Waste Management 29 (2009) 1376–1382

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Waste Management

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Medical waste management in China: A case study of Nanjing

Zhang Yong a,*, Xiao Gang b,1, Wang Guanxing a,2, Zhou Tao a,2, Jiang Dawei a,2

a Transportation School, Southeast University, Si Pai Lou 2, Nanjing, Jiangsu 210096, Chinab School of Energy and Environment, Southeast University, Si Pai Lou 2, Nanjing, Jiangsu 210096, China

a r t i c l e i n f o

Article history:Accepted 21 October 2008Available online 20 January 2009

0956-053X/$ - see front matter � 2008 Elsevier Ltd.doi:10.1016/j.wasman.2008.10.023

* Corresponding author. Tel./fax: +86 025 8379538E-mail addresses: zhang7678@126.com (Z. Yong),

(X. Gang), shiny_ever@163.com (W. Guanxing), Vjdw87@163.com (J. Dawei).

1 Tel.: +86 025 83794744; fax: +86 025 83795508.2 Tel./fax: +86 025 83793685.

a b s t r a c t

Medical waste management is of great importance due to its infectious and hazardous nature that cancause undesirable effects on humans and the environment. The objective of this study was to analyzeand evaluate the present status of medical waste management in the light of medical waste control reg-ulations in Nanjing. A comprehensive inspection survey was conducted for 15 hospitals, 3 disposal com-panies and 200 patients. Field visits and a questionnaire survey method were implemented to collectinformation regarding different medical waste management aspects, including medical waste generation,segregation and collection, storage, training and education, transportation, disposal, and public aware-ness.

The results indicated that the medical waste generation rate ranges from 0.5 to 0.8 kg/bed day with aweighted average of 0.68 kg/bed day. The segregated collection of various types of medical waste hasbeen conducted in 73% of the hospitals, but 20% of the hospitals still use unqualified staff for medicalwaste collection, and 93.3% of the hospitals have temporary storage areas. Additionally, 93.3% of the hos-pitals have provided training for staff; however, only 20% of the hospitals have ongoing training and edu-cation. It was found that the centralized disposal system has been constructed based on incinerationtechnology, and the disposal cost of medical waste is about 580 US$/ton. The results also suggested thatthere is not sufficient public understanding of medical waste management, and 77% of respondents thinkmedical waste management is an important factor in selecting hospital services.

The problematic areas of medical waste management in Nanjing are addressed by proposing some rec-ommendations that will ensure that potential health and environmental risks of medical waste areminimized.

� 2008 Elsevier Ltd. All rights reserved.

1. Introduction

During the past few years, there has been an increase in publicconcern about the management of healthcare waste on a global ba-sis (Shinee et al., 2008). Medical waste is a special category ofwaste because it poses potential health and environment risks,typically including sharps, human tissues or body parts and otherinfectious materials (Baveja et al., 2000). Approximately 15–25%(by weight) of medical waste is considered infectious (Shineeet al., 2008). Despite the fact that current medical waste manage-ment practices vary from hospital to hospital, the problematicareas are similar for all healthcare units and at all stages of man-agement, including segregation, collection, packaging, storage,transport, treatment and disposal (Tsakona et al., 2007). Improperwaste management can cause environmental pollution, unpleasant

All rights reserved.

4.xiaogangtianmen@seu.edu.cniolaZitta@yeah.net (Z. Tao),

odors, and growth of insects, rodents and worms; it may lead totransmission of diseases like typhoid, cholera, and hepatitisthrough injuries from sharps contaminated with human blood(Abdulla et al., 2008). It is of great importance to manage medicalwaste in a proper manner to avoid health risks and damage to flora,fauna, and the environment.

