Waste Management 29 (2009) 1370–1375

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Waste Management

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Hospital waste management in Libya: A case study

M. Sawalem, E. Selic *, J.-D. HerbellDepartment of Mechanical Engineering, Waste Management Engineering, University of Duisburg-Essen, Bismarckstr. 90, 47057 Duisburg, NRW, Germany

a r t i c l e i n f o

Article history:Accepted 21 August 2008Available online 25 November 2008

0956-053X/$ - see front matter � 2008 Elsevier Ltd.doi:10.1016/j.wasman.2008.08.028

* Corresponding author. Tel.: +49 203 379 3625; faE-mail address: eva.selic@uni-due.de (E. Selic).

a b s t r a c t

In Libya, as in many developing countries, little information is available regarding generation, handlingand disposal of hospital waste. This fact hinders the development and implementation of hospital wastemanagement schemes. The specific objective of this study is to present an appraisal of the current situ-ation regarding hospital waste management in Libya. Procedures, techniques, methods of handling, anddisposal of waste are presented, as well as the amounts and compositions of hospital waste. This researchwas conducted in the form of a case study. Fourteen different healthcare facilities in three cities, Tripoli,Misurata, and Sirt, all located in the northwestern part of Libya, were selected for investigation. Theinvestigation showed that the hospitals surveyed had neither guidelines for separated collection and clas-sification, nor methods for storage and disposal of generated waste. This deficiency indicates the need foran adequate hospital waste management strategy to improve and control the existing situation. The aver-age waste generation rate was found to be 1.3 kg/patient/day, comprised of 72% general healthcare waste(non-risk) and 28% hazardous waste. The average general waste composition was: 38% organic, 24% plas-tics, and 20% paper. Sharps and pathological elements comprised 26% of the hazardous waste component.

� 2008 Elsevier Ltd. All rights reserved.

1. Introduction

Over the past two decades, healthcare waste has been identifiedas one of the major problems that negatively impact both humanhealth and the environment. For many years, the World HealthOrganization has advocated that hospital waste be regarded as spe-cial waste (WHO, 1985), and it is now commonly acknowledgedthat certain categories of medical waste are among the most haz-ardous and potentially dangerous of all waste arising incommunities.

In Libya, the early 1980s witnessed the passage of a number ofenvironmental laws and decrees, the most important of whichwere: law of environment No. 7 (1982), law of atmosphere andair protection (1992), and law of transport of hazardous materials(2005). These legal instruments cover municipal waste manage-ment and pollution control, but they do not include specific man-dates regarding the management of medical waste. In fact, thereare no clearly defined regulations about the proper managementof hospital waste in Libya.

In the last few years, the Environmental General Authority in Li-bya has worked together with the ministry of health to create reg-ulations and instructions for medical waste management. Theseare still in development because there is minimal informationavailable regarding generation (quantities and compositions), han-dling and disposal of hospital waste. An appraisal of the current sit-uation regarding hospital waste management in Libya is essential.

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2. Aim of the study

The aim of this study is to derive an accurate description of ac-tual hospital waste management as the basis for an appropriatewaste management strategy. The specific objectives of this studyinclude conducting a survey of present practices (e.g. available pro-cedures, techniques, and methods of handling and disposing ofhospital waste), and determining the components and generationrates of the various types of hospital waste. Taking into accountthe environmental impacts, our evaluation of this data will helpto assess and propose possible treatment processes.

3. Materials and methods

Libya extends over 1,759,540 km2 and is divided into 22 dis-tricts (shabiats). The study was conducted in the cities of Tripoli,Misurata, and Sirt, situated in the central and northwestern partsof Libya. These cities were selected due to their differences in sizeand population. Tripoli is the capital and the largest city in thecountry, Misurata is representative of medium-sized cities, and Sirtis a typical small city. These cities serve a community of about 1.9million inhabitants (approx. 31% of the total population of Libya)and provide a broad range of clinical and medical services.

