This study was aimed at identifying the health hazards posed by hospital wastes to the sanitary workers of Combined Military Hospital, Rawalpindi and to make recommendations for the improvement of their health status.
A total number of 93 workers are employed in sanitary and housekeeping activities. Among them are 66 male and 10 female sanitary workers and 17 Ayas (female housekeepers).
A cross sectional study of all the above-mentioned workers was conducted using a structured open and closed ended questionnaire. Data was compiled and analyzed using SPSS ver 10.0 software.
This study revealed that 46% of workers were illiterate and 49% had attended primary school. Mean age was 31.8 + 8.4 years. None of the sanitary workers received any training in handling of hospital wastes. They were not routinely inspected for identification of their health problems. They were not provided with protective equipment and were never vaccinated against hepatitis B. Although some form of segregation of hazardous and non-hazardous wastes was practiced in CMH, Rawalpindi, majority (56%) of them collected and carried the two kinds of wastes in the same vehicle. 48% of them reported of sustaining one or more injuries at work. Frequently reported injuries were: cuts (47%), pricks (34%), falls (15%) and burns (4%). 26% of them reported of contracting skin diseases from wastes, while 12% caught ENT disorders, 9% gastro-intestinal disorders, 6% respiratory diseases and 8% hepatitis.
It is concluded from this study that sanitary workers of CMH, Rwp are unaware of the risks and hazards associated with handling of hospital wastes. They are exposed to biological, physical and toxic substances routinely. But they lacked the required knowledge, skills and protections to safeguard their health. There is a need to improve the training and education of all hospital housekeeping staff in the principles of management of hospital waste.
Keywords : Housekeeping, medical waste disposal.
Health care activities protect and restore health and save lives. But on the other hand they are major producers of potentially harmful wastes and byproducts . These wastes cover a diverse range of materials including infectious wastes, sharps, chemicals, genotoxic, radio-active, heavy metals etc. The major sources of healthcare wastes are hospitals and other healthcare establishments, laboratories, research centers, mortuaries and autopsy centers, animal research and testing laboratories, blood banks etc [2, 3].
Hospitals are a labour intensive industry. In some countries, up to 4% of the total work force is employed by hospitals . All the health care workers are at an increased risk of exposure to the hazards of health care waste 4. In our country sanitary workers are the worst exposed. This is due to their poor socio-economic status, low levels of education and lack of awareness and lack of any training in hazardous waste handling .
Health care waste is a reservoir of potentially harmful pathogens in sufficient concentrations to cause disease. All individuals exposed to this waste are potentially at risk. This includes doctors, nurses, paramedical staff, ayas, ward boys, sanitary workers, patients and their attendants and rag pickers . Pathogens in infectious waste may enter the body by a number of routes .
* Through a puncture, abrasion or cut in skin
* Through mucous membrane
* By inhalation
* By ingestion
There is a particular concern throughout the world about infection with HIV and hepatitis B and C viruses, for which there is strong evidence of transmission via healthcare waste [6, 7].
In Pakistan, there is lack of data on occupational exposure to health hazards in general and to healthcare workers in particular5. This study was designed to identify, examine and reduce the health hazards to sanitary workers in the Combined Military Hospital (CMH), Rawalpindi.
MATERIALS AND METHODS
This study was conducted at CMH, Rwp. CMH, Rwp is a tertiary care, teaching hospital of the Armed Forces, providing curative specialist services to the entitled serving personnel and limited services to the general public. It comprises of outpatient clinics, emergency and trauma centers, burn unit, major surgical and medical facilities including gynaecological, obstetric and paediatric services.
A cross sectional survey of sanitary workers through a structured questionnaire was carried out to find out t he levels of awareness and exposure to hospital wastes at CMH, Rawalpindi.
All sanitary workers employed at Combined Military Hospital (CMH), Rawalpindi
* All full time sanitary workers.
* Female Ayas working in the Family Wing of CMH, Rwp
* Temporary and part-time workers.
76 sanitary workers are employed at CMH Rwp. Among them 66 are male and 10 are female. 17 Ayas also work at this hospital and are involved in various housekeeping activities (male: female ratio=2.4:1). Therefore, they were also included. The entire study population was studied. No, sampling procedures were used.
A mixed open and closed-ended, structured questionnaire was developed for assessing the level of awareness and exposure.
Data was collected by personal interviews and entered into a computer database using SPSS ver 10.
Data collected through interviews was analyzed using SPSS programme ver 10.0.
Through the analysis of data, following results were obtained:
Mean age of respondents was 31.84 + 8.46 years (Fig-1).
