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~Life Science Journal, 3 (2) ,2006, Panyzping, et al, Medical Waste Management Practices in Thailand

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Medical Waste Management Practices in Thailand..

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Klinpratoom Panyapingl, Benedict Okwumabua2~

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1 . Department of Environmental Engineering, Rajamagala University of Technology

Lanna (RMTUL), Northern Campus, Chiang Mai 50300, Thailand

2. Michigan Department of Environmental Quality, Waste and Hazardous Materials Division,..

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Warren, Michigan 48092, USA

Abstract: Inappropriate medical waste management practices (WMPs) can cause hazards and risks that affect notonly the generators and operators but also the general community. An investigation of WMPs in hospitals in Thai-land has shown similar and different patterns of medical WMPs consisting of infectious waste, solid waste and haz-ardous waste, including wastewater practices. The quantity of infectious waste generated from different size of hos-pitals in Chiang Mai is at a rate of 0.17 kg/dlbed to 0.97 kg/dlbed. Most hCA'ipitalshave an incinerator wheremedical waste is burned. The ash from the incinerator should be properly disposed in a landfill. Solid waste in hospi-tals is sent to a municipal landfill. In some hospital, there is a thriving recycling program. Some hazardous waste iseither burned or sent to a private secured landfill. Others are collected in hospitals and stored for disposal. However,the assigned government agencies and a manual for helping them solve waste problems are needed. All hospitalshave wastewater treatment plants (WWTP). Some WWTP need advice for coping effectively with the WWTPproblems. In order to provide more effective WMPs in hospitals, a standard operating procedure (SOP) and regula-tions for segregation of infectious waste, solid and hazardous wastes must be developed. The SOP should outline themethod for handling hospital wastes, how to collect, segregate, treat and dispose of these wastes. Furthermore,the agency responsible for regulating incinerators and WWTPs in the hospitals should regularly visit and inspectthese facilities for improving their efficiency and solving problems when they occur. [Life Science Journal. 2006; 3(2): 88- 93] (ISSN: 1097- 8135).

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Keywords: waste management practices; medical waste; regulations; standard operating procedure J

Abbreviations: SOP: standard operating procedure; WMPs: waste management practices; WWTP: wastewater treat-ment plants

1 Introduction

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According to the World Health Organization(WHO), the waste produced by health care facili-ties carries a higher potential for hazards and risksfrom infection and injury than any other kind ofwaste[J]. Medical waste or hospital waste consistsof infectious, radioactive and toxic substances, aswell as unsafe material from activities in clinics andlaboratories in hospitals. It includes human bloodand blood products wastes, tissues, animal wastes,microbiology laboratory wastes, radioactive andchemical wastes, pharmaceutical, sharp wastes inaddition to general waste like paper, food and plas-tics[2]. Based upon the WHO 1994 report of hospi-tal waste in America, Netherlands, and France,about 85 % of the hospital wastes are actually non-hazardous waste, 10 % are infectious waste and 5%are non-infectious waste but hazardous wastes. Al-though infectious and hazardous wastes from hospi-

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tals occur in small quantity of waste, there is a highpotential of serious threat to spread out various dis-eases and hazardous materials from these wastes dueto improper disposal of dumping and burning. Thepoor management of medical waste poses risks topublic health and the environment, especially, interms of the transmission of disease by viruses andmicroorganisms, contamination of underground wa-ter tables by untreated medical waste in landfills, aswell as contamination of ambient air by uncon-trolled burning. The problem of medical waste dis-posal in hospitals has become an issue of increasingconcern, prompting hospital administration to seeknew ways of safe and cost effective management ofthe waste, and keeping their personnel infoTInedofthe advances in this field. In Thailand, the esti-mated quantity of infectious waste by PollutionControl Department (PCD) in 2000 was reportedto be a total of 13,250 tons or 36. 1 ton/day[3].These are generated from both government and pri-vate hospitals. Of 22 tons of infectious wastes are

