|Year : 2022 | Volume
| Issue : 3 | Page : 207-213
COVID-19 Biomedical Waste Management Practices among Medical Professionals in a Tertiary Hospital: Need for Safe and Sustainable Methods
Aiman Perween Afsar1, Lovenish Bains2, Anurag Mishra2, Akshit Mittal1, Sulakshna Aggarwal1, Daljit Kaur3
1 Maulana Azad Medical College, New Delhi, India
2 Department of Surgery, Maulana Azad Medical College, New Delhi, India
3 Department of Blood Bank & Transfusion Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||15-Sep-2022|
|Date of Acceptance||16-Oct-2022|
|Date of Web Publication||07-Dec-2022|
Associate Professor, Department of Surgery, Maulana Azad Medical College, New Delhi
Source of Support: None, Conflict of Interest: None
Context: The Coronavirus Disease 2019 (COVID-19) pandemic that began in 2019 has affected more than 232 million people around the world with over 4.7 million deaths as on September 30, 2021. Amidst the crisis, there has been increased generation of biomedical-waste (BMW). In April 2021, a 62% rise was observed compared to 123 metric tonnes of waste generated in February 2021. The hospital waste mismanagement has diverse ramifications as it affects the patients, healthcare workers (HCWs), public, environment, and economy. Proper BMW management aims to reduce generation, ensures efficient collection, handling and safe disposal so that it controls infection and improves safety. Aims: The present study was conducted to assess the knowledge among medical professionals regarding BMW segregation, transport, and treatment. Settings, Design, Methods, and Materials: A google formed based survey was done to assess the knowledge regarding management of COVID-19 BMW among HCWs (MBBS students, residents, and consultants) associated with tertiary care hospitals of North India. Results: The knowledge score was : for segregation − 27.4%, 59.6%, and 49.8%; transport from site of generation to site of disposal − 63.6%, 89.1%, and 95.2%; disposal − 29%, 71.9%, and 68.2%; overall score − 41.4%, 67.9%, and 61.3% among the students, residents, and consultants respectively. We found that participants with greater years of experience (residents and consultants) had better knowledge as compared to that of the students (P = 0.032). Conclusion: We found a mean score of 56.9% which is more than that of few low- and middle-income countries but less than that of European countries. The chances of infection directly correlate with lower knowledge score. Appropriate evidence-based, judicious use of PPE as per the settings and guidelines should be followed. Training aspects, periodic evaluation, and assessment should be strengthened, both for practising medical professionals and for students, to ensure a safe and sustainable healthcare system.
Keywords: Biomedical waste, COVID-19, medical professionals, infection, knowledge assessment
|How to cite this article:|
Afsar AP, Bains L, Mishra A, Mittal A, Aggarwal S, Kaur D. COVID-19 Biomedical Waste Management Practices among Medical Professionals in a Tertiary Hospital: Need for Safe and Sustainable Methods. MAMC J Med Sci 2022;8:207-13
|How to cite this URL:|
Afsar AP, Bains L, Mishra A, Mittal A, Aggarwal S, Kaur D. COVID-19 Biomedical Waste Management Practices among Medical Professionals in a Tertiary Hospital: Need for Safe and Sustainable Methods. MAMC J Med Sci [serial online] 2022 [cited 2023 Feb 1];8:207-13. Available from: https://www.mamcjms.in/text.asp?2022/8/3/207/362900
Key Messages: Perception of appropriate methods of COVID-19 biomedical waste is lacking in all strata but more so among students. Training and assessment can improve adherence to biomedical-waste management rules and ensure a safe healthcare system.
| Introduction|| |
The Coronavirus Disease 2019 (COVID-19) pandemic that began in November, 2019 has affected more than 170 million people around the world with over 3.5 million deaths as on May 31, 2021. India alone has reported more than 28 million cases, as on May 31, 2021.
Amidst the crisis, there has been increased generation of biomedical-waste (BMW). Analysis revealed that on an average, each COVID-19 infected patient in India generated approximately 3.41 kg/day of BMW and average proportion of yellow BMW (which is highly infectious) in it is 50.44%. The hospital waste mismanagement has diverse ramifications as it affects the health of patients, HCWs, general public, environment, and economy. Illegal resale and reuse of BMW, especially by rag-pickers was also reported.,
BMW management issues are less examined in India due to poor waste statistics data. This indicated the need to have a comprehensive waste management strategy as well as raising awareness among all those involved either in the generation, segregation, or treatment of COVID-19 waste. Hence, this paper evaluates the knowledge for BMW management, especially amongst HCWs as they are directly involved in assessing, examining, sampling, and treating COVID-19 patients.
