Health Care Waste Management of Funeral Homes in Cebu City - RRL
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Transcript of Health Care Waste Management of Funeral Homes in Cebu City - RRL
Chapter 3
THEORETICAL BACKGROUND
Review of Related Literature
From the days of primitive society, humans have made use of the earth’s
resources to sustain life and to dispose of wastes. In those times, waste disposal did not
pose significant problems because human populace was considerably smaller and more
land was available for the assimilation of wastes. The problems associated with the
disposal of wastes started with the growth of population and influx of human settlements
and industries. The accumulation of wastes became an inadvertent consequence of life,
making waste management form a rapidly growing area of interest. One type of waste is
the less known and less generated but more closely regulated waste called health care
waste. These wastes are those that are generated by health care providers which include
those of the subject of this particular study, the funeral establishments. These wastes are
different from those commonly produced by households and other establishments in that
they pose potential environmental and health hazards if not properly treated, stored,
disposed of or otherwise managed appropriately. This chapter presents the literature and
related studies, both local and foreign, which have direct bearing on the study of the
health care waste management of funeral establishments in Cebu City. This review
includes the definition and classification of both funeral establishments and health care
wastes. It also includes the laws and regulations governing funeral establishments and
their waste management, especially that of health care wastes, their recommended waste
management process and the risks associated with these health care wastes.
As it is quite evident today, waste management has indeed become one of the
most discussed topics, other than that of climate change and poverty. Yet as it began to
encompass a broader array of topics, the very definition itself of waste management has
become quite ambiguous. But even if waste management is a relatively new
phenomenon, it has caught the attention of governments all over the globe and today the
term waste management covers collecting, sorting, processing, recycling and reusing
materials that would otherwise be considered useless (Arshad et al, 2011).
Medical or health care wastes are in the form of solid and liquid wastes generated
in the diagnosis, treatment or immunization of human beings or animals; in medical
research; or in production of vaccines or other substances produced from living
organisms and are commonly generated by hospitals, medical or research laboratories,
clinics, veterinarians, long term-care facilities and funeral homes (Soncuya et al, 1997).
However, there is no single definition of medical waste, and thus, the terms medical
waste, hospital waste, and infectious waste have often been used interchangeably
(Akbolat et al, 2011). That is why, throughout this study, the terms medical waste, health
care waste, clinical waste and hospital waste are presumed to represent one and the same.
The World Health Organization reports that from the total of wastes generated by
health care activities, almost 80% are general waste, which are comparable to domestic
waste while the remaining 20% are considered hazardous materials, the infectious and
anatomic wastes together represent the majority or 15 % of the hazardous waste,
chemicals and pharmaceuticals amount to about 3% and sharps represent about 1% of the
total waste from health care activities (www.who.int). Lack of awareness about the
health hazards related to health care waste, inadequate training in proper waste
management, absence of waste management and disposal systems, insufficient financial
and human resources and the low priority given to the topic are the most common
problems connected with health care waste and also, many countries either do not have
appropriate regulations, or do not enforce them which makes the clear attribution of
responsibility for the handling and disposal of waste an essential issue (www.who.int). In
the Philippines, the potential hazards that health care wastes may bring about is not quite
recognized by the general public. There is still somewhat a need for them to be more
aware of the proper management of these types of wastes and also the laws and
regulations that govern their appropriate handling. There is also a need for intervention
strategies relating to the health effects of medical waste which should include continual
education and training in proper medical waste management especially to persons that are
frequently in contact with medical waste (Turnberg, 1996). As these wastes pose
significant risks, those who are involved in any process of waste management should
have appropriate knowledge and sufficient training which management should ensure and
monitor regularly.
A study by Patwary and Sarker (2012) concluded that detailed analysis of the make-
up and sources of waste from mortuaries have shown that a major proportion is initially
hazardous, and total waste becomes hazardous due to mixing with this hazardous waste
thus making all of the waste produced by the mortuaries considered hazardous. Improper
management or mishandling of these health care wastes may also lead to adverse
environmental concerns. There was even a case wherein a local mortuary inadvertently
dumped hazardous waste in barangay Maghaway, Talisay City including waste such as
life jackets, used surgical gloves, masks and cadaver bags used in wrapping the bodies of
cadavers from the sunken M/V Princess of the Stars evoking the awareness that although
the stench is not as dangerous as it is thought to be, the fluids from the material might
reach sources of drinking water or the waste could be dragged by stray dogs to populated
areas which may cause great harm (Melecio, 2008). As the proper management of the
potentially hazardous waste was not adhered to, the incident became a serious concern
especially to the residents of the area who are the most affected by any adverse
consequences. This solidifies the concept why health care waste generators, including
funeral establishments, should ensure proper waste management continually.
