HOSPITAL SOLID WASTE MANAGEMENT PRACTICES IN ZAMBOANGA CITY

A RESEARCH PAPER PRESENTED TO THE FACULTY OF THE GRADUATE SCHOOL ATENEO DE ZAMBOANGA UNIVERSITY ZAMBOANGA CITY

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER IN PUBLIC HEALTH

BY: PRECILLA MADEL D. MORONES, MD APRIL 2009

APPROVAL SHEET
This Research Paper entitled HOSPITAL SOLID WASTE MANAGEMENT PRACTICES IN ZAMBOANGA CITY prepared and submitted by Precilla Madel D. Morones, MD, in partial fulfillment of the requirements for the degree Master in Public Health is hereby accepted.

Dr. Ricardo N. Angeles Thesis Adviser ________________________________________________________________________ Approved by the Oral Examination Committee with a grade of PASSED.

Dr. Rosemarie S. Arciaga Chairman

Dr. Fortunato L. Cristobal Member

Dr. Jocelyn D. Partosa Member

Dr. Servando D. Halili Jr. Member ________________________________________________________________________ ACCEPTED in partial fulfillment of the requirements for the degree Master in Public Health.

Dr. Servando D. Halili Jr. Dean, Graduate School Ateneo de Zamboanga University

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ACKNOWLEDGEMENT

I would like to extend my appreciation to

my thesis adviser, Dr. Ricardo N. Angeles for lending me his time and expert advice on my study.

the hospital waste managers, nurses and orderlies of the hospitals in Zamboanga City for taking time to participate in my study.

ADZU-SOM for generously supporting my study.

My deep gratitude goes to my batchmates especially to Naezelle, Noreen, Putri, Sol and Kuya Mike whose untiring and generous support in all my endeavors have cheered me on.

Most of all, to the Almighty Father for giving me strength and grace.

This work is dedicated to my family -Mama, Lyn2x and MMwithout whose love and support all is meaningless.

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LIST OF FIGURES Page

Figure 1. Figure 2. Figure 3. Figure 4. Conceptual Framework . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . Flow of Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice and Methods of Waste Treatment . . . . . . . . .. . . . . . . . . . . Solid Waste Flow of Hospitals in ZC . . . . . . . . . . . . . . . . . . . . . . . 7 13 18 20

LIST OF TABLES

Table 1.

Practice and Method of Waste Segregation . . . . . . . . . .. . . . . . . . . .

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Table 2.

Healthcare Waste Disposal Practices . . . . . . . . . . . . . . . . . . . . . .. . .

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Table 3.

Transportation and Final Disposal of Waste . . . . . . . . . . . . . . . . . . .

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TABLE OF CONTENTS PAGE

APPROVAL SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACKNOWLEDGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LIST OF FIGURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LIST OF TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHAPTER I THE PROBLEM AND ITS SETTING a.) Background of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . b.) Related Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. c.) Statement of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . d.) Objectives of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . e.) Conceptual Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . f.) Significance of the Study . . . . . . . . . . . . . . . . . . . . . . . . . .. . g) Delimitation of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . h.) Definition of Term . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II METHODOLOGY a.) b.) c.) d.) e.) f.) g.) II IV V Research Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Study Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sampling Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Data Gathering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Research Instrument . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 9 10 10 10 11 12 1 4 6 6 7 8 8 8 ii iii iv iv vi

PRESENTATION AND INTERPRETATION OF RESULTS 14 DISCUSSION AND IMPLICATION SUMMARY AND CONCLUSIONS 22 27

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BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . APPENDICES A. Observational Checklist Results of Hospitals . . . . . . . . . . . . . B. Survey Questionnaire for Hospital Waste Manager . . . . . . . .

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30 31

C. Survey Questionnaire for Orderlies . . . . . . . . . . . . . . . . . . . ... 33 D. Survey Questionnaire for Nurses . . . . . . . . . . . . . . . . . . . . . . .. 36 E. Observational Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 38

CURRICULUM VITAE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 40

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ABSTRACT
This study was conducted to determine current hospital waste management practices in Zamboanga City. Twelve hospitals and 154 respondents participated in this study. Data were gathered through survey using an interviewer- administered questionnaire. Frequency distribution was used to summarize information from respondents about hospital waste management. Results showed that hospitals generate waste and use color- coding scheme and separate the different types of waste at the point of generation to segregate these wastes. Infectious wastes are separated from noninfectious wastes. There were 7 hospitals who practices treatment of infectious wastes prior to disposal by means of acetylization (8.3%), encapsulation (41.7%) and burning of sharps (8.3%). The disposal sites for infectious wastes such as sharps includes a septic vault (33.3%)which is located within the hospital vicinity, a privately owned dump site in Barangay Boalan (8.3%) and direct disposal to the city dumpsite (16.6%). On the other hand, infectious wastes of hospitals with no treatment were directly disposed to a compost pit (25%) located within the hospital vicinity and to the city dumpsite (16.6%).Non-infectious wastes of hospitals were dispose to a compost pit (25%) located within the hospital vicinity and to the city dumpsite (75%) which is the final disposal area of healthcare waste located in Brgy. Lumbangan. Although wastes were properly sorted in the hospital, the local government garbage truck collects the waste and disposes it in the city dump site- a practice that defeats the purpose of waste segregation in hospitals.