There are 179 hospitals in Libya (95 governmental hospitals and84 private hospitals) with a total of 21,590 beds. There are 1424primary healthcare facilities (Libyan Ministry of Health, 2006).Fourteen healthcare facilities were selected for surveying on thebasis of stratified random sampling from the three cities. This sam-ple was considered representative of different types of hospitals

M. Sawalem et al. / Waste Management 29 (2009) 1370–1375 1371

because it included two university teaching hospitals, two centralhospitals, two general hospitals, two specialist hospitals, two pri-vate hospitals, two private clinics, and two rural health centres.

Several methods were used to collect data. Survey question-naires were distributed by the author to various departments ineach hospital. In addition, the author assisted respondents in com-pleting the surveys. These questionnaires (in Arabic) were based onthose recommended by the World Health Organization for theassessment of hospital waste management practices (Pruesset al., 1999). Certain modifications were made for relevance tothe organization of health establishments in Libya. The question-naires contained information regarding the generation of wasteand the core aspects of segregation, collection, internal and exter-nal storage, transport, treatment, and ultimate disposal. Table 1summarizes the different aspects of hospital waste managementand the questions related to each aspect.

On-site inspections and interviews were conducted by theauthor after being authorized by hospital management. To supportand supplement information collected in the survey, interviewswere conducted with those managers responsible for environmen-tal healthcare in each hospital, as well as with all levels of employ-ees who work in collection, handling and disposal of hospitalwaste.

In each department of the surveyed healthcare facilities, differ-ent-colored plastic bags were distributed for waste collection. Thefollowing day, in the early morning, these plastic bags wereweighed before disposal to calculate total waste production. Forwaste analysis, 20% of the total collected waste from each facilitywas randomly chosen. The waste was analyzed and classifiedaccording to the WHO definition by hand sorting using protectiveequipment.

4. Literature survey

The World Health Organization (WHO) defines all waste gener-ated by healthcare establishments, research facilities, and healthlaboratories as healthcare waste. This healthcare waste is classifiedas non-risk or general healthcare waste, which is comparable todomestic waste, and as hazardous waste, which has the potentialto pose a variety of health risks. Hazardous healthcare wastemay also include infectious waste, pathological waste, sharps,pharmaceutical waste, genotoxic waste, chemical waste, wastewith high heavy metal content, pressurized containers, and radio-active waste (Pruess et al., 1999).

Waste produced in healthcare facilities in developing countrieshas raised serious concerns because of inappropriate treatmentand disposal practices (Diaz et al., 2005). An increase in the under-standing of health hazards posed by poorly managed healthcarewaste has influenced many countries to develop national and localstrategies in an effort to better manage their waste (Al-Zahraniet al., 2000). However, in developing countries, hospital waste

Table 1Number of questions related to aspects of hospital waste management.

No. Subject No. of questions

1. Demographic data about hospital 32. Waste management regulations 83. Waste management in hospitals 104. Hospital staff and their training 85. Waste generation 46. Waste separation 37. Waste collection-onsite transport 58. Temporary waste storage 39. Waste treatment 610. Off-site transport of waste 511. Final disposal of waste 6

has not received sufficient attention. In many countries, hazardousand medical wastes are still handled and disposed of together withdomestic waste, thus creating a great health risk to municipalworkers, the public, and the environment (Bdour et al., 2007).

Hospital waste management and the associated pollution prob-lems have attracted significant attention, and a great deal of re-search has been conducted on these topics in countries such asKuwait (Hamoda et al., 2005), India (Patil and Pokhrel, 2005), Brazil(Da Silva et al., 2005), Saudi Arabia (Almuneef and Memish, 2003),Iran (Askarian et al., 2004a,b), Jordan (Oweis et al., 2005), Mauri-tius (Mohee, 2005), and the United Kingdom (Tudor et al., 2005).

Hamoda et al. (2005) and Mohee (2005) offer a comparison ofwaste generation rates reported in different countries (Table 2).This comparison shows that developing countries have low wastegeneration rates when compared to industrialized countries in Eur-ope or the Americas. The difference is consistent with different liv-ing habits and standards, and due to the availability of treatmentfacilities.

Very few studies on hospital waste have been conducted in Li-bya (Altabet, 2004; Alhamroush and Altabet, 2005). Accordingly,research is required to establish a database, information and statis-tics on healthcare waste generation, collection, transportation,treatment and disposal. This will form the basis of planning, de-sign, technology development and implementation of waste man-agement facilities.

