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MEQ
14,2 An analysis of possible
scenarios of medical waste
242
management in Bangladesh
Nasima Akter
Environmental Technology and Management, Urban Environmental
Engineering Program, School of Environment, Resource and
Development, Asian Institute of Technology, KlongLuang, Thailand, and
Josef Trankler
Urban Environmental Engineering Program, School of Environment,
Resource and Development, Asian Institute of Technology, KlongLuang,
Thailand
Keywords Medical products, Waste, Management, Health care, Bangladesh
Abstract This study investigated medical waste management (MWM) practices in Bangladesh:
its present constraints, the health effect of existing practices, and the weaknesses of the current
system. Suggestions for improvement of the MWM situation have also been offered. Those
interviewed included hospital staff, waste pickers and local residents. In-depth field observations
and a questionnaire survey were conducted in June-July 2000 and March 2001. Laboratory
analyses of medical waste were done on different occasions from 1998-2001. Analyses of medical
waste showed severe contamination of pathogenic microorganism and respondents suffered from
various infectious diseases. The study identified the absence of rigorous laws related to MWM
practices. It is a necessity to improve the handling and disposal methods of medical waste in almost
all the available medical facilities.

Management of Environmental
Quality: An International Journal
Vol. 14 No. 2, 2003
pp. 242-255
q MCB UP Limited
1477-7835
DOI 10.1108/14777830310470459
Introduction
Medical waste generated from diagnosis, monitoring and preventive, curative
or palliative activities in field of the veterinary and human medicine include
infectious, hazardous and benign materials. Improper disposal of wastes in
hospitals places direct and indirect health impacts on those working in
hospitals and the surrounding communities, and on the environment. Such
practices contribute to the spread of disease, as well as pollution of the air, soil
and water. Runoff from untreated infectious wastes or human excrement
dumped on the land can contaminate surface and ground water supplies,
exposing the population to the risk of diseases and parasites. Unintentional
injuries may occur due to the exposure of improperly discarded sharps leading
to life-threatening infections such as HBV, HCV and HIV (World Bank, 2000).
The re-use of unsterilized syringes results in 8-16 million hepatitis B, 2.3-4.7
million hepatitis C and 80,000-160,000 HIV infections annually (WHO, 2000).
Uncontrolled burning of medical waste pollutes the air with acid gases, dioxins,
furans and heavy metals.
 There are currently 645 public and 288 private sector health care Possible
establishments in Bangladesh (Line Director (hospital services), 2000). Most scenarios of
have no provision for safe disposal of medical waste, yet its generation has MWM
been on an increase. An estimated 255 tons of medical waste is generated in
Dhaka every day (Rahman and Ali, 2000), most of which is dumped in
municipal bins (ADB, 1998), since only few hospitals have onsite management
system such as burning, burial, autoclave and/or waste segregation. 243
An overwhelming number of the urban poor in Bangladesh rely on the
collection of secondary materials for their primary source of livelihood. The
wastes pickers sort through waste on site; usually open dumps. They sell all
that can be recycled to agents of various industries. The waste pickers adopt
no protective clothing, exposing themselves to injury and sickness. Moreover,
the municipal dustbins of Dhaka, where the hospitals place their waste
(including human body parts (Rashid, 1996)) are left exposed to the
environment for days before collection (ADB, 1998; Akter et al., 1999). This
increases the risk of epidemics such as viral hepatitis, typhoid, pneumonia
and AIDs (ADB, 1998).

Objectives
There had been no previous study conducted on the impacts of improper
medical waste management (MWM).
The objectives of this study are as follows:
.
to review the current status of medical waste management practices in
Bangladesh;
.
to identify the health effect of existing MWM practices;
.
to identify the weaknesses of waste management; and
.
to provide a set of suggestions, strategies and policies to advance those
that exist.

