Bio Medical Waste Management & Hygiene In Healthcare Environment

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

HYGIENE AND BIOMEDICAL WASTE MANAGEMENT PLAN FOR HEALTHCARE ENVIRONMENTAL SETTING: A STUDY WITH SPECIAL FOCUS ON KERALA, INDIA

Research report prepared for

Hygiene Standard Institute by

SREEJITH A.

HSI-ASIA Email: info@ internationalhygiene.org www.internationalhygiene.org

Trivandrum 2008

1 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

CONTENTS

LIST OF TABLES LIST OF FIGURES LIST OF APPENDICES

Chapter

Title

1

INTRODUCTION

2

REVIEW OF RELATED LITERATURE

3

METHODOLOGY

4

RESULTS AND ANALYSIS

5

CONCLUSIONS AND SUGGESTIONS

Page No.

BIBLIOGRAPHY APPENDICES ACKNOWLEDGEMENTS

2 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

LIST OF TABLES Table No.

Page Title No.

2.1

Colour coding and type of container for disposal of biomedical wastes

2.2

Colour coding system – segregation

2.3

Categories of biomedical waste

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Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

LIST OF FIGURES Figure No. 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.12 4.13 4.14 4.15 4.16

Title

Page No.

Male to Female Ratio of respondents Distribution of different age group of respondents Years of working of the respondents Percentages of occurrences of accidents related to clinical wastes Distribution of scope of work of respondents Awareness towards the definition of biomedical waste Awareness towards the handling of accidents related to biomedical waste Response to the adherence of management to standard procedures Awareness of the risk exposed to the respondents themselves Awareness of the risk exposed to others Familiarity of the respondents towards the management plan Ability of the respondents to identify types of biomedical wastes Ability of respondents to segregate, contain and label the biomedical waste Awareness of the respondents towards the storage facility Awareness of the respondents to record keeping Awareness of the effects of clinical wastes to the environment

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Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

LIST OF APPENDICES Appendix No.

Title

I

Survey form

II

Questionnaire form

III

Photographs

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Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

ABSTRACT Issues of improving the management of biomedical wastes are receiving increasing attention throughout the world since healthcare institutions generate tons of biomedical waste each year. The waste generated has been increasing due to the use of disposable materials and development in medicine production. Hazardous and Toxic Materials (HTM) Office Board of Public Works, Los Angles (1995) estimated that around 15 percent of hospital waste is contaminated with infectious agents potentially hazardous

to

human

health

such

as

hepatitis

and

human

immunodeficiency virus (HIV) and to the environment. As these changes have been gradual and waste disposal was not previously perceived as a major concern, the response of the hospital field has been largely piecemeal and uncoordinated. Not only solid waste is considered as a major problem in many developing countries but other wastes such as wastewater and air pollution are also becoming serious problems. Due to the lack of investment and infrastructure, in some cases, wastewater discharged from hospitals often runs directly into nearby water bodies. Improperly discharged wastes to sewers will generate wastewater potentially dangerous to handlers. Moreover, most hospital incinerators were never designed for the disposal of large quantities of waste and consequently have become overloaded, causing air pollution in 6 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

surrounding areas. Poor waste management practices pose a huge risk to the health of the public, patients, professionals and contribute to environmental degradation In the present study an attempt is made to determine awareness about Biomedical waste management policy, practices and to assess attitude towards it and to develop a Hygiene & Biomedical Waste Management Plan for Healthcare Environmental Setting with special focus to Kerala State in the Indian union. Review of the literature and studies which are related to the topic under study was done on studies related to the problems specific to the impaired healthcare waste management as well as studies related to hygiene and biomedical waste management in healthcare environmental setting. The method adopted for the present study was survey method. The data collection was done through survey form, questionnaire, informal interviews and site visits by the investigator. The collected data were statistically analysed. From the analysis of the collected data, it was found that the management components are well in place. However there are some fields that need attention such as record keeping. The awareness towards the effects of biomedical wastes on environment if improperly handled is strong. During the site visits, photo documentation was done on various aspects

