KARACHI: Karachi being the largest city of Pakistan produces the biggest amount of medical waste, also known as clinical waste, partly due to fast unregulated growth of substandard diagnostic labs, blood banks and medical facilities where clinical waste is handled without prior risk assessment while breaches in universal precautions and violations of bio-safety protocols are common.
Medical waste is a reservoir of potentially harmful micro-organisms that can infect hospital patients, health-care personnel, sanitation workers and the public.
Among 353 public and private sector hospitals and laboratories of the city, the number of lab professionals who received regular immunisation was zero; 40 per cent recapped syringe needles after using them and 36pc discarded used syringes without cutting them.
These and other disturbing findings were the outcome of a recent survey entitled ‘Knowledge and awareness of proper waste disposal and routine bio-safety measures among healthcare workers in Karachi’.
The survey was completed in 2011 under the Jinnah University of Women, United States’ Bio-Safety Engagement Programme and Bio-Safety Association of Pakistan (JUW-BEP-BSAP) project.
Unfolding the details of this survey and two other surveys titled ‘Survey of biosafety practices and biosafety breaches in public and private sector diagnostic laboratories of Karachi,’ which were aimed at determining the level of awareness, skills and training of lab technicians and other healthcare personnel working in 18 towns of the city, renowned microbiologist Prof (Dr) Shahana Urooj Kazmi said that during these surveys it was found that among 353 public and private sector hospitals and laboratories, 46 per cent never used personal protective equipment (PPE) while handling class 2 pathogens, 40pc recapped syringe needles after using them, 36pc discarded used syringes without cutting them, thus encouraging their reuse.
It was also found that 38pc used mouth pipette to transfer samples of human origin/chemicals/blood, 58pc knew nothing about decontamination of infected waste/ incineration/hospital waste disposal techniques, 74pc confirmed having no standard operating procedures (SOPs) required to work in such set-ups, and 83pc had no record of spills/no record of accidental injuries during their lab work, 85pc of the survey participants never had any biosafety training to work with potential pathogens, she added.
Elaborating, Prof Kazmi, who is also Karachi University’s pro vice chancellor, said that the impact of training programmes and awareness seminars was reflected to some extent in the results of the last survey which was completed in 2011 on the topic of ‘Knowledge and awareness of proper waste disposal and routine biosafety measures among healthcare workers in Karachi’.
In this survey, she said, 250 participants were asked to provide information regarding standard microbiological practices, safety equipments (primary barriers), and laboratory facilities (secondary barriers).
She said that a positive response was received to questions regarding restricted access to laboratory (65pc), use of gloves (30pc), washing hands during lab work (85pc), eating/drinking in lab, handling contact lenses prohibited (10pc), mouth pipette is prohibited (45pc), policy for safe handling of sharps (32pc), careful procedure to minimise aerosol (6pc), work surface decontaminated once each day or due to spill (70pc), regulated wastes are decontaminated before disposal by an approved method (22pc) and zero per cent lab professionals received regular immunisation for agents handled in the labs, which, she said was very surprising.
She said that only 3pc of lab workers received appropriate training on hazards associated in labs, 10pc of directors ensured that before working in biosafety level (BSL) 2/3 person got proficiency in microbiological practices and techniques and operations specific to lab facility, 56pc had knowledge that they should be very much careful when handling sharp instruments and that plastic wares should be substituted for glassware, 9pc of labs used needle-locking syringes or syringe-needle units were used for injection, 7pc of labs used other safe devices, 8pc of labs followed proper procedure of disposing of broken glassware mechanically using tongs and forceps whereas only 2pc of labs used biological safety cabinets when working with infectious material, 67pc of the labs followed decontamination of lab equipment using effective disinfectants, but only 2pc of labs used proper decontamination of spills involving infectious material and 10pc of labs decontaminated contaminated equipments and materials before removal.
Moreover, protective laboratory clothing were worn by only 5pc workers, gloves worn while handling infectious material by 60pc, frequent changing of gloves 6pc, all manipulations in safety cabinets done by 6pc only, respiratory and mask used by 5pc and 80pc of labs follow proper procedure of decontaminating lab materials.
Biosafety cabinets were present in 4pc of labs, equipments that may produce aerosols were handled in safety cabinets in 5pc of labs and only 3pc of labs had an eye wash station and 76pc had adequate illumination for all activity, it was found during the surveys.
It was, however, quite amazing that many of the participants had not even seen different kind of face masks and labelled/ unlabelled autoclavable biohazard bags and were not able to distinguish between simple polyethylene-made disposable gloves, surgical gloves and examination gloves on the basis of their need and requirements, she said.
Medical waste disposal
Prof Kazmi said that only 8pc laboratories out of the 250 surveyed facilities had biosafety cabinets and well-maintained waste management plans.
