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World Review of Science, Technology and Sust. Development, Vol. 8, Nos. 2/3/4, 2011

An assessment of medical waste management in health institutions in Yenagoa, South-South, Nigeria George Nwabuko Chima
Department of Geography and Planning, Abia State University, Uturu, Abia State, PMB 2000, Nigeria E-mail: geochima@yahoo.com

Ifeanyichukwu Clinton Ezekwe*


Department of Geography and Environmental Management, Niger Delta University, Nigeria E-mail: clidnelson@yahoo.com *Corresponding author

Nicholas Opaminola Digha


Department of Geography, University of Calabar, Calabar, Nigeria E-mail: opaminoladigha@yahoo.com
Abstract: This study focuses on waste management practices of health institutions in Yenegoa, Nigeria, where rapid urbanisation; poor infrastructure and risk awareness has created a major waste management challenge. Sixty percent of health institutions in the city were studied and it was revealed that standard practice is not followed in the handling and management of biomedical wastes. About 2,000,000 kg of bio-medical waste is generated annually with infectious wastes and sharp items constituting nearly 19%. These wastes are disposed in public waste bins along streets and often dumped in open and unlined landfills. Public health education, stricter legislation and closer supervision of health service providers and training of more biomedical waste experts are recommended. Keywords: biomedical waste management; healthcare institutions; Nigeria. Reference to this paper should be made as follows: Chima, G.N., Ezekwe, I.C. and Digha, N.O. (2011) An assessment of medical waste management in health institutions in Yenagoa, South-South, Nigeria, World Review of Science, Technology and Sustainable Development, Vol. 8, Nos. 2/3/4, pp.224233. Biographical notes: George Nwabuko Chima has been an Associate Professor of Geography at the Abia State University, Uturu Nigeria since 2008 and specialises in hydrology and water resources management.

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An assessment of medical waste management in health institutions


Ifeanyichukwu Clinton Ezekwe obtained a PhD in Geography and Planning from the Abia State University Uturu in 2009 and currently lectures in the Department of Geography and Environmental Management of the Niger Delta University, Wilberforce Island Nigeria. Nicholas Opaminola Digha is a PhD student at the Abia State University Uturu and a Lecturer in the Department of Geography, University of Calabar Nigeria.

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Introduction

Human and animal activities generate by-products, many of which are discarded as useless or unwanted. These wastes could be solid, liquid or gaseous. Solid waste management constitutes one of the most urgent and important environmental problems facing environmentalists in Nigeria. There are many types of solid wastes generated from several sources. According to Ajadike (2003), the types and sources of solid wastes could be the basis for classification and categorisation. Wastes can, therefore, be classified as domestic or industrial, clinical/hospital, agricultural, mining, etc. The type of waste that originates from hospitals, clinics and laboratories is known as hospital, clinical, biomedical or medical wastes (Ajadike, 2001, 2003; Bhatia, 2005; Santra, 2006). It is ironical that hospitals and other health establishments, which provide succour to the sick and function to reduce pain and postpone death, can also create and indiscriminately dispose waste, which indeed become sources of threat to life and well-being (Bhatia, 2005; Santra, 2006; Hassan et al., 2008). Medical or biomedical waste owing to its content of hazardous substances poses serious threats to environmental health (Klangsin and Harding, 1998; Ray et al., 2005) and constitutes a continuous source of health threat to health technicians, sweepers, hospital visitors, patients and the unsuspecting general public. This is due to arbitrary management of wastes from the health institutions (Massrouje, 2001; Becher and Lichnecker, 2002; Ajadike, 2001, 2003). In West Africa, the problem of biomedical waste management stems from poor infrastructure and risk awareness. There is also the absence of sorting of at the source and all types of wastes get mixed up along the disposal chain from collection to elimination and risks arising from poor handling and treatment of biomedical remain largely ignored by all those involved including authorities, healthcare professionals and even the general public (WUF3, 2006). In Nigeria, biomedical wastes are categorised under infectious wastes (FEPA, 1991). Within this category are culture and stock of infectious agents, pathological waste, waste from surgery or autopsy that were in contact with infectious agents, sharps (hypodermic needles, syringes and scalpel blades), waste from human blood and products of blood and laboratory waste (Bassey et al., 2006). Other wastes from different kinds of therapeutic procedures in this category include chemotherapy, dialysis, autopsy and biopsypara clinical test. These procedures apart from producing pathological and infectious wastes and sharp objects also generate radioactive, chemical and toxic materials that affect human and his or her environment (Pruss et al., 1999; Henry and Heinke, 2005; Hassan et al., 2008).

