedial action.

The main objective of this paper was to analyse the present status of medical waste management in the Trachea region of Turkey and subsequently to draw up a policy regarded with generation, collection, on-site handling, storage, processing, recycling, transportation and safe disposal of medical wastes. This paper also presents the results of study about awareness on how to handle expired drugs. Initially all health-care establishments in Tekirda?, Edirne and Kyrklareli provinces in Trachea region were identified and the amounts of hospital wastes generated by each of them were determined. Current medical waste-management practices, including storage, collection, transportation and disposal, in surveyed establishments were identified. Finally, according to results, remedial measurements for medical waste management in these establishments were suggested. Unfortunately, medical wastes are not given proper attention and these wastes are disposed of together with municipal and industrial solid wastes. The current disposal method is both a public health and environmental hazard. When landfill sites are visited, many scavengers can be seen sorting for recyclable materials, a practice which is dangerous for the scavengers. In addition, it was found that some staff in health-care establishments are unaware of the hazard of medical wastes. It is concluded that a new management system, which consists of segregation, material substitution, minimization, sanitary landfilling and alternative medical waste treatment methods should be carried out. For the best appropriate medical waste management system, health-care establishment employers, managers and especially the members of house- keeping divisions should be involved in medical waste management practice.     

The use of failure mode and effects analysis to construct an effective disposal and prevention mechanism for infectious hospital waste

In recent times, the quality of medical care has been continuously improving in medical institutions wherein patient-centred care has been emphasized. Failure mode and effects analysis (FMEA) has also been promoted as a method of basic risk management and as part of total quality management (TQM) for improving the quality of medical care and preventing mistakes. Therefore, a study was conducted using FMEA to evaluate the potential risk causes in the process of infectious medical waste disposal, devise standard procedures concerning the waste, and propose feasible plans for facilitating the detection of exceptional cases of infectious waste. The analysis revealed the following results regarding medical institutions: (a) FMEA can be used to identify the risk factors of infectious waste disposal. (b) During the infectious waste disposal process, six items were scored over 100 in the assessment of uncontrolled risks: erroneous discarding of infectious waste by patients and their families, erroneous discarding by nursing staff, erroneous discarding by medical staff, cleaning drivers pierced by sharp articles, cleaning staff pierced by sharp articles, and unmarked output units. Therefore, the study concluded that it was necessary to (1) provide education and training about waste classification to the medical staff, patients and their families, nursing staff, and cleaning staff; (2) clarify the signs of caution; and (3) evaluate the failure mode and strengthen the effects.     

Investigation of health care waste management in Binzhou District,China

In China, national regulations and standards for health care waste management were implemented in 2003. To investigate the current status of health care waste management at different levels of health care facilities (HCF) after the implementation of these regulations, one tertiary hospital, one secondary hospital, and four primary health care centers from Binzhou District were visited and 145 medical staff members and 24 cleaning personnel were interviewed.Generated medical waste totaled 1.22, 0.77, and 1.17 kg/bed/day in tertiary, secondary, and primary HCF, respectively. The amount of medical waste generated in primary health care centers was much higher than that in secondary hospitals, which may be attributed to general waste being mixed with medical waste. This study found that the level of the HCF, responsibility for medical waste management in departments and wards, educational background and training experience can be factors that determine medical staff members’ knowledge of health care waste management policy. Regular training programs and sufficient provision of protective measures are urgently needed to improve occupational safety for cleaning personnel. Financing and administrative monitoring by local authorities is needed to improve handling practices and the implementation of off-site centralized disposal in primary health care centers.     

Medical waste generation in selected clinical facilities in Taiwan

This study investigated the type and amount of medical waste generated from small clinical facilities in Taiwan. We sampled 200 small medical establishments, with few or no patient beds, to survey the wastes generated and disposed. The surveyed medical facilities consisted of four groups including private clinics, medical laboratories, blood centers and public clinics. Private clinics providing surgical, dental, obstetrical, and dialysis services were included in this survey because they may generate higher amounts of infectious waste than other specialties. The overall mean general waste production rate was 3.97 kg/bed/day (or 0.075 kg/patient/day) at all the surveyed facilities, higher than that obtained from larger hospitals in Taiwan, which ranged from 2.41 to 3.26 kg/bed/day. The highest amount of infectious wastes generated among the four groups of facilities were from blood centers (3.14 kg/bed/day), followed by private clinics, medical laboratories and public clinics (1.91, 1.07, and 0.053 kg/bed/day, respectively). The overall average was 2.08 kg/bed/day. This study suggests that the waste generated at small medical facilities ranged widely.     

