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Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study
with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

HYGIENE AND BIOMEDICAL WASTE


MANAGEMENT PLAN FOR HEALTHCARE
ENVIRONMENTAL SETTING: A STUDY WITH
SPECIAL FOCUS ON KERALA, INDIA

Research report prepared for

Hygiene Standard Institute


by

SREEJITH A.

HSI-ASIA

Email: info@ internationalhygiene.org

www.internationalhygiene.org

Trivandrum

2008

© Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India.


Tel: +91-9447583751, Email:sreejiagriman@gmail.com
Suggested citation for future researches
Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study
with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

CONTENTS

LIST OF TABLES

LIST OF FIGURES

LIST OF APPENDICES

Chapter Title Page No.

1 INTRODUCTION

2 REVIEW OF RELATED LITERATURE

3 METHODOLOGY

4 RESULTS AND ANALYSIS

5 CONCLUSIONS AND SUGGESTIONS

BIBLIOGRAPHY

APPENDICES

ACKNOWLEDGEMENTS

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Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study
with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

LIST OF TABLES
Table No. Page
Title
No.

2.1 Colour coding and type of container for disposal

of biomedical wastes

2.2 Colour coding system – segregation

2.3 Categories of biomedical waste

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with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

LIST OF FIGURES

Figure Page
Title
No. No.
4.1 Male to Female Ratio of respondents
4.2 Distribution of different age group of respondents
4.3 Years of working of the respondents
4.4 Percentages of occurrences of accidents related to
clinical wastes
4.5 Distribution of scope of work of respondents
4.6 Awareness towards the definition of biomedical
waste
4.7 Awareness towards the handling of accidents related
to biomedical waste
4.8 Response to the adherence of management to
standard procedures
4.9 Awareness of the risk exposed to the respondents
themselves
4.10 Awareness of the risk exposed to others
4.11 Familiarity of the respondents towards the
management plan
4.12 Ability of the respondents to identify types of
biomedical wastes
4.13 Ability of respondents to segregate, contain and label
the biomedical waste
4.14 Awareness of the respondents towards the storage
facility
4.15 Awareness of the respondents to record keeping
4.16 Awareness of the effects of clinical wastes to the
environment

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LIST OF APPENDICES

Appendix No. Title

I Survey form

II Questionnaire form

III Photographs

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Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with
Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

ABSTRACT

Issues of improving the management of biomedical wastes are receiving

increasing attention throughout the world since healthcare institutions

generate tons of biomedical waste each year. The waste generated has

been increasing due to the use of disposable materials and development in

medicine production. Hazardous and Toxic Materials (HTM) Office Board

of Public Works, Los Angles (1995) estimated that around 15 percent of

hospital waste is contaminated with infectious agents potentially

hazardous to human health such as hepatitis and human

immunodeficiency virus (HIV) and to the environment. As these changes

have been gradual and waste disposal was not previously perceived as a

major concern, the response of the hospital field has been largely

piecemeal and uncoordinated. Not only solid waste is considered as a

major problem in many developing countries but other wastes such as

wastewater and air pollution are also becoming serious problems. Due to

the lack of investment and infrastructure, in some cases, wastewater

discharged from hospitals often runs directly into nearby water bodies.

Improperly discharged wastes to sewers will generate wastewater

potentially dangerous to handlers. Moreover, most hospital incinerators

were never designed for the disposal of large quantities of waste and

consequently have become overloaded, causing air pollution in

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Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with
Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

surrounding areas. Poor waste management practices pose a huge risk to

the health of the public, patients, professionals and contribute to

environmental degradation

In the present study an attempt is made to determine awareness about

Biomedical waste management policy, practices and to assess attitude

towards it and to develop a Hygiene & Biomedical Waste Management

Plan for Healthcare Environmental Setting with special focus to Kerala

State in the Indian union.

Review of the literature and studies which are related to the topic under

study was done on studies related to the problems specific to the impaired

healthcare waste management as well as studies related to hygiene and

biomedical waste management in healthcare environmental setting.

The method adopted for the present study was survey method. The data

collection was done through survey form, questionnaire, informal

interviews and site visits by the investigator. The collected data were

statistically analysed.

