Đánh giá kiến thức về quản lý chất thải y tế của nhân viên bệnh viện Đồng Nai

The study had achieved its main aim exploring the knowledge of health staff about HCW management. There were 393 health staff including doctors, nurses and hospital orderlies enrolled and five aspects of knowledge of HCW management including classification, segregation, collect, transportation and storage, and treatment and disposal of HCW evaluated in the present study. For the knowledge of classification of HCW, the overall proportion of participants knew the knowledge was 84.48%. Similarly, the knowledge of segregation of HCW had reached the percentage equal of 77.35%. The knowledge of transportation and storage of HCW was 78.88%. The remaining knowledge including collection and treatment and disposal of HCW had gained a low percentage, yielding 65.39% and 41.22%. Đề tài có trích dẫn Endnote thuận tiện cho sinh viên và nghiên cứu viên tham khảo

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EVALUATING THE KNOWLEDGE OF MEDICAL WASTE MANAGEMENT WITHIN MEDICAL STAFF AT BIEN HOA HOSPITAL IN PROVINCE of

DONG NAI

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WASTE MANAGEMENT WITHIN MEDICAL STAFF AT BIEN HOA HOSPITAL IN PROVINCE of

DONG NAI

Graduate student:研Pham Thi Kim Hoa Supervisor研Yung-Yu Su, PhD.

Meiho University Graduate Institute of Health care

Health-care waste (HCW) is now not a problem of developed countries butalso developing countries Along with the large extent of health care system, theauthorities of developing countries have to solve the puzzle in managing of increasingHCW Vietnam also follows this trend in which HCWs are generated uncontrollablyyear by year Poor management of HCW can threaten public health due to the fact thatHCW cause a variety of bad impacts on health conditions of health-care staff whodirectly deal with HCW, patients, and general population and on surroundingenvironment as well

HCW management in Vietnam faces a variety of difficulties Many health-carefacilities throughout the country still collect and dispose of HCW together withdomestic wastes Moreover, the knowledge of HCW management that has a crucialimpact on practice of HCW among health-care workers may not high as expected.Hence, the aim of the present study is to investigate the knowledge about HCWmanagement among health-care staff working in Bien Hoa General Hospital, BienHoa Health Center and 30 health stations in Dong Nai province To achieve this aim,the following objectives are described: (1) To identify the knowledge about existence

of HCW management document, segregation and collection of HCW, transportation ofHCW, treatment and disposal of HCW among health-care staff dealing directly toHCW management; (2) To examine the associations between the knowledge andcharacteristics of health-care staff dealing directly to HCW management

The study had achieved its main aim exploring the knowledge of health staffabout HCW management There were 393 health staff including doctors, nurses andhospital orderlies enrolled and five aspects of knowledge of HCW managementincluding classification, segregation, collect, transportation and storage, and treatmentand disposal of HCW evaluated in the present study

For the knowledge of classification of HCW, the overall proportion ofparticipants knew the knowledge was 84.48% Similarly, the knowledge ofsegregation of HCW had reached the percentage equal of 77.35% The knowledge oftransportation and storage of HCW was 78.88% The remaining knowledge includingcollection and treatment and disposal of HCW had gained a low percentage, yielding65.39% and 41.22%

First of all, I would like to express my deepest gratitude to my supervisor, Dr.Yung-Yu Su and other professors, who spent valuable time in instructing me tocomplete this thesis I could not fulfil my thesis without profound knowledge,invaluable advices and supports from my professors All of these made me put moreefforts to finish my thesis

I am also grateful to acknowledge Professor, Dr Chung, Tiech-Chi, the chairman

of graduate committee, for his consultancy, encouragement, motivation and inspirationthroughout my study in Nursing Department

Many special thanks were also sent to the Board of Directors of Nguyen TatThanh University for supporting me during my study I will always remember alluniversity officers for their help, cooperation and kindness during my study period inViet Nam as well as in Taiwan

I would like to thank the Management Board of II Postgraduate Program in DongNai province, the Directorate and the staff of the Department of Science andTechnology in Dong Nai province who have supported me from the beginning to theend of my study I would like to thank the Director of Bien Hoa General Hospital, Dr.Trang Vo Tan, the Director of Bien Hoa Health Center, and Dr Nguyen Xuân Hungwho have allowed and facilitated me in collecting data for this research I won’t forget

Dr Mai Van Dan, the Head of External Division of Bien Hoa General Hospital, for hisencouragement and supports

I would like to send my special thanks to health-care staff in departments of BienHoa General Hospital, Bien Hoa Health Center, 30 commune health stations and theDepartment of Environmental Health of Public Health Institute at Ho Chi Minh Citywho has provided precious documents used as reference in my study

My great gratitude was also given to officers, librarians, staff of dormitory ofMeiho Institute of Technology for their help and sharing as close friends during mytime of studying in Taiwan

I express my deep gratitude to Mrs Nguyen Thi Minh Chau, lecturer of PhamNgoc Thach Medical University, and Mrs Katrina, lecturer of Nguyen Tat ThanhUniversity who have spent precious time to help me to improve my English

in giving help and useful information during the data collection of the study process.Finally, I am eternally indebted to my family who have always behind me in mycareer advancement and without their helps and concerns I could not complete mythesis.

Page

Table 4.1 Demographic characteristics of health-care staff 45

Table 4.2 Knowledge about existence of and access to HCW management documents .47

Table 4.3 The proportions of health-care staff knowing about types of waste 47

Table 4.4 Knowledge about classification of health-care waste 49

Table 4.5 Knowledge about segregation of health-care waste 50

Table 4.6 Knowledge about collection of health-care waste 52

Table 4.7 Knowledge about transportation and storage of health-care waste 53

Table 4.8 Knowledge about treatment and disposal of health-care waste 55

Table 4.9 Knowledge about classification of health-care waste and characteristics of health-care staff 57

Table 4.10 Knowledge about segregation of health-care waste and characteristics of health-care staff 59

Table 4.11 Knowledge about collection of health-care waste and characteristics of health-care staff 60

Table 4.12 Knowledge about transportation and storage of health-care waste and characteristics of health-care staff 61

Table 4.13 Knowledge about treatment and disposal of health-care waste and characteristics of health-care staff 63

Abstract i

Acknowledgements ii

List of tables iii

Chapter 1 Introduction 1

1.1 Statement of this research 1

1.2 Significance of this research 2

1.3 The aim of the study 3

1.4 Chapter summary 4

Chapter 2 Literature Review 5

2.1 Introduction 5

2.2 Definition of health-care waste 6

2.3 Classification of health-care waste 6

2.4 Practices of health-care waste management worldwide 13

2.5 Current international normative framework for HCW management 16

2.6 Current situation of health-care waste management in Vietnam 19

2.7 Contents of Decision No.43/2007/QD-BYT 26

2.8 Relevant studies on knowledge of health-care waste management 34

2.9 Chapter summary 39

Chapter 3 Research Methodology 41

3.1 Introduction 41

3.2 Research design 41

3.3 Research framework and hypotheses 41

3.4 Sampling issues 42

3.5 Data management and data analysis strategy 43

3.6 Ethic issues 44

3.7 Chapter summary 44

Chapter 4 Results 45

4.1 Introduction 45

4.2 Demographic characteristic of health-care staff 45

4.3 Knowledge about existence of and access to health-care waste management documents 46

4.5 Knowledge about segregation of health-care waste 50

4.6 Knowledge about collection of health-care waste 52

4.7 Knowledge about transportation and storage of health-care waste 53

4.8 Knowledge about treatment and disposal of health-care waste 54

4.9 The relationships between knowledge and characteristics of health-care staff 57 4.10 Summary 64

Chapter 5 Discussion 65

5.1 Introduction 65

5.2 Discussing the significance results of findings 65

5.3 The principal research findings 79

5.4 Contributions and implications 80

5.5 Limitations 81

5.6 Recommendation for further research 81

5.7 Conclusion 82

References

Appendix 1 Commentation from nursing ethic committee for scientific study of Bien Hoa General Hospital

Appendix 2 The self-administered questionnaire

Chapter 1 Introduction

1.1 Statement of this research

Today health-care waste (HCW) is a crucial public health and environmental issuefor all countries over the world In United States, HCW is the third largest source ofwaste, with hospitals discarding more than 2 million tons of waste annually (Everson,2010) For developing countries, the problem draws more concern due to theincreasing development of health care services in those countries Every year, over0.33 million tons of HCW is generated in India (A D Patil & Shekdarf, 2001) It isalso estimated that there is about 0.25 million tons of HCW generated annually inPakistan (Government of Pakistan, 2005) High-income countries generate an average

up to 0.5 kg of hazardous waste per bed per day; while low-income countries generate

an average 0.2 kg of hazardous waste per bed per day (WHO, 2011b) However, HCW

is often not separated into hazardous and non-hazardous wastes in low-incomecountries making the real quantity of hazardous waste much higher (WHO, 2011b)