2. Medical waste management in China

Many studies have focused on medical waste in countries suchas Jordan (Abdulla et al., 2008), Iran (Askarian et al., 2004), Egypt(Soliman and Ahmed, 2007), Mauritius (Mohee, 2005), Korea (Janget al., 2006), Turkey (Birpinar et al., 2008), Brazil (Da Silva et al.,2005), Mongolia (Shinee et al., 2008), Greece (Tsakona et al.,2007), the USA (Lee et al., 2004), the UK (Tudor et al., 2005), andIndia (Patil and Shekdar, 2001). In many developed countries, spe-cific rules and regulations have been implemented for hospitalwaste management systems and, thus, these systems are moreeffective than those in many developing countries. The manage-ment of medical waste in many less-developed countries is oftenpoor and fraught with difficulty (Prüess et al., 1999). In manydeveloping countries such as Iran and India, there is lack of suitable

Z. Yong et al. / Waste Management 29 (2009) 1376–1382 1377

waste treatment facilities, protective measures, and efficient train-ing (Patil and Shekdar, 2001; Askarian et al., 2004).

China has historically paid little attention to the proper man-agement of medical waste, as is the case for many other developingcountries. By the end of 2003, the Ministry of Health had issued thefirst official act addressing the control of medical waste under thewaste management act and infectious ill control act, named Med-ical Waste Control Act 380 (China Department of State, 2003). Thefirst act attributes specific responsibilities to the various sectors in-volved: generators, sanitation and environment. Act 380 states thatgenerators are mandated to properly manage medical waste andthat centralized disposal of medical waste is required in China.The act also specified definitions, principles and the proceduresfor collection, transportation, temporary storage and disposal ofmedical waste. According to Act 380, medical waste is defined asany solid waste that is generated by medical treatment facilitiesand laboratory facilities operating in hospital settings that is con-sidered to be potentially hazardous to human health. In the sameyear that Act 380 was passed, the Ministry of Health and StateEnvironmental Protection Administration issued Regulation 287related to the medical waste category (China Ministry of Health,2003). According to Regulation 287, waste generated from health-care facilities is classified into five main groups, listed in Table 1.

In 2004, the Ministry of Health and State Environmental Protec-tion Administration issued the Administrative Penalty Regulation21 concerning the behaviors and the generators of improper med-ical waste management (China Ministry of Health, 2004). Further-more, Standard HJ 421-2008 (‘‘Standard of packaging Bags,Containers And Warning Symbols Specific to Medical Waste”)was implemented in 2008 (China Ministry of Health, 2008).

Although there have been efforts to construct a regulationframework related to medical waste management in China, manyinvestigations and studies have suggested that many proper wastemanagement procedures are still not being well implemented (Liuet al., 2003; Shen et al., 2003; Liang and Pang, 2005; Hua, 2005;Feng et al., 2007; Wang et al., 2008). Outside of Nanjing, manystudies have focused on the management of medical waste in citiesof China such as Foushai (Liang and Pang, 2005), Jiaozuo (Genget al., 2006), and Nanchang (Wang et al., 2008).

Recently, Nanjing, like other cities in China, has witnessed a ra-pid development in both public and private medical care establish-ments. In 1997 there were 17,599 beds in public and privatehealthcare facilities, which increased to about 20,100 by 2006.Likewise, the number of healthcare facilities in the year 1997

Table 1Classification of medical waste (China Ministry of Health, 2003).

Waste category Components

Tissues Human or animal pathological wastes, includingtissues, organs, blood, pus, and body parts andfluids

Infectious waste Blood, blood products and objects that arecontaminated with them; microbiologicallaboratory wastes; quarantine wastes; dialysiswastes; used surgical operating clothes; infectiousorgan pieces, blood and anything contaminatedwith these materials

Sharp objects Needles, syringes, broken glass, blades, and otheritems that could cause a cut or puncture

Chemical waste Hazardous chemicals, heavy metal containingwastes, pharmaceutical wastes, amalgam wastes,gynotoxic wastes, gentoxic wastes

Medicine waste Common medicines that are expired or are nolonger required or are discarded; other medicinesdiscarded that could cause cancers or geneticdiseases; the discarded vaccine products

was 1301, which increased to about 2085 by 2006. Currently, thereare 159 hospitals in Nanjing. There has been a corresponding in-crease in the number of patients being treated, adding to the al-ready large quantity of medical waste that institutions mustdispose of properly.