| Subject and Method|| |
We conducted a google form based cross-sectional study involving the medical professionals at a dedicated COVID-19 facility in Delhi over a period of 6 months in the second half of 2020. The ethical clearance for the study was obtained from the Institutional Ethics Committee of Maulana Azad Medical College, New Delhi. The sample size was calculated to be 323, with a confidence interval of 95% in a population size of 2000 healthcare professionals. A self-administered questionnaire with a scoring system comprising four sections was made. Consent for the participation was incorporated in the survey questionnaire, only those who consented were eligible to participate. Section 1 asked for baseline characteristics of the participants, Section 2 assessed knowledge of the participants regarding BMW management and policies, Section 3 was regarding segregation, transport, treatment, and final disposal of waste, and Section 4 was about waste management practices at hospital and their suggestions for improvement. This questionnaire was shared with the HCWs including MBBS students (no clinical experience), residents (Junior Residents, Post Graduates, Senior Residents; experience between 1 and 10 years), and consultants (Doctors with experience >10 years) via e-mail and social networking websites such asWhatsApp. Participation in the survey was purely voluntary and anonymous. Our primary objective was to assess knowledge level among all medical professionals and primary outcome measure was score based on answers on the google form. Our secondary objective was to assess difference of knowledge among three different groups of medical professionals (students, residents, consultants). On submission of the form, the participants were directed to infection control manual and guidelines from World Health Organization, Centers for Disease Control and Prevention, Indian Council of Medical Research for their perusal and awareness. A reminder was sent after 15 days, to participate in the study. The data were collected and assessed statistically by Microsoft Excel. Chi-square test was used to compare proportions across different groups. We found that there was significant association between training and knowledge of BMW management.
| Results|| |
The survey was sent to around 825 people and the response percentage was 50.4% (416 participants). Out of the 416 participants, 22.3% (93) participants were directly involved in COVID-19 care [Table 1]. 83% (345) of these participants had received training or had read guidelines for BMW management, in general whereas only 34.4% (143) were aware about COVID-19 BMW management. Though 92.5% (385) participants thought it was important to know about BMW hazards, legislation, yet only 41.3% (159) were aware of the government’s regulations and legislation on COVID-19 waste management. We found that 92.2% (83) of residents knew the correct sequence whereas only 64% (193) of students were aware. We found that only 27.4% (82) students knew about the correct methods of segregation, whereas 59.6% (54) of residents and 49.8% (12) consultants were aware of the correct methods [Table 2]. 86.6% (360) of all knew how inadequate management can lead to cross infection. Regarding transport of waste, 67% (202) of the students and more than 90% (106) of experienced HCWs were aware that only licensed personnel can transport the waste [Table 3]. The knowledge regarding disposal and treatment of liquid waste is lacking in all strata (average score found to be 60% in residents and 26% among students) [Table 4]. Overall, there was significant difference in the knowledge of the students (knowledge score was found to be 41.4%) and the experienced HCWs (67.98%, and 61.34% among the residents and the consultants respectively), P = 0.032.
|Table 2 Average score among participants regarding segregation of COVID-19 biomedical waste|
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|Table 3 Average score among participants regarding transport of COVID-19 biomedical-waste|
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|Table 4 Average score among participants regarding final treatment of COVID-19 biomedical-waste|
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| Discussion|| |
In India, 103 billion ton of plastic waste had been produced during the pandemic in 2020, which is second only to China that produced around 108 billion ton of plastic waste. COVID–19 waste was around 7.2 tonnes/day in July, 2020, which increased to 12.5 to 13 tonnes/day by the end of April 2021. As the pandemic continues, so will the waste, and keeping that garbage safe and contained will continue to be a challenge. In our study, we found that 86.6% were aware how inadequate management of COVID-19 waste can lead to cross infection whereas in study by Ahmed et al., 80% participants agreed that proper disposal of waste is crucial for cross-infection control. In a similar study in Thailand, the scores were found to be at a higher level (89.5%). However, the average knowledge score in three low- and middle-income countries (LMICs) Ethiopia, Nigeria, and Sri Lanka were found to be 56.8%, 45%, and 40.5%, respectively.,,
The improper disposal of COVID-19 BMW poses severe risks to public health and environment as it acts as a host of variety of pathogens. There are gaps in knowledge and practice about the implementation of BMW management protocol which are being addressed by infection control teams in some institutions. A systematic review of literature reported that the pooled prevalence of healthcare associated infection was 7.6% in high-income countries and 10.1% in LMICs where knowledge score was low.,, Thus, level of knowledge among healthcare professionals regarding BMW management directly correlates with healthcare associated infection.
Proper awareness of sequential handling, that is, Generation → Segregation → Collection → Transportation, Storage → Treatment → Final disposal, this process can help minimize cross-infections. Due to the ravaging pandemic, the Government of India has decided to utilize the services of students, therefore students must possess adequate knowledge about COVID-19 BMW management. Although there are rules and regulations for BMW Management, adherence to these rules is still low in India. Our results were better as compared to another study conducted in Bhopal where only 30% of participants had knowledge regarding BMW segregation. Knowledge was less compared to study of Ethiopia, where 83.9% doctors had knowledge about the correct ways of segregation.