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CHAPTER I THE PROBLEM AND ITS SETTING Background of the Study

One of the problems Zamboanga City is facing today is the improper handling and disposal of solid wastes. About 70% to 80% of generated solid wastes are collected in the city and the balance is either left on the streets, dumped into storm drains, esteros, canals, creeks and rivers. A large percentage of solid wastes mostly come from the industries (ZC Public Service Office, 2000). Hospital waste management is one of the biggest challenges our country is facing in addressing the countrys growing garbage problem. Public concern over the past years has been growing with regards to the disposal of wastes produced by health care facilities in the Philippines. The DOH introduced a manual on healthcare waste management practices. The manual provides practical information regarding safe, efficient and environmental- friendly waste management options. It also contains in detail, safety procedures attendant to the collection, handling, storage, transport, treatment and disposal of healthcare waste. According to the Department of Health in 2003, hospitals generate an estimated 0.6 kg/bed/day of waste. There are about 2,068 hospitals in the Philippines, including 71 hospitals under DOH, which generate about 28 tons of waste per day. Most wastes generated from the hospitals are nonhazardous general wastes. Hospital wastes are further classified by the Department of Health (Environmental Health Service). The Manual on Hospital Waste Management contains the following guidelines: 1. Pathological wastes consist of tissues, organs, body parts, human fetuses and animal carcasses; and most blood and body fluids. 1
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2. Infectious waste contains pathogens in sufficient concentration or quantity that exposure to it could result in disease. This category includes cultures and stock of infectious agents from laboratory work, waste from surgery and autopsies on patients with infectious diseases, waste from infected patients in isolation wards, waste that has been in contact with infected patients undergoing hemodialysis (e.g. dialysis equipment such as tubing and filters, disposable towels, gowns and aprons, gloves and laboratory coats) and waste that has been in contact with animals inoculated with an infectious agent or suffering from an infectious disease. 3. Sharps include needles, syringes, scalpels, saws, blades, broken glass, nails and other items that could cause a cut or puncture. 4. Pharmaceutical wastes include pharmaceutical products, drugs, and chemical that have been returned from wards, have been spilled, are outdated or contaminated, or are to be discarded because they are no longer required. 5. Radioactive wastes include solid, liquid, and gaseous waste contaminated with radionuclides generated from vitro analysis of body tissues and fluids, in vivo body organ imaging and tumor localization, and therapeutic procedures. 6. Chemical wastes comprise discarded, solid, liquid, and gaseous chemicals, for example from diagnostic and experimental work, and cleaning, housekeeping and disinfecting procedures Chemical waste may be hazardous or non- hazardous (DOH, 1997). The distribution of hospital wastes in developing countries are 80 percent general healthcare wastes, 15 per cent pathological and infectious waste, 3 percent chemical/pharmaceutical wastes and 1 percent sharp wastes (World Health Organization, 2003). With a rapidly growing population and lack of adequate disposal sites, medical waste, if not properly managed, pose serious health risks not only to the personnel who are handling the

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wastes but also to the waste collectors, to those providing disposal or picking through the wastes for recyclables, and scavengers. There are currently fourteen existing hospitals in Zamboanga City and yet, no recent publicly available data exists on how hospitals in the city dispose of their infectious and hazardous wastes. In Metro Manila however, less than 50% of the 144 hospitals studied do not have appropriate mechanisms for proper waste handling and segregation. Incineration and landfill were used for final disposal of wastes. Only two out of five hospitals had an existing waste management committee and a separate budget allocation for a waste management program. On August 2005, the Department of Environment and Natural Resources (DENR) and the Department of Health (DOH) signed a Joint Administrative Order (JAO) outlining the framework by which-hospitals and clinics can safely dispose their wastes. The signing was the culmination of efforts of the two agencies that begun in 2003 to solve the growing volume of hospital wastes in the country. Three laws have been framed to tackle the management of hospital wastes Republic Acts 6969 or the Toxic and Hazardous Substances and Nuclear Wastes Control Act of 1990, 8749 or the Philippine Clean Air Act of 1999 and 9003 or the Ecological Solid Waste Management Act of 2000. (Environment, 2005) Hazardous waste is responsible for spreading infectious and epidemic diseases. Thus, generators of such waste products should take special care in handling and disposing of this kind of waste. Improper management of waste generated in health care facilities cause a direct health impact on the community, the health care workers and on the environment (WHO, 2004). This, along with the lack of local data creates the need for the assessment of the hazardous waste management in Zamboanga City.

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Review of Related Literature

Health care wastes are in the form of solid and liquid wastes generated by hospitals, medical or research laboratories, clinics, offices of physicians and dentists, veterinarians, and funeral homes. These wastes represent a relatively small portion of the total solid waste stream, and are simple to identify, to separate, and to treat properly (DOH Manual, 2004). Several studies have been done to assess the management of hazardous wastes in the Philippines and abroad. Soncuya et al, (1997) conducted a study on hospital waste management in Metro Manila. The results showed that hazardous medical wastes were not properly handled. A large volume of infectious wastes is disposed in burial pits located at hospital sites, and in municipal landfills. Majority of the hospitals is not practicing treatment procedures prior to the disposal of their infectious waste and does not adhere to color-coding system required by MMDA Ordinance No. 16. These practices pose significant risks to humans, including direct contact and contamination of surface water or groundwater. Another study on waste management practices of hospitals in Metro Manila conducted for the Department of Health (DOH) revealed that although most of the hospitals perform waste segregation, less than 50% of the 144 hospitals studied did not have the proper mechanisms for proper waste handling and segregation. Incineration and landfill were used for final disposal of wastes. Only two out of five hospitals had an existing waste management committee and a separate budget allocation for waste management program (Molina). In Sylhet, a study entitled Hospital Waste Management in Sylhet City; it was observed that existing hospital waste collection, and handling and disposal practices of all the hospitals in Sylhet involved transport of wastes by ward boys, maid nurses and other employees from the point of generation to initial storage. Wastes are normally collected from small bowl or plastic

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bins provided for each bed and stored either in a large size plastic bag or bucket. These plastic bags or wastes from buckets are then put in a pushcart and carried to the nearest municipal bins for dumping without any segregation or treatment (Sarkar, et al, 2006). In a similar study done in Dhaka City on Solid Waste Management, it was found out that there were over 500 clinics and hospitals in Dhaka City and majority of the hospitals were not practicing safe disposal of wastes. Waste is collected from small bowls or plastic bins provided for each bed and emptied into larger containers. These containers are then conveyed by pushcart to the nearest municipal bin for dumping. The municipal bins are located either within the hospital itself or nearby outside. Municipal solid wastes are augmented by other hazardous and toxic wastes from hospitals. Since these wastes contain toxic and infectious materials, they are more dangerous than other types of wastes (Rahman, et al, 1999). Bhatia (2003) did a study in Mumbai on Biomedical Waste Management: Understanding our civic issues, health care institutions dump their infectious waste, along with the rest of the non-infectious waste, in the municipal garbage systems, posing a serious risk to public health as well as a risk of scavenging(Bhatia, 2003 ). Thus, poor management of healthcare waste poses a severe threat to public health and may also damage the .environment.

