Healthcare waste management in the capital city of Mongolia

Transcription

1 Waste Management xxx (2007) xxx xxx Healthcare waste management in the capital city of Mongolia Enkhtsetseg Shinee a, *, Enkhjargal Gombojav b, Akio Nishimura c, Nobuyuki Hamajima d, Katsuki Ito a a Department of Young Leaders Program, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya , Japan b Ministry of Health, , Government building Y, Olimpiin gudamj 2, Ulaanbaatar, Mongolia c National Institute of Public Health, Minami Wako-shi, Saitama-ken, , Japan d Department of Preventive Medicine/Biostatistics and Medical Decision Making, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya , Japan Accepted 13 December 2006 Abstract Inconsistencies are present in the management options for healthcare wastes in Mongolia. One of the first critical steps in the process of developing a reliable waste management plan requires the performance of a waste characterization analysis. The objectives of this study were an assessment of the current situation of healthcare waste management (HCWM) and characterization of healthcare wastes generated in Ulaanbaatar. A total about 2.65 tonnes of healthcare wastes are produced each day in Ulaanbaatar (0.78 tons of medical wastes and 1.87 tons of general wastes). The medical waste generation rate per kg/patient-day in the inpatient services of public healthcare facilities was times higher than in the outpatient services (P < 0.01). The waste generation rate in the healthcare facilities of Ulaanbaatar was lower than in some other countries; however, the percentage of medical wastes in the total waste stream was comparatively high, ranging from 12.5% to 69.3%, which indicated poor waste handling practices. Despite the efforts for the management of wastes, the current system of healthcare waste management in Ulaanbaatar city of Mongolia is under development and is in dire need of immediate attention and improvement. It is essential to develop a national policy and implement a comprehensive action plan for HCWM providing environmentally sound technological measures to improve HCWM in Mongolia. Ó 2007 Elsevier Ltd. All rights reserved. 1. Introduction During the past few years, there has been an increase in the level of public concern about the management of healthcare wastes (HCW) on a worldwide basis. Healthcare activities lead to the production of wastes that may cause adverse health effects. Some types of HCW represent a higher risk to health than others. Approximately 15 25% (by weight) of HCW is considered infectious. The World Health Organization has estimated that, in 2000, injections with contaminated syringes caused 21 million hepatitis B * Corresponding author. Tel.: address: shinee_e@hotmail.com (E. Shinee). infections, 2 million hepatitis C virus infections and 260,000 HIV infections (WHO, 2004). In less developed and transitional countries, waste disposal options are limited, and small-scale incinerators have been used as an interim solution. Incinerators emit a variety of harmful pollutants, including particulate matter, mercury, dioxin and furans (Malkan and Nelson, 2005). Thus, in addition to risks to health from infectious agents, long-term low-level exposure of humans to dioxins and furans may lead to impairment of the immune system, and impaired development of the nervous system, the endocrine system and the reproductive functions (WHO, 2004). Inconsistencies are present in the management options for medical/infectious wastes in Mongolia. The regulations are interim regulations that suggest a broad range of X/$ - see front matter Ó 2007 Elsevier Ltd. All rights reserved. doi: /j.wasman

2 2 E. Shinee et al. / Waste Management xxx (2007) xxx xxx options for the treatment of medical wastes, including combustion, and do not comprehensively address clear requirements for combustion facilities nor the need for licensed or special collection services and disposal facilities. Meanwhile, the hospitals have been left to devise medical waste management activities on their own. Due to the lack of trained human resources and the absence of proper HCW treatment and disposal facilities in Ulaanbaatar, healthcare wastes are not properly segregated and are apparently buried or burned in simple incinerators or in the open air at land disposal sites (Diaz, 2003). Consequently, it is imperative to develop and implement a comprehensive healthcare waste management (HCWM) policy and strategy to address the management of the wastes generated at the different healthcare facilities. One of the first critical steps in the process of developing a reliable waste management plan requires the performance of a waste characterization analysis. The objectives of this study were an assessment of the current situation of HCWM and characterization of healthcare wastes generated in Ulaanbaatar. 