7 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

of biomedical waste management methods followed by healthcare institutions. These photographs revealed that unscientific biomedical waste management techniques are followed at various levels of segregation, treatment, transport and disposal. The present study developed a hygiene and biomedical management plan for effective infection control as well as for proper record maintenance of hospitals in Kerala. The study concludes that the biomedical waste management practices followed in majority of healthcare institutions in Kerala is unscientific. However, there are a smaller minority of healthcare institutions which practice the most sound biomedical waste management methods. Training and awareness programmes are lacking in many of the cases which needs to be looked into. A further study on this topic is suggested on the incineration and the air pollution control measures to avoid the contamination from the incinerator from being exposed to the environment. A study on the awareness of the public towards the biomedical waste management also can be carried out. The awareness level may vary from person to person depending on the education background. Further study can be carried out to compare the management system of a government hospital and private hospital.

8 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

Chapter 1 INTRODUCTION 1.1 INTRODUCTION Over the years there have been tremendous advancements in the health care system. However it is ironic that the health care settings, which restore and maintain community health, are also threatening their well-being. Poor waste management practices pose a huge risk to the health of the public, patients, professionals and contribute to environmental degradation (Joseph and Krishnan 2004). It is reported that for the first time the Biomedical waste management issue was discussed at a meeting convened by the World Health Organisation regional office for Europe at Bergen, Norway in 1983. The seriousness of the issue was brought to limelight during the “beach wash- ups” of summer 1988. Investigation carried out by the Environment Protection Agency (EPA) of USA in this regard culminated in the passing of Medical Waste Tracking Act (MWTA), November 1988. With the passage of time the problem has evolved as a global humanitarian issue. In our country, this issue has attracted the attention of the Honourable Supreme Court of India and guidelines has been issued .The Biomedical waste (Management and handling) Rules 1998 lay

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Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

down clear methods for disposal of biomedical waste, defined as “any waste generated during the diagnosis, treatment or immunisation of human beings or animals or in research activities used in the production or testing of biologicals.” Pollution control boards of every state have been given the task of authorising and implementing the rules. Issues of improving the management of hospital wastes are receiving increasing attention throughout the world since hospitals generate tons of medical waste each year. The waste generated has been increasing due to the use of disposable materials and development in medicine production. Hazardous and Toxic Materials (HTM) Office Board of Public Works, Los Angles (1995) estimated that around 15 percent of hospital waste is contaminated with infectious agents potentially hazardous

to

human

health

such

as

hepatitis

and

human

immunodeficiency virus (HIV) and to the environment. As these changes have been gradual and waste disposal was not previously perceived as a major concern, the response of the hospital field has been largely piecemeal and uncoordinated (Wangsaatmaja S., 1997). Not only solid waste is considered as a major problem in many developing countries but other wastes such as wastewater and air pollution are also becoming serious problems. Due to the lack of

10 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

investment and infrastructure, in some cases, wastewater discharged from hospitals often runs directly into nearby water bodies (Nelson et al., 1993). Improperly discharged wastes to sewers will generate wastewater potentially dangerous to handlers. Moreover, most hospital incinerators were never designed for the disposal of large quantities of waste and consequently have become overloaded, causing air pollution in surrounding areas. In the present study an attempt is made to determine awareness about Biomedical waste management policy, practices and to assess attitude towards it and to develop a Hygiene & Biomedical Waste Management Plan for Healthcare Environmental Setting with special focus to Kerala State in the Indian union.

