Comparative Analysis of Healthcare Waste Management Practice in two General Hospitals in Nigeria

List of Acronyms and Abbreviations

Healthcare Wastes

Healthcare waste (HCW), is defined as ‘the total waste stream from a healthcare facility (HCF). According to the Basel, 2004 list, HCWs are grouped into Y1-4, Y6, Y14, Y16, Y29 and Y31. HCWs management is a serious environmental impacting issue that must be addressed using series of management instruments that will help to alleviate the inherent havoc that these categories of wastes have been causing and can cause to unsuspecting communities and the inhabitants. The HCWs impacts can spread through contact of various waste handlers with the generated wastes and then the transfer of contagious diseases to families, friends, neighbors and close associates. The impacts can also spread through unchecked disposal of contaminated wastewater into the public drains and also via movement from dumpsites to other areas, through surface and underground movement i.e. horizontal and vertical transmission of vectors, diseases and disease causing agents, which will eventually impact humans, animals and plants (WHO/CEPIS, 1994; WHO, 1997; WHO, 1995;INTOSAI, 2003). The type of waste of emphasis in this research work is Hospital waste.

Categories of HCWs according to UNEP/SBC-WHO 2006 report

Infectious waste, Pathological and anatomical waste, Hazardous pharmaceutical waste, Hazardous chemical waste, Waste with a high content of heavy metals, Pressurized containers, Highly infectious waste, Genotoxic/Cytotoxic waste, Radioactive waste.

Factors Affecting HCWs Generation

External Factors

• Migration; due to higher economic activities within lagos, more migrant settles into Lagos, either for the period of their business transactions or permanently, thus making HCFs patronage necessary to stay alive and also maintain their family members’ health.
• Carrying capacity; of an area, though not majorly influenced by the increase in birth of the population and not affected by predators, it is however affected by the available land and infrastructures within the locality and is thus limited (UNEP, 2002), it can be deduced that increase influx of dwellers will affect the carrying capacity of a locality as well as the available infrastructure including the health care facility use due to increase influx into the health care facilities by inhabitants of the locality thus affecting the quantity of waste generated within the health care facility.
• Growth rate; 1.8% rate of human population increase, with 2% annual increase rate has been estimated to double its size within the next 35years (Enger and Smith, 1992). With more availability of medical facilities since after the world war, death rates have also reduced (UNEP – Chemical, 2002), this will make population growth to be sustained, generation of wastes in all aspect of living per person per day will therefore increase, this will in turn increase the use of health care facilities and thus generate more wastes still.
• Global Population Growth Contribution; Nigeria is a significant contributor to global economic and environmental issues, this is implicated in the data of (UNEP-Chemical, 2002) where Nigeria was ranked No.1, 2 & 2 generators of Domestic waste Combustion, Agricultural PTS and Unintended Industry PTS respectively. This will in turn affect the dwellers, which will in turn impact on the HC as well as HCW generation.
• Environmental Quality; controlling of air, water and land pollution is a factor affecting human population growth (UNEP-Chemical, 2002), with uncontrolled pollution into the environmental medium it can be deduced that there is bound to be increase use of the health care facilities which will in turn lead to increase in the wastes generated within this sector.
• Rapid Population Growth Increases; Countries with the highest standard of living have the lowest population growth rate, people in less developed countries often try to farm marginal land, are less educated, and tend to have more children, as population increases, competition for resources will increase (Enger and Smith, 1992), and with increase education for most part of the population in many countries now, the qualities of health care and sanitation will be improved through improve awareness and technical know-how, people thus become more frequent in the health care facilities. It can be deduced therefore that this will make various health care workers attend to more patients and influx into hospital will thus lead to the generation of more waste in this sector. Africa has the highest rapidly growing human population globally, because the birth rate are affected by the view that children are a valuable resource since they can work, children will care for the parents in their old age, people cannot afford contraceptives or it is culturally or religiously not acceptable (Enger and Smith, 1992), thus the number of patient available for treatment on various health problems are expected to increase especially, when there is increase funding for building health care facilities, there is bound to be more HCW generation.
