An Overview of The Present Status Ofhospital

JIPH-352;
No. of Pages 7
ARTICLE IN PRESS
Journal of Infection and Public Health (2014) xxx, xxxxxx
An overview of the present status of

hospital waste management
in Kerman, Iran
Hamideh Bahrami a, Mohammad Malakootian b,
c
d
Seyed
Dawood
Mousavi
Nasab
, Nemat
Jaafarzadeh
,
e
b
Mehrdad
Askarian
, Sarah
Samadi
, Nayeb
Ali Ahmadi
f,
Department of Environmental Health Engineering, School of Public Health, Shahid

Beheshti University of Medical Sciences, Tehran, Iran
b
Environmental Health Engineering Research Center, Department of Environmental
Health, School of Public Health, Kerman University of Medical Sciences, Kerman, Iran
c
Department of Virology, Faculty of Medical Sciences, Tarbiat Modares University,
Tehran, Iran
d
Department of Environmental Health, School of Public Health, Ahwaz Jondishapour
University of Medical Sciences, Ahwaz, Iran
e
Department of Community Medicine, Medical School, Shiraz University of Medical
Sciences, Shiraz, Iran
f
Department of Medical Lab Technology, and Proteomics Research Center, Faculty of
Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Received 22 January 2014 ; received in revised form 14 May 2014; accepted 11 July 2014
KEYWORDS
Hospital waste;
Management;
Pollution;
Environment;
Kerman
Summary
Introduction: The management of hospital waste is a notably important issue due
to its potential contribution to environmental pollution and its undesirable effects
on public health.
Methods: This cross-sectional study was performed in eight hospitals in Kerman,
Iran. Data and information from all of the hospitals were collected using a
questionnaire and interviewing personnel. The purpose of this research was to
determine different types of waste and to evaluate the waste management
situation in Kerman. Results: The results showed that the waste composition in
hospitals included general waste (71.37%), infectious waste (23.14%),
pathological waste (0.58%), sharps (3.61%), pharmaceutical and chemical waste
(0.93%) and pressured containers (0.37%). The generation rate varied from 2.45
to 5.26 kg/bed-day with a weight average of 3.43 kg/bed-day.
Corresponding author. Tel.: +98 2122718528.

E-mail addresses: nayebalia@yahoo.com, nayebalia@sbmu.ac.ir (N.A. Ahmadi).
http://dx.doi.org/10.1016/j.jiph.2014.07.007
1876-0341/ 2014 Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University for Health Sciences. All rights
reserved.
Please cite this article in press as: Bahrami H, et al. An overview of the present status of hospital waste
management
in Kerman, Iran. J Infect Public Health (2014), http://dx.doi.org/10.1016/j.jiph.2014.07.007
JIPH-352; No. of Pages 7
ARTICLE IN PRESS
H. Bahrami et al.
Conclusions: The ndings of this research indicated that comprehensive plans and
policies should be applied to improve the present status of hospital waste
management in Kerman.
2014 Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University
for Health Sciences. All rights reserved.
Introduction
An increase in the rate of urbanization and population has changed the quality and quantity of waste
production. Environmental pollution has become
a fundamental concern due to insufcient waste
management systems, particularly in developing
countries [1,2]. Additionally, poor healthcare
waste management will result in increased
charges in healthcare settings [3]. Thus, waste
management is a very important issue [4,5]. One
study reported that 1 kg out of every 4 kg of
hospital waste was infectious [6]. Studies have
shown poor waste management situations in
some developing countries such as South Africa
and Nigeria [7,8]. According to the documents of
the World Health Organiza- tion (WHO), between
75% to 90% of hospital waste is non-risk or
generally comparable to domestic waste, while
the rest of hospital waste (1025%) are infectious
and may be a source of health risks [9]. A mixture
of infectious and general waste can cause the
entire waste to be potentially infectious [10].
Inappropriate waste management increases the
risk of transmitting diseases such as Hepatitis B,
Hepatitis C, and HIV, and increases the risk of
blood born viruses, respiratory enteric infections,
soft tissue infections and environmental pollution [1113]. According to the WHO classication,
health care waste is categorized into infectious
waste, pathological waste, sharps, pharmaceutical waste, genotoxic waste, chemical waste,
waste with a high content of heavy metals,
pressurized containers and radioactive waste [9].
The aim of the present study was to determine
the different types of hospital waste and the
various components of hospital waste per capita
and to assess the hospital waste management in
eight hospitals in Kerman city, Iran.
Methods
Study area
Kerman is the capital city of Kerman Province and
is located in the southeast of Iran in the vicinity of
the
Loot and Dasht-e-Kavir deserts. Kerman