HCW with poor management could have negative health impacts on health careworkers, waste handlers, patients and the community (WHO, 2013) Occasionally, thepublic is exposed to radioactive waste, which originates from radiotherapy treatmentand is disposed of improperly Serious accidents have been documented in Brazil in

1988 (where four people died and 28 had serious radiation burns) (IAEA, 1988),Mexico and Morocco in 1983, Algeria in 1978 and Mexico in 1962 (WHO, 2007a).InJune 2000 six children were diagnosed with a mild form of smallpox (vaccinia virus)after having played with glass ampoules containing expired smallpox vaccine at agarbage dump in Vladivostok, Russia Also in 2000, World Health Organization(WHO) estimates that injections with contaminated syringes caused 21 millionhepatitis B virus (HBV) infections, 2 million hepatitis C virus infections and 260,000HIV infections worldwide In addition, waste and by-products can also cause injuriessuch as radiation burns, and sharps-inflicted injuries (WHO, 2011b)

Many materials utilized in health-care facilities can also result in the release ofhazardous substances into environment (Laustsen, 2007) Incinerated materialscontaining chlorine can form dioxins and furans (Emmanuel et al., 2001), which arehuman carcinogens and can pose a variety of adverse health effects Incineration of

heavy metals or materials with high metallic content (in particular lead, mercury andcadmium) can lead to the spread of toxic metals in the environment (WHO, 2011b)

In accordance with increasing development of health care facilities, HCWmanagement is now a great concern of Vietnamese government According to a survey

of Department of Therapy, Ministry of Health, between 2009 and 2010 the total ofHCW in the whole country was approximately 100-140 tons/day, of which 16-30tons/day was hazardous HCW The HCW average was 0.86 kg/bed/day, of whichhazardous HCW constitutes 0,14-0,2 kg/bed/day (MOH, 2011) Recognized theproblem, in 2011 the "Prime Minister Decision No: 798/QĐ-TTg on the approval ofthe solid waste treatment investment program for the period 2011 to 2020" was issued(Prime Minister Decision, 2011) The target for the first phase (2011–2015) is the safemanagement and treatment of 85% of the total HCW and within the second phase(2016–2020), 100% of the total non-hazardous and hazardous HCW will be collectedand treated according to the existing standards

HCW management in Vietnam, however, engages a variety of difficulties Manyhealth-care facilities throughout the country still collect and dispose of HCW togetherwith domestic wastes (Acid Deposition and Oxidant Research Center, 2001) There is

of 63.6% hospitals used PE or PP bags, those are not recommended in nationalregulations, to collect HCW (IOMD., 2006) The collection efficiency is 40–67% ofgenerated HCW in big cities and 2–40% in small towns, while the average collectionrate is only about 53.4% (Asian Productivity Organization, 2007) There is stillinconsistency in the technology for collection and transportation of HCW, with a mix

of different forms (Asian Productivity Organization, 2007) For treatment and disposal

of HCW, various problems have also been identified such as lack of investment forHCW management, lack of incinerators for hazardous HCW, and environmentalpollution resulting from HCW treatment activities etc

1.2 Significance of this research

Bien Hoa City is one of the largest cities of Dong Nai province with a completehealth care system The health care system includes one general hospital (Bien HoaGeneral Hospital) which is responsible for clinical treatment, one Health Center and

30 health stations responsible for preventive health care During their operations, thehealth-care facilities have discharged a large number of HCW including both non-

hazardous and hazardous waste In the first six months of 2013, the total amount ofinfectious waste originated from Bien Hoa General Hospital is approximately 1.4 tonsand the figure will increase in the next decades (Dong Nai Health Service, 2013).Regarding to response to this urgent issue, each of health-care facility has made greatefforts to reduce HCW Nevertheless, many difficulties still exist that lead to lesseffectiveness of HCW management in the whole health care system Many health-carefacilities, especially those at commune level, do not have good practices in segregationand collection of HCW In addition, lack of equipments for segregation and collection

of HCW, poor quality of waste containers, open storage areas, and lack of incineratorsfor hazardous HCW have been addressed but not resolved yet

There is a variety of causes that lead to the mentioned difficulties, but inadequateknowledge of HCW management of health-care staff could be the most important one.With inadequate knowledge, health-care staff could perform wrong practices of HCWmanagement that in turn could result in negative impacts on their health and public,and even the surrounding environment Investigation knowledge of HCWmanagement of health-care staff therefore is necessary for health-care facilities toimprove practices of HCW In 2013, a preliminary study conducted in Bien HoaGeneral Hospital and Bien Hoa Health Center showed that the overall knowledge ofhealth-care staff was relatively high (T K H Pham, 2013) However, with the hope ofdepicting more detailed knowledge of health-care staff in the whole health care system

in Bien Hoa city, the present study was carried out The findings of the study wereused as database to point out the gaps on knowledge of HCW management amonghealth-care workers in Bien Hoa city and suggest solutions to fulfil these gaps

1.3 The aim of the study

The aim of the present study is to investigate the knowledge about HCWmanagement among health-care staff To achieve this aim, the following objectives aredescribed:

1 To identify the knowledge about existence of HCW management documents,segregation and collection of HCW, transportation of HCW, treatment and disposal

of HCW among health-care staff dealing directly to HCW management

2 To examine the associations between the knowledge and characteristics of care staff dealing directly to HCW management

health-1.4 Chapter summary

HCW is now not a problem of developed countries but also developing countries.Along with the lager extent of health care system, the authorities of developingcountries have to solve the puzzle in managing of increasing HCW Vietnam alsofollows this trend in which HCWs are generated uncontrollably year by year Poormanagement of HCW can threaten public health due to the fact that HCW cause avariety of bad impacts on health conditions of health-care staff who directly deal withHCW, patients, general population and surrounding environment as well

There are many warning reports indicating HCW is now a big problem of BienHoa city (one of largest cities of Dong Nai province), since the amount of HCWs israising but the management of HCW is still limited and ineffectively One ofunderlying causes of the poor management of HCW is the lack of knowledge of HCWmanagement among health-care staff working at health-care facilities located in thecity The studying of knowledge of HCW management of health-care workers isimportant but to date there are not any comprehensive studies conducted yet.Therefore the aim of the study is to identify the knowledge about HCW management

of health-care staff dealing directly to HCW management

Chapter 2 Literature Review

2.1 Introduction

Health-care activities are a means of protecting health, curing patients and savinglives However they also produce waste with 20% of which posing risks either ofinfection, of trauma or of chemical or radiation exposure (WHO, 2011b) Although therisks in accompany with hazardous HCW and measures of HCW management are welldocumented in international guidelines and many studies, the practices of HCWmanagement globally are still big problems that many governments have to deal withthese days, especially developing countries where technical and financial resourcesand a legal framework are still limited

This chapter describes a variety of aspects concerning to the study fromdefinition of HCW to studies on knowledge of HCW management of health-care staffworldwide Firstly, the definition of HCW is provided so that the audience have a clearconcept of HCW used in this study Five defined types of HCW including infectious,sharp, anatomical, chemical and radioactive waste and their impacts on public healthare also mentioned In the next section the audience could find a summary of globalpractices of HCW management that depicts increasing difficulties in each stage ofHCW processing To deal with global problems of HCW, international organizationshave made many efforts to develop standardized guidelines on HCW management butunfortunately that has not yet been done

The second part of this chapter largely focuses on the situation of HCWmanagement in Vietnam The Vietnamese health care system with more than 13,000health facilities at all level takes care of the increasing quantity of patients, so theamount of HCW generated each day increases as well It could be said that HCWmanagement in Vietnam is ineffective with enormous problems existing fromsegregation to disposal of HCW The government has published many official paperssuch as law, decrees, and decisions to form a national framework of wastemanagement, and Decision No 43/2007/QD-BYT is the most updated paper involving

in HCW management To end this chapter, a summary of studies on knowledge ofHCW management among health-care staff is added

