Medical waste management: A challenge for Middle Eastern countries


The healthcare sector is an important producer of waste and hazardous waste, the volume of which is exponentially increasing with the patient-centered approach and diversity of medical services (development of medical subspecialties, new interventional technologies, computerization (e-waste) of the procedures, diversification of  health care providers, education and auto-medication etc…). Another factor contributing to the volume of waste is the increase in health services’ demand due to an aging population, public education as well as the growing and improvement of health services in emerging and developing countries.

Health Care Providers: What are we generating?

Medical waste or healthcare waste is all the waste generated from health services delivered to people or animals by any healthcare provider, hospitals, institutions (laboratories, radiology and research centers, nursing home…), dispensaries, blood donation centers,  clinics,  pharmacies, beauty centers, veterinary clinics, or even at home (auto-medication or home care services).

The World Health Organization, in its second edition of Blue Book in 2014 “Safe Management of Wastes from Health-Care Activities”, classified medical waste into two categories according to their hazards:

(i) on health: risks of injury and/or infection during manipulation, and

(ii) on the environment: domestic waste called “non-hazardous” (75% to 90% of total medical waste produced) resulting from kitchen, housekeeping  and maintenance activities and hazardous waste to be handled with precaution, resulting from interventions delivered to the patients (monitoring, diagnosis and treatment).

Only 10 to 25% of medical waste are hazardous and they include: sharp tools (needles, scalpels, used or not), infectious waste with a risk of infection transmission (any waste in contact with blood, urine, secretion or other body fluids), pathological waste (human and animal tissues, organs, body fluids…), pharmaceutical waste (expired, not used, contaminated, vaccines, genotoxic waste (cancerogenous, mutagenic and cytotoxic drugs/chemotherapy medicines…), chemical waste (laboratory reagents, solvents, disinfectants, film developers, PVC, plastics, heavy metals/mercury in thermometers and amalgam…) and radioactive waste (scintigraphy, radiotherapy,…).

Hazardous medical waste: individual, public health, occupational and environmental issues

Hazardous waste may cause a variety of health and environmental risks. Individuals at risk are healthcare professionals in direct contact with the patient, cleaners, workers handling transportation and management of waste, as well as patients themselves and visitors. If managed improperly and left in general waste containers, hazardous waste can be a risk for the community as well, in particular for children.

Diseases that can be contracted from infectious waste are mainly infections (respiratory, genital, ocular, gastro-intestinal, AIDS (HIV), Hepatitis A, B, C…), while chemical waste leads to intoxication (mercury, silver, pesticides etc…), physical injuries (chemical burns, explosions, skin injuries/formaldehyde, corrosive reactions/formaldehyde, chlorine) and environmental threat (mercury…). The hazards of pharmaceutical/cytotoxic and radioactive waste are intoxication, cytotoxicity, carcinogenicity, mutagenicity, local irritant effects, and disastrous ecological consequences.

To give an example, in the year 2000, in the USA, before the implementation of guidelines for medical waste management, 66,000 healthcare professionals contracted hepatitis B, 16,000 hepatitis C, and 2000-5000 HIV infections, all with infected sharp tools.

Also, the WHO estimates that 40% of hepatitis cases and 12% of HIV cases worldwide are caused by occupational exposure among health workers, medical waste manipulators and the wider population from improper disposal of waste in municipality containers.

Legislation related to medical waste

The first act to regulate medical waste, the Medical Waste Tracking Act (MWTA), was implemented in the USA in 1988, after two children playing with medical waste in a container outside a medical office, contracted AIDS.

Since then, the overall awareness of health risks related to medical waste and the need to protect our environment to avoid an ecological disaster, led to a number of international conventions, principles and guidelines for waste management.

The most important are:

(i) the Basel convention (UNEP, 1992) which aims to decrease the generation of waste and to treat them as close as possible to the site where they are generated (transport across borders was forbidden),

(ii) the Agenda 21 (Rio, 1992) to decrease waste generation, to re-use and recycle and dispose waste properly and safely, with the goal to protect the environment, and

(iii) the Stockholm Convention on Persistent Organic Pollutants (UNEP, 2004) with the objectives of reducing the production and use of organic pollutants and decreasing the uncontrollable emission of substances and gas.

In addition, guidelines for medical waste management were set by WHO (Blue Book, first edition in 2009, updated in 2014), by UNEP (2006) and a chapter on “Waste Management” has been introduced in all manuals of hospitals’ accreditation and certification.

Hazardous medical waste: adequate and appropriate management

During the last decades, developed countries, concerned by global changes in climate and environment, experienced progress in the management of hazardous medical waste by implementing new strategies and continuous monitoring and improvement. However, emerging and developing countries are still at an early stage of implementation: despite their interest to improve quality of their health services, they are not doing enough to decrease harm from medical waste.

