INTRODUCTION
Medical waste refers to all waste generated from healthcare or diagnostic activities, specifically originating from diagnostic, monitoring, therapeutic, preventive, or palliative procedures conducted in human and veterinary medicine settings. It also encompasses any solid or liquid waste produced during treatment or immunization of humans or animals, scientific research related to these procedures, or the production and testing of biological substances1-3.
As per WHO guidelines, medical waste is categorized into general medical waste, akin to household waste, and hazardous medical waste, which poses potential health risks4-6. Hazardous medical waste includes infectious materials, pathological materials, sharps, pharmaceuticals, chemical substances, waste with heavy metal content, pressurized containers, and radioactive materials4-6. Hazardous medical waste includes infectious materials, pathological materials, sharps, pharmaceuticals, chemical substances, waste with heavy metal content, pressurized containers, and radioactive materials7,8.
Globally, an estimated 7–10 billion tons of waste are generated annually, with only around 2 billion metric tons constituting municipal solid waste, leaving the majority as medical waste9. A WHO assessment in 22 developing countries revealed that 18–64% of healthcare facilities did not adhere to proper waste disposal methods, and nearly 80% of medical waste was combined with other waste types in developing nations9,10. Worldwide, approximately 2.2 million individuals succumb to workplace-related diseases and injuries each year, while 170 million suffer serious non-fatal injuries11. In Bangladesh, it is estimated that annually, 5.2 million people, including 4 million children, perish due to diseases associated with improper waste management12,13.
In Bangladesh, a study conducted in 2012 concluded that many healthcare establishments lacked a standard hospital waste management (HWM) policy or plan, had no formal waste handling procedures, and did not provide pre-treatment of hazardous waste before disposing it in nearby recycling bins14. Another study conducted in Bangladesh found that improper oversight by the hospital administrative authority concerned was one of the major factors along with lack of awareness, inadequate supply of equipment such as waste bins, protective gear, unhygienic materials, e.g. non-disposable gloves or contaminated packaging, are responsible for the poor waste disposal systems15. Proper and efficient medical waste management is imperative during healthcare services provision, as improper disposal can lead to the transmission of diseases such as hepatitis B, hepatitis C, HIV/AIDS, and other viral infections16.
In Dhaka, with its rapid population growth, improper medical waste management poses severe health and environmental threats. Incorrect handling of infectious waste can endanger healthcare workers, patients, waste handlers, and visitors, underscoring the necessity for correct storage, handling, and disposal methods to prevent the spread of diseases like AIDS and hepatitis17. Despite numerous studies in Dhaka, limited research exists in tertiary hospitals. Hence, conducting an extensive investigation to gather baseline data is crucial for the formulation of healthcare waste management rules, regulations, guidelines, and policies in Dhaka.
This study aimed to assess the current state of hospital waste management practices, covering waste generation, segregation, collection, transportation, storage, treatment, and disposal in both tertiary private and government hospitals in Dhaka.
METHODS
Study design and settings
A cross-sectional survey was conducted to assess hospital waste management practices in a tertiary private and government hospital in Bangladesh from 1 July to 31 December 2019. Shaheed Suhrawardy Medical College Hospital, Dhaka, with 375 beds, ranks third among government-run hospitals, and at the Bangladesh Medical College and Hospital (BMCH), Dhanmondi, Dhaka, regulated by the Directorate General of Health Services (DGHS), has 300 beds. Eligible participants included doctors, nurses, medical technologists, and sanitation staff (ward boys, Aya, cleaners/sweepers) with a work tenure exceeding six months.
Study population and sampling
Participants were selected from Shaheed Suhrawardy Medical College Hospital and from the Bangladesh Medical College and Hospital (BMCH), using convenience sampling methods. This approach was chosen for its practicality in enrolling willing participants based on their accessibility. The sample size of 217 individuals was determined based on the existing pool of healthcare workers at the chosen hospitals, with a 10% allowance for potential non-response or incomplete responses.
Data collection procedure
Data collection was conducted through face-to-face interviews using a semi-structured questionnaire and Rapid Assessment Tool. The questionnaire, adapted from the UN-WHO HCWM Rapid Assessment Tool, consisted of 20 questions that assessed hospital waste management practices. This assessment covered the profile of: 1) healthcare facilities, including services offered, available beds, bed occupancy rates, and outpatient admissions; and 2) medical staff in terms of HCWM training, awareness, vaccination status, and staffing levels. Additionally, the assessment examined HCWM practices as reported by respondents, focusing on waste generation, segregation and handling, storage containers, storage areas, collection and on-site transport, off-site transport, treatment methods, final disposal, regulations, policies and budgets, and management of sanitation and wastewater. Practices were scored, with ‘1’ denoting a correct answer and ‘0’ for incorrect responses, to categorize overall practice into: Satisfactory (≤7), Good (8–14), and Excellent (≥15). The questionnaire was pre-tested on 15 respondents in Bengali, modified accordingly, and used for data collection after finalization. Prior to data collection, participants were briefed about the study’s objectives. Hospital waste materials were identified and segregated in different colored containers, as per ‘Medical Waste (Management & Handling) Rules-2008’18: black, non-hazardous/general waste; yellow, hazardous waste; red, sharp waste; blue, liquid waste; green, reusable/recycled general waste; and silver, radio-active waste. During data collection privacy was maintained, and respondents were assured about the confidentiality of the information provided by them.