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Life Science Journal, 3 (2) ,2006, Panyaping, et al , Medical Waste ManagemEnt Practices in Thailand(.[.. generated in the regional part while about 24. 1

tons of these wastes are generated in Bangkok andthe nearby area.1.1 Waste management program

The concept of waste management programhas been introduced to many activities, namely, in-dustries, business and commercial, communities,houses, and hospitals. It includes waste minimiza-tion, reduce/reuse and recycle, incinerator andlandfill. The adoption and promotion of this pro-gram are still very limited in the hospitals becauseaccrediting system is not functioning due to somebarriers, such as government regulations on medicalwaste management, lack of support from hospitaladministrators, and poor environmental awareness.Therefore, the commitment of hospital directors tobetter management is the most important criterionin promoting the waste management program tohospitals. Without support from the hospital direc-tors, good government regulations and better envi-ronmental awareness of the staff, introduction ofwaste management program will be difficult.1.2 Waste management procedures

It consists of waste collection and segregation,

storage, transportation, treatment and disposal[4J.Segregation of waste is the most important step inthe process of waste management. It allows man-agement of small quantities of waste thereby reduc-ing the risks as well as cost of handling and disposalof a large mingled waste. Segregated waste need tobe stored in identifiable containers, and must sepa-rate infectious waste from hazardous waste. The

general waste or solid waste and non-hazardouswaste transportation should be kept separate frominfectious waste and hazardous waste. The trans-

portation containers should be properly enclosed.The driver must be trained to follow established

procedures in case of traffic accidental spillage[5J .1.3 Medical waste treatment technologies

There are several medical waste treatment

technologies, namely, mechanical, thermal, chem-

ical, and irradiation processes[4,6,7J.Mechanical process is used to change the phys-

ical form of the waste to facilitate waste handling.It consists of compaction and shredding. Com-paction involves compressing the waste into con-tainers to reduce its volume. Shredding is used tobreak the waste into smaller piece. This process isnot considered acceptable for medical waste treat-ment by itself.

Thermal process is designed to use heat at lowtemperature « 150 "C) and high temperature(600 - 5,500 "C) to decontaminate medical waste.The thermal processes include autoclaving, mi-

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crowave treatment, and incineration. Autoclave is asteam sterilization technique that uses steam to con-tact with the waste directly to disinfect the waste.Microwave treatment is designed to use the electro-magnetic radiation spectrum lying between the fre-quencies 300 and 300,000 MHz to inactivate mi-crobial organism. Incineration processes use hightemperature (800 - 1, 050 "C) combustion undercontrolled conditions to convert wastes containinginfectious and pathogenic material to inert materialresidues and gases. It gives a significant volumeand weight reduction and it sterilize the waste.There is limitation of the incinerator due to the oc-

curring pollution during operation. It is needed tocontrol its temperature.

Chemical process involves the use of chemicalslike chlorine compounds for disinfection. This sys-tem needs shredding step in order to provide suffi-cient control between the waste and disinfectants.

Irradiation process is designed to use ultravio-let or ionizing radiation for irradiating and steriliz-ing the medical waste. .

Among these technologies, autoclave and in-cinerator methods are mostly used as a sequence fortreatment and disposal of infectious waste.1.4 Laws and regulations for waste management

In Thailand, there are 4 major Acts related tohospital waste, namely, Public Health, Industry,Factory, and National Enhanced and Preservation

of Environmental Quality Act, 1992[8J.

2 Objectives

Through this study, the assessment of existingWMPs and the quantification of medical waste gen-erated in Chiang Mai hospitals were performed inorder to propose the best WMPs of hospitals.

3 Materials and Methods

The data were collected by surveying and in-terviewing the key informants who respond towaste management in hospitals and using a ques-tionnaire which broadly included information on thetype, quantity of waste generated and existing dis-posal, including all WMPs. The categorization ofthe hospital waste was attempted according to theMinistry of Public Health Notification for InfectionWaste Managementm, 2002, and the related regu-lations under the 4 major Acts as mentioned above.The study was carried out in hospitals in Thailandin 2004 as shown in Table 1.

