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August 4, 2005
A prickly problem
Patients are often unnecessarily injected for upper respiratory tract disease, diarrhoea, fever or general fatigue. A variety of studies has concluded that more than 90 per cent of the injections given in developing countries are unnecessary. However, that’s all secondary to the more pressing concern –– the syringe your nurse is using might have been recycled, writes Atif Khan
Taking care of medical waste has been one of the biggest concerns of the medical administrators for a long time. Surprisingly, nothing substantial has been done over the years to tackle the problem.
In Karachi, with a population of 10 million, where garbage disposal is itself an unfinished duty, the issue of medical waste disposal needs to be looked into immediately. The problem of safe syringe disposal is one area that needs immediate attention of the concerned authorities.As in most of the Third World countries, injections are a common means of feeding medicines into the sick body. However, it’s unnecessary, sometimes. Go to a doctor with any ailment and the first thing that usually he or she will do is give you an injection. At least that’s what my neighbourhood doctor does! But apart from the doctors, the patients, too, are responsible for this.
A common belief exists throughout the Third World that injections are the best that medical science has to offer and the most efficient and rapid way of finding relief.
According to recent studies, at least 12 billion syringes are sold each year for medical injections, including about a billion for childhood immunizations throughout the world. Immunizations are estimated to account for three to 10 per cent of the medical injections given each year. Estimates of the number of medical injections given annually vary significantly, ranging from about 4.3 billion in the developing world to many billion more in the rest of the world.
From antibiotics to vitamins, analgesics or other drugs, patients are often unnecessarily injected for upper respiratory tract disease, diarrhoea, fever, or general fatigue. A variety of studies have concluded that more than 90 per cent of the injections given in developing countries are unnecessary. However, that’s all secondary to the more pressing concern of keeping safe from unsafe injection needles.The areas of the world with the highest proportion of unsafe injections are South Asia and sub-Saharan Africa. In sub-Saharan Africa, a literature review carried out by WHO researchers found that in five out of seven studies, in which the percentage of unsafe medical injections was calculated, at least half of the injections were unsafe. It’s the same case here in Pakistan, especially in an urban setting like Karachi.
According to a rough estimate, around 250,000 tonnes of medical waste is produced annually from all sorts of healthcare facilities in the country. Most of it, especially syringes and other sharp objects aren’t taken care of properly. And unknown to many, this sort of mismanagement has all the hallmarks of a major medical catastrophe in the making.
Hospital waste is categorized according to its weight, density and constituents. According to WHO classifications, medical waste has been categorized into infectious, sharps, pathological, pharmaceuticals, radioactive and others. These include waste from offices, kitchens and other places and comprise of bed linen, utensils, paper, etc.
Under the sharps category fall disposable needles, syringes, saws, blades, broken glasses, nails or items that could cause a cut. At times these aren’t disposed off properly. There are also those non-professionals who don’t know how to take care of used syringes. Patients and their relatives who routinely use syringes at home -–– and there are plenty of them -–– do not know how to dispose them off properly. They just throw them in a dustbin or other similar places, thinking that these practices are safe and an easy solution to dispose off a potentially dangerous waste item. This, in turn, leads to the potential dangerous and common practice of reusing disposable syringes.
The problem begins when people pick up used syringes from the waste and sell them. These syringes are taken to garbage dealers who then recycle them. In this environmentally conscious world, recycling is a good word, but it isn’t always one to look forward to.
Pakistan marked as Red
Infectious clinical waste and reuse of infected syringes and needles have increased the occurrence of hepatitis B and C in the country to such a level that it has been marked as ‘Red’ all over the world -–– meaning that it is one of the leading countries having hepatitis B and C.Senior consultants are of the view that almost 10 per cent of the country’s population are carriers of hepatitis viruses. “With regard to the incidence of hepatitis, Pakistan falls in the highly prevalent area in the world,” says one consultant. Prevention is the key to beating the biggest health challenge of hepatitis prevalence in Pakistan. “People should not get their bodies pricked unnecessarily.”
Jinnah Hospital’s Prof. Abul Fazal Khan says that every tenth person in the country is suffering from hepatitis B. Hepatitis C prevalence has almost similar statistics. It is a worrying fact for health professionals that most hepatitis virus carriers, are unaware of the fact and spread it unconsciously.
“There are different hepatitis viruses ranging from A to F, which commonly affect human body through infected blood and instruments, unnecessary clinical practices, contaminated water and unhygienic food,” said Prof. Khan.
Hepatitis A and E are caused due to contaminated water and unhygienic food, but the infection is cured automatically. Among pregnant women, however, the incidence of hepatitis E can be lethal. About 90 per cent pregnant women and newborns affected by hepatitis E die.
Hepatitis B and C are caused by infected surgical instruments including syringes and reused blades at barber shops, nose and ear piercings, circumcision and tattoos made by infected instruments.
