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I. A. Silva, L. P. Sant’Ana Management of healthcare waste Isis Arend da Silva¹, Luís Paulo Sant’Ana² 2Endereço para correspondência: Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM). Departamento de Ciências Biológicas, FCBS. Campus JK - Rodovia MGT 367 – Km 583, nº 5000 Alto da Jacuba CEP: 39100-000 Diamantina/MG Telefone: (38) 99244991 E-mail: [email protected] ABSTRACT Due to risks to health and environment that improperly management and disposal of waste can lead, in the last years has been an international mobilization for implementation of waste management systems. The World Health Organization published in 2014 a document on safe healthcare waste management that offers a guide for elaboration of healthcare waste management systems. According to World Health Organization a healthcare waste management systems consist of 5 steps: segregation, storage, transport, treatment and disposal. With the global pressure the trend is the development of policies around the world and the improvement of management systems. This report covers three main aspects of healthcare waste management that are in featured in the recent literature: First, the structure of the current healthcare waste management system. Second, poor healthcare waste management systems in developing countries. Finally, the importance of National Policy on Solid Waste management for the implementation of healthcare management systems. Keywords: Solid waste, waste generation, developing countries, healthcare waste Manejo de resíduo hospitalar RESUMO Devido aos riscos para a saúde e o meio ambiente que gestão inadequada e eliminação dos resíduos podem ocasionar, nos últimos anos tem-se observado uma mobilização internacional para a implementação de sistemas de gestão de resíduos. A Organização Mundial de Saúde publicou em 2014 um documento sobre a gestão segura de resíduos hospitalares que oferece um guia para a elaboração de sistemas de gestão para resíduos hospitalares. De acordo com a Organização Mundial de Saúde um sistema de gestão de resíduos hospitalares é composto por 5 etapas: segregação, armazenamento, transporte, tratamento e disposição final. Com a pressão global a tendência é o desenvolvimento de políticas em todo o mundo para a melhoria dos sistemas de gestão. Este trabalho abrange três aspectos principais da gestão de resíduos hospitalares que estão em destaque recentemente na literatura: Primeiro, a estrutura do atual sistema de gestão de resíduos hospitalares. Segundo, os sistemas precários de gestão de resíduos hospitalares em países em desenvolvimento. Finalmente, a importância da Política Nacional de Gestão de Resíduos Sólidos para a implementação de sistemas de gestão hospitalar. . Palavras-chave: Resíduo sólido, geração de resíduos, países em desenvolvimento, resíduo hospitalar UNISANTA Bioscience Vol. 9 nº 2 (2020) p. 124 - 129 Página 124 I. A. Silva, L. P. Sant’Ana INTRODUCTION because is cheaper prevent than remediate (5). This work will cover three main The current pattern of life is leading aspects of HCW management that are in to an enormous generation of different featured in the recent literature. First, the types of waste. Due to risks to health and structure of the current HCW management environment that improperly management system. Second, poor healthcare waste and disposal of waste can lead, in the last management systems (HCWMS) in years has been an international developing countries. Finally, the mobilization for implementation of waste importance of National Policy on Solid management systems (1,2,3). For example, Waste management for the implementation the Basel Convention deals with of HCW management systems. transboundary movements of hazardous, but also requires of its parties an HEALTHCARE WASTE appropriate national or domestic legislation MANAGEMENT SYSTEMS (4). The Healthcare waste (HCW) can The World Health Organization be characterized by the presence of both (WHO) published in 2014 a document on general waste and hazardous waste which safe healthcare waste management that represent serious risks to health if offers a guide for elaboration of healthcare mismanaged (5). According to WHO (5) waste management systems (HCWMS). there are five types of hazardous in the According to WHO (5) a HCWMS consist HCW: presence of infectious agents; of 5 basic steps: segregation, storage, genotoxic or cytotoxic chemical transport, treatment and disposal, each step composition; presence of toxic of is briefly described below. The author hazardous chemicals or biologically describes each step and the most safety aggressive pharmaceuticals; presence of procedures for each one, it is also radioactivity; and presence of used sharps. recommended adaptations of the steps These can transmit infectious agents that based on the local legislation or available can include HIV and hepatitis viruses B proceeds. If there is no legislation, is and C (5,6). Besides, improperly HCW recommended the use of the patterns management can spread resistant bacteria suggested by the WHO (5). Furthermore, throughout the hospital or even the city this system follows a waste management (5,7). Furthermore, chemicals and hierarchy: first waste minimization, reuse pharmaceutical waste can cause and then recycling. intoxication through acute, chronic exposure or physical injuries (5). Many of Segregation the possibilities of health damage due to HCW can lead to death, a properly HCW management save lives (5). However, The objective of waste segregation according to WHO (5) it is not just the is to separate the general waste of the about the risks, it is also an opportunity to infectious/hazardous waste which need the health care facility save money. It is special treatment (5). For safety reasons because just 20% of the waste of a the hazardous waste is usually separated healthcare facility need to receive special into two categories: used sharps and attention and management and also potentially infectious items. It is called “three-bin system”, it is a basic system of