This article was written by Dr. Mansoureh Aboufazli, Mr. Nima Reza Ali, and Ms. Niloufar Reza Ali, and submitted for the 11th Infection Control Congress.
Abstract
Hospital waste refers to the waste produced as a result of medical, laboratory, nursing, dental, pharmaceutical, and similar activities in hospitals, medical centers, and related research facilities. Hospital waste has unique characteristics compared to other types of waste and urban garbage. At the same time, hospitals are rare institutions where a wide variety of chemicals are used extensively. The World Health Organization (WHO) categorizes hazardous waste into nine types: infectious waste, pathological and anatomical waste, sharp objects, pharmaceutical waste, cancer treatment or genotoxic waste, chemical waste, waste containing high amounts of heavy metals, pressurized capsules, and radioactive waste. According to estimates, over 630 different types of chemicals are used in hospitals, of which 300 are non-toxic, 30 are toxic and hazardous, and about 300 are low-risk. Many of these substances are contaminated with infectious particles and can be a source of bloodborne diseases such as hepatitis, HIV, etc. Segregating infectious from non-infectious waste not only helps protect the environment but also prevents contamination and the spread of infection within the city by opportunistic individuals. It also reduces the likelihood of contamination among nursing and service staff. There are multiple reasons for the failure to segregate infectious waste promptly. One reason is the lack of proper training for staff and nurses, along with the shortage of knowledgeable personnel to operate up-to-date equipment. Other significant contributing factors include inappropriate methods of waste collection in medical centers and unsuitable waste transfer methods.
The different stages of medical waste management include segregation, packaging and labeling, collection, transportation, treatment, and disposal. The easiest way to identify different types of hospital waste is by using color-coded plastic bags. WHO’s suggestions for hospital waste color coding are as follows: Infectious waste – red bags, other infectious and pathological waste – yellow bags, sharp objects – yellow or red bags, pharmaceutical and chemical waste – brown bags, and non-hazardous hospital waste – black bags. To draft a comprehensive hospital waste management plan, the hospital administration should form a waste management team and allocate sufficient financial and human resources for this project. Additionally, four groups of hospital staff must undergo training. The improper disposal of waste generated by healthcare activities poses a risk to public health. In addition to the infectious agents present in this waste, exposure to toxic substances like furans and dioxins, which are released when burned, can lead to long-term health problems such as immune system deficiencies, developmental issues in the nervous system, endocrine disruption, and reproductive system disorders. In high concentrations, such exposure can cause skin lesions and liver damage in the short term. There is no doubt that proper hospital waste disposal is crucial for creating a healthy city.
Keywords: Hospital Waste – Infectious Waste Management
Introduction
Hospital waste refers to the waste produced as a result of medical, laboratory, nursing, dental, pharmaceutical, and similar activities in hospitals, medical centers, and related research facilities.
Hospital waste has unique characteristics compared to other types of waste and urban garbage. Various medical procedures are performed in hospitals, such as chemotherapy, dialysis, reconstructive surgery, childbirth, and the removal of body organs like appendectomies. Additionally, hospitals are among the rare institutions that extensively use a wide range of chemicals. Medical waste generated by healthcare facilities includes two categories: general or household waste, and hazardous waste. General waste requires special management techniques to prevent infectious risks during management. If mixed with other waste, it should not be recycled, such as blood, fluids, or contaminated clothing or waste.
The issue of hospital waste is not only a problem in developing and underdeveloped countries but has also become a challenge in many industrialized nations. For instance, Mexico, with a population of 107 million, has only three institutions responsible for the safe transportation and disposal of infectious hospital waste, which amounts to 700,000 tons annually, or 1.5 kilograms per hospital bed, according to the country’s Minister of Health. Similarly, Germany is also facing a growing challenge in this regard.
In recent years, Germany has proposed various solutions, including the “Waste Economy Plan,” which focuses on the proper management of hospital waste.
Special hospital waste, also known as infectious waste, requires a highly precise and specialized approach, especially since it raises broader social concerns, the most significant of which is the threat to the environment and ultimately to human health.
The World Health Organization (WHO) categorizes hazardous waste into nine types: infectious waste, pathological and anatomical waste, sharp objects, pharmaceutical waste, cancer treatment or genotoxic waste, chemical waste, waste containing high amounts of heavy metals, pressurized capsules, and radioactive waste.