2.2 Definition of health-care waste

HCW although is defined by 2013 WHO guideline shows a variation in definitiondepending on practical settings of different countries WHO defines HCW as allwastes generated within health-care facilities, research centres and laboratories related

to medical procedures In addition, it includes the same types of waste originatingfrom minor and scattered sources, including waste produced in the course of healthcare undertaken in the home (e.g home dialysis, self-administration of insulin,recuperative care) (WHO, 2013) However, by the guideline of HCW management ofTanzania, HCW is defined as any solid waste generated in diagnosis, treatment orimmunization of human beings or animals, in related research, production or testing ofbiological from all type of healthcare institutions, including hospital, clinics, doctor,offices, and medical labs (Manyele, 2004) In Decision No 43/2007/QĐ-BYTapproved by Vietnamese government, HCWs are defined in a simple concept as solid,liquid or gas wastes generated from health-care facilities including hazardous and non-hazardous HCW (Ministry of Health-Socialist Republic of Vietnam, 2007)

2.3 Classification of health-care waste

It is known that not all HCW is hazardous for human health Indeed, most ofHCW (approximately 75 to 90 per cent of the total amount of waste) is general HCW(non-hazardous HCW) that does not pose any particular risk to human health or theenvironment (Rutala et al., 1998; WHO, 2013) It comes mostly from theadministrative, kitchen and housekeeping functions at health-care facilities and mayalso include packaging waste and waste generated during maintenance of health-carebuilding The remaining 10-25% of HCWs is regarded as "hazardous" and may create

a variety of health risks if not managed and disposed of in an appropriate manner(Rutala, et al., 1998; WHO, 2013)

For hazardous HCW, it may be classified into different types of waste according

to the source, type and risk factors associated with its handling, storage, transport anddisposal These include (a) infectious waste; (b) sharps waste; (c) anatomical andpathological waste; (d) chemical and pharmaceutical waste; and (e) radioactive waste

2.3.1 Infectious waste

Infectious waste, accounting for 10% of all HCW, is material containingpathogens such as bacteria, viruses, parasites or fungi in a sufficient concentration thatcould result in infectious diseases (WHO, 2013) Infectious agents may enter thehuman body through several routes including puncture, abrasion or cut in the skin,mucous membranes, inhalation, and ingestion Mia et al (2012) conducted a study toinvestigate HCW management practices in many health facilities in Bangladesh andthey found that among 110 respondents being directly involved in HCW management,63% were affected by one or more diseases such as diarrhoea, hepatitis B and C, andskin diseases.

According to 2013 WHO guidelines, infectious waste includes wastecontaminated with blood or other body fluids, cultures and stocks of infectious agentsfrom laboratory work, and waste from infected patients in isolation wards (WHO,2013) Waste contaminated with blood or other body fluids could be any material,tools used in health-care settings and contaminated with patient’s blood or body fluid,whereas laboratory cultures and stocks are highly infectious waste due to containinghighly infectious agents Waste from infected patients in isolation wards includesexcreta, dressings from infected or surgical wounds, and clothes heavily soiled withhuman blood or other body fluids (WHO, 2013) Waste from non-infective patients isnot considered as infectious waste and waste from non-isolation ward may beclassified either infectious or non-infectious waste based upon the practical setting ofeach health-care facility

Incineration and modern technologies such as autoclaving, microwave are oftenthe choices of disposal of infectious waste in health-care facilities (Cole, 2000) Themodern technologies are used with higher frequency in developed countries, whileincineration is an interim method that is used by most of hospitals in less developedcountries Since most of incinerators often operate at low temperatures and do notfollow high standards, they pump into the environment toxic pollutants and hazardouschemicals such as dioxins, furans which cause bad effects on human health

2.3.2 Sharp waste

Sharps are items that could cause cuts or puncture wounds, including needles,hypodermic needles, scalpels and other blades, knives, infusion sets, saws, brokenglass and pipettes (WHO, 2013) Since being able to contact with skin, blood andother body fluids of patients, such items are usually considered highly hazardousHCW

Potential risks of sharp waste

Sharp waste may not only cause physical injuries (cuts and punctures) but alsoexert infected wounds if it contains infectious agents It is estimated that more thantwo million health-care workers are exposed to percutaneous injuries with infectedsharps every year (Prüss-Üstün et al., 2005) Infected syringe needles in accordancewith unsafe injection practices could highly result in transmitting blood-bornepathogens, including hepatitis B virus, hepatitis C virus and HIV A 1999 report of theCenter for Disease Control and Prevention (CDC) showed that there were 191American health-care workers had been acquired occupational HIV infection(Beltrami et al., 2000) In the year 2000, WHO estimated that injections withcontaminated syringes caused 21 million cases of hepatitis B infection, 2 million cases

of hepatitis C infection and 260.000 cases of HIV infection among health-care workers(WHO, 2011b) In 2009, 240 people in Indian state of Gujarat developed hepatitis Bdue to injections with used syringes those were later discovered to have been boughtthrough a black market trade of unregulated health care waste (Solberg, 2009)

Sharp waste management

The basic principle for disposal of sharp waste is to collect sharps waste inpuncture-resistant containers that prevents sharp waste from causing injuries andinfections for waste handlers After that, sharp waste could be disposed by differentmethods such as incineration, autoclave, and burying in sharp pits (WHO, 2005c).Regarding used syringes, plastic and needle portions must be treated separatelywith proper processes A study in Ukraine used mechanical needle cutters to divideplastic and needle portions of syringes, treated both parts with autoclaves and thenremelted the plastics in recycling plants and buried or melted the needles in a foundry(Laurent, 2005) The same process with a light difference has been applied in a pilotstudy by the Swiss Red Cross in Kyrgyzstan in which after autoclaving, needles wereshredded in a locally made hammer-mill shredder, whereas plastics were sold to aplastics manufacturer that remelted the plastics to make coat hangers, flower pots andother commodities (Emmanuel, 2006) In Guyana, needle cutters were also used, butthe plastic portions were treated as infectious waste and the needle portions werecollected in a 45-gallon plastic barrel with an aluminium funnel (Furth, 2007)

2.3.3 Anatomical and pathological waste

By nature, pathological waste could be considered a subcategory of infectious

waste; however it is often classified separately due to the fact that special methods ofhandling, treatment and disposal are used Pathological waste consists of tissues,organs, body parts, blood, body fluids and other waste from surgery and autopsies onpatients with infectious diseases It also includes human fetuses and infected animalcarcasses (WHO, 2013) Recognizable human or animal body parts are sometimescalled anatomical waste Most of anatomical and pathological wastes, do notnecessarily entail a health risk or risk for the environment but must be treated asspecial wastes for ethical or cultural reasons (International Committee of the RedCross, 2011)

Pathological waste management

Two traditional methods of disposal of pathological waste that have been usedwidely in many countries are interment in cemeteries or special burial sites andburning in crematoria or specially designed incinerators (WHO, 2013) Several otheradvanced technologies such as alkaline digestion and promession (a newer technologydesigned especially for human cadavers) have been also utilized In some countries,placenta waste is composted or buried in placenta pits designed to facilitate naturalbiological decomposition (WHO, 2013)

2.3.4 Chemical and pharmaceutical waste

Pharmaceutical waste includes expired, unused, spilt and contaminatedpharmaceutical products, prescribed and proprietary drugs, vaccines and sera that are

no longer required, and discarded items heavily contaminated during the handling ofpharmaceuticals, such as bottles, vials and boxes containing pharmaceutical residues,gloves, masks and connecting tubing (WHO, 2013) Genotoxic waste, a subcategory

of pharmaceutical waste, is highly hazardous and may include certain cytostatic drugs(alkylating agents, antimetabolites, and mitotic inhibitors), vomit, urine or faeces frompatients treated with cytostatic drugs, cytotoxic drugs, and chemicals and radioactivematerial (WHO, 2013) In specialized oncological hospitals, genotoxic waste mayconstitute as much as 1% of the total HCW (WHO, 2013)

Chemical waste consists of discarded solid, liquid and gaseous chemicals withtoxic, corrosive, flammable, reactive, and oxidizing properties produced fromdiagnostic and experimental work and from cleaning and disinfecting procedures(WHO, 2013) Some of common types of instrument or tool used for health-careactivities containing hazardous chemical waste are photographic fixing anddeveloping solutions, disinfecting and cleaning solutions, insecticides and

rodenticides, discarded batteries, mercury thermometers, reinforced wood panels inradiation proofing in X-ray and diagnostic departments, pressurized cylinders,cartridges and aerosol cans

Potential risks of chemical and pharmaceutical waste

Genotoxic waste or more specifically cytostatic drugs may cause bad affects onintracellular processes such as DNA synthesis and mitosis and that in turn leads tocarcinogenic or mutagenic conditions and secondary neoplasia occurring after theoriginal cancer has been eradicated by using chemotherapy (WHO, 2013) Manycytotoxic drugs are extreme irritants and have harmful local effects after direct contactwith skin or eyes Cytotoxic drugs may also cause dizziness, nausea, headache ordermatitis (WHO, 2013)

