ASSESSMENT OF MEDICAL WASTE MANAGEMENT PRACTICES IN AHMADU BELLO UNIVERSITY TEACHING HOSPITAL AND AHMADU BELLO UNIVERSITY HEALTH SERVICES, ZARIA, NIGERIA

ABSTRACT

Healthcare services are aimed at improving wellbeing and preventing potential human health risks and environmental hazards. In the process, however, wastes that are potentially harmful are generated. Poor management of these healthcare wastes (HCW) exposes the health workers, patients, waste handlers and the general public to health risks. Thus, this study focussed on the assessment of HCW management practices at Ahmadu Bello University Teaching Hospital (ABUTH) Zaria and Ahmadu Bello University Health Service (ABUHS) A.B.U. Zaria. The study utilised two sets of questionnaire to capture HCW management practices including collection, segregation, storage, disposal and treatment. One of the set of questionnaire was administered to all the waste handlers while the second set of questionnaire was administered to all the heads of waste management units in each of the hospitals. While the former was used for identifying the HCW management practices in the two hospitals, the latter was used for assessing the effectiveness of HCW management practices in the hospitals in accordance with Townend and Cheeseman (2005) guidelines. The study established the total quantities of HCW generated at ABUTH and ABUHS as 845kg and 77kg per day respectively; which translates to 1.18kg and 1.54kg per day per bed at ABUTH and ABUHS respectively. The study revealed availability of operational staff specifically responsible for medical waste management and personal protective equipment for use by medical waste handlers in both ABUTH and ABUHS. The study further revealed availability of receptacles, storage containers, dumpsites and separation of collection of sharps or infectious materials at both ABUTH and ABUHS. The study, however, also established absence of colour coding, central purpose-built storage facility, recycling on healthcare waste management in both ABUTH and ABUHS. It was concluded that both the ABUTH and ABUHS are classified as Level 2 hospitals based on their operational performance in accordance with the Townend and Cheeseman (2005) guidelines, which implies that some aspects are considered sustainable while some other aspects considered unsustainable. The study recommended more sustainable practices in the management of HCW. Given the importance of effective healthcare waste management practices and the current unsustainable level of performance, the study recommended further study on the effects of the healthcare wastes from the two hospitals on the environment (soil, water and air). Williams

CHAPTER ONE

INTRODUCTION

1.1: BACKGROUND TO THE STUDY

Encarta (2007) defines waste as unwanted or unusable items, remains, by-products or household garbage. Sinnot (1999) argues that waste arises mainly as by-products or unused reactants from the process, or as off-specification product produced through mis-operation. There is a wide variation in volume and diversity of wastes from domestic, commercial, industrial and institutional land use types. In particular, institutional land uses such as hospitals lead to the production of potentially toxic, infectious and hazardous wastes as a result of the demand for health-care activities. Despite problems arising from these unwanted wastes, a civilized society cannot do without a healthcare system because it is a basic requirement for human kind (Nemathaga, Maringa and Chinuka,2008). Undoubtedly, medical establishments play important roles in different activities by the use of modern technology to restore and maintain community health. Medical establishments include hospitals, clinics, medical centres, home health care, blood banks, veterinary offices, clinical facilities, research laboratories, clinical laboratories, and all unlicensed and licensed medical facilities(Labib, Hussein, El-Shall, Zakaria and Mohamed, 2005).

The World Health Organization (WHO) (2002) defines hospital solid waste as “any solid waste that is generated in the diagnosis, treatment, or immunization of human beings or animals, in research pertaining thereto, or testing of biological, including but not limited to soiled or blood-soaked bandages, culture dishes and other glassware”. Hospital solid wastes also include discarded surgical gloves and instruments, needles, lacents, cultures, stocks and swabs used to inoculate cultures and remove body organs(Abdel-Salam, 2010).United States Environmental Protection Agency (USEPA, 1989) refers to hospital wastes as all biological or non-biological wastes that are discarded and not intended for further use and these include pathological, infectious, hazardous chemicals, radioactive wastes, stock cultures, blood and blood products, animal carcasses, pharmaceutical wastes, pressurized containers, batteries, plastics, low-level radioactive wastes, disposable needles, syringes, scalpels and other sharp items. Others include food service, cleaning and miscellaneous wastes (Oyeleke and Istifanus, 2009), toxic chemicals, cyto-toxic drugs, flammable and radioactive wastes that can often be considered infectious (Caltivelli, 1990).

