Awareness and practice of biomedical waste management among healthcare providers in a Tertiary Care Hospital of West Bengal, India

Background: Biomedical waste (BMW) is waste generated during diagnosis, treatment, or immunization of human beings or animals or in research activities. BMW is hazardous and can be injurious to humans or animals and deleterious to environment. Effective management of BMW is a legal as well as a social responsibility. Objectives: To assess the knowledge and practice regarding hospital waste management among healthcare providers of a tertiary care hospital. Materials and Methods: The study was conducted in the Departments of General Medicine, Surgery, Gynecology and Obstetrics, and Radiotherapy among 198 different hospital staff within 3 months with the help of a predesigned and pretested interview schedule to elicit the knowledge of BMW management. An observatory checklist is used to find out practices regarding BMW management prevailing in the above wards and staff of the hospital. Results: Majority (60.6%) of the study population belonged to the age group of 21–30 years. About one-third of the total study population were junior doctors and nurses. 35.8% worked for 1 year in the hospital, and 29.8% worked within 2–5 years. All the participants had heard about BMW management, but only 1.5% had formal training. 6.6% knew about five‐color coding used for segregation of waste with red, black, yellow, blue bags and white puncture proof container. 31.3% knew correct disposal of sharps. All the participants knew about the use of personal protective measures while handling BMW and used in most of the time. 70.2% of respondents knew the use of gloves and mask together. In 33.3% of observation, it was seen that syringes were reused for the same patient. Four colored bins were used most of the time in the above-studied wards. Conclusion and Recommendation: The above study revealed certain paucity of knowledge among the healthcare providers in the field of BMW management which adversely affected their practice. There should be regular comprehensive training programs regarding BMW management for all level of workers and strict implementation of them.


INTRODUCTION
The waste produced in the course of healthcare activities carries a higher potential for infection and injury than any other type of waste.
Expansion of health care facilities with the advancement of modern technologies as well as the recent trend of using disposables has led to a high burden of health care-related wastes. Since the last three decades, unregulated handling of BMW is emerging as a serious threat to human health and safety, and many researchers have documented this as a priority area. [2,3] The absence of proper waste management, lack of awareness about the health hazards from BMWs, insufficient financial and human resources, and poor control of waste disposal are the most critical problems faced with healthcare waste. [4] The hazardous impact of medical waste on us and environment is enhanced manifold if the appropriate handling of these wastes is not adopted.
Improper disposal methods of these wastes may lead to the spread of serious and harmful diseases such as AIDS, hepatitis B and C, and tuberculosis (TB) among the healthcare personnel, waste handlers, patients and their visitors, and community where the waste is indiscriminately deposited. [5] Hospital-acquired infections have been estimated at 10% of all life-threatening diseases in the Southeast Asia region and have been identified as one of the indicators for the management of waste. [6] There are specific guidelines for segregation and management of BMW. The law envisages schedule, requisite BMW treatment facilities such as incinerator, autoclave, microwave system for the treatment of waste, or ensure requisite treatment of waste at a common waste treatment facility or any other waste treatment facility. [1] The awareness of these laws among the general public as well as the development of policies and enforcement that respect those laws are essential.
Although some Indian studies have identified gaps at local levels, there is no systematic effort to collect data from different parts of the country. [7,8] Effective management of BMW is not only a legal necessity but also a social responsibility. The scenario of awareness and practice regarding BMW management in India is still lacking. [9][10][11] A strong emphasis on cleanliness and systemic disposal of all wastes including hospital waste is aimed by the Government of India and has been launched as the "Swachh Bharat" mission with a goal to make India "cleaner and greener" to create a better livable atmosphere.
With this background, the present study has been conducted with the objectives of assessing knowledge and practices of doctors, nurses, laboratory technicians, and sanitary staff regarding BMW management of a teaching institution that may help the respective authorities and society to develop further strategy for improving the situation in future. The objectives of the study are: • To assess the knowledge among the different healthcare providers regarding BMW, its segregation, color coding, and management in the tertiary care hospital • To find out the practice regarding management of BMWs by the health personnel in the tertiary care hospital.