2. Methodology 2.1. Materials Information obtained from the City Health Department (CHD) indicated that there were 550 healthcare facilities (HCFs) operating in Ulaanbaatar in The facilities provided services to 6,389,793 outpatients and to 204,987 inpatients during the year. The Government divides the various types of facilities into three levels: primary, secondary and tertiary. In 2004, a total of 14 specialized public and 2 private large HCF in Ulaanbaatar provided special medical services to the population. The specialized public facilities provided healthcare services to 72,158 inpatients and to 629,293 outpatients. The Forensic Center is a specialized facility that provides basic healthcare to outpatients and conducts autopsies. In 2004 it provided services to 9,459 outpatients and conducted 1,751 autopsies. In this study, information was obtained to describe the existing procedures practiced in the handling and treatment of HCW produced in the capital city. In addition, a crosssectional study was conducted to characterize and quantify HCW generated in Ulaanbaatar city of Mongolia. A total of 56 HCFs operating in Ulaanbaatar were selected for the study: 15 large (13 public and 2 private) HCFs including the Forensic Center, 8 family health centers and 33 private HCFs. Due to the specification (infectious, pediatric, maternal, cancer, injury, etc.) of their services, it was not rationale to make a random sampling and almost all large facilities were included in the study. The approximate number of people served and the types of services offered by the district and family health centers are standardized. Therefore, the waste generation rate per patient/kg/day can be extrapolated to other district health care facilities and family centers. The collection of solid waste samples and the measurements were carried out in January and February The waste characterization study was conducted in accordance with WHO guidelines (Prüss et al., 1999). All of the wastes generated in the selected hospitals were weighed every day during a period of one week. Epidemiologists or officers in charge of healthcare waste took control of the collection and sorting of the medical wastes each day and recorded the amount of waste on the data sheets. The quantity and composition of the wastes were determined at each selected HCF. General wastes and medical wastes from outpatient and inpatient services were collected separately. The weighing and measurement of the wastes were performed in a designated room. General wastes were weighed, but they were not sorted. The medical wastes were previously sorted into various components such as syringes, gloves, bandages, intravenous (IV) sets, cotton, and medicines. The weight of each component of the medical wastes was recorded on special data sheets. Following these procedures, the wastes were transported to a room normally used for waste storage and a place for final disposal. The survey was carried out close to a national holiday and some surgeries were postponed until after the holidays. Therefore, the results of the composition analyses may be low in terms of pathological wastes and other wastes that result from surgical interventions Data analysis The quantity of HCW was presented in terms of kg/day and kg/patient/day for medical and general wastes, separately and combined. These data, combined with the number of patients serviced during the study, were used to determine the quantities of waste generated by each type of facility and for the entire city (Diaz et al., 2005; Enkhtsetseg et al., 2005). The waste generation rate per kg/ patient-day and the number of patients per day were multiplied to estimate the quantity of wastes generated per day in the capital city. A chi-square test (two sided) and Mann Witney test were applied using Excel and SPSS software programs. 3. Results 3.1. Description of the existing healthcare waste management system Waste segregation and storage In the HCFs, the wastes are segregated according to their characteristics, mainly into the following categories: sharps, infectious wastes, pathological wastes and pharmaceutical wastes. Although a system of color coding or labeling of waste containers/bags has been adopted, not all facilities strictly follow the national regulations to practice the color coding system. The medical wastes are segregated into: infectious wastes, sharps, pharmaceutical wastes and chemical wastes. However, in some HCFs the wastes are

3 E. Shinee et al. / Waste Management xxx (2007) xxx xxx 3 collected and stored in plastic bags, paper bags or cardboard boxes, which show inadequate waste handling practice regarding the regulations on Removal and disposal of hazardous waste (2002), and Improvement of healthcare waste management (2003). All medicines are stored at each HCF, and at the end of the year an inventory of all medicines is conducted and those that have expired are disposed of. Radioactive wastes generated at the Cancer Research Center are collected by personnel from the Atomic Energy Commission for proper storage and treatment; thus, in this study we did not address the management of radioactive wastes in detail Waste collection and disposal Most HCFs have a contract with the District Upgrading Service for waste collection, and general wastes are usually transported to the city disposal site. There is no special service for transporting medical wastes in the city; therefore, some