Management of hazardous medical waste in Croatia

This article provides a review of hazardous medical waste production and its management in Croatia. Even though Croatian regulations define all steps in the waste management chain, implementation of those steps is one of the country's greatest issues. Improper practice is evident from the point of waste production to final disposal. The biggest producers of hazardous medical waste are hospitals that do not implement existing legislation, due to the lack of education and funds. Information on quantities, type and flow of medical waste are inadequate, as is sanitary control. We propose an integrated approach to medical waste management based on a hierarchical structure from the point of generation to its disposal. Priority is given to the reduction of the amounts and potential for harm. Where this is not possible, management includes reduction by sorting and separating, pretreatment on site, safe transportation, final treatment and sanitary disposal. Preferred methods should be the least harmful for human health and the environment. Integrated medical waste management could greatly reduce quantities and consequently financial strains. Landfilling is the predominant route of disposal in Croatia, although the authors believe that incineration is the most appropriate method. In a country such as Croatia, a number of small incinerators would be the most economical solution.     

Composition and production rate of medical waste from a small producer in Greece

The objective of this work was to determine the composition and production rate of medical waste from the health care facility of social insurance institute, a small waste producer in Xanthi, Greece. Specifically, produced medical waste from the clinical pathology (medical microbiology) laboratory, the X-ray laboratory and the surgery and injection therapy departments of the health facility was monitored for six working weeks. A total of 240 kg medical solid waste was manually separated and weighed and 330 L of liquid medical waste was measured and classified. The hazardous waste fraction (%w/w) of the medical solid waste was 91.6% for the clinical pathology laboratory, 12.9% for the X-ray laboratory, 24.2% for the surgery departments and 17.6% for the injection therapy department. The infectious waste fraction (%w/w) of the hazardous medical solid waste was 75.6% for the clinical pathology laboratory, 0% for the X-ray laboratory, 100% for the surgery departments and 75.6% for the injection therapy department. The total hazardous medical solid waste production rate was 64 ± 15 g/patient/d for the clinical pathology laboratory, 7.2 ± 1.6 g/patient/d for the X-ray laboratory, 8.3 ± 5.1 g/patient/d for the surgery departments and 24 ± 9 g/patient/d for the injection therapy department. Liquid waste was produced by the clinical pathology laboratory (infectious-and-toxic) and the X-ray laboratory (toxic). The production rate for the clinical pathology laboratory was 0.03 ± 0.003 L/patient/d and for the X-ray laboratory was 0.06 ± 0.006 L/patient/d. Due to the small amount produced, it was suggested that the most suitable management scheme would be to transport the hazardous medical waste, after source-separation, to the Prefectural Hospital of Xanthi to be treated with the hospital waste. Assuming this data is representative of other small medical facilities, medical waste production can be estimated for such facilities distributed around Greece.     

Medical waste management in Turkey: A case study of Istanbul

The objective of this study was to analyze the present status of medical waste management in the light of the Medical Waste Control Regulation (MWCR) in Istanbul, the largest city in Turkey. About 17% of the hospitals, 20% of bed capacity, and 54% of private hospitals in Turkey are located in Istanbul. The first regulation about medical waste management in Turkey was published in 1993, and as a candidate state, it was changed in 2005 in accordance with EU Environmental Directives. In this work, a survey of 14 questions about the amount, collection, and temporary storage of medical wastes was applied to 192 hospitals in Istanbul through face-to-face interviews. It was found that the estimated quantity of medical waste from the hospitals is about 22tons/day and the average generation rate is 0.63kg/bed-day. Recyclable materials are collected separately at a rate of 83%. Separate collection of different types of wastes is consistently practiced, but 25% of the hospitals still use inappropriate containers for medical waste collection. Almost 77% of the hospitals use appropriate equipment for the medical waste collection personnel. The percentage of the hospitals that have temporary storage depots is 63%. Medical waste management in Istanbul is carried out by applying the MWCR.     