Objective
The aim of this study is to investigate the different types of infectious hospital waste, identify the hazards and risks of improper disposal, and examine various methods of waste treatment, disinfection, and sanitary disposal.
Research Method
This research is a review and descriptive study that examines hospital waste, public health, and sanitary disposal by reviewing multiple articles, books, Ministry of Health guidelines, and various websites on the subject.
Results
Based on estimates conducted in hospitals, more than 630 different types of chemicals are used, of which 300 are non-toxic, 30 are toxic and hazardous, and about 300 are low-risk. Part of these materials, after use, are generated as waste in the form of biological and radioactive by-products within the hospital environment. To this waste, contaminated sharp objects like syringes, surgical blades, and similar items should be added. Most of these materials are contaminated with infectious particles and are sources of bloodborne diseases such as hepatitis, HIV, etc.
The amount of waste generated depends on several factors. Health systems that have implemented waste separation schemes certainly produce less waste than those without waste management systems. In low- and middle-income countries, waste production is lower than in high-income countries. The volume of radioactive waste from healthcare facilities is generally much less than that from nuclear industries. Waste consists of 80% general waste, 15% pathological and infectious waste, 1% sharp objects, 3% chemical and pharmaceutical waste, and less than 1% special waste like radioactive materials, pressurized gas canisters, broken mercury thermometers, and used batteries. According to statistics, less than 0.5 kg of pharmaceutical and chemical waste is generated per hospital bed per day worldwide, and less than 40 grams of sharp waste is produced daily. Based on these statistics, if waste separation is properly implemented, in the worst-case scenario, only 5% of healthcare waste should be incinerated, while the rest will follow the usual recycling or transformation chain.
Separating infectious waste from non-infectious waste not only preserves the environment but also prevents the spread of contamination throughout the city by unauthorized individuals and reduces the risk of infection for nursing and service personnel.
It has been proven that there are many points of intersection between economics and ecology (environmental science), and by implementing sensible and beneficial environmental protection measures, such as separating recyclable materials, significant savings can be made, especially in the separation of waste.
Experts say such actions also impact the energy and wastewater sectors. To regulate the separation of hospital waste, the categorization of waste is of special importance. Aside from specific regulations (e.g., for radioactive waste), waste is systematically divided into five groups based on safety precautions, infection risks, and environmental health criteria:
Group A Waste:
These are wastes that do not require any special precautions for separation based on safety, infection risks, or environmental health. This includes household-like waste such as paper, glass, and synthetic materials, as well as professional waste similar to household waste, like boxes and cartons. Kitchen and dining room waste also fall into this group. In total, this group accounts for approximately 60% of waste, with 33% being paper and cardboard, 12% glass, and 5% synthetic materials.
Group B Waste:
Waste that requires specific conditions for separation based on safety and infection risks within the hospital. This includes blood, waste contaminated with bodily fluids such as wound dressings, casts, contaminated clothing and disposable items, syringes, injection needles, and surgical blades. These sharp and pointed objects must be collected separately in specific containers. This group constitutes 30% of waste. Outside the hospital, this waste is treated as household waste along with Group A waste.
Group C Waste:
Waste that requires special conditions for separation both inside and outside the hospital based on safety and infection risks. This group includes waste that legally needs to be reported and handled properly. According to the German Waste Segregation Association, infectious waste is defined as waste that can transmit diseases to humans. For instance, magazines from an infectious patient are not considered infectious waste but can be classified as Group A waste. The danger of this group of waste is often overestimated, especially since it is difficult to determine how much infectious waste is unknowingly introduced into the environment, considering only 10% of patients are hospitalized. Group C waste constitutes approximately 3% of total waste.
Group D Waste:
Waste that requires special conditions for separation based on environmental health both inside and outside the hospital, especially waste that requires strict monitoring and control, such as waste from laboratories, chemical solvents like toluene, benzene, ethanol, and other chemicals, waste from X-ray departments, waste containing iron compounds, mineral oils, synthetic oils, batteries, and residual pesticides. Group D waste makes up about 7% of total waste.
Group E Waste:
Medical waste that is subject to ethical conditions for separation, including items such as body parts, blood bags, and blood clots. Experts state that only in Groups A and D is it feasible to assess how much can be reduced or recycled through proper use, while recycling in Groups B, C, and E is impossible.
The delay in timely separation of infectious waste has several reasons. One factor is the lack of training for service and relevant staff, nurses, and a shortage of skilled personnel for modern equipment and devices. Inappropriate waste collection methods in healthcare facilities and improper waste transportation methods also significantly contribute to the problem.