HCFs use their own vehicles to transport the wastes. The data derived from the City Health Department (2005) show that 11.5% of HCFs had on-site, low-temperature, small-scale incinerators, 79.4% had contracts with these facilities to burn the medical waste, and 9.1% discharged (burnt or simply buried) the wastes at the disposal site. This indicates that HCFs in Ulaanbaatar city practice unsafe combustion. In addition, monitoring of the emissions from the incinerators is not carried out due to a lack of analytical capacity. A few facilities used autoclaves to treat infectious wastes Characterization of healthcare wastes Healthcare waste quantities The medical waste generation rate (per kg/patient-day) in public inpatient services was times higher than those in the outpatient services (P < 0.01). The outpatient facilities generated between 0.01 and 0.14 kg of medical wastes and between 0.01 and 0.79 kg of general wastes per patient/day. On the other hand, the inpatient facilities generated between 0.03 and 0.14 kg of medical wastes and between 0.12 and 0.38 kg of general wastes per patient/day (Table 1). Table 1 Summary of solid wastes generated by the public healthcare facilities surveyed Facility name Level a Patients per Waste generation day b Medical General Total (kg/ day) (kg/ day) (kg/ day) (kg/patientday) (kg/patientday) (kg/patientday) Natl. Traumatology and Orthopedic Teaching Hospital All (except burn unit) Burn unit Cancer Center Inpatient Outpatient Natl. Center for Communicable Diseases Inpatient Outpatient State Hospital No. 1 Inpatient Outpatient State Hospital No. 3 Inpatient Outpatient Maternity Hospital No. 1 II Maternal and Child Health Research Center Inpatient Outpatient Bayanzurkh District Health Center II Sukhbaatar District Health Center II Bayanzurkh District Hospital II Chingeltei District Hospital II Bayanzurkh District Family Health Center I Sukhbaatar District Family Health Center I State Dental Center Forensic Center Outpatient Autopsies Source: Enkhtsetseg et al., a I for primary level health facility; II for secondary level health facility; and for tertiary level health facility. b Average number of patients per day, in January and February 2005.

4 4 E. Shinee et al. / Waste Management xxx (2007) xxx xxx Table 2 Estimated quantity of wastes generated by all healthcare facilities in Ulaanbaatar, (2005) Level a and type of healthcare facility Patients per day b Unit quantity of waste (kg/patient-day) Total quantity of wastes Inpatient Outpatient Inpatient Outpatient generated (kg/day) Medical General Medical General Medical General Total I Family Health Centers 7, I Soum Health Centers II District Health Centers (with beds) 60 3, II District Health Centers (without beds) 1, II District Hospitals State Hospitals No. 1, 2, 3, and Hospital No , Specialized Hospitals 198 1, II Maternity Hospitals Other Healthcare Facilities II Private Hospitals (inpatient) Private Hospitals (outpatient) 1, Emergency Center and Occupational Health Center Subtotal , Forensic Center Autopsies Total Source: Enkhtsetseg et al., a I for primary level health facility; II for secondary level health facility; and for tertiary level health facility. b Based on number of patients treated in 2004, assuming treatment 365 days per year. It was found that the medical waste generation rate per kg/patient-day was higher in the tertiary level inpatient HCFs than in the secondary level HCFs (P < 0.05). Table 2 presents the estimated medical and general wastes for all HCFs in Ulaanbaatar. Projections for 365 days of treatment per year show that the HCFs in Ulaanbaatar produced about 781 kg of medical wastes and 1,874 kg of general wastes, for a total of 2,655 kg per day. The largest contributors to the waste stream were the tertiary level public facilities with a total of kg per day, and other HCFs, which contributed about 529 kg per day, followed by private (outpatient) hospitals. Together these three levels generated kg of medical wastes per day Healthcare waste composition Fig. 1a shows the percentage of medical wastes in the total waste stream. In the private facilities, the percentage of medical wastes was higher than in the public facilities (P = 0.009), although there was no statistically significant difference in the medical waste generation per kg-patientday between these two types of facilities (Fig. 1b). The contribution of medical wastes to the total waste stream varied from about % depending on the type of HCF. The percentage of medical wastes was higher in the small-private HCFs (ranging from 48.0% to 69.3%) and in the primary and secondary level public HCFs (37.6% and 31.4%, respectively), whose waste management procedures were unacceptable according to the adequate waste management procedures. The average compositions of medical wastes generated in the state service hospitals are shown in Fig. 2. As shown a b Public HCF Private HCF % wet weight General wastes Medical wastes Public Private Public Private outpatient General wastes Medical wastes kg/patient-day inpatient Fig. 1. Medical waste generation in public and private healthcare facilities (HCF).