1.2 NEED AND SIGNIFICANCE Treatment and disposal of biomedical wastes generated from hospitals should be done as per the Biomedical Waste (Management and Handling) Rules, 1998. It is the responsibility of waste generator to treat and dispose of the biomedical waste. Whereas local governments have to assist the hospitals, if they come forward for establishment of a Common Treatment Facility, by identifying suitable land, it is the responsibility of the local bodies to treat and dispose the non

11 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

biomedical waste (general waste) and treated biomedical waste generated in the healthcare institutions. The Kerala State Pollution Control Board (PCB) is the prescribed authority to implement Biomedical Waste (Management and Handling) Rules in the state. As per 1991 Census, Kerala has the highest number of hospitals (26%) in India. The Report on Private Medical Institutions in Kerala published by the Department of Economics and Statistics (1995) shows that there are about 12618 private medical institutions for all systems of medicines combined and it is roughly estimated that the solid and liquid waste generation per hospital bed is 1.3 to 2.0 kg and 450 litres respectively. About 85% waste generated in hospitals is general waste and can be handled as other solid wastes. The remaining 15% constitutes infectious and toxic wastes. More often than not, the general wastes in hospitals and biomedical wastes are allowed to mix thereby rendering the general waste also toxic and hazardous. (Economic Review, Kerala, 2004). 1.2.1 Current Issues in Management of Health Care Waste There are two main issues at present: •

The 1998 legislation by the Govt. of India and

•

Implementation

of

the

same

at

individual

healthcare

establishment level as well as whole town / city level.

12 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

The legislation has fulfilled a long standing necessity. Now this sector has got clear cut guidelines which should be able to initiate a uniform standard of practice through out the country. It would be necessary to implement proper biomedical waste management system for each and every hospital, nursing home, pathological laboratory etc. Comprehensive management system for each and every health care establishment has to be planned for optimal techno-economic viability. At the same time the final disposal for the whole town must not be lost sight of. Since there are a large number of small and medium health care establishments, common treatment and disposal facilities are essential. 1.2.2 Legal Aspects and Environmental Concern Indiscriminate disposal of infected and hazardous waste from hospitals, nursing homes and pathological laboratories has led to significant degradation of the environment, leading to spread of diseases and putting the people to great risk from certain highly contagious and transmission prone disease vectors. This has given rise to considerable environmental concern. The first standard on the subject to be brought out in India was by the Bureau of Indian Standards (BIS), IS 12625 : 1989, entitled ‘Solid Wastes-Hospitals-Guidelines for Management’ but it was unable to

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Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

bring any improvement in the situation. In this scenario, the present study assumes great significance. 1.2.3 Biomedical Waste (Management and Handling) Rules, 1998 The Central Govt. has notified these rules on 20th July, 1998 in exercise of section 6, 8 and 25 of the Environment (Protection) Act, 1986. Prior to that, the draft rules were gazetted on 16th October, 1997 and Public suggestion/comments were invited within 60 days. These suggestions were considered before finalising the rules. 1.2.4 Scope and application of the Rules These rules apply to all those who generate, collect, receive, store, transport, treat, dispose or handle biomedical waste in any form. According to these rules, it shall be the duty of every occupier of an institution generating biomedical waste, which includes hospitals, nursing homes, clinics, dispensaries, veterinary institution, animal houses, pathology laboratories, blood banks etc., to take all steps to ensure that such wastes are handled without any adverse effect to human health and the environment. They have to either set up their own facility within the time frame or ensure requisite treatment at a common waste treatment facility or any other waste treatment facility. Every occupier of an institution, which is generating, collecting, receiving, storing, transporting, treating, disposing and/or handling

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Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

biomedical waste in any other manner, except such occupier of clinics, dispensaries, pathological laboratories, blood banks etc., which provide treatment/service to less than 1000 (one thousand) patients per month shall make an application in prescribed form to the prescribed authority for grant of authorisation to carry on the work. Whenever an accident occurs concerning biomedical waste, it has to be reported to this authority. Each State and Union Territory (UT) Government shall be required to establish a prescribed authority for this purpose. The respective governments would also constitute advisory committees to advise the Governments with respect to implementation of these rules. The occupier or operator can also appeal against any order of the authority if they feel aggrieved to such other authority as the Govt. of the State/UT may think fit to constitute. 1.2.5 Environmental Concern The following are the main environmental concerns with respect to improper disposal of biomedical waste management: •

Spread of infection and disease through vectors (fly, mosquito, insects etc.) which affect the in -house as well as surrounding population.