Statement of the Problem

What is the current waste management practices of private and government hospitals in Zamboanga City?

Objectives of the Study General Objective

To describe waste management practices of private and government hospitals in Zamboanga City. 5
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Specific Objectives
1. To determine methods of waste segregation within the hospital. 2. To determine methods of disposal of infectious and toxic waste within hospital setting. 3. To determine methods of disposal (transport) of infectious and toxic waste from the hospital to the disposal site(s). 4. To determine treatment done (if any) to the waste before disposal.

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Conceptual Framework

Hospital generates Waste

Disposal

Segregate Treatment Transport Disposal Improper Waste Management Proper Waste Management

Public Health Risk

Figure 1. Conceptual Framework Figure 1 shows that healthcare facility such as hospitals must have an appropriate hospital waste management to ensure proper segregation, treatment, transportation, and disposal of waste generated by the healthcare facility. Improper waste management of hospitals would lead to an increase risk to public health threat and poor environmental sanitation.

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Significance of the Study:

The result of the study can give us data on how hospitals in Zamboanga City today manage their wastes. The paper will be presented to agencies concerned with environmental sanitation for better implementation and improve programs on hospital waste management. Moreover, this study hopes to invite other healthcare facilities to take measures towards improving their waste management systems through conducting healthcare waste assessments in their facility.

Delimitation of the Study

This research is confined only in describing practices of hospitals regarding solid waste management. The assessment was based on interviews and on-site observation. Actual waste management procedures were documented.

Definition of Terms
Hospital Solid Waste refers to all discarded waste materials from the hospitals, includes sharp (syringes, disposable scalpels, blades, etc.), non-sharps (swabs, bandages, disposable medical devices, etc.), blood and anatomic waste (blood bags, diagnostic samples, body parts, etc.), chemicals (solvents, disinfectants, etc.), pharmaceuticals, and others, and may be infectious, toxic. Hospital Solid Waste Management refers to ways of handling solid waste, which includes segregation, storage, collection, transportation, treatment and disposal.

Hazardous Waste- potentially infectious waste which includes dressings and swabs contaminated with blood, pus and body fluids, sharps, which include needle, syringes, blades etc. and blood and blood products.

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CHAPTER II METHODOLOGY Research Design

This is a cross- sectional study aimed to describe the government and public hospital solid waste management practices in Zamboanga City. The respondents were selected using purposive and convenience sampling. All respondents were hospital workers and were interviewed to learn about actual waste management practices. An observation of 12 hospitals in Zamboanga City was done regarding waste management practices performed by the different departments of the hospital. The information gathered from this study was those which exist at the time of the survey.

Respondents
The respondents of this study were: Inclusion Criteria Hospital workers of any of the following position: Hospital Waste Manager Head nurses in the ward Orderlies/waste handlers

Exclusion Criteria: Those who were absent during the conduct of the survey. Less than 3 year employees

There are 14 hospitals in Zamboanga City. However, only twelve hospitals agreed to participate in the study.

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Study Setting
According to the Regional Office of the DOH, there were 14 hospitals in Zamboanga City with a 1,316 total number of beds. Eight of which are private hospitals and six are government hospitals. No recent publicly available data on waste generation rates of these facilities. Moreover, the city has no available data on how hospitals dispose their infectious and hazardous waste and has no existing hazardous waste collector. There are six tertiary hospitals, seven secondary hospitals and one primary hospital. Among the six tertiary hospitals, one is public and five are private. The tertiary hospitals offer specialty care and are usually more equipped. They have bigger bed capacities and therefore generate more hospital waste. In general, private hospitals are more sophisticated and more equipped compared to public hospitals. In the Philippines, it is expected that private hospitals are more organized compared to public hospitals.

Sampling Method
Purposive sampling was used in the selection of hospital waste managers based on inclusion criteria. Moreover, convenience sampling was utilized in the selection of head nurses and orderlies based on inclusion criteria. Due to the schedule of shift of the nursing staff and other hospital personnel, the ones interviewed were those who were available during the visit, and at the same time, qualified in the aforementioned inclusion criteria.

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Data Gathering Procedure

An interviewer-administered questionnaire (see Appendices) was employed by the researcher among hospital staff from different department (head nurses and orderlies/ waste handlers) who is in-charge in hospital waste management and handling. Person in- charge of managing the hospital waste system which is the hospital waste managers were also interviewed (see Appendices) by the researcher to learn more about actual waste management practices in Zamboanga City. Observational checklists were utilized to monitor hospital waste segregation, treatment, transportation, and disposal methods. Walk- through observation allowed the documentation of actual practices performed by the different departments of the hospital.