5 E. Shinee et al. / Waste Management xxx (2007) xxx xxx 5 21% 14% 14% 8% 3% 7% 12% 12% 37% Syringes Gloves IV Bandages Cotton Medicines Other 3% 6% 26% 8% 29% Syringes Gloves IV Bandages Cotton Medicines Other inpatient outpatient Fig. 2. Composition of medical wastes generated in the state service hospitals (by weight). 17% 2% 14% in this figure, the major components of the medical wastes in the inpatient service were syringes, gloves and IV sets. The medical wastes generated by outpatient services contained mostly gloves and bandages. As shown in Fig. 3, the major components of the medical wastes in the private healthcare facilities were syringes, gloves, pathological materials and cotton. 4. Discussion 12% 2% 17% 36% Syringes Gloves IV Cotton Pathological Chemical Other Fig. 3. Composition of the medical wastes in the private healthcare facilities (by weight). Surveys show that the total amount of HCW generated in a hospital in an industrialized country is approximately two to more than seven times that generated in developing countries. The relatively large amounts of wastes generated in hospitals in developed countries come mostly from the very heavy reliance on disposable instruments and materials, and on increased packaging of the products used (Shaner and McRae, 2002). The medical waste generation rate per kg/patient-day in the HCFs of Ulaanbaatar was lower than in other countries such as Japan, Turkey (Mohee, 2005), and Brazil (Da Silva et al., 2005). For instance, at State Hospital No. 1 (University Hospital) in Ulaanbaatar, the medical waste generation rate per kg/patient-day was 0.2 (Diaz et al., 2005), while the generation rate at Nagoya University Hospital (NUH) was 0.6 kg/patient-day according to NUH records for April 2004 to March On the other hand, in the HCFs in Ulaanbaatar, the percentage of medical wastes in the total waste stream was comparatively high (ranging between 12.5% and 69.3%), which indicated poor waste segregation and minimization practices. In contrast, in some countries, where adequate waste management systems are in place, the percentage of infectious medical wastes ranges from 10% to 20% (Mohee, 2005). The American Hospital Association indicates that this category of wastes should not be more than 15% of the total waste stream, and a number of US hospitals have implemented good segregation programs that reduced this portion of wastes to less than 6% (Shaner and McRae, 2002). The integrity of packaging, particularly of items such as sharps, is critical to ensure the containment of wastes during their collection, storage and transportation. For sharps, puncture-proof containers are the preferred handling mechanism (Miyazaki and Une, 2005). The existing inadequate practice of packaging for sharps and infectious and chemical wastes (i.e. the use of inappropriate plastic bags, paper bags and cardboard boxes) in the HCFs in Ulaanbaatar may pose significant occupational and environmental health risks. We should consider the fact that contaminated needles and syringes represent a particular threat of disease transmission, and that Mongolia has hepatitis C virus prevalence above 10%, among the highest in the world. The global prevalence of HCV carriers is estimated to average 3%, and range from 0.1% to 10% or more in different countries (Banker, 2003). A rapid assessment of injection practices in Mongolia revealed that in 57% of injection providers the annual rate of needle-stick injuries was 2.6/provider/year (Logez et al., 2004). Healthcare workers commonly recapped used needles using a two-hands technique and counted by hand used syringes before disposal. Epidemiological studies indicated that a person who experiences one needle stick injury from a needle used on an infected source patient had risks of 30% and 1.8% to become infected with HBV and HCV, respectively. In 2002, the results of a WHO assessment conducted in 22 developing countries showed that the proportion of HCFs that do not use proper waste disposal methods ranges from 18% to 64% (WHO, 2004). Another study carried out by Guo et al. (1999) in Taiwan