mainland
1
191
extends
between
the latitudes
30 14
30cov1 and
1 east
north, and
the longitudes
56 58
57 9and
2
ering an area city of 185 km . The population of
Kerman is estimated to be approximately 515,114
[14]. In this cross sectional study, all the hospitals
that agreed to be visited (N = 8) in Kerman were
investigated over a period of 4 months from April
to August in 2012. Data and information from all
the hospitals were collected through a data
collection form that was derived from the
recommendations
of
the
World
Health
Organization for the evalua- tion of hospital waste
management in developing countries [9,15]. In
each
hospital, data
(about the general
information such as the number of wards and type
of hospital, waste segregation, storage,
treatment and nal disposal practices) were
collected by observing the process of waste management and interviewing the hospital authorities,
the heads of the wards, the environmental health
managers and personnel involved in the management of the hospital waste. Personnel and workers
involved in the management of the hospital waste
were trained to separate the waste. The
segregated waste was weighed with a spring scale
daily during a period of 8 weeks, distributed
randomly over 4 month from April to August, 2012.
Waste classication
Waste classication was performed according to
the World Health Organization classication system as follows: infectious (laboratory cultures;
waste from isolation wards; tissues (swabs) materials, or equipment that have been in contact with
infected patients; and excreta), pathological (body
parts; blood and other body uids; and fetuses),
sharps (needles; infusion sets; scalpels; knives;
blades; and broken glass), pharmaceutical and
chemical wastes (pharmaceuticals that are expired
or no longer needed; items contaminated by or
containing pharmaceuticals; laboratory reagents;
lm developer; disinfectants that are expired or
no longer needed; and solvents) and pressurized containers (gas cylinders; gas cartridges; and
aerosol cans) [9]. Due to the scant amount of
management in Kerman, Iran. J Infect Public Health (2014), http://dx.doi.org/10.1016/j.jiph.2014.07.007
JIPH-352;
No. of Pages 7
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Present status of hospital waste management in Kerman, Iran

3
waste in the hospitals varied between 69.5 and
pharmaceutical and chemical waste, they were
col- lectively grouped in one category. Due to
national and security reasons we could not access
radioactive waste materials. The weight and
composition of the waste from each hospital
were recorded on separate data sheets. The
quantity of hospital waste was presented in
terms of kg/day and kg/bed-day. The generation
rate of each hospital was calculated by dividing
the weight of produced waste by the number of
occupied beds in each hospital.
Statistical analysis
The statistical signicance of each difference
observed between various hospitals, between two
proportions, and between the various components
of hospital waste per capita were evaluated by
x2 tests, calculating the Z statistic, and one-way
ANOVA analysis, respectively. Data analysis was
performed using SPSS 16 software, and a P
value of
<0.05 was considered statistically signicant.
Results
General information on the hospitals
The summary statistics of the number of beds, bed
occupancy and number of wards for the hospitals
are shown in Fig. 1(ac).
Segregation
In 75% of the hospitals, the personnel involved in
waste handling had received training. Infectious
and pathological waste and sharps were
segregated
from
general
waste
(87.5%).
Pathological waste was segregated in 42.8% of the
hospitals. All of the hospitals used yellow colored
bags for infectious waste and placed them in
yellow bins. All of the hospitals used safety
boxes for the collection of sharps and 62.5% of the
hospitals used yellow colored bins for the
placement of safety boxes. All of the hospitals
used black colored bags for general waste and
placed them in blue bags.
Generation rate
This study revealed that the generation rate
ranges from 2.45 to 5.26 kg/bed-day with a weight
average
of 3.43
(Table
1). The
total
1315 kg/day
withkg/bed-day
a total amount
of 5205.3
kg/day,
areas were assessed according to the WHO
management
JIPH-352;
No. of Pages 7
ARTICLE IN PRESS
Figure 1 (ac) The characteristics of the hospitals in
Kerman city. (a) The number of beds, (b) Bed occupancy
and (c) The number of wards in the different hospitals in
Kerman, Iran (2012).
which included 3714.9 kg/day (71.37%) of general waste, 1204.4 kg/day (23.14%) of infectious waste, 30.0 kg/day (0.58%) of pathological
waste, 188.2 kg/day (3.61%) of sharps, 48.5 kg/day
(0.93%) of pharmaceutical and chemical waste
and 19.3 kg/day (0.37%) of pressured containers
(Fig. 2). A maximum amount of 1315 kg/day of
total waste was generated at the Afzalipour hospital while a minimum amount of 69.5 kg/day was
generated at the Artesh hospital (Table 2). Oneway ANOVA analysis results showed that there is a
signif- icant difference between the different
components of solid waste per capita in the
different hospitals but that there is not a
signicant difference between the amount of
pathological waste.
Storage
The characteristics of the temporary storage
1315 kg/day with a total amount of 5205.3 kg/day,
areas were assessed according to the WHO
management
ARTICLE IN PRESS
H. Bahrami et al.
Table 1
The average waste production per bed (kg/day) in the hospitals of Kerman, Iran, 2012.
Name of hospital
General
waste
Infectious
waste
Pathological
waste
Sharps
Pharmaceutical Pressurized
and chemical
containers
waste
Overall
Afzalipour
Shafa
Bahonar
Beheshti
Artesh
Kashani
Azahra
Seyedoshohada
All hospitals
2.422
1.843
3.535
2.431
2.094
2.272
3.000
1.968
2.450
1.008
0.619
1.527
0.008
0.563
0.516
1.067
1.084
0.794
0.006
0.011
0.049
0.000
0.000
0.015
0.025
0.101
0.020
0.296
0.068
0.072
0.008
0.079
0.141
0.044
0.169
0.124
0.047
0.022
0.055
0.000
0.000
0.042
0.000
0.048
0.032
3.801
2.571
5.255
2.447
2.779
2.995
4.135
3.398
3.434
0.022
0.007
0.017
0.000
0.043
0.010
0.000
0.027
0.013
Figure 2 The proportions of different types of hospital waste in Kerman, Iran, 2012.
requirements [9]. All of the hospitals had separate locations for the storage of hospital waste.
We found that only 12.5% of hospitals had
connected to a sewer system and 25% of hospitals had ventilation. Other characteristics of
temporary storage in more than half of the hospitals were conformed to the WHO requirements
(Table 3).
Table 2
Treatment and disposal