Globally, wastes generated from hospitals are now recognized as serious problems that have detrimental effects on the environment and/or human beings through direct or indirect contact. Exposure to hazardous healthcare waste can result in disease or injury (WHO, 1999). Diseases like typhoid, cholera, acquired immunodeficiency syndrome   (AIDS), and viral hepatitis B can be transmitted through the  mismanagement of hazardous hospital waste (Mato and Kassenga, 1997). It has been estimated that each year, there are about 8 to 16 million new cases of Hepatitis B virus (HBV), 2.3 to 4.7 million cases of Hepatitis C virus (HCV) and 80,000 to 160,000 cases of Human Immune-deficiency Virus (HIV) due to unsafe injections and mostly due to very poor waste management systems (WHO, 1999; Townend and Cheeseman, 2005). Environmental nuisance may also arise due to foul odour, flies, cockroaches, rodents, and vermin as well as contamination of underground water by untreated medical waste in landfills (Nemathaga et al., 2008).

In most countries of the world, sound management of healthcare waste has become one of the most crucial issue confronting hospitals and the society at large. Public concern and awareness on this issue are increasing via the media, conferences, strategic meetings, debates and it is a subject of several studies such as Nemathaga et al. (2008), Ajimotokan and Aremu (2009) and Abah and Ohimain (2011). Advocates of environmental protection have drawn the attention of the national policymakers to the health hazards and potential danger to natural resources caused by inadequate management of wastes (Federal Environmental Protection Agency, 1991).HCW must be properly managed in a way that minimizes risk to human health and reduced negative impact on the environment. Just as a Botanist regards a weed as a plant in a wrong place so also waste is a resource in a wrong place (Ogedengbe, 2002). Ogedengbe (2002) further argued that HCW is a resource which ifadequately managed can serve as manure for farming via composting the “biodegradable” aswell as raw materials for some factories and industries through material recovery and recycling(reuse) of the “non-biodegradable”.

As primitive as open dump method of solid wastes disposal is, Johanessen and Boyer (1999) observed that it remains the predominant means in developing countries. Rushbrook and Pugh (1999) considered the open dump method of solid waste disposal as both“naïve and dangerous” because of the leaching effects of chemicals and biological contaminantsin the wastes, which constitutes a direct route for transmission of communicable diseases.Although, incineration is not an unclean process of disposing wastes, it is still the mosteffective method of treating HCW because it involves the application of combustion processunder controlled condition at high temperature, converting wastes containing stocks ofinfectious agents and pathological materials to inert mineral residues and gases (Omotoso, Faluyi and Iyanda, 2007).However, incineration is regarded as the most expensive waste management option because itrequires capital intensive plant, highly skilled personnel and careful maintenance (Onipede and Bolaji, 2004) and it maylead to the production of dioxins, furans or other toxic pollutants as emissions and residues. Improper HCW disposal method like open air burning, land filling, dumping into water bodies is common in developing countries, constitutes environmental threats, increased vulnerability for potential transmission of communicable diseases and natural disasters.

In developing countries like Nigeria, where many health concerns are competing for limited resources, it is not surprising that the management of healthcare wastes has received less attention and the priority it deserves. Although reliable records of the quantity and nature of healthcare wastes and the management techniques to adequately dispose of these wastes has remained a challenge in many developing countries of the world, it is believed that several hundreds of tons of healthcare waste are deposited openly in waste dumps and surrounding environments, often alongside with non-hazardous solid wastes (Abah and Ohimain, 2010). Unfortunately, practical information on this important aspect of healthcare management is inadequate and research on the public health implications of inadequate management of healthcare wastes are few and limited in scope. In addition, a near total absence of institutional arrangements for HCW in Nigeria has been reported by others (Coker, Sangodoyin and Ogunlowo, 1998).