Materials and methods

Sampling for this study
Study was conducted in two major cities of Bangladesh: Dhaka, the capital city,
and Khulna, a port city southwest of Bangladesh. There are 26 government
hospitals and foundations, 133 private hospitals and clinics and 318 diagnostic
centers in Dhaka. There are 248 health facilities in Khulna of which 21 are
hospitals and clinics (which house the in-patient bed system), 12 are diagnostic
centers and the remainder are maternity centers, centers for the Expanded
Program on Immunization (EPI), and out patient departments (OPD). A total of
14 hospitals, clinics, diagnostic centers and research institutes from Dhaka, and
seven from Khulna were selected for this study (Table I).
Dhaka. Four government hospitals (covering 2,350 beds i.e. 61 percent of
total government hospital beds in Dhaka), one private hospital (national
MEQ
Name of selected hospital from Dhaka Name of selected hospital from Khulna
14,2
1. Institute of Post Graduate Medicine 1. Khulna Medical College and Hospital
Research (IPGMR) 2. Surgical Hospital, Khulna
2. Dhaka Medical College Hospital (DMCH) 3. Garib Newaz Clinic, Khulna
3. Sir Salimullah Medical College Hospital 4. Islami Bank Hospital, Khulna
244 (SSMCH) 5. Pangu Hospital, Khulna
4. Infectious Disease Hospital (IDH) 6. Mahanagar Diagnostic Center
5. National Medical Institute and Hospital 7. Bashundhara diagnostic Center
6. Ibnesina Diagnostic Center
7. Modern Clinic
8. Medinova Diagnostic Center
9. Holly Family
10. Popular Diagnostic Center
11. Delta Medical Center and Clinic
12. Institute of Child and Mother Health
(ICMH)
13. International Center for Diarrhoeal
Disease Research, Bangladesh (ICDDR,B)
14. Combined Military Hospital (CMH)
Table I.
Name of selected Note: Nos 1-7 hospitals and centers were selected for the questionnaire survey, including
hospitals and clinics these seven hospitals and centers all others were selected for interview and field investigation
from Bangladesh as well

institute and hospital), two private clinics and two diagnostic centers were
selected to represent each category in this study. These cover approximately
30 percent of total beds. The government hospitals represent the
management system of the country. They were also selected for the
questionnaire survey, interview, waste sampling, and field observation. In
addition, a health institute, an international research center, a military
hospital, a clinic and a diagnostic center were selected for interview and field
observation.
Khulna. Total bed number in the 21 hospitals and clinics are
approximately 806, of which 62 percent (500 beds) belongs to three big
hospitals (one district and two private). Of these three, two hospitals
covering 70 percent (350 beds) of 62 percent were studied. Three private
clinics were selected from the remaining 38 percent of beds (42 percent of
38 percent (130 beds)). Therefore, total coverage for this study was 78
percent of all beds present in the city. Four private hospital and clinics,
two diagnostic centers and one government district hospital were selected
for interview and field observation. Khulna was also selected for a case
study of MWM.
The three dumpsites in the country were examined: city corporations
landfill sites at Kamalapur and Matuail in Dhaka and the municipal dumping
site at Khulna.
Data collection Possible
Data were collected through field observations, interviews, and questionnaire scenarios of
survey during June-July 2000 and March 2001: MWM
.
Field observations. Made at each location using a checklist focusing on
potential problems posed by disposal of medical waste. Emphasis was
placed on waste generation in the hospitals (store, OPD, patient ward, 245
operation theatre, pathological laboratory), disposal practices, and disposal
sites. The MWM project of an NGO at Khulna (Prodipan) was visited.
.
Interview. Hospital management authority, divisional head/director,
senior administrative personnel of the hospitals or clinics were
interviewed on general hospital management, health services, waste
management, their basic understanding and view on MWM, and their
suggestions for improvement the system. City Corporation, Department
of Environment (DOE) officials, and Directorate General (DG) health
officials were also interviewed for the legal status and for their awareness
of the importance of proper MWM.
.
Questionnaire survey. Conducted for those providing medical services,
handling and disposing waste (doctors, nurses and waste pickers). Sets of
semi-structured questionnaires were used. The main purpose was to
assess the level of awareness of health effects of improper disposal, the
required skill for waste handling, and to identify the factors limiting
proper disposal. A statistically viable sample of respondents for the
survey were determined using the following equation (1). The
respondents of different categories were randomly selected:

Nz 2 p1
P
n 1
Nd 2 z 2 p1
P
where:
n = sample size to be calculated;
N = total staff 4,313;
z = confidence interval at 90 percent, i.e. 1.645;
p = estimated population proportion (0.5, this maximizes the sample
size);
d = error limit of 5 percent (0.05).
Application of the above formula with the specified values, which in fact
maximizes the sample size, yielded a total required sample of 255
respondents from the total 4,313 hospital staff. This sample was divided
into doctors, nurses and others in the proportion as they appear in the
population. The collected sample size was 385 persons comprising 55
MEQ doctors, 155 nurses and 179 others (cleaners, ward boys). Assuming 50
14,2 percent reserve (from non-response and missing staff) from the required
sample size giving 383 as requirement (255 * 1.5 383 persons).
Other than these, 117 waste pickers/local residents near hospital
vicinity and 100 of those from two municipal dumping sites at Dhaka were
selected when available.
246

Laboratory analysis of medical and municipal waste

Samples of solid waste, wastewater, and leachate from the hospitals, waste
disposal bins, disposal sites and dumping sites were collected for pathological
(microbial) analysis. during September 1998, July 2000 and March 2001 in
accordance with the International Center for Diarrhoeal Disease Research,
Bangladeshs (ICDDR,Bs) prescribed technique. Total coliform, faecal coliform,
faecal streptococci, mycobacteria, amoeba, Vibrio spp., Salmonella spp. and
Shigella spp. were analyzed using the standard methods as adopted by
environment and microbiology laboratory of ICDDR,B.