Underscoring the need for creating awareness of the importance of biosafety and biosecurity among labs/hospitals/healthcare set-up mangers, owners, CEOs and local municipal authorities, she said that mass-scale education, motivation and sense of ethics and hygiene among both the stakeholders and the healthcare workers might help reduce the risk of deadly infections.
In this regard, she pointed out that the use of PPE was not practised in a majority of the facilities (89pc) while 95pc of hospitals (a majority of them located in moderate to low socio-economic areas of the city) dumped their waste openly inside or outside the premises without proper treatment. Local municipality vehicles collected that waste either on a daily or weekly basis, depending upon the contract with the hospital administration, she added.
Highlighting the importance of training programmes initiated by BSA-Pakistan for improving biosafety guidelines compliance by clinical diagnostic laboratories in the country, Prof Kazmi, who is the professor of microbiology and immunology, said that compliance with internationally accepted biosafety and biosecurity guidelines had to be practised to minimise the exposure of laboratory workers and outside environment to potentially hazardous/infectious materials/agents/toxins being handled in clinical laboratories and hospitals which provided bulk of diagnostic services.
Besides, strict adherence to standard microbiological lab practices and techniques, know-how and training, safety equipment and facility design for worker protection, barrier to outside persons, animals and environment should be ensured to control infectious diseases, accidental injuries and release or intentional misuse of potential pathogens, she said.
She said that it was important to identify urgent gaps and priorities to recommend action to advance biosafety and biosecurity with particular attention to building sustainable capacity to strengthen national and global health and security, raising awareness, promoting high standards in safe operation of biological facilities in academic, research and medical institutions to respond to most challenging biological risks in areas with high endemic and epidemic disease incidence.
She also stressed the need for providing advice to competent national authorities for efficient waste management through dissemination of knowledge of appropriate systems, developing tools and technologies for public and veterinary health environments by utilising the concept of local solutions to local challenges.
Presenting a summary of results of various research surveys conducted by her research group at Karachi University in collaboration with Prof (Dr) Shazia Hakim of the Jinnah University for Women and Dr Sadia Nasim of the Pakistan Microbiology Research Council (PMRC), carried out over the past four years, Dr Kazmi highlighted the pioneering contributions made by Karachi University microbiologists, Pakistan Society for Microbiology (PSM) and the BSAP in the area of biosafety curriculum development, training of scholars in microbiological biosafety and aseptic techniques in the last three decades .
Biosecurity capacity building
She said that it was ironic that a majority of individuals involved in handling and disposing of infected clinical material were not aware of the potential threats to their health and the health of community as improper disposal of hospital and public health laboratory waste in open areas was a source of disease epidemics and loss of life.
Proper handling, processing and containment of all microbes as well as samples of human or animal origin infected with pathogens by the laboratory personnel were essential to contain the spread of infection, she said.
Moreover, biosecurity capacity building is essential to protect human health, agricultural production systems and consumer confidence in agri-food products and to meet international trade agreement requirements regarding food safety, animal and plant health and life.
In this regard, she pointed out that 18 hands-on training workshops had been conducted in collaboration with the ministry of health, environment, planning and agriculture and experts from the American Biological Safety Association, the PSM and the BSAP, for laboratory personnel, research scientists, graduate students and researchers from institutes involved in research and development work in the public and private sectors, food, pharmaceutical and agricultural industry.
The aim of these workshops was to develop an appreciation of biosafety and biosecurity issues, increase BSL 2-3 level knowledge and skills using hands-on experience to handle real time situations, she said.
The participants were trained on pathogen isolation, identification, proper disposal of samples, development of laboratory safety and security measures, selection and use of appropriate PPE, operation of biological safety cabinets, assessment of possible risks and animal handling procedures, she added.
Replying to a question about the impact of the training programmes, she said it was quite encouraging, but the need of the hour was to continue efforts for national biosafety capacity building in other institutions, develop biosafety curricula suitable for integration into high-school level education programmes and modular bio-risk management programme, develop appropriate legislative framework for national biosafety guidelines, policies and laboratory accreditation programmes for proper technical and community evaluation and work towards initiating funding of applied biosafety research projects by the Higher Education Commission (HEC).
Such steps, she added, would help improve know-how about biosafety issues to identify biological risks and to mitigate them by cost-effective solutions.
Prof Kazmi underscored the need for formulating institutional biosafety policies and programmes to reduce the incidence of serious infections like tuberculosis, hepatitis, bird flu, etc, and heavy economic losses due to zoonosis, livestock and crop diseases and possible threat of bioterrorism by misuse of select agents through proper monitoring of proposed work activities/procedures in compliance with SOPs by the institutional biosafety officers.