5. Results

5.1. Generation and classification of hospital waste

Solid waste generated by each hospital was weighed, and theaverage quantity of waste was determined. A summary of genera-tion rates from different types of hospitals is presented in Table 3.The highest generation rate of 1.5 kg/patient/day was found in theTripoli Medical Center, followed by 1.4 kg/patient/day in the Trip-oli Central Hospital. The lowest rates were found in the clinics andthe rural health centers. The average generation rate of hospitalwaste was 1.3 kg/patient/day.

The hospital waste analyzed was comprised of 28% hazardouswaste and 72% general waste. The qualitative analysis of generalwaste (Fig. 1) determined organics as the primary component(38%), followed by plastics (24%). The high plastic content is dueto the widespread use of disposables rather than reusables for var-ious purposes (e.g. bottles, packaging materials and bags used forfood). Paper had the third highest percentage (20%). Classificationof hazardous waste indicates that sharps and pathological wasterepresents about 26% of all hazardous waste as shown in Fig. 2.

5.2. Evaluation of the survey questionnaires and on-site inspections

5.2.1. Waste collection, separation and on-site transportSolid waste generated at all hospitals is collected by private

companies, packaged primarily in black plastic bags, and thentransported to on-site storage containers via uncovered trolleys.

Table 2Comparison of waste generation rates at hospitals in other countries.

Country Generation rate (kg/patient/day)

Saudi Arabia 1.1Iran 2.7France 3.3Spain 4.4United Kingdom 3.3Canada 4.1USA 4.4

Table 3Hospital waste generation rates in the surveyed 14 hospitals.

Generation rate (kg/patient/day) Generated waste (kg/day) Number of patients Number of beds Type Hospital name

1.3 477 370 480 Teaching Misurata hospital1.5 1160 800 920 Teaching Tripoli medical center1.3 168.75 135 223 General Ibn Sina hospital1.2 105.60 88 120 General Beni waled hospital1.2 272.80 220 370 Central Zliten central hospital1.4 714 510 600 Central Tripoli central hospital1.3 107.50 80 115 Private Alsaeed hospital1.2 82 66 85 Private Alshefa hospital1.2 92 77 120 Specialist Thoracic hospital1.1 108 95 133 Specialist Eyes hospital0.9 32.80 38 – Clinic Alekha clinic0.8 38.15 50 – Clinic Almowda clinic0.9 42.40 45 – Rural health center Algeran rural health center0.9 28.50 32 – Rural health center Tawerga rural health center

3429.50 2606 Total1.3 Average

Average general healthcare wastecomposition in Libya [mass%]

24%

9%8%

1%

20%

38%

0%

5%

10%

15%

20%

25%

30%

35%

40%

plastics textiles glass metals paper organic waste

[mas

s %

]

Fig. 1. Classification of general healthcare waste in Libya (mass%).

Average hazardous healthcare wastecomposition in Libya

74%

5%

21%

0%

10%

20%

30%

40%

50%

60%

70%

80%

other hazardous wastes sharps pathological waste

[mas

s %

]

Fig. 2. Classification of hazardous healthcare waste in Libya (mass%).

1372 M. Sawalem et al. / Waste Management 29 (2009) 1370–1375

This practice exposes visitors and patients to possible contamina-tion. In only two (14%) of the surveyed hospitals, a basic hospitalwaste management policy had been implemented. Sharps and nee-dles, and waste from the operating theaters are collected in closedplastic containers and plastic bags, respectively. They are thentransported to nearby incinerators.

5.2.2. On-site storageThe inspected on-site storage containers at all hospitals were in

poor condition. In eight hospitals (57%), the containers were placednear the main street within the hospital buildings or were locatedoutside, at the street-side curb (Fig. 3). Furthermore, these contain-ers were mostly uncovered, creating another potential hazard. Six

Fig. 3. On-site storage at one healthcare facility in Libya.

M. Sawalem et al. / Waste Management 29 (2009) 1370–1375 1373

hospitals (43%) had no temporary storage area, and waste was sim-ply dumped in the corner of a hospital room until it could be trans-ported off-site.