Research Instrument
Questionnaire An interviewer- administered questionnaire for hospital waste managers, head nurses and orderlies was formulated for this study. Questions for the hospital waste manager focused on their functions for ensuring that healthcare waste are disposed of in accordance with the national policies and guidelines. The questions were answerable by yes, no, and no idea. Each correct answer was given 1 point with the highest possible score of 13 for hospital managers. All questions were based on the guidelines set on healthcare waste management manual by the DOH. The questions for the head nurses and orderlies focused on waste segregation, storage, collection and transport, off-site transport, and treatment and method of disposal of hospital wastes. The questions were answerable with yes, no, and no idea. Each correct answer 11
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was given 1 point with the highest possible score of 16 for head nurses and 25 for orderlies. Similarly, all questions were based on the guidelines set on healthcare waste management by the DOH Manual. The questionnaire was face validated by the Head of Sanitation Department of the DOH. Modifications and corrections were done. Final questionnaire was reviewed by the researchers adviser. Observational Checklist An observational checklist was utilized to monitor hospital waste segregation, transportation, and treatment and disposal methods used in the implementation of hospital waste management practices. There are eight items on waste segregation, seven items on waste transportation, two items on waste treatment and six items on waste disposal. All items in the checklists were based on the guidelines set on healthcare waste management by the DOH Manual.

Data Analysis
The research data was processed using descriptive statistics i.e., frequencies, percentages were used to summarize information from the respondents about hospital solid waste management practices.

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Flow of Activities

Formulation of: Questionnaires and Observational Checklists Questionnaire Modification

Implementation Interviewer- administered Questionnaire Hospital Waste Manager Head nurses Orderlies/Waste Handlers Observational Checklists Waste segregation, storage, collection, transportation and disposal method. Data Analysis and Interpretation Research Output

Figure 2. Flow of Activities

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CHAPTER III PRESENTATION AND INTERPRETATION OF RESULTS

From January to March 2009, the researcher conducted a solid waste survey in order to describe current private and government hospital waste management practices in Zamboanga City. A total of 12 hospitals and 154 hospital personnel participated in the study. There were 12 hospital waste managers, 76 nurses and 66 orderlies/waste handlers were interviewed for this study. Forty- seven nurses were from private and 29 nurses from government hospitals. Fortyone orderlies were from private and 25 from government hospitals. Appropriate healthcare waste management practices depend largely of the administration and organization and require adequate legislative and financial support as well as the active participation by the trained and informed staff (DOH Manual). All hospitals studied have an existing waste management committee and have a designated a waste management officer to supervise and coordinate the waste management plan. Out of the 12 hospitals surveyed, 83.3 percent (10) revealed that their facility kept an up to date waste management plan. Moreover, 91.7 percent (11) of hospitals carry out proper procedures in the implementation of their waste management plan. In developing a waste management plan, the waste management committee needs to make an assessment of all waste generated in the healthcare facility. Only 5 hospitals or 41.7% prepare an annual report for the disposal of healthcare waste which provides data on waste generation, equipment requirements and its cost.

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Waste Segregation Segregation is the process of separating different types of waste at the point of generation and keeping them isolated from each other. By segregating waste, appropriate resource recovery and recycling technique can be applied to each waste stream. Moreover the amount of hazardous waste that needs to be treated will be minimized or reduced subsequently prolonging the operational life of the disposal facility and may gain benefit in terms of conservation of resources (DOH Manual). As shown in Table 1, majority of the respondents, nurses and orderlies (95.7%) claimed that they practice waste segregation. Approximately four percent of nurses and of orderlies said that they do not practice waste segregation. However, a respondent (.8) admitted of not having an idea regarding waste segregation. Among those who practice waste segregation, majority of the respondents made use of color- coding scheme and separating different types of waste at the point of generation. However, out of the 12 hospitals surveyed, only 50% were observed to have color-coded waste bins present in their facilities. In an interview with their hospital managers, it was found out that the hospitals who were currently not using the color-coding system used to practice this. However, they were not able to sustain it due to lack of supplies and budget. Nevertheless, they were able to develop means on how to manage their healthcare waste through separation of infectious waste from non- infectious waste.

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Table 1. Practice and Methods of Waste Segregation Question Items Nurses and Orderlies N= 142 (%) Practices Waste Segregation 136 (95.7) Methods of waste segregation Color-coding System 13 ( 9.2) Separate different type of waste at the 21 (14.8) point of generation Color-coding or separation of waste 108 (76.0)

The effective management of healthcare waste considers the basic element of waste minimization. Hospital waste minimization is centered on the elimination or reduction of the healthcare waste stream. Twenty- seven or 40.9% of orderlies/waste handlers practice waste minimization and about 57.6% (38) do not practice waste minimization and 1.5% (1) do not have any idea on waste minimization. Recycling is their main measure to achieve waste minimization. On observation, majority of hospitals made use of recycled bottles or gallon as improvised containers for their sharps.

Disposal of Healthcare Waste Table 2 shows that 75% (9) of hospitals stated that all healthcare wastes are disposed to the city dump site. Approximately 25% (3) of hospitals stated that their facility has a specific disposal sites which is a compost pit located within their vicinity. The disposal sites for sharps which is a hazardous type and infectious wastes include a septic vault 4 (33.3%), or a compost pit 3 (25%) within the hospital vicinity, city dumpsite 4(33.2%) and a privately owned dump site in Barangay Boalan 1 (8.3%).

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Table 2. Healthcare Waste Disposal Practice Question Items Disposal Site City Dumpsite Compost Pit w/in the hospital Infectious and Sharp Waste Disposal Site Septic Vault Compost Pit City Dumpsite Privately owned dumpsite Hospitals N=12 (%) 9 3 (75) (25)

4 (33.3) 3 (25.0) 4 (33.2) 1 ( 8.3)

On observation, there were 4 hospitals with septic vault and 3 compost pit within the vicinity for the disposal site of their infectious and sharp waste. Three hospitals were noted of practicing burning in a compost pit. There was no evidence of practice of incineration in all hospitals in Zamboanga City.

Treatment on Healthcare Wastes Prior to the Disposal The purpose of treating healthcare waste is to change the biological character of the waste to minimize its potential to cause harm. Figure 3 shows that 71.2%% (47) of the orderlies/waste handlers reported that they do not treat their healthcare wastes before disposal. However, 28.8% (19) of orderlies claimed to practice healthcare waste treatment for their infectious wastes and sharps. Those who claimed to practice healthcare waste treatment for their infectious waste and sharps, on-site waste treatment methods practiced include acetylization (12.1%), encapsulation (13.6%) and burning of sharps (1.5%).