segregation. It needs to have a system of UNISANTA Bioscience Vol. 9 nº 2 (2020) p. 124 - 129 Página 125 I. A. Silva, L. P. Sant’Ana colour, preferably a national system, if international transport for treatment, there is not a national system to guide this, regulated by the Basel Convention (4). the WHO has a system of colours for that. Whereas there are none of these Furthermore, the waste needs to be stored regulations can be find, international in proper containers and labelled (5). All authorities may give guidance for transport these procedures will facilitate the disposal of hazardous, which can be found in UN and also how handling each type of waste, (4). which ensure the safety of the workers. Treatment Collection The treatment of waste aims The WHO (5) points out that the neutralizes or reduces the dangerous of collection of waste needs to be very well waste for safety disposal, protecting human coordinated. It should happen daily, but the health and environment (5). According to hazards cannot be collected together with WHO (5) the waste treatment choice the general waste for avoiding depends on many factors, the most contamination (5). All waste should be important are: “waste characteristics, market with hour and local of collection technology capabilities and requirements, for facilitate the management control and environmental and safety factors, and costs the weight should be measured. It can help – many of which depend on local to find failures with the management (5). conditions” (5). Storage Disposal According to WHO (5) the storage Most part of the waste after of waste for short-term need to be done in treatment can be disposal in a controlled or a way that the waste is out of reach for sanitary landfill. Uncontrolled landfills are patients and in properly containers to avoid environmental damaged, thus gases and leaking of undesirable substances. The best other toxic component that can release to way of do that is storage it in utility rooms. the atmosphere or reach groundwater when If it is not possible it should be storage in a the material start to decompose or react in location near of the medical facility, but contact with a different materials (5). Other away from patients and public access (5). types of healthcare waste cannot be disposal in landfill due to its harm Transport characteristics, such as products which contain heavy metals or radioactive compounds (5). According to WHO (5) the transport is separated in two phases: onsite POOR MANAGEMENT OF HCW and offsite transport. The onsite transport needs to be based on the health care facility design and the routes and timing There are few journals in this area, should be planned to ensure non but with the increased concern about contamination of workers and patients (5). hazardous waste management the focus of The WHO (5) also describes basic the most recent studies is the poor procedures for transport offsite. However, management of health care waste in WHO outlines that offsite transportation developing countries. These cases can lead may be regulated by local, regional or to situations where workers, patients and national regulations, even by international even citizens are in a position of risk of regulations and agreements in case of UNISANTA Bioscience Vol. 9 nº 2 (2020) p. 124 - 129 Página 125 I. A. Silva, L. P. Sant’Ana contamination as in the studies presented the WHO standards; all countries give below. some kind of treatment to the HCW; Cambodia, China, Indonesia, Mongolia Longe & Adenuga (3) presented a and Myanmar do not follow the standards study with twenty healthcare facilities in and LAO follow partially. Nigeria, Lagos state. The major finds were inappropriate handling, disposal, storage, Those countries that do not follow treatment and no-segregation (3). The the WHO standards for the transport of professionals involved in the healthcare HCW are transporting risk HCW at the waste collection have no instructions of same vehicle that transport general waste, management or cleaning of infectious exposing the general waste to hazardous material before disposal which put their waste (10). About the treatment of HCW in life in risk and also other professionals, Asia, such as in Nigeria, the most common patients and relatives (3). Relative to treatment is incineration, most open disposal and treatment Longe & Adenuga incineration (10). As reported by Ananth, (3) reported that part of the waste does not Prashanthini & Visvanathan (10), in receive any treatment before disposal, 70% countries economically vulnerable, where practice uncontrolled open burning and the hospitals cannot afford pay for an 10% semi-controlled and the final disposal incinerator which follow the criteria for is done in open dumps mixed with general combating secondary pollution, the waste waste. Furthermore, according to Longe & is burnt using makeshift combustion Adenuga (3) there is no system of chambers, releasing toxic compounds to segregation that enhances great the air. Furthermore, this practice usually management practice and reduce happens at the hospital facilities in the occupational health and safety risks. This external areas (10). study also showed that the current method of storage is in pits mixed with general THE ROLE OF A NATIONAL waste, it has a high risk of reach water POLICY ON SOLID WASTE resources and contaminate groundwater and surface water (3). The practice of Longe & Adenuga (8), Ananth, waste incineration is extremely dangerous, Prashanthini & Visvanathan (10) Sant’ana it lead to intoxication by toxic air (14) and WHO (5) agree that a National pollutants, and the incineration does not Policy on Solid Waste is the key for mean neutralization of the compounds in countries achieve a minimum safe pattern the waste (2,5,8,9). in HCW management. Longe & Adenuga A study about HCWMS in Asia (3), Ananth, Prashanthini & Visvanathan showed similar results, mainly for (10), reported that the reason behind the developing countries. Ananth, Prashanthini poor management in the hospitals is the & Visvanathan (1) analysed