To date, little data on the long-term health impacts of genotoxic waste isdocumented due to the fact that it is hard to assess the human exposure of this type ofwaste Sorsa et al (1985) reported an excess of spontaneous abortions duringpregnancy and malformations in children of females who had been treated withanticancer agents earlier A later study in Canada also demonstrated that conclusion(Valanis et al., 1999), while a meta-analysis found only significant associationbetween exposure to cytotoxic drugs and spontaneous abortion (Dranitsaris, 2005).Chemical wastes may cause intoxication, either by acute or chronic exposure, orphysical injuries with the most common being chemical burns (WHO, 2013).Intoxication can result from absorption of a chemical or pharmaceutical through theskin or the mucous membranes, or from inhalation or ingestion Injuries to the skin,the eyes or the mucous membranes of the airways can occur by contact withflammable, corrosive or reactive chemicals (WHO, 2013)

With the same reason like genotoxic waste, the impacts of chemical waste topublic health are difficult to be recorded and measured as well However, WHO notedthat pharmacists, anaesthetists, and nursing, auxiliary and maintenance personnel may

be at risk of respiratory or dermal diseases caused by exposure to chemicals andpharmaceuticals (WHO, 2013) Reduction of this type of occupational risk could bedone through substitution of hazardous chemical or pharmaceuticals wheneverpossible and provision of protective equipments to all at risk personnel Additionally,personnel handling hazardous materials should be trained in preventive measures andemergency care in case of accident (WHO, 2013)

Chemical and pharmaceutical waste management

For small quantities of pharmaceutical waste, the available methods of disposalare return of expired pharmaceuticals to the donor or manufacturer, encapsulation andburial in a sanitary landfill, chemical decomposition in accordance with themanufacturer’s recommendations, dilution in large amounts of water and dischargeinto a sewer for moderate quantities of relatively mild liquid or semi-liquidpharmaceuticals (WHO, 2013) If the amount of pharmaceutical waste is huge, thedisposal options may include encapsulation and burial in a sanitary landfill,incineration in kilns equipped with pollution-control devices designed for industrialwaste and that operate at high temperatures, dilution and sewer discharge for relativelyharmless liquids such as intravenous fluids (salts, amino acids, glucose) (WHO, 2013).For cytotoxic waste, three options could be chosen for disposal including return

to the original supplier, incineration at high temperatures, chemical degradation inaccordance with manufacturers’ instructions (WHO, 2013) It should be noted that asincineration is the choice the temperatures of incinerators must be up to 1200°C and aminimum gas residence time of two seconds in the second chamber (WHO, 2013) Ifthese criteria could not be met, the incineration process may release hazardouscytotoxic vapours into the atmosphere

Because of the complexity of chemicals waste produced from health-caresectors, the disposal of this category of waste needs a national strategy with aninfrastructure, cradle-to-grave legislation, competent regulatory authority and trainedpersonnel (WHO, 2013) The disposal method should be a combination of measuresand depend upon the nature of hazard presented in the waste To health-care facilitiesbeing lack of technical and financial resources, the most appropriate method may bereturn chemical waste to the original supplier

2.3.5 Radioactive waste

Radioactive wastes are materials contaminated with radionuclides and areproduced as a result of procedures such as in vitro analysis of body tissue and fluid, invivo organ imaging and tumour localization, and various investigative and therapeuticpractices (WHO, 2013) There are two sources of radionuclides including unsealedsources and sealed sources Unsealed sources are usually liquids that are utilizeddirectly, while sealed sources are radioactive substances contained in parts ofequipment or encapsulated in unbreakable or impervious objects, such as pins, “seeds”

or needles (WHO, 2013)

Potential risks of radioactive waste

The affect of radioactive waste on human health depends on the type and extent

of exposure to this type of waste The consequences could be from headache, dizzinessand vomiting to much more serious problems such as severe injuries, tissuedestruction and even death (WHO, 2013) Massive impacts of radioactive waste oncommunities have not been reported yet, except several accidents resulting fromimproper disposal of radioactive waste A tragedy related to radioactive wastehappened in Brazil in which a victim opened a radioactive sealed source; consequently

249 people were exposed to radioactive waste, of whom several died or sufferedsevere health problems (International Atomic Energy Agency, 1988) Other recordedaccidents often involve exposure to ionizing radiations in health-care facilities as aresult of unsafe operation of X-ray apparatuses, improper handling of radiotherapysolutions or inadequate control of doses of radiation during radiotherapy (WHO,2013)

Radioactive waste management

In most cases, radioactive waste often has a short time of decay, so the wasteloses its radioactivity relatively quickly The treatment needed for radioactive wastetherefore is segregation and storage for decay before further treatment to eliminatebiological hazards and/or release into the environment (WHO, 2013) Other optionsfor disposal of radioactive waste are return to supplier and long-term storage at anauthorized radioactive waste disposal site

2.3.6 Non-hazardous general waste

Non-hazardous or general waste is waste that has not been in contact withinfectious agents, hazardous chemicals or radioactive substances and does not pose asharps hazard (WHO, 2013) It accounts for approximately 85% of all waste producedfrom health-care facilities and has similar properties like municipal solid waste(WHO, 2013) Some common types of general waste are paper, cardboard andplastics, discarded food, metal, glass, textiles, plastics and wood

2.4 Practices of health-care waste management worldwide

2.4.1 Health-care waste management planning in health-care facilities

Planning helps health-care facilities define the strategy for the implementation of

improved waste management and the allocation of roles, responsibilities andresources A comprehensive plan describes the actions to be implemented byauthorities, health-care personnel and waste workers (WHO, 2013) However, in manyhealth-care facilities, a HCW management plan is often neglected by authorities due tounderestimation of its importance A study in Nigeria showed that hospitals did nothave any inspective program of HCW management and no plan for treatment anddisposal of HCW in the hospitals (Longe 2006) Another study conducted in India byWHO in three different level hospitals (general, divisional, and township hospitals)showed that none of hospitals had a written waste management policy or plan, orprovided waste management training for employees Furthermore, none of hospitalshad a coding system for waste segregation so that health care staff did not know how

to segregate and collect HCW (Cole, 2000) A study in South Africa investigatedHCW management in a hospital showed that there was no clear policy and plan inplace for managing medical waste There is no definite policy or plan for purchasingthe necessary equipment and for providing the facilities for the correct management ofmedical waste in the hospital The hospital has a medical waste management guidelineprepared by the head of infection control but this is not strictly followed (Abor, 2007)

2.4.2 Health-care waste segregation, collection, storage and transportation

It is recommended that all health-care facilities should be segregated at sourceseparately HCW and general waste However, the reality is not quite like what allstandard guidelines recommended Some of bad practices of HCW segregation andcollection have been indicated in numerous studies and mainly found in developingcountries

In developing countries, HCWs are often mixed together with general waste andthen disposed of in municipal waste facilities or dumped illegally (Harhay et al.,2009) In Nigeria, HCWs are collected by municipal waste collection system anddisposed in open dumps (Longe, 2006) Weir (2002) and colleges investigated achildren’s hospital in Toronto and reported that HCW often mixed with general wasteand the hospital had to spend a sixteen time of expenditures more than usual to

resegregate the mixture of waste

For segregation of HCW, health-care facilities do not segregate HCW intodifferent categories A study in Zimbabwe found that HCW was not segregated andstored according to its composition and that hazardous HCW and non-hazardous HCWwere largely collected and stored together (Taru & Kuvarega, 2005) A study

conducted in a hospital in South Africa showed that in the wards, doctors and nurseswho use sharps are required to drop them into different containers but this is notdiligently followed The hospital does not label infectious waste with Biohazardsymbol in wast bags or bins (Abor, 2007) In Nepal most of health care facilities,governmental or non-governmental have not done systematic segregation of HCW atthe place of generation (Joshi, 2013 ; Nepal Health Research Council, 2007)