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Figure 3. Practice and Methods of Waste Treatment

An interview with the nurses revealed that 84.2% had the knowledge but did not practice sterilization prior to the disposal of blood and body fluids and feces. Thirteen percent do not have any idea how these wastes should be disposed. For those who do not practice sterilization, they disposed their pathological wastes in their sewage. In addition, there were no sterilization practices prior to the disposal of feces.

Transportation of Healthcare Wastes from hospital to disposal site Transportation of waste within the establishment could utilize wheeled- trolleys, containers, or carts that are dedicated solely for the purpose (DOH Manual). On the transportation of waste within the establishment, table 3 below shows that 93.9% or 62 orderlies/waste handlers made use of wheeled trolleys and the other 6.1% just hand-carried it because there was not much waste to carry.

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Based on the interview among orderlies/ waste handlers, 90.9% (60) stated that the local government garbage truck collects the healthcare waste and 7.6% (5) revealed that they do not need the garbage truck because they directly dispose their wastes in their compost pit within their establishment. Table 3 . Transportation and Final Disposal of Waste Question Items Orderlies/Waste handlers N=66 (%) Means of Transportation w/ in the hospitals Wheeled-trolley 62 (93.9) Hand-carried 4 ( 6.1) Collection of HCW by the local 60 (90.9) government truck

On observation, wheeled-trolleys are available for transportation of healthcare wastes in 11 hospitals. Majority of orderlies or waste handlers transporting healthcare waste were equipped with personal protective gear such as latex gloves, boots and face masks. All healthcare waste were collected daily and stored in waste storage area located within the establishment until transported to a designate disposal site. There were 11 hospitals surveyed with storage areas located within the establishment Based on the interviews done among hospital managers, nurses, and orderlies, it was found out that the city dump site is the final disposal area of healthcare waste, which is located in Brgy. Lumbangan. It was observed that although wastes were properly sorted in the hospital, the local government garbage collectors do not follow the proper segregation, transport and disposal. Moreover, the Lumbangan dumpsite has no separate site for the disposal of hospital wastes except for the sharps which are buried. This results in futile practice of proper waste disposal of hospitals.

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Hospital Waste (N=12)

Waste Segregation (N=12)

Infectious Waste N=12 (100%)

Non- infectious Waste N=12 (100%)

Treatment Done N=7(58.3%) -Acetylization (1)8.3% -Encapsulation(5)41.7% -Sharp- burning(1)8.3%

No Treatment Done N=5(41.6 %) Direct Disposal N=2 (16.6 %)

Compost Pit N=3 (25%) Non-treated infectious waste N=3 (25%) Non-infectious Waste

Direct Disposal N=2 (16.6%)

Septic Vault N=4(33.3%)

Privately Owned Dumpsite N=1 (8.3%)

City Dumpsite N=9(75%) Non-Infectious Waste N= 2 (16.6%) Treated Infectious Waste N=2 (16.6%) Non-Treated Infectious Waste

Figure 4. Solid Waste Flow of Hospitals in Zamboanga City

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In summary, there were twelve hospitals surveyed in this study. Hospitals generate waste and use color- coding scheme and separate the different types of waste at the point of generation to segregate these wastes. Infectious wastes are separated from non-infectious wastes. There are 7 hospitals who practices treatment of infectious wastes prior to disposal by means of acetylization (8.3%), encapsulation (41.7%) and burning of sharps (8.3%). The disposal sites for infectious wastes such as sharps includes a septic vault (33.3%)which is located within the hospital vicinity, a privately owned dump site in Barangay Boalan (8.3%) and direct disposal to the city dumpsite (16.6%). On the other hand, infectious wastes of hospitals with no treatment were directly disposed to a compost pit (25%) located within the hospital vicinity and to the city dumpsite (16.6%).Non-infectious wastes of hospitals were dispose to a compost pit (25%) located within the hospital vicinity and to the city dumpsite (75%) which is the final disposal area of healthcare waste located in Brgy. Lumbangan. Other data regarding hospital waste management practices would be found in appendix A.

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CHAPTER IV DISCUSSION AND IMPLICATION

Appropriate hospital waste management practices depend largely of the administration and require adequate legislative and financial support as well as the active participation by trained and informed staff (DOH Manual). A prerequisite to a successful waste management system is the establishment of a waste management committee. In Zamboanga City, all the hospitals being surveyed are aware of the existing national policies and guidelines related to healthcare waste management. It shows that they adhere to the policies and regulations of the government and through these they have organized a waste management committee and have formulated a waste management plan. In addition, hospitals are responsive in preventing the deleterious effect of improper waste disposal. Segregation is the process of separating different types of waste at the point of generation and keeping them isolated from each other. To improve segregation efficiency and minimize incorrect use of containers, proper placement and labeling must be carefully determined (DOH Manual).Waste segregation among hospitals is being practiced. Majority of the nurses and orderlies claim to observe waste segregation. This implies that the administrators ensure the adequate training of key staff members on waste segregation and disposal procedures. Moreover, they monitor and supervise proper procedures in the implementation of their hospitals waste management plan. The most appropriate way of identifying the categories of healthcare waste is sorting the waste into color-coded plastic bags and containers (DOH Manual). Out of the 12 hospitals surveyed, 50% were noted of practicing color-coding scheme. In an interview with their hospital managers, it was discovered during an interview with hospital managers that they used to