Ethical considerations
Ethical approval of the study was obtained from the ethical committee of AFMI (Armed Forces Medical Institute). Permission for data collection was obtained from the administrative head of Shaheed Suhrawardy Medical College Hospital, Dhaka, and from the Bangladesh Medical College and Hospital (BMCH), Dhanmondi, Dhaka. Written informed consent was taken from each respondent. Information of the participants was kept confidential and was not used for any other purpose except research.
Data analysis
Data analysis was done using Statistical Package for Social Science (SPSS) V.23 and Excel V.13. Descriptive statistics were calculated using mean and standard deviation (SD) for continuous variables, while frequencies and percentages were calculated for categorical variables. Chi-squared (χ2) tests were carried out for inferential analysis.
RESULTS
Sociodemographic and professional information of respondents
Overall, among the two institutions, BMCH demonstrated a higher level of practice in HWM compared to ShSMCH (89.7% vs 58.3%). Among the 139 distributed surveys in ShSMCH, respondents had a mean age of 32.8 years (SD=9.1). Females comprised 72.7% of respondents in ShSMCH and 48.7% in BMCH. In ShSMCH, nursing was the most common profession at 39.6%, while in BMCH, doctors comprised 34.6% of the study population.
More than half of the respondents had less than five years of service experience, and most of them cited mutilated or shredded syringes following usage as evidence of HW segregation. Almost half of the respondents from ShSMCH (49.6%) reported that hospital waste is stored in color-coded containers. In contrast, 70.5% of respondents from BMCH indicated that hospital waste is stored in plastic dustbins with lids. More than half of respondents (51.3%) at BMCH reported that waste records are not maintained at their workplaces. Regarding injuries related to HWM, 25.2% of respondents at ShSMCH indicated that relevant hospital records were unavailable, while this was noted by 17% at BMCH.
Table 1
Sociodemographic, professional profile, and hospital waste management characteristics of participants in ShSMCH and BMCH, Dhaka, Bangladesh, 2019 (N=217)
Distribution of hospital workers by level of practice on HWM and characteristics
Table 2 shows that ShSMCH had an average of 41.7% of health workers demonstrating good hazardous waste management (HWM) practices, while BMCH reported a significantly higher proportion of 89.7% with good HWM practices. Regarding age groups, it was found that none of the groups exhibited a poor level of practice. The majority of health workers aged 29–38 years (79.2%) and those aged ≥39 years (75.8%) had a good level of practice. In terms of professional status, all medical technicians (100%) demonstrated good levels of practice. Nearly all respondents who were doctors or medical technicians had good levels of practice compared to other professional categories.
Table 2
Distribution of hospital workers by level of practice in hospital waste management (HWM) and characteristics in ShSMCH and BMCH, Dhaka, Bangladesh, 2019 (N=217)
Assessment of HWM using UN-WHO HCWM Rapid Assessment Tool
The results obtained using the Rapid Assessment Tool of WHO are shown in Table 3 for ShSMCH and BMCH. The waste generated by both hospitals were reported for general waste (1500 vs 600 kg/day), recyclable waste (6 vs 5 kg/day), infectious (non-sharp waste) (110 vs 53 kg/day), and sharp waste (13 vs 7 kg/day). Overall, the study revealed that the amount of waste per patient generated in ShSMCH was 1.09 kg/day and 1.48 kg/day in BMCH. The UN-WHO HCWM Rapid Assessment Tool indicates that the overall state of waste management is good in ShSMCH (weighted result of 63%) and average in BMCH (weighted result of 58%), the details of which are noted in Table 4.
Table 3
Assessment of hospital waste management using UN-WHO HCWM rapid assessment tools in ShSMCH and BMCH, Dhaka, Bangladesh, 2019, (N=217)
Table 4
Final result comparison of hospital waste management practices between ShSMCH and BMCH, Dhaka, Bangladesh, 2019 (N=217)
DISCUSSION
This study showed the need for correct waste management, along with clear guidelines to improve waste management practices and the importance of how effective management and budgeting would require adequate supplies and equipment in all departments.
The gender balance of our study was similar to studies of Musa et al.19, Nagaraju et al.20, and Woromogo et al.21, and equal percentage of both males and female were found in the study conducted by Chudasama et al.22. This could be attributed to the current study’s exclusive focus on two hospitals compared to broader studies conducted across multiple Indian hospitals.