• Population Limiting Factors; The major factors that limit population are; availability of energy, availability of raw materials and food, ability to dispose of waste products, interaction between organisms, the number of women of childbearing age and of children who will themselves eventually have children, to ensure that the population grows sustainably (Enger and Smith, 1992). The ability to dispose waste that will be generated from energy use, food and raw materials production properly have been observed to generate a lot of negative impact via environmental medium pollution (Uchegbu, 2002, 2002^B; Opara, 2002), it can thus be deduced that this will eventually lead to increase visit of many of the various categories of the population to the health care facilities available to them and in turn increase waste production in the sector.
• Increased Inequality and Poverty; have in turn Increase waste generation and improper disposal: (quantity and variety), acceleration of urban population growth and increase in spontaneous settlements leading to increased informal activities have put a strain on municipal services and the ability to deal with the boom, poverty and improper formalization of Policy as well as strategy changes or adjustments to deal with the new situations have added to waste generation and management not followed with immediate adjustment strategies to remove it promptly which has lead to environmental deterioration and health hazards (Omoleke , 2004; Adelegan, 2003).
• Municipal Solid Waste Management; constitutes one of the most crucial health and environmental problems facing governments of African cities. This is because even if the cities are using 20-50 percent of their budget in solid waste management, only 20-80 percent of the wastes are collected. The uncollected or illegally dumped wastes constitute a start-point for disaster of human health and the environmental degradation. Apart from the increasing quantities, the waste composition and characterization, has changed and is still changing as urbanization evolves, incomes, and changing consumption habits have also been affected by globalization. This scenario places the already desperate urban councils in a difficult situation especially as they have to develop new strategies to deal with increasing volumes as well as strange varieties of wastes, one of which is the health care waste, ADB, 2006.
• Deteriorating Environment; According to Adelegan, (2003), Patronage of hospitals and other health care facilities in Nigeria is on the increase, Public health and urban environmental degradation have been linked to water related diseases such as diarrhea, dysentery, cholera and typhoid, the rapidly increasing populations coupled with the deteriorating environment are some of the factors responsible for this trend, hospital records have confirmed high incidence of typhoid, cholera, dysentery, infectious hepatitis and guinea worm in urban settlements of Nigeria, of all the costs of urban, environmental degradation, damage to human health is by far the highest.
• Improper Infrastructural development; The rapid growth of urban centers in Nigeria, coupled with the development of unstructured infrastructural facilities and social services have established a negative environmental incidence in many parts of the country, which is becoming deleterious to healthy living. Due to the need for environmental control, emanating from the view held by stakeholders that proper mitigation of the negative anthropogenic implication on the environment would bring about improved health and better living conditions. Detailed estimation of the impact will alleviate policymakers’ need in formulating an all encompassing environmental and health solutions that have also embedded a sound economics consideration. In addition, experiences from advanced industrialized countries indicated that in the short term, the net effect of pollution control activities is almost certain to have some macroeconomic impacts.