Results and discussion

Status of medical waste management in Bangladesh: an overview
State of legislation. There is no current law or regulation that regulates medical
waste generation and its management (BELA, 1996; Bangladesh Gazette, 1997,
2000; Dana, 1999). The government has no written legislation or guideline for
MWM or the protection of health care workers. The Directorate General of
Health Service under the Ministry of Health and Family Welfare has published
a manual (Line Director (hospital serices), 2001) for MWM. If put to practice
using firm laws, this manual will improve the current system. In September
2000, a committee of the DOE suggested guidelines including environmental
aspects in the Ministry of Health and Family Planning Clinic Act 1999. This
was put forward to identify environmentally-friendly techniques for clinical
waste disposal/management in Dhaka under the title Bio Medical Waste
Management and Process Guideline/Rules (2000.2001).

Medical waste generation

Roughly 20 percent of total medical waste generated in Dhaka is
infectious/hazardous (Kazi, 1998). The generation rate at ranges between
0.55-1.10kg/bed/day, which includes 0.169kg/bed/day of hazardous material.
The contribution of infectious, sharps and pathological waste is 10.5 percent,
3.5 percent and 1.5 percent respectively. Medical waste generation at Khulna
city ranges 0.35-0.37kg/bed/day. The categories of medical waste generation in
the 20 hospitals and clinics at Khulna are shown in Figure 1. The waste is
divided in to four categories: general all waste coming from hospitals; sharps;
non-sharps saline bags; and kitchen waste. In Khulna, average medical waste
 Possible
scenarios of
MWM

247

Figure 1.
Proportion of waste
generation in 20 health
facilities at Khulna City

produced is 1,488kg/day. Furthermore, 8,680 disposable syringes/needles are

discarded, of which 10 percent are recycled (Sumon, 2000).

Existing practices
Currently, hospitals use municipal bins and dumping grounds for disposal.
Wastes can often be found in rivers or canals near larger hospitals. Few
hospitals store waste in their net houses or closed dustbins before sending to
the city corporation bins. Generally, solid wastes, saline bags, and non-sharps
are disposed off in improper ways (Figure 2).
The questionnaire survey revealed that apart from separating
syringes/needles, hospitals do not practice waste segregation before disposal.
The waste includes items such as vials, slides, empty packets, bottles and
saline bags, and used X-ray film developing chemicals. Hence, waste pickers
sort through and sell material to traders that are hazardous.

Figure 2.
Waste disposal from
hospital
MEQ Few places where segregation has been introduced include the Institute of
14,2 Mother and Child Health (IMCH) where sharps, glass, clinical and food wastes
are kept in separate bins. ICDDR,B separates laboratory culture and waste,
needles and glasses. Prodipan, a non-government organization (NGO)-operated
clinical waste management project in Khulna provides an example for superior
practices of MWM.
248 A total of 21 percent of doctors and 18 percent of nurses stated burning as a
disposal process, however, there are no specific sites where this can occur.
Hence open fields and pavements near hospitals and clinics are used. Burning
is used only for selected solid wastes, e.g. sputum from TB patients, tested
slides, ruined bed-sheets/mattresses. Other items, including cases of
fetuses/placenta, are buried around the medical facilities or within the
hospital compound.
Some medical colleges and tertiary government hospitals have incinerators
on site. Even though no alternative method is prescribed, the DOE does not
permit the operation of incinerators due to environmental concern. Some
private institutes and NGOs operate their own incinerators for infectious waste.