Another bad practice of segregation that could be seen is the misclassification ofHCW due to colour coded system is not homogonous In a cross-sectional study,Longe (2006) found that there was not a consensus in colour code system for bags andbins in investigated hospitals In South Africa, a large survey of the Department ofAffairs and Tourism in 1997 showed that only 38% of hospitals applied colour codedbags for collecting of HCW Moreover, 46% of the hospitals were using plasticcontainers collect sharps, a practice that was not recommended in HCW management

of South Africa policies (Department of Environmental Affairs and Tourism, 2000) The storage and transportation of HCW also have its own problem A study inSouth Africa showed that HCWs were loaded directly into the pickup without puttingthem first into closed containers Given the small size of the pickups, the wastes wereusually heaped and they fall off on the roads during transportation (Abor, 2007) Thisscenario is also be seen in India hospital where HCWs are collected in mixed forms,and then transported in open carts that results in spillage of HCW (Athavale &Dhumale, 2010) A study in Nepal found that HCWs have been collected in larger binsloaded on a trolley in most of large health-care facilities, but HCWs were transportedeither in plastic bags or in the waste collection bucket In addition, locations of thetemporary storage in the facilities were not satisfactory and are close to the municipalwaste storage or near water bodies or premises of hospital (Joshi, 2013 )

2.4.2 Health-care waste treatment

There are many methods of treatment that have been used widely to treat HCW,including incineration, autoclave, microwave, chemical disinfection, and electronbeam gun technology However, it appears that combustion or incineration of HCW isthe most frequent used disposal method in countries lack of finance and resources(Abor, 2007) Along with emitting hazardous chemicals such as dioxin and furans thatare harmful for human health, incinerators also produce substances that pollute thesurrounding environment Therefore, incineration cannot be regarded as the bestmethod of disposal of hazardous HCW

Till now in most of health-care facilities, incinerators like small brick kilns havelow stack height and are operated at low temperatures that do not meet commonstandards (Oke, 2008) In a survey in India 82% of the incinerators were burningmixed waste (HCW and general waste) and 80% of the incinerators were notmaintaining the temperature norms The temperature was found optimum for dioxinsand furans formation (190-4000C) (Singh, 2003).

2.4.3 Health-care waste disposal

of sharp waste, but a part of these used sharp instruments did not disposedproperly (13% of total syringes) (Vong et al., 2002) Logez et al (2005) carried out astudy in Burkina Faso and found that used syringes did not disposed properly in 46among 52 In developing countries, HCW is often disposal of in improper manners Astudy in Cabodia showed that hospitals were overused injections that exerted a largeamount investigated health facilities (88%) A study in Bangladesh indicated that in allstudied hospitalms pharmaceutical waste and pressurized containers are disposedalong with general waste and liquid pharmaceutical waste is poured into the drainsalong with liquid chemical waste (Mia, et al., 2012) In Nigeria, HCW was collected in

a temporary storage in the campus of the hospitals and then poured into the riversurrounding the hospitals (Longe, 2006) Infected wastes then flow down to theground water or to surface water, hence spreading infectious agents in the riverstream (A D Patil & Shekdarf, 2001) This eventually can contaminate the drinkingwater system of nearby inhabitants In South Africa, HCW often are dumped intodisadvantaged residential areas and children living in these areas had a high risk ofexposing to infectious agents from HCW as they play nearby these waste pills Aexample for this bad practice of disposal HCW was that a hospital in South Africatreated 48 children with AZT after some were pricked with needles and others atepotentially lethal pills they found in a waste field in Elsie’s River (Abor, 2007)

Reuse infected sharp instruments in the hospital is also popular in severalcountries A study in Bangladesh found that some cleaners after segregating syringe-needles, saline bags, empty water bottles or tubes will sell or reuse these used wastefor their own purposes (Mia, et al., 2012) In addition, scavengers (including streetchildren) picking recyclable materials from the uncovered waste at the dumpsite maycarry millions of pathogens with them and vulnerable to various diseases (Oke, 2008;

G V Patil & Pokhrel, 2005) They can also transmit infectious diseases to otherindividuals as well

2.5 Current international normative framework for health care waste management

Although well-known risks caused by HCW to human health and theenvironment have been demonstrated through literature and data, there has not beenyet a consensus on comprehensive framework to regulate the handling, transport anddisposal of HCW Several international environmental treaties such as the BaselConvention on the Control of Transboundary Movements of Hazardous Wastes andtheir Disposal and the Stockholm Convention on Persistent Organic Pollutants havebeen introduced, but they did not addressed specific aspects of the management anddisposal of this particular type of waste In this regard, several internationalorganizations, including WHO and IAEA, have elaborated a number of technicalguidance and documents to guide their members in implementing good practices ofHCW management within their countries

2.5.1 Basel Convention

The Basel Convention on the Control of Trans-Boundary Movements ofHazardous Wastes and their Disposal (the Basel Convention) is the mostcomprehensive global environmental treaty with the aims to protect human health andthe environment against the adverse effects resulting from the generation,management, trans-boundary movement and disposal of hazardous and other wastes(WHO, 2013) It was adopted on 22 March 1989 and put in place on 5 May 1992 Thenumber of member countries today is 176

The main regulations of the Basel Convention is that every transboundarymovements of hazardous and other wastes must have agreements both from exportingand improting countries Besides, each member state must establish its national ordomestic legislation to prevent and punish illegal traffic in hazardous and otherwastes The convention also obliges its parties to ensure that hazardous and otherwastes are managed and disposed of in an environmentally sound manner Exportedwastes should be labeled according to the UN recommended standards (UNEP, 1989).The convention specifically refers to clinical wastes from medical care in hospitals,medical centres and clinics, waste pharmaceuticals, drugs and medicines andinfectious substances as hazardous wastes and need to be prohibited among memberstates

Athough widely accepted by members, the Basel Convention in practice is rarely

invoked to ensure the sound management and disposal of hazardous HCW, since thistype of waste is mostly treated within the country where it is generated.

2.5.2 Stockholm Convention

The Stockholm Convention on Persistent Organic Pollutants (POPs) (theStockholm Convention) is a global treaty to protect human health and the environmentfrom persistent organic pollutants (POPs) POPs are chemicals that remain intact inthe environment for long periods, become widely distributed geographically,accumulate in the fatty tissue of living organisms and are toxic to humans and wildlife(WHO, 2013) Polychlorinated dibenzo-p-dioxins and dibenzofurans formed andreleased to the environment by HCW incinerators and other combustion processes aretwo of chemicals listed in Annex C of the convention and need to be reduced byappropriate measures regulated by member states of the convention (UNEP, 2001)

In 2007, the convention adopted guidelines on the best available techniques(BAT) and provided guidance on best environmental practices relevant to article 5 andannex C of the convention (United Kingdom Department of Health, 2006) The BATsrecommended in the guidelines include team sterilization, advanced steamsterilization, microwave treatment, dry-heat sterilization, alkaline hydrolysis andbiological treatment The BATs for HCW incinerators require a combination ofspecified primary and secondary measures to achieve air emission levels ofpolychlorinated dibenzo-p-dioxins and dibenzofurans no higher than 0.1 ng I-TEQ/Nm3 (at 11% O2), as well as dioxin and furan concentrations less than 0.1 ng I-TEQ/litre of wastewater from the flue gas treatment (United Kingdom Department ofHealth, 2006)

2.5.3 The International Waste Management Association

The International Waste Management Association (ISWA) is recognized as aninternational, independent and nonprofit-making association, working in the publicinterest to promote and develop sustainable waste management worldwide ISWAadvocates principles for safe and sustainable management of HCW to its membercountries such as minimizing resource use where possible, reusing items whenappropriate medically, maximizing the recycling of materials, having a regularlyreviewed waste-management plan within each of health-care facility, and training inHCW management for all staff within a health-care facility In addition, ISWA alsorecommended that supports proper provisions should be made to ensure that HCWfrom minor sources is captured and treated appropriately

2.5.4 International guidelines on health-care waste management

It could be said that WHO is an international organization that made many efforts

to minimize the risks in association with improper HCW management and to facilitatethe establishment and sustained maintenance of a sound system of HCW managementamong nations worldwide by elaborating a number of policy, management andadvocacy tools for HCW management These include a policy paper on safe health-care waste management (WHO, 2004) and core principles for achieving safe andsustainable management of health-care waste (WHO, 2007b) WHO has alsodeveloped a handbook on the safe management of health-care waste (WHO, 1999), apolicy document to facilitate the elaboration of a national plan of action on HCWmanagement (WHO, 2005a), as well as specific guidelines for the safe management ofparticular categories of medical waste, such as solid HCW (WHO, 2005b), syringes(WHO, 2006) and mercury-containing equipments (WHO, 2011a) Moreover, WHOhas issued a number of information tools to raise public awareness of the risksassociated with the unsound management and disposal of hazardous medical wasteand on the measures to eliminate or mitigate these risks, including fact sheets onhealth-care waste management, wastes from health-care activities and injection safety(WHO, 2007a, 2011b)

Apart from WHO, other international organizations have been published severalguidelines involving in HCW management The International Committee of the RedCross (ICRC) put in place a guidance to complement the WHO guidelines on HCWmanagement (International Committee of the Red Cross, 2011) The InternationalAtomic Energy Agency (IAEA) also have published safety guidance on the disposal ofradioactive waste released from health-care facilities (1999) and on the management

of waste from the use of radioactive material in medicine (2005)

2.6 Current situation of health-care waste management in Vietnam

2.6.1 An increasing development of health-care facilities in Vietnam

In Vietnam, the health-care system follows a model in which health-care facilitiesare decentralized in terms of specialization Particularly, the Ministry of Health isresponsible for 11 central general hospitals and 25 central specialized hospitals, while

provincial health services are in charge of 743 provincial general hospitals, 239provincial specialized hospitals, 595 district general hospitals and 11,810 healthcenters (MOH, 2009a).