70.37% of female respondents were illiterate; remainder 29.62% had primary education. Among the males, 36.36% were illiterate, 57.57% had primary education; 6.06% had secondary education. Overall illiteracy was found to be 46.24% (n = 93). (Fig.2)
Training/instruction in Handling of Hospital Wastes
None of the respondents had received any formal training in handling of hospital wastes.
Regular Medical Inspections
100% of the respondents replied in the negative.
Hepatitis B Vaccination
None of the sanitary workers was vaccinated against Hepatitis B.
History of Illnesses
8 of the respondents reported as suffering from Hepatitis (8%).
Family History of Illnesses
None of the 8 persons reported as having Hepatitis had a family member suffering from Hepatitis.
Provision / Use of Protective Equipment
10% of the sanitary workers said that they were provided with protective equipment; 90% said no protective equipment was provided to them.
Washing / Cleaning of Equipment
74% of the subjects regularly washed/cleaned their equipment; 26% did so occasionally.
Washing of Hands before Eating / Drinking at Work
100% of subjects gave a positive response
Identification / differentiation between Hazardous and Non-Hazardous Wastes
Only 3 (3.22%) subjects said that they couldn’t differentiate between hazardous and non-hazardous wastes.
Segregation of Wastes
100% of the subjects reported that wastes are segregated into colour coded hazardous and non-hazardous wastes’ containers in their hospital.
Separate Collection of Hazardous and Non-Hazardous Wastes
86% of the subjects said that they collect hazardous wastes separately from non-hazardous wastes. 14% said that the two kinds of wastes are collected in the same container.
Separate Carriage of Hazardous and Non-hazardous Wastes
44% of the subjects carried hazardous wastes separately from non-hazardous wastes whereas 56% carried both kinds of wastes in the same container or wheelbarrow.
Collection / Carriage in Closed Containers
76% of the subjects collected and carried the wastes in closed containers. 24% carried the wastes in open trolleys or wheelbarrows.
Frequency of Washing Buckets / Wheelbarrows
100% of the subjects reported daily washing of buckets and wheelbarrows.
Method of Washing Buckets / Wheelbarrows
60% of the subjects washed their buckets with antiseptic solution, 38% with detergents and 2% with water only.
Use of Waste Baskets / Wheelbarrows in Other Tasks
100% of the subjects replied in the negative.
History of Injury from Wastes in Past 1 Year
48% of respondents had received an injury from handling of hospital wastes on one or more occasions, whereas 52% had never received any injury.
Nature of Injury
47% of the workers had received cuts from sharp objects such as blades, broken vials etc., 34% had received pricks from sharps, 15% had fallen on floors or stairs while carrying heavy loads of wastes and 4% had received burns from various chemicals. (Fig.3)
Diseases Contracted from Wastes
26% had contracted a skin condition from handling hospital wastes; 9% reportesd gastro intestinal tract disorders; 12% reported ENT disorders; 6% reported symptoms of respiratory conditions; 4% had experienced eye complaints; 8% had hepatitis and 35% did not report any health condition contracted from handling wastes. (Fig.4)
Opinion about Hazardous Nature of Hospital Wastes
72% of the subjects considered hospital wastes more hazardous than ordinary domestic waste, whereas 28% did not think so.
Opinion about Hazard of Catching Disease from Hospital Wastes
92% believed that they might contract a dangerous disease from handing hospital wastes. 7.5% did not think so.
Low literacy is the main reason for poor perception of sanitary workers towards the hazards of hospital wastes. Majority of them, (89%) are either illiterate or attended primary school.
Hospital sanitary workers never received a formal professional training in handling of hospital wastes. Majority of them received some form of instruction from their supervisors or seniors, who were themselves untrained. There is a dire need to develop training programmes for handling and management of hospital wastes for all medical professionals in general, and for all sanitary workers in particular. Training in the use of universal precautions can substantially reduce the risks to them.
Although sanitary workers are engaged in a hazardous activity that exposes them to biological, physical and toxic wastes of all sorts, there is no routine of their medical inspections as is practiced for all soldiers in the Army.
Although they receive cuts, pricks and abrasions on a daily basis, sanitary workers are not offered routine vaccination against Hepatitis B. HIV, Hepatitis B and C are some of the deadly hazards they are exposed to. This is a risk not only to them but also to their family members.
Provision and Use of Protective Equipment
Although 10% of sanitary workers reported issue and use of protective equipment, the equipment they revealed on detailed inquiry offers virtually no protection. The minimum requirement is of coveralls or dungarees, waterproof long boots, heavy industrial gloves and facemasks. To this list goggles may also be included to avoid the risk of splashes into the eyes. But the equipment our subjects were using consisted of ordinary leather or canvas shoes and occasionally gloves of thin polythene. These gloves can not protect the wearer from cuts, pricks or even abrasions.