This study is similar to the Chudasama et al.22 study conducted in India, where 247 people (87%) used proper storage facilities for collecting workplace hospital waste. The WHO Regional Office for South-East Asia, found that during the generation of syringes, disposable needle cutters should be used to damage them after use so that they cannot be reused 23. A study conducted by Wazir et al.24, demonstrated that sweepers in CMH Rawalpindi collect waste twice daily in the morning and in the evening. Dehghani et al. 25 conducted another study in Iran with waste collected three times daily, at the end of each shift. Proper management of waste in hospital wards is crucial for ensuring a safe and hygienic healthcare setting. In order to adhere to infection control protocols, maintain safety standards, address environmental issues, and comply with regulations, it is highly recommended that waste from hospital wards be collected on a daily basis or as often as deemed necessary26,27. A higher percentage of respondents in BMCH had been vaccinated against tetanus and hepatitis B than in ShSMCh, and two-thirds of respondents had undergone training regarding hospital waste management. With regard to adherence to good practices, almost the same outcome was found in a study conducted in Ethiopia by Deress et al.28 who found that (77.4%) healthcare workers practiced at a good level or adequate level.
Healthcare facilities should implement safe healthcare waste management practices through the prevention of hazardous medical waste generation as one of their overall objectives. Accumulation of medical waste in hospitals, however, indicates that healthcare waste management (HCWM) does exist, but that it is not properly implemented or developed. These differences in practice level on HWM were statistically significant by age and profession, which is similar to a study conducted in Bhutan29, potentially because when a health worker ages, he or she will generally gain more experience and improve their knowledge30.
Among the main factors that are associated with better quality of medical waste management, the particularly important ones are: the number of beds, the number of hospital days, the number of outpatient services, and the number of trained professionals for HCWM. Providing high-quality services to the community is the main responsibility of healthcare establishments; this cannot be accomplished without a proper waste-handling policy that meets international regulations.
Waste handling equipment, hazardous medical waste collection, and onsite and offsite transport were among BMCH’s strongest pursuits, while the rate of waste generation in our study is comparable to that observed in developing countries with a total hazardous waste generation rate per patient of around 0.85 kg/day, lower than other studies in Iran with a rate of 4.45 kg/day31,32. This rate is contradicted by some other studies conducted in Taiwan where the estimated daily waste generation rate at NTUH was 4.6 kg/day and in Serbia where the average annual waste generation per institution at the secondary healthcare level amounted to 29,606.71 kg and at the tertiary healthcare level amounted to 73,419.49 kg33.
The decrease in waste generation might be directly related to a more effective waste management system. The amount of medical waste generated by hospitals located in large communities and providing tertiary care is greater than that produced by hospitals in smaller, less populated areas, and so the number of healthcare services users and medical waste produced are directly proportional to the number of inpatient days. Furthermore, previous research has indicated a significant association between the type of hospital and pharmaceutical waste generation33. Similarly, according to a study in Botswana’s tertiary hospitals, waste management is often poor and staff are rarely involved in making waste handling policies34.
Personnel involved in handling healthcare waste should familiarize themselves with the main categories of healthcare waste, as defined in national or local regulations on waste classification, and with safe disposal procedures35. Thus, it is important to provide special training within the healthcare waste management sector, including medical waste management topics, to improve HCWM’s capacity for safe management.
This study underscores the need for implementing comprehensive waste management policies and educational initiatives to ensure effective waste segregation, storage, and disposal within healthcare settings. Conducting specialized training sessions for healthcare professionals can significantly enhance their understanding and implementation of proper waste management practices. Addressing discrepancies in waste generation rates among different hospitals calls for tailored resource allocation based on each facility’s size and type. Collaborative efforts between healthcare institutions, city corporations, and waste management agencies are essential for successful waste management strategies. The research emphasizes successful collaborative areas, offering a model for other hospitals to emulate.
Strengths and limitations
The study’s strength lies in its comprehensive evaluation of waste management practices in both a government and a private tertiary hospital in Bangladesh. With a sample size of 217 participants and employing a cross-sectional design, this research yielded data on waste management practices. Diverse perspectives within the healthcare sector, represented by various professionals such as doctors, nurses, and support staff, enriched the study. The utilization of UN-WHO HCWM Rapid Assessment Tool alongside a semi-structured questionnaire ensured systematic data collection.
However, this study has several limitations. The cross-sectional design restricts establishing causal relationships or assessing temporal changes between variables. Additionally, convenience sampling may introduce selection bias, potentially affecting the generalizability of findings to broader populations. Reliance on self-reported data might introduce response bias and recall errors among participants. Focusing solely on two hospitals within a specific region might limit the generalizability of these findings to diverse healthcare settings globally. Moreover, calculating sample size based on a single population proportion formula overlooks the heterogeneity among healthcare workers across different contexts.
CONCLUSIONS
Both hospitals demonstrated satisfactory practices in segregating, collecting, and transporting waste on-site. However, concerns arise regarding the security of temporary storage areas and containers, which lack proper safeguards against unauthorized access. Effective waste management necessitates adequate supplies and equipment across all hospital departments. Additionally, to promote and reinforce Hospital Waste Management (HWM) regulations and procedures, it is essential for government hospitals to prominently display safety reminders, posters, and related policy statements. Budgeting and planning HWM facilities should be integral components of short- and long-term operational plans for both hospitals and local government units. These efforts will facilitate the establishment and maintenance of compliant HWM initiatives, ensuring the availability of necessary personnel, supplies, materials, and equipment.
