ENVIRONMENTAL AND HEALTH IMPLICATIONS OF MANAGEMENT OF MEDICAL WASTES IN SELECTED HOSPITALS IN NIGER STATE, NIGERIA

ABSTRACT

Generation of medical wastes is a global issue and if not properly managed, could constitute potential risks to the environment and public health. It concerns everyone. Unfortunately, awareness that it causes environmental pollution is low in many parts of the globe, especially in the developing countries. This study was carried out with the aim of examining the environmental and health implications of management of medical wastes in some parts of Niger State, Nigeria. Accordingly, public and private hospitals were selected using purposive method. Ten hospitals were selected for the study. A cross- sectional study design was used to examine the current practice of medical wastes management systems and morbidity in children (≤ 10 years) using questionnaire, field participant observations, interviews and focus group discussions (FGD). Samples of wastewater were taken from the hospitals during the period for laboratory tests. A longitudinal study design was conducted to determine the hospitals wastes composition and generation rates. Collection and weighing of wastes from all departments of the sampled -hospitals using a calibrated sensitive weight scale for seven consecutive days were done. Data description was made using mean, graph, standard deviation (SD), frequency, and percentage.  Majority of the staff of the hospitals were nurses/midwives (49.7%), paramedical (33.8%), medical doctors (9.7%) and waste handlers (6.8%). From the responses, about 72.7% of the respondents said only syringe and needle wastes were segregated, 98.1% said that the hospitals have no waste management manual and plan while 98.6 had no specific training on medical wastes management. Use of wheel barrows was the commonest means of transporting wastes and open surface burning was the common final method of medical wastes treatment and disposal by the hospitals. Hospital wastewater treatment plants were not available in all the selected hospitals thus wastewater was discharged directly into the environment. Wastewater quality parameters (pH, BOD, COD, TSS, DO, TC and FC), all indicated severe pollution of the hospital wastewater. Risk ratios (RR) for respiratory, intestinal and skin infections were 0.25:0.18, 0.44:0.31 and 0.27:0.19 respectively indicating that, the exposed children suffered more from such diseases than the unexposed. Average generation rates of hazardous hospital medical wastes in the selected public hospitals were 0.71kg/bed/day, 0.92kg/patient/day, while those of the private hospitals were 0.10kg/bed/day and 0.13kg/patient/day. Similarly, the average rate of the total hazardous wastes generation for the inpatients and outpatients was 0.25 kg/patient/day. Percentage average hazardous wastes components generated in each of the hospitals based on the number of patient /bed/days were; H1: 58.21%, H2: 65.01%, H3: 61.41%, H4: 52.70%, H5: 64.49%, H6: 60.36%, H7: 61.33%, H8: 53.27%, H9: 67% and H10: 57.26%. From this result therefore, it could be concluded that, improper medical wastes management in the selected hospitals were generally poor due to absence of medical wastes management policies and plans, inadequate financial resources, poor awareness and training of medical personnel. Therefore, there is an urgent need for raising awareness among stakeholders on healthcare waste management issues (segregation, storage, collection, transport, treatment and disposal) and their relevance in addressing public health and environmental issues.

CHAPTER ONE

1.0   INTRODUCTION

1.1   Background to the Study

The medical waste (MW) has been considered a global problem that could poses a severe danger to the environment and public health if not properly managed (Yazie et al., 2019; Karki et al., 2020; Ghimire, 2020). These issues are associated to the way the society produces and consumes directly. It concerns all and sundry and its management is one of the critical challenges globally in the 21st century, particularly in less developed countries. This is on the grounds that, arrangement of sustainable healthcare services is essential human needs and can likewise be viewed as a ‘fundamental human right’. Since it believed that, accessibility of sufficient healthcare facilities in a given nation is a method for ensuring and restoring good health saving patients’ lives as well (Annette et al., 2013; Ahmed et al., 2018). Therefore, sustainable medical care is vital for our lives, health and wellbeing of general public. There has been an increase in public concern about the management of MW generated from medical care services on global basis particularly in less developed countries where knowledge, technology, finance and political will on Medical waste management are still lacking (Babanyara et al., 2013). In fact, the submission from researchers declared that out of the complete waste produced from health services organizations/offices, 20 percent of these can be hazardous nature and because of their high potential for diseases transmission and environmental pollution (International Committee of the Red Cross (ICRC), 2011); Babanyara et al., 2013; (World Health Organization (WHO), 2018a); (Yazie et al., 2019).