From the analysis of the collected data, it was found that the management

components are well in place. However there are some fields that need

attention such as record keeping. The awareness towards the effects of

biomedical wastes on environment if improperly handled is strong.

During the site visits, photo documentation was done on various aspects

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Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with
Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

of biomedical waste management methods followed by healthcare

institutions. These photographs revealed that unscientific biomedical

waste management techniques are followed at various levels of

segregation, treatment, transport and disposal. The present study

developed a hygiene and biomedical management plan for effective

infection control as well as for proper record maintenance of hospitals in

Kerala.

The study concludes that the biomedical waste management practices

followed in majority of healthcare institutions in Kerala is unscientific.

However, there are a smaller minority of healthcare institutions which

practice the most sound biomedical waste management methods. Training

and awareness programmes are lacking in many of the cases which needs

to be looked into. A further study on this topic is suggested on the

incineration and the air pollution control measures to avoid the

contamination from the incinerator from being exposed to the

environment. A study on the awareness of the public towards the

biomedical waste management also can be carried out. The awareness

level may vary from person to person depending on the education

background. Further study can be carried out to compare the management

system of a government hospital and private hospital.

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Chapter 1

INTRODUCTION

1.1 INTRODUCTION

Over the years there have been tremendous advancements in the

health care system. However it is ironic that the health care settings,

which restore and maintain community health, are also threatening

their well-being. Poor waste management practices pose a huge risk to

the health of the public, patients, professionals and contribute to

environmental degradation (Joseph and Krishnan 2004). It is reported

that for the first time the Biomedical waste management issue was

discussed at a meeting convened by the World Health Organisation

regional office for Europe at Bergen, Norway in 1983. The seriousness

of the issue was brought to limelight during the “beach wash- ups” of

summer 1988. Investigation carried out by the Environment Protection

Agency (EPA) of USA in this regard culminated in the passing of

Medical Waste Tracking Act (MWTA), November 1988. With the

passage of time the problem has evolved as a global humanitarian

issue. In our country, this issue has attracted the attention of the

Honourable Supreme Court of India and guidelines has been issued

.The Biomedical waste (Management and handling) Rules 1998 lay

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with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

down clear methods for disposal of biomedical waste, defined as “any

waste generated during the diagnosis, treatment or immunisation of

human beings or animals or in research activities used in the

production or testing of biologicals.” Pollution control boards of every

state have been given the task of authorising and implementing the

rules.

Issues of improving the management of hospital wastes are receiving

increasing attention throughout the world since hospitals generate tons

of medical waste each year. The waste generated has been increasing

due to the use of disposable materials and development in medicine

production. Hazardous and Toxic Materials (HTM) Office Board of

Public Works, Los Angles (1995) estimated that around 15 percent of

hospital waste is contaminated with infectious agents potentially

hazardous to human health such as hepatitis and human

immunodeficiency virus (HIV) and to the environment. As these

changes have been gradual and waste disposal was not previously

perceived as a major concern, the response of the hospital field has

been largely piecemeal and uncoordinated (Wangsaatmaja S., 1997).

Not only solid waste is considered as a major problem in many

developing countries but other wastes such as wastewater and air

pollution are also becoming serious problems. Due to the lack of

10

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Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study
with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

investment and infrastructure, in some cases, wastewater discharged

from hospitals often runs directly into nearby water bodies (Nelson et

al., 1993). Improperly discharged wastes to sewers will generate

wastewater potentially dangerous to handlers. Moreover, most

hospital incinerators were never designed for the disposal of large

quantities of waste and consequently have become overloaded, causing

air pollution in surrounding areas.

In the present study an attempt is made to determine awareness about

Biomedical waste management policy, practices and to assess attitude

towards it and to develop a Hygiene & Biomedical Waste Management

Plan for Healthcare Environmental Setting with special focus to Kerala

State in the Indian union.

1.2 NEED AND SIGNIFICANCE

Treatment and disposal of biomedical wastes generated from hospitals

should be done as per the Biomedical Waste (Management and

Handling) Rules, 1998. It is the responsibility of waste generator to

treat and dispose of the biomedical waste. Whereas local governments

have to assist the hospitals, if they come forward for establishment of a

Common Treatment Facility, by identifying suitable land, it is the

responsibility of the local bodies to treat and dispose the non

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biomedical waste (general waste) and treated biomedical waste

generated in the healthcare institutions. The Kerala State Pollution

Control Board (PCB) is the prescribed authority to implement

Biomedical Waste (Management and Handling) Rules in the state.