The survey results indicated that only 25% of
hospital autoclave their highly infectious hospital
waste before nal disposal. Approximately 25% of
hospitals were equipped with incinerators that
were out of use. All hospitals buried their waste in
sanitary landlls.
The generation rates of classied hospital waste (kg/day) in Kerman, Iran, 2012.
Hospitals
General
waste
Infectious
waste
Pathological
waste
Sharps
Pharmaceutical Pressurized
and chemical
containers
waste
Overall
Afzalipour
Shafa
Bahonar
Beheshti
Artesh
Kashani
Azahra
Seyedoshohada
All hospitals
838.0
643.3
855.5
549.4
52.4
399.8
225.0
151.5
3714.9
348.6
216.1
369.4
1.9
14.1
90.8
80.0
83.5
1204.4
1.9
3.8
12.0
0.0
0.0
2.7
1.9
7.8
30.0
102.4
23.6
17.4
1.8
2.0
24.8
3.3
13.0
188.2
16.4
7.7
13.3
0.0
0.0
7.4
0.0
3.7
48.5
1315.0
897.1
1271.7
553.0
69.5
527.2
310.1
261.6
5205.3
7.7
2.6
4.1
0.0
1.1
1.8
0.0
2.1
19.3
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Table 3 The characteristics of waste temporary
storage areas in Kerman, Iran, 2012.
Issues of temporary storage area
Yes (%)
Impermeable, hard-standing
oor
Good drainage
Easy to clean and disinfect
Connection to sewer system
Water supply
Easy access for staff
Possible to lock the store
100
Easy access for waste-collection

vehicles
Protection from the sun
100
100
12.5
62.5
100
100
100
87.5
tively [22,23]. The infectious waste in Nigerian
hospitals composed 2637% of the total waste