Funeral establishments include funeral parlors, funeral chapels, and any similar
place used in the preparation, storage and care of the body of a deceased person for burial
or cremation whose services include embalming and viewing/wake services, cremation,
casket-making, casket-selling and the provision of a chapel for the funeral
(www.doh.gov.ph). Other establishments that may fall in the group are mortuaries,
autopsy centers, crematories and morgues.
Section 93 of P. D. No. 856 classifies these establishments as follows:
Category I- establishments with chapels, and embalming facilities and
offering funeral services.
Category II- establishments with chapels and offering funeral services but
without embalming facilities; and
Category III- establishments offering only funeral services from the house
of the deceased to the burial ground.
Funeral establishments are required to comply with pertinent laws and regulations
on waste management. One of these laws is the Code on Sanitation of the Philippines of
1975 or P.D. No. 856 which regulates the establishment of all trades and occupations,
institutions, commercial undertaking, refuse disposal system, sewage collection and
disposal system, etc. including funeral establishments, in accordance with prescribed
guidelines and standards promoting environmental sanitation hygiene (www.doh.gov.ph).
Though this law may apply to virtually all industries, funeral establishments are of
particular concern since they deal with wastes that give rise to morbid attention from the
public like those of blood, body fluids, organs and cadavers. Specifically, Chapter XXI-
“Disposal of Dead Persons” of P.D. No. 856, applies to all crematories, funeral and
embalming establishments, medical and research institutions, undertakers, embalmers,
public and private burial grounds and other similar institutions. It also provides some
rules and regulations on these establishments like the fact that no funeral parlors,
embalming establishments and morgues shall be operated without a sanitary permit
(www.doh.gov.ph). However, it is important to note that this permit shall be issued only
upon compliance with the sanitary rules and regulations. This sanitary permit is
particularly important as mortuary and autopsy centers, funeral establishments are health
care providers and as such, one of the sources of medical or health care waste other than
health care facilities, institutions, business establishments and other similar health care
services (pcij.org). This permit not only serves as verification that the establishment has
complied with the code, it also serves as an assurance to the public, especially its
customers, that they observe cleanliness and promote health and wellness.
Another pertinent law is the Philippine Environmental Code of 1977 or P.D. No.
1152 which is a comprehensive program of environmental protection and management
that serves as a basis for an integrated waste management regulation starting from waste
source to the different methods of disposal. P.D. No. 1152 has further mandated specific
guidelines to manage municipal wastes, sanitary landfill and incineration, and disposal
sites in the Philippines (www.doe.gov.ph). The Ecological Solid Waste Management Act
of 2000 or R.A. No. 9003 also ensures the proper segregation, collection, transport,
storage, treatment and disposal of solid waste through the formulation and adoption of the
best environmental practices and pushes for reforms in the management of health care
waste (emb.gov.ph). As humanity became more attuned to environmental concerns, many
local and national laws have been enacted to deal with the resulting issues, including that
of waste management. These laws were made not only to ensure that proper waste
management is being adhered to but also the fact that they should make use of ecological
programs and practices that appropriately address environmental concerns.
The Toxic and Hazardous and Nuclear Wastes Control Act of 1990 or R.A. No.
6969 also plays a role in the waste management of funeral establishments. This law
covers the importation, manufacture, processing, handling, storage, transportation, sale,
distribution, use and disposal of all toxic substances and hazardous and nuclear wastes in
the Philippines. Under this law, pathogenic and infectious wastes are considered
hazardous and therefore covered by this law (emb.gov.ph). The usual connotation of the
terms “toxic” and “hazardous” are often those that are chemical and industrial in nature,
but R.A. No. 6969 elucidates the fact that even pathogenic and infectious wastes, the
wastes that are most commonly generated by health care providers such as funeral
establishments , are also considered hazardous and as such, should be properly dealt with.
The World Health Organization classifies medical or healthcare waste into
communal waste or general waste, which is comparable to domestic waste and comes
mostly from the administrative and housekeeping functions of health care establishments
including the waste generated during maintenance of health care premises, and hazardous
health care waste or special waste (whqlibdoc.who.int). Infectious and other special
wastes are collected in accordance with the relevant neutralization methods, while
general wastes are by the municipal waste disposal system (Zimmermann et al, 2011).