As per 1991 Census, Kerala has the highest number of hospitals (26%)

in India. The Report on Private Medical Institutions in Kerala

published by the Department of Economics and Statistics (1995) shows

that there are about 12618 private medical institutions for all systems of

medicines combined and it is roughly estimated that the solid and

liquid waste generation per hospital bed is 1.3 to 2.0 kg and 450 litres

respectively. About 85% waste generated in hospitals is general waste

and can be handled as other solid wastes. The remaining 15%

constitutes infectious and toxic wastes. More often than not, the

general wastes in hospitals and biomedical wastes are allowed to mix

thereby rendering the general waste also toxic and hazardous.

(Economic Review, Kerala, 2004).

1.2.1 Current Issues in Management of Health Care Waste

There are two main issues at present:

• The 1998 legislation by the Govt. of India and

• Implementation of the same at individual healthcare

establishment level as well as whole town / city level.

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The legislation has fulfilled a long standing necessity. Now this sector

has got clear cut guidelines which should be able to initiate a uniform

standard of practice through out the country. It would be necessary to

implement proper biomedical waste management system for each and

every hospital, nursing home, pathological laboratory etc.

Comprehensive management system for each and every health care

establishment has to be planned for optimal techno-economic viability.

At the same time the final disposal for the whole town must not be lost

sight of. Since there are a large number of small and medium health

care establishments, common treatment and disposal facilities are

essential.

1.2.2 Legal Aspects and Environmental Concern

Indiscriminate disposal of infected and hazardous waste from

hospitals, nursing homes and pathological laboratories has led to

significant degradation of the environment, leading to spread of

diseases and putting the people to great risk from certain highly

contagious and transmission prone disease vectors. This has given rise

to considerable environmental concern.

The first standard on the subject to be brought out in India was by the

Bureau of Indian Standards (BIS), IS 12625 : 1989, entitled ‘Solid

Wastes-Hospitals-Guidelines for Management’ but it was unable to

13

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bring any improvement in the situation. In this scenario, the present

study assumes great significance.

1.2.3 Biomedical Waste (Management and Handling) Rules, 1998

The Central Govt. has notified these rules on 20th July, 1998 in exercise

of section 6, 8 and 25 of the Environment (Protection) Act, 1986. Prior

to that, the draft rules were gazetted on 16th October, 1997 and Public

suggestion/comments were invited within 60 days. These suggestions

were considered before finalising the rules.

1.2.4 Scope and application of the Rules

These rules apply to all those who generate, collect, receive, store,

transport, treat, dispose or handle biomedical waste in any form.

According to these rules, it shall be the duty of every occupier of an

institution generating biomedical waste, which includes hospitals,

nursing homes, clinics, dispensaries, veterinary institution, animal

houses, pathology laboratories, blood banks etc., to take all steps to

ensure that such wastes are handled without any adverse effect to

human health and the environment. They have to either set up their

own facility within the time frame or ensure requisite treatment at a

common waste treatment facility or any other waste treatment facility.

Every occupier of an institution, which is generating, collecting,

receiving, storing, transporting, treating, disposing and/or handling

14

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biomedical waste in any other manner, except such occupier of clinics,

dispensaries, pathological laboratories, blood banks etc., which provide

treatment/service to less than 1000 (one thousand) patients per month

shall make an application in prescribed form to the prescribed

authority for grant of authorisation to carry on the work. Whenever an

accident occurs concerning biomedical waste, it has to be reported to

this authority. Each State and Union Territory (UT) Government shall

be required to establish a prescribed authority for this purpose. The

respective governments would also constitute advisory committees to

advise the Governments with respect to implementation of these rules.

The occupier or operator can also appeal against any order of the

authority if they feel aggrieved to such other authority as the Govt. of

the State/UT may think fit to constitute.

1.2.5 Environmental Concern

The following are the main environmental concerns with respect to

improper disposal of biomedical waste management:

• Spread of infection and disease through vectors (fly,

mosquito, insects etc.) which affect the in -house as well as

surrounding population.