15 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

•

Spread

of

infection

through

contact/injury

among

medical/non-medical personnel and sweepers/rag pickers, especially from the sharps (needles, blades etc.). •

Spread of infection through unauthorised recycling of disposable items such as hypodermic needles, tubes, blades, bottles etc.

•

Reaction due to use of discarded medicines.

•

Toxic emissions from defective/inefficient incinerators.

•

Indiscriminate disposal of incinerator ash / residues.

1.2.6 Healthcare Associated Infection According to Wenzel R.P. (1997), management of health-care waste is an integral part of hospital hygiene and infection control. Health-care waste

should

be

considered

as

a

reservoir

of

pathogenic

microorganisms, which can cause contamination and give rise to infection. If waste is inadequately managed, these microorganisms can be transmitted by direct contact, in the air, or by a variety of vectors. Infectious waste contributes in this way to the risk of nosocomial infections, putting the health of hospital personnel and patients, at risk. Healthcare associated infections (HCAIs) are preventable. As per the findings of Hygiene Standard Institute (2007) improved compliance to hygiene has been shown to reduce the number of infection outbreaks in

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Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

health care facilities, transmission of antimicrobial resistant organisms (e.g. Methicillin-resistant Staphylococcus aureus (MRSA)) and overall infection rates. Despite evidence of the benefit of hygiene, health care workers’ compliance with good hand hygiene remains universally low40 percent to 50 percent (Hygiene Standard Institute, 2007). Reasons for low compliance rates are complex and can be attributed to the existence of numerous individual, work group and institutional barriers, which makes it difficult to enhance and sustain compliance. As a result of these barriers, few projects have demonstrated sustained improvement in compliance with hand hygiene guidelines and a reduction in HCAIs rates. 1.3 STATEMENT OF THE PROBLEM The study is entitled ‘HYGIENE AND BIOMEDICAL WASTE MANAGEMENT PLAN FOR HEALTHCARE ENVIRONMENTAL SETTING: A STUDY WITH SPECIAL FOCUS ON KERALA, INDIA’. 1.4 DEFINITION OF KEY TERMS ‘Hygiene’ can generally refer to a whole range of measures, which protect health and well-being and improve the quality of life. Hygiene refers to practices associated with ensuring good health and cleanliness. In broader, scientific terms hygiene is the maintenance of health and healthy living. Hygiene ranges from personal hygiene,

17 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

through domestic up to occupational hygiene and public health (Hygiene Standard Institute, 2007). ‘Biomedical waste’ means any solid and/or liquid waste including its container and any intermediate product, which is generated during the diagnosis, treatment or immunisation of human beings or animals or in research pertaining thereto or in the production or testing thereof. (Biomedical Waste (Management and Handling) Rules, 1998). 1.5 HYPOTHESES 1. Only a very few healthcare personnel have proper awareness regarding Biomedical waste management policy and practices. 2. Healthcare personnel will show positive attitude towards biomedical waste management policy and practices. 3. The development and implementation of a Hygiene & Biomedical

Waste

Management

Plan

for

Healthcare

Environmental Setting will reduce the rate of spread of healthcare associated infections. 1.6 OBJECTIVES 1. To determine the awareness of healthcare personnel regarding Biomedical waste management policy and practices. 2. To assess attitude towards biomedical waste management policy and practices.