1.2: STATEMENT OF THE RESEARCH PROBLEM

The sustainable management of Healthcare Waste (HCW) has continued to generate increasing public interest due to the health problems associated with exposure of human beings to potentially hazardous wastes arising from healthcare (Ferreira, 2003; Da Silva, Hoppe, Ravanello and Mello, 2005; Tudor, Noonan and Jenkin, 2005). Whilst hospitals and healthcare units are supposed to safeguard the health of the community, the mismanagement of HCW poses health risks to people and the environment by contaminating the air, soil and water resources. Presently, considerable gap exist with regards to the assessment of healthcare waste management practices particularly in Nigeria and in several other countries in sub-Saharan Africa.

HCW are a special category of waste because they often contain materials that may be harmful and can cause ill health to those exposed to it. A number of studies have indicated that the inappropriate handling and disposal of healthcare wastes pose health risks to health workers who may be directly exposed and to people near health facilities, particularly children and scavengers who may become exposed to infectious wastes and a higher risk of diseases like hepatitis and HIV/AIDS (WHO, 1999; 2002; Oke, 2008; Coker, 2009; PATH, 2009; Adegbite, Nwafor, Afon, Abegunde and Bamise, 2010).

The nature and quantity of healthcare waste generated as well as institutional practices with regards tosustainable methods of healthcare waste management, including waste segregation and waste recycling are often poorly examined and documented in several countries of the world despite the health risks posed bythe improper handling of HCW (Oke, 2008; Farzadika, Moradi and Mohammadi, 2009). It is also of serious concern that the level of awareness, particularly of health workers, regarding healthcare waste has not been adequately documented.

Studies on Hospital solid waste have been carried out by different researchers. (Longe and Williams, 2006) surveyed medical waste management practices and their implications to health and environment in metropolitan Lagos. The study assessed management practices in four hospitals ranging in capacity from 40 to 600 beds. The study established average generation rate of medical waste of 0.562kg/bed/day to 0.670kg/bed/day; with infectious waste accounting for between 26 to 37% of the total volume. Only two of the hospitals investigated carried out treatment of their infectious and sharp waste types by incineration before final disposal.

Nemathaga et al. (2008) studiedhospital solid waste management practice in Limpopo provinceof South Africa. The author looked at the issues and current short comings faced by many hospitals in the province. According to the study, a major policy implementation gap was identified between the national government and the hospitals. Although modern practices such as landfills and incinerators were reported to be used, daily operations were not carried out in accordance with these minimum standards. The authors also noted that there was no proper separation of waste according to the classification demanded by the national government.

Ajimotokan and Aremu (2009), in a study titled “case study evaluation of health-care waste challenges in Hospitals within Ilorin metropolis”, found out that about 177.67Kg of waste was generated daily and the average waste generated perbed/per day was 1.56Kg. They further reported that the management of the waste was often poor, with a mixture of potentially infectious and non-infectious waste being a common sight in the hospital waste bins and hospital environment.

Abah and Ohimain(2011), in the study entitled “health care waste management in Nigeria”, focused on the estimation of the quantity,evaluation of the waste segregation practice and determination of the knowledge of health care workers regarding healthcare waste management. The findings revealed that the average amount of health care waste was 0.62Kg/person/day at the out patients ward and that the proportions of respondents who had received specific training in the management of healthcare waste was 11.5% (6/52). The number who understood the importance of HCW management in the provision of safety to the public was 46% (24/52).