Though in the conduct of the study, the researchers may come across general waste
generated by the establishments, more emphasis is geared towards the proper
management of special waste. This classification of wastes was also adopted by the
Department of Health and promulgated as guidelines for health care facilities, including
funeral establishments (pcij.org). Since the researchers are more concerned with local and
national regulations rather than that of international standards, greater attention is
accorded to the directives promulgated by the Department of Health.
Special waste consists of several different categories:
• Infectious wastes are those suspected to contain pathogens (bacteria, viruses, parasites,
or fungi) in sufficient concentration or quantity to cause disease in susceptible hosts. This
category includes cultures and stock of infectious agents from laboratory work, waste
from surgery and autopsies on patients with infectious diseases, waste from infected
patients in isolation wards and any other instruments or materials that have been in
contact with infected persons or animals.
• Pathological wastes consist of tissues, organs, body parts, human fetuses and animal
carcasses, blood and body fluids. Within this category, recognizable human or animal
body parts are also called anatomical waste. This category should be considered as a
subcategory of infectious waste, even though it may also include healthy body parts.
• Sharps are items that could cause cuts or puncture wounds, including needles,
hypodermic needles, scalpel and other blades, knives, infusion sets, saws, broken glass,
and nails. Whether or not they are infected, such items are usually considered as highly
hazardous health-care waste.
• Pharmaceutical waste includes expired, unused, spilt, and contaminated pharmaceutical
products, drugs, vaccines, and sera that are no longer required and need to be disposed of
appropriately. The category also includes discarded items used in the handling of
pharmaceuticals, such as bottles or boxes with residue, gloves, masks, connecting tubes
and drug vials.
• Genotoxic waste may include cytostatic drugs, vomit, urine, or feces from patients
treated with cytostatic drugs, chemicals, and radioactive materials. This type of waste is
highly hazardous and may have mutagenic, teratogenic, or carcinogenic properties.
• Chemical waste consists of discarded solid, liquid, and gaseous chemicals, for example
from diagnostic and experimental work and from cleaning, housekeeping, and
disinfecting procedures. Chemical waste from health care may be hazardous or non-
hazardous. They are considered hazardous if they are toxic, corrosive, flammable or
reactive. Nonhazardous chemical waste consists of chemicals with none of those
properties, such as sugars, amino acids, and certain organic and inorganic salts.
• Wastes with high content of heavy metalsrepresent a subcategory of hazardous
chemical waste and are usually highly toxic. This includes mercury waste typically
generated by spillage from broken clinical equipment and cadmium from discarded
batteries.
• Pressurized containers consist of full or empty containers with pressurized liquids, gas
or powdered materials, including pressurized cylinders, cartridges, and aerosol cans.
• Radioactive wastes are wastes containing radioactive substances. These include solid,
liquid, and gaseous waste contaminated with radionuclides generated from vitro analysis
of body tissues and fluids, in vivo body organ imaging, tumor localization, and
therapeutic procedures.
The Department of Health presented guidelines on how health care waste should
be treated in its Health Care Waste Management Manual (pcij.org). The manual serves as
a guideline for hospitals, health care centers and even to other health-related
establishments, including funeral establishments. It provides practical information
regarding safe, efficient and environmental-friendly waste management options and
contains in detail, safety procedures on the collection, handling, storage, transport,
treatment and disposal of health care wastes. However, waste management procedures
practiced by funeral establishments may vary from one another since the government
does not provide a specific standard but rather, encourages the use of the manual.
Even from the start of the waste management process, which is waste handling,
appropriate measures must be complied with. Segregation, as defined by the manual, is
the process of separating different types of waste at the point of generation, keeping them
isolated from each other and taking place as close as possible to where the waste is
generated and should be maintained in storage areas and during transport (pcij.org).
Segregation at source is a key to efficient health care waste management since with better
planning and supervision, not only the waste generation is reduced, but overall
expenditure on waste management can be controlled (NIIR Board of Consultants &
Engineers, 2005). The Department of Health has suggested that color-coding scheme be
abided by in segregating the various wastes that health care providers generate. As a
result, wastes of the same category are placed in the same container which would
facilitate the transport of these wastes to their subsequent destination. Health care wastes
are to be segregated into color-coded containers as follows:
Black Non-infectious dry waste
Green Non-infectious wet waste (kitchen, dietary etc.)