Internal Factors Affecting Waste Generation in HCFs

• Factors affecting waste generations discovered in various sections include; the number of patients, waste management practice adopted, types of health problems of patients being treated, number of visitors and accompanies, quantity brought from home, lack of waste-to wealth concepts, taste and health conditions of patients, period of drug administrations, day of the week and the type of medication prescribed for the patient.
• According to the draft of Nigeria national HCWM, 2007, Health care waste generation depends on other varieties of factors, such as established waste management methods, type of health-care establishments, the proportion of patients treated on a daily basis and the level of complexity and degree of specialization of the health facility. However, the Teaching Hospitals have been found to generate larger quantities of waste per unit than other facilities, followed by the general hospital where so many rural dwellers usually have more access.

Waste Management

Combining the definitions of Alo, (2006) and Osibanjo, (2003) waste management is the various activities from generation of waste to final disposal. It involves, strategic measures taken in the generation, characterization, quantification, storage, handling, collection, transportation, and disposal of wastes. It also covers managerial, technological and remediation measures involved in the corrective actions of existing waste practices as well as the continuous plan towards ensuring sustainable waste management within a locality e.g. Hospital Waste management in Lagos metropolis.

Past Research Works On HCWs

Researches have been conducted all over the world, on HCWs and HCWM; Coker et. al., 1999, Wong and Ramarathnam, 1994 all used quantification, physical observation and questionnaire administration as methodology for collating generated wastes data. Consultants and government agencies as well as institutions report hospital waste management in Florida; solid waste management in Florida, 2000; working draft report HCWH, 2002; Jorge et. al., 2000; international meeting report on HCWM, 2007; Alexander, 2001; INTOSAI, 2003; Shell medical waste EIA., 2002 etc. all discussed the various management intertwined activities necessary for proper HCWM. Some other researchers also dealt with data analysis tools needed for better predictions of the effect and impact of pollution as well as proper mitigations of HCWs. Longe and Williams, 2006 presented a range of between 0.562kd/bed/day and 0.670kg/bed/day with between 26% and 37% infectious waste portion for Lagos state. The UWEP report on waste management of HCFs prepared in Karachi in 2001 stated that generation of HCWs according to type of establishments in high income countries showed that the daily generation rate for general hospitals was between 2.1 and 4.2kg/bed. LAWMA findings within Lagos also reported a 1.5kg/bed/day waste generation while Pescod and Saw, 1999 recorded a range of 1-3.5kg/bed/day and between 0.3 and 0.9 kg/bed HCWs referred to as hazardous waste. The recorded percentage compositions of proportions of different types of wastes at various sources in Shaio Clinic, Bogota Showed that kitchen and cafeteria are areas where highest generation of wastes occurs followed by the surgery theatre, while gynecology ward or clinic as well as the doctors or consultants sections recorded both medium and low wastes generation. A survey of the total number of beds for each type of hospital in the capital of Sofia in Bulgaria was conducted, the quantity of wastes generated per occupied bed, showed that the quantities of potentially infectious and hazardous hospital Wastes averages around 0.4 kg/bed/day.

Research Methodology and Findings

Research Methodology

This research work was carried out between January and June, 2008 to determine the variations and similarities in the activities within two general hospitals located in separate Local Government Areas of Lagos state, so as to ensure that relevant evacuation and other HCWs management plans are properly done based on informed recommendations, it will also ensure that national regulatory guidelines compliance can be attained easily. Using Physical observation, waste quantification or estimation and documented information provided in the hospital record, sectional data within each hospital were collated and analysed by employing relevant statistical analytical tools like ANOVA,

Sectional Grouping, Mean, Median, Mode, Sd, CV etc. the collated data of the hospitals showed similarities in many areas, confirming that similar activities takes place within the HCFs and variations in other areas, confirming that many factors, both external and internal affect the generation of wastes and all other activities within an HCF. Using a combination of direct observation and wastes quantification/estimation, both primary and Secondary Data were gathered, the Primary data were collated through the field survey undertaken by visiting the chosen Hospital site for over a month each, where Oral interviews, Field video and photography, discussion with workers, quantification of various sectional wastes using two scales, one with +/-0.1 accuracy with a minimum range of 0.02g and having the capacity to accommodate 3.0kg and the second with +/-0.5 accuracy with a minimum range of 1kg and having the ability to withstand 120kg weight, observations within the HCF was also undertaken during the specified period.

The report of the National Health-Care Waste Management Plans in Sub-Saharan Countries Guidance Manual prepared collaboratively by Secretariat of the Basel Convention and World Health Organization UNEP/ SBC – WHO assessment document, prepared in 2006 is the international standard of reference for this report. The draft HCWM plan, 2007 prepared for FMenv. and the Federal Ministry of Health, National Injection Safety Forum report prepared in March 2005, as a collaboration project with USAID and JSI (MMIS project) are the national standards considered in this research work.

Choice of Hospitals for primary data collation:
Presently Lagos is one of the most populated states in Nigeria and the commercial nerve center, thus pollution issues are higher, prevalent and more visible, these are factors that informed the choice of picking Lagos as the case study for this research work. Also, a projected increase in HCWs is envisaged as the population and urbanization of Lagos towns and neighboring towns progresses, which can be accelerated by increase industrialization. In addition, attainment of a MEGA city status can only achieved when environmental issues are properly managed and appropriately mitigated.

Findings

Tables 1^a to 10^b and Figures 1 to 4 presents the various quantifications and other relevant findings within the two HCFs. 25 sections and 34 sections generate HCGWs only in OAGH and GHL respectively, some of these sections are merged together during waste quantification. The quantities of wastes produced per day per section here ranges between 0.00 and 38.00kg/day/section in OAGH and 0.02 and 62.36kg/day/section in GHL, total waste generated ranges between 48.92kg/day and 117.07kg/day in OAGH and 62.98kg/day and 170.04kg/day in GHL.