4 Results and Discussion

The waste management procedures and prac-

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amputated human body parts. A limitation of theincinerator is that air pollution problem during op-eration could not be controlled effectively. More-over, the ash from incinerator has never been ana-lyzed.

In some hospitals, the ash is buried in the hos-pital grounds. Furthermore, the operation andmaintenance cost of incinerator is very high. Thus,the medium and small hospitals prefer to send theirinfectious waste for treatment in private incinera-tors or big hospital incinerators.

The treatment and disposal of hazardouswastes is also another problem of hospital waste dueto the quantity of hazardous waste that needs notonly special handling and storage but also specifictreatment and disposal. In this case, the manual orstandard operating procedure (SOP) should providethe important information for handling, storage,transportation, treatment and disposal of hazardouswaste. In several hospitals, some liquid chemicalwaste can be recycled but others are discharged tothe WWTP. Although all hospitals have their ownWWTP (Table 3), some of them were experienc-ing problems with their WWTP due to the lack ofexperienced operators for maintenance and opera-tion of the wastewater treatment system. There-fore, problems of wastewater quality were foundduring monitoring.

The quantity of medical waste generated inkilograms per day from different hospitals is shownin Table 4. It is found that the total quantity ofwaste generated from all medium and small hospi-tals was lower than the waste generated from bighospitals. Perhaps it is due to the big hospitals be-ing equipped with modern facilities, and peopleprefer this kind of hospital for health care andtreatment. It is noted that the solid waste or gener-al waste in big (3,000 kg/day) and medium hospi-tal « 830 kg/day) was higher than that in smallhospital « 300 kg/day). The amount of haz-ardous waste in medium and big hospitals was inthe same range (about 5 kg/day), but the quantityof this waste in small hospital is not available. Insome hospitals, liquid hazardous waste was alsogenerated. On comparison of unit (kg/daylbed)contribution of infectious waste, it is found that thebig government university hospitals contribute themost. However, the quantity of medical waste cansignificantly be reduced if the hospital avoided theuse of disposable medical care materials.

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Life Science Journal, 3 (2),2006, Panyaping, et al, Medical Waste Management Practices in Thailand

tices in hospital are shown in Table 2. The sourcesof hospital waste come from patients and related e-quipment and laboratory, various wards, X-ray andpharmaceutical room, building, housing and can-teen. The existing of WMPs in hospital showedthat most hospitals have similar problems associatedwith the procedure of medical waste management.There is handling (including initial handling, stor-age, and transportation) problem that needs to beimproved in order to decrease the potential of occu-pational risks. For example, the transportation of

, infectious waste in hospital should use elevator thatdelivers only product materials. The 'container thatprovides for general waste and infectious wasteshould have enough number of contai~er in order toseparate infectious waste from solid waste atsource. If the infectious waste is contaminated withhazardous waste, it should be considered as haz-ardous waste and should be separate from infectiouswaste. In the case of infectious waste and haz-ardous waste, it should have secondary containmentto protect any leak of waste from packaging duringtheir collection, storage, and transportation.

Table 1. The sample of hospital in Chiang Mai, ThailandSize & Type Number of unit Number of bed

1. Big, G 1 1,400

2, Medium, G 1 531

3. Medium, P 1 400

4. Medium, P 1 350

5. Small, P 1 180Note: G = Government,P = Private

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In some medium hospitals, there are recyclingprogram that generate income {or the hospital.This program should be expanded to other hospi-tals. In the process of storage, ,all hospitals havethe color code and label system to identify the wastecontainer. For example, black container is used forgeneral or solid waste, yellow container is used forbottles and fluorescent lamps, and red container isused for infectious waste. The containers are madefrom plastic. In all hospitals, the treatment anddisposal of medical waste, particularly, the infec-tious waste is a very critical step in the process ofwaste management. Most of this problem comesfrom the treatment technology. Presently, inciner-ator is the only accepted treatment option to treatinfectious waste such as organic matter, tissue or