In Nanjing, medical waste management falls under the respon-sibility of the environment protection agencies. According to Med-ical Waste Control Act 380 and regulations, a centralized disposalsystem of medical waste has been constructed in the last few years.In 2002, 97 healthcare facilities participated in the centralized dis-posal system, which increased to about 409 by 2006. In 2002, thequantity of disposed medical waste was 298 tons, which increasedto about 2006 tons by 2006. It has been suggested that there hasbeen much progress in the centralized disposal and managementof medical waste in Nanjing (Hua, 2005); however, there are stillsome problems in the field of medical waste management accord-ing to the related Chinese regulations.

In order to improve medical waste management and develop amanagement strategy for Nanjing, it is important to understandand evaluate current practices in medical waste management.Information regarding medical waste management in Nanjing iscurrently insufficient.

The main objective of this study is to assess the current man-agement practices of medical waste in Nanjing. Medical wastemanagement was surveyed by gathering information regardingmedical waste generation, collection, segregating, storage, trans-portation, disposal, training, and public awareness to find potentialproblems. Additionally, some measures are suggested to improvethe present conditions and solve the identified problems.

3. Materials and methods

Data collection was carried out during site visits and by ques-tionnaires from July to August 2007. The survey was conductedin accordance with the recommendations of the World HealthOrganization for evaluation of medical waste management indeveloping countries (Prüess et al., 1999) and the information col-lected related to the amount of medical waste, the process of seg-regation and handling, storage, transportation, disposal, training,and public awareness.

Personnel from the Environment Protection Agency in charge ofmedical waste management were interviewed. They relayed adviceabout how to carry out the survey and provided their perspectivesof the medical waste management in Nanjing. According to theirrecommendations, 15 hospitals were selected for sampling. Thesehospitals can be divided into three categories according to the typeor services provided: 53.3% (8) are general care, 33.3% (5) are spe-cialized, and the additional two are Chinese medicine hospitals. Inthis study, ‘‘general hospitals” refers to hospitals that provide med-ical services and are typically the first patient contact; ‘‘specializedhospitals” refers to hospitals that provide medical services for aparticular group of patients; and ‘‘Chinese medical hospitals” refersto hospitals that provide Chinese medical services for general pa-tients. After interviewing the hospital director at each hospital,the hospitals were contacted by a survey team. The team met withhospital personnel involved in the management of the medicalwaste observing the process of waste collection and disposal.Waste was weighed every day for one week. According to awalk-through survey of all medical departments and facilities inthose hospitals, the team completed the survey of each hospital.

Moreover, in order to assess public awareness of medical wastemanagement, we interviewed 200 hospital patients, selected ran-domly from within the 15 hospitals, using a questionnaire. Thequestionnaire was reviewed and edited by experts from SoutheastUniversity and the Environment Protection Agency in Nanjing. The

1378 Z. Yong et al. / Waste Management 29 (2009) 1376–1382

survey questions involved seven aspects of waste management:medical waste classification; potential risks of the medical waste;disposal methods; breakdown of disposal costs; sources of medicalwaste disposal costs; degree of satisfaction of the current medicalwaste management; selection of hospitals based on their medicalwaste management practices. At the end of this survey, 164 ques-tionnaires were valid (the response rate was 80.2%).

Furthermore, three medical waste disposal companies, Jiangbei,Huifeng and Jingzhijie, were investigated by site visits. Much infor-mation regarding medical waste disposal was concerned with dis-posal technology, disposal expenditures, operationalarrangements, facility conditions, storage facilities, and monitoringprocedures.

The data forms and questionnaires were completed and storedfor further analysis. Data were coded and analyzed using SPSS 13software.

4. Results and discussion

4.1. Medical waste generation

In order to develop proper waste management strategies, it isimportant to have accurate information on the medical waste gen-eration rate. The generation rate of medical waste depends uponseveral factors such as the size of the healthcare facility, occupancyrate of hospital beds, medical waste segregation program, locationof the facility, type of healthcare facility, and type of servicesprovided.