Toyobo, Baba and Oyeniyi (2012) appraised the medical waste characteristics and management practices in University College Hospital (UCH), Ibadan and Obafemi Awolowo Teaching Hospital Ile-Ife in Nigeria. The authors examined characteristic of waste generation, identified waste disposal methods, assessed waste management practices, and highlighted possible suggestions towards a healthy environment for patients for the case studies. The study revealed improper waste management handling and open dump disposal methods in the two hospitals. The study subsequently recommended proper trainings and workshops should be conducted to make the resident doctors and waste management teams in the hospitals aware of the issues and practices of hospital waste management. Beside this, the study recommended that the regulation of audit process in this life sensitive issue should be maintained. Studies on healthcare wastes have not been adequately undertaken and reported in the present study area. It is not clear at this point in time what the nature of HCW is, how much is being generated and how they are managed in the study area. Besides, existing literature (Nemathaga et al., 2008; Uwa, 2008; Toyobo et al., 2012) indicates that there appears to be much difference in the way and manner wastes generated in various healthcare institutions are managed in Nigeria and hence, the necessity for this research designed to compare Ahmadu Bello University Teaching Hospital (ABUTH) and Ahmadu Bello University Health Service (ABUHS) because of the potential high risk to the health of the vast number of people who are mainly students, staff, visitors and the communities at large.

The research questions that were addressed by this study have been summarized below:

1. What is the nature of the health care waste generated in Ahmadu Bello University Teaching hospital (ABUTH) and Ahmadu Bello University Health Service (ABUHS)?
2. What is the quantity of HCW generated in the two hospitals?
3. What are the methods of waste collection and disposal in the two hospitals?
4. How effective are the HCW management practices in the two hospitals?
5. Where are the dumpsites of the two hospitals located?

1.3: AIM AND OBJECTIVES OF THE STUDY

The aim of the study is to assess the medical waste management practices in Ahmadu Bello University Teaching Hospital (ABUTH) Zaria and Ahmadu Bello University Health Service (ABUHS) A.B.U. Zaria. The specific objectives of the study are to:

1. characterize the nature of the Healthcare Waste (HCW) generated in the two hospitals;
2. determine the quantity of HCW generated in the hospitals;
3. examine methods of HCW collection and disposal in the hospitals
4. identify and map out the waste dumpsites of the two hospitals; and
5. assess the effectiveness of HCW management practices in the hospitals.

1.4: SCOPE OF THE STUDY

This study covered two hospitals, namely: Ahmadu Bello University Teaching Hospital (ABUTH) in Shika (Giwa Local Government Area of Kaduna State)and Ahmadu Bello University Health Services (ABUHS) in Samaru campus, Zaria (Sabon-Gari Local Government Area of Kaduna State. The ABUTH was primarily established for training medical students at undergraduate and postgraduate levels but it also provide healthcare services to the people within its catchment area at primary, secondary and tertiary levels. The ABUHS was primarily established for providing healthcare service to students, staff and the immediate community. The ABUHS offers both primary and secondary healthcare services and enjoys referral collaboration relationship with the ABUTH. Both hospitals are accredited by the National Health Insurance Scheme and serve the healthcare needs of their catchment areas. Each of the hospitals is made up of departments/units and wards with both skilled and unskilled medical personnel. Wastes are generated from every segment of the hospitals which needs proper management. The study focused on the waste management practices in the two hospitals with reference to general management strategy, waste collection and segregation, waste recycling, waste storage, waste treatment and offsite disposal. On the temporal dimension, the study focused on current practices in both hospitals to enable the provision of solution to contemporary problem.

1.5: SIGNIFICANCE OF THE STUDY

The concern regarding medical waste is mainly due to the presence of pathogenic organisms and organic substances in hospital solid wastes in significantly high concentrations. The substantial number of organisms of human origin in solid waste suggests the presence of virulent strains of viruses and pathogenic bacteria in undetected numbers. Improper handling of solid waste in the hospital may increase the airborne pathogenic bacteria, which could adversely affect the hospital environment and community at large. Improper medical management has serious impact on human environment. Apart from risk of water, air and soil pollution, it has considerable impact on human health due to aesthetic effects (Slack, Gronow and Voulvoulis, 2004). The safe disposal and subsequent destruction of medical waste therefore, is a key step to the reduction of illnesses or injuries through contact with this potentially hazardous material, and in the prevention of environmental contamination. It is hoped that this study will provide a practicable hospital waste management approach that will be beneficial to the government and will reduce the negative impacts on the environment and communities within the neighbourhood of the waste dump sites of the selected hospitals.

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