Proper medical waste management requires the implication of the government, municipalities, hospitals, institutions and individuals generating hazardous waste, treatment and disposal companies, NGOs, communities, donors etc.

But even in the absence of national implication, hospitals in developed countries, are still responsible of the waste they generate, and the success of their initiative depends on good organization, implication, education and training of all actors (administration, physicians, nursing, interns, cleaners…), and sufficient funding.

Medical waste management begins with the choice of material used and the segregation of waste. The steps of the waste chain management are:

(i) Minimizing and Recycling: reduction of waste generation.

(ii) Segregation: identifying the various types of waste and collecting them separately (Color-coding: WHO – UNEP/SBC 2005, different types of containers e.g. Yellow container for sharp tools and Yellow bags for “Highly infectious”) at source where they are produced. It is the best way to reduce the volume of hazardous waste requiring special treatment.

(iii) Handling of bags and containers. Bags should be closed when two-third full.

(iv) Collection and Storage: regular collection, at least once a day, collection and separate storage of different types of waste.

(v) Transport on-site and off-site: different means of transport for each type of waste.

(vi) Treatment: disinfection (chemical, controlled incinerator, autoclave…) and disposal (sanitary landfill).

The volume of total medical waste generated by healthcare providers depends on various factors: type of healthcare institutions (General, specialized, type of activities, private, public…); location (urban, rural…); size (number of beds, number of patients, bed occupancy rate); financial resources; human resources (number, competency and performance of medical and hospital staff); type of services provided; developed technologies; the waste management model, plan; the proportion of disposable (single use) and re-usable items and the economic, social and cultural status of patients.

If the total healthcare waste increases with the Gross National Income per Capita, this is not the case for hazardous waste, because high-income countries properly manage medical waste. Thus, initially the quantity of hazardous waste generated is more important in high-income countries (0.5 kg/bed/day) versus low-income countries (0.2 kg/bed/day). However, as the last do not clearly separate hazardous from non-hazardous and as the mix is considered hazardous, by consequent the real quantity in low-income countries becomes higher.

A study conducted in 2008 in Dubai – after having followed the WHO recommendations – revealed a variation in quantity of hazardous waste among the 14 hospitals surveyed, from 0.2 to 4.5 kg/bed/day with an average of 1.95 kg/bed/day. The reason of this important variation is that most hospitals apply segregation for infectious, pathological and sharps waste only, and not for other types.

Other studies show that in Iran, the average rate of hazardous hospital waste is 1.5 kg/day/bed, while in Pakistan it is as low as 0.1-0.5 kg/bed/day, and in Kuwait as high as 2.5 kg/bed/day.

In Lebanon, a population of 5.6 million (2013) is generating a total of 25,049 tons/year of medical waste, of which 5,000 are considered infectious. In addition, a study published recently, demonstrates variations in the rate of infectious medical waste in correlation with the size of the hospital: 2.45 kg/bed/day for small hospitals (<100 beds) versus 0.94 kg/bed/day for bigger hospitals (>200 beds). The study shows that small hospitals have a better waste management than larger ones and estimates the total Infectious Health Care Waste produced to 1.42 kg/capita/year.

In 1996, Lebanon started working on the implementation of a national policy and legislation (Law No. 501, dated 6/6/1996) for a sustainable healthcare waste management, taking into consideration the international agreements for environmental and human health protection. But, the barriers are multiple and at various levels: political and financial issues, the healthcare system, the lack of awareness among the community, and lately adding to this, the political instability, the presence of approximately two million refugees seeking medical services and the availability of only one specialized company for treatment and disposal of waste.

If the hospitals (administration and staff) are following waste segregation and collection policies since the last national hospital accreditation in 2011, not all of them have agreements for hazardous waste treatment. According to the Ministry of Environment, 19 hospitals in Lebanon still do not have their waste treated in 2015, and that does not take into consideration medical labs and beauty centers. The president of the Association of Private Hospitals claimed that the reason behind the non-compliance of all hospitals is the monopole of one company, which does not have the ability nor the required equipment to fulfill this work (The Daily Star, 15/02/2015).

The proper management of medical waste is a challenge for the developing countries of the Middle East. Over the last decades, the modernization of the health sector and quality of services delivered and the increase in the size of the population led to a significant increase in the quantities of medical waste generated.

Medical waste management is complex and involves raising awareness and implication of all parties concerned: the government, the public and private sectors, as well as the community. Inadequate and inappropriate handling of healthcare waste may have serious public health consequences and a significant impact on the environment.

The Middle East is currently going through a major humanitarian crisis. The Syrian conflict and the waves of displaced populations are largely contributing to the waste crisis. However, the authorities, busy with the political and security dimensions, treat the problem of costly waste management as a secondary issue. In light of the above, it could be said that the healthcare system is indeed providing services on one hand, but also causing harm to the community and to the environment on the other hand.