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In developing countries such as Nigeria, biomedical waste has not received much attention and is usually disposed of together with domestic waste (Almuneef and Mernish, 2003; Patil and Pokhrel, 2005; Khitoliya, 2007). It is a common site in Nigerian cities to see the destitute, waste scavengers and children collecting objects from dumpsites. They come in contact with medical wastes (e.g., syringe-needles, saline bangs, blood bags and even used condoms, etc.) and may even pick them up for reuse or sale as well as toys for children despite the deadly health risks involved. The collection of disposable medical items such as syringes, its re-sale and potential re-use without proper sterilisation could cause serious disease burden to nations (Tamplin et al., 2005; WHO, 2002; Blenkharn, 2006; Chauhan, 2008). Sound management of biomedical waste requires proper segregation, storage, handling, treatment and disposal because the connection of healthcare waste effluent with municipal sewage network creates public health risk and imbalance in the microbial communities in the sewage system, which in turn affects biological treatment process (Bassey et al., 2006). Management process must, therefore, conform to minimum international and national standards including the WHO standards for hospital waste management, the Federal Environmental Protection Agency (FEPA) guidelines and standard for industrial effluents, gaseous emission and hazardous waste management in Nigeria, the Basel Convention on hazardous waste and the UN-HABITATs urban management programme (WUF3, 2006). According to Bhatia (2005), segregation of wastes of different categories needs to be done in identifiable containers as shown in Table 1. For instance, sharps need special attention during segregation and storage because needles can act as reservoirs of pathogens in which they survive for a long time owing to the presence of blood (Ajadike, 2003; Bhitia, 2005). Sharps can also provide a direct route from pathogens into the bloodstream through any cut in the skin. Every room such as theatre room and laboratory ward should have containers/bags for the different types of wastes that are generated in the room, while all wastes from isolated wards should be regarded as infectious and treated as such (Santra, 2006). The safe disposal and subsequent destruction of medical waste is a key step in the reduction of illness or injury through contact with this potentially hazardous material, and in the prevention of environmental contamination. The management of medical waste is, therefore, of major concern owing to potentially high risk to human health and the environment (Da silva et al., 2004, p.14). The growing number of hospitals, clinic and diagnostic laboratories in Nigerian cities especially the rapid urbanising centres like Yenagoa exerts a tremendous impact on public health and the environment. This threat is sequel to the rapid increase in the amount of generated waste, itself a product of rapid increase in medical institutions and rapid urbanisation, moreover, the accelerated increase in both the number of medical institutions and the volume of biomedical waste generated cannot in any way be matched with the corresponding waste disposal institutions, infrastructures, technical knowledge, personnel for effective handling and disposal (Ajadike, 2003). There has been a few works on biomedical waste management in Nigeria covering mainly the Southwest and Northern parts of the country (Bassey et al., 2006; Coker et al., 2009). Not much, however, has been done in the South-southern part of Nigeria. This study, therefore, will form a premise for regional comparison on policy and practice of biomedical waste management. This study, therefore, aims at ascertaining the sources, types, quantity and composition of medical waste generated in the study area and the

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waste management system adopted by the various health institutions with a view to proffering solutions and recommendations for proper waste management as well input to health and environmental management policy.
Table 1 Classification and colour coding of containers for segregation as well as treatment and disposal of biomedical waste Type of container Colour Treat and disposal

Waste category Waste class

Category No. 1 Human anatomical waste Single use (waste tissues, organs, containers/plastic body parts, and fluids) holding bags

Red/orange Incineration/ deep burial Incineration/burial

Category No. 2 Animal waste/animal Single use Orange tissues, organs, body parts, containers/plastic carcasses, bleeding parts, holding bags/sacks fluid, blood and experimental animals used in research; wastes generated from veterinary hospitals, colleges, discharge from hospital and animal houses Single use Category No. 3 Microbiological and containers/plastic biotechnological waste (waste from laboratory holding bags cultures, stocks of micro-organism, live or attenuated vaccines, human and animal cell, culture used in research and infectious agents from industrial laboratories, wastes from production biologicals, toxins, dishes and devices used for transfer of cultures) Category No. 4 Waste sharps (needles, syringes, scalpels, blades, glass etc. that may cause puncture and cuts. This includes both used and unused sharps) Reversible single use sturdy containers of plastic, glass or metals Yellow

Local autoclaving/ microincinerations

Yellow/blue Disinfection (chemical treatment/autoclavi ng/microwaving and mutilated/ shredding of disposal Incineration/destruc tion of drugs and disposal in secured landfills Incineration autoclaving/ microwaving

Category No. 5 Discarded medicines and Reversible sturdy Yellow/blue card board/glass/ cytotoxic drugs (wastes comprising outdated plastic holding bags contaminated and discarded medicines) Category No. 6 Solid waste (items Plastic bags/sacks contaminated with blood and body fluids including cotton, dressings, soiled plastics, lines, beddings, other materials contaminated with blood) Yellow/ black