Since the provision of social amenities such as potable water, security, food, shelter, transport, energy, and communications to the society as well as its economy as a whole must go alongside with appropriate wastes management. it is unforeseen that the medical care services centres which are aimed to cure patients, vaccination, protect all and sundry health against sicknesses as well, has now known as the centres of transmission of infection and means of spreading diseases in the process of handling healthcare cases (United Nation Environmental Protection (UNEP), 2015). This is on the grounds that, the high paces of wastes produced from the healthcare facilities compounded by unsustainable MW management have been accounted for to have prompted expanded dangers in ecosystem contamination and infections transmission (Hassan et al., 2017; Yazie et al., 2019; Ghimire, 2020). Consequently, the waste produced must be properly discarded for the safety of general public (ICRC, 2011).

Regardless of this, general society and political profiles of MW management in developing nations are regularly less fortunate than other utilities provision. Lamentably, the results of doing close to nothing or in any event, nothing to address improper MW management can posed significant environmental pollution and general public health risks (UNEP, 2015). Along these lines, great dynamic about how we deal with the waste we make is one of the most significant commitments mankind can have to diminishing its effect on the normal world. This is on the grounds that, ecological maintainability is the centre issue that should be tended to for advancement to concentrate on human prosperity. However, about 75 – 90% of wastes generated by healthcare activities are categorised  as general or non-hazardous wastes while the remaining 10 – 25% are classified as hazardous or infectious wastes (Healthcare waste Management guideline (HWM), 2018; WHO, 2018a and Ankita et al., 2019). In developing nations, wastes are not regularly separated and arranged into risky or dangerous classes making the whole waste generated hazardous (WHO, 2018a).

These wastes are both in solid and fluid structures and by and large, a standard hospital produces 750 litters of wastewater on average for each bed every day with the present of pathogenic microorganisms, pharmaceutical materials, radioactive components and other harmful synthetic substances. It was ascertained that, the individuals as well as the general public can be infected by micro-organisms loaded in wastewater if not appropriately discarded (Babanyara et al., 2013). It was affirmed that wastes produced in the healthcare centres entail a profound risk of danger as well as contamination than general or municipal solid waste (Babanyara et al., 2013). The UN submission at the convention considers MW as the second most hazardous wastes after atomic emissions. Those waste pose serious threats to public and environmental health because of the potential to transmit diseases, pollute the air, contaminate soil, surface and underground water sources with the pathogenic, heavy metals and toxic substances present in it. In this manner, MW require explicit treatment before final disposal in order to protect public health and environment (Sabiha et al., 2008; Karki et al., 2020).

Scholars referred MW as all the wastes generated by all health care activities, research offices and related labs (ICRC, 2011) and (Ahmed et al., 2018). They additionally incorporate wastes formed by home human activities, for instance, dialysis and insulin infusions (WHO, 2018a). Yearly an expected 16 billion injections are given around the world, however not the entirety of the needles and syringes are discarded appropriately (WHO, 2018a). In developing nations, searching families get by reusing untreated waste materials due to free accessed to open unsanitary destinations and these are at incredible dangers particularly from sharp wastes from hospital facilities. The position of World Health Organization (WHO) which evaluated that, exposed to untreated waste syringes alone responsible between 8 to 16 million cases of hepatitis B while, 2.3 to 4.7 million cases of hepatitis C and 80,000 to 160,000 cases of HIV consistently (Emmanuel et al., 2007). Similarly, the reported findings indicated that, exposure to untreated hazardous MW caused the dead of about 5.2 million people and 4 million children in the world each year from MW related transmission diseases (Akter, 2007). Also, in 2010 risky syringes cause 33,800 new contaminations instances of HIV, hepatitis B and hepatitis C (WHO,2018a).

In many developing nations, guidelines administering safe management of MW are either missing or inadequate. In these nations, unsustainable clinical wastes management practices such as poor separation, treatment and final disposal affect the environment and potential for the transmission of diseases. The submission on appraisal done in 22 Africa nations by WHO shows that, ranges from 18 to 64% of healthcare facilities (HCFs) in the region does not utilize legitimate waste removal techniques (WHO, 2004). Notwithstanding the way MW are rarely ineffectively dealt with in these nations making extra environmental fiascos since MWs likewise contain a huge extent of polyvinyl chloride (PVC) plastics. At the point when PVC plastics are burned, they discharge dioxin into the atmosphere. Dioxin is a lipophilic and bio-aggregate poison, which climbs the natural way of life effectively from plants to creatures and afterward to individuals. Dioxin is a notable human cancer-causing agent, endocrine and destruction of immune system through the water and air transportation (Esubalew, 2015).