According to a survey, Prof. Akram says it was found that hepatitis C prevalence had almost reached epidemic levels in the Gujranwala and Wazirabad areas. The only reason behind the spread of disease was the common practice of piercing the nose and ears, and making tattoos with infected instruments at different melas. Saying that an effective vaccine was available to prevent hepatitis B, Prof. Akram adds that no vaccine is available to prevent the hepatitis C virus. For now, this disease can only be avoided through prevention.
On the other hand, some doctors including medical superintendents of different hospitals claim that the incidences of hepatitis B and C were not alarming, but consultants are nevertheless trying to help sell vaccines manufactured by different multinational pharmaceutical companies. — Mansoor Malik
These syringes are taken and at the most ‘cleaned’ by having them boiled in saline water, repackaged and sold. Though the price of brand- new syringes is not that high, yet, there are many in Pakistan’s poor strata of the society who can only afford to buy these deadly recycled syringes.
Many drug addicts also reuse the syringes, which is almost equivalent to inviting potentially fatal diseases like Aids. If a syringe, previously used by an Aids patient, is reused, it can infect the person using it. Similar effects can be found in hepatitis A and B, typhoid and even boils.
The WHO-affiliated Safe Injection Global Network (SIGN), recently estimated that globally, about 260,000 –- or five per cent — of all annual HIV infections occur because of unsafe injections in healthcare settings. However, this is a conservative estimate. Other studies have estimated that unsafe injections have caused as many as 20-40 per cent of HIV infections in Africa.
Furthermore, most hepatitis related deaths that result from unsafe injections, occur in Asia. According to a study, each year unsafe injections kill 1.2 million people from hepatitis B and hepatitis C infections (and 100,000 from HIV). It is estimated that more than one million of these deaths will occur in Asia, including 475,000 in India and 382,000 in China.The most basic response to unsafe injections is to make safe injection equipment universally available. This should be accompanied by training on the proper use of that equipment and community education on the importance of safe injections and their appropriate use.
A study in 2003 estimated the cost of a comprehensive global programme that included safe injection equipment, training and education at about $905 million per year.
At present the best way of disposing off medical waste including syringes is by incinerating them and burying the ash. But sadly, even this measure is often too much to ask of hospitals and medical facilities in the country.
In Karachi alone, there are more than 300 hospitals of all sizes and 250 official maternity homes where any wild guess into the use of syringes would suffice.
Incineration should take place at high temperatures to prevent possible carcinogenic by-products from being produced. Thus, the traditional means of burning waste in open-air areas, is not the right way.
Incinerators: the other options
Though incinerators are the dominant means for taking care of hospital waste, they are not necessarily the best. Nevertheless there are techniques that, if applied properly, will make the job safer for everybody.
Steam autoclaving
Steam autoclaving is the most widely used and most efficient alternative medical-waste treatment technology. Most of the available autoclaves are designed to handle both biohazard and normal hospital wastes simultaneously. However, they cannot treat pathological animal wastes, chemotherapy, and low level radioactive wastes. These wastes have to be treated separately.
Medical waste autoclaves usually jointly operate with a shredder and a compactor (to minimize the waste volume).
Chemical treatment
In chemical treatment systems an anti-microbial chemical such as sodium hypochlorite, chlorine dioxide or peracetic acid, decontaminates the medical waste.
Microwave radiation
Medical waste enters the system by batch or continuous mode, where it is wetted with steam or water and heated by microwave radiation at decontaminating temperatures.
Others
Some systems use a combination of infra-red radiation and forced hot-air convection to treat the waste. The waste then is compacted, which prepares it for the landfill. Other systems use gamma radiation to heat the waste to disinfecting temperatures. A portion of the solid residue obtained is recycled, while the remainder is disposed off. Several other thermal systems currently under development use steam, oil, electricity or some form of radiation as their source of heat.
Disposal of pathological waste
Pathological waste (body parts, research animals, etc.) cannot be disposed off by autoclaving. For disposal of such waste, either crematoria (burning) or burial should be performed.
Training
The hospital staff should also be trained in helping to dispose off the waste properly. n -– Atif Khan
Recycling in Lahore
The unscrupulous practice of recycling used disposable syringes, drip needles and other clinical items is playing havoc with the lives of people in Punjab by spreading infections and blood related diseases including hepatitis and Aids.Improper disposal of infectious waste by private hospitals, clinics and laboratories in the province is adding to the occurrence of infections and blood related diseases. There are about 120 government and private hospitals and, hundreds of clinics and labs in the provincial metropolis alone, which generate tons of clinical waste every day.
Different studies suggest that around 45 per cent of the diseases in the province are preventable. The eight teaching hospitals in Lahore have, however, been made to segregate infectious and clinical waste from civic waste and send it to the Children’s Hospital for incineration, where an incinerator was installed last year.
Still, most teaching hospitals have failed to ensure the destruction of disposable syringes, needles and sharp edged items, which are ultimately sold by hospital employees to agents for re-cycling after a ‘mere washing’ in the washing plants established in different city streets.