Health effect of medical waste

Pathological analysis of waste. Combined results of analysis during 1998, 2000
and 2001 are summarized in Tables II and III. First samples collected in 1998
(Table II) showed severe contamination of all selected pathogens, e.g.
Salmonella spp., Shigella spp., mycobacteria and amoeba. Identification of
coliform or feacal coliform in all collected samples, presence of V. cholerae (non-
0139 strain), Vibrio spp. and Salmonella spp. in sampling of DMCH surgical
department waste indicates the unsafe disposal of waste without any treatment
or disinfection of infectious waste (Table III). As Colgate (2001) mentioned,
bacteria are the most successful living organisms on planet and many can be
hazardous or even fatal to humans. The highest concentration of such
organisms can be found in hospitals and consequently medical waste poses a
potential risk for staff, patients and operators responsible for its eventual
disposal. A history of diseases in the respondents (following section) might
support the aforementioned findings of pathological analysis of waste.
Disease history. Cleaners, sweepers, ward boys, ayas (female health workers)
and laboratory assistants all handle medical waste. Nurses and doctors are also
exposed to it while dealing with patients, while waste pickers and those living
near hospitals or disposal bins come in contact with the waste. The following
analyses were done using data from the questionnaire survey.
Disease within 15 days of contact. A survey determining the prevalence of
diseases within 15 days of disposal indicated that 41 percent of nurses suffered
from diseases contracted in this short time frame. Similarly, 60 percent of the
cleaners/ayas, and 57 percent of waste pickers/local residents also suffered
ailments. From municipal dumpsites, 85 percent of waste pickers and local
 Salmonella Shigella Mycobacteria Amoeba
Source of waste sample (/100ml or gm) (/100ml or gm) (/100ml or gm) (/100ml or gm)

Dustbin, Sir Salimullah Medical College Hospital 2.5 10 6.4 10 2.3 10 3.8 10
Basin water, Sir Salimullah Medical College Hospital 2.7 10 1.1 10 1.1 10 3
Dustbin, Dhaka Medical College Hospital 3.2 10 3.6 10 4.7 10 5.3 10
Basin water, Dhaka Medical College Hospital 3.2 10 1.7 10 15 ,1
Solid waste, Dhaka Medical College Hospital 2.5 10 2.0 10 5.6 10 3.9 10
Wastewater, Dhaka Medical College Hospital 2.9 10 3.1 10 3 1.2 10
Infectious Disease Hospital basin water 1.6 10 35 10 5 ,1
Infectious Disease Hospital dustbin 2.3 10 7.7 10 1.8 10 6.2 10
Delta Medical Center and Clinic soil 3.1 10 7.2 10 3.4 10 2.7 10
Popular Diagnostic Center water 6.8 10 1.2 10 7 5
Possible

different sources in
medical waste
analyzed from
Pathogens in
MWM

September 1998
Table II.
249
scenarios of
 14,2

250
MEQ

Table III.
Pathological

collected from

(July 2000 and

21 March, 2001)
obtained results
hospital, dustbin,
analysis of waste

and dumpsites and

Total coliform/ Faecal coliform/ Feacal streptococci/ Salmonella spp./
Sample no. 100ml or gm 100ml or gm 100ml or gm Vibrio spp. Shigella spp.

Solid waste, Ibnesina Diagnostic Center 3.2 106 1.7 106 3.2 104 V. cholerae non 01, Absent
non 0139 present
Leachate, Ibnesina Diagnostic Center 1.6 108 1.3 108 3.6 106 Absent Absent
Solid waste, IPGMR 8.4 107 6.0 107 4.4 104 V. cholerae non 01, Absent
non 0139 present
Leachate, IPGMR 7.2 107 4.8 107 1.2 105 V. cholerae non 01, Absent
non 0139 present
Solid waste 1.2 105 1.1 105 V. cholerae non 01, Absent
non 0139 present
Leachate, DMCH 2.2 108 6.0 107 V. cholerae non 01, Absent
non 0139 present
DMCH (medicine) 3.8 107 3.2 107 1.6 106 Absent Absent
DMCH (Surgery) 6.8 108 2.4 108 8.4 107 V. cholerae non 01, Salmonella spp.
non 0139 present present
DMCH (Urology) 3.6 106 2.4 106 3.6 104 Absent
Dustbin, IPGMR 3.9 109 2.9 109 2.0 106 Absent Absent
residents had diseases of some kind within 15 days of contact with hazardous Possible
waste. Apart from that, 11 percent of nurses and cleaners, 19 percent of waste scenarios of
pickers and local residents and 7 percent residents had infectious diseases MWM
(Figure 3). These included skin diseases, allergy, hepatitis B/C, diarrhea and
dysentery.
251
Chronic diseases
Figures 4 and 5 illustrate the findings of chronic diseases and the speculations
as to the origin of the diseases. A total of 47 percent of nurses suffered chronic
diseases, of which 13 percent were infectious. Of these, 45 percent existed for
one year; 37 percent were job related; and about 89 percent of nurses consulted
physicians. They believed the lack of facilities to disinfect hands/instruments
and overcrowded wards caused them to work far beyond their capacity.
Among the cleaners and workers, 64 percent had chronic diseases, of which
39 percent were infectious, majority of whom suffered for up to a year. The
majority (55 percent) of the waste pickers and local residents around hospitals
suffered from chronic diseases lasting two to five years, of which 41 percent
were infectious. A total of 7 percent had more than one infectious disease. Most
(57 percent) were unaware of the cause of their diseases. It was found that 83
percent waste pickers suffered from chronic diseases of which 24 percent were
infectious. A total of 40 percent suffered for up to one year and 35 percent for up
to five years. Only about half (51 percent) visited a doctor since they often do
not regard allergy or skin diseases as an illness. Frequent illnesses include the
common cold, fevers and headaches. Non-infectious diseases included
abnormal blood pressure, arthritis, rheumatic fever, ulcers, gastric
stomachache, ophthalmic and ear problems, tonsilitis, sinusitis and diabetes.
Of the respondents, 23 percent had more than one infectious disease. Chronic

