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					REVIEW OF RELATED LITERATURE

Definition
         The World Health Organization (WHO) defines all waste generated by healthcare
establishments, research facilities, and health laboratories as healthcare waste. This healthcare waste is
classified as non-risk or general healthcare waste, which is comparable to domestic waste, and as
hazardous waste, which has the potential to pose a variety of health risks. Hazardous healthcare waste
may also include infectious waste, pathological waste, sharps, pharmaceutical waste, genotoxic waste,
chemical waste, waste with high heavy metal content, pressurized containers, and radioactive waste.9

        The Department of Energy and Natural Resources (DENR) created a Classification of Hazardous
Waste based on these four characteristics: ignitable, corrosive, reactive, or toxic in accordance with the
Toxicity Characteristic Learning Procedure (TCLP). Pathogenic waste is classified under Miscellaneous
Wastes which includes pathological wastes (tissues, organs, fetuses, blood, and bloody fluids) and
infectious wastes, and sharps. 3

Effects on Health
        All individuals exposed to hazardous health-care waste are potentially at risk, including those
within health-care establishments that generate hazardous waste, and those outside these sources who
either handle such waste or are exposed to it as a consequence of careless management. 9

        These types of wastes may contain any of a great variety of pathogenic microorganisms, which
may enter the human body by a number of routes (e.g. bruises, inhalation, etc.). 9 It may contain fewer
bacteria than household refuse, but it generally contains more human pathogenic species. Despite this,
only around 3% of the total volume of clinical waste may be infectious, although cross-contamination
may render the entire load potentially hazardous.1 Certain infections, caused by more resilient agents,
pose a significant risk to the general public and to hospital patients. For instance, uncontrolled
discharges of sewage from hospitals treating cholera patients have been strongly implicated in cholera
epidemics in some Latin American countries. 7

         For serious virus infections such as HIV/AIDS and hepatitis B and C, health-care workers,
particularly nurses, are at greatest risk of infection through injuries from contaminated sharps (largely
hypodermic needles). Other hospital workers and waste-management operators outside health-care
establishments are also at significant risk, as are individuals who scavenge on waste disposal sites
(although these risks are not well documented). The risk of this type of infection among patients and the
public is much lower. 7

Waste Management in the Philippines
         In several countries in Asia, including the Philippines, wastes, segregated or not, are collected by
workers employed by the health care establishment. These waste handlers are usually the cleaners or
janitors of the premises and are aware of local opportunities for recycling of components of the waste.
They are, however, either unaware of, or insensitive to, the hazards associated with handling health
care waste and generally take no precautions in handling, transporting and separating the waste. They
are not supplied with protective clothing or special equipment and are thus vulnerable to the high risk of
handling infectious waste and sharps. 8

       Pre-treatment of infectious waste, as required by the Metropolitan Manila Authority (MMA) and
Department of Health (DOH), is not practiced.10 The most common facilities used for storage of
infectious waste are plastic bags, covered bins/trash cans, and glass jars with covers. Due to inadequate
segregation of infectious from non-infectious wastes which is in violation of the color code system as
mandated by MMA Ordinance No. 16., much of the generated hospital waste is being disposed directly
to municipal landfills, some of which are uncontrolled and occupied by thousands of squatters. The risk
posed to the general public by transport and disposal of these wastes with the general municipal waste
is high. 2

        As mentioned, health care wastes are collected by the municipal waste collection service and
transported for disposal with municipal waste. Apart from those wastes which are incinerated or buried
on site at some hospitals, all types of wastes are mixed and transported, often along with municipal
solid waste, to municipal landfills. 8

       The existing treatment capacity is insufficient for the proper disposal of the major part of
medical wastes generated in Metro Manila area. Survey shows that existing capacity for incinerating
these wastes totals to less than 3 tons/day, whereas the total daily quantity of dangerous medical
wastes generated was estimated to at least 12.4 tons (8.5 tons/day for National Capital Region alone). 2

Regulation of Hospital Waste in the Philippines
        Hospital waste is primarily regulated by three laws, namely, the MMA Ordinance No. 16,
Hospital Licensure Law (Republic Act No. 4226) and the Toxic Substances and Hazardous and Nuclear
Waste Control Act of 1990 (Republic Act No. 6969).

         The highlight of the first ordinance is the provision obliging all hospitals in Metro Manila to use
four types of trash bags for easy identification of waste. These are the following; (1) black trash bag for
non-infectious dry waste; (2) green trash bags for non-infectious wet waste; (3) yellow trash bags for dry
and wet chemical and other potentially infectious waste, pathological waste, chemical waste and sharps
contained in puncture-proof containers covered with solution of lime; and (4) orange trash bags with
trefoil sign for radioactive waste that will be stored in the hospital until rendered as inactive and/or
disposed in accordance with the prescribed rules and regulations of the Philippine Nuclear Research
Institute.