It is supposed to be that the amount of health-care facilities can meet the needsfor health care in the whole country However, with an increasing population everyyear, health care system has to be suffered a high burden of taking care population'shealth Indeed, it is estimated that the number of bed per 10,000 population in 2005was 17.7, but the figure had risen up to 22/10,000 population (General StatisticsOffice of Vietnam, 2011) That also means a significant increase of HCW generationexists and that needs to be resolved at once

2.6.2 Generation of health-care waste in Vietnam

The amount of HCW in Vietnam is increasing year by year, both HCW andhazardous HCW (Ministry of Technology and Environment, 2003) In 1995, the total

of overall HCW in the whole country was 248.3 tons/day of which hazardous HCWwas 55.4 tons/day However in 2002 the overall HCW was 263.9 and hazardous HCWwas 58.9 (Ministry of Technology and Environment, 2003) According to a survey ofDepartment of Therapy, Ministry of Health, in the period of 2009 to 2010, the total ofHCW in the whole country was approximately 100-140 tons/day, of which 16-30tons/day was hazardous HCW The average HCW was 0.86 kg/bed/day, of whichhazardous HCW constitutes 0,14-0,2 kg/bed/day (MOH, 2011) The reasons for theincrease may be due to (N C Pham, 2004): (1) increase in utilizing single-use toolssuch as syringes, tongue depressors, stent, fluid bags, cottons, and drapes (2) increasenumber of bed in health-care facilities at all levels; and (3) more health-caretechniques were applied in diagnosis, laboratory, and treatment (Dinh, 2003)

The amount of HCW varies based on the number of bed of hospitals, types ofhospital, the clinical procedures conducted in hospitals and the amount of usedresources in hospitals as well The 2009 statistics showed that the amount of HCW for

36 central hospitals was 31.68 tons/day, with an average of 1.53 kg/bed/day The mostHCW generated hospital is Cho Ray Hospital with 3.72 kg/bed/day and the least HCWgenerated hospitals are Central Recovery Hospital and Central Psychological Hospitalwith only 0.01 kg/bed/day (MOH, 2009b) Regarding private sector health facilities, asurvey carried out in Ha Noi capital revealed that there were 33 private clinics orhospitals located in Ha Noi and the amount of HCW produced daily by these facilitieswere approximately 0.7 tons/day (Nguyen, 2012)

Hazardous HCW, which only account for small amount of total HCW, is of greatconcern due to its impacts on health and environment In 1995, the proportion ofhazardous HCW was 22.31% of total HCW and it was unchanged in 2002 According

to a survey of Ministry of Health and WHO, in the year of 2009 hazardous HCWaccounted for 22.5% of total HCW (Ministry of Health-Socialist Republic of Vietnam

& WHO, 2009)

The quantity of hazardous HCW is different among areas in the whole country.Most of hazardous HCW concentrates in big cities In terms of areas, the south-easternarea generates largest amount of hazardous HCW (32% of total hazardous HCW),yielding 10,502.8 tons/year, followed by Hong River area (21%) Provinces or citiesproducing large amount of hazardous HCW (> 500 tons/year) are Ho Chi Minh city,

Ha Noi, Thanh Hoa, Dong Nai, Vinh Phuc, Da Nang, Khanh Hoa, Thua Thien Hue,

An Giang, Can Tho, Nghe An, Phu Tho, Hai Phong, Long An (Ministry of Socialist Republic of Vietnam, 2010a)

Health-Hazardous HCW also varies depended on types of health-care facility Manystatistics showed that in 36 central hospitals belong to MOH the amount of hazardousHCW that needed to be disposed of was 5,122 kg/day, accounting for 16.2% of totalHCW The average hazardous HCW was 0.25 kg/bed/day There are four hospitalsgenerating radioactive waste including Bach Mai Hospital, Central General HueHospital, Central General Thai Nguyen Hospital and K Hospital (Ministry of Health-Socialist Republic of Vietnam, 2010b)

2.6.3 National regulatory framework of health-care waste management

In 1985, the Vietnamese government developed the National Program forEnvironmental Protection and published the National Strategy for Natural ResourceProtection In 1990, the State Committee of Science (now called Ministry of Science,Technology, and Environment-MOSTE) developed a National Plan for theEnvironment and Sustainable Development Four years later, the EnvironmentalProtection Law was established and then revised in 2005 In addition to thislegislation, there are many other laws and decrees that relate to the environment such

as Directive No 199/TTg dated 3 April 1997 on “Urgent measures to manage solidwaste in urban and industrial areas", Decision No.155/1999/QD-TTg dated 16 July

1999 by the Prime Minister promulgating regulations on hazardous wastemanagement

At the same time, Law No.3575/1999/QD-BYT was approved to oblige hospitals

and other medical institutions to take appropriate means to HCW management.However, HCW management in most of hospitals across the country did not take intoeffect As a result, in 2005 the government published a decision related to HCWmanagement that applied to 84 most polluting hospitals in the country (DecisionNo.43/2007/QD-BYT dated 30 November 2007 of Ministry of Health promulgatingRegulation on Health Care Waste Management) and an update of LawNo.3575/1999/QD-BYT which was issued in 2007 (Ministry of Health-SocialistRepublic of Vietnam, 2007)

Although the regulatory framework has been established, the violations of HCWmanagement have been going on somewhere in the whole country with a big scandal

on the illegal recycling of potentially hazardous HCW in the summer of 2007(VietnamNews, 2007) The government, therefore, issued HCW management as anenvironmental problem that needs to be solved through strict inspections of hospitals

to enforce the implementation of the new regulation On 25 May 2011, the "PrimeMinister Decision No: 798/QĐ-TTg on the approval of the solid waste treatmentinvestment program for the period 2011 to 2020" was issued with the first phase(2011–2015) focused on safe management and treatment of 85% of the total HCW andthe target of the second phase (2016–2020) was to be collected and treated 100% ofthe total non-hazardous and hazardous HCW in the country (Prime Minister Decision,2011)

2.6.4 Practices of health care waste management in Vietnam

Segregation, collection and transportation of HCW

Regarding segregation of HCW, 95.6% of hospitals in all provinces segregateHCW, of those 91.1% use specialized tools for separating sharp waste (AcidDeposition and Oxidant Research Center, 2001) A survey of Department of Therapy

in the period of 2002-2003 showed that there were 88% hospital and other health-carefacilities segregated HCW at source with regulations of Ministry of Health, butmissegregation of HCW still exists (Ministry of Health-Socialist Republic of Vietnam,2003)

For collection of HCW, there are 63.6% of hospitals at all levels in the countryused PE or PP plastic bags for collecting HCW (Institute of Occupational Health andEnvironmental Sanitation, 2006) Most of HCW are collected in HCW container;however, just a few of hospitals (central or provincial hospitals) uses recommendedcontainers A survey of Ha Noi Health Service in 2009-2010 carried out to investigate

HCW management in 74 hospitals revealed that 66.67% hospitals used wastecontaining bags with proper thickness and capacity and only 30.67% hospitals usedwaste containing bags with proper color coding system There were 58.33% hospitalused waste containing bins or containers with cover on the top, while 66.67%hospitals used waste containing bins with labelling (Ha Noi Health Service, 2010) Astudy of Hoang in Dong Anh Hospital, Ha Noi showed that only 12.5% wards in thehospital had all coloured coded waste containing bags (Hoang & Phan, 2011) Themain reason for using unregulated tools of collection of HCW may be due to financiallimitations in each of health facilities The in-depth interviews conducted in the study

of Hoang showed that because of lack of money, the hospital authorities must buycheaper and thinner waste containing bags compared to those regulated in theDecision to meet the requirement of usage in all wards of the hospital (Hoang & Phan,2011)