We found gaps in knowledge about BMW transportation. This is comparable to another study where average score regarding transportation was 64% amongst students. In a survey done in China during COVID-19 pandemic, it was found that the majority proportion (37.8%) were non-compliant to BMW guidelines. Out of these, 71.4% of respondents lacked knowledge of proper disposal, collection of waste. According to WHO, personnel involved in handling BMW should wear appropriate gear, and 77% (232) of students and 90% (110) trained HCWs were aware of this.
More than 96% (111) of experienced HCWs had excellent knowledge regarding spill management, whereas, only 67% (202) students were aware [Table 4]. Students must be provided training to combat these frequently encountered situations. Only 44% (132) of students knew about the right methods of disposal and treatment of waste whereas, 72% (65) residents and 68% (17) consultants knew about the right practices [Table 4]. Low level of awareness regarding final disposal of wastes increases the risk of infectivity once waste has left hospitals, and has adverse environmental impact, in the form of soil pollution.
Significant relation was found between years of experience and knowledge score [Figure 1] and [Figure 2]. Trained professionals had higher knowledge score (67.9%, and 61.3% among the residents and consultants respectively) as compared to that of students (41.4%). From the results, it has become clear that there is still a need to educate the students and residents about the problem of BMW and its management. Unless the healthcare professionals are aware, it cannot be ensured that BMW ends up at the right place. Thus, repeated and comprehensive training (starting with induction of all new appointees to once a year thereafter) is a very critical step to reduce waste generation. According to a study conducted in Spain, there was a significant reduction in the monthly average healthcare waste volume of 6.2%, after an interventional training. Significant differences regarding BMW segregation before and after intervention were found. It also helped reduce monthly expenditure by &z.euro;125,205. El-Sharkawy reported significant improvement of knowledge from 25% to 78% after educational intervention.
|Figure 1 Comparison of scores among students, residents and consultants.|
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Appropriate, evidence-based, judicious use of PPE as per the settings and procedure should be followed, as elaborated in the Ministry of Health Guidelines. This can help in reduction in generation of COVID-19 BMW, especially PPE related. The right practices in the form of avoiding of injuries, vaccinations, and following universal regulations should be promoted. Although Central Pollution Control Board has made it mandatory for all healthcare centers to display BMW signages, around 35% (145) of participants said that there were no signages displayed in their institution. This highlights the intervention of administration to bring about a change. 90% (375) of the participants think it is difficult to remember the steps for management. Therefore, it becomes more essential to put up signages at all required sites. [Table 5] gives a brief overview of framework for BMW Management in COVID-19 era (based on WHO multimodal strategy).
|Table 5 Framework for BMW management in COVID-19 era (based on WHO multimodal strategy)|
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Strengths and Limitations
It is one of its kind surveys about BMW especially during COVID-19. The scoring system helped in understanding the shortcomings and correct answers were provided to rectify them. Firstly, the response rate to the survey (50.42%) was moderate, in line with other studies. The survey participation rate was good among the students. Secondly, there is lack of studies in this subject in the Indian context; when COVID-19 waste segregation and disposal awareness is the need of the hour. This assessment is useful due to poor available data of COVID-19 BMW. Lastly, our study also assessed the knowledge of students who are going to be recruited for COVID-19 management in hospitals. Hence, an evaluation of their gap of knowledge becomes of paramount importance to reduce cross-infection by mishandled BMW.
Our study had a few limitations. Firstly, the survey was essentially for doctors; however, the nursing and paramedical staff also must possess adequate knowledge about BMW management. Secondly, the response rate was moderate among residents and less response rate was observed from consultants. Moreover, it being a single-center study, the results cannot be generalized at a national level. As this is an e-survey with voluntary participation and those who did not participate may be systematically different from those who participated, thus the possibility of respondent bias remains. We included all MBBS students including first year students who have not been taught about BMW management at all.
| Conclusion|| |
Overall, the average score was found to be 41.4%, 67.98%, and 61.34% among the students, residents and consultants respectively. Low level of knowledge has been shown to have direct impact on infection spread. Personal protective equipment (PPE) should be used judiciously. It is of paramount importance to dispose and segregate the COVID-19 BMW carefully to prevent spread of infection. Training aspects regarding BMW management should be strengthened so that the current, existing, and future regulations are practiced diligently. Gaps in knowledge, attitude, and practices of BMW management should be addressed. Periodic evaluation and assessment should become routine to enforce a safe and sustainable healthcare set-up. Strict implementation of BMW management rules is the need of the hour.
Aiman Perween Afsar − conceptualization, methodology, validation, formal analysis, investigation, data curation, writing − original draft, visualization.
Lovenish Bains − conceptualization, methodology, validation, investigation, data curation, writing − original draft, writing − review & editing, visualization, supervision, project administration.
Anurag Mishra − validation, investigation, writing − review & editing, supervision.
Akshit Mittal − formal analysis, investigation, data curation, writing − review & editing.
Sulakshna Aggarwal − formal analysis, investigation, writing − review & editing.
Daljit Kaur − formal analysis, investigation, data curation, writing − review & editing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]