In the in-patient sections of OAGH, the total waste generated within each section ranges between 0.00 and 19.84kg/day, the Non-sharp HCWs ranges between 0.00kg/day and 13.62kg/day and the total generated in all the section together ranges between 13.80kg/day and 47.50kg/day, this is equivalent to between 44.17% and 61.59% of the total generated wastes in all the sections, the domestic waste portion ranges between 0.00kg/day and 6.22kg/day, while the collective total ranges between 17.44kg/day and 29.67kg/day which is equivalent to between 38.41% and 55.83% indicating that more HCWs were produced in the wards. Sharps generated in each ward ranges between 0 and 198 pieces/day giving a collective total of between 321 and 772 pieces/day, which leads to the production of between 0sharp box/month and 14 sharp boxes/week in each section and this is equivalent to generating between 22sharp boxes/week and 54sharp boxes/week. Between 0 and 19 patients are usually found in each of the wards and a collective total ranging between 50 patients/day and 111patients/day. In the in-patient sections of GHL, the total waste generated within each section ranges between 0.46 and 20.62kg/day, the Non-sharp HCWs ranges between 0.04kg/day and 10.26kg/day and the total generated in all the section together ranges between 23.84kg/day and 42.62kg/day, this is equivalent to between 33.32% and 38.98% of the total generated wastes in all the sections, the domestic waste portion ranges between 0.38kg/day and 10.36kg/day, while the collective total ranges between 47.71kg/day and 66.72kg/day which is equivalent to between 61.02% and 66.68% indicating that less HCWs were produced in the wards in contrast to that of OAGH. Sharps generated in each ward ranges between 0 and 181 pieces/day giving a collective total of between 389 and 849 pieces/day, which leads to the production of between 0sharp box/month and 13 sharp boxes/week in each section and this is equivalent to generating between 27sharp boxes/week and 59sharp boxes/week. Between 0 and 30 patients are usually found in each of the wards and a collective total ranging between 154 patients/day and 231patients/day.

In the out-patient sections of OAGH, the total waste generated within each section ranges between 0.04 and 13.90kg/day, the collective total ranges between 19.48kg/day and 57.34kg/day, the Non-sharp HCWs ranges between 0.00kg/day and 10.10kg/day and the total generated in all the section together ranges between 8.3kg/day and 28.08kg/day, this is equivalent to between 42.61% and 48.97% of the total generated wastes in all the sections, the domestic waste portion ranges between 0.00kg/day and 3.8kg/day, while the collective total ranges between 11.18kg/day and 29.26kg/day which is equivalent to between 51.03% and 57.39% indicating that less HCWs were produced in the out-patient sections of OAGH in contrast to that of the In-patient sections of the same hospital (OAGH). Sharps generated in each section ranges between 0 and 330pieces/day giving a collective total of between 54 and 1,059 pieces/day, which leads to the production of between 0sharp box/month and 17sharp boxes/week in each section and this is equivalent to generating between 3sharp boxes/week and 53sharp boxes/week. Between 0 and 397 patients are usually attended to in each of the Out-patient sections and a collective total ranging between 379patients/day and 1,050patients/day. In the out-patient sections of GHL, the total waste generated within each section ranges between 0.02 and 13.03kg/day, the collective total ranges between 34.8kg/day and 90.42kg/day, the Non-sharp HCWs ranges between <0.02kg/day and 10.14kg/day and the total generated in all the section together ranges between 1132kg/day and 36.72kg/day, this is equivalent to between 32.53% and 40.61% of the total generated wastes in all the sections, the domestic waste portion ranges between <0.02kg/day and 12.84kg/day, while the collective total ranges between 23.48kg/day and 53.68kg/day which is equivalent to between 59.39% and 67.47% indicating that less HCWs were produced in the out-patient sections of GHL this is similar to what was found in the same section of OAGH. Sharps generated in each section ranges between 0 and 372pieces/day giving a collective total of between 110 and 1,504 pieces/day, which leads to the production of between 0sharp box/month and 19sharp boxes/week in each section and this is equivalent to generating between 6sharp boxes/week and 75sharp boxes/week. Between 1and 365 patients are usually attended to in each of the Out-patient sections and a collective total ranging between 303patients/day and 1,031patients/day, this is similar to that of OAGH.

Note: estimated quantities of the sharp boxes was based on a minimum of 80 items and maximum 120 items, which was taken to be equivalent to ¾, filled sharp box. Some of the sections are not directly attended by patients unless they are referred there thus, the number of patients attended to in such sections were not fully used, considerations were however made for situations when patients were not attended to and may need to revisit the section at another date without going to any other section, in the light of this the whole patients attended to was assumed to be new in radiology section and their number was fully used for the calculation while 10% of that in the laboratory sections were incorporated as new patients. For the water use analysis, the assumed totals were based on the assumption that 100L will be used per patient daily, while 60L out of this will be channeled directly into the public drain in the In-patient sections, also, 20L will be used in the Out-patient sections with about 0.05L being channeled directly into the public drain, it was also assumed that about 25% of the out-patient will need to use the toilet facilities available within the hospital where water will then be utilized, armed with these assumptions, the total water utilized within the in-patient and Out-patient sections of the OAGH and GHL was thus calculated based on the number of patients attended to within each section.