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Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

3. To develop a Hygiene & Biomedical Waste Management Plan for Healthcare Environmental Setting with special focus to Kerala State in the Indian union. 1.7 METHODOLOGY IN BRIEF An anonymous survey form and questionnaire (Appendix I and II) were developed after literature search and review. The survey form and questionnaire were designed to suite six categories of personnel associated with health care settings, i.e Doctors, House surgeons, Students (Final year), Nurses, Paramedical and Auxiliary Staff. Pilot survey was carried out by distributing the survey form and questionnaire to fifty personnel from all the six categories. Validity and reliability were ascertained. The period of study was from August 2007 to February 2008. The pretested anonymous survey form and questionnaire were distributed to personnel from all the above six categories in Kerala. Informal consultations with healthcare personnel were also done. Health care settings covered included Medical college hospitals, Dental college hospitals, General hospitals, Private hospitals, Community health centres, Primary health centres, Laboratories, Dental clinics and Veterinary hospital. The respondents were asked to indicate their views on biomedical waste management policy, practices and their

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Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

attitude related to the issue. Opportunity was also given to give details regarding certain questions asked. To document biomedical waste management practices, photographs were taken. All data management and analysis were carried out using Microsoft Excel. 1.7.1 Method adopted The normative survey method was adopted for the study, as it was found to be the most appropriate method for collecting data. 1.7.2 Sample selected for the study For the present study, a representative sample from 20 healthcare institutions of Kerala state was selected. The sample size was 488 which included 198 males and 290 females. The mean age of the sample was 35. Health care settings covered included one medical college hospital, one dental college hospital, two private hospitals, two community health centers, three primary health centers, five laboratories, five dental clinics and a veterinary hospital. 1.7.3 Tools used for the study The data for the present study were collected using the Survey form and Questionnaire on hygiene and biomedical waste management prepared by the investigator. 1.7.4 Statistical technique used for the study

20 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

The statistical technique used for the analysis of the collected data was Estimation of simple percentage. 1.8 SCOPE OF THE STUDY The present study attempts to determine awareness of healthcare personnel towards Biomedical waste management policy and practices and to assess their attitude towards it. The study also tries to develop a Hygiene & Biomedical Waste Management Plan for Healthcare Environmental Setting with special focus to Kerala. A representative sample of 488 healthcare personnel from 20 healthcare institutions of Kerala state was selected for the study. The study will be useful in assessing the awareness level and attitude of healthcare personnel towards biomedical waste management policy and practices and in providing training programmes for improving the same. The study will also help in developing a Hygiene and biomedical waste management plan which in turn will help in reducing the spread of healthcare associated infections. 1.9 LIMITATIONS OF THE STUDY Despite the efforts made by the investigator to make the study as precise and objective as possible, certain limitations have crept into the study and the investigator was able to identify them.

21 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

1. The study was conducted on a sample selected from healthcare institutions

of

three

districts

of

Kerala

viz.,

Thiruvananthapuram, Idukki and Kozhikode. Extending the study to other districts in Kerala was not possible due to the limited time at the disposal of the investigator. More generalised results would have been obtained from the study if a large sample from more districts was used. 2. The study concentrated on issues related to biomedical waste management only. The study can be further expanded by focusing on issues related to Hygiene, Environment, Sanitation, Safety and Health.

1.10 FORMAT OF THE REPORT The study is reported in five chapters, the following being the details. Chapter 1: INTRODUCTION This chapter contains all the relevant sectors and details pertinent to the area under investigation. Chapter 2: REVIEW OF RELATED LITERATURE Presents the review of related literature and studies pertaining to the study undertaken.

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Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

Chapter 3: METHODOLOGY Gives a detailed description of the method adopted for the study, tools used for the study, the sample taken, administration of the tools and an account of the statistical techniques used for analysing the data obtained from the study. Chapter 4: RESULTS AND ANALYSIS Concerned with the analysis of the data followed by the results of the study. Chapter 5: CONCLUSIONS AND SUGGESTIONS Summarises the study in retrospect. The important findings and a few recommendations for further research are presented.

The report is followed by Bibliography and Appendices pertaining to the study.

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Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

BIBLIOGRAPHY 1. Anthony, L. (2006). Potential risks and hazards of not implementing a proper clinical waste management system. Waste Management Conference and Exhibition, 2006. 2. Barr, D. (1960). Encyclopaedia of Educational Research. New York: Mac Millan Company. 3.