“I agree that hospital employees are part of the mafia that collect used disposable syringes and drips and make them available to the unscrupulous traders involved in washing and re-packaging for re-use,” said Services Hospital medical superintendent, Dr Riaz Chaudhry. He added that it was necessary that syringe needle cutters be made available in all hospitals and ensured that all needles were cut accordingly.
Dr Chaudhry said that the use of re-cycled syringes, needles and other clinical items that contain blood residual and micro-organisms can cause different infections –– typhoid, jaundice, hepatitis B and C and HIV/Aids.
A nurse at Lady Willingdon Hospital, a major obstetrics and gynaecology hospital in the province, said that no syringe cutter was available and she was compelled to throw the syringes in the general waste bin.
Professor of Medicine at King Edward Medical College/Mayo Hospital, Dr Javed Akram, said health professionals were also facing legislation problem with regard to the recycling and reuse of syringes. He said the Drugs Act did not empower the drug inspectors to challan those involved in the unscrupulous practice of procuring used disposable syringes and recycling them for reuse. “It is a strange fact that medicines are covered in isolation, but the syringes that are means to inject the medicine are not,” he observed.
Prof Akram said the government needed to take steps to bring syringes in the fold of legislation to curb the incidence of infectious and blood related diseases.
There are around ten factories in Lahore producing disposable syringes, besides a number of unregulated used syringes washing plants established in different parts of the city.
A visit to different dumping sites in the city, including Bund Road and Mahmood Booti, reveals scavengers busy in separating plastic bags of glucose, blood, urine, catheters, CVP lines, syringes, needles, razors, blades, glass slides, branulas, canulas and other sharp items to sell them to unscrupulous traders who recycle the material or market the used medical disposables after packing them afresh. Drug addicts also pick up syringes and reuse them to inject drugs.
Medical experts claim that infectious waste — pathological waste, tissues, blood and blood products, surgical dressing, disposable gloves, chemotherapy and pharmaceutical waste, cotton swabs, soiled dressing from treatment area and waste from operation theatres — being dumped without proper arrangements is not only posing a threat to hospital and laboratory employees but also to the surrounding environment. –– Mansoor Malik
In developing countries, single-chamber incinerators are commonly used because they are relatively inexpensive, though they operate at low temperatures and produce toxic gases. However, after the waste is burned, the ashes left after the incineration process must be buried.
At present, “practically no environment-friendly, low-cost options for safe disposal of infectious waste exist, although some research is underway,” said one doctor.Nevertheless, despite the risk of toxic by-products, incineration is generally preferred to burying medical sharps waste, which creates the risk that when auto-disposable syringes are not used, syringes will be “recycled” —- that is, repackaged, resold, and reused, as it happens in Pakistan.
In developing countries, medical waste disposal is often inadequate, and the waste ends up in garbage dumps, which people scavenge for items to sell, including injection equipment. This practice not only puts scavengers at great risk of injuries from needle pricks, it also has the used syringes ending up back in the healthcare system.
Syringes need to have their needles removed first. Removal of the needles from used syringes can render them unfit for reuse and safe for disposal. Various types of removal of needles or size reduction technologies are available.
Some types require a source of electrical power (needle burner), but their wide application in developing countries is limited, particularly in remote areas. Additionally, these burning devices must be regularly maintained and operated carefully.
Needles can also be removed from the syringe after administering the injection by small manually operated devices. The mutilated syringe needs to be disinfected prior to disposal with other waste. Then there are shredders that cut sharp objects into small pieces. This technology requires a worker skilled in the operation and maintenance of sometimes heavy-duty, rotating equipment.
Simple shredders can be made from a manually operated grain mill. Due to the risk to workers during operation, only disinfected needles and syringes should be processed. Shredding can only be done in the developing countries when large quantities of used needles and syringes are available, implying a centralized system involving collection and transportation from various settings.
Needles from used syringes are today also found on the streets of ones neighbourhood, right next to the doctor’s home, or right around the corner. If the government isn’t doing enough to tackle the problem then at least the medical professionals should take the lead. This way, we can contribute and help cut the rate of potential HIV and hepatitis infections. Not to mention the prick and the pain.
Types of hospital waste
Other forms of hospital waste include the following:
Infectious: Materials that contain pathogens in sufficient concentrations or quantities that if exposed, can cause diseases. This includes waste from surgery and autopsies on patients with infectious diseases.
Pathological: These include tissues, organs, body parts, human flesh, foetus, blood and body fluids.
Pharmaceuticals: Drugs and chemicals that are returned from hospital wards, which may be spilled, outdated, contaminated or are no longer required.
Radioactive: Solids, liquids and gaseous waste contaminated with radioactive substances used in diagnosis and treatment of diseases e.g goitre.
Others: Waste from the offices, kitchens and other rooms, including bed linen, utensils, paper, etc. –– Atif Khan
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