Results from the survey suggested that 33% of the hospitals sur-veyed generated less than 100 kg each day, 47% of the hospitalsgenerated between 100 and 200 kg per day, and 20% of the hospi-tals generated more than 200 kg per day. According to this survey,the average generation rate of medical waste produced at the 15hospitals is between 0.5 and 0.8 kg/bed day with a weighted aver-age of 0.68 kg/bed day. These results were compared with the gen-eration rates determined in other studies from different cities inChina, as well as from different countries. In the study performedin the Jilin province in China, the average generation rate of med-ical waste was about 0.5 kg/bed day (Shen et al., 2003). A studyconducted by Abdulla et al. (2008) indicated that the weightedaverage generation rate was 0.83 kg/bed day in northern Jordan.Birpinar et al., 2008 investigated 192 hospitals in Turkey and re-ported an average generation rate of 0.63 kg/bed day. Mato andKassenga (1997) reported an average generation rate of 1.5–3.9 kg/bed day. Finally, Tsakona et al. (2007) reported an averagegeneration in Greece of about 1.9 kg/bed day. According to a sum-mary by Diaz et al. (2008), the total amount of healthcare wastegenerated in selected hospitals in developing countries varied from0.016 to 3.23 kg/bed day, and the percentage of infectious waste inthe total healthcare waste stream in developing countries wasabout 63% (from 0.01 to 0.65 kg/bed day).

By the end of 2006 in Nanjing, the number of hospital beds was20,100 and the average bed-occupancy was 75.59%. Thus, the totalquantity of the medical waste in Nanjing was estimated at about3771 tons in 2006, given that the average generation rate was0.68 kg/bed day for 365 workdays. Comparing this estimate withthe tons of medical waste recorded by centralized disposal in2006, it is suggested that a great deal of medical waste was re-moved by other unmanaged channels. According to this survey,there are two main problems with medical waste generationmanagement:

� Although the amount of medical waste generated for every hos-pital is monitored by the Environment Protection Agency, basedon Medical Waste Control Act 380, the medical waste weight is

only calculated by departments with the hospital. Thus, it is easyfor the hospitals to ignore other statistics of medical waste gen-eration such as the source, type, and time.

� In accordance with this survey, some hospitals surveyed havenot constructed an effective management framework for collect-ing data on medical waste generation. There is a lack trainedpersonnel responsible for collecting statistics of medical waste.

4.2. Segregation and collection

In light of Act 380, medical waste has been divided into five cat-egories: sharp waste, infectious waste, tissues waste, chemicalwaste and medicine waste. The medical waste should be segre-gated for collection by using colored bags and containers (plastic,metal or paper) as stated in the current legislation. This surveyshowed that 73% of the hospitals use segregated collection for allmedical waste, while 27% of the hospitals have not yet imple-mented segregated collection for all medical waste. The segrega-tion practices have been applied as follows: infectious waste wascollected in yellow bags; municipal waste was collected in blackbags; sharps were collected in plastic containers; and cytotoxic/cytostatic drugs were collected in their original packaging. The seg-regation practices of the selected hospitals in Nanjing were similarto the medical waste management practices reported in the litera-ture (Tsakona et al., 2007). In 80% of the hospitals, trained person-nel took charge of the collection activity, while in 20% of thehospitals they did not. From these observations, some problematicpractices were identified:

� In some hospitals, the workers handled medical waste withoutany protective equipment. In Istanbul, approximately 77% ofthe hospitals use appropriate equipment for their collection per-sonnel (Birpinar et al., 2008). As Medical Waste Control Act 380outlined, workers are required to wear appropriate uniformsand protective equipment when collecting medical waste.

� Although a system of color coding or labeling of waste contain-ers/bags has been adopted in these 15 hospitals, all hospitals didnot strictly follow the color coding system issued by nationalstandard HJ 421-2008. Because of the absence of appropriatelabeling, it is difficult for the public and workers to identifythe source and the type of medical waste.

� In some cases, infectious waste was mixed with municipal wastebecause of lack of sufficient segregation, while in other cases,the municipal waste was collected as medical waste. These prac-tices may increase the cost of disposing medical waste and therisks posed to public health and the environment.