Hospital profile
This study was conducted in the preselected departments of North

MATERIALS AND METHODS
The study was an observational, cross-sectional, hospital-based study conducted with a duration of 3 months from December 2014 to March 2015 in the Departments of General Medicine, Surgery, Emergency, Gynecology and Obstetrics, and Radiotherapy of North Bengal Medical College and Hospital among different level of healthcare providers such as junior doctors, nursing staff, laboratory technicians, sweepers, and waste handlers in the respective departments.
There are 493 healthcare providers in the above-mentioned wards and indoors among the above-mentioned groups of participants. Forty percent (198 participants) of them were taken as study population by convenient sampling. All willing participants were informed about details regarding the purpose of this study, and prior informed verbal consent was taken from each of them. An observatory checklist was used to collect data on practices regarding BMW.
Das and Biswas: Biomedical waste management in a teaching hospital Six visits in each of the prefixed wards on 3 consecutive days -3 visits in the morning and 3 visits in the afternoon were made to observe the practice of BMW segregation and management among the health care persons. Study subjects were also assured of the confidentiality and anonymity of their identity throughout the study.

Respondent's profile
It is revealed from Table 1 that among a total of 198 respondents, 65.2% were females and the rest 34.8% were males. The majority (60.6%) of the study population belonged to the age group of 21-30 years. Only 1% of the subjects were below the age of 20 years, 35.8% of the subjects were engaged in housekeeping. About one-third of the total study population were junior doctors and nurses. The majority (35.8%) worked for 1 year in the hospital, and 29.8% worked within 2-5 years.
Among the whole study population, minimum age of any participant is 18 years and maximum is 65 years. The mean of age of the total subjects is 31.80 years with standard deviation 10.34.

Knowledge about biomedical waste management
About 58.1% of the study subjects resided within campus area and the rest outside it. All of them had heard about BMW and its management, but only 1.5% of the subjects had formal training, and 30.8% of them knew about BMW rules 1998. 77.3% of the subjects knew that posters were already present in their working area. Figure 1 shows that only 6.6% of them knew about five-color coding used for segregation of waste with red, black, yellow, blue bags and white puncture proof container.   Awareness regarding BMW rules varied among different workers, and it is found to be statistically significant (Pearson Chi-square = 41.406, df = 3, P = 0.000) from Table 3.

Practice of biomedical waste management among the healthcare providers
Seventy-two observatory visits were made with a checklist in six different wards. Six observations were done in an emergency, medicine, and surgery indoors each in different male and female wards. Six observations were done in the Departments of Gynaecology and Obstetrics and radiotherapy each. Three visits were done both in the morning and evening of the duration of half an hour approximately without prior intimation within 1 month using a checklist to observe the practice regarding management of BMW among all categories of healthcare providers.
In 33.3% of observations, it was seen that syringes are reused for the same patient but in 25% of observation, syringes are reused for different patients also. Almost all the on-duty nursing staff agreed that all the intramuscular (IM) needles and syringes and those, which are contaminated with blood or other body fluids, are never reused, and it contributed to 41.7%. In the wards where the syringes were reused for the same patients, the syringes are washed with normal saline (NS) only and in cases where the syringes are used for different patients; the syringes were dipped into the disinfectant solution for a certain period and then sterilized by boiling. Disinfection with hypochlorite was seen in one-quarter of the visits and 11.1% with other disinfectants. These findings are observed in Table 4 Posters showing color coding for segregation of BMWs were provided by the authority. This institution has tie up with a private waste removal company named Greenzen Bio. Pvt. Ltd., for collection, removal, transport, and permanent disposal of all kinds of BMWs. In each and every ward, there are posters and/or guidelines in working areas except in the Radiotherapy ward, where no posters or guidelines were displayed in the working areas. There was no poster for red color code in any of the wards of the hospital and the guidelines and picture of waste container for disposal of BMWs in the black color-coded posters are wrongly printed, which is leading to an erroneous practice for the same.
In the wards, only black-, blue-, and yellow-colored plastic bags are found along with white translucent puncture proof containers but in none of the above-mentioned wards any red-colored plastic bag was found. On the contrary, in the radiotherapy department, no plastic bags were there, but bins were found in the daycare chemotherapy room. A white puncture proof container was present but never used. All kinds of wastes were deposited in the bins and then thrown indiscriminately out of the department in free, open land nearby. No segregation, disinfection, proper packing, and storage were done following/according to the BMW rules 1998.
No bins were found to be covered with lid; rather, all of them were placed openly in all (of) the wards. In about 50% of the observation, duty staffs placed the infected BMWs in the disinfectant solution as per the BMW rules 1998. In all the wards, priority was given to disposal of the sharps, and disinfection with hypochlorite (1%) or   In radiotherapy ward, no bags were in seen in six observatory visits. G and O = Gynecology and obstetrics, PPR = Puncture proof container Das and Biswas: Biomedical waste management in a teaching hospital other solution was done. In practice, it was observed that most of the time in all wards, gloves and masks were used as PPM.
During observatory visits, radiotherapy department had no colored bags for BMW. In emergency and medicine wards, there was the universal use of yellow bins and white puncture proof container, but there was no use of blue and black bins in medicine wards. In surgery, all the bins were seen to be used in various proportions.
In about 50% of the visits to gynecology wards, all bins were used.