Using the average number of patients found in all the sections of OAGH the values of utilized water in the out-patient sections was found to range between 16.43 and 2737.86L/day/section, with a total of 8054.27L/day, and equivalent to 14.54L/pat./day, while the quantity discharged directly into the public drain ranges between 0.04 and 6.85L/day/section, with total of 19.12L/pat./day, and equivalent to 0.03L/pat./day. The various mean of quantified utilized water the Out-patient sections of GHL showed that the total water values was found to range between 3.57 and 1947.85L/day/section, with a total of 9674.14L/day, and equivalent to 13.34L/pat./day, while the quantity discharged directly into the public drain ranges between 0.01 and 4.87L/day/section, and total of 23.80L/day, and equivalent to 0.03L/pat./day. The variations in the statistical data confirmed the heterogeneity characteristic of HCWs.

The values of total water utilized in the In-patient sections of OAGH was found to range between 71.43 and 1714.29L/day/section, with a total of 8299.99L/day, and equivalent to 103.75L/pat./day, while the quantity discharged directly into the public drain ranges between 42.86 and 1028.57L/day/section, with total of 4980.02L/day, and equivalent to 62.26L/pat./day. 0.24% of the total utilized water in the out-patient sections was discharged A gross total of 19354.26L/day was estimated to be the value for water utilized in OAGH having added the total values calculated for Laundry, Canteen and utensils cleaning, a total of 7999.19L/day was estimated as being the quantity discharged into the public drain, which is equivalent to 60.00% of the total water utilized within the wards. 0.25% of utilized water in the out-patient sections was discharged. The values of total water utilized in the In-patient sections of GHL was found to range between 128.57 and 2485.71L/day/section, with a total of 19214.27L/day, and equivalent to 100.07L/pat./day, while the quantity discharged directly into the public drain ranges between 77.14 and 1465.71L/day/section, with total of 11482.85L/day, and equivalent to 59.80L/pat./day. A gross total of 33838.41L/day was estimated to be the value for water utilized in GHL having added the total values calculated for Laundry, Kitchen, Canteen and Utensils cleaning, a total of 16456.65L/day was estimated as being the quantity discharged into the public drain. 59.76% of water utilized within the wards was discharged into the public drain. Collectively, about 41.33% of the total water utilized in OAGH was discharged into the public drain without any form of treatment, while, 48.63% of the total water utilized in GHL was discharged into the public drain without any form of treatment.

The ANOVA analysis of OAGH In-patient sections shows that the Non-sharp HCWs and total HCWs data were less significant, the gross total, domestic wastes and sharps HCWs data less non-significant, this collectively shows that though the analysed data were generated within different sections, but the rate of generation was similar, this can be buttressed with the fact that most sections attends to the same number of patients daily, also the wards have similar total number of beds and the bed occupancy rates were also similar. The error exhibited on the analysed data was however shown to be very small as indicated by the very closely related values of the actual and the corrected values of the sum of squares. The ANOVA test was carried out at 0.05 or 95% confidence level. The ANOVA analysis of GHL In-patient sections showed that only the Non-sharp HCWs exhibited low Significance while all other data showed low non-significance, this non-significance is probably due to similar activities within the sections as explained for the OAGH. Exhibited error was also very low, as shown by the corrected sum of squares.

The ANOVA analysis of OAGH Out-patient sections showed that the Sharps, Non-sharps and Total HCWs exhibited between High and moderate Significance while domestic and gross total waste data showed low non-significance, this non-significance is probably due to varied activities within the sections. Exhibited error was still shown to be very low, indicated by the corrected sum of squares, except for domestic waste data. The larger sum of squares corrected values in the gross and domestic waste data may be due to varied attendance at the sections, because of strict adherence to clinic days observed in the hospital, thus the number of patients were very low in some days and relatively high in other days, making waste generation to vary significantly during these periods. The ANOVA analyses of the Out-patient sections of GHL are predominantly characterized by high significance for all the collated data of the various quantified waste categories. This is totally different from what was observed in the OAGH data and this exists due to the similar reason of high heterogeneity in activities within each section, the level of accuracy of the collated data in GHL was however shown to be better than that of OAGH as indicated by the corrected sum of squares.