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practice the color-coding system, but was not able to sustain it due to lack of budget and supplies. However, they were able to develop means on how to manage their healthcare waste through separation of infectious waste from non- infectious waste. For example, sharps which are considered as an infectious waste and a very hazardous class are segregated by having specific containers where to dispose and therefore, not mixed up with general wastes. Less than 50 percent of respondents practices waste minimization and recycling is their main measure to achieve waste minimization. Waste minimization is centered on the elimination or reduction of the healthcare waste stream. Recycling is collecting waste and processing it into something new. Many items in the hospital can be recycled. Items such as organics, plastic, paper, glass and metal can be recycled easily (DOH Manual). An effective healthcare waste management considers the basic element of waste minimization therefore it is beneficial for all hospitals in Zamboanga City to implement such measures. The purpose of treating healthcare waste is to change the biological character of the waste to minimize its potential to cause harm. Most common and approved technologies and processes used in healthcare treatment are (1) Thermal process relies on high heat to destroy pathogens (disease-causing microorganisms), (2) Chemical uses heated alkali to destroy tissues, organs, body parts, and other pathological wastes that can be used to treat prion- contaminated animal waste and cytotoxic wastes, (3) Biological Processes uses an enzyme mixture to decontaminate healthcare waste and the resulting by- product is put through an extruder used to remove water for sewage disposal, (4) Irradiation systems which treats waste containing potentially infectious microorganisms (DOH Manual). A large percentage of the respondents do not practice waste sterilization prior to the disposal of blood and body fluids and feces. This could pose a risk in spreading diseases. When waste that has not been pretreated is being transported outside the

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hospital, or dumped openly, pathogens can enter the atmosphere. These pathogens can find their way to drinking water, foodstuffs, soil, etc., or they can remain in the ambient air (Manyele, 2004). And also, pathogens present in waste can enter, and remain in the air within the hospital for a long period, in the form of spores or as pathogens themselves. Patients and their attendants also have a chance of contracting infections caused by airborne pathogens or spores. As to transportation of hospital waste, it was found out that the local government garbage truck collects the waste as confirmed by the orderlies/ waste handlers (90.9%). It was observed that although wastes were properly sorted in the hospital, the local government garbage collectors do not follow the proper segregation, transport and disposal. This results in futile practice of proper waste disposal of hospitals. And lastly, the final disposal of all healthcare waste including infectious wastes is in the city dump site which is in Barangay Lumbangan. In Lumbangan dump site, there is no assigned area for hospital wastes except for the sharps which are buried. The area is open to public access which may pose a serious health risk to garbage handlers and scavengers. It is likely that these people will become infected due to exposure to hospital waste. Therefore the spread of infectious organisms through various means from hospital wastes can increase the risk of spread of infectious diseases. According to the Revised Rules Governing the Regulations, Licensures and Operation of Hospitals and other Health Facilities in the Philippines there are required documents to be accomplish before an initial licensed to operate can be issued. One of the requirements is the proper management of waste and having a waste management plan in their facilities. Under

Section 13 all hospitals and other healthcare facilities shall be monitored regularly and records should be made available to determine compliance with these rules and regulations. As part of

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monitoring the healthcare facilities, inspection of waste management practices is being done quarterly. Hospitals are inspected if they do have a waste management program, presence of an Environmental Compliance Certificate number, if solid waste is collected, treated and disposed of in accordance with the Health Care Waste Management Manual of the Department of Health, 2004. In addition, hospitals are observed on practices of segregation, coding and labeling of waste, treatment of solid wastes prior to disposal. Treatment of sharps includes at least the following: Autoclave, Chemical, Disinfection, Ionizing, Radiation, and microwave. Treatment of infectious and pathological wastes includes at least the following: Autoclave, Chemical Disinfection, Ionizing Radiation, and Microwave. Treatment of hazardous chemical and pharmaceutical wastes include: Delay to decay or Chemical Decomposition and if hospitals uses proper methods of waste disposal in accordance with the Health Care Waste Management Manual of the Department of Health, 2004: Municipal/City Collection and Disposal System (General Non-Infectious Dry/Wet Chemical) Safe Burial on Hospital Premises Septic/Concrete Vault (Sharps) or Private Waste Treaters (Sharps Infectious Pathological) Memorandum of Agreement with Private Waste Treaters is available and updated. And

presence of protective equipment and clothing appropriate to the risks associated with the handling, storage, and disposal of wastes are provided to and used by personnel. It is essential that everyone concerned by healthcare waste should understand that hospital waste management is an integral part of health care, and that creating harm through inadequate waste management reduces the overall benefits of health care. Proper hospital waste management is an important aspect in minimizing infection and saves the environment.

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CHAPTER V SUMMARY, CONCLUSION AND RECOMMENDATIONS

In summary, the study determines the current hospital solid waste management practices in Zamboanga City. Waste segregation among hospitals is being practiced through color-coding scheme and separation of infectious waste from non- infectious waste. A small fraction of hospitals practices healthcare waste treatment for their infectious wastes and sharps prior to the disposal. Although wastes were properly sorted in the hospital, the local government garbage truck collects the waste and disposes it in the city dump site - a practice that defeats the purpose of waste segregation in hospitals. The researcher recommends that hospitals develop a waste management plan aimed at adequately managing hospital waste using simple, sustainable system, and is affordable that minimizes the impact to the environment. Other methods of waste segregation should be evaluated in lieu of the full implementation of the color- coding system due to lack of budget. Some hospitals are already doing this but it is not know whether this is either acceptable or effective. Hospitals should conduct regular orientation on the hospitals waste segregation and waste management policies to patients and new staff. Reactivate committees and hold monthly meetings to discuss and address issues related to updates on waste management and environmental health awareness. Dissemination of information through supervisors/managers of each department and discussed to their members. Hold event such as Waste Management Week or an Infection Control Week once a year. Consider training of all those garbage collectors by the DOH, because there is a need for education as to the hazards of improper disposal of healthcare waste.

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The city government should propose a separate dumpsite for all healthcare wastes and set limit to public access to decrease the risk of epidemics of infectious diseases. Other recommendation for future research would be to determine the waste generation rate of hospitals in Zamboanga City.