As indicated by WHO (2019), air contamination in Nigeria is deteriorating, as figures from the 2017 State Global Air database ((SOGA) demonstrated that the nation drove Africa in air contamination related deaths. As indicated by the report of Health Effects Institute and  the  Institute for Health  Metrics  and  Assessments,  more than  114,000 unexpected premature deaths in Nigeria in 2017 were inferable from air contamination. As indicated by the 2019 SOGA report discharged on Wednesday 3 April 2019, Western Sub-Saharan Africa has the second most noteworthy particulate issue (PM2.5) exposures on the planet, with Niger (94 µg/m3) positioning the most elevated. Cameroon was second most noticeably awful with (73 µg/m3) and followed intently by Nigeria (72 µg/m3). In the West Africa sub state in 2017 around 264,000 losses of lives were credited to air contamination. In Nigeria, contamination levels surpassed the WHO rule for open air PM2.5 as much as multiple times (WHO, 2019).

The WHO also, suggested yearly rule for PM2.5 is 10 µg/m3. PM2.5 are ultra-fine particles of 2.5 micrometres or less in measurement, which are connected to heart infections, stroke and lung malignant growth. However, in Nigeria, urban areas do not consistently screen and report their air quality. Air contamination in Nigeria is caused essentially by fumes from vehicles, flames from waste material and diesel generators (WHO, 2019). There is a critical connection between the air pollution and MW management practice in the region, since surface open burning of mixed MW is the commonest practice in those countries. In most developing countries, including Nigeria and Niger State in particular, the use of substandard incinerators and pits/open surface burning of medical wastes are common practice which profoundly contributes to the air pollution problems in the region (Plate 1).

Plate I: Treatment and final disposal practices in the study areas (Open surface burning) (Source: Field work, 2018)

Unfortunately, studies in this regard in developing countries are few and limited in scope. Indeed, this gap requires a wider research.   Similar submission by Omofunmi et al. (2016); Yazie et al. (2019)   has it that, in developing countries, practical information on hospital wastes management is inadequate and limited in scope especially those for the development of strategic management plans for hospital wastes. Though, information on MW management practice in Niger State is limited in both primary and tertiary care facilities asserting that, MW is poorly handled in respects to segregation, treatment, collection, transportation and training of healthcare personnel. It was also established that, the techniques of wastes treatment/handling before disposal as well as the management agencies required for hospital wastes treatment were lacking (Shaibu, 2014).

To establish effective sustainable MW management system, it is imperative to know the current practice, wastewater treatment practices, healthcare waste composition and generation rates. The significance of the forgoing has been highlighted by their inclusion in Sustainable Development Goals (SDGs). Specifically, SDG 3 emphasizes the insurance of healthy living and promotion of well-being for all at all ages (United Nation (UN), 2019). Strengthening primary health care on medical wastes  generated, their management practices and adequate motivation of professional workforce in terms of funding and other supports. Sadly, however, these are far from the reality in most developing countries. Thus, the realization of SDG 11 goal is a far-fetched issue in most developing countries (UN, 2019). Consequently, these will contribute to the large amounts of healthcare wastes being generated. Therefore, a comprehensive research is required for the development of a sustainable MW management system that can minimize the health and environmental risks in a given country. Thus, Niger State, if it is to be recognized in the committee of states that are ready to realize the SDG goals especially SDGs 3, 6 and 11, needs to consider management of wastes and particularly the healthcare wastes a major issue in its fiscal planning. However, with the promotion of circular economy and its application in MW management thus,  will lead to the significant attainment of the SDGs, particularly SDGs 3, 6, 9, 11 and 12 (Adenaike and Omotosho 2020).

1.2       Statement of the Research Problem

The interactions with key ministries, departments and agencies in Niger State, profoundly helped this study in identifying the major issues associated with the current practices of MW management in the selected hospitals. Although some researches have been carried out in Nigeria and Niger State, notably are those by Umar and Mohammed (2014), Joshua et al. (2014), Shaibu (2014), Olufunsho et al. (2016), Omofunmi et al. (2016) and Sawyerr et al. (2017), they have been characterised by limited coverage of core issues.

The previous scholarly work did not cover MW composition, generation rates, characteristic of wastewater generated, their treatment as well as current MW management practices of the large public and private hospitals in the state. Furthermore, there paucity of reports on the available management practices, policies and strategic plans for sustainable MW management in Niger State.