Medical waste management in Jordan: a study at the King Hussein Medical Center

As in many other developing countries, the generation of regulated medical waste (RMW) in Jordan has increased significantly over the last few decades. Despite the serious impacts of RMW on humans and the environment, only minor attention has been directed to its proper handling and disposal. This study was conducted in the form of a case study at one of Jordan's leading medical centers, namely, the King Hussein Medical Center (KHMC). Its purpose was to report on the current status of medical waste management at KHMC and propose possible measures to improve it. In general, it was found that the center's administration was reasonably aware of the importance of medical waste management and practiced some of the measures to adequately handle waste generated at the center. However, it was also found that significant voids were present that need to be addressed in the future including efficient segregation, the use of coded and colored bags, better handling and transfer means, and better monitoring and tracking techniques, as well as the need for training and awareness programs for the personnel.     

Evaluation of the available air pollution control technologies for achievement of the MACT requirements in the newly implemented new source performance standards (NSPS) and emission guidelines (EG) for hospital and medical/infectious waste incinerators

After many years of research and debate, in August of 1997 the United States Environmental Protection Agency (EPA) issued New Source Performance Standards (NSPS) and Emission Guidelines (EG) for medical/infectious waste incinerators in the United States. These new emissions and operational standards establish considerably more restrictive limitations on air emissions for medical/infectious waste incinerators and will undoubtedly have a significant impact on the over 2300 hospitals presently operating an incinerator on-site. This paper will explore the options available to these facilities, and those facilities which may be considering installation of an incinerator, relative to achieving compliance with the NSPS and EG for medical/infectious waste incinerators.     

Characteristics and management of infectious industrial waste in Taiwan

Infectious industrial waste management in Taiwan is based on the specific waste production unit. In other countries, management is based simply on whether the producer may lead to infectious disease. Thus, Taiwan has a more detailed classification of infectious waste. The advantage of this classification is that it is easy to identify the sources, while the disadvantage lies in the fact that it is not flexible and hence increases cost. This study presents an overview of current management practices for handling infectious industrial waste in Taiwan, and addresses the current waste disposal methods. The number of small clinics in Taiwan increased from 18,183 to 18,877 between 2003 and 2005. Analysis of the data between 2003 and 2005 showed that the majority of medical waste was general industrial waste, which accounted for 76.9%-79.4% of total medical waste. Infectious industrial waste accounted for 19.3%-21.9% of total medical waste. After the SARS event in Taiwan, the amount of infectious waste reached 19,350 tons in 2004, an increase over the previous year of 4000 tons. Waste minimization was a common consideration for all types of waste treatment. In this study, we summarize the percentage of plastic waste in flammable infectious industrial waste generated by medical units, which, in Taiwan was about 30%. The EPA and Taiwan Department of Health have actively promoted different recycling and waste reduction measures. However, the wide adoption of disposable materials made recycling and waste reduction difficult for some hospitals. It has been suggested that enhancing the education of and promoting communication between medical units and recycling industries must be implemented to prevent recyclable waste from entering the incinerator.     

Hazardous medical waste generation rates of different categories of health-care facilities

Goal of this work was to calculate the hazardous medical waste unit generation rates (HMWUGR), in kg bed(-1)d(-1), using data from 132 health-care facilities in Greece. The calculations were based on the weights of the hazardous medical wastes that were regularly transferred to the sole medical waste incinerator in Athens over a 22-month period during years 2009 and 2010. The 132 health-care facilities were grouped into public and private ones, and, also, into seven sub-categories, namely: birth, cancer treatment, general, military, pediatric, psychiatric and university hospitals. Results showed that there is a large variability in the HMWUGR, even among hospitals of the same category. Average total HMWUGR varied from 0.012 kg bed(-1)d(-1), for the public psychiatric hospitals, to up to 0.72 kg bed(-1)d(-1), for the public university hospitals. Within the private hospitals, average HMWUGR ranged from 0.0012 kg bed(-1)d(-1), for the psychiatric clinics, to up to 0.49 kg bed(-1)d(-1), for the birth clinics. Based on non-parametric statistics, HMWUGR were statistically similar for the birth and general hospitals, in both the public and private sector. The private birth and general hospitals generated statistically more wastes compared to the corresponding public hospitals. The infectious/toxic and toxic medical wastes appear to be 10% and 50% of the total hazardous medical wastes generated by the public cancer treatment and university hospitals, respectively.     