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BIBLIOGRAPHY
Artajo, E. (2000). Retrieved November 6, 2008 from http:www.zamboanga.net Bhatia, J. (2003).Biomedical Waste Management Department of Health (DOH)(2004). Healthcare Waste Management Manual. Manila, Philippines Environment Issue (2005).DENR, DOH Issue Guidelines on Hospital Waste Management Kazi, N.M. (1999). Solid Waste Management. Bangladesh Centre for Advances Studies Mair, A.D., Gaac,G.J and Dinisco,M. (2003). Solid Waste Management in the Philippines: A small Island Manyele,S.(2004).Effects of Improper Hospital waste management on occupational health and safety.Arf Newslett on Occup health and safety 14:30-33. Molina, Victorio (undated), Waste Management Practices of Hospitals in Metro Manila, College of Public Health, University of the Philippines Rahman, M. H., Ahmed, S. N. and Ullah, M. S. (1999). A study on hospital waste management th in Dhaka City. 25 WEDC conference, Addis Ababa, Ethiopia. pp.342-345. Rogers DEC, Molefe S, Gcwense Q, van den Bergh C, Kristiannsen T, and Otto JB, (2006) Projections for health care risk waste management, prepared for Department of Environmental Affairs and Tourism and National Department of Health, CSIR project 8600/HT4150 May, report No. msm/ep/er/2006/0031/b, DEAT project 12/9/6 Sarkar, S.K., Haque, M.A. and Khan, T.A. (2006) Hospital Waste Management in Sylhet City.ARPN Journal of Engineering and Applied Sciences Vol. 1 No 2 Soncuya,R.T.,Matias,L.D. and Lapid, D.G. (1997), Hospital Solid Waste Management:Two Casse Studies in Metro Manila, Philippines. Center for Advanced Philippine Studies, Quezon City, Philippines Soncuya, R. and Villoria , L. (1993), Solid Waste Study of Mandaluyong and San Juan, UNDP- Metropolitan Environmental Improvement Program (MEIP), Quezon City World Health Organization (WHO)(1983). Management of wastes from hospitals, World Health Organization, Regional Office for Europe, Copenhagen. World Health Organization (WHO) (2004.)Safe Health Care Waste Management. Geneva, Switzerland.

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APPENDIX A Observational Checklist Results of Hospitals Question Items With Waste Management Committee With Waste Management Officer 12 (100%) With Written Waste Management Plan 12 (100%) With System of Waste Segregation (Infectious waste from non- infectious waste) Presence of Color- coding system Yes No Presence of Sharps in other container Storage area within the vicinity Yes No Presence of Practice of Burning in a Hole Yes No Presence of Practice of Dumping in a Pit Yes No Does not Practice Incineration Presence of latex gloves, boots and mask as personal protective equipment for orderlies/waste handlers Hospitals (N=12) 12 (100%)

12 (100%)

6 (50%) 6 (50%) 12 (100%) 11 (91.7%) 1 (8.3%) 3 (25%) 9 (75%) 3 (25%) 9 (75%) 12 (100%) 12 (100%)

Trolleys or carts are available for transportation of HCW Yes No

11 (91.7%) 1 (8.3%)

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APPENDIX B
Survey Questionnaire for Hospital Waste Manager Name: ______________________________

Questions
1. Are you aware of the existing government policies, laws and regulations related to healthcare waste management? 2. Does your facility form a waste management committee who develops a waste management plan for the facility? 3. Do you designate a waste management officer to supervise and coordinate the waste management plan? 4. Do you keep an up to date waste management plan? Have you ever evaluated your management plan? When? ___________ 5. Do you allocate financial resources to ensure efficient operation of the waste management plan? 6. Do you allocate personnel resources to ensure efficient operation of the waste management plan? 7. Do you monitor proper procedures in the implementation of your waste management plan? 8. Do you appoint immediate successor in the event of personnel leaving key positions in the waste management committee or temporarily assign responsibility to another staff member until a successor can be formally appointed? 9. Do you ensure adequate training for key staff members on waste segregation and disposal procedures? How many personnel do you have trained in managing hospital waste? _______________When they were last trained? ________________ 10. Do you designate staff responsible for coordinating and implementing training courses on waste segregation and disposal procedures? 11. Do you attend complaints and legal matters regarding existing and unforeseen problems arising from the implementation of the program? 12. Do you establish a good working relationship to other related

Yes

No

No idea

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agencies by proper referral, consultation and cooperation concerning healthcare waste management? Which agencies? __________ 13. Do you prepare an annual report for the disposal of healthcare waste which provides data on waste generation, equipment requirements and its cost?

( Ask for a copy )

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APPENDIX C
Survey Questionnaire for Orderlies/Waste Handlers Name: _______________________Age: _______Department: ___________Years of Service: _________ Questions Yes No No idea 1. Do you practice waste segregation? How? [ ] color- coding [ ] separate different type of waste at the point of generation. 2. Do you practice waste minimization? How? [ ] reduction at source [ ] use of reusable rather disposable products [ ] Recycling waste and process it into something new [ ] composting of food discards and kitchen waste 3. Have you received training in the past year on healthcare waste management? 4. Were you thought about the color coding for waste segregation? 5. Are you applying the color coding system in your vicinity? 6. What is the color of the bin for uncontaminated dry waste such as office supplies? (answer: Black) ______________ 7. What is the color of the bin for uncontaminated wet waste such as leftover food? (answer: Green) _______________ 8. What is the color of the bin for contaminated disposable non- sharp equipments such as gloves?( answer: Yellow) _______________ 9. What is the color of the bin for chemical waste including those with heavy metals?( answer: color yellow with black band) __________________ 10. What is the color of the bin for contaminated wastes which contain radionuclides? (answer: orange) _________________ 11. What is the color of the bin for sharps and pressurized containers? (answer: Red) ______________ 12. Do you find needles and syringes and other sharp waste mixed with infectious or general waste?