All the workers had a good attitude regarding personal hygiene and washed their hands before eating or drinking. However, there is a need to provide them with adequate washing and toilet facilities.
Segregation of Wastes
At CMH Rwp, segregation of hazardous and non-hazardous wastes is generally practiced. Non-risk waste and garbage are collected in blue or green buckets with lids and hazardous wastes are collected in red buckets. Hypodermic needles are cut and collected in small needle cutting containers of hard plastic. But, what is lacking is the proper understanding and training among the actual producers of hazardous wastes; namely nurses, nursing assistants and doctors. They do not understand the implications of carelessly mixing the hazardous and non-hazardous waste streams. Another problem is that the buckets provided for collection of wastes in wards, nursing stations, operating rooms etc. are ordinary buckets and were not designed for collection or transport of hazardous wastes. So their lifting and carriage is not without hazards. 56% of the workers do not carry the two kinds of wastes separately. They just empty the buckets or bins containing infectious wastes into open wheelbarrows, mixing both waste streams and carry them to the dump.
Washing of Waste Containers and Equipment
As per instructions from the medical directorate, waste bins and wheelbarrows used for transporting wastes must be washed with antiseptic solutions after each collection round. But 100% of the respondents reported that these items are washed once daily. Again 60% of them washed these items with antiseptic solutions while 38% washed with detergents and some with water only.
Work Related Injuries and Illnesses
48% of sanitary workers reported of receiving injuries at work. Identical results were also reported in a study  done at Alice Hamilton Occupational Health Center, Washington, DC, USA, in which incidence rate of injuries among medical laboratory staff housekeeping staff was found 46 injuries per 100 housekeepers per year. Cuts and pricks were the most frequent injuries. These findings are comparable to survey carried out by Sarrie C. et al8 in which 65% of housekeepers indicated that they do not always report their injuries. However majority of them just wash their injuries with water and do not even bother to report their injuries. This observation highlights the importance of training and increasing the level of awareness among sanitary workers regarding the risks posed by seemingly minor injuries.
26% of the workers reported contracting skin conditions, such as blisters, rashes, itching etc. from wastes. Others reported gastrointestinal (9%), respiratory (6%), and hepatitis (8%) symptoms. These findings are comparable to those of Akter N. et al . But 35% did not believe that they had ever received any disease from their work. This prevalence is much lower than expected because almost all of them are working with virtually no protection at all. It is possible that majority of subjects did not report their health problem out of embarrassment or fear of disciplinary action against them.
Perception of hazard
Although 28% of the sanitary workers consider hospital waste no more hazardous than ordinary domestic wastes, majority of them (92.5%) believed that they were at risk and could catch a dangerous disease from handling hospital waste. This observation can be understood in the light of their socio-demographic profile. Majority of them are either illiterate or poorly educated. They were never trained nor instructed regarding the hazardous nature of their jobs. They are not provided with protective equipment or vaccination to protect their health. So many of them believe that their job is not different from ordinary municipal sanitary workers.
Limitation of Study
Since these workers were not tested in the laboratory for Hepatitis B, C and HIV due to financial problems, therefore, actual prevalence of these infections could not found out. It is recommended that further study including Hepatitis B, C and HIV testing of sanitary workers should be carried out to know the actual prevalence of these diseases in sanitary workers of Combined Military Hospital (CMH) Rawalpindi.
This study has revealed that sanitary workers of CMH Rwp are not aware of risks and hazards associated with handling of hospital wastes. They are exposed to biological, physical and toxic hazardous substances on daily basis. They perform one of the most important functions in the smooth operation of any healthcare facility. But they have to perform this hazardous activity without the required knowledge, training or protective measures to protect themselves.
There is a dire need to improve upon the training and education of all the hospital housekeeping staff, so that the persons most exposed to the hazards of contracting diseases from hospital wastes are made aware in procedures of handling the hazardous wastes and protecting their own health.
1. All sanitary workers should receive a basic training in handling of hospital wastes at the time of their enrolment / employment.
2. There should be regular refresher courses/cadres and hands on training for sanitary workers.
3. All hospital staff especially nurses and nursing assistants must be trained and instructed in the principles of hospital waste management.
4. There should be a programme of thorough medical inspection of all sanitary workers at regular intervals.
5. Sanitary workers should be provided with protective equipment. This must include aprons or dungarees, facemasks, heavy industrial gloves and waterproof long boots.
6. The quality and design of waste bins and trolleys used for internal transport of infectious wastes needs to be improved.
7. Adequate washing and toilet facilities should be provided for all workers on hospital premises.
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