         Under the Hospital Licensure Law, hospitals are categorized as government or private hospitals.
It also specifies the needed physical facilities of a hospital for solid waste management such as the
physical plant, hospital equipment and maintenance of these physical facilities.

        The Toxic and Hazardous and Nuclear Wastes Control Act of 1990 covers the importation,
manufacture, processing, handling, storage, transportation, sale, distribution, use and disposal of all
unregulated chemical substances and mixtures in the Philippines. The law also defines the prohibited
acts and provides for administrative and criminal penalties.10

Problems in Medical Waste Management
        In developing countries, medical waste has not received much attention and it is disposed of
together with domestic waste. Massrouje et. al. conducted a study among health workers in Gaza, which
revealed that medical waste in Gaza is not given sufficient priority or concern. There is no system of
medical waste management, a lack of necessary supplies and facilities, a lack of knowledge among
health workers and a lack of coordination among different ministries. However there is generally a
positive attitude to improving medical waste management among those surveyed and interviewed. And
they concluded that a national program for medical waste management is essential in Palestine. 6
         Pathogenic waste management is also a problem in countries despite having a national program
on medical waste management. Information dissemination and implementation of & adherence to
policies have been key problems in these countries.

         In Lagos Metropolis, Nigeria, Longe et. al. found-out that the medical waste management
practices in hospitals indicate absence of full compliance with the protocol stipulated in the guidelines
and standards of environmental pollution control in Nigeria. They have encountered problems in
collection, segregation, storage, treatment, and disposal among the hospitals that were observed. 5

        A study by Hassan et. al. in Dhaka, Bangladesh revealed that there is no proper, systematic
management of medical waste except in a few private Health Care Establishments that segregate their
infectious wastes. Some cleaners were found to salvage used sharps, saline bags, blood bags and test
tubes for resale or reuse. 4

         After review of these studies, it is evident that there are many flaws in the compliance,
implementation and even in the construction of guidelines concerning hospital management not only in
the Philippines but also in many countries around the world. Several studies have isolated what these
flaws are and have even come as far as recommending several steps that may be undertaken to address
these flaws.
         These recommendations included establishment of directorates responsible for medical waste
management, coordination of different ministries, provision of adequate supplies and health education
including encouragement of studies on different aspects of medical waste, such as the creation of
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database information in different sectors, risk analysis and disposal methods.

        Since case studies in the Philippines have only focused on two distinct hospitals in Metro Manila
the authors of this paper have deemed it prudent to include yet another prominent hospital such as the
University of Santo Tomas.

        This paper aims to assess the compliance of University of Santo Tomas Hospital regarding the
handling, collection and storage of Pathogenic waste in accordance to the Health Care Waste
Management Manual of Department of Health and the Procedural Manual Title III of Dao 92-29
“Hazardous Waste Management” of DENR. After the completion of this paper, the authors are hopeful
that recommendations appropriate for the University of Santo Tomas will be constructed and steps to
improve hospital waste management may be instigated.

Sources:

1. Blenkharn, J.I.,2005. Lowering standards of clinical waste management: do the hazardous waste
regulations conflict with the CDC’s universal/standard precautions?. 18 South Road, London W5 4RY, UK

2. Department of Environment and Natural Resources. 1993. Pasig River Rehabilitation Program:
Feasibility Report on Hospital Hazardous Waste Management in Metro Manila. Volume I

3. Department of Environment and Natural Resources. 2004. Hazardous Waste Management.
Procedural Manual Title III of DAO 92-29
4. Hassan, M., Ahmed, S., Rahman, K., Biswas, T. 2008. Pattern of medical waste management: existing
scenario in Dhaka City, Bangladesh. BMC Public Health. 8:36

5. Longe, E.O., Williams, A., 2006. A Preliminary Study of Medical Waste Management in Lagos
Metropolis, Nigeria. Iran Journal of Environ. Health Sci. Eng., 3:2:133-139

6. Massrouje, HTN., 2001. Medical waste and health workers in Gaza governorates. Eastern
Mediterranean Health Journal

7. Mühlich, M., Scherrer, M., Daschner F.D. 2003. Comparison of infectious waste management in
European hospitals. Institute for Environmental Medicine and Hospital Epidemiology, Freiburg University
Hospital, Hugstetter. Str. 55, 79106 Freiburg, Germany

8. Pescod, S. 1998. Hospital Waste Managementi n Four Major Cities. WASTE. Urban Waste Expertise
Programme

9. Prüss, A., Giroult, E., Rushbrook, P., 1999. Safe Management of Wastes From Health Care Activities.
World Health Organization, Geneva

10. Soncuya, Matias, Lapid. 1997. Hospital Waste Management in the Philippines, two Case Studies in
Manila. WASTE. Urban Waste Expertise Programme

				
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