A large portion of hospitals (90.9%) collect HCW every day, but some have poorinfrastructure so that they could not design a separate path for offsite transportation ofHCW (Hoang & Phan, 2011; Institute of Occupational Health and EnvironmentalSanitation, 2006) The collection efficiency is 40–67% of generated waste in big citiesand 2–40% in small towns The average collection rate is only about 53.4% (AsianProductivity Organization, 2007) The survey of Ministry of Health showed that 77%hospitals were equipped with yellow bags and containers for collection of hazardouswaste, 76% hospitals are equipped with green bags for collection of general waste,27% hospitals are equipped with black bags and containers for collection of chemicalsand genotoxic waste, and 24% hospital are equipped with puncture-proofing plasticcontainers for sharp waste (Ministry of Health-Socialist Republic of Vietnam, 2003).For transportation of HCW, there are only 53% of hospitals use standard vehicles

to transport hazardous HCW and 53.4% of hospitals have a cover at the top of storageareas, of which only 45.3% meet the requirements of national HCW managementguidelines (Institute of Occupational Health and Environmental Sanitation, 2006) Ingeneral, the vehicles used for transportation of HCW in health-care facilities arelacking and unsatisfactory with the national standards It is due to the fact that thereare few of companies that product these types of vehicle, so hospitals could notequipped with sufficient quantity According to a survey of JICA conducted inhospitals located in 5 big cities including Hai Phong, Ha Noi, Hue, Da Nang and HoChi Minh city, the main HCW transporters are wheel container, trolley and other

vehicles and there are a few of on-site storage areas having air conditioners or airoperators (JICA, 2011)

After collecting, HCW is transported to temporary storage areas within thehospitals and in most of health-care facilities off-site transported to municipal landfills

by municipal environment companies Since vehicles of these companies are designedfor transportation of municipal waste, so the transportation of HCW is often not safeand sometimes HCW may leak or dump out vehicles that result in a high risk ofspreading hazardous agents or substances to residential areas (JICA, 2011)

Treatment and disposal of HCW

Non-hazardous HCWs in most of hospitals are collected, transported and treated

by municipal environment companies These HCW will be transported to wastelandfill at local areas but the treatment and recycling process do not followed thenational regulations In addition, there are a few of companies being official in charge

of collecting and recycling HCW, so recycling of HCW engages many difficulties In

2010, several scandals relevant to HCW treatment took place in which HCW wascollected and transported outside hospitals without treatment and then recycled to beused in public settings (Socialist Republic of Vietnam, 2011)

Regarding hazardous HCW, there are 68% of total of hazardous HCW are treated

by standard methods, the rest are treated improperly and these could causeenvironmental pollutions and health impacts to public In large cities such as Ha Noi,

Ho Chi Minh, there are companies specialized in treatment and disposal of HCW withthe main tasks of collecting, transporting and eliminating hazardous HCW for allhospitals in these cities In fact, Ho Chi Minh City has an incinerator that is belong to

Ho Chi Minh City Environmental Company (HCITENCO) with capacity of 7 tons/dayand gas pollution control, while in Ha Noi a incinerator that is belong to UrbanEnvironment Company (URENCO) has capacity of 3 ton/day without a gas pollutioncontrol (Acid Deposition and Oxidant Research Center, 2001) In other provinces themodels of treatment of HCW are totally different Provincial hospitals in Thai Nguyen,Hai Phong, Can Tho use incinerators served for a group of hospitals, while Nghe AnGeneral Hospital has incinerators located in the campus and be responsible fortreatment of HCW for other hospitals in the whole province (Ministry of Health-Socialist Republic of Vietnam, 2010b)

2.6.5 Health-care waste management in Dong Nai province

Health-care waste generation in Dong Nai

As other provinces in the country, Dong Nai has established a complete healthcare system that serves more than 2.4 million people (dongnai, 2012) The quantity ofHCW also increases along with the increasing needs of seeking care of communities.

A report of Environment and Resource Services showed that the total of HCWgenerated in Dong Nai in 2006 was approximately 431 tons/year (Environment andResources Service, 2010) By 2012, the amount of HCW in Dong Nai had reached3,595 tons/year, of which hazardous HCW accounted for 2 tons/day (T K H Pham,2013)

Segregation, collection and transportation of health-care waste

After the Decision No.43/2007/QD-BYT published, health sector authorities havedisseminated regulations on segregation, collection and treatment of HCW to allhealth-care facilities in the province through training and educating for health careworker who working in departments of infectious control However, practices of HCWmanagement up to now are not as good as supposed

In principle, the classification of HCW must be done immediately at the wastegeneration site and HCW must be contained in bags or containers according toregulations Additionally, hazardous HCW should not be mixed together withdomestic waste Through many inspections of Dong Nai Health Service, most ofhospitals do not follow these regulations (baodongnai, 2012) In district hospitals such

as Trang Bom General Hospital and Bien Hoa General Hospital the segregation ofHCW is performed in a simple manner After segregated at each ward in the hospitals

by health-care staff, HCW is collected and dumped into only one container by hospitalorderly In Bien Hoa General Hospital, there were lacks of tools and equipment forsegregation, collection of HCW In addition, waste collectors had poor knowledgeabout segregation and lack of awareness on the risks of HCW (baodongnai, 2012).Bad practices of segregation, collection and transportation of HCW are also theproblems in provincial hospitals Specifically, in Dong Nai Children's Hospital, HCWsometimes is mixed with general waste, the temporary storage that are often an openarea do not meet the national requirements, and waste containing bags are torn thatleads to bad smelt and insects gathering at the storage

Firgure 1 Inspectors of Ministry of Health investigated the temporary storage at Long Thanh General Hospital (Source: (baodongnai, 2012))

Treatment and disposal of health-care waste

To disposal of HCW in the whole province, there are 6 HCW incinerators,including three furnaces with a capacity of 300 kg/day (located at Long Thanhhospitals Long Khanh hospital and Dinh Quan hospital), two furnaces located at Cam

My general hospital and Dau Giay general hospitals (both are district hospitals), andone incinerator located in Traditional Medicine Hospital with capacity from 800-1,000kg/day Of those, the incinerator in Traditional Medicine Hospital operated by DongNai URENCO company is the biggest and served for disposal of HCW for the wholeBien Hoa city However, operated more than ten years and frequently overloadedmake the incinerator seriously degrade Consequently, the incinerator pumped a largeamount of dust, bad smell and hazardous substances (ashes, CO, lead) that posed airpollution and health impacts on surrounding communities and patients treated atTraditional Medicine Hospital (baodongnai, 2012) In 2012, the incinerator stoppedworking; therefore the Dong Nai URENCO had to collect and then transport all HCWgenerated in Bien Hoa city to incinerators located in Ho Chi Minh city and BinhDuong province Other incinerators although are still working, the efficiency is sopoor that URENCO also have to transport HCW generated in hospitals where theseincinerators located to Binh Duong province for treatment and disposal (baodongnai,2012)

2.7 Contents of Decision No.43/2007/QD-BYT

2.7.1 Classification of health-care waste

Infectious waste

a Sharp waste (Grade A): Sharps are items that could cause cuts or puncture woundsand be contaminated with pathogens They include: needles, hypodermic needles,infusion sets, scalpels and other blades, knives, saws, broken glass and pipettes

b Non-sharp infectious waste (Grade B): Waste is heavily soiled with human blood orother body fluids and waste comes from infected patients in isolation wards

c Highly infectious waste (Grade C): Waste comes from laboratory activitiesincluding laboratory cultures and stocks, discarded instruments or materials that havebeen in contact with persons or animals infected with highly infectious agents

d Pathological waste (Grade D): Pathological waste consists of tissues, organs, bodyparts, blood, body fluids, human fetuses, infected animal carcasses and other wastefrom surgery and autopsies on patients with infectious diseases

Hazardous chemical waste

a Pharmaceutical waste includes expired, unused, spilt and contaminatedpharmaceutical products, prescribed and proprietary drugs, vaccines and sera that are

no longer required

b Hazardous chemical waste used in health-care facilities

c Genotoxic waste includes certain cytostatic drugs, vomit, urine or faeces frompatients treated with cytostatic drugs, chemicals and radioactive

d Waste with high density heavy-metal contents including mercury (spillage frombroken clinical equipments), cadmium (battery, storage cell), lead (wood panels ormaterials containing lead used in radiation proofing in X-ray and diagnosticdepartments)