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Life Science]aurnal , 3 (2) ,2006, Panyaping, et al ,Medical Waste Management Practicesin Thailand

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"Procedure

\ I. 8olid Waste(SW)

- 8ource

- Segregation

- Storage

- Transportation

- Treatment &Disposal

II. HazardousWaste(HW)

- 8ource

- Segregation

- Storage

- Transportation

- Treatment &

Disposal

III. Infectious

Waste (IW)- 8ource

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- Segregation

- Storage

- Transportation

- - Treatment &

Disposal

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Big,Government

- Buildings,housing &canteen

- At source &separate fromIW

- Black bag &Big bin- In (carriage& lift) & out(Truck)

- MunicipalLandfill

- Wards, X-ray& pharmaceuti-cal rooms

- Chemical

Bottle, Battery,fluorescent lamp

- Yellow Bin

- In (carriage& lift) & out(Truck)- Privatecompany

- Patients &related equip-ment & lab.- At source &separate fromSW

- Red bag &Bin

- In (carriage& lift) & out(Truck)

Autoclave,incinerator &Municipal land-fill

Table2. Procedure of WMPs in hospitals

Size & Type of Hospital

Medium,Government



- Black bag &Big bin


- Recycle &Disrasal in Mu-nicipallandfill


- Chemical


- Identifiedcontainer- In (carriage& lift) & out(Truck)

- Storage fordisposal

- Patients &

related equip-ment & lab.- At source &

separate fromSW

- Red bag &Bin

- In (carriage& lift) & out(Truck)- Autoclave,incinerator &Municipal land-fill

Medium,Private

-Buildings,housing &canteen


- Black bag


- MunicipalLandfill


- Chemical


- Identified Bin


- Storage fordisposal

- Patients &


separate fromSW

- Red bag &Bin


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Medium,Private


- At source&separate fromIW

- Black bag


- MunicipalLandfill


- Chemical


- Identifiedcontainer

- In (carriage& lift) & out(Truck)- Private

company

- Patients &


separate fromSW

- Red bag &Bin


Small,Private

-Buildings,housing &canteen

- At SOurce&separate fromIW

- Black bag


- MunicipalLandfill


- Chemical


-Bin


- Municipal'landfill

- Patients &


separate fromSW

- Red bag &Bin

- In (carriage& lift) & out(Truck)- Autoclave,incinerator &Municipal land-fill r.

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Life Science Journal, 3 (2),2006, Panyaping, et al, Medical Waste Management Practices in Thailand

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Size & Type

1. Big, G

2. Medium, G

3. Medium, P

4. Medium, P

5. Small, P

Table 3.

Type of WWTP

Activated Sludge

Activated Sludge & Oxidation Ditch

Activated Sludge I Aerated Lag=n

Activated Sludge

Activated Sludge

Wastewater treatment plant in hospitals

Main problem

WWTP maintenance and operation

No expertise operator & WWTP maintenance and operation

Same

Same

Same

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Table4.

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Quantity of medical waste generated in hospitals

Type of waste Quantity generated (kgl day)

Infectious waste 0.97 kg/daylbed (1352.08)

Solid waste 3,000Hazardouswaste 4 - 5

Infectious waste 0.53 kg/daylbed (279)Solid waste 830

Hazardous waste 3 - 5

Infectious waste 0.17 kg/daylbed (100)Solid waste 300

Hazardouswaste

Infectious waste

Size & Type

1. Big, Government

2. Medium, Government

3. Medium, Private

4. Medium, Private

5. Small, Private

Solid waste

Hazardous waste

Infectiouswaste

Solid waste

Hazardous waste

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6.7 IIday (liquid chemical waste)

0.17 kg/daylbed (29.89)

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5 Conclusions

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The WMPs in hospitals are drawn from the in-vestigation as follow:

1) All hospitals sent general waste or solidwaste to the municipal landfill.