Figure 3.
Disease within 15 days
among the respondents
MEQ
14,2

252

Figure 4.
Types of chronic
diseases

Figure 5.
Opinion on source of
diseases

infectious diseases were hepatitis B/C, typhoid, skin disease/allergy, diarrhea,

dysentery, TB and malaria.
Evidently, only waste pickers suffered from TB, malaria and typhoid. This
could be because some microbial cultures like pathogens causing TB, patient
samples (e.g. blood, sputum, stool) are thrown into bins without sterilization.
Solid waste pollution causes the spread of at least 49 vector-borne diseases
including typhoid, dengue, and diarrhoea (Daily Star, 2000). Wastes arises from
the following diseases: cholera, leprosy, anthrax, paratyphoid A, B, C;
pestilence, smallpox, poliomyelitis, dysentery (bacterial), rabies, tularemia,
typhus abdominalis, virus-induced hemorrhagic fever, brucellosis, diphtheria,
meningitis/encephalitis, Q-fever, tuberculosis (active form) and virus hepatitis Possible
(Gleis, 1997). scenarios of
MWM
Proper MWM in Bangladesh: problems identified
Problems and possible solution identified by respondents
Field observation endorses that there are problems in managing waste properly 253
in hospitals themselves. Results of interview and questionnaire survey of
doctors and management personnel are nailed down. Clearly, the authorities
are not sufficiently aware of proper handling and disposal of waste (52 percent
of responses). At the same time, government is not giving due importance to
this issue (28 percent). As a result no intensive law promulgated and lacks its
enforcement and no monitoring authority for this matter to oversee.
Respondents opined to improve the situation of MWM (Table IV).
Awareness was identified as top priority (24.7 percent). They also pointed out
job specification, supervision and monitoring of activities in and around
hospitals. Training, budget allocation, appropriate technology and law
enforcement should be taken into account for a proper MWM system.

Problem of a proper MWM: analyzed situation

.
There is no specific institute responsible for MWM.
.
Lack of cooperation within and among various agencies is a pertinent
problem. Few local initiatives have been undertaken by some NGOs.
.
Lack of awareness of potential risks.
.
Hospital authorities tend to overlook health issues as it involves large
sums of money.
.
Lack of in-house management. Selected items like saline bags and
containers are recycled centrally in some hospitals.
.
Unauthorized medical waste segregation, recycling and reused is often
conducted in and outside hospitals by informal sectors.

Suggestions provided by respondents % of responses

Awareness through mass media, seminar, and training 24.7

Job distribution, responsibility, supervision and monitoring 23.7
Trained manpower 12.4
Increase government budget in health sector 11.3
Incinerator or improved technology 10.3 Table IV.
Appropriate guideline 7.2 Suggestions for
Chain of command should be maintained 7.2 improvement of
Law enforcement authority should be sincere to their job 3.1 MWM situation in
Proper place for waste disposal 1 Bangladesh
MEQ Conclusion and recommendations
14,2 Improving MWM is a necessity for Bangladesh.
The improvements suggested below for proper MWM can pave the way in a
series of small steps to ensure the well being of the community:
.
Formulation and implementation of laws, regulation and guidelines.
254 .
Awareness building of hospital staff and the public about the risk
involved and the proper procedures.
.
Proper in-house management: identification and segregation of material.
.
Institutional cooperation must be increased between hospitals. Larger
hospitals may share their facilities with smaller clinics. Government
bodies must also collaborate (e.g. City Corporation, DOE) to find solutions
for proper management.
.
Treatment technology for infectious waste: Autoclave can be used in
small clinics and laboratories to disinfect. Central incinerators reduce air
pollution and are cost effective.
With these measures considered seriously, the current system of MWM in
Bangladesh can be greatly benefited providing the community with higher
safety from threatening ailments and keeping the environment from such
dangerous pollutants.

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