5.2.3. Hospital waste treatmentSix hospitals (43%) were equipped with incinerators. However,

only two (14%) were operational. The working incinerators exhib-ited operational problems and skilled workers were often unavail-able. The incineration process was not subject to internal orexternal monitoring.

5.2.4. Off-site transportThe municipality is responsible for off-site transportation of the

waste to the final disposal site. The frequency of collection variedfrom daily to three times a week. Municipal waste workers collectthe solid wastes from on-site storage containers and transportthem along with general domestic waste. In general, trucks and(in some cases) open tractors were used for off-site transportation(Fig. 4). The open tractors passed through residential areas, therebyincreasing potential risk to the public and the environment.

5.2.5. Final disposalAll hospitals disposed of their waste, along with general domes-

tic waste, in an open dumping site outside of the city. In these open

Fig. 4. Transportation of hospital waste in Libya.

dumping sites, hospital waste was randomly mixed with generaldomestic waste and was then buried or occasionally incinerated.

5.2.6. Training and educationOf the personnel surveyed, 85%, including managers, cleaning

staff, and environmental workers, were not trained in hospitalwaste management and did not have a detailed description of theirduties in respect of waste handling; 55% of doctors and nurseswere unaware of hospital waste management protocols andshowed insufficient knowledge of the potential hazards; and 90%of municipal workers responsible for transportation of hospitalwaste to final disposal sites had not been alerted to hazards asso-ciated with hospital waste. Complete protective equipment wasused in four hospitals (30%), while in five hospitals no protectiveequipment was used at all (36%).

5.2.7. Hospital waste management and regulationsThis study revealed that no regulations regarding the disposal of

hospital waste exist in any of the hospitals surveyed. No referenceliterature on hospital waste management was available in the jobdescription documents of hospital staff, and there were no clearlydefined procedures for collection and handling of waste in hospi-tals. No regular reports were compiled in any of the hospitals. Nodocumentation was available concerning the collection and dis-posal of waste, nor the methods used to perform these tasks.

6. Discussion

Waste generation rates depend upon several factors, such as thetype of healthcare establishment, level of instrumentation, andlocation. The higher generation rates at Tripoli were due to themedical centers in the capital of Libya being more developed gen-eral public facilities, and thus serving a larger number of patientsin comparison with other hospitals. It should be noted that theaverage waste generation rate obtained in this study lies withinthe range of values estimated by WHO (1.3–3 kg/patients/day)for countries in North Africa and the Middle East (Alhamroushand Altabet, 2005).

In general, no WHO-recommended appropriate and adequatewaste containers were used in the majority of hospitals.

As previously mentioned, incineration is the only existing treat-ment system used for infectious waste and sharps. Operational ele-ments including temperature control, height of smokestack, andrates of smoke production were inappropriate. In Libya, proper reg-ulations, standards and guidelines do not exist.

The dumping sites received negative assessments: lack of fencesto prevent access by stray animals; burying of the wastes randomlywithout any precautions related to the types of waste; and dump-ing sites located near agricultural areas and occasionally near res-idential areas.

Because of the hazards of medical waste, it is important to takeprecautions in handling, separating, collecting, and storing thistype of waste. In addition, sterilization methods are required toprevent contamination of landfill sites. The methods must becost-effective, easily implemented, and low-maintenance. Small,simple, and decentralized solutions for rural sites are as importantas waste incineration facilities in larger cities.

7. Conclusions

Nearly all hospitals in the studied area practice poor wastemanagement. Regulations regarding proper methods of waste han-dling and disposal do not exist. Studies and reports on waste man-agement were missing in all surveyed hospitals. Typically,handling of hospital waste was assigned to poorly educated work-

1374 M. Sawalem et al. / Waste Management 29 (2009) 1370–1375

ers who perform all activities without proper protection, trainingand guidance. Insufficient segregation, classification and treatmentof waste were noted at all surveyed hospitals. For the most part,hospital waste was still being dumped and mixed with domesticwaste, which was collected, transported and disposed of in a sim-ilar manner as general municipal solid waste. Environmental mea-sures or recycling programs were not available.