Additionally, the lack of specialized waste separation containers, insufficient waste transport trolleys, a shortage of safety equipment (masks, gloves, etc.), and the absence of specialized cold storage for waste with proper temperature and ventilation capabilities are other factors contributing to the delay in timely separation of infectious waste.
Discussion and Conclusion
Since hospitals are the primary generators of waste, they are responsible for the disposal and/or recycling of waste, which involves separately handling and managing waste. The various stages of medical waste management include segregation, packaging and labeling, collection, transportation, treatment, and disposal. The easiest way to identify different types of hospital waste is through the use of color-coded plastic bags.
The World Health Organization (WHO) recommends the following color codes for hospital waste:
- Infectious waste: red bag
- Other infectious pathological and anatomical waste: yellow bag
- Sharps: yellow or red bag
- Pharmaceutical and chemical waste: brown bag
- Non-hazardous hospital waste: black bags
– Hospital waste storage facilities should be impermeable, well-drained, washable, disinfectable, and equipped with a water supply. The storage should be accessible to staff but inaccessible to animals, insects, and birds.
– If there is no cold storage in the facility, the maximum storage time in temperate climates is 72 hours in winter and 48 hours in summer. In hot climates, it is 48 hours in cold seasons and a maximum of 24 hours in hot seasons.
– Anticancer waste must be stored separately from other hospital waste in dedicated storage facilities.
– Radioactive waste should be stored in impermeable containers according to national laws and properly labeled. All containers and packages should be labeled with information regarding the producer and the contents. This information can be written directly on the container or on a label affixed to it.
To develop a comprehensive hospital waste management plan, the hospital administration must form a waste management team and allocate adequate financial and human resources for the project. Additionally, four groups of hospital personnel should be trained: managers and decision-makers, doctors, nurses and nursing assistants, and cleaning staff. All individuals involved in waste collection, transportation, and disposal should receive training as well. Improper disposal of healthcare waste can pose significant risks to public health.
Proper disposal of healthcare waste is possible in both small rural clinics and large healthcare centers, provided that sufficient infrastructure is available. However, the amount of waste generated in large healthcare centers and public health facilities (such as immunization activities) has been particularly problematic, especially in developing countries where resources may be limited.
Disposal options for healthcare waste are also limited. If waste is not properly transported and disposed of centrally, it may pose significant risks to waste transport workers and others involved in waste management. In addition to the infectious dangers of such waste, exposure to toxic substances like dioxins and furans released from incineration can have long-term effects on the immune system, neurological development, endocrine system, and reproductive health at low exposure levels, and cause skin lesions and liver disorders at higher, short-term exposures.
The World Health Organization has set maximum acceptable levels for dioxin and furan exposure for the human body, but it has left the regulation of emissions from incinerators to individual countries. However, second-generation incinerators meet acceptable standards in this regard. Over the past decade, many countries have reduced the presence of these substances in the environment by implementing stricter standards for incinerator emissions.
While waste prevention is the highest priority in new waste and circular economy laws, recycling and resource recovery, whether in materials or energy, and waste disposal are secondary concerns. Each type of waste must be evaluated for its potential for recycling. Additionally, the method of waste segregation and whether the process is in operation or still in the planning stage must be documented in the waste management plan.
It is worth noting that a waste management economic plan has a five-year validity and can be reviewed by governmental agencies, especially as this plan now serves as a tool for institutional planning. It provides information on waste volume, segregation costs, and risks and weaknesses in waste management processes. The waste management plan is updated annually based on a waste balance report, which must be submitted to governmental agencies. According to experts, a comprehensive analysis is essential for creating an economic waste plan. Furthermore, the plan should consider waste type, volume, segregation and recycling methods, the safety of transport and recycling workers, and segregation costs. This information gives a detailed picture of various material categories and the volume of materials classified by these categories. Another critical aspect of the waste management economic plan is site and institutional inspections, providing insights into the rationale behind waste transportation practices and working conditions. Proper preparation of waste collection tools, such as large containers, and a precise timeline are also essential.
In conclusion, a waste management economic plan should not only meet legal requirements but also serve as a key planning tool for establishing a sound waste management rationale. Undoubtedly, creating a healthy city for all residents requires ensuring all factors that contribute to public health and hygiene are in place. Proper disposal of hospital waste plays a critical role in achieving this goal.