1.3       Aims and Objectives

The aim of this study was to identify the environmental and health implications of current medical wastes management practices in selected hospitals in Niger State, Nigeria. This aim was achieved through the following specific objectives:

i.      Examination of the current practices of medical waste management in Niger

State.

ii.      Determination of the characteristics of hospital wastewater

iii.     Investigation of morbidity in children (≤ 10 years) within the medical waste disposal and treatment of the study area.

iv.      Determination of the compositions of solid medical wastes and generation rate.

1.4       Research Questions

i.      What are the current management practices for medical waste operational systems in healthcare establishments in Niger State?

ii.      What are the characteristics of hospital wastewater?

iii.      What are the impacts of the use of sub-standard medical waste incinerators and other disposal methods on the vulnerable population surrounding such operations?

iv.       What  are  the  compositions  and  generation  rates  of  medical  wastes generated?

1.5       Justification of the Study

The justification of this research is based on threats of poor MW management to human life and environment due to low awareness of its pollution among the stakeholders, particularly in less developed nations and Niger State specifically. This study sought to create awareness among the stakeholders. Since improper handling of MW leads to transmission of different kind of diseases and environmental pollution imposing huge costs on the public and the government, investigation of hospital wastes management and treatment is germane. Disposal of unsafe medical wastes such as contaminated syringes and needles (Plate II) has been reported to have caused 21 million hepatitis B virus (HBV) infections making 32% of all new infections, 2 million hepatitis C virus (HCV) infections (40% of all new infections) and at least 260,000 HIV infections (5% of all new infections) (WHO, 2018). Thus, investigation of this issue in the study area is very important.

Plate II: Open surface mixed medical wastes disposed. Source: Field survey, 2019

Also,  this  study is  germane due  to  following  contributions:  Ascertained  the issues surrounded the current practices of MW management at the public and private healthcare facilities in the state, the results and recommendations from the study can be utilized to help ensure sustainable MW management the state thus, help to reduce environmental impacts, health risks to patients, healthcare personnel, visitors and the community at large. In addition, findings of the study could provide an opportunity to the Ministry of Health to collaborate with the relevant stakeholders in terms of training on best global practices on proper management of MW and the research may also help the Government in developing policies and planning strategies to address the current practices of MW management in the state.

1.6       Scope and Limitation of the Study

The study covered Ten (10) selected hospitals in the geo-political zones of the state. One referral hospital in the state (IBB Specialized Hospital Minna); Six (6) General hospitals (GH); In addition, three (3) private hospitals (one from each zone) were studied. The hospitals selection profoundly depended on the research topic as the implications of MW are influenced by hospital size, proportion of inpatients and outpatients treated on a daily basis, type of healthcare establishment, hospital specialization, hospital location and established waste management methods (Razali and Ishak, 2010). In this study, MW management practices, hospitals wastewater treatment system, waste composition, their implications on the environment and human health particularly children less than or equal to the age of 10 years were examined. In addition, the wastewater from these hospitals were collected and examined for some microbial and physico- chemical properties. Thus, this study aimed at examining hospital waste composition and generation rate, wastewater quality parameters and morbidity on children exposed to them.

1.6.2    The limitations of this research

The key limitations of this study were difficulties in terms of obtaining information from the doctors who were too busy by attending to the patients and several numbers of visits to some parents in order to obtain the required information on their children concerning the topic of study.

1.7       Study Area

The study which was investigated in Niger State, North-Central Nigeria involved selected towns in three political zones of the state (Minna, Kontangora, Bida, Suleja and Wushishi). The state has a land area of 76,363 square kilometres with population of 4,082,558 (National Population Commission, Census 2006). It is bordered by Kwara and Kogi states in the South West. FCT and Kaduna state in the North East. The state is also bordered by Kebbi and Zanfara states in the North West. Niger State is within the savannah region (Ministry of Land and Survey, 2019). Figure 1.1 shows the location of the study area.

The study covered 10 selected hospitals (Table 1.1). The public hospitals with respective bed capacities; IBB Specialized Hospital Minna (100), General Hospital Minna (296), Minna Public Hospital New Extension (150), Public Hospital Kontagora (250), Public Hospital Bida (100), Public Hospital Suleja (140) and Public Hospital Wushishi with 87 bed capacities were chosen for the research work. Also selected for this study as the private hospitals with their bed capacities were; Standard Hospital Minna with 50, Maraba Hospital Bida with 20 and Al-Azeez Hospital Kontagora with 24 respectively. These are amongst the largest hospitals which generate considerable amounts of hospital solid wastes and wastewater in the state. Since they have the average flow of inpatients and outpatients of between 50 and 200 per day.

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