15

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with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

• Spread of infection through contact/injury among

medical/non-medical personnel and sweepers/rag pickers,

especially from the sharps (needles, blades etc.).

• Spread of infection through unauthorised recycling of

disposable items such as hypodermic needles, tubes, blades,

bottles etc.

• Reaction due to use of discarded medicines.

• Toxic emissions from defective/inefficient incinerators.

• Indiscriminate disposal of incinerator ash / residues.

1.2.6 Healthcare Associated Infection

According to Wenzel R.P. (1997), management of health-care waste is

an integral part of hospital hygiene and infection control. Health-care

waste should be considered as a reservoir of pathogenic

microorganisms, which can cause contamination and give rise to

infection. If waste is inadequately managed, these microorganisms can

be transmitted by direct contact, in the air, or by a variety of vectors.

Infectious waste contributes in this way to the risk of nosocomial

infections, putting the health of hospital personnel and patients, at risk.

Healthcare associated infections (HCAIs) are preventable. As per the

findings of Hygiene Standard Institute (2007) improved compliance to

hygiene has been shown to reduce the number of infection outbreaks in

16

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health care facilities, transmission of antimicrobial resistant organisms

(e.g. Methicillin-resistant Staphylococcus aureus (MRSA)) and overall

infection rates. Despite evidence of the benefit of hygiene, health care

workers’ compliance with good hand hygiene remains universally low-

40 percent to 50 percent (Hygiene Standard Institute, 2007). Reasons for

low compliance rates are complex and can be attributed to the

existence of numerous individual, work group and institutional

barriers, which makes it difficult to enhance and sustain compliance.

As a result of these barriers, few projects have demonstrated sustained

improvement in compliance with hand hygiene guidelines and a

reduction in HCAIs rates.

1.3 STATEMENT OF THE PROBLEM

The study is entitled ‘HYGIENE AND BIOMEDICAL WASTE

MANAGEMENT PLAN FOR HEALTHCARE ENVIRONMENTAL

SETTING: A STUDY WITH SPECIAL FOCUS ON KERALA, INDIA’.

1.4 DEFINITION OF KEY TERMS

‘Hygiene’ can generally refer to a whole range of measures, which

protect health and well-being and improve the quality of life. Hygiene

refers to practices associated with ensuring good health and

cleanliness. In broader, scientific terms hygiene is the maintenance of

health and healthy living. Hygiene ranges from personal hygiene,

17

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through domestic up to occupational hygiene and public health

(Hygiene Standard Institute, 2007).

‘Biomedical waste’ means any solid and/or liquid waste including its

container and any intermediate product, which is generated during the

diagnosis, treatment or immunisation of human beings or animals or in

research pertaining thereto or in the production or testing thereof.

(Biomedical Waste (Management and Handling) Rules, 1998).

1.5 HYPOTHESES

1. Only a very few healthcare personnel have proper awareness

regarding Biomedical waste management policy and practices.

2. Healthcare personnel will show positive attitude towards

biomedical waste management policy and practices.

3. The development and implementation of a Hygiene &

Biomedical Waste Management Plan for Healthcare

Environmental Setting will reduce the rate of spread of

healthcare associated infections.

1.6 OBJECTIVES

1. To determine the awareness of healthcare personnel regarding

Biomedical waste management policy and practices.

2. To assess attitude towards biomedical waste management

policy and practices.

18

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3. To develop a Hygiene & Biomedical Waste Management Plan

for Healthcare Environmental Setting with special focus to

Kerala State in the Indian union.

1.7 METHODOLOGY IN BRIEF

An anonymous survey form and questionnaire (Appendix I and II)

were developed after literature search and review. The survey form

and questionnaire were designed to suite six categories of personnel

associated with health care settings, i.e Doctors, House surgeons,

Students (Final year), Nurses, Paramedical and Auxiliary Staff. Pilot

survey was carried out by distributing the survey form and

questionnaire to fifty personnel from all the six categories. Validity and

reliability were ascertained.