The ANOVA analysis of quantified waste data of HCGWs sections in OAGH showed that the data analysed exhibited low significance, the corrected sum of squares was however very high, this can be said to be due to the variations in administrative activities within the sections which determines the quantity of generated wastes, also contributed can be the short period devoted to quantifications. The ANOVA analysis of quantified waste data of HCGWs sections in GHL showed that the data analysed depicted low significance but the corrected sum of squares was also very high as exhibited by the OAGH data of similar sections, similar reason may be said to have caused this. In conclusion, high significance existed in the data collated in the Out-patient sections of both OAGH and GHL, though obvious variations are seen in the two data from the different HCF. Moderate to low significances were generally observed the In-patient and HCGWs sections analysed data in the HCFs, this can be attributed to the fact that patients within the wards of OAGH ranges between 0 and 25 per section daily and the beds also ranges between 1 and 19 in each section with a mean of 9, while in GHL, patients ranges between 0 and 26, while the beds ranges between 7 and 25 with mean of 18, in the same vein, the number of workers in the HCGWs sections are usually similar daily, whereas, the Out-patient sections shows higher variations in sectional activities and the number of patients seen within the various sections also differs considerably.

To explain further the information gathered from the one-way ANOVA analysis and other observations, the variations and similarities of sections were further presented using various statistical grouping tables, where values of the mean of analysed data that differs by +/- 0.15 for HCGWs generating sections or ± 0.5 for sections under the HCWs generating sections. Groups will be arranged in ascending order of quantified wastes, thus group denoted as group 1 will have group members with least quantified waste. Out of the 25 sections identified in the HCGWs section of OAGH, 10 groups can be formed. Group 3 have the highest number of sections (7), followed by group 1 (5), groups 5 to 10 however have one member only. Out of the 33 sections identified in the HCGWs generating sections in GHL, 12 groups can be formed Group 2 have the highest number of sections (9), followed by group 1 (7), group 6 to 12 however have one member only. Out of the 11 sections identified in the In-patient sections of OAGH, 6 groups can be formed. Groups 3 and 4 have the highest number of sections (3) each, followed by group 1 (2), groups 2, 5 and 6 have one member only. In the In-patient sections of GHL, out of the 15 sections identified, 8 groups can be formed. Group 5 have the highest number of sections (5), followed by groups 1, 3, 4 and 6 (2), groups 2, 7 and 8 have one member only. In the Out-patient sections of OAGH, out of the 20 sections identified, 7 groups were formed. Group 1 has the highest number of sections (7), followed by groups 5 (4), then groups 3 and 4 (3) groups 2, 6 and 7 have one member only. In the Out-patient sections of GHL, out of the 31 sections identified, 8 groups were formed with the section each having quantified wastes that differs from each other within + or- 0.50 target. Groups 1 and 3 have the highest number of sections (9), followed by groups 2 (5), then groups 4 (3), groups 5, 7 and 8 have one member only, while group 6 have 2 member.

1. Gynecology
2. Female Medical
3. Female Surgical
4. Male Medical
5. Male Surgical
6. Pediatrics
7. Casualty
8. Maternity
9. Female Isolated
10. Male Isolated
11. Private Room

Figure 1 · Number of Beds and Number of Patients in the OAGH Wards

Presentation of OAGH Pictures

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1. Scavengers at work during waste packing in OAGH and using bare hand used for packing wastes to put pure water sachet into mouth when thirsty.
2. Scavengers at Abule Egba Dumpsite, rushed at the deposited content of the waste vehicle, (collected in OAGH) not minding the type of waste being poured.
3. Other Hazardous wastes generated within the wards in OAGH.
4. Overfilled Deposit shed in OAGH, leading pouring of mixed wastes into the entrance of the deposit site.
5. Inappropriate waste found in the red nylon in OAGH.
6. Different types of HCWs collected with liquid content of urine bag still inside it, indicated by the inflation of the bag in OAGH.
7. Improper partitioning of waste container in OAGH.
8. Medical waste collection drum filled with cartons in OAGH.
9. Sharp box placed at the entrance of OAGH waste collection shed.
10. Collection of all wastes together in OAGH by LAWMA staff.
11. Air Pollution, caused by using dilapidated vehicle to collect waste in OAGH by LAWMA staff.
12. Waste collection contractor using bare hands to pack mixed HCWs in OAGH.
13. Sharp box collected with all other wastes in OAGH.
14. Another view of waste deposition at the entrance of OAGH waste deposit shed.
15. Recyclable cardboard cartons deposited into the waste shed in OAGH.
16. Overflowing domestic wastes section in OAGH.
17. Researcher kitted with PPEs during the data collation.
18. Protruding sharp packed into the red nylon in OAGH.
19. Brown bag containing laboratory wastes packed with other wastes during LAWMA collection in OAGH.