� There is a lack of waste minimization and effective recyclingpractices.

4.3. Storage

After the medical wastes are segregated and collected, the staffshould move them from the location of generation to temporarystorage in Nanjing, based on the current regulations. The tempo-rary storage location, storage containers and storage managementhave a direct impact on the resulting environmental and healthrisks at the hospital, which must be well sanitized and securedfor access only to authorized personnel (Prüess et al., 1999).

According to the results from the survey, 93.3% of the hospitalshad a temporary storage location. This situation is better than insome other cities. Da Silva et al. (2005) reported that in southernBrazil about 85% of hospitals have external storage areas for med-ical waste management. Birpinar et al. (2008) reported that inIstanbul 63% of the hospitals have a temporary storage depot and

Z. Yong et al. / Waste Management 29 (2009) 1376–1382 1379

94% of these depots satisfy the MWCR requirements. Askarian et al.(2004) reported that in Iran 80% of hospitals have a temporarystorage area.

Of the hospitals in this study, 75% had well sanitized temporarystorage areas, compared to 26.7% of the hospitals in investigated inIran (Askarian et al., 2004). In this study, only 53.3% of hospitalsused standardized packaging containers, and only 33% of the hos-pitals had some special logo in the storage location.

Form on-site observations, some problematic aspects in thestorage practices are identified as follows:

� In some cases, locations of the temporary storage are not satis-factory and are close to the municipal waste storage. In one case,the medical waste was stored together with the municipalwaste.

� Inappropriate storage practices were observed in some hospi-tals. Although these hospitals have used containers such as blueplastic barrels, in many cases the yellow bags filled with medicalwaste were put directly on the floor of the storage location. Thispractice leads to environmental and personnel risks.

� In some cases, there are no personnel responsible for the storagelocations, such that anyone could take medical waste from thesehospitals.

� Workers typically do not wear sufficient protective gear, whichincreases the potential health risks.

� In some hospitals, storage areas were not sufficiently cleanedafter the medical wastes are transported to disposal facilities.

4.4. Training and education

Proper training must be carried out with hospital employees todevelop awareness of health, safety and environmental issues (Mo-hee, 2005). If the understanding of medical waste disposal meth-ods is increased, medical waste management will be greatlyenhanced. Each hospital in this study assigned a person to takeresponsibility for waste management while in Iran only 46.7% ofhospitals assigned a person to be responsible for medical wastemanagement (Askarian et al., 2004).

Of the hospitals surveyed, 93.3% provided training for staff atsome point, while only 20% of the hospitals had ongoing trainingand education. The survey indicated that training programs regard-ing medical waste management for doctors, nurses and technicianswere limited in Nanjing. Birpinar et al. (2008) reported that, inIstanbul, 98% of hospitals organize courses for their collection per-sonnel, and healthcare services organize training programs regard-ing medical waste management for doctors, nurses, andtechnicians; almost 63% of healthcare services organize coursesat least once a month, while 31% organize courses at least twicea year. Askarian et al. (2004) reported that 60% of hospitals in Iranprovided some training for cleansing staff; however, newly hiredwaste management personnel were not trained properly. Abdullaet al. (2008) reported that 29% of the hospitals in northern Jordanhad not provided training to doctors and other personnel regardingmedical waste management and the related hazards; 57% ofhospitals provided limited training for support staff (maintenanceengineers, cleaning workers). In developed countries, such as theUSA, there are effective training programs and educational plansrelated to medical waste management for all staff (Askarianet al., 2004).

According to the survey, some problematic areas were found inthe field of training and education:

� There is a lack of sufficient training and education programs forall hospital staff. In some hospitals, the training and educationprograms were only focused on the doctors and nurses, while

the cleaning workers and technicians did not receive any train-ing regarding how to deal with medical waste to avoid relatedrisks.

� The training and education mechanism in some hospitals havenot been developed. In these hospitals, there is a lack of effectiveorganization controlling and evaluating the performance of thetraining and education programs for medical waste manage-ment. In fact, some hospital staff lack proper understanding ofmedical waste management despite being trained and educatedseveral times a year.