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Classification and colour coding of containers for segregation as well as treatment and disposal of biomedical waste (continued) Type of container Colour Yellow/ black Treat and disposal Disinfection, chemical treatment/autoclavi ng and mutilated/ shredding Proper treatment before discharge Disposal in municipal landfill Chemical treatment and discharge into drains for liquids and secured landfill for solids

Waste category Waste class

Category No. 7 Disposable solid waste Reversible sturdy (wastes generated from containers plastic disposable items other holding bags than the waste sharps such as tubing, and intravenous sets) Category No. 8 Liquid wastes Not applicable

Not applicable Black

Category No. 9 Incineration ash (ash from Plastic bags/sacks incinerations of any biomedical waste) Sturdy Category No. 10 Chemical waste containers/plastic (chemicals used in production of biologicals, holding bags chemical, as insecticides, etc.)

Yellow/ black

Source: Adapted from Bhatia (2005) and Santra (2006)

The study area

Yenagoa is the capital city of Bayelsa State in South-south Nigeria. It lies within longitude 6 10 and 6 26 East and 4 51 and 5 0 North. It is situated in the Upper Niger Delta, a low-lying, broad deltaic plain, which slopes gently in a southerly direction into the Atlantic Ocean. The river Nun/Ekole and the Epie Creeks flank the study area and are connected by a network of streams and canals usually inundated by annual floods. Groundwater occurs under water table conditions and climate falls under the A type of Koppens system of climatic classification with high tropical rainfall and temperatures (Oyegun, 1999). The population of the study area is over 300,000, a landmass within 300 km2 (Azaiki, 2003) and the city is a typical high growth third world urban centre. The flood-prone and high water table geology provide a higher risk of environmental pollution from poor waste management practices.

Materials and methods

An extensive questionnaire administration with in-depth interviews and field observation was adopted for this study. A simple random sampling technique was used in selecting healthcare institutions for the study representing about 60% of major healthcare institutions in the city. Waste generated by these establishments were monitored and analysed over a 30-day period between October and November 2007 using the Incinerator Institute of America (1968) method. Descriptive statistics and tables are used in data presentation. Seven healthcare establishments located in Ovom and Epie sections of the city including one federal medical establishment, four private hospitals and two medical laboratories were used for this study.

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Results and discussion

Data collected from the field survey are presented in Table 2.


Table 2 Healthcare institutions SITE 1 SITE 2 SITE 3 SITE 4 SITE 5 SITE 6 SITE 7 All survey Waste generation rates in the study area Patients Beds 360 150 56 200 60 40 50 916 Out patients 2600 1200 500 700 680 100 480 6260 Total patients 2960 1350 556 900 740 140 530 7176 Waste generation rate kg/day 1122 380 185 324 225 80 178 2494 kg/bed/day 2.78 2.67 3.32 1.67 3.67 2.00 3.56 19.67 kg/patients/day 0.34 0.30 0.34 0.22 0.30 0.29 0.34 5.51

The survey result from Table 3 indicates that about 7176 patients are attended to daily by the sampled institutions and the total volume of waste generated ranged from 1122 kg/day, 2.78 kg/bed/day and 0.34 kg/patient/day in SITE1 to 80 kg of biomedical waste in a day in SITE 6. The total volume of biomedical wastes generated by these healthcare establishments in this survey (60% of healthcare institutions) in a day is 2494 kg. Concomitantly, it can be estimated that all healthcare establishments (100%) in Yenagoa generate about 5000 kg of biomedical wastes per day and nearly 2,000,000 kg ((5000 kg)365) of wastes yearly. Table 3 is an analysis of the types of wastes generated in all the surveyed healthcare establishments and their various percentages: Table 3 indicates that about 70% of the total wastes generated were general waste, 13.2% were infectious waste, 8.4% were plastic waste, 5.5% were sharps and about 3% liquid wastes. This shows a higher rate of infectious waste compared with the study carried out in Ibadan (3%) while closely related to the findings in Abuja (12.4%). The difference may be because the Ibadan survey has a wider geo-economic coverage. The survey further revealed that apart from the federal medical institution in the city, none of the other health establishments in the study has incinerator(s). All hazardous materials except plastic and polymers materials can be incinerated. Incineration has been favoured as a good means of managing medical wastes (Patil and Pokhrel, 2005), while Bakoglu et al. (2004), Karademir (2004) and Maoa et al. (2007) are of a contrary opinion because of the apparent health risks emanating from emissions of polychlorinated dibenzodioxin and dibenzofuran (PCDDIF) from medical waste incineration. Incineration when properly managed could be a veritable technology for the management of medical wastes in the absence of a better and affordable technology (Hassan et al., 2008). In all the healthcare establishments, storage bins were not categorised. The different colour codes were not used. This implies that the wastes so far generated are not segregated before storage and final disposal. Investigations also reveal that these wastes were disposed in the public waste disposal bins along the major roads and streets in the city.