Yellow Infectious and Pathological waste
Yellow with black band Chemical waste including those w/ heavy metals
Orange Radioactive waste
Red Sharps and pressurized containers
After the wastes have been segregated correspondingly, these must be collected
and stored in a waste storage area that is marked with warning sign: "CAUTION:
BIOHAZARDOUS WASTE STORAGE AREA - UNAUTHORIZED PERSONS KEEP
OUT" until transported to a designated off-site treatment facility. This storage area for
health care wastes should be located within the establishment or research facility but
away from public access areas and in cases where the health care facility lacks the space,
daily collection and disposal should be enforced (pcij.org). As it has been mentioned
previously, health care waste is different from the waste generated by households and
other establishments by the fact that health care wastes are potentially hazardous. This is
why it is often emphasized that these wastes should only be handled by trained personnel
and should not be easily accessed by the general public.
Proper collection and transport is a significant component in health care waste
management, which is why the collection must be designed to attain efficient transfer of
waste while minimizing the risks to personnel handling them. Waste should not be
allowed to accumulate at the point of production and a program for their collection and
transportation should be established as part of the health care waste management plan and
also, staff should ensure that waste bags are tightly closed or sealed to prevent spilling
during handling and transportation (pcij.org). In the collection of health care wastes,
important aspects include the frequency and volume to be collected. The health care
waste generator should make certain that collection is not too infrequent that the wastes
eventually accumulate beyond their capacity and cause problems nor too frequent that it
becomes inefficient and costly. It is also imperative to note that the waste containers
should be properly sealed and are easy to load and unload during transport.
The health care waste generator is responsible for the safe packaging and
adequate labeling of waste to be transported for treatment and final disposal and these
should comply with the national regulation governing the transport of hazardous wastes
or Republic Act No. 6969 and maintain that it presents no danger to the public during
transport and also, it is imperative to be aware that they are ultimately responsible for
ensuring that their wastes are properly treated and disposed of in an approved disposal
facility and that all health care waste to be transported shall be transported only by a
DENR-accredited transporter or carrier (pcij.org). The study is limited only to the waste
management programs that the funeral establishments are implementing, and so, the
handling by the subsequent collecting system would be beyond the scope of the research.
However, it is to be emphasized that it is the health care generator, the funeral
establishment, that has the responsibility of ensuring that the transporters or carriers they
employ are duly accredited by the proper authorities.
The purpose of treating health care waste is to change the biological and chemical
character of the waste to minimize its potential to cause harm and incineration used to be
the method of choice in treating health care waste, however, with the implementation of
the Clean Air Act of 1999, this method is no longer (pcij.org). Today, autoclaves or
steam sterilizers are the most common treatment method as they have the lowest capital
costs among alternative technologies (Emmanuel, 2007). For a long time, the preferred
treatment used to be incineration and even up to now, most of the public still assume that
health care waste are still subject to this treatment . However, with its banning by the
Clean Air Act of 1999 as a response to environmental concerns, it is now the alternative
processes that are more ecological that are advocated and being utilized.
The Manual on Health Care Waste Management provides three suggested waste
disposal systems which include the sanitary landfill, which is an engineered method
designed to keep the waste isolated from the environment, the safe burial on
establishment premises and lastly, the septic or concrete vault, which is especially
suitable for the disposal of used sharps and syringes (pcij.org). The proper health care
waste disposal is a paramount concern not only for the health sector or the
environmentalists but also for society, which is affected invariably as well. The health
care waste generator, the funeral establishments, have the fundamental responsibility of
ensuring that the wastes to be treated and disposed of are processed in government
approved treatment and disposal facilities.
Health care wastes represent only a very small percentage of the entire waste
generated by humans. However, even if they constitute only an infinitesimal fraction,
they should be dealt with strictly and accordingly as they provide greater risks than those
of other types of wastes. Improper handling and disposal of potentially hazardous wastes,
including health care wastes, may become a considerable sociological problem today as it
may affect human health, the environment and the economy. They pose risks to human
health due to their potential to spread diseases and may even cause illness or death from
exposure to toxins and chemicals. An incident in Russia illustrates the danger: children
playing with waste bins near a health center were infected with live strains of smallpox
from exposure to discarded ampoules of the vaccine (Bryant, 2000). Also, the emergence
of an army of human scavengers in recent times who make their living from refuse
dumps have added another dimension to the general concern on medical waste disposal
(Oruonye, 2012). In developing countries, scavenger families who make a living of
recycling materials from open dumpsites are at great risk especially from sharps waste
(Emmanuel, 2007). Improper disposal can also inflict problems to the environment and
the economy. Cleaning up of improperly disposed wastes and contaminated sites can be
damaging to the natural environment and be costly and time consuming, particularly in
poor communities.