4.5. Transportation

According to Act 380, Nanjing has constructed a central disposalsystem for medical waste. The hospitals have the responsibility forproviding on-site transport of medical waste, while off-site trans-port to the final disposal site is handled by disposal companies.These companies are also in charge of the final disposal of medicalwaste in Nanjing. Medical waste is transported through pre-estab-lished routes, which include specific corridors and elevators oneach floor, and are strictly used to transport waste from the inter-mediate storerooms to the final storerooms in the basement of thehospital (Askarian et al., 2004). The disposal companies arrange forspecial trucks to collect medical waste from various hospitals onceevery 1–2 days. Commonly, the off-transport times are determinedby the transport distances and the quantity of medical waste.According to scientific standards, infectious waste in tropical areascan be kept in a temporary storage area for 24 h during the hot sea-son and up to 48 h in cooler seasons (Prüess et al., 1999). The sche-dule for collection of medical waste by the disposal company wasoften uncertain, which creates a more complex problem for thesehospitals.

The off-site transport activities are organized by the disposalcompanies. The off-site transport costs are included in the totaldisposal costs paid by the hospitals. Some problems were observedat the off-site transport stage for medical waste:

� The truck routes are still not monitored by the Environment Pro-tection Agency. In some cases, the medical wastes were lost inthe process of off-site transport activity. In contrast to this situ-ation, in 2002, an on-line manifest system was established tomonitor the medical waste transportation in Korea (Jang et al.,2006).

� The drivers and the trucks do not always strictly follow Act 380.According to the requirements of Act 380, licenses are requiredfor the drivers of the trucks that transport medical waste.

� In many cases, the medical waste was transported by impropermethods. For example, the drivers or workers handle the medi-cal waste bags manually with no protective measures.

� The logistics containers are not fully used in the procedure oftransport, which often increased the risks to people and theenvironment. Additionally, the plastic and paper bags wereoften punctured by some sharp medical waste items.

� Medical waste was often transported together with industrialwastes.

4.6. Disposal of medical waste

Centralized disposal of medical waste has been implemented inNanjing since 1997. According to Act 380, hospitals are not permit-ted to dispose of their own medical waste. Three private disposalcompanies, Jiangbei, Huifeng and Jingzhijie, are responsible formedical waste disposal generated from the hospitals in Nanjing.The Environmental Protection Agency is responsible for monitor-

Table 2Responses by patients to questionnaire on medical waste management in Nanjing.

Question Response

1. Do you know about the medicalwaste and its categories?

Very clear (1%); clear (20%); medium(33%); not clear (46%)

2. What are the potential risks ofmedical wastes?

Great risks (49%); medium risks (46%);a few risks (1%); no risks (0%); not clear(4%)

3. What type of facility will beresponsible for final disposal ofmedical waste in Nanjing?

Special disposal facility (72%); solidwaste incinerator (12%); solid wastecollecting station (5%); other places(11%)

4. What is the breakdown of themedical waste management costs?

Dedicated containers investments(18%); monitoring facilities (31%);transportation costs (31%); disposalcosts (40%)

5. Are you satisfied with the medicalwaste management in Nanjing?

Very satisfied (1%); satisfied (9%);medium (53%); unsatisfied (27%); veryunsatisfied (10%)

6. Who do you think should pay formedical waste management costs?

Patients (24%); local government(39%); disposal companies (17%);hospitals (20%)

7. Are the medical waste managementpractices an important factor for youin selecting hospital services?

Very important (2%); important (35%);medium (40%); unimportant (22%);very unimportant (1%)

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ing the disposal of all medical waste. From this survey, the medicalwaste generated from all selected hospitals was transported to thecentralized disposal facilities. The disposal costs of medical wasteis about 580 US$/ton, while in northern Jordan the monthly costof disposal is between 70 and 1330 US$/month (Abdulla et al.,2008).