Non-hazardous health-care waste

Non-hazardous or general waste is waste that has not been in contact withinfectious agents, hazardous chemicals or radioactive substances and does not pose arisk of burn or explosion It includes:

a Waste comes from clinical wards (except isolation wards)

b Waste from health-care activities including blood bottles, glass containers, plasticmaterials These items are not in contact with blood, body fluids and other hazardouschemical substances

c Waste from paper works including paper, magazines, documents, packaging,cardboard, PVC bags

d External waste: leaves and waste from surrounding areas of health-care settings

2.7.2 Segregation of HCW

Colour codes

1 Yellow: Infectious waste

2 Black: hazardous chemical and radioactive waste

3 Green: non-hazardous waste and small pressure vessel

4 White: recycling waste

Waste containing bags

1 Yellow and black waste containing bags must be made of non-halogenated plastic(not PVC) such as PE or PP

2 The recommended thickness of waste containing bags must be at least 0.1 mm, andthe size of bags must be fit with the weight of waste The maximum capacity of wastecontaining bags should be 0.1 m3

3 Outside of bags must have an alert line at two-third of the bag and the sentence "DONOT CONTAIN OVER THAT LINE"

4 All bags must follow recommended colour coding system

Sharps containers

1 Sharps containers must be in accordance with disposal methods

2 Sharps containers must meet all following requirements: (a) The cover and bottom

of the containers must be sturdy in order not to be pierced; (b) Water-proof; (c) Propersize; (d) Easy open lid; (e) Large opening to accommodate sharps without thrust; (e).Outside of sharps containers must be labeled "FOR SHARPS WASTE ONLY" and analert line at two-third of the sharps containers and the sentence of “DO NOT

CONTAIN OVER THAT LINE"; (g) Yellow; (h) Having straps or fixed system; (i).Sharps waste does not spill out as moving the sharps containers.

3 For health-care facilities having syringe needle destroyers or syringe needle cutters,sharps waste containers must be made of metal or sturdy plastic, reusable and must bepart of the design of destroyers or cutters

4 For plastic sharps containers, they must be cleaned, disinfected by standardsterilized process before reusing for containing health-care materials Aftersterilization, all previous functions of sharps containers must be kept

Waste bins

a A waste bin must be made of high density plastic and sturdy or made of metal withfoot pedal Waste bins with capacity over 50l must have wheels

b Yellow bins used for yellow waste containing bags or boxes

c Black bins used for black waste containing bags or boxes For radioactive waste,waste bins must be made of metal

d Green bins used for green waste containing bags or boxes

đ White bins used for white waste containing bags or boxes

c The capacity of waste bins depending on weight of waste and is between 10l to250l

g Outside of waste bins must have an alert line at two-third of the bins and thesentence "DO NOT CONTAIN OVER THAT LINE"

Sympols for health-care waste

The outside of waste containing bags or bins must have symbols of specific waste:

a Bags and bins containing infectious waste have the symbol of hazardous biomedicalwaste

b Bags and bins containing genotoxic waste have the symbol of genotoxic waste andthe sentence "GENOTOXIC WASTE"

c Black bags and bins containing genotoxic waste have the symbol of radioactivewaste and the sentence "RADIOACTIVE WASTE"

d White bags and bins containing recycling waste have the symbol of recycling waste

2.7.3 Collection of HCW

1.The locations of waste bins

a Each department in health-care facilities must clearly locate the places for wastebins and sources of releasing certain waste must have the proper type of waste bins

b At the location of waste bins, there must be instructions of segregation andcollection of waste

c Waste bins must be used properly followed regulations and be cleaned every day

d Clean waste containing bags must be supplied at waste generated sources in order topromptly replace for used bags that are transported to storage areas within health-carefacilities

2 Each type of waste must be collected properly followed colour coding system onwaste containers

3 Do not mix hazardous HCW with non-hazardous HCW If that happens, the mixture

of waste must be treated and disposed of like hazardous HCW

4 Each waste bag only contains an equal amount of waste of two-third of the bag andthen tie closely before transporting to storage areas

5 The frequency of collecting waste: hospital orderly or staff who are responsible forcollecting waste must done the task of collection of waste at source and then transport

to storage areas at least once a day and as necessary

6 The infectious waste must be treated at source before transporting to storage areaswithin the health-care facilities

2.7.4 Onsite transportation of solid health-care waste

1 Hazardous and non-hazardous HCW originated from clinical ward/department must

be transported separately to the storage areas within health-care facilities at least once

a day and as necessary

2 Health care facilities must design a separate pathway and schedule fortransportation of HCW It is avoidable to transport HCW across patient care areas andother clean areas

3 Waste containing bags must be tied closely and transported by specialized vehicles

It is prohibited to drop, spill waste/wastewater and emit bad odor duringtransportation

4 The trolley used for HCW transportation must meet following requirements: highedge, closed lid and bottom, easy for picking up waste, cleaning, disinfecting anddrying

2.7.5 HCW storage outside health care facilities

1 Hazardous and non-hazardous HCW must be stored in isolated rooms

2 Recycling or reusing HCW must be stored separately

3 The HCW storage areas must be meet the following requirements:

a Far away from canteen, hospital wards, public pathways, and crowded areas at least

10 m

b A separate pathway for HCW transporting vehicles entering to health-care facilities

c Storage areas must have ceiling, protective fences, doors and locks Animals,rodents and unauthorized persons are prohibited to enter this area

d Storage areas must be in accordance with the amount of waste generated by care facilities

health-e Storage areas must be equipped with hand-washing tools, means of protection forpersonnel, tools and chemicals for cleaning

f Storage areas must have drainage system, water-proofing walls and floor, goodventilation

g It is recommendable to equip storage areas with air conditions or air ventilation

4 Storage time of hazardous HCW within health-care facilities

a Storage time of hazardous HCW within health-care facilities is not over 48 hours

b If the health-care facilities equip air conditions in storage areas: the storage timecould be last over 72 hours

c Anatomical waste must be buried or disposed of every day

d For health-care facilities have an amount of hazardous HCW under 5kg/day,collection frequency is at least twice a week

2.7.6 HCW transportation outside the health-care facilities

Transportation

1 Health-care facilities must have contracts with legal establishments in transportationand disposal of HCW In case of not any establishments exists in the local, health-carefacilities must report to the local authorities for dealing with

2 Hazardous HCW must be transported in dedicated vehicles to ensure hygiene andmeet the requirements of "Circular No 12/2006/TT-BTNMT December 26, 2006 ofthe Ministry of Natural Resources and Environment on guidelines of conditions ofpractice and procedure for documentation, registration, license provision, codes forHCW management"

3 Hazardous HCW prior to transportation to the disposal site must be packed in thecarton to avoid cracks or breakage in transit

4 Anatomical waste must be put in two slayers of yellow bag, separately packed inbarrels or boxes, sealed lid and labeled "ANATOMICAL WASTE" before beingtransported for disposal

Tracking and transporting record for HCW

Each health-care facility must have a tracking record system to track the amount

of waste generated daily, and records that document the HCW have alreadytransported to disposal site All of these records must be based on the forms regulated

in Circular No 12/2006/TT-BTNMT December 26, 2006 of the Ministry of NaturalResources and Environment

2.7.7 Treatment and disposal of HCW

Model of treatment and disposal of hazardous HCW

a Model 1: a focal point treatment center for all health-care facilities

b Model 2: an establishment of treatment and disposal of HCW for a cluster of care facilities

health-c Model 3: onsite treatment and disposal of HCW areas within health-care facilities

Technologies for treatment and disposal of HCW

The processing technologies of hazardous HCW include: burning in standardincinerators, autoclaving, microwave technology and other non-burning technologies.Encouraging the adoption of friendly environmental technologies

Initial treatment technologies of HCW

1 HCW must be safely treated at source originating HCW

2 Initial treatment methods of HCW could be one of the followings:

a Chemical disinfection: soaking hazardous HCW in 1-2% solution of Chloramines

B, Javen 1-2% within minimum of 30 minutes or in chemical disinfection agentsregulated by manufacturer's manual or by Ministry of Health guideline

b Autoclaving: HCW are put in autoclave and operates properly based on themanufacturer's manual

c Spoiling HCW consecutively at least 15 minutes

3 After initial treatment, infectious HCW could be mix with other kinds of hazardousHCW and dumped or put in yellow plastic bags In case of initial treatment withautoclave, microwave or other modern technologies, HCW could be treated as generalwaste

Treatment and disposal methods of infectious HCW

1 Infectious HCW could be treated by one of the followings:

a Autoclave

b Microwave disinfection

c Burning