6 6 E. Shinee et al. / Waste Management xxx (2007) xxx xxx showed that the reported incidences of needle-stick and sharps injuries were 1.30 and 1.21 per person, respectively, in a 12-month period. In the detailed study, it was observed that about 9.2% of these injuries were related to poor waste handling practices. The hospitals in Japan promote the vaccination against Hepatitis B for the waste handling staff (Guidelines, 2005) and this practice can easily be introduced in Mongolia. There is still a lack of specialized services for the collection and final disposal of medical wastes in Ulaanbaatar. Thus, the wastes are not properly segregated, collected and disposed, which may lead to a negative impact on public health and on the environment. Incinerators are dangerously polluting technologies that will virtually undermine the objectives of the treaty on Persistent Organic Pollutants (POPs). The Stockholm Convention on POPs, which has been ratified by Mongolia (2004), identifies waste incinerators as the principal source of dioxins and furans, which are among the initial 12 substances being targeted for continuing minimization and ultimate elimination by the global community. Considering this, many countries have taken actions to treat and dispose of HCW using environmentally safer, non-combustion technologies. The National Inventory on Low Combustion Organic Pollution, (2005) revealed that ash generated by the waste incinerator at the Child and Maternity Hospital (which is one of the few special incinerators in the city) had the highest concentrations of dioxin/furans and contained a total TCDD-TEQ (2000 pg/g concentrations) several orders of magnitude above those measured in municipal sewage sludge solids, ash generated by power plants, and kiln dust from cement and lime factories (UNIDO, 2005). If we consider the fact that almost all (90.9%) HCFs in the city practice unregulated combustion (low-temperature incinerators, simple stoves or open burning) to dispose of medical wastes, we realize that the situation is very serious and requires immediate action to protect the public and the environment. Therefore, the use of environmentally sound non-combustion technology is the best option; however, if we consider incineration as an interim solution for the treatment of medical wastes, the existing low-temperature incinerators should be banned, and modern incinerators equipped with proper air pollution control units can be used as one of the methods to treat and dispose of the HCW. Thus, issues such as rigorous segregation, emission standards, vigilant monitoring, regular maintenance, proper disposal of ash, and enforceable sanctions for nonperformance should be addressed. 5. Conclusion A total of about 2.65 tonnes of healthcare wastes are produced each day in Ulaanbaatar. The contribution of medical waste to the total waste stream varies from 12.5% to 69.3%, depending on type of healthcare facility. The wastes are not properly segregated, collected and disposed, which may lead to a negative impact on public health and on the environment. Despite the efforts for the management of wastes, the current system of healthcare waste management in Ulaanbaatar city of Mongolia is under development and is in dire need of immediate attention and improvement. There are fundamental problems with respect to waste management, such as a lack of a comprehensive policy and strategy, the absence of proper infrastructure, inadequate knowledge and skills of health sector personnel, and poor occupational and environmental health practices, which may lead to further deterioration of the situation in Ulaanbaatar city of Mongolia if not addressed adequately. The Government needs to make a critical decision on how to organize HCW treatment facilities in Ulaanbaatar city, whether it be to set up central facilities or to require individual treatment and disposal facilities. It is essential to develop a national policy and implement a comprehensive action plan for HCWM, providing environmentally sound technological measures to improve HCWM in Mongolia. Acknowledgements The authors wish to thank all of the members of the healthcare institutions that participated in the survey. The authors would like to express thanks to Dr Luis F. Diaz and Ms Linda Eggerth of CalRecovery, Inc. (Concord, USA) for assisting in establishing the methodology and in the analyses of the data from the waste characterization program. Finally, the authors would also like to extend their most sincere appreciation to the World Health Organization for supporting this study and for their continued collaboration in the management of solid wastes in Mongolia. 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