DISCUSSION
A descriptive, hospital-based study was conducted among 198 healthcare providers including junior doctors, nurses, technicians, and waste handlers of a teaching institution to find out the knowledge and practice regarding BMW and its management. In observatory sessions, it was seen that only black-, blue-, and yellow-colored bins were found, but red-colored bins did not exist. No bins were found to be covered.
All of the participants have heard about BMW management. It is similar to studies carried by Chudasama et al. [12] in a tertiary care hospital in Rajkot and Madhavi et al. in Khammam, [13] who found 95.4% and 94.8% of the participants were aware of BMW, respectively.
In the Rajkot study, [12] approximately 96.5% of subjects knew that different colored bags were used for segregation of BMWs whereas almost all the participants (100%) from our study opined the same. Only 6.6% knew correctly about all the colors used for coding. Results from a study conducted in a tertiary care hospital of West Bengal [6] among the junior doctors show that nearly 76.4% of the subjects knew about various types of color-coded bags for collection of BMW. In a separate study in Rajkot, [12] 84.4% of participants identified all colored bags used for BMW collection. A study conducted by Imtiaz et al., [17] in a tertiary care hospital, Uttar Pradesh, suggested that correct knowledge regarding the same was adequately sufficient across all 4 groups of healthcare personnel which was similar to another study by Mathur et al. [18] in Lucknow.
In a study conducted in Dhule (Maharashtra), [19] results show that a maximum number of nurses (80.2%) and 18.9% of sanitary workers and 42.8% technicians correctly had the knowledge of blue or transparent white container for disposal of sharp wastes. However, in our study, it was found that 45.9% of subjects had the knowledge of the same and identified the puncture proof white container correctly.
Almost 84.3% of the healthcare providers had knowledge about the necessity of disinfection. Among them, 36.4% participants suggest that bleaching solution is used for the purpose whereas 32.8% do not now about the solution used and 18.7% believe it to be hypochlorite (1%) solution.
Nearly 77.3% of the healthcare providers knew that posters with different color codings were already present in their working area, displaying the name of different bins for BMWs. On the other hand, the study carried out by Chudasama et al. in a tertiary care hospital in Rajkot concluded that 81.2% of study population agreed to the fact.
The study conducted in Rajkot [12] depicted that about 40.4% of the subjects knew about BMW management categories, which is much higher in comparison with the current study, where it is found to be only 11.6%. In contrary to the present study, about 52.2% and 55.9% of the study population in two studies conducted by Madhavi et al. in Khammam [13] and Basu et al. [16] among interns in West Bengal have a correct knowledge of the same. In another study conducted by Madhukumar and Ramesh in Bangalore, [20] it was only 38.5%.
All the subjects acknowledged that various kinds of harmful and infectious diseases can spread through BMWs. With 41.4% HIV/AIDS tops the list, followed by hepatitis B/C, TB, and other infectious diseases with 37.9%, 17.7%, and 3%, respectively. This is in contrast to the study by Chudasama et al., [12] who pointed out that 74.5%, 56.0%, 8.5%, and 53.2% participants, respectively, concluded that HIV/AIDS, hepatitis B, TB, and other infectious disease can spread through BMWs following the above-mentioned sequence and can cause harm to mankind and the environment.
About 64% and 65.2% of the respondents were aware of the correct Biohazard symbol in studies by Sanjeev et al. [14] and Madhavi et al., [13] respectively, which is similar to 61.6% response rate from this study.
Only 3.5% of the respondents knew the correct maximum time limit of keeping the BMWs around hospital premises.
About 31.3% respondents knew the sharps should be deposited in white-colored Puncture proof (PPR) container followed by 16.7% participants who suggested blue-colored plastic bag for the same purpose.
About 37.9% of health care personnel did not have any idea regarding disposal of cytotoxic drugs whereas 32.8% agreed that black-colored plastic bags should be used for this purpose.