Presentation of GHL Pictures

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1. Unkempt surrounding in GHL, due to dumping of obsolete equipment.
2. Urine bags filled with urine and dumped into the waste container for disposal in GHL.
3. Cesspool waste (human excreta) found at the back of emergency ward of GHL.
4. Wastewater flowing into the public drain without any form of treatment in GHL.
5. Improper waste collection in the theater section of GHL, where body part was lumped with other HCWs generated.
6. Another view of Anatomic waste found in GHL theatre HCWs container for disposal into the transit point and to be collected later into the public dumpsite.
7. Mixture of domestic and other HCWs generated in the Laboratory section of GHL.
8. Mixture of domestic and HCWs lumped together in the blood bank section of GHL.
9. Waste collection practice in GHL, where yellows nylon and its HCWs content is dropped into the black nylon containing domestic wastes.
10. Already dropped yellow nylon seen inside the black nylon in GHL.
11. Waste scavenging. in GHL.
12. Scavenging animal in the deposit shed in GHL.
13. Recyclable boxes thrown into waste shed in GHL.
14. The back of the ground floor of the Doctor’s quarter in GHL, where passersby and patients’ relatives utilizes as convenience both at night and during the day time.
15. Already analysed Laboratory samples through into the overflowing wastes in front of the waste collection shed, which is located along a major road, where scavengers can have access to it in GHL.
16. Old Sharp deposit pit in GHL, where a separate room, located close to the main entrance of the hospital is being used for storing sharp boxes, which is usually collected separately.
17. Researcher, during the data collation.
18. Sharp found in the wastes and sample containers in GHL.
19. Laboratory wastes packed with waste samples of patients for onward deposition into the waste shed in GHL.

Conclusions

Total waste segregation was not practiced on the HCFs sites used as case studies, no waste reduction or minimization measures exists on site, Information and communication process is lacking in most sections and it is affecting environmental practices. Many sections do not keep proper records on the quantities of materials used for treating patients; neither do they normally quantify their generated wastes daily. Staff and visitors are not incorporated into the waste management data. Co-disposal of domestic and HCWs is the normal practice existing in HCFs in Lagos and co-collection of the generated wastes by wastes collectors was also observed to be the norm and non observance of most colour codes recommended for keeping wastes was the practice.

Highly infectious wastes like in DOT, VCT Laboratories are packed and disposed along with all other wastes. No form of water treatment facility was seen on the HCFs used for the data collation of this project. All the bathrooms and wash-hand basins drains are directly linked to the public gutters. No maternity wards, ANC, CWC or pediatrics clinic exists on the GHL facility, these sections have been converted to a separate hospital and with separate management. Miscellaneous allocations are presently being used to address environmental issues in the HCFs. All sections do not have adequate posters on HCWs management information, however, some wards and Out-patient sections have information posters about treatment of HCWs and handling sharps in GHL, none was found in OAGH.

Improperly monitored transit points exist on the HC facilities. Non-observation of wastes meant for different colour coded containers is the general practice. Non-availability of nylons affects workers willingness to observe colour codes. All forms of containers were used to carry wastes on the HCFs. Non-challant attitude to waste segregation are observed amongst all categories of staff in the health care sector and ways of ensuring enforcement have not been determined. Properly handled Kitchen and canteen wastes generated in both HCFs can be recycled as Dog food or sold out to those producing organic fertilizers. Monitoring and evaluation of wastes management activities have not been planned for in HCFs.

Due to the practice within the GHL that prevents patients’ visitors to stay within the ward overnight, most of them make use of any hidden area to ease themselves at night, thus polluting the environment, especially under the Doctors’ quarters (that is being managed by a separate management and all health care workers are now being allocated to the building), this building is strategically located and has close proximity to the emergency wards, thus many night visitors uses the dark to liter the place with human faeces and urine such that the section exhumes foul odour that does not befit the status of an health facility, broken beds and other bad or obsolete office equipment also liters this place and no form of cleaning has been done there for over three years before the collation of this data. In OAGH the aesthetic of the environment has been better protected because one visitor is entitled to stay with the patient, this has also eased the stress of work of staff when there is need to perform special duty on the patient, like bathing and helping the patient to use the toilet. The wards were observed to be devoid of unwashed human body odour as compared to many sections of the GHL. There is high variation in the values of wastes generated within each section, indicating very highly heterogeneous and dynamic system.

A total of 99 beds were present in OAGH while 271 existed in GHL. According the information provided from the record section of GHL, more males were admitted into the wards in GHL in 2007, but more death occurs among admitted females. More females attended the out-patient sections in GHL in 2007, but more males’ death occur here. This type of information could not be assessed in OAGH.