Bdour, B. Altrabsheh, Hadadin, N. and Al-Shareif, M. (2006). Assessment of medical waste management processes: A case study of the northern part of Jordan. Waste Management.

4. Best, J. W. (1950). Research in Education. New Jersey: Prentice Hall Inc. 5. Best, J. W. and Kahn, J. V. (1996). Research in Education (7th edition). New Delhi: Prentice Hall of India Pvt. Ltd. 6. Blenkharn, J. I. (2005). Medical waste management in the south of Brazil. Waste Management. 7. Collins, C. H. (1991). Treatment and disposal of clinical and laboratory waste. Medical Laboratory Sciences. 8. Economic Review, Kerala 2005.

24 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

9. Hazardous and Toxic Materials (HTM) Office Board of Public Works,

Los Angeles,

1995,

Fact

Sheet:

Medical Waste

Management, Enviro Search, Los Angeles, USA. 10. Hillway, T. (1969). Research Design- Handbook of Educational Research. 11. Hygiene

Boston: Houghton-Mifflin Company. Standard

Institute

(HSI)

(2007).

http://www.internationalhygiene.org/ 12. Ibrahim, Z. B. (2005). Management and Disposal of Clinical Waste (Case Study: Hospital Kebangasaan Malaysia). Universiti Teknologi Malaysia. 13. Joseph, J. and Krishnan, A., (2004). Hospital waste management in the

union

territory

of

Pondicherry-

An

exploration.

www.pon.nic.in/citizen/science/ppcc-new/joe.pdf 14. Lavelle, P. (1998). How Hazardous Is Hospital Waste? World Wastes. 15. Martin, C. (2006). Best Management Practices for Hospital Wastes. Hospital and Clinical Wastes Reduction and Management Conference.

25 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

16. Ministry of Environment & Forests, GOI. (1998). Biomedical waste laws

and

regulations.

http://envfor.nic.in/legis/hsm/biomed.html 17. Mouly, G. J. (1963). The Science of Educational Research. New Delhi: Eurasia Publishing House. 18. Nelson, D., Chistie, K., Snelling, J., and Scott, P., (1993). Trends in Medical Waste Management in Asia, Enviro Search International Inc., Utah, USA. 19. Office of Solid Waste RCRA Hazardous Waste (2004). e-Manifest Roadmap conference proceedings. US Environmental Protection Agency. 20. Reinhardt, P. A. and Gordon, J. G. (1991). Infectious and Medical Waste Management. Lewis Publishers. 21. Tsakona, M., Anagnostopoulou, E. and Gidarakos, E. (2006). Hospital waste management and toxicity evaluation: A case study. Waste Management. 22. Turkman, B. W. (1978). Conducting Educational Research (2nd edition). New York: Harcourt Brace Jovanovich Inc. 23. Turnberg, W. L. (1996). Biohazardous Waste: Risk Assessment, Policy, and Management. John Wiley & Sons Inc. 26 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]

Suggested citation for future researches Sreejith A., (2008), Hygiene and Biomedical Waste Management Plan for Healthcare Environmental Setting: A Study with Special Focus on Kerala, India. Hygiene Standard Institute (HSI), Trivandrum, India.

24. U.S. Environmental Protection Agency (1991). Medical Waste Management and Disposal. Noyes Data Corporation. 25. Walker, R. (1989). Doing Research- A Handbook for Teachers. Great Britain: Cambridge University Press. 26. Wangsaatmaja, S. (1997). Environmental action plan for a hospital. Thesis submitted for the degree of Master of Engineering at Asian Institute of Technology School of Environment, Resources and Development Bangkok, Thailand. 27. Wenzel, R. P. (1997). Prevention and control of nosocomial infections, 3rd ed. Baltimore, MD, Williams & Wilkins.

27 © Sreejith A., Environmental Policy Researcher, Trivandrum, Kerala, India. Tel: +91-9447583751, Email:[email protected]