There are several medical waste disposal methods, such asincineration, steam sterilization (or sanitation), microwave sanita-tion, chemical disinfection, dry heat disinfection, and disinfectionwith superheated steam (Jang et al., 2006). Only incineration tech-nologies have been implemented by the three disposal companiesin Nanjing. Currently, the major fraction of healthcare waste col-lected in developing countries is incinerated (Diaz et al., 2005).With the strict environmental protection regulations and laws,the incineration technology has received some criticism from thepublic and researchers in recent years. The disadvantages havebeen discussed in many studies (Jang et al., 2006; Lee et al.,2004; Diaz et al., 2005). Medical waste incinerators can emit vari-ous toxic pollutants such as carbon monoxide, particulate matter,and hydrogen chloride; have high operation and maintenancecosts; and require ash disposal.

Some problematic areas were identified in the stage of medicalwaste disposal:

� Medical waste disposal options are limited, and small-scaleincinerators have been used as a last solution. Incinerators emita variety of harmful pollutants, including particulate matter,mercury, dioxins and furans.

� Each company incinerates about 2 tons of medical waste everyday. Because the quantity is low, there are no economies of scaleand the disposal cost is high.

� The emissions of medical waste incinerators and the ash dis-posal were not strictly monitored in this survey.

� Each company is responsible for disposal in some region in Nan-jing. Thus, the collection of medical waste from various hospitalsis often not in accordance with Act 380.

� Medical waste storage practices need improvement, and second-ary pollution can occur in the disposal facilities.

� In some cases, workers responsible for the medical waste incin-erators lacked necessary training and knowledge.

� A disposal cost mechanism has not been developed based on themarket economics. Higher disposal costs often encourage somehospitals to dispose of medical waste themselves.

� The disposal companies sometimes disposed medical wastetogether with municipal waste by means of incineration.

4.7. Public awareness of medical waste management

Seven questions in the questionnaire were related to publicawareness of medical waste management. The questions and re-sponses are given in Table 2. It is important for medical wastemanagers to take public awareness into account in developing aneffective strategic program in Nanjing.

From the questionnaire survey, some valuable conclusions areidentified:

� Public understanding of medical waste procedures is lacking.Moreover, the survey showed that people under age 40 hadmore awareness of medical waste, likely due to a generallyhigher level of education.

� The majority of respondents were confused about the differ-ences between medical waste, recyclable waste and ordinarygarbage, and how they should be handled and disposed.

� The respondents thought that medical waste management costsare ranked as follows: disposal costs, monitoring facilities con-struction costs, dedicated container investments and transporta-tion costs.

� In constructing a creative operational mechanism for improvingwaste management, it is interesting to note that 24% of respon-dents stated they were willing to pay the related medical wastemanagement costs.

� The majority of the respondents are considerably dissatisfiedwith the medical waste management in Nanjing.

� Only 23% of the respondents considered medical waste manage-ment as unimportant or very unimportant when selecting hospi-tal services. These results suggest that if the hospitals improvetheir medical waste management, their market credibility willbe enhanced.

5. Conclusions

The number of private and government hospitals in Nanjing isconstantly increasing. This leads to an increase in the total quantityof medical waste generated from various hospitals. Although theMinistry of Healthcare together with State Environmental Protec-tion Administration has developed regulations aimed to ensureappropriate handling and processing of medical waste, there is stillneed to put these regulations into practice based on integratedmedical waste management options. To achieve this, current med-ical waste management practices in Nanjing should be evaluatedfrom the viewpoint of integrated management. In conclusion, themain findings of this study are identified below:

� The medical waste generation rate ranged from 0.5 to 0.8 kg/bedday with a weighted average of 0.68 kg/bed day.

� The segregated collection of various types of medical waste hasbeen conducted properly in 73% of hospitals, but 20% of the hos-pitals still use inappropriate personnel for medical waste collec-tion. Protective measures, the color coding systemimplementation, waste minimization management, and effec-tive recycling practices were not sufficient in some cases.

� 93.3% of the hospitals had temporary storage areas. Some stor-age practices were not strictly conducted in accordance withthe requirements of the regulations.

� 93.3% of the hospitals surveyed have provided training for staff,while only 20% of the hospitals had ongoing training and educa-tion. This suggests that there is a lack of sufficient training and

Z. Yong et al. / Waste Management 29 (2009) 1376–1382 1381

education programs for all hospital staff and that the trainingand education mechanism in some hospitals is still notdeveloped.