In GHL, between 6 and 75sharp boxes are generated per week and between 1and 365 patients are usually attended to in each of the Out-patient sections, the collective total number of patients seen in this section ranges from 303patients/day to 1,031patients/day, this is similar to that of OAGH where between 3 and 53sharp boxes are generated per week and between 0 and 397 patients attended to in each of the Out-patient sections and a collective total of patient ranges between 379 and 1,050patients/day. In OAGH In-patient sections, between 22sharp boxes/week and 54sharp boxes/week are produced., between 0 and 19 patients are usually found in each of the wards and a collective total ranging between 50 patients/day and 111patients/day. In GHL, sharps generated in the wards ranges between 27sharp boxes/week and 59sharp boxes/week. Between 0 and 30 patients are usually found in each of the wards and a collective total ranging between 154 patients/day and 231patients/day.

A lot of Xyrofoam packs were used for packaging pharmaceutical products and food items bought for workers and patients. These xyrofoam packs are normally made with Ozone depleting substances, which can be easily released during burning, a method of waste disposal generally practiced within Nigeria and in the dumpsites. The disposal of medical waste in municipal landfills without prior treatment to eliminate or reduce contaminations may pose serious health threat and environmental hazards if not stopped. Landfills were also observed to be open dumps without adequate design consideration to guaranty their protection of the environment from the disposal of such hazardous wastes. Leachates from beneath the landfill base could have the possibility of containing heavy metals and other organic pollutants that could lead to gross contamination of surface and groundwater resources.

Generally, waste management has not been organized into a structured format that is in line with national and international laid down guidelines, by both generators and collection agencies, however, significant is already being placed on the proper management of waste by the government of Lagos state. therefore a monitoring and evaluation system must be put in place to mandate all the stakeholders to comply with policy, when it is eventually launched.

Recommendations

Official waste audit should be undertaken and training of environmental and waste auditors for HCFs should be undertaken. Collaboration of waste auditors with financial auditors will expose financial misappropriation and fund diversion or any form of fraud. Imposition of documentations of consumables and appendage of signature or signatures will help to verify actual amount of consumed materials, which will then be correlated with declared amount on account records. Formulation of HCWM policy should be undertaken.

Any form of non-challant attitude should be checked by regular training and retraining of personnel and application of sanctions when all the relevant elements and instruments have been put in place. Adequate training curriculum must be developed for various categories of HC workers.

Seasonal data collation must be done for accurate quantification to be achieved and the highly heterogeneity of data must be considered while deciding the sessions for data collations. Peculiar nature of a particular settlement must be put into consideration for the collated data.

Funding of Environmental projects must take definite percentage of the monthly allocations in the hospital. Regular and periodic replacement of PPEs must be done using a time-table of how long the producer of such equipment stipulated for it to be used. Information dissemination should be intensified while better communication channels should also be established for prompt circulation of relevant information.

Construction of an E. T. P. within each HCF will reduce exposure of community settlers to contaminated wastewater poured directly into the public drain without any form of prior treatment. International standards relevant to the management of waste within and outside the African setting should be consulted to be able to adequately address HCWM issues.

Monitoring of transit point to prevent dumping of household wastes used by workers and visitors should be done to prevent increase waste load that will mean increase money for its disposal. The use of smaller nylons for collection of HCWs in sections where very small quantities are generated and then collection into larger special nylons for daily disposal will help to reduce wastage of larger nylons and also prevent handlers (who normally keep this type of wastes for long) from being infected.

Extensive research on the subject matter of hospital waste should be funded at various levels and done for adequate period to be able to have reliable data bank that will be useful for effective management of the wastes.

Combination of treatment technologies (like autoclaving, sterilizing, disinfecting and shredding) should be explored for proper HCW treatment, before final collection at the transit point by LAWMA officials for final disposal either in an incinerator or on a controlled landfill.

Use of environment friendly waste-to-wealth measures like waste-to-energy and recycling where possible should be explored to ameliorate the land use for keeping solid wastes.

Since most sections have similar activities at the HCFs, supply of HCWs disposal and handling materials can be easily determined and estimated appropriately. Arrangement for waste collection should also be based mainly on the total generated waste of HCFs so as to make sure that solid waste accumulation is prevented in all HCFs, by prompt and timely evacuation. Regular quantification of generated wastes should thus be made compulsory to relevant staff.

Since significant is already being placed on the proper management of waste by the government of Lagos state, therefore a monitoring and evaluation system must be put in place to mandate all the stakeholders to comply with policy, when it is eventually launched.

References

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