twelve lack of National or Local legislation to countries, these just four countries comply guide the healthcare facilities. A HCW with all requirements of the World Health management system is the integration of Organization (WHO) about HCW internal and external management. The management. According to Ananth, external transport and disposal are Prashanthini & Visvanathan (1) China, indispensable parts of a HCW management Indonesia an LAO do not have properly system, and if the country has not systems of waste segregation; Indonesia regulations for these steps of the process, it and Myanmar do not follow the WHO will put the public in risk independent of standards for storage and LAO, Mongolia the internal management. WHO (5) and Thailand follow partially; Cambodia, showed some alternatives in case of a Indonesia, LAO, Myanmar do not follow country there is no safe external UNISANTA Bioscience Vol. 9 nº 2 (2020) p. 124 - 129 Página 126 I. A. Silva, L. P. Sant’Ana regulations for transport and disposal, but Ministry of Health. only this way is they are just provisory measures. In many possible achieve an adequate and cases the hazardous waste need to be send sustainable management (13). to specialized facilities that are not even in the same country and a National Policy CONCLUSION ensuring the compliance with safe management is the first step for In conclusion, the current system of international cooperation (4,5). HCW management is focused on security A study in Brazil shows the harder than sustainability even considering importance of a National Policy on Solid principles of minimization, reutilization Waste: Guimarães, Sabagh & Fialho (11) and recycling. This system follow five studied the HCWMS of The National basic steps, the compliance with the five Institute of Quality Control in Health steps is essential for neutralizing the risks (INCQS). They have a computerized for health and environment. Furthermore, system that allows them track down the the studies in the developing countries waste, register the time that the waste showed clearly that the most medical remain at the institutions, date, quantity facilities are not complying with the first generated, and it also allows them make step that is segregation. It creates a chain comparative surveys and improve the reaction, since each step depend upon the quality of their management system (11). good development of the previous step. Guimarães, Sabagh & Fialho (11) reported Besides, the success of HCW that the segregation of waste has been management systems is related with the successful, the INCQS follow the national presence of laws and regulations. The role standards and regulations, a system of of a national policy on solid waste is to colours is present and there is a properly protect the people and environment, system of labelling and symbology. providing control and increasing awareness Guimarães, Sabagh & Fialho (11) also about the risks people are being submitted found the safety handling and transport are in places where the standards are not being also following the national standards. followed. Moreover, the World Health Furthermore, the waste is receiving Organization has been performing a clearly treatment before final disposal, sterilization role in the incentive to the creation of or incineration. Guimarães, Sabagh & national laws and regulations, to the Fialho (11) reported that the incineration assistance to medical facilities to improve process is being undertaken following or to implement safety measures regard to safety standards by the Environment HCW management systems and rising Agency, the toxic gases from the international awareness as well. incineration process may undergo filtration. As for the final step, that is Finally, HCW management disposal, the waste has been deposited in systems depend upon national laws and landfills (11). regulations and however, some developing countries are facing difficult in the A similar situation was reported in implementation for lack of national Mongolia, where a National System has regulation the WHO provide guidance and been improving the HCWM in the country provisory options to comply with the and facilitating the shift to environmentally safety patterns. With the global pressure friendly technology like non- incinerating the trend is the development of national technology (12). A study in Bolivia also policies around the world and the highlights the improvement in the improvement of HCW management healthcare waste management after the systems. introduction of an Integral system by the UNISANTA Bioscience Vol. 9 nº 2 (2020) p. 124 - 129 Página 127 I. A. Silva, L. P. Sant’Ana ACKNOWLEDGMENTS 665/85349/1/9789241548564_eng.pdf?ua= 1>. Viewed: 21 Jan, 2016. The authors are grateful to Griffith University. (6) STEVENS, M & DICKINSON D. Needlestick injuries in an era of HIV: technical and personal aspects. African REFERENCES Journal of AIDS Research, vol. 6, no. 1, pp. 41-48. 2007. (1) EL-FADEL, M, FINDIKAKIS, AN & (7) NOVAIS C, COQUE, TM, LECKIE, JO. Environmental Impacts of FERREIRA, H, SOUZA, JC & PEIXE Solid Waste Landfilling. Journal of LUISA. Environmental contamination with Environmental Management, vol. 50, no. vancomycin-resistant enterococci from 1, May, pp. 1-25. 1997. hospital sewage in Portugal. Applied and (2) HESTER, RE & HARRISON RM. Environmental Microbiology, vol. 71, Environmental and health impact of solid no. 6, June, pp. 3364–3368. 2005. waste management activities. Royal (8) BATTERMAN, S. Findings on an Society of Chemistry. 2002. Assessment of Small-Scale Incinerators for (3) LONGE, E & ADENUGA, I. The Health-care Waste, Water, Sanitation and challenge of healthcare waste management Health Protection of Human Environment in Ogun state, Nigeria: A case study from World Organization, Geneva. 2004 twenty selected primary health centres. (9) GAUTAM, V. Biomedical waste International Solid Waste Association management: Incineration vs. (ISWA). 2013. environmental safety. Indian Journal of (4) UNEP n.d. 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