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Table 3

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Type of biomedical wastes generated in all surveyed healthcare establishments in the study area SITE1 SITE2 kg/% kg/% 788 260 (70.2) (68.4) 132 40 SITE3 kg/% 120 (64.9) 25 (13.5) 20 (10.8) 12 (6.5) 8 (4.3) 185 100% SITE4 SITE5 kg/% kg/% 250 (77.2) 40 (12.3) 20 (6.2) 9 (2.8) 5 (1.5) 324 100% 168 (74.7) 20 (9.8) 15 (6.7) 15 (6.7) 7 (3.1) 225 100% SITE6 SITE7 kg/% kg/% 50 (62.5) 15 130 (73) 28 13.2 70 Total kg/%

Colour Type of wastes Black General waste (kitchen waste, medicine box)

Yellow Infectious waste (cotton bandage, placenta, blood and urine bags) Green Plastic waste (syringe without needle, saline bags, gloves)

(11.8) (10.5) 113 (10.1) 36 (9.5) 24 (6.3) 20 (5.3) 380

(18.7) (15.7) 8 (10) 6 (7.5) 1 (1.3) 80 10 (5.6) 6 (3.4) 4 (2.3) 178

8.4

Red

Sharp items 57 (needle, blade knife, (5.1) vial-ampoule) Liquid waste Total 32 (2.8) 1122

5.5

Blue

2.9

100% 100%

100% 100%

The field survey also indicates that wastewater from these health institutions were not treated and are freely channelled into the public sewer systems, which discharge into nearby streams and waterways. They thus become sources of pollution to these water bodies and potential pollution recharge sources for the shallow aquifers that abound in the area. This situation conforms to the findings in medical institutions in Abuja and Ibadan to the effect that wastes are disposed into municipal dump sites while management practices expose staff, patients and the general populace to unnecessary health risks (Bassey et al., 2006; Coker et al., 2009). The study also indicated that most of the healthcare establishments have no biomedical waste management personnel. In fact, out of the seven institutions studied, only one representing 8.6% of surveyed institutions have a medical waste expert. It can thus be estimated that over 90% of health establishments in Nigeria may not have medical waste experts. These findings are not far from the situation in India and some other Southeast Asian countries (WHO, 1995; Patil and Shekdar, 2001) and definitely in tandem with the earlier findings of Ajadike (2003) who concluded that more waste management experts are needed in Nigerias health institutions. Experts who appreciate the risk and hazardous nature of these wastes will handle them in line with standards from points of generations to points of disposal. These experts are aware that any mistake in handling could result in costly health and environmental outcomes.

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Recommendations

It can be deduced from this study that apart from the FEPA guidelines categorising biomedical wastes as infectious there is a lack of strong institutional framework and legislation for effective management of biomedical waste in Nigeria. Therefore, legislation on biomedical waste management like Indias Biomedical Wastes Management and Handling Rules and in line with the Dakar Declaration, the Basel Convention on hazardous wastes, WHO Hospital Waste Management Standards is of urgent importance. Raising of awareness and the formation of expert committees comprising health officials and other stakeholders to fashion out modalities for both economic and sustainable management of biomedical wastes is expedient. This should include publicprivate partnership arrangements whereby health institutions can make use of expensive medical waste management technology without necessarily acquiring them. The managers of health institutions such as hospitals, nursing homes, clinics, dispensaries, veterinary institutions, animal houses, pathological laboratories and blood banks should ensure that wastes are segregated from points of generation and colour coded prior to storage and handling.

Conclusion

The generation of medical waste in Yenagoa, Nigeria, has been increasing in quantity and variety owing to the increasing number of healthcare establishment and the use of disposable items, and increasing population and city size. Medical waste generation is estimated at nearly 2,000,000 kg per year of which infectious wastes and sharp items constitute nearly 19%. These wastes are disposed in public waste bins along streets and often mixed with domestic or household wastes and disposed of in municipal solid waste landfills without treatment. The management and disposal of medical wastes in Nigeria is, therefore, a very serious and growing environmental health problem that deserves adequate attention. This situation has received little or no attention despite their potential environmental hazards and public health risks, and the problems associated with management could be summarised as follows: inadequacies in equipment, skills, personnel, funding and general institutional failure in supervision and enforcement of compliance (Ajadike, 2003) and a lack of proper legislation and institutional framework for this sort of hazardous waste management.

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