The period of study was from August 2007 to February 2008. The pre-

tested anonymous survey form and questionnaire were distributed to

personnel from all the above six categories in Kerala. Informal

consultations with healthcare personnel were also done. Health care

settings covered included Medical college hospitals, Dental college

hospitals, General hospitals, Private hospitals, Community health

centres, Primary health centres, Laboratories, Dental clinics and

Veterinary hospital. The respondents were asked to indicate their

views on biomedical waste management policy, practices and their

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attitude related to the issue. Opportunity was also given to give details

regarding certain questions asked.

To document biomedical waste management practices, photographs

were taken. All data management and analysis were carried out using

Microsoft Excel.

1.7.1 Method adopted

The normative survey method was adopted for the study, as it was

found to be the most appropriate method for collecting data.

1.7.2 Sample selected for the study

For the present study, a representative sample from 20 healthcare

institutions of Kerala state was selected. The sample size was 488

which included 198 males and 290 females. The mean age of the

sample was 35. Health care settings covered included one medical

college hospital, one dental college hospital, two private hospitals, two

community health centers, three primary health centers, five

laboratories, five dental clinics and a veterinary hospital.

1.7.3 Tools used for the study

The data for the present study were collected using the Survey form

and Questionnaire on hygiene and biomedical waste management

prepared by the investigator.

1.7.4 Statistical technique used for the study

20

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The statistical technique used for the analysis of the collected data was

Estimation of simple percentage.

1.8 SCOPE OF THE STUDY

The present study attempts to determine awareness of healthcare

personnel towards Biomedical waste management policy and practices

and to assess their attitude towards it. The study also tries to develop a

Hygiene & Biomedical Waste Management Plan for Healthcare

Environmental Setting with special focus to Kerala. A representative

sample of 488 healthcare personnel from 20 healthcare institutions of

Kerala state was selected for the study. The study will be useful in

assessing the awareness level and attitude of healthcare personnel

towards biomedical waste management policy and practices and in

providing training programmes for improving the same. The study

will also help in developing a Hygiene and biomedical waste

management plan which in turn will help in reducing the spread of

healthcare associated infections.

1.9 LIMITATIONS OF THE STUDY

Despite the efforts made by the investigator to make the study as

precise and objective as possible, certain limitations have crept into the

study and the investigator was able to identify them.

21

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with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

1. The study was conducted on a sample selected from healthcare

institutions of three districts of Kerala viz.,

Thiruvananthapuram, Idukki and Kozhikode. Extending the

study to other districts in Kerala was not possible due to the

limited time at the disposal of the investigator. More generalised

results would have been obtained from the study if a large

sample from more districts was used.

2. The study concentrated on issues related to biomedical waste

management only. The study can be further expanded by

focusing on issues related to Hygiene, Environment, Sanitation,

Safety and Health.

1.10 FORMAT OF THE REPORT

The study is reported in five chapters, the following being the details.

Chapter 1: INTRODUCTION

This chapter contains all the relevant sectors and details

pertinent to the area under investigation.

Chapter 2: REVIEW OF RELATED LITERATURE

Presents the review of related literature and studies

pertaining to the study undertaken.

22

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Chapter 3: METHODOLOGY

Gives a detailed description of the method adopted for the

study, tools used for the study, the sample taken,

administration of the tools and an account of the statistical

techniques used for analysing the data obtained from the

study.

Chapter 4: RESULTS AND ANALYSIS

Concerned with the analysis of the data followed by the

results of the study.

Chapter 5: CONCLUSIONS AND SUGGESTIONS

Summarises the study in retrospect. The important findings

and a few recommendations for further research are

presented.

The report is followed by Bibliography and Appendices pertaining to

the study.

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BIBLIOGRAPHY

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a proper clinical waste management system. Waste Management

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2. Barr, D. (1960). Encyclopaedia of Educational Research. New York:


Mac Millan Company.

3. Bdour, B. Altrabsheh, Hadadin, N. and Al-Shareif, M. (2006).

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24

© Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India.


Tel: +91-9447583751, Email:sreejiagriman@gmail.com
Suggested citation for future researches
Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study
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25

© Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India.


Tel: +91-9447583751, Email:sreejiagriman@gmail.com
Suggested citation for future researches
Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study
with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

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26

© Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India.


Tel: +91-9447583751, Email:sreejiagriman@gmail.com
Suggested citation for future researches
Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study
with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

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27

© Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India.


Tel: +91-9447583751, Email:sreejiagriman@gmail.com