2) The handling of medical waste should beproperly implemented within hospitals and sent offsite for disposal.

3) An adequate infrastructure for collectionand transportation of the waste within and fromeach hospital to treatment facilities should be pro-vided.

4) A pollution prevention plan should be pre-pared and hospital staff should be trained on theplan's implementation.

5) The incinerator should be improved and in-spected t-o reduce the impact on air quality prob-lem.

6) WWTP should be inspected regularly andbe required to solve occurring problems.

7) A manual for handling hazardous wasteshould be prepared to cope with this waste in hospi-tals. The small quantity of hazardous waste shouldbe accumulated until sufficient quantity is stored for

transportation to the treatment and disposal facilitythat is located in the central part of Thailand, a

long distance away, to avoid high cost of disposal.8) The quantity of infectious waste in big hos-

pitals is a higher rate (0.97 kg/daylbed) than thatin medium hospital (0.17 - O.53 kg/daylbed) andsmall hospital (0.17 kg/daylbed).

9) The standard operating procedure (SOP)that contains the outline of handling method, howcollection, segregation, treatment and disposal aswell as the regulation for segregation of infectiouswaste from hazardous waste should be clearly devel-oped and operated.

10) Assigned agency should visit and inspecthospital's treatment facilities such as incineratorsand wastewater treatment plants in order to im-prove the efficiency of these facilities and to solveproblem when they occur.

11) Moreover, a website to promote efficientdissemination of information and to improve exist-ing medical WMPs as well as to reduce environmen-tal pollution and health hazards in the region shouldbe done.

In conclusion, based upon the result of thisstudy, it is recommended that the procedure of the

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Life Science Journat, 3 (2) ,2006, Panyaping, et al ,Medical Waste Management Practices in Thailand

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best WMPs in hospital should be provided as theSOP for implementation by the hospital staff.Moreover, tht; laws and regulations related to seg-regation of infectious waste from hazardous wasteshould be urgently imposed.

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AcknowlegmentsThis paper is a part of the study project on de-

velopment of hazardous waste business in the north-ern part of Thailand. The authors would like tothank RMUTL, Chiang Mai and Fulbright Thai-land-US Educational Foundation for the cooperationin this project. Thanks also go to the staff of gov-ernment and private hospitals for their ge~erousprovision of information and fruitful discussionsthroughout this study.

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Correspondence to:Klinpratoom Panyaping, Ph. D. .

Department of Environmental EngineeringRajamagala University of Technology Lanna (RM-TUL)Northern Campus, Chiang Mai 50300, ThailandEmail: [email protected] ;klinpratoomp@yahoo. com

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References

1. World Health Organization. Managing Medical Wastes inDeveloping Countries. 1994.

2. Ministry of Public health. Notification for InfectiousWaste Management. Available from http: / /www. ana-maio moph. go. th/[2004 September 1] 2002.

3. Pollution Control Department, Ministry of Science,Technology and Environment. State of Thai Environ-ment in 1999. Thailand. 2000.

4. George T chobanoglous, Hilary Theisen, Samuel Vigil. In-tegrated Solid Waste Management Engineering Principlesand Management Issues. McGraw-Hill, Inc. USA.1993;978.

5. USEPA. Office of Solid Waste/Communications, Infor-mation, and Resources. Management Division. RCRAOrientation Manual. Section II, Ill, and V. 1998.

6. Michael D. LaGrega,Phillip L Buckingham,JeHrey C E-vans. Hazardous Waste Management. McGraw-Hill Com-panies, Inc. USA. 2001; 1202.

7. Reinhardt PA and Gordon JG. Infectious and Medical

Waste Management. Lewis Publishers, USA. 1991;280.

8. Pollution Control Department, Ministry of Science,Technology and Environment. Laws and Standards onPollution Control in Thailand, 4th 00. , 2000; 285.

Received February 14, 2006

medical waste management practices in thailand j · the advances in this field. in thailand, the...

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