Analyses of the recycling potential of medical plastic wastes

This study analyzed the recycling potential of plastic wastes generated by health care facilities. For this study, we obtained waste streams and recycling data from five typical city hospitals and medical centers and three animal hospitals in Massachusetts. We analyzed the sources, disposal costs and plastic content of medical wastes, and also determined the components, sources, types and amounts of medical plastic wastes. We then evaluated the recycling potential of plastic wastes produced by general city hospital departments, such as cafeterias, operating rooms, laboratories, emergency rooms, ambulance service and facilities, and animal hospitals. Facilities, laboratories, operating rooms, and cafeterias were identified as major sources of plastic wastes generated by hospitals. It was determined that the recycling potential of plastics generated in hospital cafeterias was much greater than that in other departments. This was mainly due to a very slight chance of contamination or infection and simplification of purchasing plastic components. Finally, we discuss methods to increase the recycling of medical plastic wastes. This study suggests that a classification at waste generating sources, depending upon infection chance and/or plastic component, could be a method for the improved recycling of plastic wastes in hospitals.     

Alternatives for treatment and disposal cost reduction of regulated medical wastes

Many hospitals or health care facilities have faced financial difficulties and thus they have attempted to find cost-effective treatment and disposal methods of their regulated medical wastes (RMWs). This study investigated generation volume and sources, composition, and treatment and disposal methods for RMWs obtained from three out of the five typical city hospitals in Massachusetts for which we could obtain relevant data on medical waste. Also, this study compared the generation patterns and amounts of RMWs between the hospital and the medical school. The yearly operational treatment and disposal costs of RMWs based on different treatment and disposal methods were analyzed for one hospital. The most cost-effective option of four different treatment and disposal options studied was to combine on-site incineration and microwave technologies. Finally, this study identified measures for the effective waste characterization methods for the reduction of treatment and disposal costs of RMWs. By careful exclusion of non-RMW from RMW waste streams, hospitals can reduce the RMW volume that requires special treatment and reduce disposal costs.     

Medical waste management in Ibadan, Nigeria: obstacles and prospects

Quantification and characterization of medical waste generated in healthcare facilities (HCFs) in a developing African nation has been conducted to provide insights into existing waste collection and disposal approaches, so as to provide sustainable avenues for institutional policy improvement. The study, in Ibadan city, Nigeria, entailed a representative classification of nearly 400 healthcare facilities, from 11 local government areas (LGA) of Ibadan, into tertiary, secondary, primary, and diagnostic HCFs, of which, 52 HCFs were strategically selected. Primary data sources included field measurements, waste sampling and analysis and a questionnaire, while secondary information sources included public and private records from hospitals and government ministries. Results indicate secondary HCFs generate the greatest amounts of medical waste (mean of 10,238 kg/day per facility) followed by tertiary, primary and diagnostic HCFs, respectively. Characterised waste revealed that only approximately 3% was deemed infectious and highlights opportunities for composting, reuse and recycling. Furthermore, the management practices in most facilities expose patients, staff, waste handlers and the populace to unnecessary health risks. This study proffers recommendations to include (i) a need for sustained cooperation among all key actors (government, hospitals and waste managers) in implementing a safe and reliable medical waste management strategy, not only in legislation and policy formation but also particularly in its monitoring and enforcement and (ii) an obligation for each HCF to ensure a safe and hygienic system of medical waste handling, segregation, collection, storage, transportation, treatment and disposal, with minimal risk to handlers, public health and the environment.