Practice
Segregation of BMW at the site of generation is found to be nil among our study population. On the contrary, the study by Chudasama et al. [12] figured out that the correct response for the same was as high as 86.9%. Studies conducted in Chennai [21] and Davangere [22] also found out the same to be 82.4% and 70%, respectively.
BMW management according to color coding is also found to be nil among the study subjects. This may be due to the presence of considerable proportion of cleaning/sanitary staff as respondents.
Fifty percent of the participants destroyed the needles after use either by cutter, shredder, or mere by mutilation. In a study conducted in Dhaka, Bangladesh, by Sarker et al., [23] destruction of needles was done in 26.1%, 19.5%, 22.7%, and 21.6% by medical doctors, nurses, technologists, and cleaning staff, respectively.
In 33.3% cases, needles were reused for the same patient after NS wash, and in 25% cases, it is even reused for different patients after dipping it into disinfectant solution and then boiling it in the sterilizer within the ward only. Needles and syringes, after intramuscular use or when visibly soiled with blood or body fluid, then were never reused again.
In only 25% and 11.1% findings disinfection of infected BMWs, particularly the sharps are done using hypochlorite solution and some other disinfectant solution, respectively before disposal. In a study in Rajkot by Chudasama et al., [12] the same finding counted to be 84.8%.
In any ward, there was no provision for maintenance of any BMW record which is just opposite to finding of Chudasama et al., [12] where the researchers noticed it be 74.5% for the same. The condition of the BMW injury reporting was also the same. There was no record of any injury. Moreover, none of the respondents ever knew how to notify the authority and officially record a BMW related injury.
Chudasama et al. [12] in their study depicted the same to be 17.4%.
In all the wards, no bin was covered with lid; rather, all of them were kept open. All kinds of waste were collected in the bins and thrown in open land nearby in radiotherapy ward. PPR container in both gynecology and obstetrics ward and radiotherapy department was never used for the purpose and remained empty at a corner of the working area.
Gloves and masks were the PPM used by all subjects; however, in addition, apron was used in case of maternity (gynecology and obstetrics) wards. In a Palestinian Hospital study, there were no protective equipment or clothes available for most workers. [24] Chudasama et al. in his Rajkot study [12] found 84.8% used PPM while handling BMW.
Thus, this study enlightens us regarding the existing knowledge and practices of various levels of health care professionals regarding BMW management in North Bengal Medical College and Hospital, a tertiary healthcare center in West Bengal, India. The researchers recommend similar studies should therefore be performed with a large sample size. The need for more research and accurate, authentic data to provide an evidence base for the future decision-making and for drafting a proper and up to date guideline is highlighted.

CONCLUSION AND RECOMMENDATION
The study revealed a lack of knowledge in different tiers of healthcare providers which adversely affects their practice. Healthcare professionals and government should work together to develop standard feasible policies for BMW management. Even the color-coded bags were there, it was not used; hence, there should be strict implementation of BMW rules for all health care providers and facilities to ensure safety and protection to all health care staff and should be mandatory for all to be trained in this regard. Regular intensive training programs should be held, especially for paramedical and housekeeping staff to develop their practical skill. Moreover, adequate supplies and equipment should be available in all departments to take care of wastes. It is likely that public sectors and private medical care centers should also be incorporated into this matter as soon as possible.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.