Our study reveals a serious need to establish and implement aproper medical waste management strategy to control and im-prove the current situation in Libya. Necessary steps include pro-tecting the safety of employees, in-patients, and out-patients.Just as important is training regarding the handling and managingof waste for all personnel in contact with medical waste. Wastemust be classified into hazardous and general medical waste. Ade-quate interim waste storage facilities must be installed, and thesemust include designated separate hazardous waste storage con-tainers. In addition, sterilization methods are essential to stop con-tamination of landfill sites by infectious waste.

This study will be followed by further investigations to examinelandfill usage of hospital waste under desert conditions, and to de-velop new and improved sterilization methods that are compatiblewith the available resources in Libya.

Annex (1) Translation of survey questionnaire for managersresponsible for environmental healthcare

1. Are you aware of any environmental legislation in Libya? If yes,please list.

2. Are you aware of any specific legislation applicable to hospitalwaste management? If yes, please list.

3. Are you aware of any regulations, guidelines, and documents onmanagement of hospital waste in Libya?

4. Who is responsible for enforcing and controlling the legislationand regulation?

5. Does a hospital waste management plan exist in Libya?6. Are there special administrative departments for hospital waste

management in the ministry of health?7. Does your hospital compile regular reports regarding hospital

waste management?

(2) Translation of survey questionnaire for employees inhospitals

(a) Hospital data8. Name of hospital...............................................................................9. Location.............................................................................................

10. Type of hospi-tal.................................................................................No. of beds(total) ........................No. of daily patients.................................

(b) Hospital waste management

11. Are you aware of any legislation applicable to hospital wastemanagement?

12. If yes, please list:13. Are you aware of any guidelines for hospital waste manage-

ment in Libya?14. If yes, please list.15. Are there manuals or guidelines for hospital waste manage-

ment in your hospital?16. Does your hospital have a waste management plan?17. Who is responsible for waste management in your hospital?18. Does your hospital have a waste management team?

19. Are there any waste management responsibilities includedin the job descriptions of hospital supervisory staff?

20. Are there any instructions from hospital managers to work-ers for dealing with hospital waste?

21. Are there any defined procedures for collecting and handlingwaste from specific units in the hospital?

22. Are there regular reports about waste that must be providedto the hospital management?

(c) Staff and their training

23. What is your job and responsibility?24. Is there a job description detailing the tasks of the waste

management staff?25. What is their qualification and level of education?26. Does the waste management staff have information about

the dangers of hazardous waste?27. Do they use protective equipment during handling of waste?

Complete () some () none ()28. Did they receive any training on hospital waste management

at the time they started their job in the hospital?29. Did they receive any training on hospital waste management

during their job?

(d) Waste generation and separation

30. How much waste is produced daily in each department?31. How much waste is produced daily in the hospital?32. What type of waste is produced generally?33. Are there any previous statistical data regarding waste gen-

eration rates in your hospital?34. Are there defined separation methods for the waste

produced?35. If yes, how?36. Are there different color codes for bags or containers for

waste collection?37. Is there any labeling on waste bags or containers?

(e) Waste collection and on-site transport

38. Who is responsible for waste collection?39. How often is waste collected?40. Are open or closed trolleys used for collection and transport?41. Are there special trolleys to transport hazardous waste?42. Are there defined routes for transportation of waste in the

hospital?

(f) Storage and waste treatment

43. Is there temporary waste storage in the hospital?44. Are wastes mixed together in the storage area?45. How long does the waste stay in the storage area?46. Are there defined procedures for waste treatment in the

hospital?47. Are there any instructions for waste treatment in the

hospital?48. What kind of waste treatment facilities are available in the

hospital?49. Are there incinerators in the hospital?50. Which types of waste are sent to incinerators?51. Is there any control of the operating conditions of

incinerators?

(g) Off-site transport and final disposal

52. Who is responsible for waste transportation to final disposalsites?

53. What kind of trucks are used to transport waste from thehospital?

54. Are there special trucks to transport hazardous waste?

M. Sawalem et al. / Waste Management 29 (2009) 1370–1375 1375

55. Are there any defined routes for transportation of waste tofinal disposal sites?

56. Where are the locations of final disposal sites?57. Are there special disposal sites for hospital waste?58. What kind of landfill is used as the final disposal site?59. Are there defined procedures for the disposal of waste?60. Are all types of waste mixed together at this site?61. How is hazardous waste disposed of?

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