� Centralized disposal of medical waste has been implemented inNanjing based on incineration technology. The disposal cost ofmedical waste is about 580 US$/ton; the quantity of medicalwaste is low and does not allow for economies of scale. Storagemanagement, worker training, disposal transaction mechanismsand emissions monitoring are still insufficient.

� Survey respondents showed various levels of understandingof medical waste categories, risks, costs and disposal meth-ods. There was insufficient and improper understanding ofmedical waste risks and management by many respondents,and 77% of respondents thought that the medical waste man-agement was an important factor when selecting hospitalservices.

6. Recommendations

The current practices of medical waste management in Nanjingwere observed and some problematic areas were identified. Basedon these findings, it can be noted that there is potential to improvethe medical waste management in the local context. To overcomethese obstacles, some recommendations are presented for differentaspects of medical waste management.

� Generation– A medical waste minimization management framework

should be implemented in order to reduce the amount ofmedical waste generated by hospitals (Mohee, 2005).

– Apart from the weight, the types, sources, and the character-istics of medical waste generated should be monitored basedon the information system.

– There is a need to manage the life-cycle of every type of med-icine in hospitals, which consists of purchasing, using, collec-tion, segregation, transportation and final disposal.

� Segregation and collection– Proper training should be provided to everyone involved in

the waste management process regarding appropriate segre-gation practices and the potential hazards associated withimproper procedures such as handling without protectivemeasures (Tsakona et al., 2007).

– A system of color coding or labeling of waste containers/bagsaccording to the requirements of the national standard HJ421-2008 should be used consistently.

� Storage– Strict control of temporary storage areas should be imple-

mented. Only medical waste handlers should be allowed toenter these areas.

– Proper locations of temporary storage areas should beenforced, i.e., away from other functional areas, such asmunicipal waste storage areas.

– There is a need to keep the storage areas clean.– Good quality logistics containers should be purchased.

� Information system application– The information system of the hospitals needs to be

improved.– There is a need to improve the RFID technology implemented

in the hospitals.

� Training and education

– Training and education programs for all personnel should beconducted; training of new staff and cleaning workers shouldbe emphasized.

– The effectiveness of training and education programs shouldbe periodically evaluated.

� Transportation

– A manifest on-line system should be implemented to moni-

tor transportation routing of medical waste.– Fixed schedules for transportation should be defined, thus

reducing the complexity of medical waste management.– Good quality transportation containers/packaging for medi-

cal waste should be used.

� Disposal

– In order to create environmental benefits, it is necessary forNanjing to renew disposal facilities and the technology ofmedical waste disposal. New alternative disposal technolo-gies that are more environmentally friendly should be imple-mented (Diaz et al., 2005).

– The market mechanism must be introduced to balance theinterest conflicts between hospitals, government, disposalcompanies and the patients, because the disposal costs aredirectly determined by the Environmental Protection Agency.

– Professional training of workers should be strengthened,especially regarding how to deal with ash.

– Some advanced operators for medical waste disposal shouldbe introduced from other cities or abroad to create marketcompetition of Nanjing.

– Ash and air pollutants generated from medical waste inciner-ation, such as HCI, CO, Hg, Cd, and SO2 should be measured.

– Workers’ health and safety in disposal facilities should beprotected by the use of proper protective clothing and by fol-lowing safety guidelines.

– The monitoring system should be improved by installing airpollution control systems.

� Public awareness– The participation and enthusiasm of the general public and

their knowledge of medical waste should be enhanced byusing various techniques, such as propaganda boards, theinternet and the public welfare advertisements.

– A medical waste strategy in Nanjing should be evaluated byanalyzing the public’s awareness of medical wastemanagement.

Acknowledgements

This study was funded by National Natural Science Foundationof China (No. 50806013). The authors would also like to gratefullyacknowledge the assistance of professors from the US. We aregrateful for valuable comments and suggestions for improvementsfrom these anonymous reviewers.

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