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13. Do you separate contaminated sharps such as needles and syringes from uncontaminated sharps such as broken glass and nails? 14. Are containers of sharps puncture-proof and fitted with covers? 15. Are bags and containers for infectious waste marked with the international infectious substance symbol? 16. Do you segregate radioactive wastes according to its physical form? 17. Do you place appropriate containers or bag holder in all locations where particular categories of waste may be generated? 18. Are waste collected daily (or as frequently as required) and transported to the designated central storage site? 19. Is there a storage area for healthcare waste which is enclosed and is located within the establishment? 20. Do you replace colored garbage bags immediately with new ones of the same type after disposal of waste? 21. Does the establishment utilize wheeled trolleys, containers, or carts in the transportation of healthcare wastes? 22. Do you use personal protective equipment in handling waste such as heavy-duty gloves, boots, etc.? If no, why? [ ] not available [ ] uncomfortable [ ] unnecessary [ ] others ______ 23. Are healthcare wastes transported to the municipal dump? If not, where is it thrown? ___________________ 24. Is there an on-site treatment of healthcare wastes before disposal of waste? If yes, how? ____________________________________ 24. Does the local government garbage truck collect the hospital wastes? If not, who does? _____________________ 25. What protective measures against personal injury are available? [ ] Personal protective equipment such as disposable gloves and boots [ ] availability of soap and warm water [ ] immunization against 33
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hepatitis B and tetanus infection [ ] training on how to deal with injuries and exposure in handling healthcare wastes

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APPENDIX D
Survey Questionnaire for Nurses

Name:____________________Age:___Department:_________Years of service:____

Yes 1.Is there a person assigned in your facility that is responsible for overseeing the hospitals waste management practices? Who? ________________________ 2. Do you practice waste segregation? How? [ ] color- coding [ ] separate different type of waste at the point of generation. 3. Do you practice color-coding scheme for healthcare waste? 4. Do you have separate containers for sharps? What is the color of the container? (Ans: Red)_______________________ 5. Do you occasionally mix sharps with non-sharps? 6. Do you dispose contaminated disposable non- sharp equipments such as gloves in a specific container? What is the color of the container? (Ans: Yellow) _______________ 7. Do you dispose uncontaminated dry waste such as office supplies in a specific container? What is the color of the container? (Ans: black )_______________________ 8. Do you dispose uncontaminated wet waste such as leftover food in a specific container? What is the color of the container? (Ans: Green) _________________ 9. Do you dispose contaminated wastes which contain radionuclides in a specific container? What is the color of the container? (Ans: orange)_________________ 10. Do you do any form of waste treatment prior to the disposal of infectious waste? What methods? _______________________ 11. Do you have a storage area for wastes collected prior to disposal? 12. Are waste collected daily (or as frequently as required) and transported to the designated central storage site? When is the time of collection? ______________________ 13. Does the establishment utilize wheeled trolleys, containers, or carts in the transportation of healthcare wastes?
ADZU-SOM RESEARCHES/MPH2009/MORONES,PRECILLA MADEL D.

No

No idea

35

14. Do you practice sterilization prior to the disposal of pathological wastes such as blood and body fluids? If not, how are these being disposed? ___________________ 15. Do you practice sterilization prior to the disposal of feces? If not, how are these being disposed? ___________________ 16. Are bags and containers for infectious waste marked with the international infectious substance symbol?

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APPENDIX E
Observational Checklist Questions 1. The facility has a waste management committee who develops a waste management plan for the facility. 2. The facility have a designated a waste management officer to supervise and coordinate the waste management plan. 3. There are written guidelines or a written facility plan on HCWM. 4. A system for segregation of hospital waste is being practiced. 5. Infectious waste is segregated from noninfectious waste. 6. Color-coded waste bins are present in all areas. 7. All waste bins have appropriate colored bin liners. 8. No sharps in other waste containers. 9. Hospital wastes waiting for disposal stored in an appropriate waste storage area located within the establishment. 10. There is no evidence of practice of open burning on the ground in the facility. 11. There is no evidence of practice of burning in a hole or in an enclosure in the facility. 12. There is evidence of practice of incineration in the facility. 13. There is evidence of practice of burial in the hospital premises. 14. There is evidence of practice of dumping in a pit in the facility. 15. There is evidence of practice of dumping in an unsupervised area in the facility. 16. Presence of maintenance problems with the equipment used for treatment and disposal. 17. Heavy duty gloves are available as personal protective equipment for the waste handler. 18. Latex gloves are available as personal protective equipment for the waste handler. 19. Boots are available as personal protective equipment for the waste handler. 20. Goggles are available as personal protective equipment for the waste handler. 21. Masks are available as personal protective 37
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yes

no

comments

equipment for the waste handler. 22. Apron is available as personal protective equipment for the waste handler. No available personal protective equipment for the waste handler 23. Trolleys, containers, or carts are available for transportation of healthcare wastes. 24. There is evidence of practice of sterilization prior to the disposal of pathological wastes such as blood and body fluids. 25. There is evidence of practice of sterilization prior to the disposal of feces.

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CURRICULUM VITAE PERSONAL INFORMATION

Name: Age: Sex: Civil Status: Precilla Madel D. Morones 25 Female Single

Date of Birth : September 17,1983 Address : Religion : Father : Mother : Sun St., Bamboo Drive, Tumaga Interior, Zamboanga City, Philippines Christian Manolo B. Morones Edelyn D. Morones

EDUCATIONAL BACKGROUND GRADUATE

Degree : School : Place : Medicine School of Medicine, Ateneo de Zamboanga University Zamboanga City, Philippines

Year of Graduation : 2008

COLLEGE
Degree : School : Place : Bachelor of Science in Psychology Ateneo de Zamboanga University Zamboanga City, Philippines

Year of Graduation : 2004

HIGH SCHOOL : Marian College, Ipil Zamboanga Sibugay Province

ELEMENTARY : Malangas Central Elementary School, Malangas Zamboanga Sibugay

Province 39
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