[23]. This study revealed that the generation rate
ranges from 2.45 to 5.26 kg/bed-day with a weight
average of 3.43 kg/bed-day (Table 1), and our
results are
in line with the other studies performed in developing countries [20,23]. For instance, the waste
generation rate in Taiwan varied between 2.41
and
3.26 kg/bed-day [24]. In addition, the greatest and
lowest rates of infectious waste were observed
in the Bahonar and Beheshti hospitals with 1.527
and 0.008 kg/bed-day, respectively (P < 0.001).
The
Beheshti hospital is a psychiatric hospital with
resources and legal initiatives and had little infectious waste production.
results indicated that hospital waste management
management
The average amount of infectious waste produced in different hospitals of Kerman city was
87.5
0.794 kg/bed-day. This is close to the rate
25
from Iran by Amooei in 2004 [25] but lower than
100
corresponding values reported for several studies
100
many places in Iran [2628].
The amount of hospital waste production varied between 69.5 and 1315 kg/day for each
hospital in Kerman, and the total waste of the
Discussion
hospitals was 5205.3 kg/day, which included
1204.4 kg/day (23.14%) of infectious waste and
The key to minimization and the effective man188.2 kg/day (3.61%) of sharps. Mohammadianagement of hospital waste is segregation. In this
Fazli et al. (2013) found that infection waste and
research, 75% of the hospitals personnel involved
sharp objects composed 31.36% and 1.38% of the
in waste management have adequate information
total waste in Zanjan hospitals, respectively [29].
about the segregation of waste. Infectious and
The World Health Organization has estimated
pathological waste and sharps were segregated
that the ratio of infectious and sharp waste to
from general waste (87.5%).
total hospital waste in hospitals in developing
The results of our study showed that the segrecountries should be 15 and 1%, respectively [9].
gation criteria in Kerman hospitals were lower
This rate is higher in Iran and most likely means
than the standard criteria of Iran; however, the
that ordi- nary waste and infectious waste are not
criteria are acceptable in comparison to the
segregated properly and are mixed.
reported results of studies conducted in other
Various factors such as the hospital location,
countries [16]. For instance, in a study performed
the
number of beds, and the cultural background
in northern Jor- dan, only 10% of sharps were
can inuence waste generation [9]. This study
collected in yellow bins [17]. In the present study,
revealed the need for upgrading the temporary
all of the hospitals used yellow colored bags for
storage area in the sewer system, water supply
infectious waste and placed them in yellow bins.
and ventilation to meet the WHO requirements. In
All of the hospitals used safety boxes for the
all of the hospitals waste was transported to the
collection of sharps and 62.5% of the hospitals
nal disposal area in less than 24 h in accordance
used yellow colored bins for the placement of the
with the Iran and WHO requirements [9,16]. Our
safety boxes. The separation of waste is the main
results also doc- umented that the treatment and
challenge in health care settings and needs
disposal of waste in the hospitals of Kerman did
legislative denitions and classications [18,19].
not conform to the standard criteria of Iran and
The waste generation in hospitals in developing
the WHO [9,16].
countries was reported to be 0.0163.23 kg/bedday [20]. The total and infectious waste
generation rates in Brazilian hospitals were
reported
to be 3.245 and 0.57 kg/bed-day,
Conclusions
respectively [21]. The waste generation rate in
the Fars Province in
Iran
and
Nigeria
hospitals varied between
Planning for the management of hospital waste is
1.2514.8 and 0.5620.67 kg/bed-day, respeca function of the quality and quantity of wastes.
The
Inaccessible for animals, insects, and
birds
Good lighting
Good ventilation
Far from kitchen
Protective clothing
87.5
tively [22,23]. The infectious waste in Nigerian
results indicated that hospital waste management
management
ARTICLE IN PRESS
6
in Kerman was not consistent with the standards
in Iran, which may impact human health and the
environment. Our ndings indicated that only 25%
of hospital use autoclaves for infectious waste
before nal disposal and approximately 25% of
the hospitals were equipped with an incinerator
that was out of use. As the disposal and segregation of waste is not performed according to the
recommended standards of Iran, the development
of clear plans, policies and regulations is needed
to improve healthcare waste management. This
regulation needs to coincide with strict enforcement at the national and global levels. To achieve
this, technical and nancial assistance is required.
Additionally, our results revealed a great need to
establish proper hospital waste management systems to improve the current status in Kerman.
Funding
This study received nancial support from Kerman
University of Medical Sciences.
Competing interests
None declared.
Ethical approval
Not required.
Acknowledgments
This article is the result of a research project
(grant 87/47), approved by the Vice-Chancellor for
Research of the Kerman University of Medical Sciences and Health Services, Iran, hereby is highly
appreciated. The authors thank the staffs of hospitals for their cooperation during the study.
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JIPH-352;

Journal of Infection and Public Health (2014) xxx, xxxxxx

An overview of the present status of

Department of Environmental Health Engineering, School of Public Health, Shahid

Corresponding author. Tel.: +98 2122718528.

JIPH-352; No. of Pages 7

Loot and Dasht-e-Kavir deserts. Kerman

Present status of hospital waste management in Kerman, Iran

areas were assessed according to the WHO

1315 kg/day with a total amount of 5205.3 kg/day,

areas were assessed according to the WHO

JIPH-352; No. of Pages 7

Treatment and disposal

Present status of hospital waste management in Kerman, Iran

Easy access for waste-collection

tively [22,23]. The infectious waste in Nigerian

hospitals composed 2637% of the total waste

results indicated that hospital waste management

tively [22,23]. The infectious waste in Nigerian

results indicated that hospital waste management

JIPH-352; No. of Pages 7

Present status of hospital waste management in Kerman, Iran

Available online at www.sciencedirect.com

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