Several studies have been done to assess the management of hazardous wastes
abroad, especially in developing countries. A study conducted by Sarkar et al (2006) in
Bangladesh observed that wastes of most hospitals are normally collected from small
bowls or plastic bins provided for each bed and stored either in large plastic bags or
buckets which are then put in a pushcart and carried to the nearest municipal bins outside
for dumping without any segregation or treatment. These open dumps are of ready
access to scavengers who collect used blood bags and syringes and to domestic animals
and pests that could potentially spread diseases. In Lagos, Nigeria, a study was also
conducted and results showed that even though medical waste attracted a high level of
segregation in most hospitals, it is generally co-disposed with the municipal solid waste
stream by waste handlers (Longe, 2006). Also, non treatment of infectious waste before
final disposal was observed along with open dumping either within the hospital premises
or at government recognized dumpsites. Another study, that of Kumar et al (2010), also
found that collection, storage, handling by the staff, transportation for disposal and final
disposal of health care wastes in Pakistan were not up to the national and World Health
Organization guidelines.
A study by Blenkharn (2007) concluded that the standards of performance in
clinical waste management of hospitals in the United Kingdom remain poor, with
evidence of neglect of basic hygiene, housekeeping and safety standards. Also, despite
the implementation of the Hazardous Waste Regulations 2006 that provides further
control on all wastes management issues, the reality of clinical waste management in
some National Health Service (NHS) hospitals continues to be largely inadequate. A
comprehensive study by Ananth et al (2009) was also conducted to assess the health care
waste management of 12 countries which comprise of Cambodia, China, Indonesia,
Japan, Laos, Malaysia, Mongolia, Myanmar, Vietnam, Thailand, Singapore and the
Philippines in relation to the World Health Organization (WHO) requirements. It was
revealed that the economically developed countries, Japan and Singapore, have
established compliance with the WHO requirements for quite obvious reasons – financial
and policy support, regulatory push and willingness of healthcare service providers while
the other countries are at different stages of establishing systems and processes to ensure
appropriate handling and management of healthcare waste. The study then concluded that
health care waste management is a subject of concern among all selected developing
countries of the study since though some countries are ambitious about taking health care
waste management progressively, they either lack knowledge, strategies, legislations,
budgets or a mix of all.
In the Philippines, quite a few studies have also been conducted to evaluate the
management of health care wastes. A study on hospital waste management in Metro
Manila showed that hazardous medical wastes were not properly handled (Soncuya et al,
2007). Majority of the hospitals do not adhere to the color-coding system as
recommended and have no treatment procedures prior to the disposal of their infectious
waste while some even continue to dispose their infectious wastes in municipal landfills
together with general wastes. Another study on waste management practices of hospitals
in Metro Manila conducted by Molina for the Department of Health revealed that
although most of the hospitals perform waste segregation, less than 50% of the 144
hospitals studied did not have the proper mechanisms for proper waste handling and
segregation (Alfaro, 2009). The study also revealed that some hospitals make use of
incineration for final disposal of wastes. In Zamboanga City, a study by Morones (2009)
showed that waste segregation among hospitals is being practiced through color-coding
scheme and separation of infectious waste from non- infectious waste. However, though
wastes were properly sorted in the hospital, the local government garbage truck collects
the waste and disposes it in the city dump site - a practice that defeats the purpose of
waste segregation in hospitals. A similar study on clinical laboratories in the same locale
conducted by Alfaro (2009) revealed that waste segregation is done by majority (89%) of
the laboratories, however, the methods are not completely implemented in terms of color
segregation schemes, containers, and waste categories.
Unlike other countries, the Philippines has no definitive law or standard that
governs the management of health care wastes. Instead, only the laws that govern
common or general wastes are readily available. Data found from the Department of
Health only include licensing requirements, qualifications, and the Health Care Waste
Management Manual (Alfaro, 2009). And so, the regulations that deal with the
management of health care wastes are mostly just the guidelines presented in the Health
Care Waste Management Manual promulgated by the Department of Health. From the
review, it has been presented that there are very few studies and journals in the
Philippines that tackle the subject of health care wastes and their management. Most, if
not all of them, only study only the health care wastes generated by hospitals and clinics
and not of other institutions like funeral establishments. Presently, there are very few
studies found describing waste management practices of funeral establishments from
local libraries and other sources such as online search engines and websites for journals.
However, those that were found focused more on the handling and disposal of cadavers,
which is outside the scope of this study. Considering the health hazards related to health
care waste, this research is essential in providing information of waste management of
funeral establishments in Cebu City and to promote proper health care waste management
practices.